Building back better

A few months ago, I joined President Clinton as a volunteer to, in his words, help Haiti ``build back better'' after a series of storms in 2008 destroyed an estimated 15 percent of already beleaguered Haiti's GDP. We had just been meeting about these efforts and a series of upcoming forums to be held in Port-au-Prince, and I was then going to join colleagues from Partners In Health in central Haiti, where I have had the good fortune to work with remarkable Haitian medical colleagues for many years. The day before our New York meeting, Port-au-Prince was flattened by an earthquake. There is not a lot left to be said, but having just returned from Port-au-Prince, there are some points worth underlining.

If Haiti is to ``build back better,'' as President Clinton has been saying, there are lessons to be learned from our efforts, not always honorable or effective, to help Haiti over the past two centuries. This can change and must do so, if we are to be real partners in responding to this latest misfortune.

The scale of the disaster is coming into view. All of the clichés born of extremity came to mind as I saw the city of Port-au-Prince in the dark after this huge earthquake. Symbols of authority and some sort of civility were flattened or tottering. The National Palace looked like a meringue pie that had been sat on. A foul smell hung over the General Hospital, which had just run out of diesel fuel and was surrounded by the injured, the sick, and, of course, piles of those who did not make it. But contrary to rumors of looting and mayhem, the city of two million was quiet, which in itself was unusual. I had never experienced Port-au-Prince without the blaring of radios and car horns. And I expect it will remain this way -- calm, as long as people are offered dignity and respect and the necessities of daily survival: food, water, sanitation and shelter.

The public open spaces of the city (there are few of these) and many streets have been closed off by the citizenry seeking protection from both aftershocks and troublemakers (there have been more of the former than of the latter). What strikes me from Port-au-Prince, apart from the enormity of the disaster, has been the magnitude of the response among those unaffected, whether within Haiti or without -- the simple desire to help -- and the difficulty we will face in seeking to match that goodness with the surpassingly enormous need. So far the desire to help has not been matched to the need, and there are several things to keep in mind as the situation on the ground changes rapidly.

First, rescue and relief efforts are far from over. Although for some they are too late, for others they are just beginning. The head of the United Nations here, who stepped in to replace a fallen comrade, just told me that by digging through rubble they have found someone alive under the ruins of their headquarters. Throughout the city and in the debris of a number of public buildings, people can be heard calling for help. Some are texting on phones that they are alive. It must be no different in other devastated cities, such as Jacmel in the south.

Rescuing survivors will take heavy equipment and experts. These are being brought in now from around the world. But this enormous outpouring of concern and support will be hard to receive. The airport in Port-au-Prince is clogged with aircraft. Some are turned away. All day yesterday, I was with a group of surgeons and anesthesiologists who had brought their skills and supplies. They had to wait many hours before being cleared to land, not because the control tower was destroyed (it was), but because there simply were so many aircraft requesting clearance. A plane full of requested personnel and supplies circling overhead while people die is the right metaphor for the challenges facing us in the short term. Making sure this concern is translated into meaningful rescue and relief efforts is a significant challenge, and here are some basic points that experts in disaster relief make all the time.

Second, in-kind donations are not really what is needed now. I attended a meeting at the U.N. in which this was underlined to assembled ambassadors and donors. Send money, not in-kind donations. To my surprise, the only exception noted that day was Meals Ready to Eat, as there is no way to cook safely in Port-au-Prince at present.

To this I would add that some people do have in-kind services to offer. Trauma specialists are a good example, but in addition to the obvious supplies, surgeons need blood banks, water, and space in which to work. Fuel is needed for generators. All of these are in short supply. So even when a response is highly specific and of obvious utility, like the call for trauma specialists, anesthesiologists, orthopedists, and hospital supplies, coordination is king. But coordination also requires resources -- telecommunications equipment, vehicles, fuel, and cash, to say nothing of feeding and housing of staff. And so coordination can exist in principle and be visible on the ground, yet still be a key goal.

In other words, we cannot give up on improving coordination by dismissing important actors as unable to perform their function. The Haitian people, victims of yet another series of blows, are already helping one another, and many have built up informal networks to help their neighbors in need of food, water, or first aid. The Haitian attitude expressed in the saying, ``If there's enough for two, there's enough for three'' has no doubt saved many lives over the past 72 hours. Coordinating with the people of Haiti means getting messages out on the radio and cellphone, when these services have been restored, to direct people to places where basic needs can be met.

Third, the Haitian government has been dealt a severe blow and not just to its buildings. If at a quarter to five in the afternoon an earthquake takes down not only the National Palace but also the Ministry of the Interior, the State Department, the Tax Bureau, and the Ministries of Finance, Planning, Public Works and Public Health, as well as the parliament building, you can well imagine the gaps created in an already weak public sector. The situation at the United Nations mission is similar. Although the U.N. headquarters collapsed and most of its leadership remains unaccounted-for, the U.N. is rebuilding. Central to this effort is the U.N. arm responsible for bringing together humanitarian groups including nongovernmental organizations to ensure a coherent response to emergencies. The World Food Program, too, has expertise in responding to such disasters; it is already present in Haiti.

Fourth, aid should be coordinated and conceived in a way that shores up Haitian capacity to respond. The planeload of surgeons mentioned above were responding to a call from the Haitian National University hospital. It should be noted that the leadership of that hospital (also surgeons) and the director of nursing have been at their posts for days. They are showing up to work even without the coordination and cash and supplies they need. Identifying such priceless local partners is important for many reasons related to relief and rescue, but it is most important for reasons related to recovery.

Some of this emergency response can be done with longer-range views in mind. Schools must be rebuilt, but in the interim, children must be back in school soon, and rebuilding the city's housing stock will require a different kind of urban planning and a long-term commitment to respect for the Haitian people's wishes.

Finally, I was reminded last night that rescuers will get tired. I went to see my hardy colleagues -- Haitian, Americans from Boston and Miami, Irish, and Cuban. A couple of them had been in Port-au-Prince before the quake -- attending, ironically, a meeting on disaster preparedness -- and had spent every waking moment attempting to assuage suffering the scale of which most of us have never seen. Here again, coordination and cash are king. Just like everyone else, they will need food and a safe place to sleep. Two of my medical colleagues have been sleeping in a jeep. Another two have spent the past two nights without any sleep at all. One of my Haitian colleagues had a dressing on her hand but did not comment on it. She was looking for water and food for the rescuers and, of course, worrying about her own family, some of whom were still unaccounted for.

Like so many of my Haitian colleagues, she represents what is best about that country: an inextinguishable spirit of resistance that represents hope even in the darkest of times.

Paul Farmer is the Presley Professor of Social Medicine at the Harvard Medical School, the co-founder of Partners In Health, and the deputy to Bill Clinton, United Nations Special Envoy for Haiti.