If we fail to act, page 2

Author: Paul Farmer, M.D.

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A nation undermined

The situation in Haiti is no less dire. Again, we need to understand history if we are to understand how human values, and which ones, come into play. Haiti, once France’s most lucrative colony and born of greed and slavery, became an independent republic 200 years ago. Haitians should have much to celebrate. The country is the birthplace of many values that we celebrate as modern, as it was the first nation in the world to outlaw slavery, the source of vast European profits. A slave revolt, unprecedented and unequaled since, transformed the colony of Saint-Domingue into Latin America’s first sovereign nation.

Haiti’s second constitution, promulgated in 1805, declared that all citizens, regardless of skin color, were to be known as nègres, prohibited foreign ownership of land and reclaimed as the country’s name the term used by the island’s indigenous people. Haiti meant “high country” to the original inhabitants, millions of Arawak who had almost all died out a century after Columbus landed in 1492.

Haiti in 1804 had few friends. The small country, in cinders after a decade of war waged successfully against Europe’s greatest powers, was surrounded by the slave economies of Jamaica, Cuba and the southern United States. Its leaders tried to make some friends by helping Simón Bolívar and others cast off colonial rule in the New World. One of the conditions of this assistance was that slavery be abolished in the nascent republics of South America. And Haitian troops, former slaves, marched east to abolish slavery in what is now the Dominican Republic, the nation with which it shares its small island.

Haiti’s first century as an independent nation was a difficult one. Bolívar did not keep his promise, and he tried to block Haiti’s formal participation in international affairs. The Dominican Republic remains a country in which racism—and dislike of all things Haitian—is tolerated or condoned. Throughout the 19th century, Haiti remained isolated by trade embargoes and the world’s refusal to recognize a country born of a slave revolt. The 20th century was no easier: Gunboat diplomacy was followed, in 1915, by U.S. military occupation. Franklin Roosevelt ended the occupation in 1934, but decades of military and paramilitary dictatorships ensued. Haiti’s first democratic elections were not held until 1990.

What transpired over the next 14 years is much disputed, but Haiti’s brief experience with democracy is readily documented. We do know this: In spite of a spectacular coup attempt (by Duvaliériste and paramilitary forces) between the elections and the installation of the president-elect, the inauguration of the liberation theologian Jean-Bertrand Aristide took place on February 7, 1991.

Father Aristide’s government policies reflected liberation theology and the corporal works of mercy: Ambitious programs to promote adult literacy, public health and primary education were quickly launched, as were campaigns to raise the minimum wage (opposed vigorously by Haitian and U.S. factory owners) and to promote land reform (opposed by those with large and often fallow land holdings). Tensions were high, and in September the Aristide government was overthrown by yet another military coup, this one anything but bloodless.

Thus the modern Haitian military, a creation of the U.S. occupying force in the 1930s, once again took power. (Some will note a certain symmetry here with the recent history of Rwanda. In the case of Haiti, as elsewhere in Latin America, it was the U.S. government and not France that gave assistance and training to the army.) The degree to which the first Bush administration secretly abetted the 1991 coup is much debated and may not be known for years. But there is no doubt that a CIA asset in Haiti formed and led the vicious paramilitary group named FRAPH, credited with many of the murders committed during the years following the coup.

1992 Haiti was like a burning building from which the only exit was over the Dominican Republic border or across the sea. Tens of thousands of refugees embarked for the United States. The United Nations soon condemned the U.S. policy of forcibly returning Haitian refugees and declared post-coup Haiti “a human-rights nightmare.” Hundreds of thousands of “internal refugees” fled the pro-Aristide urban slums—which were targeted by the military and paramilitary forces—for rural hiding places or the neighboring Dominican Republic, famously hostile to Haitians.

A change in U.S. policy

During endless negotiations orchestrated by the United Nations and the Organization of American States the military dictators refused to budge. Then Bill Clinton, who had promised during his U.S. presidential campaign to grant sanctuary to Haitian asylum seekers and to restore constitutional rule to Haiti, took office. But the flood of unwelcome refugees to Florida forced his administration into another strategy—to stanch the flow by stopping military and paramilitary terror in Haiti.

Instrumental in shaping the policy that eventually led to the re-establishment of constitutional rule in Haiti was John Shattuck, former vice chairman of Amnesty International. He joined the Clinton administration in June 1993 as assistant secretary of state for Democracy, Human Rights and Labor. Within 18 months after Clinton took office, Shattuck recalls, “disaster had struck in Somalia, Rwanda, Haiti, Bosnia and China. Human-rights conflicts were erupting or escalating in virtually every part of the world.”

Since Haiti is a close neighbor with strong ties to the United States, the crisis in “our backyard,” just then generating huge numbers of refugees, loomed larger than the catastrophe evolving in Rwanda. Clinton, says Shattuck, favored using military force, if necessary, to restore democracy in Haiti. “The strategy had many opponents inside the Beltway, but the president knew it was time to reach over their heads and take it to the public.”

How did Clinton come to feel so strongly about this matter when Washington’s power elite saw little reason to waste time and energy, or to jeopardize American lives, on account of Haiti? On September 14, 1994, the day before Clinton was to present his proposal to the U.S. public, Shattuck brought him photographs of the atrocities taking place there.

“I spread my photos of the disfigured faces and bodies of Haitians who had recently been attacked by the FRAPH on a coffee table in the Oval Office,” Shattuck says. “Examining them closely one at a time, the president swore quietly, ‘Those bastards,’ and vowed that Haiti’s reign of terror would be brought to an end. The statistics I summarized for the president spoke for themselves. . . . As I talked, the president stared at the hacked and mutilated bodies of men, women and children trapped on an island ruled by thugs.”

And so the U.S. military deed was done. Constitutional rule was restored to Haiti in 1994. Not a single American life was lost to hostile fire during the course of the operation.

But there are many ways to undermine a popular democracy. What followed was a decade of “structural adjustment” programs forced on Haiti by the same international community which had declared that Haitian democracy should be restored. Aristide served out what little was left of his term and became the first Haitian president to hand over power to another elected president.

Aristide was re-elected by a landslide in 2000. But he pulled little economic weight, since the bulk of his support came from the poor rather than Haiti’s wealthy elite, notoriously reluctant to pay taxes. The “new” U.S. policy gurus on Haiti, who came into the White House with the next Bush administration, were precisely those who’d disparaged the left-leaning Haitian populist during the first Bush administration. A virtual embargo on aid or credits to the cash-poor Aristide government ensued.

Haiti in 2004 was the most impoverished nation in the hemisphere; the aid embargo was strangling the country. Shortly after its bicentennial celebration, Haiti endured its 33rd coup d’état and lost tens of thousands to violence, floods and epidemic disease.

Questions and ironies abound. Haiti was the first state in the Western Hemisphere to put into practice the modern notion of rights: the first to proclaim universal equality among the races, the first to offer a sanctuary to oppressed refugees. Then why is Haiti the hemisphere’s most HIV-affected nation? Why does Haiti, the source of much of 18th-century France’s wealth, now stand as one of the poorest and most volatile countries on the face of the earth? Why is political stability so elusive, and why are violence and rights violations so endemic? Why is it so difficult, even when the tools of the trade are made available, to practice good medicine and public health in the Western Hemisphere’s neediest nation?

We might seek to answer these questions by asking “what went wrong” in Haitian politics and culture. But such narrowly focused investigations give less truthful answers than an attempt to understand Haiti’s history and its place in the modern world economy—the webs of power that link us all. Simply put, Haiti’s poor majority is by no means to blame for the mess it finds itself in, today or at any point in the last 200 years.

Not all the news from Haiti is bad. I know from my own experience that it is possible to deliver high-quality health care in rural central Haiti, where there are neither paved roads nor electricity. Haiti also can claim to have led the charge against AIDS in the poor world, having launched some of the first integrated prevention-and-care programs. A new funding mechanism, the Global Fund to Fight AIDS, Tuberculosis and Malaria, allowed Haiti to ramp up long-standing efforts to prevent new infections and to improve care for the sick.

Even as some poor nations seemed ready to concede defeat in the struggle against what had become the world’s leading infectious cause of adult death, Haiti could point to real victories. The corporal works of mercy, at least many of them, helped to promote these victories. But is mercy enough?

Health care and the missing movement

As much as “human rights” have become a value to which every political party lays claim, have we of the international community done enough to push for the rights of the poor? Surely the answer to this question is a resounding no. Is the right to health care somehow special? Perhaps. Health is primordial. As Flannery O’Connor put it, “You can’t be any poorer than dead.” We have discovered that some people who don’t think much about the right to food or housing or employment are sympathetic to the right to health care.

In Haiti, only 90 minutes from Miami, civil and political rights matter. Scores of people die each week while fighting to restore constitutional democracy there, but the daily struggle is mostly for survival. And although Haitians do not enjoy a right to health care, they do, in my experience, have systematic and comprehensive notions about such rights. An expanding notion of human rights is now emerging, but it is coming from the poor rather than from the mainstream human-rights groups that receive their funding from the powerful.

Many of the patients Partners In Health serve are articulate in asserting tout moun se moun—every one is human. The currency of this proverb is striking in Haiti, the very land in which human rights have so long had little reality. The subtext of this saying, tout moun se moun, is usually that poor people deserve access to food, education, housing and medical services. We hear this sort of commentary almost every day in our clinics in central Haiti.

The commodification of medical care is one of the biggest human-rights issues facing the “modern” world today. This “modern” world consists, for many, of a hut with a dirt floor, thatch roof and no running water only a short journey away from air-conditioning, cable TV and antibiotics. As in Kenya and even Rwanda, modern health care is available, for a price, in the private clinics of the city, but rarely available to a patient without money. Such patients are effectively locked out of the modern world, with its shiny laboratories and amazing medications.

Spanning the worlds of rich and poor is what human-rights organizations, aid organizations and universities do; so do the international cooperation agencies of rich-world governments. Wealthy and powerful institutions have certain obligations to the rest of the world. What are these obligations? Do wealthy and powerful people who do not support the sometimes noxious policies of their own governments have obligations to the victims? Good answers to these questions will emerge only when the lucky few whose actions can span these worlds come to understand the struggles of people facing poverty and disease.

The political and moral culture of mainstream human-rights or aid organizations or affluent universities seems, at times, to have grown up on a different planet from Haiti or Rwanda. That feeling of separateness accounts for the indifference that allowed the 1994 genocide, for example, to occur. How do we spread the desire to stand with the victims, to stop the killing? Without such sentiments we will live in a world divided, in increasingly violent fashion, between haves and have-nots. Sentiments, of course, and mercy do not suffice. But the promise of social movements based on solidarity and empathy and corporal works remains alive, however tenuously.

For the phrase “never again” to inspire something other than cynicism, nothing less than a global movement will do. Why do we need a movement to promote the “rights of the poor,” and how might such a movement prevent events like those in Haiti, Rwanda and Sudan? The relationship of poverty to human rights is no mystery to those who live in poverty, as we learned in rural Haiti; nor is the relationship of poverty to violence, including extreme violence and genocide. I’ve learned a great deal about rights by listening to people in Haiti and Rwanda.

Every year for the past decade our Haitian patients and co-workers have sponsored a conference on health and human rights. In 2004, as in previous years, the huge crowd included patients with AIDS who were receiving proper therapy for the disease at no cost to them. Many more in the audience were dying of untreated or inappropriately treated AIDS, but these individuals—not yet patients, to their dismay—were from elsewhere in Haiti and were there to fight for their right to health care.

One of the speakers was none other than Joseph. Since his miraculous resuscitation, he has been involved in AIDS prevention efforts and has become an eloquent spokesman on behalf of people living with AIDS and with poverty. On that day, he spoke with passion and with a certain humor about his own near-death experience and about his hopes for the future. “One of the things I’d like to do is to learn how to read,” he said. “It’s ridiculous that even today adults who are poor do not know how to read.”

A number of questions were raised: Should people dying of AIDS be spared only if they can pay for the antiretroviral therapies that will save them? Should people living in poverty have a right to primary education, to learn how to read? Should they have the right to food and shelter? Should the notion of mercy be extended to include its corporal works? The people who showed up to discuss health care in a church in rural Haiti knew that the answers were self-evident: yes, of course. But such questions would strike some of my colleagues in both the international health and human-rights “communities” as absurd, as leading to a terrifying blank check. This is because most external determinants of disease—poverty, inequalities of all sorts—are considered off-topic by many human rights experts and policy makers.

The view of many of my academic colleagues seems to be that good scholarship and activism don’t mix. The view of many of my human-rights colleagues seems to be that social and economic rights—those violated by poverty and disease—are “pie in the sky.” They say they’re having a hard enough time getting civil and political rights respected. And the view of many in both sectors seemed to be that the victims themselves should be “empowered” to start their own social movements. Yet those gathered in central Haiti had already started their own social movement. The “missing movement” needs to take place among the privileged, and on the grounds of empathy and solidarity.

The people living with HIV who spoke at the conference were aware of the long list of reasons marshaled by experts to show why we cannot provide “cost-effective” care for AIDS, for example, in the world’s poorest communities. The list of reasons is not often overtly racist and does not include anything approaching frank contempt. The reasons (or pretexts) for not addressing these complex diseases are framed more indirectly. We’ve heard, for example, from a senior U.S. Treasury Department official that Africans lack a “concept of time” and so cannot adhere to complex therapeutic regimens. Even a “lack of wristwatches” has been advanced as a reason not to treat.

The Haitian AIDS sufferers had heard these reasons and retorted, as they had done in previous conferences on health and human rights, “We may be poor, but we’re not stupid.” They were familiar with the thousand other excuses we dish up to explain genocide, human-rights abuses, the persistence of poverty, the growth of inequality and the futility of trying to fight diseases as complex as AIDS in places as poor as Haiti.

No death of a young person can be called good. But I’ve seen almost nothing worse than dying of combined AIDS and poverty, incontinent and dirty and hungry and thirsty and in pain. I’ve experienced almost nothing worse than hearing that a Rwandan woman, raped during the genocide and now dying of AIDS, cannot be treated because she cannot afford the laboratory tests and medications required to treat her disease.

Whether or not we avert our gaze from these horrible deaths, they are happening now. Those who must face structural violence every day encounter precious little in the way of support for the right to food, water, housing or medical care. Even within the human-rights movement, where civil and political rights are privileged, there is far too little support for social and economic rights—despite the Universal Declaration of Human Rights stipulating, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

Indeed, following this mandate led Partners In Health from rural Haiti to shantytowns in Peru to prisons in Siberia and on to the former killing fields in Rwanda. But for these basic rights to be extended to all those who need them—a prescription that would prevent, in my view, much of the violence and much of the terrorism about which we read—we will need a movement based in nations like the United States, wealthy nations that now control the fates of billions who live far from their shores.

Human rights and corporal works of mercy

For millennia now, philosophers and theorists have sought to understand why violence occurs and why we fail each other in the face of unnecessary suffering. Anthropology and other social disciplines have also grappled with these questions. Such reflection takes on urgency in many of the places in which I’ve worked. In Haiti, Rwanda and even Boston, service to the destitute sick reveals the sharp limitations of what can be done to allay misery without a broad understanding of why some people have so little while others enjoy a peculiarly modern surfeit. Without a right to health care, for example, modern medicine and public health become commodities to be bought and sold. Such arrangements will never suffice if our goal is to relieve premature morbidity and mortality—the primary obligation, surely, of a physician.

I have seen the utility, but also the limitations, of a human-rights model. Conventional human-rights frameworks, only a couple of centuries old, have focused on civil and political rights, and human rights advocates may point with pride to certain victories. But defeats are as common, and they’re more glaring now than ever.

A young Haitian man lies dying of AIDS, but without a right to antiretroviral therapy, what hope is there for his survival? What hope is there if he obtains the necessary medications but has nothing to eat? Writing from rural Rwanda, or from Haiti, leads me to reflect on the corporal works of mercy. As I’ve confessed, I didn’t pay much attention before. But I now know that these injunctions—again, feed the hungry; give drink to the thirsty; clothe the naked; shelter the homeless; visit the sick; visit the prisoners; bury the dead—strike me as worthy goals for those seeking guidance in diminishing suffering, whether due to disease or to violence.

There are spiritual works of mercy, as well—reconciliation, forgiveness, comforting the afflicted, and praying for the living and the dead, to name a few. Cynics might argue, in the inelegant language of our day, that these are not readily “operationalized.” These debates will go on, no doubt, indefinitely. But in the 21st century we cannot argue honestly that it is impossible to develop effective strategies for works of mercy. If we fail to link new human rights understandings to a broader movement for social justice, we will have no shortage of dead to bury. In that case, perhaps that is the only corporal work of mercy we will deserve to claim as our own.

Paul Farmer is founding director of Partners In Health, an international charity organization that provides direct health-care services and undertakes research and advocacy on behalf of those who are sick and living in poverty. He is also a professor of medical anthropology at Harvard Medical School and an attending physician at the Brigham and Women’s Hospital, Boston.