The biggest problem with post-disaster relief efforts like Haiti's is the unreasonable ambitions we have for them.
This week has seen a predictable outpouring of disappointment about the state of Haiti one year after the country’s devastating earthquake. It was predictable in part because some deserving causes for scorn — the pace of rubble removal, the slow dispersal of reconstruction funds, the cholera outbreak — have emerged over the last year. But it was predictable mainly because not a natural disaster goes by without year-after retrospectives bemoaning slow progress. Hurricane Katrina, the Asian tsunami, the Bam earthquake in Iran — all saw the same story unfold. We should have done better, but a large part of the problem is that our expectations of what can be achieved within 12 months of a natural disaster are often wildly optimistic.
It is worth thinking about how much worse it might have been. When the quake first struck, medical experts weren’t just worried about the logistical difficulties of importing sufficient food and supplies — they were terrified about the risk of tetanus, gangrene, measles, and meningitis. Jeffrey Sachs warned five days after the quake that “Haiti will suffer a quick death of hunger and disease unless we act.” A cynic might read that, look at the recent cholera outbreak, and say “one out of two ain’t bad.” But that cynic would be seriously underestimating the scale of the tragedy averted this past year as the country struggled to recover.
The earthquake was by far the largest natural disaster in terms of mortality as a percentage of country population that we have seen in recent decades. The per-capita death toll was 3,000 times that of Hurricane Katrina. It left 1.3 million Haitians living in camps. In the quake zone, 30 out of 49 hospitals collapsed or became unusable.
Beyond the immense scope of the initial tragedy, the earthquake hit a country with some of the lowest-quality government services in the world and one that was a breeding ground for a range of infectious diseases even before disaster struck. In 2008, according to the Pan American Health Organization, only 19 percent of Haiti’s households had access to adequate sanitation, 40 percent lacked access to clean water, and 40 percent were unable to access basic nutritional needs. Sixty-five percent of preschoolers had anemia. Despite progress in health over the last 40 years, vaccine coverage for diseases including measles and whooping cough hovered just above 50 percent. Haiti had the highest HIV burden and rates of tuberculosis infection in the Western Hemisphere. Malaria is endemic — there were over 100,000 cases in 2005 — and acute respiratory infections were rampant, with pneumonia accounting for one out of every five child deaths.
Past humanitarian catastrophes in similar situations have seen mortality rates rocket in crowded, unsanitary camps as children in particular were felled not just by cholera but salmonella, meningitis, hepatitis, measles, respiratory infections, and malaria. Cases of acute respiratory infections increased fourfold in Nicaragua after Hurricane Mitch in 1998, for example. The Haitian camps hold more people than lived in the camps for Rwandan refugees in Goma in the Democratic Republic of the Congo. But in 1994, the Goma camps saw 12,000 killed by cholera alone and fatality rates among the infected of over 12 percent. By contrast, a national surveillance system for disease set up by donors and the government in the aftermath of the Haiti earthquake found no evidence of epidemic spread or disease clusters in the first four months after the quake — indeed cases of respiratory infections, malaria, and diarrhea were all on the decline.
The recent cholera outbreak in Haiti has blighted that record and (deservedly) attracted alarm. It has already affected nearly 150,000 people and killed over 3,000. It broke out 55 miles from the nearest camp but spread rapidly to every part of the country — aided on its way by the havoc wreaked by Hurricane Tomas. With adequate preparations, many of those deaths could have been avoided. Mortality from cholera was about 6 percent of cases at the start of the outbreak, with fears it might rise. But since then, the rate of new infections has fallen and mortality has declined to 2.2 percent, thanks to rapid response by government, donors, and NGOs.
Meanwhile, the donor community has given 1.1 million people access to drinking water, installed 11,000 latrines, and constructed 19,000 transitional shelters. Pregnant mothers are seeing doctors and nurses, many for the first time. Children are being vaccinated, and some are going to school. Quality of life for many in the camps may be better than it was before the quake.
Why, then, the widespread sense of disillusionment with the global response? A large part of the problem is that donors routinely promise too much too fast from aid — particularly in the aftermath of disasters. At the March donors’ conference which raised nearly $10 billion in pledges for Haiti, some spoke of a “Haitian Renaissance” or a “second independence” for the country. U.N. Secretary-General Ban Ki-moon foresaw “a sweeping exercise in nation-building on a scale and scope not seen in generations.”
We should know by now that after an apocalypse is not the perfect moment for outsiders to come in and remake a country. Following the invasions of Afghanistan and Iraq, too many swallowed the heady idea that we were starting with a clean slate and could reinvent economies and societies for success. But the institutions that underpin economic development cannot be reconstructed overnight — and they are never built from scratch.
Progress on reconstruction has been achingly slow, it’s true. We could be doing better if we used more aid money to employ Haitians and if we had coordinated flows better and put at least some more resources through the Haitian government. We would be doing better if the donor community had actually paid up more than 10 percent of the reconstruction money it promised in March. And we’ll never do as well as the lofty rhetoric of those donor conferences might suggest. Aid agencies and donor groups have done themselves and everyone else a disservice by inflating expectations about the speed of recovery. But what they can realistically deliver, and what they successfully delivered in Haiti, is the services necessary to elevate a hellish situation to a merely horrible one.