Reviews in three Canadian dailies of Paul Farmer's Haiti After The Earthquake

Below are three reviews in Canadian dailies of Paul Farmer's Haiti After the Earthquake:
1. The Gazette (Montreal), July 22, 2011, by René Bruemmer
2. The Globe and Mail, July 25, 2011, by Roger Annis
3. The Toronto Star, July 17, 2011, by Jennifer Wells

Haiti After the Earthquake, By Paul Farmer, PublicAffairs, 431 pages, $30

Dr. Paul Farmer has a prescription for Haiti

Reviewed By René Bruemmer, The Gazette (Montreal), Saturday July 23, 2011

Haiti, in many ways, represents a global failure: despite the efforts of international development experts, aid organizations, foreign governments and the infusion of billions of dollars over the last four decades, the quality of life in the poorest country in the western hemisphere has only got worse.

Writer and frequent visitor to the country Mark Danner called Haiti “the great petri dish of foreign aid.”

In his new book, Haiti After the Earthquake, doctor and anthropologist Paul Farmer, a professor of public health at Harvard University who has spent nearly 30 years there as the co-founder of the Partners in Health aid organization, the country’s largest supplier of health care, says: “Few would agree that it has been a successful experiment.”

On Jan. 12, 2010, the effects of this failure became tragically clear. An earthquake that would have been much less catastrophic elsewhere killed 300,000, according to government estimates, and left 1.5 million homeless. Farmer describes the reasons for the scope of the destruction in medical terms as an “acute on chronic event.” It was devastating, he writes “because a history of adverse social conditions and extreme ecological fragility primed Port-au-Prince for massive loss of life and destruction when the ground began shaking on Jan. 12.”

A perennially fractious and unstable government plagued by corruption has led to the majority of international funding being channelled to non-governmental aid organizations, which in turn led to an even weaker government unable to provide for its people. It is a recurrent theme of the book that carefully monitored funding must be directed toward rebuilding Haiti’s civil service and governance so the country can finally build the lasting infrastructure necessary to look after itself.

Farmer describes how Haiti came to be such a fragile state, and suggests how to “build back better.” He gives an account of the country’s 200-year history and describes how Haiti’s political instability and ecological devastation, along with foreign intervention and unfair trade policies, have combined to make it so weak.

To humanize what could have been merely an academic study, and as a reminder of why it matters, Farmer and 12 contributors recount their experiences during and immediately after the quake. The recollections of people like Farmer and his colleagues, working around the clock as the bodies pile up, serve as chilling and sad examples of the horrors the world’s inequalities can render.

Farmer recounts one phone call from a friend, “an airport employee who rushed home to find his house destroyed and his 7-year-old son trapped under the rubble. The boy, Richardson, would perish, but not for three hours – and not without begging his parents and youngest sister for a sip of water.”

In a beautiful passage, Nancy Dorsinville, a Haitian United Nations adviser and former Partners in Health worker, recounts how she reunites with a Chinese UN security worker she had met briefly days before just before the quake. He has just learned his fellow peacekeepers had been killed.

“When he reached me, he simply put his head on my shoulder. … He did so in a familial way – as if he, a Chinese man from a faraway land, and I, a Haitian woman in her native land, were kinfolk. It was as though, immersed together in this tragedy, we had been compelled to know each other intimately and discovered that we were, in fact, the same.”

Those who have read Farmer’s earlier books on Haiti, which have railed against international interference and corporate interests, may notice a change of tone. Farmer was recently named UN Deputy Special Envoy for Haiti, under Special Envoy Bill Clinton. Once a strident voice in little-read academic publications and left-leaning books demanding social justice, Farmer has become, somewhat to his chagrin and the amusement of his colleagues, a reluctant member of that establishment in an effort to do more good. The urging of Clinton, whom Farmer treats with near reverence, had much to do with it. His railing against the establishment has become much more subdued, which will disappoint some.

But Farmer still has a lot to say about the delivery of aid for Haiti, and the international development community in general. Chief among his suggestions are transferring much more of the aid directly to Haiti’s government so it can build a proper civil service that can provide health care, education and shelter for generations to come. (Less than 0.3 per cent of all Haitian quake relief coming after the earthquake went to the public sector, Farmer notes.)

He cites the example of U.S. president Franklin Roosevelt’s enormous job creation projects during the Great Depression in suggesting that Haitians be given employment to let them build their lives, and he espouses foreign investment as another means to create jobs.

He finds hope in Haiti’s modest rise in the years just before the earthquake, the efforts of some aid organizations and the UN, and in the example of Rwanda, which managed to rebuild itself after its genocide.

Farmer provides an in-depth look at the causes behind Haiti’s ills and presents solutions for the country’s revival. Whether Haitians and the international community can find a way to finally make them work remains to be seen.

“Until the basic needs of the Haitian majority are met – food and shelter, education and health care, jobs that promote dignity – there will be scant peace in Haiti,” Farmer writes. “This was true before the quake, and it remains so after.”

(The Gazette is Montreal's English-language daily newspaper.)

Dr. Paul’s prescriptions for Haiti’s ills

Reviewed by Roger Annis,
Globe and Mail print edition, Tuesday, July 25, 2011

Paul Farmer has written an essential book for understanding the country that was shattered by the earthquake of Jan. 12, 2010.

The stark drama of the days and weeks that followed goudo goudo (the neologism whose vocalization, Haitians say, most closely resembles the sound of those frightening moments when the earth shifted) is dramatically captured in his personal account of rushing to the country to join Haitian and international medical colleagues in treating earthquake victims. Thirteen of his colleagues and family members, as well as other writers, also recount their experiences and observations in the form of short essays and a powerful foreword to the book.

The uniqueness of Farmer’s written contribution to this new stage of Haiti’s history is the piercing historic and social/political dimensions he offers to the reader. He brings to its pages a deep examination of Haiti’s vulnerability to the devastating blow it suffered and the sharp shift in policies and practices now required if the country is to move forward. In so doing, he offers insights into why, 18 months later, the relief and reconstruction effort is bogged down.

“It’s the argument of this book that rebuilding capacity – public or private – in Haiti requires sound analysis of what, exactly, has gone so wrong over the past four decades,” he writes in the opening pages.

Farmer has long been a sharp critic of the role of foreign governments and agencies in Haiti, most particularly the U.S. government. His 1995 The Uses of Haiti is a valuable primer on the country’s history.

As a Harvard University medical graduate, Farmer was a co-founder of the renowned global health agency Partners In Health. Haiti was the country of PIH’s beginnings, in the mid-1980s. The agency, alongside its Haitian partners, Zanmi Lasante and the Health Ministry, has blossomed into one of the country’s largest health providers, serving more than one million people in Haiti’s Central Plateau and Lower Artibonite regions and, since 2010, tens of thousands in the earthquake zone, including the largest displaced-persons camp in Port au Prince.

In Haiti, PIH has pioneered new and successful approaches to the treatment of HIV/AIDS, drug-resistant tuberculosis and a host of other poverty-related diseases, falsely considered intractable by some in global health circles.

“Doctor Paul,” as PIH’s patients fondly refer to him, titles one chapter of the new book A History of the Present Illness. It traces the long history of destructive, foreign intervention. Elsewhere, he describes how the embargo of development aid to Haiti’s government imposed by the United States (and Europe and Canada) after the 2000 election prevented the building of water-treatment facilities in the very region of the country where cholera was inadvertently (but negligently, all the same) introduced in October, 2010. (Joia Mukherjee, medical director of Partners In Health, who pens the foreword to Haiti After the Earthquake, wrote a scathing commentary on this precise story at the time the epidemic struck.)

Again at the outset of the book, Farmer describes the oft-misguided “proliferation of goodwill” directed at Haiti over the decades that has produced such poor results. “Thus did clinics sprout up without much aid to the public-health system; thus did schools arise by the hundreds even as the Ministry of Education faltered; thus did water projects proliferate even as water security (like food security) became enfeebled.”

His central prescription for righting Haiti’s woes is the fostering of strong national government and public institutions, financed by a national taxation system and assisted by foreign aid that develops Haitian capacity, rather than undermining it or serving intervention.

If there is one piece of the Haiti puzzle absent from the book that warrants attention, it is the Security Council military and police mission in Haiti known as MINUSTAH, now into its eighth year. Serious questions need to be asked about the legal basis of its presence as well as its exorbitant cost, amounting to many hundreds of millions of dollars a year.

Farmer’s engagement in Haiti took a turn in August, 2009, when he accepted an appointment as deputy special envoy on Haiti to the United Nations from the secretary-general’s special envoy on Haiti, former U.S. president Bill Clinton. There were those who worried that his critical voice on Haiti could be blunted in exchange for the greater policy influence he could presumably exercise in the new role.Thankfully, his voice is as sharp and perceptive as ever.

Roger Annis is a co-ordinator in Vancouver of the Canada Haiti Action Network. He just returned from directing a four-member, 10-day fact-finding mission to Haiti.

(The Globe and Mail is the largest of Canada's two national daily newspapers).


Haiti After the Earthquake by Paul Farmer

Reviewed by Jennifer Wells, Toronto Star, Sunday July 17, 2011

Seven months after the Haiti earthquake of January 2010, Paul Farmer took a 20-minute chopper flight from Port-au-Prince to Léogâne in the company of former U.S. president Bill Clinton.

The observed aerial view of the quake’s epicenter — “pancaked buildings and slab roofs angled downward like wet cardboard” — reinforced what we tragically knew: After all those months, only a teacup full of rubble had been cleared from the earthquake zone. There were few notes of optimism amid the misery.

On the ground, Farmer did something enterprising — journalistic, even. He hung back. Clinton, the United Nation’s special envoy for Haiti, was swept up in a group of officials and aid workers eager to show off new shelters being erected for displaced Haitians who were camped out by the tens of thousands under tents, tarps and, as a last resort, bed sheets.

Farmer — who, among his many abilities, can claim fluency in Creole — decided he wanted to take a “quieter look” at the temporary houses. Fewer than 30 “t-shelters” had been thrown up from a planned goal of 100,000. Casting his clinical eye, Farmer found them “something of a disappointment: solid two-by-fours were used as supports, but the walls were of white plastic; the roofs, cheap tin.”

Clinton and his entourage were ushered toward a “model” shelter. Farmer kept his ears open. “The model t-shelter Clinton visited was inhabited by a woman who had nothing good to say about her new home,” Farmer writes. “She launched a stream of invective in Creole even as the disaster-relief folks were describing, in English, the sturdiness of the t-shelters — ‘these are built to withstand high winds and to serve as transitional shelters that can tide people over until more permanent shelters are built; they’re much safer than tents.’ The model inhabitant scowled and complained, ‘Who would want to live in a house like this? The walls could be split open with a kitchen knife.’”

How gratifying it would be if Farmer’s latest book, Haiti After the Earthquake, were heavy with such moments. The Harvard University doctor has achieved revered status on the Haiti file, having worked in the country on and off for close to three decades. Co-founder of Partners in Health, which has become the standard bearer for health services delivery in Haiti, Farmer’s early work was focused on the village of Kay in the Central Plateau, a wretched settlement of the impoverished and the suffering who had lost their homes and agricultural lands to flooding caused by the building of a hydroelectric dam.

Farmer started a two-room clinic nearby at Cange, which grew into a full-fledged hospital with branches and roots extending into social and long-term health supports. When I visited the hospital some months after the quake, I wandered through a maze, past operating rooms and a pediatric ward, and sat with women hard at work in a shaded courtyard making that nutritional wonder food: peanut butter. There were patients everywhere in this “medical Mecca” — those are Farmer’s words.

He has big billing to live up to. When Pulitzer Prize-winning author Tracy Kidder was moved to write Mountains Beyond Mountains (2003) about the good doctor, who holds a PhD in anthropology, he acknowledged that his subject inspired “moral envy” among its readers. The book dubbed Farmer “a man who would cure the world,” which set the bar rather high. Farmer saw himself more simply as “a poor people’s doctor,” an infectious diseases specialist who wondered how any serious practitioner could study emergent pathogens in a country like Haiti without accepting social inequality as a factor.

The summer before the quake, Clinton named Farmer as his deputy special envoy at the UN. “He knows the country. He loves the people. They love him,” Clinton said then.

Reading Haiti After the Earthquake makes me wish Farmer had declined the offer.

Within weeks the poor people’s doctor found himself being transported in an armoured car — in a motorcade no less — with a bodyguard. “Clinton counseled me to focus on two broad agendas: the medical and public health issues I knew best but also the economic issues that influenced who got sick and who did not,” Farmer writes, admitting that he sometimes felt lost in his new role as a dollar-a-year man.

Somehow, in addition to spending time in the UN bubble he intended to keep up his teaching and clinical work, which meant toing-and-froing to Harvard as well as spending a great deal of time in Rwanda, where Partners in Health has focused much of its efforts.

And a book on top of all of that.

In his previous writings — I’m thinking especially here of The Uses of Haiti, published in 2006 — Farmer was angrier; angry and aseptic, which is a potent combination.

It would be good to hear an angry Paul Farmer right now. Given his stature, such words just might have some effect.

Those who read the shelter report in The Nation last week must be angry. The investigative piece examines American-built trailers used as classrooms in Léogâne. The trailer project was a Clinton Foundation initiative, approved by the Interim Haiti Recovery Commission, which Clinton co-chairs. Classes were prematurely suspended at two of the four installed schools this year due to temperatures in the trailers frequently exceeding 100 degrees, The Nation reports. A 6th Grader confided that her teacher would regularly distribute painkillers to children suffering from headaches in this let’s-boil-the-students atmosphere. In one trailer, levels of formaldehyde were found at two and a half times the level at which the Centers for Disease Control say children can experience adverse health effects. Formaldehyde is deemed a known carcinogen by the International Agency for Cancer Research.

If Farmer is angry now, he doesn’t much show it, coming across instead as merely unsettled.

His self-stated mandate in writing the book was to “lend clarity to the debates about reconstruction” as well as serving as an account of the first months after the quake.

That first task eludes him. Pondering the effectiveness of the recovery commission, he notes the $3 billion in projects approved in its first three months. Most of those projects remained incompletely funded or not funded at all. Why? “It wasn’t clear why, other than the usual bureaucratic siloing.”

So there’s the clarity piece.

Farmer throws down “foreign-grown political obstructions” and “bookkeeping tricks” as root causes, along with a lack of “absorptive capacity.” In other words, too few on-the-ground resources were available to deal with funds being tantalizingly waved offshore. Should the commission fail in its mandate, Farmer frets that the default mode will be to blame the Haitians.

As to the second task — a personal account of the time that followed 4:53 p.m., January 12 — Farmer suffers an emotional disadvantage. He was in Miami reading The Best and the Brightest when the 7.0 tremblor hit the capital and areas beyond. His first desire upon hearing the news may have been to go to his second home in Haiti, but his first obligation was to head to New York for an emergency UN session, where he found himself sitting on a dais, behind Clinton, wishing he were in Port-au-Prince, helping.

Three days later he flew to the capital aboard a private jet. “A soon as we opened the door, it hit us: a charnel-house stench filled the air of the windswept runway. I knew this smell but never imagined I would encounter it in an open space.”

Yes, that bit holds promise.

But soon enough Farmer is back in harness with Clinton, back in the bubble.

Even his recount of the cholera cruelty is strangely feeble, which seems especially odd coming from an infectious diseases expert who argued for a maximum assault against the epidemic (ie., vaccines) versus the adopted minimalist approach (health education and the distribution of chlorine tablets). Farmer wanted an investigation into the source of the outbreak. Genetic fingerprinting and point of origin were important in his view to predicting the speed with which the cholera might spread and in pinpointing appropriate treatment. The UN unconscionably denied — repeatedly — that its base near the town of Mirebalais, on a tributary of the Artibonite River, was the source of a crisis that has felled more than 4,000 Haitians (thus far).

By his own account, Farmer’s response was exceptionally meek. “It was certainly not my attention to fan the blame game,” Farmer writes. He quietly suggested to the then head of the UN mission that it “might be prudent” to conduct an investigation.

Surely we need smart, knowing people like Farmer to do much more than that. Consider the July issue of Emerging Infectious Diseases, a CDC journal. “Our findings strongly suggest that contamination of the Artibonite and one of its tributaries downstream from a military camp triggered the epidemic,” concludes the study. Here’s the bit I found most interesting: “Determining the origin and the means of spread of the cholera epidemic in Haiti was necessary to direct the cholera response, including lasting control of an indigenous bacterium and the fight for elimination of an accidentally imported disease.”

Nine months have passed since the outbreak.

Well, there’s much to get riled up about.

Farmer can sound exasperated — give him credit for that. A year after the quake he revisits Parc Jean-Marie Vincent. Or at least he appears to revisit the park, though he writes as a distanced observer. The park is the second largest displacement camp in Port-au-Prince, run by a Partners in Health team under Dr. Dubique Kobel. I visited the park a month after the quake, and interviewed Kobel there. Some 35,0000 Haitians were barely making do in the camp, a stultifying patchwork of makeshift shelters on a sun-baked plain of a place. It was awful. Menacing. People were fighting. The stink was terrible. Kobel was tireless, cheerful, patient as the camp dwellers lined up to see this good doctor.

It was Kobel, displaced from his own home, who started operating on people in the park the day after the quake. Two weeks later, physicians from Partners in Health came by, stayed, and Kobel, miracle worker, soon became a paid staffer.

At the time of the anniversary, PIH was still running the camp with no end date in view. “We were sick of hearing the words ‘exit plan’ from disaster-relief NGOs,” Farmer writes. “How could we leave when most of the conditions that had first led us to work in the camps persisted a year after the quake?”

What of the future?

That’s a mug’s game, and, sadly, Farmer decides to play. Before he hands the final 52 pages of Haiti: After the Earthquake over to a dozen writers who were invited to add their own essays, he engages in a frivolity of imagination. Let’s say it’s 2015. Where will Haiti be?

On the one hand, reconstruction could be in fabulous shape. On the other, the disaster could be ongoing. Health care and education? Same deal. Yes, the analysis gets as thin as that.

I suspect that Farmer’s publisher had hoped to get what ultimately reads like an anniversary book out long before now. I suspect that Farmer too late came to the realization that he didn’t have it in him to get the job done right. I know that the opportunity to write a better book lies before him.

Jennifer Wells is a Star feature writer. (The Toronto Star is the largest circulation daily newspaper in Canada.)