Paul Farmer: Rebuilding Haiti, but 'building back better'

The UN deputy special envoy talks about rebuilding Haiti and why "it's not just houses and buildings, it's an entire process of development."
Dr. Paul Farmer is a co-founder of the respected non-profit organization, Partners in Health, which delivers free health care to the poor in Haiti, Rwanda, Peru, Russia, Malawi and Guatemala, among other places. ((Lucas Jackson/Reuters))

As Haiti prepares for presidential and legislative elections at the end of November, there's pressure to speed up the slow and frustrating work of relief and reconstruction in areas devastated by January's earthquake.

The six-month anniversary of the quake came and went in June, with considerable criticism about the million-plus Haitians still stranded in tent cities and the international community's dubious commitment to deliver billions of dollars pledged for reconstruction.

There is a bold international vision for Haiti. It's described as a kind of Marshall Plan to "build back better," as the mantra goes. But achieving it is no easy task.

Among Haiti's high-profile champions are two men who shuttle continually between the embattled country and various world capitals, drumming up support and money.

The first is former U.S. president Bill Clinton, the United Nations' special envoy to Haiti. The second is his deputy, Dr. Paul Farmer, a Harvard professor and physician who fell in love with Haiti in the 1980s as a medical student and has spent the past generation working there and elsewhere, trying to bring First World health care to the very poor.

Farmer is a co-founder of the respected non-profit organization, Partners in Health, which delivers free health care to the poor in Haiti, Rwanda, Peru, Russia, Malawi and Guatemala, among other places.

Partners in Health already operates a health centre and teaching hospital in Cange, in rural central Haiti, and is constructing a new teaching hospital in Mirebelais, about 60 kilometres northeast of Port-au-Prince. When he's not in Haiti, Farmer works as a physician at Brigham and Women's Hospital in Boston and teaches medical anthropology at Harvard Medical School.  His life's work inspired a Pulitzer Prize-winning book by Tracy Kidder, called Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.

Clinton made Farmer his deputy special envoy to Haiti in 2009. Then came the earthquake and his skill set couldn't have been more useful.

Since the disaster, which killed more than 200,000 people and injured 300,000, Farmer has been helping to map out a relief and reconstruction plan. Farmer's particular concern, though, is helping Haiti to develop a national public health-care system.

Even for someone so dedicated to Haiti, it is an incredible challenge.

CBC producer Jennifer Clibbon recently interviewed Paul Farmer about the reconstruction process in Haiti and current priorities.

CBC News: You just returned from two high-profile fundraising and policy meetings in New York last week, the annual Clinton Global Initiative and the United Nations General Assembly. From your perspective, what did Haiti come away with from these meetings? 

Paul Farmer: The Clinton Global Initiative conference has, as one of its chief goals, bringing together unlikely partners. People who might represent traditional philanthropy, business people, people involved in humanitarian and direct service work and political figures. So, it's a very unusual mix in my experience and, most of the time, not much comes out of that mix. 

Dr. Paul Farmer, right, the U.N. deputy special envoy for Haiti and Bill Clinton, the special envoy while touring the General Hospital in Port-au-Prince, Monday, Jan. 18, 2010, six days after the earthquake. (Lynne Sladky/AP)

But because of the structure of the Clinton Global Initiative, where people make public commitments to do some very specific endeavours, I think we got a lot more of those.

One is that the number of people seeking to be part of the Haiti Action Network, [a group of CGI members which meets to generate projects], is growing. There are a lot more projects this year than in the previous two years.

One of the things Haiti walks away with is more people interested in responding to the challenges Haitians are facing right now. And that's a good thing.

The Clinton Global Initiative is timed to happen at the same time as the UN General Assembly. So there's a parallel set of discussions going on between nation-states and diplomats about how to help Haiti best to respond to the situation now. I think there is some good movement on policy and projects. 

[At the United Nations], one of the things that may seem small but what I thought was important, was a meeting between the Rwandans and the Haitians.

Rwanda, of course, clawed its way back from absolute hell after 1994. And Haiti faces a really grim situation in terms of how many people are homeless and displaced. I'm optimistic about their collaboration.

CBC News: Clinton said in June that he wasn't happy with the progress in sorting out the tent camps. As obstacles, he cited: poor co-ordination and government direction, land ownership issues and dependency on foreign aid. It's still hurricane season. What are your worst fears for the people in tent camps? And what are some solutions in your view?

Paul Farmer: The worst fears are easy to outline. One, that there will be loss of life because of storms and flooding.

Another, that cramming over a million people into such uncomfortable and makeshift shelters is going to lead to problems in the camps themselves. It requires the patience of Job to endure those kinds of conditions.

Those all remain serious problems. And they are structurally given, in the sense of land ownership issues, because a large fraction of those people were not homeowners but renters. The reasons for returning to damaged housing to rebuild it, some of those reasons just aren't there.

People talk about dependency on foreign aid. I get that critique and have made it many times myself, but it's also true that in terms of the basic services that Haitian people have been demanding (health care, education, sanitation and water), these were not widely available to the poor, prior to the earthquake. That's another structural problem that predates the earthquake.

So moving people out of those precarious camps is going to require, as Clinton said, very co-ordinated efforts to provide services and also to create jobs, and the chance for people to own housing. Those are long-term endeavours.

CBC News: When ex-president Clinton and others talk about reconstruction in Haiti, they have used the term, "build back better." Economists like Paul Collier and many others have talked about a Marshall Plan for Haiti. Is that still the vision? And how are Haitian ideas being incorporated?

Paul Farmer: I would say that is still the ambition, to "build back better" and to have a very sweeping and well-funded plan.

Even with these massive pledges that were made at the March 31 donors' conference [at the United Nations in New York, $5.3 billion US was pledged], the amount of money per capita over the next decade, even if the pledges were met, is not large. 

It comes out over the years to under a couple of hundred dollars per Haitian per year, if the pledges were met. And we know a lot of the pledges have not been met. That's something president Clinton is working on, to how to make sure those promises are kept.

A Marshall Plan is in some ways a stirring reminder of how ambitious rebuilding should be. But a lot of things have changed since the 1940s.

There wasn't the big class of contractors after World War II. Now there is a whole machinery of aid. A lot of the money, foreign aid, really doesn't get to the poorest. 

For example, a lot of foreign aid never leaves the United States. That's not a great situation for Haiti right now. The job should be to move as much as possible of those pledges to create Haitian jobs. That's not really the way foreign aid is constructed now. That is going to require some reform, I think.

In my area of interest, which is public health and education, that requires a strong public sector. Haiti didn't have that before the earthquake.

About 20 per cent of its federal workforce was killed in the earthquake. Something like 28 out of 29 federal buildings were destroyed. There's really a lot of work to be done there as well. 

You'd be hard-pressed to find a country in postwar Europe where that occurred, even though the losses were horrific. It [the devastation] was so concentrated in Port-au-Prince, the most heavily populated part of the country, that Haiti is still reeling from that.

How are we making sure Haitian perspectives are involved?  I don't think we should give ourselves very high marks yet on that score. Because to do that, you'd have to go into the most heavily affected areas and make sure that the people living in camps, that their views are incorporated.

A lot more work needs to be done to incorporate the poor majority into the process. It's a real process, the democratic engagement of people living in these camps, people who lost homes or never owned them. Incorporating them into the process is important and needs to be stepped up.

CBC News: You've spoken about developing Haiti's first-ever comprehensive health system. You helped build a health system in Rwanda. And you've called for a Marshall Plan for health care in the developing world.  Partners in Health is constructing a big new hospital and training complex in central Haiti, in Mirebelais. What is your dream and what is possible for moving toward a public health system in Haiti?

Paul Farmer: In my view, it's a dream that we know could be realized.

More than 300,000 people were injured in the Haiti earthquake. ((Marco Dormino/Reuters/UN))
You are right to call it a public health plan. It's not the only kind of health plan — there is a private sector in health care. But the NGO [non-governmental organization] and humanitarian sector should, in my view, pay a lot more attention to the public health system.

That's the safety network for the majority, or it should be. So that not everything is all fee-for-service and without an insurance plan. There has to be a basic insurance plan to cover all families. Rwanda has fought hard to establish exactly such a plan.

Between 2005 and now, some basic health coverage as insurance has been extended to the majority of the Haitian population. Now, does it have problems? Yes. Does more infrastructure need to be built? Of course.

But what we've done as Partners in Health in Haiti over the past decade is to focus exclusively on helping to rebuild public-sector hospitals in central Haiti.

That's why we are building this big teaching hospital in central Haiti with the Ministry of Health, so that it fits into this co-ordinated network of public hospitals that is meant to be available to all Haitians in the area.

That's not how a lot of aid has gone into Haiti. A lot of it has gone into the NGO sector or into mission or church hospitals. They are good things to have. But the more we can co-ordinate with the public health sector, the more we'll have a safety net.

CBC News: How would this idea for a Marshall Plan for public health in the developing world be organized?

Paul Farmer: We have to be very flexible in how to administer an endeavour like that. What we described, in talking about a Peace Corps or Medical Corps, the problem there is usually that there's not enough focus placed on training in-country professionals.

Global health can't be people like my students and trainees at Harvard going to Haiti to replace and filling in gaps. It has to be aggressively linked to train local providers. That's what we are trying to do. That requires a lot of funding.

In fact, I'm going to the National Institutes of Health to talk about this topic.

There are all these levels of engagement that are necessary. One is to build a (public health-care) system. Two, to train a local workforce: that has to be doctors, nurses and community health workers who can provide health care in the village, clinic and hospital level. It would benefit from trainees, as I've been lucky enough to have at Harvard and the teaching hospital.

Finally, the system of course has to have a social security net. So, when all those layers are addressed, that's what a Marshall Plan would look like.

CBC News: The big question is: where is the money for reconstruction? Only a fraction of all pledged money from the international community has been disbursed so far. Are you starting to get worried that the money won't come through?

Paul Farmer: I've always been worried the money would never come through. This is not the first donor conference that I've attended. That's always been a concern.

CBC News: Haitian elections are coming up in late November. Over the years, you have been quite critical of foreign intervention in Haitian politics. It's a flawed political system. How do you expect the legislative and presidential elections will impact reconstruction?

Paul Farmer: My concern is that this process needs to not distract from the reconstruction.

That's a difficult thing to do. President Clinton was saying this: 'How would you like to try and rebuild Haiti, even as [it is] preparing, as the Haitian constitution requires it, elections?' My concern is that all Haitian people and parties be allowed to participate.

CBC News: The Haitians have always been praised for being so brave in this crisis. How do you think Haitians themselves evaluate the relief efforts of the UN,  the international aid community and their own government?

Paul Farmer: If you are one of the one-plus million people living in those camps, you are not going to give high marks. I am not expecting that we're getting a good grade from the primary victims. We're just going to have to keep working harder to improve the quality of what we're doing.

CBC News: You've written powerfully and emotionally about Haiti for a generation. You've now been given the keys to the car. You've been given the opportunity, as special deputy envoy, to help rebuild Haiti and help bring the voices of Haitians to that process. But you have to mesh your idealism with the world of realpolitik. How is that working out?

Paul Farmer: It is a challenge to move between the worlds of the people I might serve as a physician and the world of policy-makers.

I do think that the earthquake was a wakeup call to a lot of the latter, that so far the aspirations of the great majority of Haitians have not been met. That opening, it's still not closed.

In terms of "building back better," it's not just houses and buildings. It's also the entire process of development and the involvement of the majority. That has to be "built back better" too. 

I think there's a little more chance of that now, than before. I'm not suggesting that it's easy to span those worlds. I doubt it is for anybody. But there is a little more opening than before.


Jennifer Clibbon is a producer with the CBC News radio syndication service. She lived in China from 1990 to 1994, working as an English teacher and freelancing for CBC Radio, The Canadian Press and The Associated Press. She returned to China in 2005 as a field producer for CBC TV-NYT documentary series China Rising.