Haiti After the Earthquake (5 page)

But I didn't move a leaden muscle and did not wake again until the sun was high in the sky.

A
lthough many of those
who came to Haiti right after the quake claimed to have expertise in disaster relief, there was ample reason for skepticism. From the beginning, we struggled to help the injured and otherwise afflicted, but it wasn't always clear what needed to be done. We continued in this emergency mode for days, furnishing direct care to the injured and displaced, while trying to make (or help others make) decisions about the coordination and delivery of services. This tension was everywhere: on the one hand, a particular injured or sick person, but on the other, decisions about shelter or clinical services for hundreds of thousands of displaced people. Most of the policy decisions were, of course, not being made by physicians. But never before had my medical colleagues been pushed to think harder about challenges so far removed from clinical care.

In many ways, however, this tension—between serving those right in front of you and seeking to reduce the longer-term risk of others ending up in front of you—has been the chief tension of my work for years. This tension has animated the work of my students, trainees, and coworkers, too, because poverty and inequality are the drivers of most of the diseases and misfortunes we see. Even an
earthquake is not only a “natural” disaster, just as the destructiveness of Hurricane Katrina and the storms that struck Haiti in 2004 and 2008 were influenced by many factors besides weather. These events reveal the social roots of disaster.
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It's an undisputed fact that, even before the quake, Haiti, Latin America's first independent nation, was plagued by political, economic, and ecological fragilities. Part of this book's project is to examine how Haiti and its institutions became so weak: to lay out the history of the chronic ailment. The other main topic of this book—beyond an account of the quake—is this tension between praxis and policy: the struggle between direct service, which is what doctors are supposed to provide, and policy, which is what politicians and legislators are supposed to formulate with, in theory, the guidance of the citizenry they represent.

For years, I'd sought to face this challenge through direct service to the poor—especially those affected by infectious diseases—and, as a professor at Harvard Medical School, by writing and teaching about the large-scale forces that shape vulnerability to suffering and premature death. This dual mandate is, as I've said, a fact of life for my students, trainees, and for all my colleagues at Partners In Health. We work in a dozen nations—including the United States—where the poor suffer disproportionately. During my first decade in Haiti, I mostly left policy alone, except to critique it. In books and articles, my colleagues and I sought to bridge the gap between service and policy or at least to help inform policy discussions. But writing for an academic audience is not the same as sitting through policy meetings and diplomatic conferences. Academic physicians, including those in the field now called social medicine, would be hard-pressed to show concrete ways in which research and writing shape health policy or lead to improved implementation of services.

Health care does not exist in a separate universe from politics. Fiscal policy, infrastructure, wages, taxation—all affect the practice of medicine, and we learned, over the years, that seeking to improve health policy was one of the best ways to defend the modest gains we'd achieved for our patients. This effort to link praxis and policy
started on the local level. For example, our work with Haiti's national tuberculosis and AIDS programs in the late eighties began in a handful of towns and districts. A few years later, thanks in large part to Dr. Jim Kim, another founder of Partners In Health and then also a Harvard faculty member, and to Dr. Jaime Bayona, a Peruvian colleague, we became more engaged in international health policy debates about tuberculosis, including the more difficult-to-treat forms of drug-resistant tuberculosis. “Difficult-to-treat” did not mean “untreatable,” we argued, again and again, in meetings and in obscure medical journals.
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Unlike many in the international agencies we sought to persuade, we had direct clinical experience treating patients with drug-resistant tuberculosis, and we could claim some degree of authority thanks to high cure rates in Haiti and Peru.

These debates led us to Russia, which was facing epidemics of drug-resistant tuberculosis, as the United States had faced a few years prior. In Russia and elsewhere in the former Soviet Union, these epidemics were large and were proving especially deadly inside prisons.
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The financier-philanthropist George Soros had donated more than twelve million dollars to provide tuberculosis care in Russian prisons. He'd asked our team to help because conventional treatment approaches were failing to cure patients with drug-resistant strains. But the program as conceived still did not have enough financing for second-line medications (needed to treat drug-resistant tuberculosis) or enhanced lab capacity, which would permit clinicians to discern which patients needed such drugs. When we asked Soros for more money, instead of saying yes, as we expected, he said no. It would be a mistake, he explained, to let governments off the hook.

It was this work (and Soros himself) that led me in the 1990s to visit the White House, where Hillary Clinton became a patron of our efforts to raise the standard of tuberculosis care in Russian prisons and elsewhere. (TB was not a regional epidemic, but a global threat.) She soon also became a friend and mentor. Over the next decade I saw firsthand how high-level policy interventions could open up new—and sometimes vast—possibilities for improved delivery of services to the poor and marginalized. In one prison in western
Siberia, we worked with the Russian Ministry of Justice, to bring case-fatality rates from 26 percent (more than a quarter of those on treatment died) to close to zero within two years.
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The drugs were expensive, but they worked, and better planning and pooled procurement would drive costs down further. In its first year of operation, the Gates Foundation supported an ambitious program to scale up these complex interventions in Peru while also augmenting efforts in Russia.

The tuberculosis pandemic was one complex health problem among many, and neither Russia's prisons nor Lima's slums were the world's poorest settings. Other epidemics were spreading in Africa, even as science gave us new tools to fight them. By the close of the millennium, it was obvious that we needed a radically different approach to the health problems of the poor. Existing models were premised on the idea that public health and medicine should be cheap. But these anemic approaches wouldn't do much to lessen the burden of disease on the poor. Those on the front lines encountered millions with AIDS and tuberculosis and malaria, and also every imaginable cancer and noncommunicable disease. Because these patients were poor before they became sick, we needed something other than fee-for-service models. We also needed heavy investments in infrastructure, training, and direct services, especially for the bottom billion—the poorest and most marginalized. Implementation was the biggest challenge—and figuring out how to finance it.

AIDS was not only the leading cause of adult death in many of the places we worked; by the year 2000, it surpassed tuberculosis as the world's leading infectious killer. As we showed in central Haiti, effective diagnostics and therapeutics for AIDS could be delivered to even the most destitute sick with the help of community health workers.
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But few seemed interested in funding AIDS care in poor countries. Policy debates pitted prevention against care—as if these were competing priorities rather than complementary ones—and many thought doing both would be too expensive. Partners In Health had been able to finance AIDS treatment in central Haiti because of the generosity of people such as Tom White, a Boston contractor who
had given us millions of dollars over the years. But dependence on angel investors wasn't going to save millions of lives in Africa, much less integrate prevention and care and strengthen weak health systems. “You need billions, not millions, of dollars,” Jeff Sachs, a development economist and colleague at Harvard, observed.
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In December 2000, Sachs and his wife, Sonia, a pediatrician, came to central Haiti to meet some of our AIDS patients, most of whom were flourishing with the help of antiretroviral drugs—the very drugs that many health policy experts argued were too difficult to administer in such poverty-stricken settings. On the spot, Sachs promised to work with the United Nations and several governments to create new funding mechanisms to respond to AIDS, tuberculosis, and malaria, three diseases that by 2001 were claiming six million lives a year. He kept his promise. I was lucky enough to travel to New York with the Haitian delegation, led by another health advocate, First Lady Mildred Aristide, to the first UN general assembly on AIDS. We collectively pushed for new resources to respond to what was then a fairly new and now global threat. A group of Harvard faculty also published a consensus statement arguing that AIDS care and prevention needed to be integrated in the settings hardest hit by the disease.
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A year later, with the help of Sachs and many others, including heroic AIDS activists, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was born. One of the Global Fund's first major grants went towards AIDS programs in Haiti. That same year, a group of physicians lobbied the new U.S. administration to pursue the same agenda, and before long, George W. Bush launched the U.S. President's Emergency Plan for AIDS Relief. Together, these two programs brought billions of dollars to bear on the neglected diseases of the poor, and saved—no exaggeration—millions of lives. We believed that these disease-specific programs could, if designed properly, be used to strengthen health systems generally, as they had done in central Haiti.
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Jim Kim left Harvard for the World Health Organization to pursue this vision—bringing better medical services to the world's bottom billion—on the level of global policy. (Jim later became president of Dartmouth College and was responsible for Dartmouth's
significant presence in Haiti in the first weeks after the quake.)

It was during these years, when I was shuttling between Haiti and Harvard, that President Clinton launched the Clinton Health Access Initiative (CHAI) and became another mentor and colleague. At an AIDS meeting in Barcelona in the summer of 2002, he made plans to come to Haiti and encouraged us to work in Rwanda. “You watch,” he predicted then, “Rwanda will become a model of smart development.” Shortly thereafter, Ira Magaziner, the other driving force behind CHAI, also visited AIDS patients—many of whom had to all intents and purposes risen from the dead after receiving the right treatment—and facilities in central Haiti.

By 2003, when President Clinton arrived to announce his foundation's intention to help out in Haiti, we were ready to extend our work throughout the center of the country. Indeed, we'd already started and had a crackerjack Haitian team led by Fernet Léandre, Maxi Raymonwille, Loune Viaud, and many others. It was about that time that Louise Ivers, David Walton, Evan Lyon, and Joia Mukherjee, introduced earlier, joined the Haiti team to scale up our efforts within the public sector health system. With support from the Global Fund, we designed our effort to help not only AIDS patients but all patients, and to focus on prevention at the same time. The idea was to work in public facilities (such as the General Hospital, which is where Clinton made his announcement), rather than competing with or supplanting them. The Haitian government was squarely behind the plan. I was as enthusiastic as I'd ever been about linking direct service to training (at Harvard and in Haiti) and research that might inform health policy.

We'd also launched, with Cuban colleagues and the Aristide Foundation, a new medical school that would focus on improving the health of the Haitian poor, especially in rural areas.
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(The great majority of Haiti's health professionals worked in Port-au-Prince.) We were set for a good decade, I thought, and so did our students and trainees at Brigham and Women's Hospital (the Harvard hospital where I trained and where we'd launched training programs for young doctors committed to global health).

But then came the February 2004 coup in Haiti, which further weakened the public health infrastructure.
¹⁰
Haiti's president and his wife, our staunchest advocates in the fight against AIDS, were spirited away to the Central African Republic in a way that resembled nothing so much as the “extraordinary renditions” of suspected terrorists described in the popular press. Haiti's elected government was replaced by a group of unelected officials (unelected by Haitians, in any case), and the Prime Minister, Yvon Neptune, was tossed in jail without charges. It was a dispiriting time, in large part because of the lies and distortions that figured prominently in many official policies, including some of my own country.

Although the Global Fund efforts went forward, the Clinton Foundation declined to work in Haiti under the régime installed after the coup (an honorable gesture, which made absolutely no impression on the de factos, as they were called). Instead, the Clinton Foundation urged Partners In Health to launch a major rural health initiative in Rwanda with the national government's health authorities. I'd visited Rwanda before and admired its governance, born of horrible circumstances and still subject, at the time, to legitimate critique and negative propaganda (some of which came from France, some from surviving architects of the 1994 genocide, but also some from more credible voices in human rights circles). In the fall of 2004, we made a long-term commitment to begin a comprehensive rural health initiative in Rwanda.