Haiti After the Earthquake (29 page)

Léogâne is close to Port-au-Prince, but it takes hours to get there by road because of traffic south of the city; the road had also been damaged by the quake. Clinton and I were instead flying by Russian helicopter (manned by Ukrainian pilots eager to have their photos taken with him). The view from above was still difficult to bear. Seven months after the quake, less than 2 percent of the rubble had been removed from Port-au-Prince and the surrounding areas.
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The heavy machinery needed to crush and clear rubble was in short supply. During most of the twenty-minute flight, there was not a glimpse of green. But the southern sprawl of Port-au-Prince gave way to farmland as we neared the temblor's epicenter.

Even in the farmland, many concrete buildings had collapsed, and from the chopper, pancaked buildings and slab roofs angled downward like wet cardboard. Decades of shoddy and helter-skelter construction visibly marked the social fault lines of the disaster. The
building codes for Port-au-Prince were less than two pages long, and it was likely that Léogâne didn't even have those.
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We'd heard that 90 percent of the town had been damaged or destroyed, but many people were probably living as they had before: in tin-roofed shacks that were almost too small to fail. So in another of Haiti's ironies, many of the poorer people's shacks were more or less intact, while concrete Léogâne lay in ruins. Debris clogged the streets, footpaths, and drains; people were pushing wheelbarrows and carrying buckets of water.

As UN officials, aid workers, and locals led President Clinton around, I hung back to get a quieter look at the temporary houses and shelters, called t-shelters. Close to a hundred thousand of them were supposed to be built in Léogâne—that had been the goal—but fewer than thirty had been erected so far. And although the name
t-shelter
itself suggested impermanence, they were something of a disappointment: solid two-by-fours were used as supports, but the walls were of white plastic; the roofs, cheap tin. Like the spontaneous tent cities, the t-shelters were poised in an uncomfortable space between the temporary and the long term. They were too flimsy to last for long and already threatened by the elements. When I'd worked in Léogâne two decades before, the rainy season invariably resulted in dramatic flooding throughout the city, including the hospital wards, when the local river jumped its banks. It didn't look like the t-shelters would be high and dry for long.

Soon, private musings about these shelters were echoed by publicly aired complaints from the beneficiaries. The model t-shelter Clinton visited was inhabited by a woman who had nothing good to say about her new home. She launched a stream of invective in Creole even as the disaster-relief folks were describing, in English, the sturdiness of the t-shelters—“these are built to withstand high winds and to serve as transitional shelters that can tide people over until more permanents shelters are built; they're much safer than tents.” The model inhabitant scowled and complained. “Who would want to live in a house like this? The walls could be split open with a kitchen knife. It's tiny. I used to live in a three-story building!” The
counterpoint was bizarre and discouraging for those who understood both versions of the tale. I was relieved not to be the translator. A Potemkin village this was not.

I was ambivalent about visiting the sugar refinery in Darbonne. Harvesting sugar cane is one of the most brutal forms of labor, and one historically linked to slavery from the sixteenth century on. Anyone who knew Haitian history, remote or contemporary, would be leery about the industry. The harvest was unpleasant in Florida, grueling in the Dominican Republic, and economically unviable in Haiti—again for reasons beyond the control of the cane cutters who were now greeting Clinton. And in all three countries, this harsh work was often done by Haitians.

But as we walked through the mill, my spirits lifted: a thirty-foottall portrait of Jean Dominique greeted us on one of the larger façades. For long years, he had fought the good fight and paid the ultimate price. He would've been disappointed by the slow pace of recovery after the quake and sent lots of young journalists out to document the reasons (and excuses) for delays. He also would have deplored contracts without benefits to Haitian firms. So it seemed right to see Jean Dominique smiling over an enterprise that promised to create better prices for the region's cane growers and cutters.

Haitians weren't the only workers in this mill, which reared up out of a green sea of cane. The Darbonne refinery had been, since its launch in 1983 on a loan from the World Bank, something of a white elephant. In its best years, it was only marginally profitable because cheap sugar imports—thanks to huge subsidies in the United States, especially—flooded Haitian markets. Another problem was the dwindling harvest: farmers on small plots of land were competing not only with U.S. trade subsidies but also with the technical advantages of agribusiness. Much of the harvest here was still done manually, which meant that cane cutters in Léogâne ended up doing the same sort of work whether in their home country or in any other. They would prefer, surely, to stay home, if they could make a living. After sputtering along for a few years, the Darbonne mill closed, to be re-opened in 2001 when Cuba kicked in $2.5 million in operating capital and a great deal of technical assistance. But the refinery still
produced under capacity, providing only 2 percent of the sugar consumed nationally. Haiti, once the largest producer of sugar on the planet, couldn't compete with Dixie Crystals.

Then along came the call for biofuels, many of them made from sugarcane. Greg Milne, the young lawyer on our team, briefed me on the situation. Three years ago, an energy company invested in the mill to keep it from going under, and it soon generated three megawatts of electricity in addition to scaling up its sugar output (including syrup for alcohol fermentation). Maybe this white elephant would, with Cuban help and some investment, be given a second lease on life. Maybe it would help generate power for a region with little electricity.

At the time of our visit, the plant employed about 250 people. Greg Milne and others estimated that modest investments and upgrades could increase sugar and electricity output tenfold, especially if investments also went to local cane growers to increase their access to tools, credit, and better prices for their produce. Seeing Cuban and Haitian workers on the job, it didn't seem far-fetched to imagine that initiatives like this one—doing CPR on a moribund refinery—could guide our efforts to resuscitate the foreign aid apparatus. In any case, it seemed like a good use of Cuban expertise, and although the entire biofuels debate seemed impossibly complex, here was an agroindustrial effort that also generated electricity in a rural region that needed it desperately. This combination of potential positive outcomes, and Jean Dominique's symbolic approbation, made me feel better about visiting this outpost of an industry long associated with cruelty and coerced labor.
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Although my attention was focused on health care, I was learning a lot on visits like these. As hard as it was to be a cheerleader for sugar production or biofuels, it wasn't hard to applaud higher incomes for Haitian farmers, more electricity, and more processing capacity. In general, smaller-scale agriculture seemed to strike a better deal for the poor than did industrial and agroindustrial projects. With a fish farm or produce cooperative, farmers,
ti machann,
and others moving or selling their own produce might in principle enjoy more autonomy and higher incomes than factory workers. But the
decline in agricultural production and continued ecological destruction made it hard for anyone tilling the soil or fishing to survive without improved processing capacity and ready access to credit. The microfinance boom had helped some families but had not prevented the rapid rise of food insecurity or the persistence of child servitude.

As noted, Haiti had been buffeted about in the global economy for centuries. Its first transaction, the Columbian exchange, wiped out the indigenous Taino population. (Léogâne, in fact, had been heavily populated by the Taino in 1492, when the global economy was born; its patron saint is the Taino Queen Anacaona.) As noted, the slave labor system put in place by the Spanish and French extracted immense profits from cash crops such as sugar and coffee. Such history tempers any romanticism about sugar refineries, coffee-washing stations, or even mango-processing plants. But on that August day, in the company of a couple of peasant cooperatives, some Haitian investors, a dozen Cuban technicians, and a former U.S. president, it felt good to leaven a visit to troubling temporary shelters with an effort to create jobs and electricity and processing capacity. Although anxious to return to medical tasks, I knew that poverty-reduction efforts, better wages, and improved access to the fruits of modernity would make our medical work easier and more effective.

Such were the insights of social medicine, a discipline I learned from Haitians and from mentors at Harvard. It was social medicine we tried to practice in Haiti and elsewhere in the world, from the poorer parts of Boston to the rural reaches of Rwanda, Malawi, and Lesotho. But the masters of this field were surely the Cubans, who, along with Aristide, had founded a new medical school in Haiti. The school was one among many worthy efforts shuttered by the 2004 coup. Most of the students had been able to continue their studies in Santiago, Cuba, however. At the close of a summer in which no students would graduate from Haiti's state medical school, sixty-seven newly minted doctors were due to receive their diplomas. One had been born and raised in Cange, and most others were from similarly humble backgrounds. I'd been one of the only American doctors involved in their first year of training and was honored to be asked to
be the
parrain
—literally, the “godfather”—of their class. (The godmother chosen was Marie-Laurence Lassègue, to whom I'd handed my satellite phone amidst the din of Toussaint Louverture Airport not long after the quake.)

I didn't know what to do for these young men and women other than to welcome some of them to our hospitals as interns. Claire and Loune suggested I give them each a stethoscope and one of my books. The ceremony took place at the Karibe Hotel, which, though damaged in the quake, was open for business. I didn't have to speak, and just sat there with Minister Lassègue and other dignitaries (the Cuban and Venezuelan ambassadors, and the leaders of Haiti's Ministry of Health), to celebrate the return to Haiti of this bumper crop of Cuban-trained doctors. Thirty of them approached me after the ceremony about forming a study group to stay in touch and keep learning. (They would be scattered across Haiti after years of study together in Cuba.) Most would have too little support—in the way of clinical supervision or didactic sessions—so some younger U.S.trained doctors, including Natasha Archer and Michelle Morse, promised to help mentor them and connect them to a web-based platform we'd developed at Harvard. The students were full of trepidation and enthusiasm.

The graduation ceremony was one of the happier moments of the summer of discontent, and it made me all the more anxious to see the Mirebalais hospital up and running. It was possible, just then, to imagine a time when these young physicians could work in a hospital worthy of their talent and training.

The ceremony was also a reminder of my own students and the Department of Global Health and Social Medicine at Harvard, which I chaired. The work in Haiti was central to its mission, but the new academic year was about to begin. Classes would start soon, and I was unprepared. For the previous eight months, it had been all earthquake, all the time. It was daunting and emotionally difficult to think about teaching anything unrelated to the health challenges after the quake. What lessons could be drawn from the previous eight
months? What links existed between short-term relief and the long slog of reconstruction? Observers and participants alike were struggling to make sense of what had transpired since the quake. There were plenty of stories and reports noting how little had been achieved. But most of the conclusions seemed premature: it was early to say much about the pace of reconstruction, other than that it was slow. And the pace would have been slow in less devastating circumstances, as we'd learned after the storms of 2008.

There were also other projects to keep going (and growing) in a dozen other countries. We were behind schedule to open the flagship public hospital in Rwanda's Burera district.
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It would be smaller than the one we were starting in Mirebalais but was nonetheless the largest we'd built to date, and we'd poured blood, sweat, and tears into it. In fact, the hospital was a poster child for swords-to-plowshares projects because it lay on the site of a former military base near the Ugandan border. We launched the project with the Rwandan government and broke ground in the summer of 2008. We'd promised a glorious product by the close of 2010, and were a month or two behind. These promises, and others made outside Haiti, found their way back into my thoughts as August drew to a close.