Paul Farmer

More than five years have passed since the heart of Haiti was crushed by a cataclysmic earthquake that killed at least 230,000 people, only to be followed by an outbreak of cholera later that year that has left about another 9,000 dead. Billions of dollars in international aid have begun to show gains in infrastructure reconstruction, but improvements in health and sanitation remain far from meeting the country's needs, leaving Haitians still vulnerable to epidemic disease and generally poor health. Haiti, proud of its place in history as the first black republic, created in 1804 in the wake of a slave revolution, has never reached its potential over two centuries of political turmoil, dictatorship, black-mulatto racial strife, France's imposition of crippling economic reparations on its former colony and later an American invasion and occupation that lasted two decades. The country has long suffered the worst human development levels in the Western Hemisphere by virtually every measure, including in health care, with high rates of infant mortality, malnutrition and stunted children. In 2010, cholera rolled across a country without sewage systems or reliable potable water for drinking or washing. In October 2014, during an international conference in Washington on Haiti's water and sanitation situation, the World Bank pledged $50 million to improve coverage of these services over the next three years. "We have made significant progress in controlling the cholera epidemic in Haiti, but too many people are still getting sick," said Jim Yong Kim, the World Bank president. "Cholera remains endemic and water borne diseases are one of the leading causes of infant mortality." Global health specialists recall that the Ebola epidemic in West Africa apparently started in one village in Guinea and moved rapidly through Sierra Leone and Liberia, where governments did not have adequate health systems. Only in Nigeria, where the first case of Ebola arriving from Liberia met a well-prepared emergency public health service response, the disease never spread. In early June 2015, the Government Accountability Office, the investigative arm of the United States Congress, released a detailed report on successes but also delays and cancellations in promised American post-earthquake aid programs in Haiti, among them health service improvements. It cited numerous problems, including the American partnership with the Haitian Ministry of Public Health and Population and other government offices and outside contractors. The US is Haiti's largest single source of assistance. "According to USAID/Haiti officials, factors that affected the activities' results and caused delays included lack of staff with relevant expertise, unrealistic initial plans, challenges encountered with some implementing partners, and delayed or revised decisions from the Haitian government," the report said, adding that "low government interest" was another factor. The Haitian government under President Michel Martelly -- a popular musician known as Sweet Mickey -- has drawn considerable criticism in Haiti and from the US and other international donors for its handling of the country's continuing crises. "For example," the US accountability report said: "as of September 2014, work on the State University Hospital in Port-au-Prince had begun but was scheduled to end 3 years later than planned. USAID/Haiti officials noted that delays in rehabilitation of the hospital, which occurred during the procurement phase, resulted from lengthy negotiations among the activity's donors -- the U.S., French, and Haitian governments -- and from logistical challenges due to the Haitian government's decision to keep the hospital open during the rehabilitation. USAID/Haiti officials attributed delays at other sites to land tenure issues, delays in the Haitian government's approval of activity design, lack of relevant construction engineering experience among USAID staff, and lack of local technical capacity." The United Nations has met similar problems. Haiti, with its weak infrastructure further crumbled by the earthquake, is still suffering greatly from the toll the disaster took on its educated and skilled technical and policy experts, who could have served as experienced local partners. The UN estimated that the earthquake killed more than 16,000 of Haiti's civil service employees and destroyed almost all government ministry buildings. Ninety-six UN peacekeepers were also killed, along with the civilian head of the UN mission, Hédi Annabi. There is no longer a dispute as to where the outbreak of a virulent strain of cholera endemic in South Asia was introduced in Haiti. The outbreak was almost immediately traced to an encampment of Nepali soldiers deployed as UN peacekeepers in a watershed feeding the Artibonite River, the most important waterway in the country. Nepal had apparently not tested its soldiers before sending them to Haiti, as required. (Nepali soldiers are still serving there, with contingents from 19 other countries.) Insufficient or carelessly constructed latrines, the responsibility of a UN contractor, allowed contaminated sewage to reach the Artibonite, in which people bathed and collected water for drinking or cooking. Haiti had no defenses to stop it. The dispute that continues, however, is whether and to what level the UN should be held accountable to the victims of the cholera epidemic. Since November 2011, the Institute for Justice and Democracy in Haiti has pressed claims against the UN, demanding not only compensation for victims but also the installation of a national water and sanitation system to control the epidemic, which was still infecting 15,000 people in the first 10 months of 2014, according to the Center for Infectious Disease Research and Policy at the University of Minnesota. (In 2011, total infections for the year numbered about 352,000.) The UN has consistently claimed immunity under international agreements and refused to accept responsibility, although it has invested in public health projects. In October 2013, the Institute for Justice and Democracy, which works in Haiti to support and train civil society, moved with other petitioners to a US Federal District Court in New York, where oral arguments were heard the next year. In January 2015, the judge hearing the case dismissed its demand for a waiver of UN immunity, arguing that only the UN could take that step. The plaintiffs are appealing that decision. In light of what happened to Haiti and its extremely fragile to nonexistent public health system, the UN peacekeeping department does not deny that Nepali peacekeepers introduced the cholera epidemic in a country previously free of cholera. The UN, with numerous countries and nongovernment organizations, turned their attention and donations immediately after the outbreak to health and sanitation. Some crucial projects have nevertheless fallen behind schedule in the last five years, and a few public rumor mills have tried to block other projects, such as a vaccination drive promoted by Paul Farmer of Partners in Health, who is also Secretary-General Ban Ki-moon's special adviser on Community Based Medicine and Lessons Learned from Haiti, working with the Haitian ministry of health. Despite the misinformation being spread, experts consider the vaccine drive successful in its early stages if not promising for future control of cholera, the Center for Infectious Disease Research and Policy in Minnesota reported in February 2015. The US Government Accountability Office said in its report, based on months of investigation in Haiti and Washington, D.C., that since the 2010 earthquake, American government agencies have allocated $4 billion to earthquake-related efforts, including $2.7 billion for reconstruction. The US Agency for International Development (USAID), which was allocated over half of the reconstruction funding, "has directed its efforts to eight sectors: energy, shelter, ports, education, governance and rule of law, economic security, health, and food security," the report said. "As of September 30, 2014, the US Agency for International Development (USAID) had allocated $1.7 billion to the Haiti reconstruction effort, directing more than half of this funding to the health and food security sectors." While some infrastructure projects, including an electrical power plant in northern Haiti, have been completed, the US has reduced plans for three of the 17 key noninfrastructure projects, such as providing access to basic health care.

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Paul Farmer

Health Services Still Lag in Haiti, Shadowed by Cholera

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