Seven months after the January 12, 2010 earthquake that devastated Haiti, I returned for the third time. This time, not to help the wounded, to perform surgeries, but to help facilitate further funding for the University Hospital and to feel and see with my own eyes what changed, what hasn't and what needs to. The world has moved on to the next disaster, from the BP Gulf Oil Spill to the floods in Pakistan, but the memories of that first week after the quake -- the smells, the loss, the destruction, the extraordinary heart of the Haitian people -- worked its way under my skin. It is a part of me. It is the poorest nation in the Western hemisphere where 55 percent of the population earns less the $1.25 a day and 58 percent of children are under-nourished, and it is not rebounding. Though there is less rubble in the roads and pockets of rebuilding have started, still today 1.6 million people are homeless and still in the tent camps (often made from sheets and sticks) -- or living on the median of a highway in Carrefour, doused in exhaust and dirt and hoping to survive each night as they sleep with cars flying by, deprived of all human dignity and decency as they bathe and defecate in view of everyone.
The night Wyclef Jean was disqualified from running for president (he has since petitioned to change the rules), a young energized crowd gathered outside the restaurant where they waited expectantly for the news. Long convoys of heavily armed UN peacekeeping forces in armored trucks patrolled the streets ready for riots that never came. As we quickly drove past the crowd, I asked Clairveux, our young driver, what he thought of the upcoming election in November. "Education is the only thing that will lift up the people," Clairveux said. Most of the population in Haiti, where the life expectancy is 55, is under 30. They are the future of Haiti. Yet 85 percent of the education in primary and secondary schools is expensive and private.
The most important determinant of the health of a population is not access to food, shelter, money, jobs or health care, but education. The health of Haiti reflects this education gap. It is a country, which has among the worst health statistics in the world -- infant mortality (59 per 1000 live births vs. 2.4 for Bermuda), maternal death (only 25 percent of births occur in a health facility or with a birth attendant), and 50 percent of the population have no access to health care. Haiti has only one-fifth the minimum number of health professionals recommended by the World Health Organization, only 18 percent of women of childbearing age have access to contraception, and 2.2 percent of the population have HIV or AIDS.
Since the earthquake the aformentioned issues have become an "acute on chronic problem," Paul Farmer says. The earthquake was a catastrophe on top of an already disastrous situation. How can Haiti rebuild its government with limited resources, money and expertise? An already weak public sector handicapped by two centuries of failed foreign policies has been nearly crippled. Only 10 percent of the donations or pledges since the earthquake have been used or dispersed to those in need. Imagine all but one of the US government buildings flattened (27 of 28), loss of one third of its civil service, a loss of 50 percent of the nation's GDP (gross domestic product), no significant tax revenue (1.8 percent of government revenue) and a cost of rebuilding the nation equal to 120 percent of the total GDP of the country. Where do they start?
Despite billions of dollars of foreign aid historically funneled through 9,000 NGOs (non-governmental organizations) -- more per capita than any other nation, most of which operate and act independently of the government -- none of this aid helps build the capacity of the government to govern or build infrastructure. Haiti has often been referred to as the "Republic of NGOs."
Nation building presupposes the existence of a functional government with adequate financial resources to build education, health care, housing and sanitation and support economic development. Of the $1.8 billion of aid sent to Haiti after the earthquake only 2.9 percent has gone to the government. This mirrors decades of the world's polices and actions toward Haiti, which has weakened the public sector. Perhaps driven by political motives or concern over corruption, the end result of the neglect of the public sector in Haiti is a government that has limited capacity to plan, fund and implement national reconstruction and rebuilding. It is a veritable catch-22.
Visiting the primary public hospital in Haiti, where I spent the early days after the quake, I saw improvements in the form of slow, steady changes. All the NGOs left in early July. Things are back to 70 percent of pre-earthquake operations according to Dr. Alix Lassegue, director of the hospital. But what does that mean? He asked me to bring 2 EKG machines to the hospital. Imagine the main University Hospital in America not having an EKG machine in the emergency room. A woman came in with a gunshot wound and there weren't enough dressings for her wound in the emergency room. The director of the hospital had to walk across to street to buy anesthesia medication to bring to the operating room. That is because since 1930 the public health sector has received little support from the government beside salaries. And those are woefully inadequate. Doctors working for NGOs are paid $3,000 a month, while those working for the hospital make $500 a month, making it hard to staff the hospital, often leaving medical residents and patients unattended.
The first grant to the public sector since the earthquake for $3.8 million arrived at the hospital the first week of August for salary support by retention and performance bonuses for six months. We had submitted a proposal to the American Red Cross through David Meltzer, who directs international relief. After the quake I discovered he is my long lost cousin, and that we share common great-grandparents. Dr. Lassegue told me this was the first week since the earthquake that he was able to bring staff back to the hospital and pay them. Most had not been paid since before the earthquake. How can we rebuild (or build for the first time) the public sector if there is no funding to even create a plan, nonetheless support government institutions and public sectors like health care and education?
The Interim Haitian Recovery Commission was established to provide a transitional structure to aid the government to conduct strategic planning and coordination and implement resources from bilateral and multilateral donors, non-governmental organizations, and the business sector complete with transparency and accountability. The Robert F. Kennedy Center for Justice and Human Rights, led by Kerry Kennedy, has led the implementation of online transparency and accountability for the Commission. It has been slow to get off the ground but had its second meeting while I was in Haiti on August 17, co-chaired by President Clinton and the Haitian Prime Minister Jean-Max Bellerive with the support of the new executive director, Gabriel Verret, the economic advisor to President Preval. $1.6 billion of projects were submitted for review and 4 were accepted including a $94 million back to school program, a $200 agriculture initiative, a $17 million rubble removal and recycling program and the building of a $15 million, 320 bed teaching hospital in Mirbelais funded by Partners in Health. But because all the pledges from the donor nations have not been given yet, there is only $95 million in the Multi-Donor Trust Fund. Private business are reaching out to support economic development through the building of hotels, convention centers, solar energy projects, kibbutz-like agriculture communities or Lakous that provide food security, jobs, education and resources to rebuild the land and revitalize rural Haiti. This is all needed.
Yet the majority of funds from donor nations have not been paid into the multi-donor trust fund. Over $1 billion of aid donated by individuals to NGOs like World Vision, Care or the American Red Cross remains to be distributed as part of the relief and recovery. The donors want to provide the funds. The problem is the lack of clear strategic and operational plans by Haiti for Haiti. The NGOs or foreign governments can't create Haiti's plan. The Haitian government must do that with whatever technical support and capacity building they require. The supply of money exists and the need is huge. But coherent, comprehensive, coordinated and well-integrated plans, which fit into an overall plan for the rebuilding and reconstruction of all public sectors -- health, education and sanitation -- haven't been fully developed, while maintaining support of Haiti's private economic development. The projects must fit Haiti's plan. The plan doesn't need to fit in to the NGOs or donors' projects.
Clear communication within the government and with multiple aid partners and limited leadership still plague forward movement. We met with the Ministry of Health for six hours. They have an outline of an 18-month operational plan for the health sector, and the plan to create a 10-year strategic and operational plan. But they didn't have any funding or the full spectrum of technical expertise to even create the fully fleshed out, strategic and operational plan to submit for funding to the Commission for approval. They are not fully informed yet about how they need to interface with the commission.
I recognize the world's view of Haiti is tainted -- from voodoo to AIDS to corruption to violence, much of which is the result of the world turning its back on Haiti, dating back to the slave revolt when Haiti was once of the most economically productive places in the world -- the jewel in France's crown -- to military occupation by America, the support of despots and embargoes and now natural disasters. In meetings with the Ministry of Health, Tourism, Rebuilding, Public Works, with Leslie Voltaire, the presidential candidate, and Gabriel Verret, executive director of Interim Haitian Recovery Commission (and economic advisor to President Preval), I was struck by the passion, commitment, intelligence and understanding of Haiti's handicaps and willingness to cooperate in planning, business development and the genesis of a new kind of nation free from constraint and corruption from within and without.
And there are pockets of light and hope emerging, areas where the public sector is shored up, where pressure is relieved and suffering abated. At HUEH, the state University Hospital, I met with Megan Coffee, the only "blanc" left -- a young infectious disease doctor from University of California, San Francisco who singlehandedly set up a 55-bed tuberculosis ward within the hospital after the nation's sanatorium collapsed. Yet the patients are in sweltering tents without air-conditioning, and there is not enough oxygen to treat those whose lungs were ravaged by untreated TB. But with persistence and the help of her Haitian team of nurses and staff (who have not been adequately paid and who do not have enough food to eat) she has brought many back from the brink of death. One 24-year-old woman weak from long standing untreated tuberculosis with lung scarring and heart failure that we would see only in 80-year-olds in America, stayed in her camp until she was near-death. Finally she was brought for care after the quake. She is recovering, but still must be tethered to a large oxygen tank because there is no portable oxygen concentrator in the country for her.
Back in the recesses of the hospital before the quake there were 48 disabled children living in one dark room, often neglected with little food or attention because of lack of resources. Paul Farmer and his colleagues from Partners in Health, Loune Viaud and Nancy Dorsinville found them after the quake and brought them to a farm, Zanmi Beni, or "The Blessing of Friends Farm," that Paul told me he purchased as his 50th birthday present. There, the children sat under the shade of the trees, carried out of neglect and starvation. They were playing, eating and being cared for with dignity and kindness and with the blessing of friends.
Haiti needs friends now. There is a Buddhist saying that when your heart breaks, it can break open or closed. Let your heart break open for Haiti, mine did. They will need the blessings of friends for a long, long time.