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Promises, Promises -- What It Will Take to Rebuild Haiti

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$5.3 billion over the next two years. A total of $9.9 billion for three years or more. The amounts pledged to support relief and reconstruction at the March 31 international donors' conference for Haiti were impressive. So was much of the accompanying rhetoric about recognizing Haitian leadership and empowering the Haitian people. Overall, March 31 was a very good day for Haiti, with one very big caveat: now these pledges and principles have to be translated into concrete, effective, and sustained action.

In the streets and resettlement camps of Port-au-Prince, the promises and rhetoric were greeted with a healthy dose of skepticism. Nearly three months after the January 12 quake, the scene remains grim. An impoverished city of three million people--long without adequate building codes, sanitation or waste management--has been reduced to a patchwork of ruins and fetid shanty settlements. As the first torrents of the rainy season pour down and the hurricane season looms, hundreds of thousands of people live in makeshift shelters with little or no access to sanitation, many on slopes where they could be swept away by mudslides, others on patches of low-lying ground that will inevitably become a toxic stew of mud, garbage, and human waste. Children remain out of school and the medical infrastructure of Port-au-Prince lies in ruins.

To understand the skepticism with which Haitians receive even the most generous pledges of support, take a few moments to reflect on the country's rich history and its people's hard-earned sense of pride and dignity. Haiti was born of a slave revolt that defeated the three major colonial powers of the day: France, England, and Spain. The idea of a nation of free blacks struck fear not only in the defeated colonial powers but also in the United States, fear that resulted in isolation and political manipulation from the time of Thomas Jefferson to George W. Bush. Control of Haiti's free populace has taken the form of military occupation, externally backed coups and dictatorships, and mountains of debt. Each method assured that the one thing that Haitians fought for--self-determination--would be limited.

What will it take for Haiti to win the struggle for dignity at last?

First, it will take recognition of what it truly means to say that the response to this tragedy must be led by Haitians and must include civil society. Haiti has a democratically elected but impoverished government. If we believe in democracy, if we understand that civil society refers to collective action around shared interests and values, there can be no greater actor in Haitian civil society than the democratic will of the Haitian people. Yet civil society is too commonly construed as anything that is "not government." The thousands of non-governmental organizations that are active in Haiti, with little or no local participation or presence, should not be equated with civil society. Let Haitian organizations and the Haitian democratic process be the arbiters of aid effectiveness. This could be accomplished by setting up a board to oversee relief that is largely Haitian and representative of the population.

Second, it will take significant, long-term investments. The $9.9 billion pledged on Wednesday was encouraging. But it falls short of the $11.5 billion UN target over the next decade and is dwarfed by the $150 billion that was committed for relief of New Orleans, a city of 200,000 people, after Hurricane Katrina. Moreover, Haitians know from painful experience that money pledged does not mean money delivered. Less than a third of the aid pledged to Haiti after the devastating 2008 hurricanes has ever been disbursed. It is important to develop a long-term relief plan that has, embedded within it, a monitoring and evaluation plan and advocacy strategy to hold the donor community to its promises.

Lastly, steps must be taken to ensure that assistance gets to the most vulnerable. While it is convenient to talk about developing markets as a rebuilding strategy, the trickle-down economics of the last decades have too often resulted in worsening inequality throughout the world, and particularly in Haiti. Former President Bill Clinton recently admitted as much. In an interview, he acknowledged that policies enacted during his administration to open up Haiti's markets to imports of cheap, subsidized rice from the United States had devastated Haiti's agricultural economy and domestic food production, contributing to increased hunger and malnutrition. Social protection must be made a top priority as Haiti rebuilds, particularly education and health. These priorities should be driven by the grass roots and supported to increase access to these basic rights.

The challenges are great. The key to surmounting them is the very sense of history and pride that leads the Haitian people to react with skepticism to promises of help and with determination and solidarity to disasters both natural and man-made. This spirit was summed up for me in an exchange with one of my cherished colleagues in Haiti, Dr. Fernet Leandre, during the first days after the earthquake. "This is an apocalypse," I said as we looked at the death and destruction around us. "Slavery was an apocalypse, too," he replied. "And we overcame that."

Dr. Joia Mukherjee is Medical Director of Partners In Health and an Associate Physician in the Division of Global Health Equity at Brigham and Women's Hospital in Boston.