Dr. Paul Farmer, UN Deputy Special Envoy for Haiti and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, released a new book last week to coincide with the 18-month anniversary of the Jan. 12, 2010 earthquake. In addition to containing a dozen short essays by various contributors, Haiti After the Earthquake provides Farmer's firsthand account of his relief and reconstruction efforts as a diplomat and co-founder of the NGO Partners in Health, which has over a quarter-century of experience in Haiti.

Farmer is perhaps unique in his successful straddling of distinct, and at times, conflicting spheres of international development. While having authored numerous indictments of U.S. policy toward Haiti, in early 2009 he contemplated accepting a position in the Obama State Department to coordinate overseas health initiatives or to run the U.S. Agency for International Development (USAID). Shortly thereafter, former President Bill Clinton, who was appointed UN Special Envoy to Haiti in April 2009, asked him to be his deputy at the United Nations. He was apparently undeterred by Farmer's prior denunciations of the "cynical realpolitik of Bill Clinton's presidency" of the 1990s. In particular, Farmer had characterized as an "abomination and a crime" Clinton's continuation of "his predecessor's policies" of indefinite detention of Haitian asylum seekers in a Guantánamo Bay naval base, which "resembled a dungeon." Farmer and Clinton have since forged a camaraderie as the Clinton Foundation assisted Partners in Health in its AIDS initiatives in Haiti in 2003, and, in "an honorable gesture," the foundation "declined to work in Haiti under the regime installed after the coup" in 2004 against Jean-Bertrand Aristide, the democratically elected president (28). Clinton then spurred Farmer to launch a major rural health initiative in Rwanda, where Farmer currently resides, and in the book, Farmer refers to Clinton as a "mentor and colleague" (27).

While delving into some history and politics, Haiti After the Earthquake's aim is narrower than Farmer's previous works like The Uses of Haiti. Farmer's overriding concern, as related in the book, is how to "build back better," considering that "the quake offered a chance to do reconstruction right" (38, 100). The book often highlights Farmer's endeavors to promote a principled, Haitian-driven agenda within elite spheres of policymaking. He explains how he accepted Clinton's honorary post at the UN, despite its "huge, largely military, presence in Haiti" (38). Farmer had strongly condemned the UN-bolstered de facto government after the coup d'etat, and in the book, he continues to express his "doubts about the peacekeeping mission in Haiti, stemming from the events of 2004 and after" (41). Although he delimited his own agenda within the UN to health, education and food security, his ambitions and influence are much broader. Upon entering the UN, he "insisted on bringing Haitians onto the team—none had been proposed," while hoping to "move the [UN's] focus from military assistance to development assistance, from security to human security, towards freedom from want" (37-38).


One of Farmer's official goals, food security, allows him to lay out a broad economic vision, informed by Haitian voices. Agriculture, he notes, "continued to be hammered by the forces of nature, by the punishingly unfair political economy…and by the simple fact that few young Haitians wanted to work in a sector that offered diminishing returns…Addressing these problems required massive pro-poor investments in agriculture, which would do more to alleviate Haitian poverty than fifty thousand new assembly jobs" (35). One of the essay contributors to Haiti After the Earthquake, journalist and UN Secretary-General Ban Ki-moon's former spokeswoman Michèle Montas-Dominique, conducted a series of surveys and discussion groups with displaced persons, farmers and tradespeople. Farmer made sure her findings were presented at the UN's International Donors Conference in March, 2010. On the issue of agriculture, she found:

The Haitians we spoke to, including city-dwellers, stressed agricultural production as a top priority. Agriculture—perhaps more than any other sector—is considered essential to the country's wealth, and the prevailing sentiment is that the peasantry has always been neglected. Invariably, interlocutors made concrete demands for training, equipment, seeds, easier access to credit, and the introduction of modern agricultural techniques…Many people said they would rather work on the land than seek informal jobs in the towns, from selling second-hand clothing in the streets to the "cash for work" menial jobs available since the quake. All agreed that the country can and should become self-sufficient in food. (268)

In a CEPR paper published over a year ago entitled "Using Food Aid to Support, Not Harm, Haitian Agriculture," we noted that it is crucial "to immediately reduce the harm caused by imported, subsidized rice. This can be done by having the international community immediately commit to buying Haitian rice" at a premium, to then distribute nationally. France's commitment to increase locally purchased rice for food aid, which we wrote about this week, could provide the impetus for other donor countries to follow suit.

Haitian infrastructure

Haiti After the Earthquake's dominant argument is to use aid to support, not harm, Haitian institutions. Farmer approvingly quotes journalist Linda Polman, who says "disasters generally attract a garish array of individual organizations, each with its own agenda, its own business imperatives, and its own institutional survival tactics" (214). Farmer's book echoes his latest report on donor disbursements, which is unstintingly critical of the relief effort, targeting the lack of follow-through on international aid pledges, and the fact that over 99% of relief funding "circumvent[s] Haitian public institutions," making recovery "almost impossible." In such an environment, Farmer, writing at the twilight of President Prèval's tenure, argues in his book against overzealous critiques of Haitian corruption. Denouncing the evisceration of Haiti's public sector, he sets out to refute a persistent tendency to "blame the Haitians: their culture, institutions, and lack of ownership over reconstruction and development schemes" (212):

[I]t's not very helpful to criticize a government such as Haiti's in a vacuum. A sound analysis situates Haitian politics and bureaucratic performance in a broader context, historical and geographical. Few years in Haiti's history are unmarked by foreign intervention or meddling of some kind. What we know about democracy in Haiti is this: whenever a popular leader (elected by significant margins) is given a chance to hold office, he will, as surely as night follows day, soon face embargoes and bad press and possibly worse. No one would deny that the current government has certain inveterate weaknesses, but perhaps it's time to let Haitian democracy run its course, to let Haitian civil services grow and take root. Second, to avoid corruption, public institutions--from the line ministries to facilities such as the General Hospital--need an infrastructure of transparency: modern bookkeeping, electronic disbursement of payroll, performance-based financing, effective communications technology. For the last two decades, the Haitian state has been starved of resources. Long accustomed to paltry tax revenues, embargoes intended to pressure the governments in the direction of foreign business interests emptied the meager federal coffers. Instead, money flowed to NGOs, which wittingly or unwittingly weakened the public sector. By the close of the millennium, the Republic of NGOs had undermined the Republic of Haiti's capability to fulfill its government mandate. (369)


The book describes a range of strategies he has deployed toward this aim—strengthening Haitian institutions—with varying degrees of success. As sharp critiques against NGOs such as the Red Cross were further amplified during the cholera epidemic, Farmer explains how Port-au-Prince's General Hospital, "months after the quake, still faced the double burden of the biggest caseload in the country and perhaps the biggest facility funding shortage. But international NGOs had raised millions of dollars for earthquake relief." Farmer's team "went to the American Red Cross and asked them to invest money in salaries for nurses, janitors, surgeons, and others at the General Hospital. It took convincing by a number of people (including President Clinton), but they said yes. The Red Cross provided—through what was for them a modest grant—invaluable medical equipment and staff salary support" (211).

Haiti After the Earthquake helps elucidate Farmer's influence within the UN's bureaucracy as well. When in late 2010 the cholera outbreak was first reported, along with almost-immediate speculation of UN troops' role in its transmission, Farmer publicly called for an "aggressive investigation" of its source, including the hypothesis that UN forces from Nepal were responsible. Edmond Mulet, then head of the UN mission in Haiti, refused to take the possibility seriously, stating: "It's really unfair to accuse the U.N. for bringing cholera into Haiti. We don't want to stigmatize any nation or any people." In the midst of "reluctance to delve further into what caused the outbreak" on the part of the UN, Centers for Disease Control and World Health Organization, Farmer spoke out to the press again, saying that it "sounds like politics to me, not science." At the same time, according to Haiti After the Earthquake, Farmer provided Mulet with a copy of a book he had written, "which describes the predictable responses to epidemic disease that we were seeing with cholera. When I returned a few days later, Mulet had read most of the book, highlighting passages with a yellow marker." Farmer also promised him that his recommendations to investigate the outbreak's origin were "eminently technical" (197). Thus, the Associated Press reported:

But Mulet now says Farmer was right all along, and that he is consulting with experts, including a French epidemiologist who met with him this week to discuss how to investigate the Nepalese base.
"We agree with him there has to be a thorough investigation of how it came, how it happened and how it spread. ... There's no differences there with Dr. Paul Farmer at all."

Haiti After the Earthquake also contains Farmer's reflections on significant failures. As we noted last week, debates on the prioritization of treatment versus prevention have inhibited efforts to fight the spread of cholera, which is currently infecting about 1,000 people a day in Haiti. Farmer explains the gridlock among health organizations and clinical experts as divided between ideological "battle lines":

[O]n the one hand, the minimalists favored heavy investment in health education and massive distribution of chlorine tablets for drinking-water disinfection. On the other hand, the "maximalists" argued that, although there might be no way to stop cholera in its tracks in Haiti, all the tools for preventing its spread (from improved sanitation, including chlorine tablets, to effective and safe vaccines) and for treating those already stricken (from rehydration and replacement of electrolytes to antibiotics) needed to be promptly integrated with the more restrained public health responses. (199)

Farmer squarely places himself in the maximalist camp, considering it "absurd" that with more than $57 million committed by the U.S. alone to fighting cholera, "it was impossible to launch a comprehensive, integrated response, including ramping up vaccine production" (202). But in spite of devoting his energy to pushing this agenda in conference calls, consensus statements and opinion pieces in widely circulated magazines, he writes that he felt "nothing less than shame. If our goal had been to scale up on integrated and comprehensive cholera response using all available interventions, including vaccine, we had failed miserably" (207).

Aristide and the elections

Dr. Farmer's insistence on promoting the will of Haiti's "poor majority" has sometimes led him to completely step outside established channels. Farmer's book leaves out his participation as a signatory of a full-page advertisement in the Miami Herald's Sunday edition on Jan. 23. It stated that the "United States, France, Canada, and the United Nations forces in Haiti" were blocking former President Aristide's right as a Haitian citizen to return from exile in South Africa. Considering that "10,000 people took to the streets in Port-au-Prince to commemorate President Aristide's birthday and call for his return," Farmer, along with over 150 others, "call[ed] on the international authorities, particularly the United Nations and the United States government, to end their opposition to President Aristide's return."

Similarly, in the lead-up to Haiti's flawed elections in Nov. 2010, which were supported by the U.S. and UN, Farmer publicly expressed his concern "that all Haitian people and parties be allowed to participate." Though the book was written before Martelly's inauguration in May, Farmer reiterates his view that the "exclusion of the political party identified with Aristide [Fanmi Lavalas] will mean less participation in the electoral process. But a strong government requires strong civic support and not only from the vocal members of 'civil society'—code…for the non-poor. The non-poor are a minority in Haiti, a tiny economic elite and small middle class" (227).

The blame game

Haiti After the Earthquake is a departure from Farmer's more outspoken writings, and this undoubtedly stems from his responsibilities as a UN representative working closely with Bill Clinton and major donor governments, the U.S. in particular. For example, although he played a pivotal role in moving the UN toward greater transparency and accountability in the wake of Haiti's cholera outbreak, he is careful to stress that "it was certainly not my intention to fan the blame game" (194).

This diplomatic quality has been reflected in his recent media appearances. Last week, he focused on aid and development when WNYC's Leonard Lopate asked him whether "Barack Obama [will] be apologizing for his administration's actions after he leaves office." Farmer demurred. "Actually," he replied, "the US government has been really trying hard to improve the quality of our development assistance and humanitarian aid to Haiti."

Similarly, in his book, Farmer rightly lauds Hillary Clinton's stated philosophy on aid coordination:

Hillary Clinton put it succinctly: "the government of Haiti must and will be in the lead. We cannot any longer in the twenty-first century be making decisions for people and their futures without listening and without giving them the opportunity to be as involved and make as many decisions as possible." (90)

Haiti After the Earthquake concentrates on development assistance, but whatever the Obama administration's intentions on this front, it made concerted efforts to prevent Aristide's return, and consistently opposed democratic, inclusive elections. Secretary of State Hillary Clinton, outside of the realm of aid coordination, did not adhere to her commitment to allow Haitians to make their own decisions when she blatantly subverted Haiti's exercise of sovereignty and democracy.

When pressed to comment on this particular theme last week on Democracy Now!, Farmer provided his theory for why, according to WikiLeaks, the U.S., Canada and others financed the elections, knowing they were exclusionary:

Some of it sounds like Cold War thinking to me: [the Haitian] people keep on electing these left-wing nuts, and we won't have it. And whereas when I'm living and working there, what I hear is people, not as left-wing or right-wing or—it's really who's going to side with the poor majority? And again, I think it's their business to choose the leadership that they want.

On PBS's Charlie Rose Show, Farmer continued: "You really can't pursue public health goals without some level of social stability, and I think that's going to come more quickly if we actually let the Haitian people choose their own governments and decide what their own destiny is going to be, and support that." It seems unlikely, however, that Farmer's aspirations for Haitian self-determination will ever be shared within the U.S. State Department.

Its priorities have changed little since 2000, when, as Farmer noted in his Congressional testimony last year, "the U.S. administration sought, often quietly, to block bilateral and multilateral aid to Haiti, having an objection to the policies and views of the administration of Jean-Bertrand Aristide, elected by over 90% of the vote…Choking off assistance for development and for the provision of basic services also choked off oxygen to the government, which was the intention all along: to dislodge the Aristide administration." The current administration reprised the U.S. role of the previous decade, assuring that Haiti's "popular movement, to a considerable extent excluded from formal participation in the [2010] elections, was scattered and leaderless in Haiti" (239).

Haiti After the Earthquake offers insight into Paul Farmer's decision to work within the domain of elite policymaking and the complex considerations that accompany his role as a UN diplomat. The book serves as partial documentation of this impressive balancing act—pushing for a comprehensive agenda committed to Haiti's poor majority while effectively maneuvering within inflexible, and at times, hostile realms of international decision-making. It is worth mentioning that this period in his career may be shortlived—Clinton's Special Envoy mandate is set to terminate at the end of this year. This book, like the recent UN Special Envoy Office's report, clearly portrays Farmer's growing frustration and disillusionment in the face of the reaffirmation of the old aid trends that continue to undermine Haitian institutions. His next step remains to be seen.