Short and Bitter Lives

By Paul Farmer, Le Monde diplomatique, July 2003

HAITI’S dictator François Duvalier (Papa Doc) was succeeded by his son, Jean-Claude (Baby Doc) in April 1971. Their regime was accurately described as a kleptocracy, and their strategy of distributing foreign aid, mostly from the United States, was theft (1). After their 29-year rule, Haiti was governed by a military administration that soon became a dictatorship. During this time foreign aid flowed in, although only a trickle ever reached its intended destination.

In 1990 democratic elections brought a Catholic priest to power, Father Jean-Bertrand Aristide, head of the Fanmi Lavalas (Lavalas Family) movement. He was inspired by liberation theology and his election brought hope to those fighting to improve health conditions in Haiti. But in 1991 a military coup abruptly dashed these hopes. In the central region, where we run a community clinic, economic and social conditions quickly worsened. Yet the number of people seeking treatment at our clinic dropped. We were threatened and our clinic was targeted for repression (2).

The coup’s immediate impact was severe, with thousands killed and hundreds of thousands displaced. The next three years were catastrophic for healthcare. There were outbreaks of measles and other diseases for which vaccines are available; there were also epidemics of dengue fever.

Haiti’s infant, juvenile and maternal mortality rates are the highest in the northern hemisphere. HIV/Aids and tuberculosis are now the leading causes of death among young adults (with rapes committed by military personnel and their attachés worsening the Aids situation). These infectious diseases are linked to, or worsened by, malnutrition. During the years of the military coup, 1991-94, the nationwide network of clinics and public hospitals fell into disrepair, and most healthcare professionals fled the country.

The situation began to change when, with UN Security Council resolution 940 providing cover, US troops landed in Haiti in September 1994, toppling the military regime. On 15 October Aristide became president, though the country he inherited was described as a field of ruins. A broad international coalition announced plans for $500m in foreign aid. All observers agreed that rebuilding the health and social services infrastructure would be impossible without massive injections of capital. The Inter-American Development Bank (IDB) and financing bodies approved and launched projects to revamp the education, health and transport systems (many roads had been destroyed).

But for reasons connected with Haiti’s political crisis, none of which corresponded to vital interests in the northern hemisphere, this aid never materialised (3). Help for Haiti’s poor, which should have flowed into the public sector, was distributed by governmental agencies. Even these revenues have dropped significantly. Last year infectious diseases were ravaging the country, morale among healthcare workers was low and Haiti was the only nation in the northern hemisphere where life expectancy was below 50.

With 100 beds and 12 Haitian doctors, Zanmi Lasanté is one of Haiti’s largest private not-for-profit clinics. Yet we have received no significant financial aid from the Haitian government, the IDB or even the US Agency for International Development (Usaid). As neutral observers, we are also direct victims of the collapsing public healthcare system. With more clinics and hospitals closing their doors, the destitute are being turned away. That is why they come to our clinic. In 2000 there were no doctors or nurses to care for Thomonde’s 40,000 residents.

After the disputed elections of 21 May 2000, the US, the European Union and international financing organisations froze aid to Haiti (4). This embargo has targeted the northern hemisphere’s most vulnerable population, the poorest people with the most fragile economy, ecology and society. The impact has been profound, as an IDB report noted: its officials concluded that the major factor behind economic stagnation is the withholding of both foreign grants and loans, associated with the international community’s response to the critical political impasse. These funds are estimated at over $500m (5).

If the IDB can conclude this, why is it among the institutions punishing Haiti? US Congresswoman Barbara Lee said in spring 2002: The US has used its veto powers on the IDB’s board of directors to stop all loans designated to Haiti and has chilled funding opportunities at the other financial institutions, pending a resolution of the political situation in Haiti. This situation is unique because the loans in question have been approved by the bank’s board of executive directors, and the Haitian government has ratified the debt and signed contractual documents. This veto is particularly disturbing since the charter of the IDB specifically states that the Bank shall not intervene in the politics of its member states. The Bush administration has decided to leverage political change in a member country by embargoing loans that the Bank has a contractual obligation to disburse (6).

Consider IDB loan no 1009/SF-HA: $22.5m was earmarked for the first phase of a project to decentralise and rebuild Haiti’s healthcare system. The need for improvements was urgent since there are only 1.2 doctors, 1.3 nurses and 0.4 dentists for every 10,000 Haitians. Most of them are concentrated in the city, whereas most Haitians live in rural regions such as those we serve. And 40% of people have no access to any primary healthcare, while HIV and tuberculosis rates are by far the highest in Latin America.

The IDB project was supposed to target 80% of people, giving them access to primary health care through the construction of low-cost clinics and local health dispensaries. The funds would have been used to purchase equipment and essential medicines. According to its own criteria, to be considered a success the project would have to result in the infant mortality rate dropping from 74 to 50 deaths per 1,000 live births; a drop in the juvenile mortality rate from 131 to 110 deaths per 1,000 births; a fall in the birth rate from 4.6 to 4.0; and a fall in the mortality rate attributable to the lack of proper healthcare from 10.7 to 9.7 per 1,000. These goals were not overly ambitious. Most people who evaluated the project found it feasible and well designed. And the state of urgency was obvious.

Another blocked loan was supposed to improve access to drinking water. Even people who are not healthcare professionals know that drinking contaminated water is probably the leading killer of Haitian children; typhoid fever also kills many adults and adolescents. Experts at the Centre for Ecology and Hydrology, part of the United Kingdom-based Natural Environment Research Council, developed a water poverty index, which they used to evaluate 147 countries in 2002. Haiti came last. Whenever we treat new patients with typhoid or other diseases linked to contaminated water, we call them IDB kids. Our staff was quick to point this out to the IDB’s local director, who visited the clinic last year.

Why is there a hold-up? For the IDB to disburse funds, the Haitian parliament had to ratify the loan agreement. However, the office of prime minister became vacant in June 1997. In October 1998 the health minister presented the project to Haiti’s obstructionist 46th legislature, which is against the president. For weeks parliament failed to meet. When it finally did, it could not get a quorum. The crisis continued when the Chamber of Deputies was dissolved and the government proved unable to organise new legislative elections. Initially set for September 1999, these finally happened on 21 May 2000. But the results of these elections did not please either the Haitian elite or its foreign supporters. Aristide’s supporters claimed victory, and Aristide won the presidential elections the following November.

In October 2000 the more representative 47th legislature was sworn in. The new parliament voted immediately to ratify the health project, along with the three other vital IDB loan agreements. These funds, totalling $146m, were earmarked for education, drinking water and road construction. On 8 January 2001 Haitians were told that the money was still en route, according to an official decree in the governmental newspaper. Three months later the IDB had still not disbursed the loan, although it announced its intention to work with Aristide’s new government and to finance projects in the pipeline.

The IDB laid down conditions: one was that the Haitian government would have to repay $5m in loan arrears. On 15 May, even though not a penny of this or any other IDB loan had been disbursed, the IDB told Haitians that their government would be required to pay a 0.5% credit commission on the entire balance of undisbursed funds, effective 12 months after the date the loans were approved. As of 31 March 2001, Haiti owed the IDB $185,239.75 in commission fees for loans it never received. Fees relating to five IDB loans taken out in previous decades totalled $2,311,422. The IDB told the government that repayment would begin on 15 September, with the balance due on 5 October 2001. In mid-May, amid rumours that it was about to close its offices in Haiti, the IDB announced that its representatives and top staff had been recalled to Washington for consultations.

According to the Associated Press, these consultations were not heartening. The chief IDB officer in Haiti called for the repayment of $20m in loan arrears and reform [of governmental] economic practices before Haiti could be granted access to the pre-approved loan. Many of the outstanding loans had been made to dictatorships and military juntas. Even if the education loan went through, the IDB officer acknowledged that if other loans are not added, Haiti will probably be paying back more than it is getting (7).

This is not the first time Haiti was obliged to repay more than it received. In 1825 France’s King Charles X ordered former French slaves to pay 150m francs before France would grant diplomatic recognition to Haiti, Latin America’s oldest republic. A French diplomat recently told me, without irony, that during François Mitterrand’s presidency, Haiti still owed us part of that debt.

Analysing loans in such detail may seem nitpicking. But the loan embargo has dealt poor Haitians a serious blow. The public infrastructure has been ruined and there is no money left for drinking water or primary education. The international aid embargo has affected the whole population. As Haitians are fond of saying, you can’t get blood from a stone.

(1) Hancock Graham, Lords of Poverty: The Power, Prestige and Corruption of the International Aid Business, Atlantic Monthly Press, New York, 1989.

(2) See Paul Farmer, The Uses of Haiti, Common Courage Press, Monroe, ME, 1994 (new edition forthcoming).

(3) René Préval, the prime minister in the previous administration and a supporter of the Lavalas movement, was sworn in as president on 7 February 1996, replacing Aristide, who was constitutionally prevented from serving a second consecutive term. The Lavalas movement was subsequently rocked by serious infighting, seriously weakening Préval’s government.

(4) These elections aimed to re-elect parliamentary deputies and senators. Although they did not invalidate the results, observers from the Organisation of American States did challenge the methodology used to determine the vote percentages.

(5) Roberto Machado and D Robert, Haïti: situation économique et perspectives, Inter-American Development Bank, economic evaluation of the country, 2001.

(6) Report by Congresswoman Barbara Lee, 23 May 2002. See also Congressional Resolution 382: Urging the President to end any embargo against Haiti and to no longer require, as a condition of providing humanitarian and development assistance to Haiti, the resolution of the political impasse in Haiti, and for other purposes, 107th Congress, 2nd session, 2002.

(7) Michael Norton, Haiti Clamors for Release of Blocked Loans That Might Take Years to Disburse, Associated Press, New York, 11 March 2002.