Sen­a­tor John Kerry (D-MA) con­ducted a hear­ing of the For­eign Rela­tions Com­mit­tee to exam­ine res­cue, recov­ery and recon­struc­tion efforts in Haiti. Paul Farmer, United Nations Spe­cial Envoy for Haiti was a fea­tured witness.

Wash­ing­ton, DC

Watch hear­ing here.

Read UN Deputy Spe­cial Envoy Dr. Paul Farmer’s full tes­ti­mony below

Tes­ti­mony of Dr. Paul Farmer to the US Sen­ate Com­mit­tee on For­eign Relations

27 Jan­u­ary 2010

Thank you for invit­ing me to tes­tify today before the Sen­ate Com­mit­tee on For­eign Rela­tions. I speak as the U.N. Deputy Spe­cial Envoy for Haiti—President Clin­ton, as you know, is the Spe­cial Envoy—and also as a physi­cian and teacher from Har­vard who has worked for over twenty-five years in rural Haiti. Today, my hope is to do jus­tice to Haiti not by chron­i­cling the events of the past two weeks, which are well known to you, but by attest­ing to the pos­si­bil­ity of hope for the coun­try, and of the impor­tance of mean­ing­ful invest­ment and sus­tain­able devel­op­ment in Haiti.

That said, I will not pre­tend that hope is not at times dif­fi­cult to muster.

As I was fly­ing from Port-au-Prince to Mon­treal on Mon­day, headed to a con­fer­ence on coor­di­nat­ing responses to the mas­sive earth­quake, I did the painful math in my head and counted close to fifty col­leagues, friends, and fam­ily mem­bers who had lost their lives in the space of a minute.

The after­noon of the earth­quake, sev­eral of my col­leagues from Part­ners In Health and the UN, were, iron­i­cally, in Port-au-Prince for a meet­ing about dis­as­ter risk reduc­tion. Part­ners In Health, through its Hait­ian sis­ter orga­ni­za­tion, pro­vides health care to the rural poor. By focus­ing on train­ing and employ­ing local tal­ent, we have grown a great deal over the years. We are cur­rently serv­ing a pop­u­la­tion of well over 1.2 mil­lion and count about five thou­sand employ­ees, most of them com­mu­nity health workers.

Of course, not all our col­leagues sur­vived. But the vast major­ity of them did sur­vive, and they have spent the last two weeks work­ing day and night to relieve the stag­ger­ing suf­fer­ing of the wounded and dis­placed. Pres­i­dent Clin­ton, our col­leagues, and I have been in the cities of Port-au-Prince, Jacmel, and Léogâne, as well as the less-affected Cen­tral Plateau and Art­i­bonite Val­ley. Every­where we have seen acts of great brav­ery and solidarity.

In addi­tion to the hero­ism of friends and col­leagues, I would like to note for the record the dig­nity and patience of the long-suffering Hait­ian peo­ple. Dur­ing a visit last week to Haiti’s largest teach­ing hos­pi­tal, which shares a cam­pus with the ruins of the nurs­ing and med­ical schools, Pres­i­dent Clin­ton remarked that no other peo­ple in the world would be so patient and calm in the face of so much suf­fer­ing. This obser­va­tion, though accu­rate, must not be mis­un­der­stood. Peo­ple in Haiti are afraid not only for their options and futures, but still quite sim­ply for their safety. A few nights ago, we sat in empty wards: hear­ing of impend­ing after­shocks, the patients bolted out­side with their IVs dan­gling from their arms. They refused, as have so many, to sleep inside the building—any building—but instead found tar­pau­lins and sheets, and lay down in the open courtyard.

This scene has repeated itself through­out the coun­try and is a reminder of the logis­tics chal­lenges fac­ing all those who would be involved in the pro­vi­sion of shel­ter, clean water, and health­care. The relief efforts, focused now on address­ing the ini­tial wave of dev­as­ta­tion from the earth­quake, will soon turn to a new set of con­cerns. Hastily cob­bled together camps are at risk of out­breaks of cholera and other water­borne dis­ease. The Hait­ian gov­ern­ment has wisely pro­posed avoid­ing huge camps, which will be dif­fi­cult to man­age, but we must has­ten our efforts to get tents, tar­pau­lins, and latrines or com­post­ing toi­lets to Haiti. It is hum­bling to see the relief efforts be so slow—in large part because deliv­ery of ser­vices was so weak before the quake. Now we must do more to get food and water to peo­ple every day for some time to come. Cre­at­ing safe schools and safe hos­pi­tals, even makeshift ones, is a known need in rebuild­ing a soci­ety, and storm resis­tant hous­ing must also be a care­fully con­sid­ered pri­or­ity since there is lit­tle time before the rainy sea­son. Stu­dents need to be back in school; the plant­ing sea­son can­not be missed and requires fer­til­izer, seeds, and tools.

How will we fund such set­tle­ments, ongo­ing relief, the sow­ing of seeds, and the recon­struc­tion that must fol­low? Major pledges have been made by the U.S., Canada, Japan, Spain, Brazil, the Euro­pean Union, the Inter-American Devel­op­ment Bank, the World Bank, and others.1 Indeed, most coun­tries have responded. Even in far away and once-afflicted Rwanda, a group of com­mu­nity health work­ers mak­ing less than $200/month have been able to pull together $7000 in dona­tions for their col­leagues in Haiti. This is but a small por­tion of the bil­lions needed, but hard to sur­pass as an elo­quent tes­ti­mony of human solidarity.

Even if ade­quate resources are avail­able, the task before us will be extremely dif­fi­cult. Med­ical jar­gon, though at times arcane, can be help­ful here. Today, Haiti is fac­ing what we would term “acute on chronic” prob­lems. Before Jan­u­ary 12, the coun­try was already fac­ing huge long-term chal­lenges in pub­lic health and edu­ca­tion, the unem­ploy­ment rate over 70%, and a major­ity of its pop­u­la­tion was liv­ing on less than two dol­lars a day. Food and water inse­cu­rity were already huge problems.4 Does this cat­a­stro­phe cre­ate a chance for all of us to have a sounder, more solidarity-based rela­tion­ship with Haiti? Or is it to be yet another chap­ter in a jere­miad of suf­fer­ing and abuse of power? In my last tes­ti­mony here, in 2003, I expressed con­cern that the lat­ter pos­si­bil­ity was likely given our poli­cies at that time. Today I will spend my time focus­ing on the poten­tial for an entirely recon­sid­ered rela­tion­ship between the two old­est inde­pen­dent coun­tries in the Amer­i­cas: Haiti and my own.

Let me offer, as one exam­ple of the dif­fi­cult rela­tions between Haiti and the inter­na­tional com­mu­nity (and an echo of the nineteenth-century machi­na­tions I dis­cussed in my last tes­ti­mony before this com­mit­tee), the donor con­fer­ence I attended here in Wash­ing­ton last April. It was one of only two donor con­fer­ences I have ever attended, the sec­ond being in Mon­treal ear­lier this week. The results of the first are note­wor­thy and wor­ri­some: despite $402 mil­lion pledged to sup­port the Hait­ian government’s Eco­nomic Recov­ery Pro­gram, when the coun­try was try­ing to recover from a series of nat­ural dis­as­ters result­ing in a 15% reduc­tion of GDP, it is esti­mated that a mere $61 mil­lion have been disbursed.5 In the Office of the Spe­cial Envoy, we have been track­ing the dis­burse­ment of pledges, and as of yes­ter­day we esti­mate that 85% of the pledges made last year remain undisbursed.

Many of us worry that, if what’s past is pro­logue, Haitians them­selves will be blamed for this tor­por. But as we have argued before, there are seri­ous prob­lems in the aid machin­ery, and these have con­tributed to the “deliv­ery chal­lenges” on the ground.6 The aid machin­ery cur­rently at work in Haiti keeps too much over­head for its oper­a­tions and still relies over­much on NGOs or con­trac­tors who do not observe the ground rules we would need to fol­low to build Haiti back bet­ter. The fact that there are more NGOs per capita in Haiti than in any other coun­try in the hemi­sphere is in part a reflec­tion of need, but also in part a reflec­tion of over­re­liance on NGOs divorced from the pub­lic health and edu­ca­tion sectors.

Haiti will con­tinue to need the con­trac­tors, and the NGOs and mis­sion groups, but more impor­tantly we will need to cre­ate new ground rules—including a focus on cre­at­ing local jobs for Haitians, and on build­ing the infra­struc­ture that is cru­cial to cre­at­ing sus­tain­able eco­nomic growth and ulti­mately reduc­ing Haiti’s depen­dence on aid.

In other words, what we need is a way of “build­ing back bet­ter” that strength­ens gov­er­nance but also strength­ens the Hait­ian econ­omy to pro­vide for the needs of its peo­ple, espe­cially the vast major­ity of Haitians who are des­per­ately poor. There is an oppor­tu­nity not only to build Haiti back bet­ter, but to build a more func­tional and ben­e­fi­cial aid struc­ture. Over the past two decades, US aid poli­cies have see­sawed between embar­goes and efforts to bypass gov­ern­ments, includ­ing elected ones not to Washington’s taste. Nei­ther the inter­na­tional com­mu­nity nor the United States pro­vided cred­i­ble, long-term, finan­cial invest­ment in Haiti. Restruc­tur­ing for­eign aid and for­giv­ing Haiti’s crip­pling debts are essen­tial to help­ing the coun­try recover. US laws, includ­ing the For­eign Assis­tance Act of 1961 and its later revi­sions, pre­vent direct invest­ment in the pub­lic sec­tor; we will need to revisit these poli­cies. Debt for­give­ness is also needed to ease the finan­cial drain that would oth­er­wise hin­der eco­nomic recov­ery and growth.

In build­ing back Haiti, a cred­i­ble body that has been work­ing in Haiti could help to house a recov­ery fund. We need to com­mit funds and also to dis­burse them. To quote Jeff Sachs, “Haiti does not need a pledg­ing ses­sion; it needs a bank account to fund its sur­vival and reconstruction.”9 Such an account should be man­aged in col­lab­o­ra­tion with part­ners, the UN, and, of course, Hait­ian lead­er­ship, which would work directly and openly with part­ners to design and imple­ment recov­ery plans coor­di­nated at cen­tral and local lev­els. The effort must include a com­pre­hen­sive post-disaster needs assess­ment, which should be sup­ported by the US and other partners.

Might such plans work? In some of the dark­est moments of the last two weeks, when the inca­pac­ity and lack of coor­di­na­tion of insti­tu­tions on the ground was revealed repeat­edly, I have thought often of Rwanda and what hap­pened there in 1994. As a physi­cian and teacher at Har­vard, I have been lucky to work with the Clin­ton Foun­da­tion, Part­ners In Health, and the gov­ern­ment of Rwanda on rebuild­ing health infra­struc­ture in three of the last four dis­tricts that lacked cen­tral hos­pi­tals. As in rural Haiti, this has been a very pos­i­tive expe­ri­ence. It has resulted in thou­sands of jobs for Rwan­dans, and has cre­ated a broadly acces­si­ble health care infrastructure—all with a mod­est price tag com­pared to tra­di­tional aid contractors.

If such progress can be made in Rwanda, which boasts strong lead­er­ship but in 1994 was the poor­est coun­try in the world,11 then one hopes it can be made else­where. In part because of this pos­i­tive expe­ri­ence of work­ing together with the Clin­ton Foun­da­tion in Rwanda (and in Malawi and Lesotho), I joined Pres­i­dent Clin­ton six months ago as his deputy in the UN role he orig­i­nated. As Spe­cial Envoy for Haiti, Pres­i­dent Clin­ton has focused his atten­tion not only on hold­ing donors to the finan­cial pledges they made, but also on reduc­ing the risk of dis­as­ters and on job cre­ation through the mas­sive pub­lic works that are nec­es­sary to refor­est Haiti, pro­tect water­sheds, and improve agri­cul­tural yield—the back­bone of the Hait­ian econ­omy. Pri­vate invest­ment in Hait­ian busi­nesses, espe­cially small and medium-sized ones, is crit­i­cal to ren­der­ing Haiti free of any depen­dence on aid—the goal of Rwanda by 2020, and more­over, a goal likely to be met. Haiti also has, he noted, great poten­tial as a tourist attrac­tion but lacks the infra­struc­ture to wel­come the mil­lions of peo­ple who should see Haiti’s nat­ural beauty and his­toric trea­sures like King Henri Christophe’s Citadel.

This has been our mis­sion: to build back bet­ter from the 2008 storms. We believe that these efforts were begin­ning to bear fruit. We had sched­uled a meet­ing last week in the Hotel Mon­tana to bring in another round of investors and also to dis­cuss job cre­ation. As many of you know, this hotel is no longer stand­ing, and most inside it per­ished on Jan­u­ary 12. But the need for such invest­ments, and the need for pub­lic works that would cre­ate hun­dreds of thou­sands of jobs, remains.

If there is any sil­ver lin­ing to this cloud, it is that we can push job cre­ation. It is a strange irony that sup­port­ers of eco­nomic assis­tance to Haiti are now obliged to shill for “cash for work” programs—for the quaint notion that peo­ple should be paid for their labor. Let us at least be hon­est: it is absurd to argue that vol­un­teerism and food-for-work pro­grams will cre­ate sus­tain­able jobs. But if we set the ground rules on recon­struc­tion cor­rectly, we will be able to cre­ate sus­tain­able jobs.

In other words, if we focus the recon­struc­tion efforts appro­pri­ately, we can achieve long-term ben­e­fits for Haiti. The UNDP is help­ing to orga­nize pro­grams of this kind, which should be sup­ported and extended around the coun­try. Putting Haitians back to work and offer­ing them the dig­nity that comes with hav­ing a job and its basic pro­tec­tions is exactly what brought our coun­try out of the Great Depression.

This was always the right thing to do, and aid pro­grams per­sis­tently fail to get it right. So here is our chance: if even half of the pledges made in Mon­treal or other such meet­ings are linked tightly to local job cre­ation, it is pos­si­ble to imag­ine a Haiti build­ing back bet­ter with fewer of the social ten­sions that inevitably arise as half a mil­lion home­less peo­ple are inte­grated into new communities.

Haiti needs and deserves a Mar­shall Plan—not the “con­tain­ment” aspects of that pol­icy, unless we are explicit about con­tain­ing the ill effects of poverty, but the social-justice ele­ments. But we need to be hon­est about the dif­fer­ences between post-war Europe and Haiti in 2010. Part of the prob­lem, I’ve argued, is the way in which aid is deliv­ered now as com­pared to in 1946—well before the term “belt­way ban­dits” was coined. We need a recon­struc­tion fund that is large, man­aged trans­par­ently, cre­ates jobs for Haitians, and grows the Hait­ian econ­omy. We need a recon­struc­tion plan that uses a pro-poor, rights-based approach far dif­fer­ent from the char­ity and failed devel­op­ment approaches that have marred inter­ac­tions between Haiti and much of the rest of the world for the bet­ter part of two centuries.

Our coun­try can be a big part of this effort. Debt relief is impor­tant, but only the begin­ning. Any group look­ing to do this work must share the goals of the Hait­ian peo­ple: social and eco­nomic rights, reflected, for exam­ple, in job cre­ation, local busi­ness devel­op­ment, water­shed pro­tec­tion (and alter­na­tives to char­coal for cook­ing), access to qual­ity health care, and gen­der equity. Con­sid­er­ing all these goals together ori­ents our strate­gic choices. For exam­ple, cash trans­fers to women, who hold the purse strings in Haiti and are arbiters of house­hold spend­ing, will have sig­nif­i­cant impact. This is a chance to learn and move for­ward and build on lessons learned in adversity—to build hurricane-resistant houses with good ven­ti­la­tion to improve air qual­ity from stove smoke; to build com­mu­ni­ties around clean water sources; to refor­est the ter­rain to pro­tect from ero­sion and to nur­ture the fer­til­ity of the land for this pre­dom­i­nantly agri­cul­tural coun­try. It is the chance to cre­ate shel­ter, grow the local econ­omy and incomes, and invest in improved health. This will do much to decrease the risk of another calamity, and to decrease the vul­ner­a­bil­ity of the poor—especially as we face the sec­ond wave of prob­lems, includ­ing epi­demic dis­ease born of the earthquake.

As a doc­tor, I can tell you that bad infra­struc­ture and thought­less pol­icy are vis­i­ble in the bod­ies of the poor, just as are the ben­e­fits of good pol­icy and well-designed infra­struc­ture. In my almost 30 years in Haiti I have wit­nessed many polit­i­cal inter­ven­tions and mul­ti­ple coups. They have been unpleas­ant, even if their effects pale in the shadow of what we are now expe­ri­enc­ing. Many peo­ple look at Haiti and despair. They say that aid is wasted, that there is no hope for this coun­try. I would answer them with the pos­i­tive expe­ri­ence of build­ing Haitian-led pro­grams in the Cen­tral Plateau and Art­i­bonite Val­ley regions that have cre­ated five thou­sand jobs for peo­ple who would oth­er­wise have no steady work. I advance this model not because it is asso­ci­ated with our efforts, but because job cre­ation is the surest way to speed up the cash flow that is essen­tial now. It is also the fastest way to make amends for our past actions towards Haiti, which have not always been honorable.

Sit­ting before you, I am at my core opti­mistic about the pos­si­bil­i­ties before us and the poten­tial of our sup­port to help res­cue and trans­form our poor­est neigh­bor. The response from cit­i­zens of the United States to the recent events in Haiti has been over­whelm­ing and encour­ag­ing. There is the promise of sol­i­dar­ity by our lead­er­ship to make long-term com­mit­ments to the kinds of invest­ments needed in Haiti—and to ful­fill­ing them.

For two cen­turies, the Hait­ian peo­ple have strug­gled for basic human and eco­nomic rights, the right to health care, the right to edu­ca­tion, the right to work, the right to dig­nity and inde­pen­dence. These goals, which Haitians share with peo­ple all over the world, should direct our poli­cies of aid and rebuilding.

As I wrote with col­leagues in a recent op-ed—which is avail­able in my writ­ten testimony—as physi­cians work­ing in Haiti, we know first-hand that Haiti itself will soon be the casu­alty if we do not help build back bet­ter in the way envi­sioned by Haitians themselves.

1) Walker, P. “Haiti earth­quake aid pledged by coun­try.” Guardian.co.uk 26 Jan­u­ary 2010. Avail­able at: http://www.guardian.co.uk/news/datablog/2010/jan/14/haiti-quake-aid-pledges-country-donations (Accessed Jan­u­ary 27, 2010)

2) Flintoff, Corey. “In Haiti, a low-wage job is bet­ter than none,” All Things Con­sid­ered, June 14, 2009.

Avail­able at: http://www.npr.org/templates/story/story.php?storyId=104403034 (Accessed Jan­u­ary 27, 2010)

3) In 2006, the World Bank esti­mated that 78% of Haiti’s 9 mil­lion peo­ple lived on less than $2 per day. See Haiti at a Glance, World Bank, Devel­op­ment Data Group (DECDG). Avail­able at: http://siteresources.worldbank.org/INTHAITI/Resources/Haiti.AAG.pdf (Accessed Jan­u­ary 26, 2010).

4) For an overview of Haiti’s water inse­cu­rity and past delays in inter­na­tional com­mit­ments to address this cri­sis, see Varma MK, Sat­terth­waite ML, Klas­ing AM et. al. Wòch nan soley: The denial of the right to water in Haiti. Robert F. Kennedy Memo­r­ial Cen­ter for Human Rights, Cen­ter for Human Rights and Global Jus­tice at NYU School of Law, Part­ners In Health, and Zanmi Las­ante, 2008. Avail­able at: http://www.chrgj.org/projects/docs/wochnansoley.pdf (accessed Jan­u­ary 27, 2010).

5) This esti­mate of dis­burse­ments was pre­pared in Jan­u­ary 2010 in an inter­nal mem­o­ran­dum of the UN Office of the Spe­cial Envoy For Haiti. Pres­i­dent Clin­ton, in his capac­ity as UN Spe­cial Envoy, fre­quently appealed to donors to ful­fill their com­mit­ments. See Hel­prin, J, “Bill Clin­ton chides nations over help to Haiti.” Asso­ci­ated Press„ Sep­tem­ber 9, 2009. Avail­able at: http://www.newsvine.com/_news/2009/09/09/3243861-bill-clinton-chides-nations-over-help-for-haiti (accessed Jan­u­ary 27, 2010).

6) Farmer, P. “Chal­leng­ing ortho­dox­ies: The road ahead for health and human rights.” Health and Human Rights: An Inter­na­tional Jour­nal 2008; 10(1): 5–19.

7) Daniel, Tren­ton, “Bill Clin­ton tells dias­pora: ‘Haiti needs you now,’” Miami Her­ald, August 9, 2009. Avail­able at: http://www.miamiherald.com/news/americas/haiti/story/1179067.html (accessed Jan­u­ary 27, 2010).

Farmer P, Smith Fawzi MC, and Nevil P. “Unjust embargo of aid for Haiti.” The Lancet 2003; 361: 420–423.

9) Sachs, J. “After the earth­quake, how to rebuild Haiti from scratch.” Wash­ing­ton Post, 17 Jan­u­ary 2010. Avail­able at: http://www.washingtonpost.com/wp-dyn/content/article/2010/01/15/AR2010011502457.html (Accessed Jan­u­ary 27, 2010)

10) Repub­lic of Rwanda, Min­istry of Health, and Part­ners In Health. African Rural Health­care: An Eval­u­a­tion of the South Kay­onza, Rwanda Project (2005–2011). Pro­gramme Report, Min­istry of Health, 2006.

11) United Nations Devel­op­ment Pro­gramme. Human Devel­op­ment Report: 1997. New York: Oxford Uni­ver­sity Press, 1997. 146–148. Avail­able at: http://hdr.undp.org/en/media/hdr_1997_en_indicators1.pdf (accessed Jan­u­ary 27, 2010).

12) Repub­lic of Rwanda. Rwanda Vision 2020. Kigali: Min­istry of Finance and Eco­nomic Plan­ning, Repub­lic of Rwanda, 2002. Avail­able at: http://www.cdf.gov.rw/documents%20library/important%20docs/Vision_2020.pdf (accessed Jan­u­ary 27, 2010).