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February 17, 2010; New England Journal of Medicine | One of the most respected NGOs operating in Haiti before, during, and after the January 12th earthquake has been Partners in Health, founded in 1987 by Paul Farmer. Its Haitian operation found itself the largest health care provider in the nation after the earthquake destroyed much of the nation’s health care infrastructure. The author of this article views the international medical response to Haiti as exceptionally praiseworthy. However he notes that some 200,000 Haitians may have died in the earthquake (the Haitian president estimated 300,000 people died, and the earthquake caused a higher proportion of orthopedic injuries (per population) than any other disaster. The government’s ability to direct aid and relief was largely destroyed as most government agencies were located right at the epicenter of the earthquake. Even if the government had been functional, it wouldn’t have had a huge effect, as “Haiti’s vulnerability to disasters stems fundamentally from poverty.” The author (from PIH) suggests that Haiti’s poverty reflects poorly not only on the roles of Western governments, but on the private aid organizations that have been in Haiti—at least 10,000 NGOs were in Haiti before the earthquake. He suggests that Haiti’s pre-earthquake condition is a “sad indictment” on the NGOs in Haiti that haven’t functioned particularly well with each other or the Haitian government: “Collectively, private aid organizations have constituted a parallel government that has not coordinated its efforts or been accountable in any way to the Haitian citizenry. Taking pride in PIH’s work, the author calls on other NGOs to “include Haitian authorities in all projects and employ and train Haitians” as part of their relief programs. That lesson might be well taken among domestic nonprofits as well. A failure to employ local people in leadership and staff positions creates a lack of symmetry between nonprofits and the communities they are serving—services are delivered but something is missing, the aspect of community-building or community development that is crucial to sustainable social progress.—Rick Cohen