Haiti After the Earthquake (21 page)

These questions were forced on us every day. They brought back the experiences of individuals and families, neighborhoods, and cities, the injured and the whole, the caregivers who sought to tend to broken bones and crushed limbs. Grim lists were always step one in any analysis of the quake.

Step two, a month or two after the quake, was to take stock. As they say in medicine, you have to do the physical exam yourself: to palpate and percuss and listen to the patient. A thorough examination, whether termed a “post-disaster needs assessment” or something else, must progress rapidly and be linked to quantitative assessments, however imperfect. (Data were still hard to come by—at least hard data—and we knew that even the official numbers one sees in reports and news stories are a product of guesswork.) When four storms hit Haiti in the fall of 2008, Haiti's GDP was said to have dropped by 15 percent.
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Then what was the cost, in every sense, of
the quake? Although it was still early to lay out the economic costs of the earthquake, it would be far greater than those of the storms. Estimates of the body count still varied. By March, as the donors' conference approached, some said 220,000 dead; others more and others less. By late March, we knew that a third of Haiti's population had been affected directly, and this meant that most Haitians would be affected as the displaced sought safer places to live. An estimated 25,000 nonresidential buildings had collapsed and, even worse, some 225,000 or more homes. Some reports claimed that close to 40 percent of all federal employees were injured or killed and 28 out of 29 government ministries leveled.
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Again, the numbers were all over the map. Another assessment noted that about half of all public-sector health facilities in Port-au-Prince collapsed or were deemed unsafe; some 14 percent of Ministry of Health employees died, and two-thirds lost their homes.
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And injured was not the same as killed, as the experiences of Shelove and Carmen and Sanley suggest. The extent of inner-city damage, along with the inability of the local and international authorities to move swiftly to address the shelter crisis, was the reason why crammed and unsanitary informal settlements, almost one thousand of them a month after the quake, had blossomed across the city and to the south; they spread north as people sought safe shelter. Haiti, already food-insecure and vulnerable to flash floods (because of deforestation), might have to feed an estimated two million displaced people with a mix of locally grown and imported food. The rainy season would arrive by April or May, then hurricane season after that.

What was the status of the health system after the quake? The kinds of problems we encountered at the General Hospital existed throughout the country, even far from the quake zone. Before the quake, only 5 percent of the government's budget went to the health ministry—Rwanda's commitment was more than twice that—and consequently, stock-outs of key medications and supplies were the rule, public-sector staff were poorly paid, clinic hours were short, and health indicators were some of the worst in the hemisphere. The
quake had clearly worsened a bad situation: the post-quake influx of medical aid saved lives but didn't do much to help the public sector recover.
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In clinical medicine, questions like these are answered by seeking the best available data, often from the lab or other diagnostic studies or the patient's history. The events of January 12 and after are best approached by understanding Haiti's remarkable and troubled history, to which we now turn.

O
ne month after the earthquake,
the wrack and ruin in Haiti was still more or less unchanged. This was, in a sense, a paradox: countless people were looking for work just as billions dollars of aid were pouring into Haiti and huge amounts of work needed to be done. Why were so many still unemployed? In clinical medicine, the evaluation of every patient follows a certain logic. Physicians working in Haiti used this logic every day, not only when caring for individual patients, but when contemplating the enormity of the problems facing the country.

By some macro indicators, Haiti had made slow improvements the year before the quake. Agricultural outputs had increased; infrastructure projects were underway; foreign investment began to trickle into Haiti. However, short-lived gains did little to address the country's deep-rooted social and economic problems: shoddy housing, bare hillsides and overfished waters, scarce access to clean water and modern sanitation, an undesirable business environment, cashstrapped health and school systems, high structural unemployment, frequent political upheaval. On top of these longstanding problems came the worst natural disaster to befall the region in centuries: an “acute-on-chronic” event.

A month later, there was little evidence to suggest that the tsunami of goodwill that crashed over Haiti after the quake could effectively address such layered afflictions. Whether one looked at job creation, health, education, potable water, or safe and affordable housing, similar conclusions could be drawn. First, great weakness in the public sector made it difficult to deliver even basic services at a significant scale; second, not enough of the pledged earthquake relief reached those in need through mechanisms that might address this central weakness. In other words, existing development and reconstruction machinery did little to mitigate Haiti's acute-on-chronic problems in spite of many good intentions and extraordinary generosity. Might responding to the acute needs of people displaced and injured by the earthquake afford us a chance to address the underlying chronic conditions that had rendered them so vulnerable in the first place? To answer this question, we need to know the history of the present illness.

Haiti, an independent nation for more than two centuries, has the worst health indices in the Western hemisphere. Whether we look at malnutrition, maternal mortality, or life expectancy at birth, Haiti is an outlier in the region—not just in comparison with the United States or Canada but also with the more modest economies of Jamaica, Cuba, and the Dominican Republic. Such outlier status looms large in any discussion of Haiti's future health and economic development. (Haitians are not surprisingly tired of their homeland being labeled “the poorest country in the Western hemisphere.”) But few agree about the causes of Haiti's present condition. Simple stories of corruption or ungovernability (although real problems) do little to explain the chronic nature of such problems nor can we invoke the crutch of cultural difference to explain the challenges before Haiti.

To be credible, and to yield workable recommendations for building Haiti back better, to use Clinton's optimistic phrase, analysis of Haiti's current woes must be historically deep and geographically broad. Such an approach may also provide some inoculation against the old and pernicious tendency to blame solely Haitians—and Haitian culture—for their misfortunes. This default logic relies on the erasure of history.
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For many who arrived in Haiti immediately after
the quake, history began the moment they got off the plane. But Haitians from all classes will tell visitors that to understand Haiti's problems, you need to understand its history. As Mark Danner has written:

Haiti's history has been recounted before in a literature of mixed quality. This includes a Haitian bibliography that is quite robust, considering the low literacy rates since independence. In the nineteenth century, Haiti contributed more books per capita than any other country in Latin America. From the end of the revolution in 1803 to the withdrawal of U.S. Marines in 1934, after a nineteen-year occupation, Haitian élites wrote tome after tome in impeccable French about the country's glories and travails.
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Although books in Haitian Creole, the lingua franca, remain rare, Haitians from all classes seem to agree about the nation's beginnings: the colonial experience and the fight against slavery constitute the template of modern Haiti.

The story starts at the close of the fifteenth century. Haiti was the site of Europe's first New World settlement after one of Columbus's three ships foundered off the northern coast of Haiti in 1492. The island's native Taíno population, numbering at least in the hundreds of thousands (some demographers say millions),
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was mostly wiped out within a century of the Columbian exchange by assault from pathogens ranging from slavery to smallpox. When a 1697 treaty ceded the western third of Hispaniola (Columbus's name for the island called
Ayiti
by its doomed inhabitants) to France, not a single
Taíno remained alive. For those who say Haiti's history is written in blood, this is the first chapter.

The second chapter is equally brutal. Although the Spanish began importing slaves from Africa in the first decades of the sixteenth century, it was the French who moved the slave trade into high gear: by the mid-eighteenth century, Haiti was the Americas' chief port of call for slavers. By 1540 some thirty thousand in chains had reached Haiti's shores.
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Saint-Domingue—the name given to the French colony on Hispaniola from 1659 until it became the independent nation of Haiti in 1804—became the world's leading exporter of coffee, sugar, and other tropical produce. It brought in more income for the French, noted Moreau de St-Méry (the chief French chronicler of the era), than all their other colonial possessions combined.
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Moreau de St-Méry's two-volume treatise wasn't able to completely sanitize the horrors and excesses of the period. But it was the Haitian slaves who would later write the most damning accounts:

Revolts were frequent everywhere chattel slavery was practiced. But none had succeeded in ending slavery, much less founding a nation in which slaves would become citizens. In Haiti, the numbers were heavily skewed in favor of the slaves, who accounted for 85 percent of the colony's population by the time of the French revolution.
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A major uprising in 1791 laid waste to many of the plantations and fields in the north and soon coalesced into a full-scale revolution led by former slaves such as Toussaint Louverture. European armies from all the great powers of the era (and the newborn republic to the north) proved no match for those organized by Louverture. But the
slave leader was soon kidnapped in a parley with the French, later dying in a French prison, probably of tuberculosis.

Such treachery only stiffened the resolve of the Haitians, now under the leadership of the fiery Jean-Jacques Dessalines, who vowed to fight for as long as it took to found an independent nation. It would be the epic battle of the era. In 1801, Napoleon sent his brother-in-law, Captain-General Leclerc, to retake the colony. Leclerc sailed at the head one of the largest armadas ever to set forth for the New World; his more than forty thousand troops included not only French soldiers but also German, Polish, Swiss, and Dutch mercenaries. But the European troops fared poorly against the guerilla tactics of the Haitians, as General Leclerc, who later died there (of yellow fever), was to learn. In one of his last letters home, Leclerc wrote that the only remaining tactic was to “destroy all the negroes in the hills, men and women, sparing only children under twelve, destroy half of those living in the plains and leave behind not a single man of color who has worn a uniform—without this the colony will never have peace.”
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Dessalines and his irregulars routed the French and their conscripts by November of 1803. On January 1, 1804, Dessalines declared Haiti a sovereign nation, the first (and only) one born of a slave revolt. “I have given the French cannibals blood for blood,” he said. “I have avenged America.”
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The end of slavery in Haiti caused ripples throughout the Americas, from Venezuela to the United States and back to Europe, where plantation slavery had been spawned. Many have observed that most modern human rights movements trace their origins to the fight to end the slave trade and slavery itself. Britons proudly claim that this fight began in their own country, when Thomas Clarkson, William Wilberforce, and others used moral suasion and legal and political means to end the British slave trade.
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But the first decisive blow against slavery was struck in Saint-Domingue in 1791, culminating in the defeat of Napoleon's vast army in the hills and plains of his soon-to-be former colony. For those who doubt the grand aspirations of the victorious slaves—to establish an independent republic free from slavery—we have only to consult the historical record. The discovery,
in late March 2010, of the only surviving copy of Haiti's 1804 Declaration of Independence in the British National Archives leaves no doubt: Haiti's military leaders used rights language unstintingly. These are Dessalines words: