Paul Farmer Examines Haiti 'After The Earthquake' The physician and anthropologist has spent 30 years treating patients in Haiti. In Haiti After The Earthquake, he details what it was like on the ground in the days after the 2010 quake — and why the country is still struggling to recover.

Paul Farmer Examines Haiti 'After The Earthquake'

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This is FRESH AIR. I'm Dave Davies, filling in for Terry Gross, who has the week off.

A year and a half after the earthquake in Haiti, there was still widespread suffering in the country despite an enormous outpouring of sympathy and pledges of aid. Today we'll get a look at the challenges of rebuilding Haiti from Paul Farmer, who's known internationally for his efforts to bring medical care to some of the most impoverished areas of the world.

He's a founding director of Partners in Health, which has worked to improve health services in a dozen countries, including Rwanda, Lesotho, Peru, Kazakhstan and Haiti, where Farmer has longstanding personal ties.

After hurricanes and tropical storms hit Haiti hard in 2008, Farmer was named a U.N. special deputy envoy to Haiti, working under former President Bill Clinton, which meant that when the earthquake struck in January of last year, Farmer found himself at the center of international relief and reconstruction efforts.

In his new book, Farmer writes about his own experiences and the frustrations of trying to rebuild the country. Besides his work for the U.N. and Partners in Health, Farmer is chair of the Department of Global Health and Social Medicine at Harvard Medical School and chief of the Division of Global Health Equity at Brigham and Women's Hospital in Boston. His book is called "Haiti After the Earthquake."

Paul Farmer, welcome back to FRESH AIR. Let's look at Haiti now, a year and a half later, and I want to talk just a little bit about the condition of the country, and then we'll talk about why things have unfolded as they have.

First of all, one simple question. There were as many as 200,000 deaths, I believe. What became of all the bodies?

Dr. PAUL FARMER (Author, "Haiti After the Earthquake"): Well, the question of what to do about the bodies really was - arose on the night of the quake, just because there were so many people in the streets of the city and under the rubble. And you were reminded every day after the quake, starting the second day, by the smell, really, that the city was full of people - remains.

And so there were some discussions in Haiti and outside of Haiti in the first 48 hours about, like, would there be some way to preserve the bodies, to bring cooled trailers, et cetera. There was quite a bit of discussion. But I can tell you, from the general hospital one of the biggest problems was that the main morgue in the city was - the power was out.

The power, as you know, was out all over the city. In fact, flying into Haiti after the quake at night, all you could see down below was really small fires and occasional lights coming from small generators. And when you got out of the plane, you realized immediately that body disposal was going to be a major challenge.

And so in the end, a lot of people who lost their lives initially, who could be moved, ended up in mass graves. And then after - even to this day, of course, as rubble is cleared, remains are found, and obviously it's a little bit easier to dispose of the remains with more respect for religious services, et cetera now. But in those first few days, it was - you know, it was moving people by truck into mass graves, very, very unfortunate.

Difficult to know how one might have done it differently, but it was indeed very tragic for those who lost their family members and would never be able to bury them properly.

DAVIES: A year and a half later, how much of the rubble has been cleared?

Dr. FARMER: Some estimates are that about maybe 25 percent have been - has been cleared, which doesn't sound like much, and it doesn't feel like much, but -and so if you go to Port-au-Prince right now, you'd probably think they just had an earthquake. But if you had been there right after the earthquake, you know, 16, 17 months ago, you can see the improvement.

I'd just give an example of - the main building that I used to visit in Port-au-Prince is the Ministry of Health. There were probably about 29 such federal buildings in Port-au-Prince, and 28 of them were damaged or destroyed. So basically the entire federal infrastructure was damaged or destroyed.

And so going to the general hospital from the airport, you know, we would drive right by what was the Ministry of Health. And you know, it had collapsed, and you would see papers and records and office furniture spilling out into the street.

And then a year later, when I went back there, there wasn't a single stone left. So that rubble has been completely cleared, and that has been the case for a number of buildings that were wholly demolished during the quake, and again, a lot of the federal infrastructure, the big buildings, were among those. And then a lot of them have been cleared.

A bigger problem has been clearing damaged or destroyed housing and commercial buildings, in part because very often they are abutting buildings that are not destroyed and sometimes not even badly damaged. So this strange, you know, fecklessness of, you know, you'll have one building that's intact surrounded by several that are down, this makes clearance very difficult.

DAVIES: How many people are still without permanent homes?

Dr. FARMER: The estimates right now are that there was a peak at one point three million in the summer and fall after the quake, that as many as 800,000 are still without shelter all these many months later. And of course this is a reflection not only of the destruction of the housing stock, some estimates have 225,000 homes destroyed, but this huge number is not simply a reflection of what got destroyed in the quake.

It's also a reflection of very poor access to housing for poor people in the urban areas of Haiti that has been a longstanding problem and as I mentioned in the book that you were good enough to read.

DAVIES: Right, and we should mention, that 800,000 is out of a country of, what, nine million, right?

Dr. FARMER: Right.

DAVIES: Right. Now, a cholera epidemic erupted in Haiti last year. First of all, just explain the illness for us.

Dr. FARMER: Cholera is a waterborne bacterial disease that causes very distinctive, explosive watery diarrhea, and it can shrivel a very healthy person, kill them in a matter of hours. It's really one of the few infectious disease emergencies that we see. It's also, of course, a public health emergency because it's spread through poor sanitation.

And everywhere it's been the companion of disruption and natural disaster and war, and for a long time, but in places with really good basic - what's called in the jargon water security, you really don't see explosive epidemics of cholera.

DAVIES: Well, let's talk about them, the state of health conditions and particularly the cholera epidemic. Is that under control?

Dr. FARMER: No, no, the cholera epidemic is not under control. It is - just a little bit of background, it's the first big recrudescence of cholera in the Americas since the end of the - an epidemic that really swept through Peru and ended in 1993, perhaps. I think that was - the last cases were around then, maybe '94.

But since then, there have not been major outbreaks of cholera, and - but again, if any country was a mineshaft canary for the reintroduction of cholera, it was Haiti, and we knew it.

So I would say that the epidemic is not only not under control, but it - you know, it sort of exploded on the scene like a bomb, causing some hundreds of thousands of cases. Again, there's poor reporting capacity in Haiti, so we're not sure how many, and you know, upwards of 6,000 deaths. Again, that's probably an underestimate on both scores: the number of cases and the number of deaths. It's a big rebuke to public health and to all of us working in health care in Haiti.

DAVIES: I know there's a lot of unemployment in these encampments and in the country generally. What about kids? Are they in school?

Dr. FARMER: Kids are not in school, but again, if you go back to the month before the quake, December of 2009, I was in a meeting with people working in education in Haiti, primary education, including the leaders from the ministry and a number of NGOs working on education, and it was estimated then that half of all school-aged children in Haiti were not in school.

And it may be that there are as many kids in school now, or will be in the fall, as there were before the quake. There's a lot of catch-up to do. And there are many barriers to having children in school, even in the public system, which is very weak in Haiti and usually related to some kind of fee or a uniform or the need for books and shoes.

There are a lot of structural barriers in the way of children going to school. They're not really cultural barriers because Haitians value education very highly, and that is true of people living in poverty in the rural areas and people living in poverty in the urban areas.

And in the camps and everywhere I've ever been in Haiti over the last 28 years, education is highly valued. So the strategy has to be how to remove those barriers and also how to improve the quality of pedagogy and the number of safe schools that we have.

DAVIES: We're speaking with Paul Farmer; he's the founding director of Partners in Health. He's also a United Nations deputy special envoy to Haiti. He's written a new book called "Haiti After the Earthquake." We'll talk more after a short break. This is FRESH AIR.

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Dr. FARMER: If you're just joining us, our guest is Dr. Paul Farmer. He teaches at the Harvard Medical School. He's also the founding director of Partners in Health, which provides medical services to the poor in many countries, including Haiti, where he is a United Nations deputy special envoy. He's written a new book about the country called "Haiti After the Earthquake."

DAVIES: Well, I want to talk about why things haven't gotten better in Haiti or at least haven't progressed as they should. And this is something that you deal with a lot in the book. And one of the things that I had forgotten was that even before this earthquake in January of 2010, things - Haiti had suffered a couple of other natural disasters in 2008. Remind us of those.

Dr. FARMER: In 2008, Haiti was hit by four hurricanes or tropical storms in the space of as many weeks. And it wasn't the first time that that had happened, of course, but it was, you know, a pretty stunning set of blows. In one place, the third-largest city in Haiti, called Gonaives, the city was virtually underwater for weeks, and downtown, it was hip-high in the streets. And so Haiti was really recovering from those natural disasters when the quake happened.

DAVIES: Now, of course one of the things that you note in the book is that improving health conditions in an impoverished place like Haiti is not just a matter of will and medical effort, it's a matter of dealing with, you know, the surrounding poverty and underdevelopment of the economy.

And you write that the government of Haiti was often ignored by international relief agencies and nongovernmental organizations, and you say that it was known as the Republic of NGOs, meaning there were all of these aid organizations, all of them working around and ignoring the Haitian government itself, and that over time that undermined everyone's efforts. Give us an example of this and why it is harmful.

Dr. FARMER: Well, let me give an example that's self-critique, because this is another thing I've learned in trying to write critically about NGOs, is that umbrage will be taken, and even the most constructive critique is difficult to get out there in part because a lot of NGOs are defensive in posture.

And I think you could do an analysis regarding why this would be so. They're struggling for what they regard as scarce resources. I understand all that. So to use our own example, Partners in Health has been working in Haiti for 25 years.

In the first 10 or 15 years, I would say that we've got a lot of good work done with our Haitian colleagues. Again, this is all Haitian-led, built up an organization with the Haitian leadership. All the employees were Haitian, providing good medical services or at least decent ones, but to a fairly restricted area.

And we saw that as our medical efforts grew, at the same time a lot of the public-sector medical programs were failing in the same area. And so about 10 years ago we said, well, what if we end up being guilty of what we're criticizing - that is, allowing the public health sector to collapse even as we grow? What if we're also guilty of that, and how could we make plans, plan better so that we end up reinforcing public health and also public education?

In Haiti, what had happened was the public sector was weak and underfunded, and people talked a lot about corruption and inability to get things done, and so they'd build these parallel systems, the NGOs, hence the Republic of NGOs.

So what we did 10 years ago was to decide that all of our expansion would only occur in the public sector. So what that meant would be we wouldn't build our own hospitals or clinics but rather rebuild or build public-sector clinics and move our staff into those clinics and facilities and try to beef up the public sector that way.

So this is not the only way to strengthen public health and public education in Haiti. It's just one way. And we've encouraged others to join us in this and make it less of a cosmetic effort.

Now, after the earthquake, ironically, that argument got harder to make because the public sector was precisely the group most affected by the earthquake in terms of personnel, numbers of lives lost, but also infrastructure. So now it's even a greater challenge to work effectively with the government, and yet it's even more important to do so.

DAVIES: Help us understand why it doesn't work for private aid agencies, NGOs, to come in and build their own network. I mean, if you go into central Haiti and build your own clinic, you hire Haitians, you treat Haitians, you do good things, why isn't that just as good as the government doing it?

Dr. FARMER: Well, you know, it can be just as good, but take the example of cholera. Again, cholera exploded, as I said, like a bomb. It also exploded in some of the very areas where we were working hardest and longest, and that is not because we weren't aware of the importance of clean water, it's that the NGO sector can't replace public works and not in, you know, Philadelphia or Boston and not in Rwanda or Haiti either.

So for some services you can have service providers that are not public. I mean, the Harvard teaching hospitals where I work are private not-for-profit hospitals. So I'm not making some ideologically driven critique of private-sector engagement. It's just to say there needs to be some public safety net.

And I think that's especially true for the poorest, because after all, an NGO doesn't have a mandate, a legal mandate, to provide basic access to health and education and clean water for the citizenry of Haiti or the citizenry of Honduras or the United States. Really, that's a public-sector pact, to provide these services.

The majority of education in Haiti, probably 85 percent of primary and secondary education in Haiti, is private, and I think it's not an accident that that system is so privatized, and Haiti is also the country with the highest rates of illiteracy in the hemisphere.

So there is this connection, I think, and I do believe that Rwanda has again provided an example of how this can work better.

DAVIES: So you can provide services, you can build capacity, but as private organizations, you're not going to be able to provide clean drinking water, probably, for everybody, and you need to - you want an enduring commitment from public-sector forces so that these things remain.

You know, a lot of NGOs are reluctant to work with government organizations, particularly in places like Haiti, because they say, you know, they're weak, they're ineffective, they're corrupt. These organizations have to justify to private donors how their money is spent. And so one can understand their reluctance. And Haiti seems particularly bedeviled by a weakness in the public sector. Why is the government of Haiti and its institutions, why have they been so chronically weak over the years?

Dr. FARMER: One of the reasons, of course, is too little investment, and I mean money, I mean money going into the public sector, into the health and education and into public works, roads, et cetera. Amy Wilentz wrote a book some years ago called "The Rainy Season," in which she described how the well-to-do in Haiti, instead of, you know, paying taxes for improving roads, just bought bigger and better Land Rovers.

That kind of mentality of we're not going to be investing in the public good, in the commonwealth, is - it does, as you said, bedevils Haiti. And I will go back to the chronic explanation, but I would like to just give an example to some numbers, again post-quake, about how extreme this is.

And if - it's hard to know how much reconstruction aid has been really pledged to Haiti or delivered. We can know how much is pledged, but it's hard to know how much has been delivered. But on the acute relief after the quake, we tried to look at some figures, and again this was my colleagues at the Office of the Special Envoy.

We tried to look at numbers and came up with a figure of $1.7 billion that went into direct humanitarian relief after the quake. And Secretary Clinton told me that more than half of all American households donated to earthquake relief, which is a pretty stunning and generous figure.

And trying to parse what happened to that massive contribution, about 34 percent of it went to civil and military projects. So for example, we had - and I describe this in the book, the U.S. naval ship the Comfort was certainly deserving of its name after it arrived in Haiti on day eight after the quake, bringing into play about a dozen more operating rooms and a great number of surgical specialists who saved many lives.

It's expensive work, but I doubt that anyone thought that that was money wasted. So that's 34 or so percent. Thirty percent - I gave the Comfort as an example, of course, just one of many efforts like that.

Thirty percent went to United Nations or international NGOs, 29 percent to other NGOs and private contractors. About six percent were in-kind donations, and less than one percent went to the Haitian government. So if you feel that the Haitian government, including the public health sector and the education sector, are important players in relief, then that number is way too small.

DAVIES: Paul Farmer's book is called "Haiti After the Earthquake." He'll be back in the second half of the show. I'm Dave Davies, and this is FRESH AIR.

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DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross.

We're talking about efforts to rebuild Haiti, where there's still widespread suffering a year and a half after the earthquake that struck near Port-au-Prince. Our guest is Paul Farmer. He's a founding director of Partners in Health, which helps to improve health services in impoverished areas of the world. And he's a U.N. deputy special envoy to Haiti. His new book about reconstruction efforts in the country is called "Haiti After The Earthquake."

You have, and your organization Partners in Health, has worked for many years in Rwanda. Your family now lives there. It's hard to think of a more destructive experience for any society than the genocidal violence there in the early '90s. But things have changed. Give us a picture of Rwanda today.

Dr. FARMER: Well, I just returned from Rwanda last night and after the genocide, say 1994, '95, Rwanda was probably the poorest country on the face of the Earth and some development experts were all too ready to write it off as a lost cause. And now it has a rapidly growing economy. It has a great deal of social stability.

There's been very significant investments in my areas of interests, which are health care and education. There's decent infrastructure and it's an environment where corruption is being tackled as a real priority. And, you know, you see it - in my line of work, you see just dramatic reductions over the last several years in infant mortality, juvenile mortality, maternal mortality, access to primary and secondary education. Plus there is just a, if I can, an ethos there, a can-do spirit that you can that is really quite palpable. Even in the rural reaches where we've done most of our work Rwanda is still a well-kept secret and should be a beacon for recovery for Haiti and for the places.

DAVIES: One of the things you write is that a lot of - that some private aid organizations didn't like the way the Rwandan government dealt with them, because the Rwandan government wanted I guess to run things and some NGOs simply left. Is this a key? Have they learned how to deal with private aid organizations in a way that Haiti hasn't?

Dr. FARMER: Rwanda has indeed learned how to deal with private aid organizations in a way that Haiti hasn't. Yes. You said it beautifully. They are heavy-handed. The Rwandans are heavy-handed. But it's their country and they're saying look, here is our development plan and you need to get on board this shared vision or, you know, the airport's over there.

And that happened after the genocide during a very difficult time for the Rwandan government. All attention was focused on the Rwandans, you know, in the refugee camps on the, what was then, Zaire. And there's a great struggle inside Rwanda just to recover and rebuild, and this friction with the NGOs, which was quite principled from what I can tell, meaning that the Rwandans had a very good point. We need to coordinate your efforts and it's not optional. That friction was difficult for them I'm quite sure because they did not have a lot of allies at the time.

And some of the NGOs that were really asked to leave, they didn't just pack up, and they were asked to leave, describe their unceremonious departure as a violation of their rights. And the Rwandans and the government said well, we're not here to protect your rights. We're here to rebuild our society and we want partners who are going to play along with us. Now this is really focused at the larger groups.

The small missionary groups, the....

DAVIES: Can you think of an illustration of this? I mean what would they fight about?

Dr. FARMER: For example housing policy, resettlement of refugees, how are people going to live after the genocide? Were there going to be - there were, after 1996, there were over a million refugees to repatriate. Where were they going to live? There were contested claims on every bit of property, every house. That's one example. Another is if there was massive participation in some groups in the violence, which there was, how would you fight impunity? Are you going to put, you know, a quarter of a million people in jail? And if so, how are you going to feed them?

These are all examples of the arenas where everything that the government proposed was really hotly contested by major NGOs and sometimes there was a lot of, you know, out of all this heat there was illumination too. There was also friction that was very difficult. And they stuck with their strategy and formalized this over the last decade as a development plan they called Vision 2020, where do we want to get by the year 2020?

And as I say in the book, you know, it's not as if they just divorced the NGOs because that's a long time to draw out a divorce all the way to 2020. They're looking for the right partners.

DAVIES: We should also note that, you know, the government of Rwanda has been accused of committing atrocities in Congo. I mean a lot of the, you know, the Hutus who fled after the government, after the Tutsi government took power, fled to Congo and there were military operations there. But one of the things that I wonder is that is the big difference between Rwanda and Haiti affective political leadership? I mean, Haiti has been paralyzed it seems for so long by factional strife and ineffective leaders. And the Kagami regime in Rwanda, is it simply a matter of better political leadership?

Dr. FARMER: Well, if you were to make a list of the top five differences maybe that would be at the top. But there's still a lot to be done.

I have worked a lot as a physician in prisons in Rwanda and Russia, somewhat in Haiti. And one of the things that impressed me in the Rwanda prisons was that first of all the conditions were very poor. But what did impress me was that there was an orderly way of having - clearing out the prisons through a process that the Rwanda is called kachacha which is, you know, really their attempt to have truth and reconciliation efforts on a community level, so very impressed by it. And Haiti has a very much smaller prison population. But the majority of people in those prisons have never had any kind of due process. When I say the majority, over 90 percent.

And I was happy to learn that Rwanda sent four prison experts, one of whom I know quite well, to Haiti to help with the, again, how can you better improve the function of the prisons. And that could be - I don't know as much about that as I do healthcare, but I can tell you that the way that the way the Ministry of Health in Rwanda is run makes very effective use of a large number of partners, NGO partners and also pushes forward this strategy that is really aimed at a similar standard of care in all of the districts in Rwanda. We need that in Haiti as well. I think there's a lot that could be learned at many different levels.

DAVIES: You know, as I hear you talk about this, I mean, I hear you trying to remain upbeat and give credit to those of goodwill who are trying to help and be optimistic about the future. But I have to say that as I read the book it was pretty dispiriting. And the picture I got was one of more bureaucratic governmental dysfunction than anything and it was hard to feel optimistic that Haiti will be rebuilt better. Am I misreading this?

Dr. FARMER: No, I'm afraid you're not. I mean, I - for those of us who consider it a great privilege to work with Haitians, I think, you know, it is a dispiriting moment. You know, it is not going to be an easy road to hoe and hey, there's a lot of fair-weather friends. Haiti has a lot of fair-weather friends, you know, who've already in and out and have left Haiti. And again, there's still these huge problems of housing, infrastructure, rubble clearance, basic provision of services, like healthcare and education. So, you know, we could use more help but it's got to be coordinated and it's got to be, got to create jobs for Haitians.

That's one of the things that I think should have been easier to do to create hundreds of thousands of jobs, decent jobs, and that hasn't happened yet. There have been some tens of thousands of jobs created but not hundreds of thousands and that's a shame.

DAVIES: It also strikes me that you're somebody who's been really effective at building effective, you know, medical treatment facilities in a lot of places. And in this role as a U.N. special deputy envoy, you're having to tackle the bigger broader stuff, economic development issues, I mean how you govern a country. You going to stay with that or do you want to get back to something that's more in your field?

Dr. FARMER: I would very much like to get back to direct delivery of medical care and really to focus on rebuilding in the healthcare sector and also in training physicians and nurses. I am full of respect for people who try to take on these big development questions inside government and outside. And, but the satisfactions that one gets in direct service are quite gratifying emotionally and personally.

And so I think for me and, you know, making sure that there's enough of my time spent on teaching and delivering care, is really going to keep me in this for the long run. And I think most of my coworkers, including my Haitian coworkers feel the same way - that sometimes when the big picture is just overwhelming or daunting or discouraging there's always the possibility of the little picture, that is responding to a problem. I mean it's not like cholera is a little problem. Cholera is a huge problem. But it is within our reach, I think, to improve the quality of services offered to people with cholera and the quality of preventive services in a region. And so I want to try and do both those things and many of my coworkers are doing that as well.

I have now been working with some of my Haitian coworkers for over a quarter of a century. And many of our American and other partners have been at this for a long time. There are real insights that these implementers have that should be shared in policy circles.

So I think it's unacceptable to say well, we just love taking care of patients and working on specific areas and so we can't be bothered to think about policy. Because if we do that the policy won't be informed by the insights that one gets from implementation. So we're not going to stop doing the policy work or trying to be a voice in policy work, and it's just - it is very draining sometimes and the rewards are very different from what we do get in direct service.

DAVIES: Well, Paul Farmer, thanks so much for speaking with us.

Dr. FARMER: My pleasure. Good to be back.

DAVIES: Paul Farmer teaches at Harvard Medical School and is founding director of Partners in Health, and a U.N. deputy special envoy to Haiti. His new book is called "Haiti After the Earthquake." You can read an excerpt on our website,

Coming up, Kevin Whitehead reviews and new box set of music by The Modern Jazz Quartet.

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