Contributed by Pierre Minn (McGill University)
Two months after the catastrophic earthquake that devastated Port-au-Prince and its surrounding areas, hundreds of thousands of Haitians continue to lack basic resources such as shelter, food, water, and sanitation. Public health experts warn of outbreaks of cholera, typhus and other infectious diseases, while the “ordinary” pathologies that Haitians have confronted for years: malnutrition, diarrheal diseases, and maternal mortality continue to ravage the population. With time, the consequences of the earthquake will likely fade into the pre-existing deprivations and challenges faced by Haiti’s poor majority: routine resource scarcity, and an uphill battle to meet basic needs and stay alive.
As international governments, the Haitian government, and non-governmental organizations struggle to meet the needs of the earthquake victims, a familiar refrain is heard: that a lack of coordination is impeding relief efforts to distribute aid to those in need. I have been paying close attention to official reports and media articles that discuss this lack of coordination, as it was a theme that appeared repeatedly during my doctoral fieldwork in Haiti from 2007 to 2009. The following incidents, drawn from my fieldwork before the earthquake, serve to provide some background for my thoughts on the coordination and the lack of coordination of international medical interventions in Haiti.
Last year, while conducting research at a large public hospital, I noticed a number of boxes outside a public hospital’s depot, where most donations of medicine and materials were stored. The boxes (over a hundred of them) each contained thirty-six bottles of Omnicef solution. Omnicef is a cephalosporin antibiotic, and this particular dosage was for treating infections in children. The medicine was being thrown away because it had expired two months earlier. Following the Ministry of Health’s guidelines on the disposal of expired pharmaceuticals, these potentially live-saving medications were discarded – I later saw them in the hospital’s incinerator.
The second incident goes back a few years. A Haitian-American friend who directs a small medical aid NGO received a note from a peasant woman in the village where the organization works. The note, presumably written by someone else on the woman’s behalf, pleaded for money for her children. The final line of the note read: “They’ll tell you that we have other people who help us, but it’s not true. We don’t have anyone else, it’s only you.”
The final scene is drawn from a meeting I attended of the HaitiHealthWeb, a recently-created informal network of international organizations working on health care issues in northern Haiti. Half of those in attendance were Haitian administrators, clergy and medical professionals, and half were visiting American volunteers, primarily nurses and doctors, as well as two American NGO directors living in Haiti. A representative from each organization was asked to describe their group and its mission. After a few introductions, it became clear that despite the presence of the Haitian participants, the American volunteers were the target audience for all of the communication that was taking place. The comment that best exemplified this was from an American NGO director who said to the group, “Whenever you’re here in Haiti, I hope that you’ll let me know, and we’ll take you around to different communities.”
The subject of coordination emerged repeatedly in conversations and interviews during my research. Everyone who has talked to me about coordination (Haitian nurses, doctors, hospital employees and administrators, and foreigners carrying out medical interventions in Haiti) all expressed that 1) There isn’t enough coordination of international health interventions and 2) More coordination would lead to more efficient use of aid, improved health services, and better outcomes.
As one Haitian physician told me:
“Here’s why coordination is important: International aid groups send us certain kinds of material, but we don’t really use them. If only there were better coordination with the hospital administrators and heads of each ward… They send us a lot of the things we don’t need, and we never use them. They could send us the things we do use; there are a lot of things we’re lacking. I think that’s a lack of coordination. Coordination is so important. If there’s good coordination, it lets you see the results of the aid you’re giving.”
A Haitian medical resident told me the following in response to my questions about coordination:
“In terms of aid, the people who give are satisfied to just give, but they don’t really have oversight over what they’ve given. But also, the people who receive aid distribute it poorly, they use it poorly… We have things that are rotting in the depot, and when you prescribe medicine for a patient, they don’t have money to buy it. They [the hospital administrators] only give out the medicine when it’s expired.”
In terms of foreign aid workers’ comments on the lack of coordination, they often complained about not knowing what other medical interventions are happening nearby. After working in an area for months or years, they learn (often by coincidence) that another international group doing similar work is active in the same zone. This represents not only lost opportunities for sharing resources and information, but also a potential threat in terms of competition for funding, patients, and visibility.
If everyone agrees that more coordination would be better, why isn’t it happening? Much of the answer lies in pragmatic considerations: many of the international groups and agencies I observe have directors and leaders who visit Haiti for short periods, and for many aid groups, the bulk of their time is spent carrying out clinical interventions. Others are busy with internal staff meetings, appointments with pre-existing partners, and employee and program management. Networking, building coalitions, brainstorming partnerships or coordinating are simply not prioritized.
Language poses another formidable barrier. Although I’ve heard foreign physicians minimize this obstacle (an American doctor once told me, “We speak the same language: medicine!”), I have sat through countless meetings where, despite the presence and hard work of competent translators, meanings were distorted and intentions misread because of language barriers. And while translation can work for formal meetings, it is nearly impossible for the kinds of casual conversations and informal encounters that build interpersonal relationships and lay the foundation for collaboration. Not surprisingly, most of the effort I’ve witnessed to learn another language has been on the part of Haitians.
Another consideration: who should be responsible for coordinating the aid? For the health network described above, an American physician took on the task, and, using simple web-based tools, was able to contact and stay in touch with specific individuals and organizations with fairly limited effort. For the time being, the network offers organizations an opportunity to hear about what other groups are doing, to meet individuals working in the same field, and potentially to pool resources. However, at the meeting I described, several major players in the area’s medical landscape were absent, including any representatives from the three largest hospitals in northern Haiti. After the meeting, when I asked the coordinating physician if anyone from MSPP (the Ministry of Public Health and Population) was involved in the network was involved, he asked, “Who’s that?”
Granted, it is not always easy to coordinate with MSPP. Several organizations in the network have waited months or even years for basic accreditation for their clinics, despite filling out and submitting all the required paperwork. Like other ministries, MSPP’s extreme centralization in Port-au-Prince means that local branch offices and representatives have little authority or resources. And yet, for the founder of a health network that comprises over a dozen health organizations to not recognize the name of the Ministry of Health is troubling to say the least.
In thinking about the government’s potential role in coordinating aid, one understands why it would be more advantageous to skirt the state. Coordination can very easily lead to centralization and the concentration of resources and authority, which is frequently named as one of Haiti’s major social and political problems. (The perils of centralization have been dramatically illustrated by the impact the earthquake has had on the country as a whole.) Examples of centralized resources and procedures abound: the administrators at public establishments in northern Haiti (and anywhere else in the country) cannot hire, promote or fire any of their personnel at any level without the written approval of the Minister of Health in Port-au-Prince. International aid offers a wide variety of resources and possibilities that are unavailable through the state, so it’s easy to understand why coordination and centralization would often be less appealing than autonomy and flexibility.
Still, these are basically pragmatic considerations – demands of time, effort and energy impeded coordination. But there are other dimensions to consider – for example, the interests that various stakeholders have in not coordinating. In the letter my friend received from the peasant woman, for example, the latter denied the existence of other sources of support. Whether or not this woman (whose children were malnourished and whose quality of life was abysmally low) did indeed have another source of support is not as interesting as the fact that she felt the need to deny its existence.
Wealth and resources are often kept out of sight in Haiti. They may hide behind high walls, be stashed away in boxes or handkerchiefs, or disappear through expenditures abroad. “Big shots don’t spend their money in Haiti,” I was told. At one level, wealth is hidden to prevent its violent or forcible removal (through theft or kidnapping) and to protect oneself from others’ jealousy, resentment and solicitations. In addition, potential recipients also have an interest in hiding existing wealth and resources from potential donors. Most Haitians are aware of foreigners’ obsessive search for the poorest of the poor, the neediest, the most neglected, and therefore must present themselves as worthy recipients. While visiting a hospital with a group of potential donors from Canada, I overheard a physician tell the nurse who was guiding the group on their visit, “Don’t be afraid to show your bellybutton,” in other words, the hospital’s vulnerabilities and weaknesses. Another nurse told me that she believed that hospital administrators were letting one specific ward fall into a terrible state of decline with the hopes that an organization would be appalled by its condition, tear it down and rebuilt it.
The desire to hide wealth and resources is complicated by pressures to do just the opposite: to display one’s credentials as a trustworthy recipient of outside support, as one who has been entrusted in the past, and who is able to correctly manage future resources. Sometimes the two tendencies can exist simultaneously, as when I saw Haitian health professionals show buildings that fell into neglect, equipment that broke down, and empty pharmacies, all framed as evidence of prior support that dried up and moved elsewhere, justifying a new intervention and renewal of resources. In addition, potential recipients want to maintain their dignity. The people I spoke with emphasized the irony of Haiti’s history as the world’s first Black republic and only successful slave revolution, juxtaposed with its current dependence on international aid to meet the basic needs of its citizens.
I returned to Haiti not long after the earthquake, and found that the tendencies and trends I have described above have intensified in the wake of the catastrophe. Although many new individuals and organizations are becoming involved in international medical aid initiatives, they are often doing so under the auspices of established institutions, and more importantly, following the channels and patterns that have been laid down through centuries of foreign medical initiatives and interventions in Haiti. Disasters do not happen on blank slates, and implementing successful health programs in Haiti will require an appreciation of the contradictions and subtleties of providing care across steep gradients of social, economic and political inequalities.
Pierre Minn is a doctoral candidate in the Departments of Anthropology and Social Studies of Medicine at McGill University. His research focuses on the moral economy of international medical aid in Haiti.