Testimony of Dr. Paul Farmer to the US Senate Committee on Foreign Relations
Thank you for inviting me to testify today before the Senate Committee on Foreign Relations. I speak as the U.N. Deputy Special Envoy for Haiti—President Clinton, as you know, is the Special Envoy—and also as a physician and teacher from Harvard who has worked for over twenty-five years in rural Haiti. Today, my hope is to do justice to Haiti not by chronicling the events of the past two weeks, which are well known to you, but by attesting to the possibility of hope for the country, and of the importance of meaningful investment and sustainable development in Haiti.
That said, I will not pretend that hope is not at times difficult to muster.
As I was flying from Port-au-Prince to Montreal on Monday, headed to a conference on coordinating responses to the massive earthquake, I did the painful math in my head and counted close to fifty colleagues, friends, and family members who had lost their lives in the space of a minute.
The afternoon of the earthquake, several of my colleagues from Partners In Health and the UN, were, ironically, in Port-au-Prince for a meeting about disaster risk reduction. Partners In Health, through its Haitian sister organization, provides health care to the rural poor. By focusing on training and employing local talent, we have grown a great deal over the years. We are currently serving a population of well over 1.2 million and count about five thousand employees, most of them community health workers.
Of course, not all our colleagues survived. But the vast majority of them did survive, and they have spent the last two weeks working day and night to relieve the staggering suffering of the wounded and displaced. President Clinton, our colleagues, and I have been in the cities of Port-au-Prince, Jacmel, and Léogâne, as well as the less-affected Central Plateau and Artibonite Valley. Everywhere we have seen acts of great bravery and solidarity.
In addition to the heroism of friends and colleagues, I would like to note for the record the dignity and patience of the long-suffering Haitian people. During a visit last week to Haiti’s largest teaching hospital, which shares a campus with the ruins of the nursing and medical schools, President Clinton remarked that no other people in the world would be so patient and calm in the face of so much suffering. This observation, though accurate, must not be misunderstood. People in Haiti are afraid not only for their options and futures, but still quite simply for their safety. A few nights ago, we sat in empty wards: hearing of impending aftershocks, the patients bolted outside with their IVs dangling from their arms. They refused, as have so many, to sleep inside the building—any building—but instead found tarpaulins and sheets, and lay down in the open courtyard.
This scene has repeated itself throughout the country and is a reminder of the logistics challenges facing all those who would be involved in the provision of shelter, clean water, and healthcare. The relief efforts, focused now on addressing the initial wave of devastation from the earthquake, will soon turn to a new set of concerns. Hastily cobbled together camps are at risk of outbreaks of cholera and other waterborne disease. The Haitian government has wisely proposed avoiding huge camps, which will be difficult to manage, but we must hasten our efforts to get tents, tarpaulins, and latrines or composting toilets to Haiti. It is humbling to see the relief efforts be so slow—in large part because delivery of services was so weak before the quake. Now we must do more to get food and water to people every day for some time to come. Creating safe schools and safe hospitals, even makeshift ones, is a known need in rebuilding a society, and storm resistant housing must also be a carefully considered priority since there is little time before the rainy season. Students need to be back in school; the planting season cannot be missed and requires fertilizer, seeds, and tools.
How will we fund such settlements, ongoing relief, the sowing of seeds, and the reconstruction that must follow? Major pledges have been made by the U.S., Canada, Japan, Spain, Brazil, the European Union, the Inter-American Development Bank, the World Bank, and others.1 Indeed, most countries have responded. Even in far away and once-afflicted Rwanda, a group of community health workers making less than $200/month have been able to pull together $7000 in donations for their colleagues in Haiti. This is but a small portion of the billions needed, but hard to surpass as an eloquent testimony of human solidarity.
Even if adequate resources are available, the task before us will be extremely difficult. Medical jargon, though at times arcane, can be helpful here. Today, Haiti is facing what we would term “acute on chronic” problems. Before January 12, the country was already facing huge long-term challenges in public health and education, the unemployment rate over 70%, and a majority of its population was living on less than two dollars a day. Food and water insecurity were already huge problems.4 Does this catastrophe create a chance for all of us to have a sounder, more solidarity-based relationship with Haiti? Or is it to be yet another chapter in a jeremiad of suffering and abuse of power? In my last testimony here, in 2003, I expressed concern that the latter possibility was likely given our policies at that time. Today I will spend my time focusing on the potential for an entirely reconsidered relationship between the two oldest independent countries in the Americas: Haiti and my own.
Let me offer, as one example of the difficult relations between Haiti and the international community (and an echo of the nineteenth-century machinations I discussed in my last testimony before this committee), the donor conference I attended here in Washington last April. It was one of only two donor conferences I have ever attended, the second being in Montreal earlier this week. The results of the first are noteworthy and worrisome: despite $402 million pledged to support the Haitian government’s Economic Recovery Program, when the country was trying to recover from a series of natural disasters resulting in a 15% reduction of GDP, it is estimated that a mere $61 million have been disbursed.5 In the Office of the Special Envoy, we have been tracking the disbursement of pledges, and as of yesterday we estimate that 85% of the pledges made last year remain undisbursed.
Many of us worry that, if what’s past is prologue, Haitians themselves will be blamed for this torpor. But as we have argued before, there are serious problems in the aid machinery, and these have contributed to the “delivery challenges” on the ground.6 The aid machinery currently at work in Haiti keeps too much overhead for its operations and still relies overmuch on NGOs or contractors who do not observe the ground rules we would need to follow to build Haiti back better. The fact that there are more NGOs per capita in Haiti than in any other country in the hemisphere is in part a reflection of need, but also in part a reflection of overreliance on NGOs divorced from the public health and education sectors.
Haiti will continue to need the contractors, and the NGOs and mission groups, but more importantly we will need to create new ground rules—including a focus on creating local jobs for Haitians, and on building the infrastructure that is crucial to creating sustainable economic growth and ultimately reducing Haiti’s dependence on aid.
In other words, what we need is a way of “building back better” that strengthens governance but also strengthens the Haitian economy to provide for the needs of its people, especially the vast majority of Haitians who are desperately poor. There is an opportunity not only to build Haiti back better, but to build a more functional and beneficial aid structure. Over the past two decades, US aid policies have seesawed between embargoes and efforts to bypass governments, including elected ones not to Washington’s taste. Neither the international community nor the United States provided credible, long-term, financial investment in Haiti. Restructuring foreign aid and forgiving Haiti’s crippling debts are essential to helping the country recover. US laws, including the Foreign Assistance Act of 1961 and its later revisions, prevent direct investment in the public sector; we will need to revisit these policies. Debt forgiveness is also needed to ease the financial drain that would otherwise hinder economic recovery and growth.
In building back Haiti, a credible body that has been working in Haiti could help to house a recovery fund. We need to commit funds and also to disburse them. To quote Jeff Sachs, “Haiti does not need a pledging session; it needs a bank account to fund its survival and reconstruction.”9 Such an account should be managed in collaboration with partners, the UN, and, of course, Haitian leadership, which would work directly and openly with partners to design and implement recovery plans coordinated at central and local levels. The effort must include a comprehensive post-disaster needs assessment, which should be supported by the US and other partners.
Might such plans work? In some of the darkest moments of the last two weeks, when the incapacity and lack of coordination of institutions on the ground was revealed repeatedly, I have thought often of Rwanda and what happened there in 1994. As a physician and teacher at Harvard, I have been lucky to work with the Clinton Foundation, Partners In Health, and the government of Rwanda on rebuilding health infrastructure in three of the last four districts that lacked central hospitals. As in rural Haiti, this has been a very positive experience. It has resulted in thousands of jobs for Rwandans, and has created a broadly accessible health care infrastructure—all with a modest price tag compared to traditional aid contractors.
If such progress can be made in Rwanda, which boasts strong leadership but in 1994 was the poorest country in the world,11 then one hopes it can be made elsewhere. In part because of this positive experience of working together with the Clinton Foundation in Rwanda (and in Malawi and Lesotho), I joined President Clinton six months ago as his deputy in the UN role he originated. As Special Envoy for Haiti, President Clinton has focused his attention not only on holding donors to the financial pledges they made, but also on reducing the risk of disasters and on job creation through the massive public works that are necessary to reforest Haiti, protect watersheds, and improve agricultural yield—the backbone of the Haitian economy. Private investment in Haitian businesses, especially small and medium-sized ones, is critical to rendering Haiti free of any dependence on aid—the goal of Rwanda by 2020, and moreover, a goal likely to be met. Haiti also has, he noted, great potential as a tourist attraction but lacks the infrastructure to welcome the millions of people who should see Haiti’s natural beauty and historic treasures like King Henri Christophe’s Citadel.
This has been our mission: to build back better from the 2008 storms. We believe that these efforts were beginning to bear fruit. We had scheduled a meeting last week in the Hotel Montana to bring in another round of investors and also to discuss job creation. As many of you know, this hotel is no longer standing, and most inside it perished on January 12. But the need for such investments, and the need for public works that would create hundreds of thousands of jobs, remains.
If there is any silver lining to this cloud, it is that we can push job creation. It is a strange irony that supporters of economic assistance to Haiti are now obliged to shill for “cash for work” programs—for the quaint notion that people should be paid for their labor. Let us at least be honest: it is absurd to argue that volunteerism and food-for-work programs will create sustainable jobs. But if we set the ground rules on reconstruction correctly, we will be able to create sustainable jobs.
In other words, if we focus the reconstruction efforts appropriately, we can achieve long-term benefits for Haiti. The UNDP is helping to organize programs of this kind, which should be supported and extended around the country. Putting Haitians back to work and offering them the dignity that comes with having a job and its basic protections is exactly what brought our country out of the Great Depression.
This was always the right thing to do, and aid programs persistently fail to get it right. So here is our chance: if even half of the pledges made in Montreal or other such meetings are linked tightly to local job creation, it is possible to imagine a Haiti building back better with fewer of the social tensions that inevitably arise as half a million homeless people are integrated into new communities.
Haiti needs and deserves a Marshall Plan—not the “containment” aspects of that policy, unless we are explicit about containing the ill effects of poverty, but the social-justice elements. But we need to be honest about the differences between post-war Europe and Haiti in 2010. Part of the problem, I’ve argued, is the way in which aid is delivered now as compared to in 1946—well before the term “beltway bandits” was coined. We need a reconstruction fund that is large, managed transparently, creates jobs for Haitians, and grows the Haitian economy. We need a reconstruction plan that uses a pro-poor, rights-based approach far different from the charity and failed development approaches that have marred interactions between Haiti and much of the rest of the world for the better part of two centuries.
Our country can be a big part of this effort. Debt relief is important, but only the beginning. Any group looking to do this work must share the goals of the Haitian people: social and economic rights, reflected, for example, in job creation, local business development, watershed protection (and alternatives to charcoal for cooking), access to quality health care, and gender equity. Considering all these goals together orients our strategic choices. For example, cash transfers to women, who hold the purse strings in Haiti and are arbiters of household spending, will have significant impact. This is a chance to learn and move forward and build on lessons learned in adversity—to build hurricane-resistant houses with good ventilation to improve air quality from stove smoke; to build communities around clean water sources; to reforest the terrain to protect from erosion and to nurture the fertility of the land for this predominantly agricultural country. It is the chance to create shelter, grow the local economy and incomes, and invest in improved health. This will do much to decrease the risk of another calamity, and to decrease the vulnerability of the poor—especially as we face the second wave of problems, including epidemic disease born of the earthquake.
As a doctor, I can tell you that bad infrastructure and thoughtless policy are visible in the bodies of the poor, just as are the benefits of good policy and well-designed infrastructure. In my almost 30 years in Haiti I have witnessed many political interventions and multiple coups. They have been unpleasant, even if their effects pale in the shadow of what we are now experiencing. Many people look at Haiti and despair. They say that aid is wasted, that there is no hope for this country. I would answer them with the positive experience of building Haitian-led programs in the Central Plateau and Artibonite Valley regions that have created five thousand jobs for people who would otherwise have no steady work. I advance this model not because it is associated with our efforts, but because job creation is the surest way to speed up the cash flow that is essential now. It is also the fastest way to make amends for our past actions towards Haiti, which have not always been honorable.
Sitting before you, I am at my core optimistic about the possibilities before us and the potential of our support to help rescue and transform our poorest neighbor. The response from citizens of the United States to the recent events in Haiti has been overwhelming and encouraging. There is the promise of solidarity by our leadership to make long-term commitments to the kinds of investments needed in Haiti—and to fulfilling them.
For two centuries, the Haitian people have struggled for basic human and economic rights, the right to health care, the right to education, the right to work, the right to dignity and independence. These goals, which Haitians share with people all over the world, should direct our policies of aid and rebuilding.
As I wrote with colleagues in a recent op-ed—which is available in my written testimony—as physicians working in Haiti, we know first-hand that Haiti itself will soon be the casualty if we do not help build back better in the way envisioned by Haitians themselves.
1) Walker, P. “Haiti earthquake aid pledged by country.” Guardian.co.uk 26 January 2010. Available at: http://www.guardian.co.uk/news/datablog/2010/jan/14/haiti-quake-aid-pledges-country-donations
(Accessed January 27, 2010)
2) Flintoff, Corey. “In Haiti, a low-wage job is better than none,” All Things Considered, June 14, 2009.
Available at: http://www.npr.org/templates/story/story.php?storyId=104403034
(Accessed January 27, 2010)
3) In 2006, the World Bank estimated that 78% of Haiti’s 9 million people lived on less than $2 per day. See Haiti at a Glance, World Bank, Development Data Group (DECDG). Available at: http://siteresources.worldbank.org/INTHAITI/Resources/Haiti.AAG.pdf
(Accessed January 26, 2010).
4) For an overview of Haiti’s water insecurity and past delays in international commitments to address this crisis, see Varma MK, Satterthwaite ML, Klasing AM et. al. Wòch nan soley: The denial of the right to water in Haiti. Robert F. Kennedy Memorial Center for Human Rights, Center for Human Rights and Global Justice at NYU School of Law, Partners In Health, and Zanmi Lasante, 2008. Available at: http://www.chrgj.org/projects/docs/wochnansoley.pdf
(accessed January 27, 2010).
5) This estimate of disbursements was prepared in January 2010 in an internal memorandum of the UN Office of the Special Envoy For Haiti. President Clinton, in his capacity as UN Special Envoy, frequently appealed to donors to fulfill their commitments. See Helprin, J, “Bill Clinton chides nations over help to Haiti.” Associated Press,, September 9, 2009. Available at: http://www.newsvine.com/_news/2009/09/09/3243861-bill-clinton-chides-nations-over-help-for-haiti
(accessed January 27, 2010).
6) Farmer, P. “Challenging orthodoxies: The road ahead for health and human rights.” Health and Human Rights: An International Journal 2008; 10(1): 5-19.
7) Daniel, Trenton, “Bill Clinton tells diaspora: ‘Haiti needs you now,’” Miami Herald, August 9, 2009. Available at: http://www.miamiherald.com/news/americas/haiti/story/1179067.html
(accessed January 27, 2010).
8) Farmer P, Smith Fawzi MC, and Nevil P. “Unjust embargo of aid for Haiti.” The Lancet 2003; 361: 420-423.
9) Sachs, J. “After the earthquake, how to rebuild Haiti from scratch.” Washington Post, 17 January 2010. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2010/01/15/AR2010011502457.html
(Accessed January 27, 2010)
10) Republic of Rwanda, Ministry of Health, and Partners In Health. African Rural Healthcare: An Evaluation of the South Kayonza, Rwanda Project (2005-2011). Programme Report, Ministry of Health, 2006.
11) United Nations Development Programme. Human Development Report: 1997. New York: Oxford University Press, 1997. 146-148. Available at: http://hdr.undp.org/en/media/hdr_1997_en_indicators1.pdf
(accessed January 27, 2010).
12) Republic of Rwanda. Rwanda Vision 2020. Kigali: Ministry of Finance and Economic Planning, Republic of Rwanda, 2002. Available at: http://www.cdf.gov.rw/documents%20library/important%20docs/Vision_2020.pdf
(accessed January 27, 2010).
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