Sunday, January 27, 2013

No Urgency for the Poor

Elie Joseph, February 2012
(Photo by John Carroll)

How long should we let hundreds of thousands of Haitians live in horrid tents and shacks after the earthquake of 2010? They have been living in squalid conditions for three years now.

And how long should we let a two year old little boy named Elie live with a hole in his heart in one of these tents in Port-au-Prince? Until he dies? Yes, until he dies.

When I first examined Elie in February of 2012 he was a tiny irritable toddler who clung to his mother more fiercely than any baby I had ever checked. He refused my exam as much as he could. He did not want to be separated from his mom even by the diameter of my stethoscope head. 

I feared for Elie from the start with the loud murmur in his chest and his "don't touch me" demeanor. He seemed so fragile and knowing, which seemed like red flags for trouble.

The swishing noisy heart murmur I heard with my stethoscope was turbulence of blood flowing through a tiny hole between the lower chambers of his heart. It is the most common congenital heart defect and is called ventricular septal defect. This defect made his heart and lungs do extra work with each heart beat. Over time it had thrown Elie into congestive heart failure and predisposed him to multiple bouts of pneumonia.

So I treated Elie with medication for the extra fluid in his lungs and with antibiotics for his pneumonia. I put him on vitamins and medication for the worms that lived in his gut. I got his mother's phone number and gave her money so he could get a chest x ray and an echocardiogram. She did everything I asked of her.

Elie definitely needed heart surgery. Even though this is routine heart surgery in the States, it takes a skilled surgeon and cardiovascular team to repair the hole in a heart like Elie's once he is on the bypass machine. Once the hole in the septum is exposed by the surgeon, the actual repair of the hole takes about 15 minutes using a small piece of the heart sack as the patch. Pediatric heart surgery is done in Haiti by random surgical groups that occasionally come to Haiti, but is not available most of the time for the majority of Haiti's children--especially ones like Elie who live under tents.

I notified an American organization that takes Haitian kids to the Dominican Republic for heart surgery. Elie was put in their data base. I wanted to be optimistic that Elie would be operated.

Elie lived with his parents Elifete and Claudette and his four year old sister Karen in a tent in Cite Aviation. Aviation is densely populated tent city in Port-au-Prince where the Haitian Air Force was located years ago. 

Cite Aviation, January 25, 2013
(Photo by John Carroll)
Elie's parents had lived in downtown Port-au-Prince before the earthquake. But when the temblor destroyed the capital on January 12, 2010 their house was fissured and they had to move to a tent at Aviation. Besides the Josephs, 1.5 million other Haitians were scattered to numerous other tent cities throughout the capital.

Elifete pointing to roof of tent, January 25, 2013
(Photo by John Carroll)

The months crawled by after the quake and Elifete was able to buy some concrete, mix it, and pour a 9 by 12 foot floor for his one room tent. He shored the tent up with with wooden stakes. His walls and roof are made from blue and gray tarp that don't leak too much in the rain. The one room has a single bed with a clean white sheet. Two walls facing each other have wooden shelves filled with clean plates. Elie's only toy also sits on one of the shelves. It is a pole with a giraffe at top. Around the pole are multicolored plastic rings to move up and down.  And one can push open a little wooden door on one of the walls that leads to a "kitchen" which is a couple of feet wide and long. A simple recho (iron grill) sits on the ground where Claudette cooks rice and beans with charcoal.

Thousands of displaced people live in Aviation. The corridors are narrow between the tents and shacks. There are no secrets in Aviation.

Elie was born in April, 2010 at the Red Cross and moved into the tent with his family. But Claudette was worried about his cough, his shortness of breath, and his poor ability to breast feed. Elie always seemed so weak...

However to due to Claudette's excellent care Elie was able to survive somehow in the filthy subhuman environment of Cite Aviation.

With the help of the American organization Elie obtained his Haitian passport in June which would be necessary for him to travel to the Dominican Republic...a mere hour away by bus. Claudette's passport was held up due to bureaucratic reasons. There is absolutely no urgency for the poor...

Claudette recounted that she did not hear back from the American group about her passport to travel with Elie after June, 2012. To separate Elie from his mom and drag him to the Dominican Republic without her did not seem like the thing to do. He needed his mom for so many reasons. Claudette continued to take Elie back to the pediatric clinic each month for exams and medications that were keeping him alive. 

The rainy seasons came and went and Elie somehow hung on. He didn't get cholera or die after Hurricane Sandy struck Haiti in the fall of 2012.

September, October, November of 2012 went by without news about Claudette's passport.

Yesterday Elie's parents came to the clinic. Elie was not with them. They told me Elie had diarrhea and vomiting in the tent last month in early December. They quickly took him to a hospital on airport road where he was admitted. Elie was fragile and it doesn't take much to push a little one like this over the edge. According to Claudette, the hospital staff started an IV, gave him oxygen, and started some medication. 

Claudette and Elifete Joseph, January 25, 2013
(Photo by John Carroll)

Elie was in the hospital for seven days and his diarrhea stopped. But it sounded like his breathing became more labored. Claudette and Elie clung to each other as usual and talked to each other. Elie did not eat during his entire hospital stay. On hospital day number seven Elie quit breathing and died. He was 2 years and 8 months old. Joseph is buried in Gran Cemetaire in Port-au-Prince.

Elifete and Claudette told me the story about Elie's hospitalization and death with no emotion whatsoever. It was told in the same manner I might describe to you about going to the grocery store or something stupid like that.

Can you imagine if you in Peoria had a toddler who was diagnosed with a congenital heart defect that could be permanently fixed with heart surgery but you couldn't get it done? Can you imagine living in a tent for the past three years and have no job to feed your family or your sick toddler? Can you imagine being told you need to walk to a latrine a long ways from your wretched tent in order to have a bowel movement and then have to pay one Haitian dollar for having the bowel movement in a totally rotten and smelly hole? That is exactly what the Joseph family is enduring the last three years. 

Would you be upset to have to bury your medically neglected two year old boy and get loans from friends and neighbors to bury him? Would you be a tad bit upset?

I asked Elifete and Claudette if they thought it was the Haitian governments responsibility to help them out in the tent. They calmly replied that yes they thought it was the government's responsibility but in three years they had never seen anyone from the government visiting their tent city. They said they would be happy if a government official did visit. I asked them if they are angry about their situation. They said they are not angry that they live in these dire conditions. They explained to me that they have no money to build or rent. They didn't take it any further than that. They never blamed anyone for anything and they didn't blame anyone for Elie's death. 

And in my opinion this attitude is not only the Joseph's. My guess is that the majority of the estimated 350,000 still homeless people in Haiti's tent cities don't really blame anyone. It wouldn't help anyway.

Elie's Toy
(Photo by John Carroll)
But just because many displaced Haitians don't seem to blame anyone doesn't mean that their conditions are suddenly acceptable and fair. It is the opposite, of course. This is all cruel and seemingly hopeless right now as the tent cities seem to become permanent.

We all need to know that we failed Elie, including me. Big mistakes plus little mistakes plus big negligence plus little negligence all adds together and equals death. Just because his parents don't know how it all works, doesn't mean people aren't at fault.

And we are all failing the hundreds of thousands of innocents living in the tents now. There is no urgency for the poor. There never has been.

John A. Carroll, MD

Wednesday, January 23, 2013

Letter from Haiti by Amy Wilentz (Posted by Roger Annis on CHAN)

Letter From Haiti: Life in the Ruins 

By Amy Wilentz, The Nation,  January 9, 2013 (print edition of Jan. 28, 2013)

Sometimes you can’t help but be sickened by the behavior of certain international organizations helping Haiti recover from the devastating January 2010 earthquake—hit, that is, by a wave of real physical nausea. The other day, I spent an afternoon in the displaced persons camp across from the ruins of St. Anne’s church in downtown Port-au-Prince. The place was awful, as awful as you can imagine squalid emergency living quarters might be—homes consisting of tent, tarp, tin, sheets, plywood, some cardboard—after three years of dust, dirt, sewage, torrential storms and, to top it off, Hurricane Sandy, which killed at least fifty-four people in Haiti.

Across the street from the camp, where an estimated 600 families are living, Chérestal Jean-Fougère, a camp leader, showed me the portable toilets that had been brought in by relief agencies in the first days after the earthquake. For months, a cleaning company contracted by international relief organizations and consisting of men in rubber regalia came regularly to wash out these toilets with high-powered hoses connected to special pump trucks. I remember watching them back then and wondering how long this miracle could last. Now I have my answer: for the past six months at least, Jean-Fougère said, no one has come to clean. The contract for the job has run out.

It shows. At the edge of the rocky field that was once the St. Anne sanctuary, the five or six portable toilets are festering shit holes, overflowing with stinking excrement and pieces of cardboard that have been used as toilet paper. On some, the doors hang open on broken hinges. “No one goes into these anymore,” Jean-Fougère told me. I asked him where residents font leurs besoins now, and he pointed to the curb and also to a gaping hole in the street. When I looked down into this, I saw brackish brown water, glinting and moving. This is the water the camp residents also use for laundry and bathing, Jean-Fougère added.

I toured the camp with Jean-Fougère and some others, a tight scrum of kids and teenagers traveling in our wake. He talked about the usual crises of these camps: gang rapes, routine robberies. (“Stealing what?” I wondered as I peered into the raggedy, unfurnished tents and shacks.) We squelched over a swatch of black carpeting being used to absorb rainwater in front of one older woman’s tent. Behind her living area, family groups were stacked, as if in an apartment building, in the nooks and crannies of a playground set that dated back before the earthquake, when this space across from the church was a well-kept public square known as the Place St. Anne. One family occupied the jungle-gym section of the playground, another the platform above the yellow plastic slide. Two more families had set up house under the slide, behind walls made of daisy-patterned sheets. Xavier François, an elderly man, smiling and skeletal, told me his family was killed in the earthquake. He lives nearby under a flapping, deflated tent that hovered three feet above the ground and barely covered a bed frame with no mattress but some old plastic sheeting on it. François had nothing else in this abode.

Now, I’m not blaming the condition of these people entirely on the international organizations. But in the past half-year, outside efforts have created a serious problem. During the spring and summer, several groups working together, including the colossal International Organization for Migration, continued to depopulate a number of camps by offering residents $500 per family to move out. With this $500, displaced people are able to afford rent in non-camp housing for about a year. People living in many of the biggest and most visible camps were given money and relocated, and those camps were taken down.

This was an achievement of sorts, even though many of the people who moved ended up in rubble-strewn neighborhoods or, worse, in windswept interim camps outside the capital, square-box townships with no nearby commerce or jobs or culture. It could be argued that the original post-earthquake camps were worse than these newly slapped-up places, although some of the camps had a lively Haitian bustle that’s totally absent in the new townships. The camp people who wanted to be out soon told me they refused to remain for another Christmas; once Christmas was past, they said, they would not submit to a third earthquake anniversary in the camp. But here they were, still in the St. Anne camp just days before the January 12 anniversary.

That $500 handout is the problem. Haiti, insofar as it exemplifies the regime of international development, is a world of unintended consequences. Walking around St. Anne, I kept thinking to myself: “Come on, people, get yourselves out of this situation. Go anywhere other than this!”

But they’re not going anywhere. The people in the St. Anne camp and the other 490 or so remaining camps are angry and confused. They cannot accept the fact that outside organizations would offer $500 per family to the residents of one camp to move out, but not to those in another camp. So the St. Anne residents are hanging on, unwilling to start up a new life elsewhere for fear of missing out on that $500, to which they understandably feel entitled, if only for the incredible suffering they’ve endured. To the average Haitian, $500 is a huge sum, roughly equivalent to the average yearly salary: say, $50,000 for a US citizen.

A few days after I left Chérestal Jean-Fougère at St. Anne’s, I was supposed to meet two Haitian friends for dinner at the Hotel Montana, which sits between Port-au-Prince and Pétionville, the wealthier financial hub up the hill from the capital. The Montana exists only marginally, because the five-story, 145-room building pancaked to the ground in the earthquake, killing some eighty people. It has not been rebuilt, exactly, although new structures have gone up that are much closer to the ground and earthquake resistant. The rebuilt restaurant and bar was where I was to meet my friends.

The problem was that on this very night, the new luxury Royal Oasis hotel was being inaugurated, and le tout Port-au-Prince had been invited to the formal gala. Because there’s only one two-lane road on that side of town, I had to plan my arrival at the Montana carefully so as to avoid getting stuck in the insane SUV traffic of the elegantly dressed guests coming to celebrate the opening.

The “five-star” Royal Oasis is a violation of human decency. Not because it’s big and luxurious in a desperately poor country, although it is that: it has 128 rooms, five restaurants, five bars, a conference center, an art gallery and an upscale shopping mall. But the indecent, depraved thing about it is that—amazingly, astoundingly—its construction was financed in part by grants from organizations ostensibly providing post-earthquake reconstruction funds: $7.5 million from the World Bank’s International Finance Corporation went to the Oasis project, as well as $2 million from the Clinton Bush Haiti Fund, the recovery group headed by former presidents Bill Clinton and George W. Bush. (Having funded the Oasis, among other enterprises, the Clinton Bush fund announced that it was ceasing operations at the end of 2012.) The Royal Oasis is one of the few post-quake projects that have come to fruition, unlike dozens of housing and school construction projects.

Let me underline this: these funds were given to a project that was intended to erect a luxury tourist hotel in a country that for the past thirty years has not had a serious tourism industry. And in a country that has suffered a catastrophic earthquake—one that razed several cities, killed an estimated 200,000 to 300,000 people and left more than a million homeless. Many sidewalks in the capital remain strewn with rubble. The people of the St. Anne camp are among the approximately 358,000 Haitians still living in unacceptable conditions in camps around the capital and outlying areas. PS: There’s also an ongoing cholera epidemic.*

Some have suggested that the World Bank was simply underwriting a place where its employees could stay comfortably and sip espresso at meetings while trying to figure out why Haiti remains so poor. But the Oasis is not the only post-quake tourist accommodation: according to the tourism ministry, a new boom in construction will leave Port-au-Prince with almost twice as many hotel rooms as it had before the earthquake. But as you can probably imagine, there will not be twice as many tourists to occupy them. Some have suggested that many of the new hotels are sophisticated money-laundering operations for drug traffickers, where no one is expected to stay.

I managed to make my way through the Oasis traffic jam to my friends at the Montana. These were people who live, as foreigners who work in Haiti put it, “up the hill”—meaning richer Haitians, those with office jobs, investments, businesses, many of whom work with international development organizations. My friends that evening fit into a number of those categories. When I described my day in the St. Anne camp, and the bubbling anger of the people and their threats to demonstrate and even riot, my friends had a simple analysis. “Of course it’s Aristide,” they said, referring to the deposed Haitian president Jean-Bertrand Aristide, who returned from exile in 2011 but has not been seen or heard from since, creating a kind of mystique around this formerly voluble and visible figure. My friends’ analysis is this: just as you don’t have coups without money, you don’t have social unrest without money. These people believe all political unrest these days, whether in camps or schools, is paid for. They point the finger at Aristide, and in a way, they’re right: as a symbol of the Haitian people, Aristide is still significant, and when the people raise their voices, up the hill they hear Aristide’s voice.

* * *

A few days later, I went with some other friends to check out the Oasis up close, with no inaugural crowds. We tried, for the fun of it, to get a reservation at one of the hotel’s five restaurants, but not one was open for business. A single exclusive table of eight people, some of them members of the Haitian aristocracy and some former US embassy personnel, was being served dinner, alone among a sea of empty tables. A friend and I got into the elevator on the second floor after checking out a second restaurant that looked like a contemporary bistro in Rome, to go and see the $1,320-a-night presidential suite on the ninth floor. But the minute we pressed nine, the power in the cabin went off. We laughed nervously: Wasn’t this typical? In the dark, we discussed our predicament. Why had we ever stepped into an elevator in Port-au-Prince? My friend told me that although inaugurated, the hotel would not be opening to guests for another month or so. He vividly described our decomposing bodies being discovered in the elevator by hotel employees at that future moment.

“Who the heck are these people?” he said he could hear them saying. At that point, I pressed the alarm button—for a minute or so. No one came to answer our call, although we could tell from the light beneath the elevator door that the power was on elsewhere. My friend laughed. He’s a businessman in Haiti, and he knows how little interest a hotel manager here might have in “the Client” and the Client’s problems. Finally, the power came on in the elevator and—miracle—the doors opened. A housekeeper watched us emerge with some amusement.

Here’s my proposal: take the 600 families of St. Anne and put them in the Oasis. Those rooms were paid for, after all, with funds that ought to have benefited the camp dwellers. The people of St. Anne can stay at the Royal Oasis for free, and World Bank and Clinton Bush fund officials will pay $300 a night for the right to change the Haitians’ linens and polish their toilets, until the $9.5 million with which their organizations financed the project is paid back.

But first fix the elevator.

* * *

Routes for foreign intervention into the heart of Haiti are plentiful. About two years after the earthquake, news items started to appear about the search for gold and other precious metals in rural Haiti, but this was not new news: ever since I started visiting the country in the mid-1980s, there had been rumors like this. In fact, these rumors seem to coincide with unrest. Once again, here was gold emerging during a time of uncertainty and worry. Earthquake reconstruction fever was dying away, and the crisis caravan was beginning to pick up stakes and move on. Yet the country was still in its usual state of crisis within the global economy, and also in the throes of post-earthquake traumatic stress disorder. (In Haiti, there is no real “post” to the traumatic stress; it just goes on and on.)

Haiti’s global story began with gold. Columbus made landfall in the New World on Haiti’s north coast. Before returning to Spain, he left a settlement behind to dig for gold. The settlers enslaved the indigenous Arawak population and set them to work mining ore. Within fifty years, almost the entire Arawak population perished from overwork, starvation and disease, creating a need for imported labor in the form of African slaves.

Most of the exploration and future mining will take place in the same general area where sailors from Columbus’s fleet first began digging—far from earthquake land, in other words. In fact, most of the money being spent by private enterprise and by international organizations to “develop” Haiti in the wake of the earthquake is in undamaged areas such as the north, where it has been encouraged by funding from the Inter-American Development Bank and the World Bank, as well as by former President Clinton and soon-to-be-former Secretary of State Hillary Clinton. Foreign development groups and the Haitian government claim that “Haiti is open for business,” but in the north you see billboards in French saying that, more specifically, “The North” is open for business.

The terrain had already been prepared for international mining before the earthquake. About two weeks after the catastrophe, reports began filtering in of a gold exploration firm buying shares of a company that held drilling permits in one part of the country. About a year later, a new internationally supported and promoted Haitian government was in place, and the extractors were ready. Gold is now valued at about $1,700 an ounce (a night in the presidential suite at the Oasis, plus some left over for shopping). Silver and copper are also thought to lie in plentiful millions of ounces below Haiti’s fields, hills and mountains.

Speaking about Haiti’s gold last May, Dieuseul Anglade, a geologist and then director of Haiti’s Bureau of Mines, was widely quoted as saying that “if the mining companies are honest and if Haiti has a good government, then here is a way for this country to move forward.” This was not a statement from a naïve person; Anglade, who had worked for the bureau for the better part of three decades, was no doubt making a point. Two points, really. One, Haiti has never had a good government. Two, it’s very hard, if not impossible, to find a gold mining company that has ever experienced even a short bout of honesty. While Anglade was still at the bureau, the new government under President Micky Martelly, a popular singer, signed a memorandum of understanding (MOU) with Eurasian Minerals and with Newmont Mining, one of the world’s largest extraction enterprises, to authorize exploratory drilling. Anglade felt that the agreement contravened Haitian law and refused to sign the document. Instead, he says, it was signed by the minister of public works, whose agency is in charge of the Bureau of Mines. Anglade himself was fired.

“They want everything,” Anglade told me recently, referring to the mining firms. “The taxes to be levied on them are too favorable. They have been given too many advantages and too few taxes. Haiti’s share of the profits from these mines must total 50 percent.” Under the terms of the MOU, the sections in Haiti’s longstanding mining conventions protecting that 50 percent have been eliminated.

Outside exploiters are in the habit of using extravagant terms. At the height of the sugar plantation slave economy, Haiti was known as “the Pearl of the Antilles.” One international minerals exploration official recently called Haiti “the sleeping giant of the Caribbean.” The square mileage now licensed for exploration to outside mineral and metal extractors is the equivalent of about 15 percent of the country’s total land mass, according to one estimate. So far, there has been no sign of onsite government monitoring, even though Newmont has been known to pollute and also to use tough-guy methods with labor at some of its sites, most recently in Peru. It’s disturbing that destructive extraction activities may go forward unsupervised in a place where so little attention is paid to public safety, the environment and fair taxation. And yet Ludner Remarais, director general of the Bureau of Mines, could not contain a kind of giddy, laughing delight as he told me how proud Haiti should be to attract the interest of world-class firms like Newmont. “They are a big North American company,” he said. “Newmont is a guarantee for us in Haiti for the development of the mining sector.”

No doubt Newmont could be a good partner in exploring Haiti’s precious metals reserves. But good partners need strong regulations. If Haiti indulges in its usual business practices when dealing with extractors, the only real tax on them will be bribes and gifts to Haitian businessmen, large landholders and politicians. The only obstacles to the rape of the land will be peasants, who are easily swept away. And the sole addition to the Haitian economy will be the enrichment of those associated with mining—and I don’t mean lowly miners. Meanwhile, rivers and ecosystems, already fragile in this environmentally damaged country, could be poisoned, leading to even lower agricultural output.

* * *

More news from the north: at the new garment factory run by Sae-A, a South Korean apparel giant with twenty-two factories worldwide, 1,290 workers are making T-shirts for Walmart and, soon, Target. (The T-shirts retail for about $5.50, while most of Sae-A’s Haitian workers make less than $5 a day.) The plant is a vast, brightly lit factory—no ancient Bangladeshi sweatshop firetrap, this—in a huge new post-earthquake industrial park in Caracol, far, far from the destruction wrought by the quake and far also from any of the new townships where former camp people are living, lured by the promise of factory jobs to places where no factories have been built.

Caracol and its power plant and soon-to-be-implemented port were financed by $220 million set aside just after the earthquake by the US Agency for International Development (USAID) and the Inter-American Development Bank. The South Korean firm was offered many financial incentives to become the first big post-quake factory to try its luck in Haiti. The justification given for spending earthquake redevelopment money in non-earthquake-affected areas was that it would help decentralize the country and take population pressure off the capital. Perhaps, but tell that to the people in St. Anne. Tell that to bony old Xavier François, living under his broken tent.

The huge Caracol park is on a solid new road financed by the European Union (no potholes, unlike Haiti’s old National Highway No. 1). The road extends from the northern city of Cap-Haïtien all the way to the border with the Dominican Republic, for easy export and import of goods and supplies. Most businesspeople dealing with mining or the industrial park fly into Cap-Haïtien from Miami or Port-au-Prince, but because I wanted to see the places in between, we drove up along the rutted, washed-out national highway. It’s an eight- or nine-hour drive that should take three hours.

There are plans for renovating and expanding Cap-Haïtien’s airport, but none under way for fixing the national highway. Cap-Haïtien is a more livable city than Port-au-Prince, with far less population pressure. It’s near the greatest tourist sights in Haiti: the Citadelle, King Henri Christophe’s early-nineteenth-century mountaintop fortress, and Sans-Souci, the king’s palace at Milot, to which decent roads have also been built with foreign funding. Cap-Haïtien is also near Labadee, the beach resort and Royal Caribbean cruise stop. For years, the tourism ministry has been pointing to the north as a plausible center for tourism, and now the international community seems to agree.

It’s as if the international community had thrown up its hands in despair over the rest of Haiti, especially those areas affected by the quake. It’s as if the recovery people had decided to develop the north as virtually another country and tossed the south, along with hundreds of thousands of displaced people, into the poubelle of history. “You could call it ‘getting on with what’s possible,’” a friend of mine who works in development said, shrugging.

Estrella, a Dominican firm, won the contract to build the industrial park, which is to employ some 60,000 if all goes well. Indeed, the Dominican Republic has been seizing on Haiti’s post-earthquake vulnerability to make economic and cultural incursions into its historic rival’s territory. For sale in the markets of Haiti are Dominican sausage, Dominican eggs, Dominican tomato paste and canned sardines, Dominican ketchup and mayo, and Dominican spaghetti. You can have an entire Haitian Creole meal these days made exclusively from foods imported from the DR. I’ve watched these meals being prepared by women in the camps.

The new economic plan for Haiti is less about Haiti than it is about imports and exports: it’s a maquiladora plan that undermines agriculture and pushes more and more Haitians into the global cash economy, where most cannot compete for resources in any meaningful way. Certainly, the new plan means that Haiti will be less and less able to feed its people. That’s been the trend for years, since the United States began dumping surplus subsidized rice into the Haitian market. Now it’s accelerating.

* * *

At the garment factory, my guides were intent on showing me the First World norms of the place. They showed me the foam pads for workers to stand on (many of the women are on their feet for an entire eight-hour work day). They point out the Haitian music on the speakers. They tell me about the very modern electronic sewing machines from Japan. They discuss the cooling system. The cooling system makes this garment factory not a sweatshop but just a… shop.

South of Caracol park, housing is going up, but no one—including people closely affiliated with Caracol—will say whether this housing, subsidized by USAID, is destined to be used by Caracol employees. Each house there cost a stupendous $31,000 to build, according to The New York Times. The Sae-A factory workers have to pay a substantial part of their wages for transportation, so if the deal were done fairly, nearby housing might be a boon to them. Or they might, as is the tradition in such employment, end up paying rent to the company and buying lunch from the company and… There is a union at the Sae-A plant, but I did not get the impression that it’s entirely free from management control.

Another part of the northern development plan is the University of King Henri Christophe in Limonade, built after the earthquake just a few miles away from Caracol and completely financed by the Dominican Republic. Like the Sae-A plant, the university is a fantastic new facility that looks like an architect’s model. Even the 2,000 students there seem like little figurines, while the well-kept, well-irrigated shrubs and flowers look like model shrubs and flowers.

Inside, this impression is not dispelled. Kids mill around the landings and courtyards, flirting and chatting. They kick a ball in a central meeting area that has the breadth and openness of a parade ground in Beijing. The reason the students seem to have a lot of time on their hands is that there are very few classes at Limonade. The problem is not finding students; there were 7,600 applicants for 2,000 spots. The problem is finding qualified teachers to come live in Limonade and teach them.

Jean-Marie Théodat, the new dean, talked to me about the shock of coming home from Paris to lead the school after living abroad for some thirty years. He’d been teaching geography at the Sorbonne. “Of course,” he said, “we are building institutions in a fairly empty landscape; it’s not like the Sorbonne. Still, our model here in Limonade would be Silicon Valley. We want synergy between the university, the industrial park and the tourist industry of the north.” The university’s emphasis, Théodat added, is on science and technology, although the humanities are also represented. He said he has commitments from fifty teachers or professors, but he needs twice that many. The students’ books are gifts from Haitians in the Francophone diaspora community (the school, which is associated with the State University of Haiti in Port-au-Prince, teaches in French). The students live in rented rooms or apartments in nearby communities, but soon there will be dormitories and a cafeteria. I asked Théodat if the new building is earthquake-proof. “We’ll see when there is an earthquake,” he answered, smiling. He continued with the tour: “I want every student to see at least one teacher every day. In any other country, we would be facing a strike by now.”

Half an hour away from the new university stands the Citadelle, the great icon of Haiti’s sovereignty. It’s a complicated symbol no matter how you parse it. With a bit of help from German engineers, the former Haitian slaves, as post-revolutionary masters of their fate, erected this massive fortress on the top of a mountain with a commanding view of the northern coast and Cap-Haïtien. It was King Henri’s lookout, his defense against foreign (especially French) incursions against the infant Haitian nation, as well as against any simmering domestic plots or uprisings.

As I came upon the towering, colossal Citadelle, its walls were swathed in a swirling mist—first hidden in cloud, then revealed. I was moved by the monument, even though I knew it was not what Haitians often made it out to be: it had defended Haiti against nothing, even though it remains a symbol of profound national meaning. Its old cannonballs were stacked like lemons in the market; they’d been ready for battle since the 1820s.

The afternoon I was there, the Citadelle’s floors were slick with rain and moss. The day was growing dark and the giant fortress rose over me like a skyscraper, weirdly modern and huge, Brutalist in style. Peasants from below, whose families have lived in the shadows of King Henri’s battlements for generations, walked with us up the steep and narrow road, constructed in the 1990s with USAID financing. Alongside us trudged guides with mules and donkeys. As I walked, the men told me how glad they would be if their daughters or sisters could get a job at the Sae-A factory. It would be like a miracle, they said. King Henri’s old dream of liberty and sovereignty soared above me at the top of the mountain, but at Caracol that morning, I had seen what his descendants had been brought to.

And no surprise: when the invaders finally did return, they debarked in Port-au-Prince, not the north. Weakened by generations of corrupt rule, civil war and a crushing early national debt, the Haitians were not a serious match for the US Marines and their nineteen-year occupation ]1915-1934], a dispiriting and repressive time that prepared the way for decades of dictatorship by the Duvaliers. Against all these exploiters and kleptocrats, the Citadelle was useless. As it has been, also, against the army of development organizations and multinational investors and lenders who, along with their Haitian sidekicks in government and business, have only further impoverished the country since the fall of the Duvalier dynasty, while making noises about their support for democracy and the encouragement of civil society. Rather than providing a defense against foreign incursion, the Citadelle—like Haiti’s deep pool of cheap labor, like its gold and even (incredibly) its recent catastrophic natural disaster—has become just another attraction, another national resource that keeps the outside exploiters coming down.

* [The author could also have noted that hundreds of thousands more Haitians are living in informal camps that escape the official registry (IOM) of internally displaced people, including those who followed Sean Penn’s promises in 2010 of new urban development and services beyond the northern fringe of the then-existing city limits of Post au Prince, in Corail-Cesselesse.]

St. Catherine's Hospital in Cite Soleil

Pediatric Admit Room, St. Catherine's Hospital--Cite Soleil
(Photo by John Carroll--January 23, 2013)

Tuesday, January 22, 2013

Cholera in Soleil in 2012

Young Haitian Doctor

Pediatric Clinic in Cite Soleil, January 22, 2012
(Photo by John Carroll)

Yesterday I spoke with a young Haitian doctor.

He is a tall handsome dark skinned guy who has a gentle smile. He just graduated from one of the medical schools here in Port-au-Prince and is doing his year of Social Service for the Haitian government.

He is from Port-au-Prince and had an expensive Littmann stethoscope wrapped around his neck. It was not the usual flimsy nursing stethoscope that is ubiquitous here. I would say he is from the "middle class" of Haitian society.

He is spending this year in an "under served" area here in Haiti, which could be almost anywhere in Haiti. There is no attending physician present and so he is unsupervised and has no formal hospital teaching. There are no resident physicians available either to answer his questions or help him out. He has very little equipment and very little support even triaging patients to the proper location.

However, he seemed very upbeat.

I asked the young doctor what he was planning for his residency next year.  He smiled and said that he would try and get a residency in Europe. Their are very few residency spots here in Haiti due to a lack of quality hospitals with teaching programs.

When I asked him what kind of doctor he wanted to be his answer was interesting. He said that he would like to do echocardiograms, or put in pacemakers, or be an "invasive gastroenterologist".

Haiti of course should have doctors that are proficient in all of these areas. But what they need the most are young physicians who want to specialize in public health and really learn how to treat tuberculosis and AIDS and cholera and other infectious disease problems that plague this place.  But in order for this to happen, there has to be a push by the State of Haiti.

And what do I mean by push?

Young Haitian doctors are not thrilled with the idea of having multitudes of sick, coughing, cachectic, dying, and thrown away people dressed in rags, showing up on their office doorstep with no money to pay for their services.  Haitian doctors need to be paid fairly by the State of Haiti to care for people who have no funds.  And Haitian residencies need to be created and expanded which would train many young doctors in public health and infectious disease.

The young physician above needs to stay in Haiti. And the State of Haiti should make it worth his time.

John A. Carroll, MD

Monday, January 21, 2013

Sunday, January 20, 2013

Praying Man

January 19, 2013--Medical/Dental Clinic Cite Soleil
(Photo by John Carroll)

Who is this Praying Man and why is he praying?

He is a slum dweller from Cite Soleil and is praying that our dentist would pull one of his painful and rotten teeth.

Yesterday he was in line in our medical/dental clinic in a notorious neighborhood in Soleil. He patiently waited for hours sitting on a wooden bench with dozens of other dental patients with chronic pain.

However, it wouldn’t be. The hour was late and the patient before Praying Man turned out to be our last dental patient. This last patient was a very afraid thin young woman whom our dentist needed to cajole and use the art of dentistry to successfully and painlessly extract her tooth.

So our Praying Man was promised first spot in the morning to have his tooth pulled. He was happy with this as he left the clinic.

However, things in the neighborhood around the clinic were not good yesterday. The young men in the area were smoking Haitian weed (boz) and seemed more angry and agitated than usual.

One member of our team told me that her name was called multiple times and motions were made to bulging waste lines indicating guns underneath. These men are called bandits by the local Soleil community.

Our Haitian staff, who always have their ear to the ground in Soleil, told us after clinic that it would not be safe for us to have clinic today. So clinic was cancelled today.

With this decision, one of our nurses shrieked in despair that the Praying Man would not get his tooth extracted now. Most Haitians never see a dentist in their lifetime. And hundreds of other medical and dental patients that would have been examined by our thirty-member team will not be checked or treated today.

So Soleil remains inhuman. It is terrible inside the little corridors. It is terrible in every way you can imagine.

The Haitian National Police won’t enter this area of the slum. And when the UN soldiers have come in the past, they have shot everything up and killed innocents and bandits at the same time.

And so the bandits rule here. They have no jobs. They have no life. They have no future. They have nothing to lose. So they intimidate and kill "when needed".

Liberals hate to have anyone attack "the bandits in the slum". But the bandits need to stop their bad behavior because their own neighbors suffer greatly as a consequence.

And conservatives need to stop supplying the bandits with their bullets. The big guys on the hill need to help provide jobs. The bandits need jobs, not bullets. Wouldn’t it be nice if they went from bandits to businessmen? 

And travel warnings to Haiti from the American Embassy? Please stop these warnings. Most blans will be ok in Haiti. Praying Man won't.

Cite Soleil, January 19, 2013 (Photo by John Carroll)
So I am sorry, Praying Man, that we did not pull your tooth and relieve your pain a little today. And I am so sorry for all of our liberal and conservative talk that ultimately does so little for you.

We will be back tomorrow morning.

Keep the faith (kembe fem).

John A. Carroll, MD

Tuesday, January 15, 2013


It is just never a good idea if someone is going to "discern" whether you will receive medical care or not.

Sunday, January 13, 2013

It Doesn't Make Much Difference

It doesn't make much difference if you are poor and uneducated in Peoria or Port-au-Prince. You don't have much of a chance.

If you, or your equally poor neighbor, or the local mafia, or the "good guy" at your community center, doesn't throw up barriers, someone else will.

And for the rest of us silence and keeping one's head buried in the sand is golden.

Monday, January 07, 2013

Haiti Still Waiting for Recovery

Haiti: Still waiting for recovery 

Three years after a devastating earthquake, the “Republic of NGOs” has become the country of the unemployed 

The Economist, print edition, Jan 5th 2013 

“HAITI is open for business”, Michel Martelly, the country’s president since May 2011, likes to proclaim. His government has backed up this talk by making it easier for foreigners to own property and by setting as a goal that Haiti climb into the top 50 countries in the World Bank’s ranking for ease of doing business (it now comes 174th out of 185). In November the president opened a gleaming arrivals hall at Toussaint Louverture airport. Mr Martelly himself is in such constant motion abroad—courting donors and investors, he says—that his peregrinations and the per diems alleged to be associated with them have become a source of mordant jokes. 

But gangbuster growth, hoped for as the country rebuilds itself after the earthquake of January 12th 2010 that wrecked the capital, Port-au-Prince, and killed tens of thousands of people, has failed to materialise. In the 12 months to the end of September the economy expanded by a modest 2.5%. It was the second year of dashed expectations: the IMF had forecast growth of 8% in both 2011 and 2012. 

Thanks in part to tropical storms that in 2012 inflicted what the UN Food and Agriculture Organisation called “colossal” damage on Haiti’s farmers, the cost of living, especially for food and housing, has risen dramatically. Most of the donor-supported cash-for-work programmes set up after the earthquake have come to an end. Many of the NGOs that thronged the country, and which threatened to eclipse the government, have departed. “We’ve gone from being the Republic of NGOs to the Republic of Unemployment,” says Frantz Duval, the editor of the country’s leading newspaper, Le Nouvelliste. Around three-quarters of Haitians are either unemployed or try to make ends meet in the informal economy. 

Mr Martelly won 67.5% of the votes in an election in which less than a quarter of the electorate voted. He remains popular. But his critics grumble that his policies amount to putting Haiti up for sale. They argue that 15-year tax holidays offered to foreign investors will hinder the government’s efforts to cut its dependence on dwindling foreign aid. For the moment this complaint seems academic: despite the tax breaks, as well as the promise of duty-free import of components and export of final goods and cheap labour, few foreign investors have set up shop. 

The United States staked its prestige and $124m—its biggest single post-quake investment—on Caracol, an industrial park in the north of the country. So far the park has only one tenant, Sae-A, a South Korean textile manufacturer, with 1,050 workers (though its owners claim the number could rise to 20,000). With its colourfully painted, dedicated power plant, Caracol is still a beautiful ghost town. 

Haiti’s prime minister, Laurent Lamothe, a 40-year-old telecoms entrepreneur, calls Caracol a “work in progress”. He says a Haitian-owned paint factory will soon open there, and a Dominican clothing firm recently signed a contract. Some observers think that potential investors are deterred by fear of social instability and lack of clarity over land rights. Mr Lamothe replies that the government is conscious that Haiti lacks a “perfect” business environment but is “making great strides in creating it”. 

The problem is that at the same time as Haiti needs investment to generate social stability and economic growth, it also needs social stability and better infrastructure to attract investment. There are some signs of progress, besides the new airport terminal. Most of the earthquake rubble is finally gone from the capital’s streets. The most visible refugee camps have been emptied. Several new hotels, aimed at attracting those elusive business visitors, are due to open. The first of them, the Royal Oasis, welcomed hundreds of high-society Haitians to its opening in December, where they frolicked in its five bars and around its still-unfinished infinity pool. 

And yet more than 350,000 Haitians are still living in tents in scattered camps; many of those who have moved out have returned to substandard housing in hillside shanties and seaside slums. A cholera outbreak that has killed more than 7,500 people since October 2010 remains a threat, with cases spiking after each tropical storm. Epidemiologists blame poor hygiene at a military base of the UN peacekeeping mission for the outbreak, though the UN has denied responsibility. 

Billions of dollars of aid were pledged to Haiti after the earthquake, amid much talk about “building back better” and working with—not around—the government so as not to perpetuate the “Republic of NGOs”. But according to reports from the Centre for Global Development, a Washington think-tank, and the UN Special Envoy for Haiti, many aid pledges were unfulfilled. And in practice, most of the money that was disbursed went to a handful of international bodies, which mainly spent it on temporary relief (tents, shelters, water-tankers and so on) and the salaries of expat staff. Grand schemes to remake Haiti came almost to nought, partly because they lacked local input: outsiders have finally come round to the view of many Haitians that what is most needed is speedy and cheap housing. 

Donor-fatigue is mounting. The UN humanitarian “cluster” system, intended to co-ordinate the response to the crisis, ended with 2012. The UN has launched a new humanitarian appeal for $144m to tackle cholera, homelessness and food shortages, but a similar appeal for $151m in 2012 went largely unfunded.

Direct budget-support for the government totalled less in 2011 and 2012 than before the quake, according to the IMF. The government is also hampered by its lack of suivi, or implementation capacity. Many public employees are time-servers who owe their jobs to past patronage; many in Mr Martelly’s administration lack experience of government. Donors complain that it is hard for them to support projects that lack the proper paperwork. As a result, hospitals stand unfinished. Rebuilding of the main Hôpital Général has stopped. 

To fill the gap, Mr Martelly relies on Petrocaribe, an aid scheme set up by Venezuela’s Hugo Chávez, which supplies Haiti and several other countries with subsidised oil. By reselling a chunk of the oil, the government gets up to $400m a year, or about 4% of GDP. Mr Martelly plans to use this to rebuild a corridor of government offices in Port-au-Prince and to pay for several social programmes, including cash transfers to the poorest. The aid comes without the strings that many other donors attach. No wonder that Mr Martelly and Mr Lamothe attended a mass a few days before Christmas to pray for Mr Chávez’s recovery from cancer surgery. 

Wednesday, January 02, 2013

Haiti's Long Road (New York Times)

The New York Times

January 1, 2013

Haiti’s Long Road

On the eve of the third anniversary of the earthquake that devastated Haiti in January 2010, the country remains in a fragile state. Billions of dollars in aid and lofty promises to “build back better” have brought it only so far. A recent article by Deborah Sontag of The Times showed, in disheartening detail, the distance between hope and reality.
Ambitious projects are stuck on drawing boards or have been held up, she wrote, “by land and ideological disputes, logistical and contracting problems, staffing shortages and even weather.” A recovery commission led by the Haitian prime minister and former President Bill Clinton was meant to oversee the great rebuilding, but was slow to get started and is now defunct, with not much to show for its 18-month mission.
The flood of aid has slowed to a trickle; much of what was promised was never delivered or remains undisbursed, or was disbursed but not actually spent, or was spent on things like emergency food, water and tents, which are important but don’t leave a lasting imprint. Money for long-term recovery has proved hard to spend, or slow to show results.
More than $1 billion allocated for Haiti remains in the United States Treasury, almost all of it for recovery, though America is hardly the only donor sitting on unspent aid. And more than 350,000 people who lost their homes that terrible day are still living in tent camps. The rubble has finally been cleared, but building permanent homes has taken a back seat to other matters.
The Times article reads like a catalog of missteps, of old mistakes and new ones that together present — to put the most optimistic spin on it — fresh opportunities to learn. One was the tendency of humanitarian aid organizations to go back to what they had been doing before the earthquake, in areas like sanitation, health, education and transportation, without the guidance of a broad plan and clear priorities for how best to repair the nation. Another failure has been the persistent unwillingness to include Haitians in the planning and execution of projects, leaving them feeling like bystanders in their own country and squandering opportunities to build government ministries and institutions capable of sustaining themselves once the world’s attention and donations are gone.
Most recovery aid has been channeled through foreign agencies, nonprofit organizations and private contractors, a practice that inflates administrative costs and perpetuates cycles of dependency. And then there was the simple and shameful failure of global donors to meet their promises to deliver money and aid.
The State Department and other defenders of the international response point to some progress, like a new industrial park north of Port-au-Prince, the capital, providing the first 1,300 of what are supposed to be many thousands of manufacturing jobs. They say homes are being built, even if permanent ones are rising slowly and expensively. They plead for patience in a country where institutions were weak or nonexistent before the quake, which all but destroyed the government, flattening nearly every ministry and killing 20 percent of Haiti’s civil servants.
Throughout the halting recovery, Haitians have borne up under other severe but unrelated afflictions: destructive storms, food shortages and disease. A recently announced 10-year and $2.2 billion effort to rid Haiti and the Dominican Republic of cholera by improving water and sanitation will require close coordination among the Haitian government, the United Nations, United States and other partners. Senator John Kerry, who has paid astute attention to Haitian issues in the Senate, will be well placed to do so if he becomes the next secretary of state. As long as the miseries continue, the need for the world to get this right remains.