The catastrophic earthquake that struck Haiti on January 12, 2010, was the 9/11 of humanitarian disasters. The death and misery that resulted were beamed out to a global television audience, unleashing public sympathy on an unprecedented scale. More than half of all U.S. households donated to the relief operation. But whereas the government responses to the nearly 3,000 killed on 9/11 have ensured that that event has remained at the center of global attention for the decade since, memories of the more than 200,000 Haitians slain by the earthquake, and of the approximately 4,000 more who died of cholera after it, have quickly faded.

To his discussion of this receding tragedy, Paul Farmer brings passion, medical expertise, and a long and intimate engagement with Haiti. His account of the year following the earthquake works on three levels: personal, practical, and analytic. Farmer's wife is Haitian, and so among the thousands whose lives were in jeopardy were his own relatives and friends. Reflecting these ties, his book is laden with anecdotes and emotion, as is surely appropriate: mass tragedies need to be distilled through detail down to a scale to which one can relate. Thus, Farmer's readers meet a 25-year-old woman named Shilove, representative of a generation of young migrants who escaped rural isolation for Port-au-Prince. There, the hope of arrival met the reality of a jerry-built tenement. Caught in the quake, trapped under concrete, her leg crushed, she managed to crawl into the street before passing out. Two days later, she was found by a nongovernmental organization (NGO) worker, and her leg was bandaged up, uselessly. Then, a passing priest took her to a hospital, where she received the only medical intervention that could save her life: amputation. At least hers was not an amputation performed in the street without anesthetic. She was more fortunate than some.

Readers will wince, but such human appeals are also a spur to action. Farmer is not just personally engaged; he is a practitioner, twice over. A charismatic doctor, in 1987 he founded Partners in Health, a public health NGO operating in 12 countries that by the time of the quake had established ten hospitals in Haiti. Its triumphs, frustrations, and direct experiences with life-and-death emergencies had given Farmer a window onto the problems and possibilities of delivering health care. Unlike many NGOs, Partners in Health works closely with the official system -- in Haiti, the Ministry of Health, which, like most of Haiti's other ministries, was reduced to a pile of rubble by the quake. Farmer's practical work for Haitians had also brought him into association with former U.S. President Bill Clinton, who shared his passionate concern and respect for Haitian society. By the time of the quake, Clinton was the United Nations special envoy for Haiti and Farmer had become his deputy. Farmer got to watch the international community in action from a high vantage point and see firsthand how the potential for collective action was hobbled by procedure and division. 

Farmer also brings to bear his abilities as a professor of public health at Harvard Medical School to analyze both Haiti's health crisis and its wider socioeconomic problems. His apt medical analogy for Haiti's condition is "acute-on-chronic": an urgent crisis occurring in the context of persistent social dysfunction. The chronic condition amplifies the acute condition, constrains responses to it, and is itself so debilitating that it must be treated if the country is to recover from the acute condition. And let there be no doubt: in Haiti, the social dysfunction stems from government failure.


It was failures of governance that explained why the earthquake was so devastating: a larger shock in Chile weeks later was far less lethal thanks to superior building standards there. Poor governance in Haiti has also hamstrung the response to the disaster. A state that was incapable of meeting social needs even before the earthquake saw its limited capacity smashed at the same time as needs exploded. To make matters worse, an election loomed, contributing to the paralysis. Politically, the post-earthquake year was dominated not by the tasks of relief and reconstruction but by a protracted presidential campaign, one mired in corruption, the legacy of which has been the further alienation of citizens from their government. 

Given the urgency of Haiti's needs and the weakness of its institutions, the only option was hands-on international assistance, but even this faced an insuperable difficulty. Farmer argues that the origins of government failure in Haiti were hostile external interventions, first by France in the colonial era and then by the United States, the most recent instance being U.S. involvement in the murky exile of President Jean-Bertrand Aristide in 2004. A democratically elected populist politician with a large following among the poor, Aristide was ousted by gang-related violence and has since blamed his loss of power on the intervention of the United States, which facilitated his exile. Thus, both deep history and recent events have left Haitians with a widespread suspicion of external intervention, which has severely constrained even benign assistance. 

The conjunction of crushing needs and the state's incapacity created fertile ground for NGOs: even before the quake, there were around 10,000 of them in the country. Farmer, who ran one himself, is highly critical of the way they often bypassed the Haitian government completely. "Government officials had no way to provide oversight or coordinate their work," he writes, calling the coordination of NGOs one of the "biggest challenges in health care provision." The problem, as Farmer points out, is that NGOs will never be big enough to meet Haiti's nearly endless needs -- for example, half of all Haitian children get no schooling -- and yet in doing their work, they often end up undermining the government. They hire away its best people, and more fundamentally, their prominence teaches citizens to look to them for services rather than to pressure the government to provide them. 

This tension between wanting to replace an ineffective state and trying not to further undermine it is a common one faced by outside actors in dealing with fragile states such as Haiti, but here again, the earthquake turned Haiti's problem from chronic to acute. Motivated by an unprecedented wave of global sympathy, governments pledged nearly $10 billion for relief and reconstruction. But donors were unwilling to hand this cash over to the Haitian government, a distrust Farmer criticizes. His model of successful recovery from social disaster is Rwanda, a country he knows well, and one where international donors' supportive attitude toward the government in the wake of the 1994 genocide helped build an effective state. The challenge in Rwanda was arguably more daunting: the sheer scale of the catastrophe there was even larger than the one in Haiti, and the country most surely had fewer opportunities for development.

But the crucial factor that separates the two countries is their governing elites. Since 1994, Rwanda has been governed by a cohesive, dedicated, and competent team whose members have eschewed patronage and corruption. Haiti's governing elite, in contrast, has been nothing short of venal. What Farmer fails to acknowledge is that this elite would have been equally venal had donors been more supportive; it would just have had more to steal. Although Farmer's attribution of the origins of dysfunction to the history of malign external interference is reasonable, it does not follow that if only donors were to rely on domestic political processes, all would come out right. I know Haiti far less well than Farmer does, but Haitian reformers whom I greatly respect, such as the former prime minister and civil-society activist Michèle Pierre-Louis, argue the opposite: that change cannot be generated solely from within. Malign intervention in the past may have driven Haiti into a trap of dysfunction. Although this has made future benign intervention more difficult, it has also made it necessary. 

Donors' apprehensions about handing money over to the Haitian state were well founded: the government was manifestly in no position to manage either relief or reconstruction. Indeed, giving huge sums to the Haitian government would likely have triggered the type of rent-seeking behavior that typically follows oil discoveries in fragile states. Yet the business-as-usual alternative was even less attractive: a frenzy of uncoordinated activity by NGOs and donor agencies that were disconnected from Haitian society. That approach is hard to resist. The combination of need, publicity, and money that followed the quake is believed to have spawned around 5,000 new NGOs. Before the disaster, the legacy of NGOs' activity was already strewn all around Haiti in the form of useless projects; Farmer gives the poignant example of $30 million abandoned windmills.


The immediate challenge facing Haiti in 2010 was figuring out how, practically, to convert $10 billion in aid into a transformative recovery. "Building back better" became the catch phrase. Although the task was daunting, it was not particularly complicated. People needed to be rehoused in locations that were less prone to earthquakes, and these locations needed to provide jobs and social services. This meant essentially establishing new cities. The first phase would be building homes and infrastructure, a process that would generate construction jobs. The second phase would be an evolution in employment from the temporary task of construction to more sustainable jobs, underpinned by a base of firms producing light manufactures for export to the U.S. market (to which Haiti was granted privileged access). Such urban growth is common in successful developing societies around the world, and $10 billion devoted to pump-priming could spur a lot of it. 

But the more fundamental challenge was finding a decision-making structure to actually set these actions in motion. Neither the Haitian government nor the zoo of NGOs and development agencies looked promising. Although this dilemma is normal in fragile states, where conditions are typically chronic but not acute, it is rarely resolved, because outsiders find the reality too uncomfortable to be squarely faced. Instead, donors lurch from turning a blind eye to acting outraged, to bypassing governments by funding NGOs, to occasionally suspending aid. In Haiti, the acute-on-chronic crisis made this reality unavoidable.

The result was a potentially far-reaching innovation, one that could serve as the prototype for aid in fragile states: the Interim Haiti Recovery Commission, a hybrid organization jointly run by the government of Haiti and the international community that has, albeit only temporarily, the authority to act on its own. Its two leaders are the outgoing Haitian prime minister, Jean-Max Bellerive, who, as a former minister of planning, understands the core task, and Clinton, whose long commitment to Haiti is much appreciated locally. The commission was set up to break the logjam of dysfunction, tell donors what to fund, tell NGOs what to do, and provide the necessary authorizations on behalf of the government. In the longer term, it will need to evolve into something fully Haitian that can supersede those parts of the state that are essential yet, realistically, beyond reform. 

Unsurprisingly, the commission has created many enemies. Although the Haitian government has gone along with the commission, it has done so only reluctantly; government ministries see it as a threat to their own power and ability to plunder, and they have publicly criticized the commission as an encroachment on Haitian sovereignty. Yet prickly assertions of sovereignty are an inadequate response to reasonable concerns. Realizing this, the government of Rwanda, when it was managing its reconstruction, took the initiative and proposed to donors that they share power in the financial kitchen. By both reassuring donors and forcing a degree of responsibility onto them, the Rwandan government gradually built the conditions for expansive donor support.

Internal posturing has not been the only problem the Interim Haiti Recovery Commission has run into. International agencies and NGOs see it as a threat to their unaccountable power. Their opposition delayed the commission's establishment and has impeded its actions at every turn. Given these obstacles, it is fair to ask if the commission was a mistake. The answer lies in its track record, and one simple indicator here is the clearance of rubble. As Farmer says, this was the most urgent and straightforward reconstruction priority, yet there has been little progress. In fact, a construction-sector NGO did act with appropriate urgency, bringing in a giant rubble crusher. But the equipment was held up in Haitian customs for five months. This inordinate delay was due not to inefficiency: it was the deliberate outcome of self-serving domestic lobbies indifferent to the public interest. Alongside clearing the rubble, new homes were needed, yet to this day, people are still living in tents. The key impediment has been not material but legal: unresolved disputes about land titles have frozen building activity. Across the spectrum, essential actions have been frustrated by the predatory behavior of narrow interest groups, and frustration has begotten cynicism. The only solution is decisive authority. Far from abusing Haiti's sovereignty, the commission has been too cautious.

It has, however, done enough to demonstrate why some such decision-making structure is necessary. For example, the commission succeeded in attracting to the country the world's largest garment firm, which committed to bringing 20,000 jobs to a new city to be built on the northern coast, away from the earthquake zone. Winning this investment required sophisticated coordination. Donors had to be persuaded to provide funds for assigned parts of the necessary supporting infrastructure. The U.S. Congress had to be persuaded to improve market access for Haitian-made garments. The Haitian government had to provide the necessary permission and regulatory framework. In the aftermath of an earthquake, a cholera epidemic, and a deeply flawed election, attracting this investment was no small achievement. Predictably, despite being precisely the type of development that Haiti now needs, this very project is being opposed by a ragbag of romantic NGOs arguing that a garment plant would harm the environment. As Farmer wryly notes, "critics are too numerous to count in all Haitian endeavors." 

Haiti should not be a fragile state. It is in a good neighborhood, surrounded by prosperity and peace. It abounds in opportunities, including producing light manufactures for the vast and proximate North American market, developing horticultural exports such as mangoes, and even tourism. The commission is the right solution to the "acute-on-chronic" conundrum: Haiti urgently needs massive foreign finance but has a governing system that is unfit to handle it. Now that there is a newly elected government -- President Michel Martelly took office in May -- the commission needs renewed authority. At last, the political building blocks are in place for the decisions that can begin to realize Haiti's potential. As that happens, the governing elite will start to smell the opportunities of economic progress more strongly than the opportunities for public plunder, and the need for shared authority will pass. The earthquake triggered a moment of global concern in which Haiti received pledges of appropriately massive support. Since the quake, attention has receded. By bringing Haiti's appalling tragedy back to the world's attention, Farmer's passionate book should help get those pledges honored.

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  • Paul Collier is Professor of Economics at Oxford University and the author of The Bottom Billion. Following the Haitian hurricanes of 2008, he worked with the Haitian government on the report Haiti: From Natural Catastrophe to Economic Security.
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