ARTICLE - AID SPAWNS BACKLASH IN HAITI

AID SPAWNS BACKLASH IN HAITI
(Wall Street Journal) - By Jose De Cordoba

PORT AU PRINCE, Haiti—The Hopital de l'Universite d'Etat d'Haiti, the country's largest public hospital, is so chronically underfunded and decrepit that it has the reputation as a place where people come to die, not get better.

After January's devastating earthquake, there was hope the hospital could turn things around.

Scores of foreign doctors from international medical charities flew in to treat the injured.

Charities donated new equipment, and the hospital set up its first intensive care unit. There was talk of ongoing cooperation with foreign medical schools.

Ten months later, the foreign doctors and charities are gone. The intensive care unit is closed. An unused defibrillator and a cardiac monitor lie askew atop a cart. Nobody at the hospital is trained on how to use either piece of equipment.

"Now the hospital is the way it was before the earthquake," says Dr. Alix Lassegue, the facility's director.

The tale of the general hospital casts a stark light on why Haiti has struggled to capitalize on the kindness of strangers. Donor countries like the U.S. have pledged nearly $10 billion to rebuild.

Because donors have long been concerned about corruption in Haiti's government, an estimated 70% of this year's money will be channeled through charities, otherwise known as nongovernmental organizations, or NGOs.

But as the past few months have made clear, there is little coordination among the NGOs or between the NGOs and Haitian officials. Some NGO plans don't fit or clash outright with the plans of the government. Some are geared toward short-term relief—a classic case of giving a man a fish instead of teaching him to fish. More than a million people are still living in tent cities across Haiti, fueling a cholera epidemic that has killed 796 people even as NGOs have rushed to contain it. The United Nations has asked for $164 million to help combat the disease.

There is now a growing debate over the role of NGOs in Haiti. Defenders of NGOs say there is no choice but to work through charities given the inefficiency and alleged corruption of Haiti's government. Transparency International ranks Haiti 146 out of 178 countries in its Corruption Perception Index.

Critics say the NGOs have put Haiti in a Catch-22: By building a parallel state that is more powerful than Haiti's own government, aid groups are ensuring Haiti never develops and remains dependent on charities. "The system as it is guarantees its failure," says Laura Zenotti, a political scientist at Virginia Tech University who has studied NGOs in Haiti.

"A word for the NGOs," warned former President Bill Clinton, the U.N.'s special envoy to Haiti, at a ceremony here marking the six-month anniversary of the earthquake, "tell us what you are doing, and where."

Even NGOs with a long history in Haiti sometimes show a cavalier attitude toward the authorities, Haitian officials say. For two months, the government refused to allow a new obstetrics hospital built by Medecins Sans Frontiers to open, saying the group ignored its request to locate the hospital elsewhere to better cover the country's health needs. "They didn't even ask permission to build, and when we asked them to stop, they didn't stop," says Dr. Claude Surena, the coordinator of Haiti's national commission to reconstruct the health system.

Paul McPhun, who oversees MSF in Haiti, says the group did inform the government about its new hospital, which replaced one destroyed in the quake, and only as the hospital neared completion did the location become an issue. Mr. McPhun says MSF could have done a better job of "giving updates" to the ministry of health, but the urgency of saving lives after the quake was too acute. "To continue in Haiti, we need to be partners and have to be a part of the reconstruction plan, but I don't think anybody knows what those plans are," he says.

It is a bind other countries have faced as NGOs have expanded in strength and numbers since the 1980s. Haiti is one of the world's most extreme examples of a country that both needs NGOs and has also, say critics, been held back by them. Called "the Republic of NGOs," Haiti is believed to have more aid groups per capita than any nation, perhaps as many as 10,000, according to the World Bank. The NGOs range from international giants such as Save the Children, Catholic Relief Services and Medecins Sans Frontiers (known in English as Doctors Without Borders) to a plethora of U.S. evangelical churches that help one school or one Haitian church at a time.

Aid groups provide four-fifths of social services here, according to a 2006 analysis by Washington's National Academy of Public Administration, a congressionally chartered, nonpartisan group of management experts. Jean Palerme Mathurin, economic adviser to Prime Minister Jean-Max Bellerive, says NGOs may account for as much as a quarter of Haiti's gross domestic product. He says the NGO presence has permanently "infantilized" the country, creating a vicious cycle: The government lacks the money—and historically, the inclination—to provide social services. Those services, therefore, are provided by NGOs, which means the government, in turn, has no incentive to improve.

Paul Farmer, founder of Partners in Health, an NGO which, in conjunction with the ministry of health, is the country's largest health provider, believes that NGOs and foreign governments should channel some of their funds directly to the Haitian state. "NGOs have flourished in number and size as the public sector has withered in Haiti," says Dr. Farmer.

Many of the NGOs are a world apart from the rest of Haiti, headquartered in rented mansions in the affluent mountaintop Port au Prince suburb of Petionville. Here, fleets of SUVs with stenciled initials of the organizations are constantly on the move. "There must be hundreds," said Hans van Dillen, the former representative for the Holland division of MSF, earlier this year. "Cars, cars, cars, clogging up the streets of Port au Prince."

Sitting at a table in the leafy home where MSF Holland is based, Mr. van Dillen recalled a mad scramble after the earthquake as different NGOs fought each other to control sites to put up field hospitals and medical tents, as he said, "putting their logo over your logo." At night, most aid workers disappear. Fearing kidnappings and other crimes, NGOs typically have strict curfews for their staff beginning as early as 6:30 p.m.

There is no doubt the aid money has saved thousands of lives here and provided relief to millions, especially in the aftermath of the earthquake. But whether the efforts of well-funded aid groups—some of which have been in Haiti for 50 years—can improve Haiti's long-term outlook is another matter. Life for millions of Haitians has barely improved over the decades. In terms of economic development, Haiti ranks 149th—just ahead of Sudan—out of 182 countries tracked by the U.N.

The challenges to remaking Haiti's public health-care system are on display at the Hopital de l'Universite. Its annual budget is just $5 million, 95% of which goes to pay salaries. As a comparison, MSF raised $100 million for its Haiti program after the quake. The Red Cross raised $816 million.

Hours after the quake hit, the hospital became a bloody triage center. Hundreds of injured Haitians lay on the ground in front of the complex, screaming in pain or lying in shocked, stunned silence. The nursing school collapsed, killing some thirty student nurses. The badly cracked pediatric wing was evacuated, forcing patients into makeshift army tents.

Within days, scores of foreign doctors arrived, working around the clock in horrific conditions, sometimes performing amputations without anesthetic.

Dr. Claire-Marie Cyprien, a Haitian-American anesthesiologist from Florida, says the other foreign doctors she worked with "were very dedicated" and quickly turned things around. She helped amputate the hands of her sister, who lived in Haiti. The Haitian doctors, just emerging from an almost indescribable disaster, appeared lost, she says. "In retrospect, I think they were a bit dazed, and we shunted them aside."

The hospital director, Dr. Lassegue, stayed at his post, as did Marlaine Thompson, the chief nurse. Many of their colleagues, dealing with family tragedies, didn't return for months. "Many were traumatized," said Dr. Lassegue.

To manage relations with the foreign doctors, Dr. Lassegue asked two prominent NGOs, California-based International Medical Corps, known as IMC, and Partners in Health to act as the liaison with all other medical groups working in the hospital.

At the height of the emergency, there were 19 NGOs at the hospital. Dr. Lassegue says these included Medecins Sans Frontiers, the Norwegian and Canadian Red Cross, Scientology Volunteers Ministry, Operation Blessing, Mission of Love, the Duke University Team, the Mount Sinai University Team, and the Bomberos Unidos Sin Fronteras, a Spanish firefighters' group.

Haitian doctors acknowledge the contributions of the foreign doctors. Nevertheless, there was friction. "They came, they helped, it was good, but they didn't work with Haitian doctors," says Dr. Max Harry Kernisant, a surgeon at the hospital. He says that while there is no doubt that the foreign doctors did excellent work, he sometimes felt their attitude betrayed condescension and arrogance, and that they were partly driven to build up their numbers on medical operations to drum up contributions.

Things would be worse if it weren't for NGOs, says Samuel Worthington, president of InterAction, an umbrella group that represents major U.S. aid groups, including IMC. "What NGOs can say is that there are a lot more kids in school, a lot less mothers dying, thanks to their efforts," says Mr. Worthington, who expects his members to be in Haiti for 50 years. "As long are there are social problems, there will be NGOs working here."

Between them, IMC and Partners in Health managed the emergency room and staffed the hospital's first intensive-care unit. There was talk about making the ICU a permanent fixture, through ongoing cooperation with foreign medical schools.

But by March, the only NGOs with doctors on hand were IMC and Partners in Health. Most doctors worked in two-week rotations, and the staff was stretched thin as it tried to man the emergency room and the ICU at the same time. By the end of July, both groups had pulled their doctors out. Partners in Health says it decided to return to its focus on health in rural areas. In conjunction with Haiti's ministry of health, it has broken ground on a new teaching hospital.

Jason Erb, IMC's Haiti director, says the group left after six months as part of an agreement with the hospital's administration. He says it was a strain for IMC to keep a volunteer program at the hospital, but IMC would have found a way had the organization been asked to. IMC is still in Haiti, where it maintains a network of 15 primary care clinics, and runs nutrition and mental-health programs.

Since the charities left, the hospital is back to business as usual. The occasional rat scrambles across the grounds, and sewage seeps from broken pipes by the emergency room, where dozens of half-naked patients lie in narrow cots. "And what happens now? We are in the same situation as before," says Dr. Kernisant.

Some help may be on the way. U.S. Secretary of State Hillary Clinton and French Foreign Minister Bernard Kouchner recently signed a joint memorandum to provide $50 million to rebuild the hospital. The agreement doesn't specify when the money will start flowing in. In July, the American Red Cross agreed to make a $3.8 million grant to the hospital to pay staff bonuses.

In the meantime, 20 miles from Port au Prince in the devastated town of Leogane, Medecins Sans Frontiers has opened a new hospital in place of the impromptu field hospital it set up in the days immediately following the quake. Shipped in containers from Europe, the "hospital-in-a-box" comes complete with an operating room.

While doctors in Haiti's public hospitals often go unpaid, sometimes juggling two or three jobs and using outdated equipment, MSF doctors are earning top dollar, in local terms, plus bonuses. The aim, says MSF, is to hand over the facility to Haiti's ministry of health once the earthquake emergency is over.

MSF's Mr. van Dillen was unapologetic about scooping up Haitian staff, many of whom worked at hospitals destroyed by the quake. But worried about the long-term impact that hiring away doctors could have on the country, he lowered the bonus to 50% of salary, rather than the original 100%. He also said MSF is exploring ways to work with the ministry of health, including combining some of its facilities in Carrefour, a heavily damaged area on the edges of Port-au-Prince, with facilities at a next-door Haitian hospital that suffered earthquake damage.

"It would help get us away from the parallel system we have built," he said, "which is good for Haiti's poor now, but not good for Haiti in the future."