A new 320-bed teaching hospital in a town of 100,000 would be a big deal anywhere in the world, worthy of the display of pride — the brass band and the speeches — at a cornerstone-laying ceremony here last month.
But this was boosterism against a backdrop of deforested mountains. It was a rare sign that Haiti can be built back better, as former President Bill Clinton vowed after January's catastrophic earthquake.
Port-au-Prince remains choked with rubble. More than a million survivors still live under tarps or in tents. Wealthy nations have sent only a small fraction of the billions of dollars they pledged in March for building roads, schools and water systems.
The hospital in Mirebalais, 38 miles northeast of Port-au-Prince, is still just a graded site and a blueprint. But it's a blueprint for a modern building with solar panels and landscaped courtyards that will be turned over to the Haitian government after it opens in early 2012. It will have as much floor space as a Walmart Supercenter, enough for operating theaters and the country's first intensive care unit.
And it will train future doctors and nurses with the long-term goal of breaking the country's historical dependency on foreigners — one humbling symbol of which was the U.S. Navy's medical vessel, the Comfort:
"On the seventh day after the earthquake,'' said Paul Farmer, one of the speakers at the ceremony, "the best hospital in the country was floating in the bay of Port-au-Prince.''
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Farmer is a Harvard-trained doctor and anthropologist who spent his teens in Hernando County. In 1987, he helped found Partners in Health, or PIH, the medical organization for the poor that is building the hospital.
Clinton, the United Nations special envoy for Haiti, named Farmer as his deputy and cited the group's work as a model for rebuilding. A New York Times editorial in August called PIH "exemplary.'' Haiti's minister of health, Dr. Alex Larsen, said it is "our best partner in Haiti.''
Farmer would say PIH doesn't have much competition. A lack of private partnerships with the government, he says, is a major reason the aid delivered so far has accomplished so little.
Private charities raised more than $1.4 billion from individuals and corporations in the United States in the first six months after the quake, according to Indiana University's Center on Philanthropy. These groups also received much of the $1.8 billion in emergency aid from public sources, including the U.S. government, that was tracked by the United Nations. Just 0.3 percent of that went directly to the Haitian state.
Bypassing the government in Haiti has long been justified by its corruption and volatile politics. This was U.S. policy during the final term of former President Jean-Bertrand Aristide, who was ousted in 2004. Even now, the largest aid group in Haiti, the International Federation of the Red Cross, makes it a practice not to contribute directly to foreign nations.
But most of the estimated 10,000 aid groups working here are more accountable to overseas donors than to Haitians, Farmer said. Over the years, these organizations have taken on the job of providing public services — usually poorly — rather than building a government that can do this work itself.
"The rules of the road for development assistance need to be rewritten," Farmer testified in July to the Congressional Black Caucus, "not to favor contractors and middlemen and trauma vultures, but to favor the victims of the quake.''
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The Red Cross, which raised more than $800 million for earthquake relief, says it's doing all it can for these victims.
It fed more than 1 million Haitians for a month after the earthquake and still trucks water to 40 percent of the population of Port-au-Prince, the capital.
But the weakness of the government —- its inability to clear or secure land —- has frustrated one of the main long-term efforts listed on the Red Cross website: "semipermanent shelters to house 165,000 people.''
L'Annexe de la Mairie, a camp of 850 tarp-covered hovels at the base of the towers for the national radio station, is one of the few public parcels of land that can be used for building. And as of early September, it was the site of the Red Cross' biggest housing project in Port-au-Prince — 51 partially completed plywood houses with metal roofs.
Even here there's a problem: If the Red Cross is to finish its plan to build shelters for 350 families, it will have to displace 500 others.
Pascal Panosetti, an international Red Cross housing coordinator, said the organization is working with both groups of residents. It has handed out kits of timber, tarps and tools to help those who must move. It is screening candidates for new houses to select the most deserving, including elderly and disabled residents.
But a group of about a dozen parents who stood outside the settlement's temporary school last month remained skeptical of the Red Cross program.
They worried the corrupt camp committee that had earlier hijacked the distribution of food and other aid would do the same with housing, favoring friends and family. And though none of them said they were satisfied with life at the settlement — the wandering pigs, the mud, the trampled piles of garbage and the leaky tarps — it's all they have.
"This is public land,'' Mona Altanor, 38, said through a translator. "I'm not going anywhere.''
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In one way, the formula for providing aid is simple, said Beverly Bell, an associate fellow for the Institute for Policy Studies, a Washington think tank, who has worked in Haiti on and off for three decades: The better an organization knows a country, the more it can help.
"And I can tell you, you will never find a foreign (aid organization) more successful and more sensitive than Partners in Health,'' she said. "They have a beautiful respect for the Haitian culture and treat every Haitian individual with respect.''
The Red Cross didn't arrive in force until after the earthquake. Farmer first came to Mirebalais in 1983. Two years later, while still a medical student, he helped open a clinic in the nearby town of Cange. That clinic laid the foundation for Zanmi Lasante, the Haitian affiliate of Partners in Health.
As for the new hospital, there's no question it has the support of the people of Mirebalais (pronounced MEER-ba-lay).
Many of them were outraged in 2007 when the Haitian company that ran the old hospital in town allowed a pregnant woman who couldn't afford treatment to die outside its doors. The following January, the mayor of Mirebalais led a mob that pulled all the patients out of the old hospital, chained it shut, and drove them to a new PIH hospital in a nearby city.
That was when PIH started planning a regional health care center in Mirebalais. The earthquake's devastation made expansion of the plans a necessity. Several buildings at the national teaching hospital in Port-au-Prince had been damaged. The nursing school had been leveled, entombing more than 100 students and faculty members.
"It smelled like a carrion house,'' Farmer said in September. "Ten days after the quake I was sure it would take years before medical teaching infrastructure could be rebuilt in Port-au-Prince.''
PIH, which has raised about $85 million for earthquake recovery, will pay the $15 million to build the hospital (a small fraction of the amount it would cost in the United States) as well as $8 million annually to run it.
Besides donating the land, the government will set medical policy. Most important, the Haitian state will own this hospital as it does 11 other clinics and hospitals PIH has established in central Haiti. Eventually, the Ministry of Health can staff that network with its own doctors, nurses and administrators.
Said Corrado Cancedda, a PIH doctor who flew in from Rwanda for the ceremony: "Your ultimate goal is to make yourself unnecessary.''
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The immediate goal is to enlist Haitians as directly as possible in helping their own cause.
"Our model is on-the-ground, shoulder-to-shoulder accompaniment,'' said Ted Constan, PIH chief program officer.
Take the case of 1-year-old Bosquette Jude, who was brought to the PIH hospital in Cange in late August with symptoms of severe malnutrition — lethargy, rust-colored hair and a bloated abdomen. She quickly began to recover, her swelling going down, her weight climbing, under the care of a medical staff that is almost entirely Haitian. Only a handful of the PIH's 212 doctors and 5,600 total employees in Haiti are from foreign countries.
Her therapy consisted mainly of eating PIH's brand of fortified peanut butter, Nourimanba, made at a Haitian-staffed factory in Cange. It uses peanuts raised by local farmers, who receive seeds from PIH's agricultural development group, Zanmi Agrikol, and a guarantee the group will buy their entire harvest.
Bosquette's family would be referred to an Agrikol program that supports 1,400 struggling farmers — giving them tools, seeds, advice on planting, a fruit tree to boost the output of their land, and another tree to help build and hold topsoil in the denuded countryside.
The American Red Cross and World Vision, a Christian aid group that raised $192 million for earthquake recovery, have smaller staffs than PIH. But both employ thousands of Haitians through a system of temporary labor called cash-for-work. World Vision also runs a food-for-work initiative that pays workers directly with beans or rice.
These programs have a place in post-earthquake Haiti, where the unemployment rate is an estimated 70 percent, said Elizabeth Ferris, a senior fellow with the Brookings Institution, a public policy organization in Washington.
But in the hierarchy of aid-based employment, food-for-work is at the bottom because it denies recipients the right to choose how to spend their earnings. Cash-for-work is next, Ferris said, and PIH's approach is at the top.
"Giving people steady employment and directly involving them in the process has greater long-term benefits, is more sustainable, and there is more dignity."
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Ali Lutz, PIH's Haiti program coordinator, pulled off a chaotic highway outside of Port-au-Prince and drove through steel gates toward a large house with a swimming pool in the middle of a fruit orchard.
"Welcome to the oasis,'' Lutz said.
She had arrived at Zanmi Beni, a home for developmentally disabled children that PIH opened after the earthquake with the help of the Christian charity Operation Blessing. The 54 children here are cared for round-the-clock by twice as many staffers, who provide physical therapy, education, meals, hugs and playtime. On this afternoon in early September, teenagers in wheelchairs watched a large-screen television in the shade of the fruit trees. Younger children ran in and out of the house and across its paved patios.
Zanmi Beni contrasts starkly with the tent schools World Vision operates at settlement camps throughout Port-au-Prince, where teachers work without books and children receive snacks of cheese and crackers instead of hot meals.
The contrast is even sharper when compared with the plight of thousands of disabled children sleeping on the ground at places such as L'Annexe de la Mairie, the camp of 850 tarp-covered hovels.
To some, showering so few with so much might not seem fair. But these children, most of whom had been abandoned at the teaching hospital in Port-au-Prince before the quake and neglected after it, are the beneficiaries of PIH's core philosophy, called a preferential option for the poor.
"The most resources go to those who need it most,'' Lutz said.
Put another way, people in poor countries have the same right to decent lives as those in rich ones. This explains the fish ponds in the courtyards of PIH hospitals, the rousing soccer match on a field next to the hospital in Cange, and the decision to fly cervical cancer patients from Haiti to the Dominican Republic for treatment.
In 1998, when Farmer started treating HIV patients in Haiti with expensive antiretroviral drugs — now a standard protocol that helped dramatically reduce the country's HIV infection rate — he was seeking a preferential option for the poor.
He is again in Mirebalais, where PIH is building not a bare-bones facility but one "providing the highest standard of care,'' he said at the ceremony. "So the best hospital in this country would not be floating in the harbor off Port-au-Prince, but would actually be on land.''
Dan DeWitt can be reached at firstname.lastname@example.org.