After not Graduating

Not every family graduates from CLM.

The record since the program took off in 2007 is striking. 144 of the 150 families who participated in the initial pilot graduated, and the team has maintained that 96% graduation rate ever since. 3395 families have succeeded thus far.

The criteria are straightforward, nothing fancy. A family must be eating at least one hot meal every day. They must have two sources of income and $185 worth of productive assets. They can have no untreated cases of malnutrition and must be living in a house with a good tin roof. We want the woman of the family to have a plan for the future and the confidence to know that she can succeed.

But that leaves about 4%, or about 140 families, who haven’t graduated. That’s really a lot.

They fail to graduate for lots of reasons. For some, the case manager has failed to establish the trusting relationship that our program’s work depends on. We had a member named Marie who went behind her case manager’s back and sold all the goats that we gave her. He continued to try to work with her, but her dishonesty continued. And that was when he was able to see her. Much of the time, she ducked his weekly visits.

We don’t know as much as we should about the women like Marie, about what they do after their cohort graduates. We have anecdotes that suggest that many continue to make progress. Marie herself finished building her house after we had moved on, and she continued to build up her charcoal business as well. But we don’t have the resources to ensure follow-up.

But Mimose is doing ok.

She and her husband Wozèn live in Mazonbi, a remote area at the end of a rocky, twisting road that follows a secondary ridge northwest from Gran Boulay, a village on the mountain that separates the Central Plateau from the plain that contains the suburbs north of Port-au-Prince. When they joined our program in June 2013, they had three small children. She had once had a small commerce, but had lost the money one day when she was at market. Then she became pregnant with her last child, and couldn’t really move around. The boy was born right before she entered the program. Wozèn took on the whole responsibility for supporting the household by farming their small plot, and doing day labor in their neighbors’ fields.

The issues that interfered with her graduation were nothing like those we saw with Marie. We evaluate women after twelve months to see how much progress they have made towards the program’s goals, and at the twelve-month mark Mimose was ready to graduate. She and Wozèn had worked hard to build a well-constructed two-room house, using money she saved from her weekly stipend to making it larger than most of the houses that CLM members build. She was once again managing a small commerce, and though she had had trouble with her goats, she had enough assets overall to meet our graduation criteria.

IMG_0157

But then she ran into problems. She and Wozèn chose not to use contraceptives, and she became pregnant once more. The pregnancy made it impossible for her to get her small commerce to market – each of the local markets she sells at is a considerable hike from her home at the lower end of Mazonbi – and the money that she had in it frittered away as she and Wozèn worked to cover household expenses.

She and Wozèn had been struggling from the start to make something of their investment in goats. A jealous neighbor had killed three of them, and though they pursued restitution with their case manager’s help, the most they could get to replace their losses were two small goats that the man’s aunt gave them so that he could avoid prison. They reluctantly accepted the aunt’s offer because she had been a very good neighbor to them for a long time. They thought they owed her their cooperation. Shortly before the 17-month evaluation, which would determine whether Mimose could graduate, the two replacement goats died.

So the only productive assets that they had were a couple of chickens from a flock that the couple had been keeping to provide Mimose with the extra protein she needed during the last stages of her pregnancy, and a field they had planted with beans. It was less than our graduation criteria demand. The last thing we were able to do for her before we left Mazonbi and its environs was to arrange for another CLM member to give Mimose two more goats so that she and Wozèn could get started once more.

But it didn’t take long for them to begin to build their household back up again. Mimose gave birth to a healthy baby, and decided that her fourth child would be her last. The couple made the effort to get her to the hospital in Mirebalais for the childbirth, and she had the doctors their tie her tubes. “Four children is enough,” she explained. Wozèn added, “Children are expensive. They have to eat, and they have to go to school.”

While she was in the last months of pregnancy, Wozèn took good care of their new goats, and they grew quickly. But he and Mimose were constantly concerned about goat thieves. The area around Mazonbi is spotted with little hills and valleys. Wherever they might choose to tie their goats to graze, the goats would be hidden most of the time. And there are numerous little paths that lead to Croix-des-Bouquets and Titayen, easy routes to market for someone who decides to lead away a neighbor’s goats. So they sold them and looked for another way to invest the funds.

Then a neighbor asked them about farming a field that they could not afford to plant, and they agreed to rent it to him for two years. They took the rental money, added the money from the sale of the goats, and bought a cow. They paid a lot for the cow – about $260 – but they thought it was a good investment. “It’s a big cow,” Mimose explains.

And now Mimose is ready to get back into her commerce. In the coming weeks, she plans to apply for a loan from Fonkoze, once again joining the women who were in CLM with her. She’ll send Wozèn to purchase rice and beans and other basics for her in Croix-de-Bouquets, and then she’ll bring them for sale in the local markets in Labasti, Dalon, and Ti Sekèy.

We’re optimistic about Mimose. She and Wozèn work hard and together, and they learned enough during 18 months with their case manager to have an excellent chance to succeed over the long term.

Not Ready for Credit

Programs like Chemen Lavi Miyò are called “graduation” programs. Participants spend eighteen months with us. Then they graduate. We hold a celebration, and we hand out certificates. Then the women move on to bigger things.

We are part of Fonkoze, a large microfinance institution, and while finding customers for our banking operation is not our goal, we do encourage graduating members to join Fonkoze’s credit programs if we think they could benefit. And we believe those programs can help many of our graduates continue their struggle to lift their families out of poverty.

So while we were planning the graduation of 347 families in December, we worked hard with our partners in the banking side of Fonkoze to arrange for loans. Case managers recommended approximately half of all graduates for credit, and most of them received their loans right away.

Case managers don’t decide by themselves whether a woman should join the credit program. Their recommendation emerges from conversations they hold with each CLM member in the months just before graduation. CLM members need to understand what it takes to succeed with credit, and they need to want to take the risk that comes with a loan. They also need to be clear about the difference between credit programs and CLM. The fact that Fonkoze provides both can lead to unrealistic expectations when they leave CLM to join credit. Finally, the case manager needs to be convinced that a prospective graduate will be able to manage a small business that can absorb the extra capital that the loan provides. Unless it can borrowed money will be more of a useless burden than a helpful tool.

Miraclide is a recent graduate from Niva, a large swath of farmland just south of Mirebalais. She made enormous progress during her 18 months with us, but did not decide to take on a loan when she graduated. It’s instructive to see why.

She lives with four children along the paved highway that runs from Port au Prince, through Mirebalais, and then on to the north. When she joined the CLM program, she had little that she could call her own. She had been forced to sell the one goat that she owned in order to rent the room they slept in. As her year-long lease was expiring, she wondered what she’d do. The father of one of her kids would send her about $1.50 a day, but it was all she had to feed all of them. She was pregnant at the time.

Shortly after she joined the program, she found a spot nearby that another neighbor was willing to rent to her for five years. Her case manager helped her figure out how to assemble the money she’d need to make her payments. So with the program’s support she built a small house and a simple pit latrine on the land. She started to care for the livestock we gave her – two goats and a pig – and they multiplied, despite the epidemic of Teschen Disease that was sweeping through the region, killing many of the pigs.

She also started a small commerce, and it began to take off. At first, she sold cosmetics: soaps and shampoos, perfumes and lotions. She would place them with a series of saleswomen who already had stands that they sold from along the highway. They would make a small commission on the sale. She might give a woman $10 or $20 worth of merchandise, with payment scheduled a week or two later, after it was sold. Her merchandise moved well, because she didn’t have much competition. Local merchants who were selling cosmetics were mostly selling hers.

But there was a problem. The women who were making the sales wouldn’t always pay her on time. Each delayed payment would affect the amount of new merchandise she could purchase, so her business began to shrink.

Fortunately, she and her case manager were quick to identify the problem. Leaving her merchandise to be sold on consignment meant giving up too much control, because she couldn’t know when she’d be paid. She decided to sell off her cosmetics business and try earning money another way.

By then, she had given birth to her second child, and because she had her baby on her hands, she couldn’t choose anything that involved a lot of time out of the house. That’s why she decided to sell basic food products – like rice, oil, bullion cubes, sugar, flour, and tomato paste – out of her home. Neighbors would come to her when they weren’t able to make it to the market in Labasti or Mirebalais, or when they just needed a few ingredients to make a simple meal.

Once again, her sales started out strong. But her difficulty collecting the money she was owed persisted. Women who sell out of their homes face enormous pressure to sell on credit. Their closest neighbors come by, asking for a cup of rice or a measure of cooking oil. Something they need to feed their children. They promise to pay the next morning or the next week. It’s difficult to say “No.” She’s your neighbor. You’re around her every day. And her children, the children your own children play with, may be hungry.

It’s also difficult to collect these debts. You can go a customer’s home, and make a lot of noise, but Miraclide was unwilling to make ugly scenes. And even an ugly scene might not help. The woman might simply not have the money when she said she would have it.

So Miraclide’s business continues to stumble along. She earns enough to keep herself and her children fed, but her income shrinks and then grows again as the amount of money she has in her clients’ hands increases and diminishes. When the school year is over, she’ll be able to use her older girl as a babysitter, and then move her business to the market. That will help. People who come to the market expect to pay cash. But it will only help for a couple of months. When her girl goes back to school in the fall, she’ll be stuck again. As long as she has to stay with her baby, she won’t be free to invest herself fully in the business she needs to make herself and her girls prosper.

If you ask her how she feels about the progress she’s made, she gets excited. “I had nothing. I was living in someone else’s home. I remember what my life was like, and I’m determined to manage my livestock so I can continue to move forward down the road.”

And she hopes to be able to join Fonkoze’s credit program some day, but right now a loan seems like a bad idea. She doesn’t feel confident that she’d consistently be able to make her payments. It would always depend too much on the women who owe her money. And she doesn’t want to have to sell off livestock – the only insurance that she has –to pay off a debt.

So she’ll wait. She’s young and her little girls are young, too. She’s learned that she can run a business, and she’s confident that she’s be able to flourish as soon as she’s free to really get to work.

Rose Marie Takes Her First Loan

IMG_0494

Walking through Derasin, to the home that Rose Marie and her husband Emmanuel shared before they joined the CLM program, you would not have imagined that the couple living there would need the help that CLM offers. The yard surrounding their home was always richly planted, covered with healthy-looking patches of beans and corn. Large, old mango trees provided comfortable shade. You would have assumed that anyone living in such an area would at least have plenty to eat.

But nothing about those fields or trees belonged to Rose Marie or Emmanuel. As Rose Marie struggled with her third pregnancy, the family would get by on whatever Emmanuel could bring in through irregular day labor. They frequently faced days without solid meals, getting by on abandoned mangos or boiled leaves.

Then the family joined CLM, and things began to change. Emmanuel continued to seek day labor, whether in his neighbors’ fields or in the sand pits that line the main highway along the ridge separating Port au Prince from the Central Plateau. Rose Marie stayed home, looking after their two children and taking care of the livestock they received from CLM. She would use their weekly stipend to ensure that her children were eating well, but she’d also use part of it to buy poultry. She began keeping chickens, ducks, and turkeys, and they all prospered.

As her due date approached, however, life became more difficult. She is a tall, strong woman. But she was becoming enormous. Her previous pregnancies had been nothing like this. Her feet and ankles began to swell so much that it became hard to move around at all. And Derasin is far enough off the main road that she would need to walk just to get to where a truck could pick her up to take her to the hospital. Preeclampsia is a serious threat to the women of rural Haiti, and her case manager, Georges Zetrenne, kept a close eye on her situation. CLM’s driver Wilfaut made four trips to the hospital with her before she finally gave birth to twins.

Having the twins to take care of changed her life. She was limited to what she could do around the house. Emmanuel would have to work even harder to bring in whatever income he could. Between the pressure he was under to earn their daily bread, and Rose Marie’s inability to leave the twins, the couple was forced to make a difficult decision. Their two older children had finally started going to school, but neither parent was able to walk them to the one they were attending. They had to keep them at home and hope to start over the following year.

Shortly before Rose Marie graduated, the couple hit a bump in the road. They lost a large pig and a cow to disease in quick succession. They suspected jealous neighbors. They had harvested good crops on farmland they rented, and their livestock was starting to take off. The deaths of such large animals were sudden and mysterious. But rather than cry over their losses, they decided to move out of the house they had built on Rose Marie’s land. So they packed up what they owned and moved to a small place on land that Emmanuel’s family owns in Fond Cheval, near the sand mine that was becoming their most important source of steady income.

The day after graduation, Rose Marie took out her first Fonkoze loan. She had been in a credit program offered by one of Fonkoze’s competitors in the past, before joining CLM, but it hadn’t worked out. She would borrow enough money to buy a pig and some poultry. The pig would mature over the term of the loan, and she’d sell it to repay the loan and its interest. The poultry would remain as her profit. Because she generally had good luck with poultry, and her family was small, it seemed like a good arrangement.

But Teschen Disease is a serious threat to pigs in the Central Plateau, and Rose Marie’s luck ran out. She lost a pig to the disease, and had to sell off other assets just to pay back what she owed.

Facing the chance upon her graduation from CLM to join Fonkoze’s credit program, Rose Marie made a different sort of plan. Fond Cheval is a bigger and livelier place than Derasin, and she and Emmanuel decided to use their move as an opportunity. They began selling cellphone minutes, and the business took off. They decided to use credit to accelerate the sales. The loan is important, because cellphone minute sales can only work if you have enough cash in the business to be able to provide change all the time. Having the correct change ready is one of the most important competitive advantages that a salesperson can offer to clients in the Haitian countryside. Without it, she and Emmanuel would have had to choose between losing customers to other venders or selling on credit. Thanks to their loan, they can now sell as much as 2500 gourds worth in a day. That’s translates into 200 gourds of profit. They had no trouble making the first of their three repayments. And they did not need to shrink their business to do so, even though they have also been using some of their earnings to help feed their kids.

And they are nowhere near ready to stop. They’re already planning what they will do with their next loan. “We want to increase the loan just a little. But we won’t put more money in the business we have,” Rose Marie explained. “We’ll add another, new business.” The twins are still small enough that one or the other of them has to stay at home all the time, so Emmanuel will stay with the twins and sell phone minutes from home on market days, while Rose Marie buys sacks of produce that she can then divide into retail quantities and sell in front of their home.

Rose Marie and Emmanuel have struggled since they joined CLM, but they have made real progress, too. They are ready to send their older children back to school in their new home community, and are committed to helping all their children to a better life.

Emilienne and Kendy

Emilienne joined the CLM program almost a year and a half ago, and is preparing to graduate in December. She is originally from Zilia, a very rural area tucked in close to downtown Mirebalais, but she spent much of her life in Port au Prince, raising her children together with her husband in Cité Soleil, one of the city’s most notorious slums. “There were so many people there, I could always sell something. I’d just set up my business outside my front door.”

But crime in Cité Soleil was rising. And then disaster struck. While Emilienne was pregnant with her last child, her husband died. So despite her ability to earn a living in Port au Prince, she decided to move back to Mirebalais. Her oldest children were already off on their own, and she found family members willing to take two of her younger children in. So she moved into a small room in a cousin’s house in downtown Mirebalais. She was pregnant, but alone, supporting herself making and selling tablèt, a handmade praline-like candy.

One night, she woke up alone in her room, and knew that her time had come. She had her baby without waking up anyone. “I had my boy, washed him off myself, and cut his umbilical cord. Then I got up, went out, closed the door behind me, and started to make my candy. The next morning, my cousin heard a baby crying in my room, and asked me whether I had had my child.”

By the time she joined CLM, she had moved back out to Zilia, with her young boy, Kendy. She was living in a straw shack, on a cousin’s land. She supported the two of them by buying a couple of twelve packs of crackers on credit every day, and selling them at the Mirebalais – Port au Prince bus station. She’d pay for the crackers at the end of the day.

She chose goats and small commerce, and got to work. She started working to develop her small commerce while Kendy helped by watching her goats. And they began to flourish. Her goats grew and eventually had kids. But Zilia is a difficult neighborhood. Though it is sparsely populated and even a little remote, it is also very close to downtown Mirebalais. And so it’s more subject to crime than more distant areas. She and Kendy lost two goats to theft. Little Kendy was so heartbroken that she was too busy comforting him to worry about the losses.

At the same time, her business started to grow. She continued to sell crackers — with her own money, now — but added other snacks, even cold drinks.

IMG_0230

The commerce has been growing. She and Kendy set up the business each morning, before he goes to school.

But it isn’t always smooth sailing. Just last week, a young man passed by and tried to steal 50 gourds by reaching his hand into her basket. Fortunately, Kendy saw him. “Kendy ran after the man and grabbed him. The man tried to deny that he had taken the money, but Kendy saw where he put it. He grabbed the guy and wouldn’t let go. Kendy made so much noise, that people came up. By-standers tried to hit Kendy to drive him off, but he wouldn’t give up. Eventually, the man gave the money back, but I was so mad. Who know’s what could have happened to Kendy? And for just 50 gourds.”

Emilienne is excited about the progress she’s made. “I have a new house, I have livestock, and I have my business. I’m taking good care of Kendy.” Her dream is a simple one. “Kendy’s everything to me now. I just want to give him the chance to live a good life.”

Pase Kado

August 24, 2014

When our director, Gauthier, describes the way our team moves, he talks of a “bale”, or a broom. We sweep through each neighborhood, integrating all the residents who qualify for the program before we move to the next neighborhood. And we generally pass through an area only once.

But even Gauthier will admit that we’re not perfect. We can miss people for various reasons.

The problem we have faced most often is from women who choose not to join program. As poor as the families we aim to serve are, they can be afraid to take advantage of what we offer. It must seem too good to be true. And they often have neighbors and family members who encourage them in their distrust, jealous that they have not qualified for the program themselves.

But we’ve made a lot of progress at preventing such problems in the years since we first started. We’ve added community meetings to the first steps we go through early in the process. Once we decide whom we will invite into the program in a given community, we invite the community’s leaders to listen to an introduction to the program, trying to get them to be our advocates to families who might be on the fence. It’s made a difference.

Even so, however, we occasionally find people who have fallen through the cracks, and we haven’t found a dependable way to help them. They remain a small stain on our dream of eliminating extreme poverty in the Central Plateau, but the small stain is important when we consider what it really means to leave a family behind: hunger, sickness, and a future with very little hope.

Roselène is an example. She lives in a remote corner a Venis, a sprawling patchwork of hilly farmland just south of Mirebalais. We had no trouble finding just over 50 families to work with in the area. When our selection team passed through Venis, we talked to Roselène and her husband, but we didn’t qualify them for CLM because of a misunderstanding.

Members of our team were trying to identify what larger livestock the couple might have. We don’t take families who own large, valuable animals like cows or mules. They saw Roselène’s husband managing a cow and a horse, so they asked him whether he owned them. People will often hide their wealth if they know that we have something to offer to the ultra poor, so one of the people on our team told the couple that we would be offering free vaccinations to livestock, but we had to talk to the true owners. Roselène’s husband was only looking after the animals for a wealthier neighbor, but rather than risk losing that chance to get vaccine for animals in his care, he lied and said they belonged to him. So our team moved on to the next house.

Shortly after that, we started serving the neighborhood. As the members started to make progress towards lifting themselves out of extreme poverty, Roselène could only watch. We had left her behind. And a couple of weeks later, the owner of the cow and the horse took them back from her husband. They were left with nothing.

But in every neighborhood we work in, we establish a Village Assistance Committee. These committees are made up of local volunteers, and they help us ensure the program’s success in various ways. They support members on days when the case manager is not around, either helping them contact the case manager or intervening directly. They provide an added layer of supervision, ensuring members learn to take care of the assets we give them. And they bring resources to members who need extra help as they are beginning to turn their lives around.

The committee in Venis has been especially active, and as the months went by they expressed frustration at the fact that we were doing nothing for Roselène, though they identified her as one of the poorest women in the area.

Rather than complain about it, however, they took action. Committee members decided to pitch in to buy her the roofing material she would need to build a new house, and they contributed the lumber by culling it from their own land. They were managing a small effort to build a community latrine, but they took some of the materials they has set aside and built a latrine for Roselène instead, redesigning what they would build for the community along more limited lines to compensate for the extra expense.

But to get Roselène on the road out of extreme poverty, even on a slower track than the one we usually provide our members, would require some investments beyond what the committee members were able to provide, so they asked us to help.

First, we needed to establish that Roselène is as poor as they say. We have occasionally heard from committees about families that need our help only to discover that the families are not as poor as we’ve been led to believe. So Elvoit, the case manager who works in Venis, went to meet her, and he redid the selection survey. Without the livestock that her husband had pretended to own, she qualified easily.

Then I went out to verify his findings. I wasn’t sure where she lived, but I had an easy way to find her. I went to Jésumène, a CLM member from Venis whom I know well, and asked her whether she could show me where her husband’s other wife lives. Jésumène and Roselène are matlòt, or women married to the same man. It felt like an awkward question to ask, but Jésumène showed no awkwardness in her answer. She was glad we were going to help Roselène. She talked about how badly Roselène had been doing since their husband became sick, unable to work. Jésumène herseld has two older sons who can help her. The second, Bonapart, is especially hard working. And she has CLM as well. But Roselène, she said, really needed help. She called over one of her daughters, who led me straight to Roselène’s house.

A short interview was enough to show me that the committee was right. This enabled me to mobilize some of our resources. We gave her a water filter and a five-gallon jug, and we found a little money to pay a local builder to start work on her home.

But there is not much a woman can do to change her family’s life if she has no assets to develop. Though we think of our program as a comprehensive approach to poverty alleviation, the core of what we do is on the economic side. Roselène was happy about her new house and latrine, but she needed a way to generate income, too, and fortunately we had a solution.

Since the very beginning of the program, we have operated with a consistent principle: the assets we give our members are theirs to keep. The program was developed for families too poor for credit, so our leadership decided to base it entirely on grants.

New partnerships can mean new opportunities, however, and they can also call for compromises with groups whose principles are different from ours. The 360 CLM members in the group I work with right now were sponsored in part by Heifer International, a major organization that we were working with for the first time. (See: http://www.heifer.org.) At the core of Heifer’s approach is a practice they call “passing on the gift.” The poor who receive livestock from Heifer are expected to give offspring to other members of their community. It is a way to ensure that the benefits Heifer provides are shared as widely as possible. We have generally felt that our members are too poor for such and approach, that they need the ability to accumulate their own assets quickly to escape persistent hunger.

So we worked out a compromise. Members supported by Heifer would receive four goats instead of two, and then pass two of the offspring on to other deserving families. Fortunately, Venis is one of the neighborhoods where our work is partially supported by Heifer, so all 52 members there received extra goats. They are now reaching the point at which we can begin to ask them to give some away.

Tuesday, Elvoit worked together with the Village Assistance Committee to organize a small, ceremonial passing-along of the gift to Roselène. He selected Paquese Salomon, a woman from Rato, which sits along the entrance to Venis from the north. Paquese has been particularly successful with her livestock. Though she started with nothing, she already has more than $400 worth and has set aside almost $150 more to buy another large animal. The minimum standard for graduation from CLM is about $200, and she has a few more months in the program to continue growing. She’s doing very well.

So they invited Gauthier and me to join them. It would be our first experience with Passing on the Gift, so we wanted to be present. We sat in a circle in Paquese’s front yard. Nine of the committee members were there, including the two who are, themselves, CLM members. There were speeches from Elvoit, from Gauthier, from the Committee’s president, and from one of the CLM women who sits on the Committee.

Gauthier especially wanted Paquese to speak, because we wanted to know what giving away assets might feel like for a member of CLM. So he asked her to say a few words.

“Se te kondisyon an,” was her initial response. “That was the deal.” She knew that the reason she had received four goats instead of two was that she’d have to give two of them away.

But Gauthier wanted to hear more, so he asked her how she really felt about it in her heart, and the committee president expressed his desire to hear her as well. So she thought for a moment, and then finally explained that she was really happy. “I used to live like she was living. I had the same kind of problems. Now I’m someone who’s able to help.”

We are unlikely to make Passing on the Gift a regular part of CLM. It is complicated to administer, and might turn out to be expensive. But for Roselène and Paquese, it offered real rewards.

How Memène and Chiver got rich

More about Memène and Chiver
July 6, 2014

Memène was pleased when I asked her to stand up at the three-day workshop for CLM participants. Gauthier, our program director, was about to speak to the group. I had spoken to him about Memène several times over the last year, and I thought he’d want to hear about her progress from her.

She has generally seemed like a shy woman, but she hopped right up off the bench chair with a big smile. “My husband and I just sold a pig. Between that money, and some money I earned from my small commerce, we were able to buy a cow. And he just got paid for some farm work he was hired to do, and earned enough to buy two more. We have three now.”

That puts them a long way from where they were when they joined CLM. They live in an especially poor corner of Demare, an agricultural area tucked behind Labastille, the most important weekly market in Southern Mirebalais. A hillside that was once covered with dilapidated straw shacks but now sparkles with shiny new tin roofs on a half-dozen CLM houses.

It is not as though they simply took off once they joined the program. We evaluate all families after six months. The survey we use is meant to serve case managers, helping them focus their attention of members who are progressing more slowly. Families are scored as fast climbers, slow climbers, or slow-slow climbers. Memène scored as a slow climber, and Christian, her case manager, noted that he was concerned because she seemed unwilling or unable to set her mind on any sort of a plan.

And that was the least of her problems. She was also subject to a lot of abuse, so much so that we had to bring in a representative of the Haitian government’s Ministry of Women’s Affairs to see her and Chiver. We had tried to get her out of the house or to get Chiver past his violence by ourselves, but we hadn’t had much success. (Click here)

But bringing in the law seems to have turned the trick. We have been keeping close track of the couple ever since we first heard about the violence, and they both report that it has stopped. “Now when Memène makes me mad, I know I have to walk away,” Chiver explains. Memène’s view is even simpler. “Things are really good.”

Many CLM graduates are able to buy a cow before they graduate. Some are even able to buy one before they reach the twelve-month mark in the program. But the achievement of Memène and Chiver is exceptional. From zero chickens to three cows in just twelve months. And from a member we expected to advance especially slowly.

For rural Haitians, cows means a lot. If you take good care of them, they grow reliably and, so, gain greatly in value. A heifer will eventually provide young, which can add a lot to a household’s wealth over the course of years. And cows are a lower-risk investment than other large livestock. If they die, you can sell the beef. Pack animals, which are more useful for the most part, become food for scavenging dogs.

But a cow is also a status symbol, a sign of wealth. It affects the way that communities perceive its owner and the way its owner perceives herself. When Chiver first surprised me by showing me the three cows, I joked that he was now a “gran nèg,” or rich guy. He liked the joke, smiling broadly. But part of what he liked was that it was only half a joke. A family with three cows really is wealthy, at least comparatively. And even if he and Memène continue to have problems to resolve, he knows he is now much better off than some of the people living around him.

But I didn’t quite get it. As badly off as they had initially seemed to be, I was having a hard time imagining how they had turned things around so quickly. So I went to chat with them to see whether I could figure things out.

The first possibility I had to consider was that we had mis-selected Memène for the program. We are good at selection, but we aren’t perfect. If they had had wealth we didn’t know about right from the start, that would explain a lot. This seemed pretty likely, because the couple had proven itself capable of working hard and profitably. I really wondered how such hard, productive workers could have been as poor as we thought they were. I went back to their initial selection forms, and they said that Memène had had very little wealth at all. No livestock whatsoever, for example. But I asked her about this, and she reaffirmed that she had had nothing. And her case manager said the same thing. I thought back to they way she and Chiver described the fights they had had to me, and one of Chiver’s consistent accusations had been that Memène had come to him with nothing. “I took you in right off the street,” he would say. He eventually came to feel sorry to have spoken to her that way, but the accusation itself was evidence that Memène had been as poor as we thought she was.

But there was another possibility. Chiver might have owned some livestock that our case managers had decided not to include on Memène’s form. It would have been a reasonable decision. Their relationship seemed anything but reliable. If they both identified his livestock as definitively his, she would be in dire poverty the moment they broke up. Or she would be forced to stick with him because of her poverty. But Chiver told me that he didn’t have anything when we started. Not that he hadn’t ever had animals. He had started to build up wealth a couple of times, but had always had to give them up. Most recently, he had accumulated a handful of goats, but had had to sell them off when his father had a sudden need for cash.

So I sat down with Memène and Chiver in front of their new CLM house. Chiver was weaving palm leaves into thin walls that he could use to surround their latrine. It sits close to a narrow footpath that leads to a working sugarcane mill, and the latrine’s original wall had been knocked over by a horse that had passed by carrying a load of sugarcane. Memène and I sat on small chairs in the little bit of shade that the front of their one-room house could provide, and the two kids were jumping around on their bed, inside. Chiver sat on the ground as he wove.

I tried to explain my question to Memène: They had proven how hard and effectively they are willing and able to work. Their wealth was growing quickly right in front of us. How, I asked her, could two such capable young people have gotten as poor as they had been?

I had a hard time getting the question out clearly. Memène sat in silence at first. Chiver looked at her and told me that she didn’t understand. He started to help me explain. This itself was progress. He knew better than to simply answer for her.

Eventually Chiver and I were able to pose the question clearly. Memène is a woman of few words, but her own were clear enough. “Se te pwoblèm nan kay la.” That means, “It was the problems we had around the house.”

Chiver then explained. They had been struggling just to make sure there was food in the house every day. He would have to find work as a day laborer just so he, Memène, and the kids could eat. Day labor pays a little more than $1 per day. And you can’t make a meal for two adults and two kids for much less than that. A contract to weed or plant an entire garden could be worth several thousand gourds, but you might have to wait a long time to be paid. Chiver couldn’t wait. Every meal, every day, depended on him.

“Once Christian started bringing Memène money every week, I was able to look for contracts. I didn’t need to work by the day any more. When Memène started her commerce, things got ever better.”

As soon as they escaped the daily struggle with hunger, Chiver was able to turn his attention to more lucrative contract work. By the time we bought Memène her pig, he had purchased one too. She now keeps the family fed by herself, which means that Chiver can focus on work that will continue to make them wealthier. They even invited her little brother to move in with them. There is plenty of food to go around, and the younger boy can help look after the little kids. That gives her more time both to do the heavier housework – like laundry – and to take care of her small business.

When we talk about their dreams, things have gotten clearer, too. They know that they cannot simply continue to buy large animals. There are only so many Chiver can take care of on the very little bit of land they have access to. But someone willing to work as hard as he does on other people’s farms would have every reason to hope for success if he could start accumulating farmland of his own. It won’t be easy. The land in Demare is expensively fertile, and the titles aren’t always clear. Chiver is afraid that he could spend a lot of money on a piece of land, and then find out that he didn’t buy it from the real owner.

But when you talk to them about the prospect of buying some farmland, they get giddy. They both like to farm, and you can tell that owning their own land is their dream. If they can start working on it while we are still with them, we can probably secure some reliable help with the deeds.

So Memène andChiver are well one their way to a better life, one that they’ll be able to sustain over the long haul.

More about Anise

The Next Step with Anise
June 1, 2014

It has been encouraging to see how Anise and Mackenson have grow stronger since Mackenson was admitted to the University Hospital that Partners in Health opened in Mirebalais. I wrote about them earlier in the week. (See: http://www.apprenticeshipineducation.com/compliance/.) They still have a long way to go, but the signs are very positive. The sickly, lifeless infant we first brought to the hospital has turned playful and energetic. He still needs to put on some weight, but he’s eating now, and his diarrhea has slowed down, so there is every reason to thing that he will.

And it’s probably not surprising that Anise’s health seems to have improved as her boy’s has. She has been sickly almost since we met her. One of the things that delayed getting her baby to the hospital was the fact that she was too weak to carry him. She would have needed a neighbor or a family member to go to the hospital with her, and she wasn’t able to mobilize anyone. We eventually had our driver and Anise’s case manager, Nerlande, take her and Mackenson to the emergency room. He was admitted, and she has simply stayed there with him.

In their first days in the pediatric ward, she seemed to get worse. She was losing sleep, sitting up all night in an uncomfortable wooden chair next to her baby’s bed. She looked exhausted, and her feet started to swell significantly. One morning when I visited them, I happened to come as the pediatric resident was making her rounds. I asked her whether they had noticed Anise’s feet. The doctor responded that she had, and that they had tried to get Anise to go to the emergency room. They were, she said, worried that it could reflect a heart problem. But when Anise got to the emergency room, and had to wait to be checked in, she grew frustrated, worried about Mackenson, and she returned to the children’s ward. When the emergency staff called for her, she was gone.

The doctor told me the story, and I immediately thanked her and responded that we would see to it that Anise got seen, but that meant finding someone to sit with Mackenson for the time it would take for Anise to get through what are very long lines at the hospital, which is sometimes overwhelmed by the needs it serves. So I contacted Nerlande and another case manager on our team, Hilaire, and we went to Anise’s house to find someone from her family to help her out.

No one was willing to go. Anise and her children have been living with her father, Anice, ever since he got into a conflict with Mackenson’s father, Genson. Anice pressured Anise to come back to live with him, and she complied. But he has been unwell, and didn’t feel strong enough to go to the hospital to stay with his daughter and grandson. The other residents of Anice’s lakou, or yard, are his son, Anès, and Anès’s wife and children. Both of them said they couldn’t go either.

I returned to the hospital that evening, only to find that Anise seemed to be deteriorating. Her feet were continuing to swell. They were misshapen, and she was in pain. Part of the problem was the chair she had been sitting in for several days. The hospital has comfortable lounge chairs, with footrests that can be raised, for family members staying overnight with patients. Anise was entitled to one, but all the ones we could find in her ward were taken. I saw a healthy young man relaxing in one, and I asked him to let Anise use it, pointing to her obvious need.

He refused. He said he was sorry, but didn’t see why he should have to be uncomfortable while everyone else had a nice chair.

I got really angry. I don’t swear in Créole. I think of how silly Haitian young people always seems to me to sound when they swear in English, misusing bad language that they can’t quite pronounce. But I was pretty mad, and I’m afraid I made a little bit of a scene, using words I don’t have a lot of practice with. Fortunately, the other man was willing to swear as well, so the embarrassing scene was not all mine, even if I was probably the only one embarrassed.

The scene, such as it was, achieved three results. First, for the next two days, the man called me a shameless pig every time I walked by him. He then left the hospital with the sick person he had been there with. Second, Anise smiled for the first time since I had gotten her to the hospital. At first, I thought she was simply amused, just as her case manager and the nurses seemed to be. But it eventually became clear that she liked the fact that I was angry on her behalf. Third, and most importantly, as soon as I left, the nurses scrounged up another recliner, which Anise has been in ever since.

But we still needed to find someone to go to the hospital to stay with Mackenson while Anise sought care for herself. Frustrated at our continued failure to mobilize her family, Hilaire started talking to neighbors, saying in his exasperation that we would pay someone willing to go right away. We finally found a woman, helped her make her own childcare arrangements, and then took her to the hospital. She spent two days in the pediatric ward, together with Anise, and Anise got through the hospital’s lines. They couldn’t find much wrong with her – anemia, some kind of minor infection – and as sickly as Anise had first gotten since we first met her, she has been improving markedly.

Meanwhile, we knew we had another problem to help her face. She will not be in the hospital with Mackenson forever. His improvement has been even more rapid than hers. But we could not imagine how she would flourish if she simply returned to the same living situation she had grown sick in in the first place.

We wanted to see whether we could patch things up between her and Genson. His was clearly committed to helping her as the mother of his child, but we were not sure whether he was willing to get back together. We felt that any help he offered would continue to go to waste unless she moved out of her father’s home. We have a lot of evidence that suggests that Anise’s father Anice is a big part of her problem.

Here, things get complicated. We felt that Genson was open to much more than just distant support, but Anise’s position was initially unclear. She was coming to understand that her own family was doing nothing for her. Her only help during her sickness had come from Genson and the CLM team. But her father had told her that if she and Genson got back together he would never speak to her again. And Anise said that her mother, who was living in Port au Prince, working as a housekeeper, agreed with her dad.

So Nerlande called the mother, and it turns out that she was more open than Anise believed. The first positive sign was that she quit her job in Port au Prince the very day she learned of Anise’s situation, and she rushed back to Mirebalais to sit with Anise at the hospital. She explained to us that she had returned home to take care of her child. She also mobilized her older son, Anise’s brother Jean Claude. He is not Anice’s child, but lives just a few hundred feet away. He had been distressed to see her sister’s deteriorating condition, but hadn’t been sure how to interfere between her and her dad.

As soon as his mother said that she was going to take responsibility for Anise, however, he felt entitled to act on his mother’s behalf. He told Nerlande that he wanted us to arrange a meeting between him and Genson, so the four of us sat together one afternoon. His wife, who is Genson’s older sister, was with us as well.

Jean Claude told Genson that he hoped that he and Anise would get back together, and that he and his mother would back them in the face of opposition from Anice.

But Genson hesitated. He reaffirmed his commitment, but was worried about bringing Anise straight into his own home. He was afraid of creating the appearance that he was after the stuff we had given her, which was in Anice’s hands. Madan Jean Claude agreed with her brother’s hesitation, and added that she didn’t think that the time was right for them to get back together. Anise was still too sick to do anything for herself.

The discussion went in circles, until Jean Claude then came up with a compromise. He would give Anise a spot on his land where Genson could build a little house for her. Anise and her mother would move into the new house, and stay there together. Genson would help them out, but would continue to live in the same little shack he built when Anise left him.

That left us with one piece to resolve. Genson and Jean Claude were willing to provide the lumber the house would need, and Genson was ready to do the work. But they needed roofing, and the tin we had given Anise was still on a half-built house in her father’s yard.

So I said that we would come the next day with a team and take responsibility for taking the roofing, along with the livestock we had given Anise, and bring it all to Jean Claude’s house, where Genson would be responsible for it. The two men and Madan Jean Claude all agreed to this proposal. But we all also agreed that we could do nothing without knowing what Anise wanted.

Nerlande went immediately to the hospital to talk to Anise. We couldn’t think of such a plan unless she liked the idea. So Nerlande sat with her and her mother, and they discussed the matter. Anise liked the idea so much that she asked us to bring her to the yard when we sent our team to take her tin roofing. She wanted to clear all her possessions out of her father’s house so that she wouldn’t have to return.

We made our plans to return the next day. We called on a couple of extra case managers. When we walk into a situation of potential conflict, we like to appear in numbers. It is safer for everyone. So there were five of us – four case managers and I – who walked into the yard with Anise, and explained the situation to her father. One of the case managers started to remove the tin. We had invited a skilled builder from the neighborhood to do the work. He’d be faster and better at it than we could be. But we think it is important for us to start the job. That helps remove all responsibility for it from the builder.

Anice was furious. As Anise started collecting her things, he told her that she had to give him her birth certificate. He was finished with her, but he was the one that had given her the birth certificate, so it was his right to take it away. Anise was unsure what to do, but she quickly got the bag with her most important possessions – like her own birth certificate and those of her kids – into Jean Claude’s hands. He whisked them away, and by the time Anice knew what had happened, he was in a losing argument with Jean Claude instead of with Anise.

But he kept on arguing, making a lot of noise. In a sense, it was the best thing that could have happened, because his obvious unreasonableness turned the gathered spectators against him. His son, Anès, eventually came. He is husband to another CLM member and they live in a house they share with Anice. I was worried about what he would think of it all. Whatever his position, we would have to keep working with him on behalf of his wife. But he started arguing with his father on our behalf. We know for a fact that he was part of the conflict with Genson, but whatever the source of that conflict, he appeared to have seen that Anise will be better off with Jean Claude and Genson than with his father and himself.

So we are pleased with the way things are turning out. We believe in Genson’s goodwill and his capacity to help Anise start moving forward again, and we think that they have strong and reliable allies in Jean Claude and his wife.

In a sense, we are now more worried about Anès and his wife. If we are to help them – and they are struggling very badly, too – we will have to continue to deal with Anice. We will have to either repair the damage we’ve done to our relationship with him or at least reduced his ability to get in his family’s way.

Compliance

Anise and the Question of Compliance
May 23, 2014

I just finished reading a really good book by Paul Farmer. I think that most people I know will have heard of him. He’s widely admired as a doctor who joined Partners in Health in Haiti in the ‘80s, and helped to turn it into the international powerhouse it has become. Though Partners in Health has collaborated closely with Fonkoze for many years, and though I’ve worked extensively with their wonderful staff since I joined the CLM program, I’ve never met him. Hope I do some day.

The book I read is called Infections and Inequalities. Farmer writes about AIDS, HIV, and Tuberculosis, and how epidemics of such diseases are shaped by a larger global epidemic of inequality. Effective therapies become ever more available thanks to advances in medical science, but are often inaccessible to the poor, who are the diseases’ main victims. Farmer points out that, especially in the case of tuberculosis, the poverty of its treatment in poor environments is a threat to everyone, poor and wealthy alike. Half-treated or poorly treated cases of simple tuberculosis can turn into drug-resistant ones given time, and those drug-resistant cases can then become outbreaks that spread beyond the poor communities they emerge in.

But the way an insufficient attention to tuberculosis among the poor can threaten some “us”, too, isn’t really his point. He wants us to think more seriously about the reasons that are offered for not providing expensive medication to sick people who are poor. He writes of claims that are made about the cost effectiveness of expensive drug regimes in environments of intense poverty. Some say that we should focus instead on broader development initiatives, that we are better off treating poverty itself rather than the particular problems it exacerbates. We could combat a lot of poverty with the money that the most advanced drugs for HIV require.

Farmer will have none of such talk. He argues that it’s a false choice. An example he offers to display its falsity involves the lack of access to expensive second-line TB drugs in Peru at a time when the Peruvian government was spending hundreds of millions of dollars on fighter jets and even more to service its debt to banks in wealthy nations.

He also talks about those who cite evidence of poor compliance with drug regimens in some poor settings. It is argued that, again especially in the case of TB, providing expensive second-line drugs to TB patients is downright dangerous since they don’t follow though with the instructions they receive and, so, are especially likely to nurture increasingly resistant strains of the disease. Farmer asks us to look carefully at what this poor compliance consists of, and he points to studies that show that high-quality treatment made convenient and affordable doesn’t run into compliance problems.

“Compliance” is one way we could label an issue that we face all the time. It can be hard to convince our members to change their habitual behaviors in ways that we know will serve them well. We fight hard to get our members to use the water filters we give them and to keep their surroundings clean and to give up their habitual bare footedness. These all represent simple decisions they could make that would be certain to improve their lives. But they are all decisions that are hard to get many of our members to make. Many fail to comply with the advice we provide.

But, in line with Farmer’s argument, we should ask ourselves whether framing the question by talking about compliance is really constructive. Anise is only one example, but she’s the one who happens to be on my mind these days. She’s a single mother of two from Niva, a large area immediately south of downtown Mirebalais that stretches along both the national highway and a major local road that leads all the way to downtown Saut d’Eau. Her first boy’s father abandoned them both to their fate long ago, but Genson, the father of her second boy, who was born shortly after Anise joined our program, still lives close by and supports Anise and their son Mackenson as much as he can, even though he and Anise are no longer together.

Genson regularly sends her such money as he is able to support their child. That should, I suppose, go without saying. After all, Mackenson is his child, too. But it doesn’t go without saying in Haiti. Our program is filled with children whose fathers take no responsibility for them. Like the father of Anise’s first child. But Genson isn’t like that. He’s committed to Mackenson. The problem is that Anise’s family uses any money that Genson gives her to by food for them all: her father, her brother, her sister-in-law, and their kids.

We brought Anise and Mackenson yesterday to a mobile health clinic we organized in Venis, a remoter area farther to the south. It wasn’t really near her home, but we told her she’d need to come because Mackenson has been sick. As soon as Wilfaut, our driver, dropped off Dr. Luc, who ran the clinic, in Venis, he drove back to Niva to collect Anise and a couple of others who needed attention. We knew there was no chance she’d be able to get to Venis by herself, just as she had been unable to get Mackenson to the hospital in Mirebalais. When they arrived, Dr. Luc didn’t really examine either of them. He just to a quick look at the obviously sick infant, and told us to get him to the emergency room immediately. So Wilfaut sped off with Anise, Nerlande, and Mackenson.

As they were walking out the door, someone asked Anise very pointedly how she could have allowed her baby to deteriorate to such a degree, and she burst into tears. As weak as she is, she had to hold herself up herself by clutching a support post as she cried. Nerlande grabbed one of her arms – Anise was carrying Mackenson on the other – and she led her to the truck.

For a couple of weeks, Anise’s case manager, Nerlande, had been trying to pressure Anise to bring her baby to the hospital. The baby had been sick: weak and with persistent diarrhea. But Anise never went. Going to the hospital would not be a simple matter for her. She herself has been unwell since before Mackenson was born. She can’t really eat, and we don’t really know why, so she’s weak. Carrying her baby for a day is more than she can manage. She’d need a neighbor’s help, and she hadn’t been able to recruit anyone to give her a hand. Nerlande had been providing instructions, but Anise had not complied.

Working with Anise has been hard for Nerlande, and she’s already had to be creative. Early after childbirth, we discovered that Anise was too weak to nurse him. She was producing no milk to speak of. We got her to see a doctor. I had taken her to the hospital a couple of times myself on the back of my motorcycle, but she wasn’t getting better. We also started buying formula to reinforce the inadequate nutrition that Anise could provide her boy. The milk initially worked wonders. Mackenson quickly grew both in size and in liveliness. All this while Anise, herself, failed to improve.

Nerlande came to believe that part of Anise’s problem is her separation from the baby’s dad. Genson is a poor, hardworking man willing to take responsibility for them both and even to help with her older child, who is not his. But when a conflict erupted between him and the rest of Anise’s family, particularly her brother, she chose to side with the latter. She let her brother and father drive Genson from their home, which is on her father’s land. And no amount of peacemaking – at least to this point – has been able to bring them back together.

We can’t pressure her to rejoin Genson, even if we suspect it would be the best thing for her. She and I last spoke in the children’s ward in the PIH hospital in Mirebalais. She sat, cradling her child, explaining she was happy to see that the swelling in his feet had gone down some. The ward nurse had just expressed herself to me less optimistically. The hospital staff cannot yet speak of progress, she explained, because though the baby had already been with them for a couple of days his diarrhea continues.

But as Anise spoke with me she explained the problem. Genson argues with her too much, and she can’t stand the stress. She needs to feel at peace. At the same time, her parents have each separately assured her that they’ll never speak to her again if she gets back together with Genson. Apparently, his family looks down on hers, and they’ve made secret of that fact. They hold his family’s attitude against him.

In any case, Anise has a lot to manage and has very few resources – financial, personal, social, or otherwise – to manage it with. Staring soberly at the barriers before her, one cannot reasonably frame the fact that she does not follow directions in terms of compliance.

There is some hope, though it seems born almost of despair. In her first three days at the hospital with Macken, Genson visit a couple of time, bringing money each time to ensure that she can find something to eat. The hospital itself will provide food for her baby while he is there. Her own family came on once, and it was only to ask her for money, saying that they had nothing to feed her older boy.

None of this is lost on Anise. Sitting in the chair in the hospital, wakeful in her fear for her little boy’s life, she’s been turning her situation over in her mind. We don’t want her to feel forced to return to a man she is not attached to, but we do want her to feel able to make a decision that she feels is best for herself and her boys. I’m hoping that, when they leave the hospital, she will decide to sit down with Nerlande and Genson and try to work things out. We may have to meet with the two families as well.

But this is all just to say that the context within which Anise is stuck making her choices is very far from innocent. Her poverty, her poor health, and her family situation all enter into a calculus that frames her live choices for her long before she can think of making them. Until we can help her neutralize some of the aversive factors that shape her reality, we cannot reasonably speak of her “compliance” with our well-intentioned advice or of “choices” that she makes at all.

Safine and Ti Pijon

Safine and Ti Pijon

April 28, 2014

Safine and Ti Pijon are neighbors. They live in Redout, an area just above Trianon on the road from Mirebalais to Port au Prince. Ti Pijon is an older woman, with children and grandchildren in her care. Safine is a mother of eight, but she’s much younger than Ti Pijon. She also is new to the area. She grew up in Boucan Carré, but moved to Redout when she got together with Maxo, the father of her youngest kids.

Safine and Maxo shared a house on rented land, but Safine’s dream was to have a place of her own. She worked hard to build a comfortable four-bedroom house for herself and the kids on the rented land, but eventually decided to sell it piece-by-piece so that she’d be able to buy land, and she bought a small plot, right near Ti Pijon’s house at the end of December. It took her some time to build her new, one-room house on the plot, and in the meantime she and her children slept in a corner of Ti Pijon’s front room. They had gotten to know each other through their participation in CLM, and Ti Pijon had decided to do her fellow-member a favor.

It was a really big deal, because Safine had nowhere else to go. And the friendship they built in the months they spent together was good for them both. If one had food, both families enjoyed the meal. Safine’s children took to calling Ti Pijon grandma, and Ti Pijon’s children behaved as though they had found a second mom.

Shortly after Safine bought the land, her relationship with Maxo degenerated. There was violence, but she managed to throw him out. The final straw was when he had come to Ti Pijon’s house drunk, and fought with Safine there. Safine went to court, and though she eventually decided not to press changes, Maxo and his family had to agree that he would leave her alone for good.

But just after the trial, her relationship with Ti Pijon started to fall apart. Ti Pijon had avoided the trial, and rumors had come back to her that Safine had said that Ti Pijon had come between her and Maxo by telling him that she had been sleeping outside of her home when he had thought she was staying with Ti Pijon and the kids. The fact is that Safine had begun avoiding sleep in Ti Pijon’s home out of fear of Maxo. She would leave her children there each night, and join them after daybreak. Ti Pijon had also heard that when Safine moved into her just-finished house, she had complained to other neighbors that Ti Pijon was saying that she had her own house now, that it was time for her to go.

Soon, they were no longer on speaking terms. And they were each telling their young children not to walk the fifty feet to the other woman’s yard. When Safine started a little trade in homemade doughnuts, she wanted to offer a few to Ti Pijon’s littlest boys, but Ti Pijon grew angry at the older one for accepting the gift.

Their case manager, Hilaire, watched the relationship unravel, and he could hardly believe his eyes. The friendship between the two had been exemplary. It had been the sort one could use as a case study to teach the importance of solidarity among the ultra poor in their fight to escape extreme poverty. And now they showed all the traditional Haitian sign of hostility, short of actual violence. Hilaire decided he had to act, so he asked them to agree to meet with him, and he asked me to come along.

I started the meeting with a little speech. I recounted the history of their friendship as I understood it. I said that we all knew how much Ti Pijon had done for Safine, and that we knew Safine was sincerely grateful as well. Theirs had been a friendship I felt I could talk about anywhere in the world if I wanted to explain the sorts of things that make CLM work. I had come because Hilaire had asked for my support as he worked to figure out whether we could help them repair the breach that had opened between them. I couldn’t pretend to understand where their hostilities had come from, but I hoped we could help them find a better way to move forward. Hilaire then said that we wanted to listen to each to see whether we could figure out what had gone wrong.

Ti Pijon then started to talk. She is a church-going, Christian woman, she explained, so when she saw Safine’s problems, she welcomed her into her home. She had offered what she could, and only wanted to apologize because the fact that her little shack had only one door made it necessary for her to enter the front room, which she had given over to Safine, anytime she wanted to go into or out of her house. She was sorry.

She had supported Safine even to the point of caring for her kids at times when Safine was on the run, hiding in other neighbors’ houses to avoid Maxo’s drunken rage. The night after their last fight, he had insisting on sleeping in Ti Pijon’s house with his children even though Safine had fled. Because Ti Pijon has no husband, she decided she had to move into a neighbor’s house for the night to avoid any appearance that she had spent the night with Maxo.

Then she had heard disturbing rumors. Safine was, she heard, putting her down behind her back. Safine was blaming her for the end of her relationship with Maxo. Ti Pijon would go as far as exchanging greetings with Safine, and she would do her neighborly duty if Safine or Safine’s children were sick. But they could never be friends again. As it stood, she had not decided to stop saying, “Hello,” to Safine, but Safine had stopped saying “Hello” to her.

I asked Ti Pijon not to say “never.” Haitians say, “demen pa pou nou.” That means, “Tomorrow does not belong to us.” It’s a way of saying that the future is not in our hands. I told her that I was happy she would agree to exchange greetings with Safine, and that for the rest she should just follow where her heart guides her.

Safine spoke next. No one could claim, she said, that she had forgotten how much she owes to Ti Pijon. But things had changed. Ti Pijon had listened to rumors, and let those rumors come between them. Ti Pijon had begun avoiding Safine, and had instructed her children to avoid her and to stop playing with Safine’s children as well. She was not the one who had said that Ti Pijon had come between her and Maxo. She was glad to be rid of the guy. It was Maxo who had blamed Ti Pijon. She had not claimed that Ti Pijon had said that it was time for her to move into her own house. She had said that another neighbor had told her so. She could never forget what Ti Pijon had done from her, but she had heard from another neighbor that Ti Pijon had said Safine shouldn’t talk to her anymore, and so she had stopped saying “Hello.”

Hilaire listened to them respectfully, but then he started to speak again. He said that he would always talk to them with the greatest respect. Ti Pijon could easily be his mother, and Safine his sister. But he had to tell them that they were both in the wrong. They had let a bunch of ill-meaning neighbors spoil their friends by listening to rumors when they should have been listening to each other instead. “Yo di,” or “They say,” was coming up in everything that they said. Yo di that Safine had complained that Ti Pijon had spoiled her marriage. Yo di that Ti Pijon had said that Safine shouldn’t greet her anymore. If the two of them would stop listening to rumors, they might go back to being friends. And they both had experienced just how valuable the friendship could be.

The women listened. They scowled, but they listened.

And finally something must have happened inside Ti Pijon. She had been sitting with her back turned distinctly in Safine’s direction, but as they rose, she grabbed Safine around the neck and started tickling her. “You like tickling me, now we’ll see how you like it.” The two women were laughing and crying at the same time.

Hilaire had to stay with them for their regular weekly visits, but I went off. When I saw him that afternoon, he said that Ti Pijon had shown up at Safine’s house with food before his half-hour with Safine had passed. His peace mission had been a success.

Jean Hilaire

April 23, 2014

 My palms are almost perfectly square, and my fingers are short. I think my hands look a little like my father’s whose hands would look something like his father’s in turn, except that my grandfather’s fingers were deformed by the years he spent making furniture after the advent of supermarkets wiped out his very small grocery store.

 All this is just to say that my hands are not large, so I should not be able to enclose a 19-year-old man’s bicep between my middle finger and my thumb. I can’t get my fingers anywhere near around my own very skinny arm anywhere but at my wrist.

 So it was a shock to see just how thin Jean Hilaire had gotten.

I hadn’t seen him in months. When we were selecting new members in Pyèrèt, where he lives, he was always around. He served as our guide, helping us find the households we had been referred to so that we could conduct the surveys we needed to conduct. He made that part of the process easy because he knew everyone and was willing to help.

His mother and younger sister, who is a teenage mother of two, both joined the program, and one of our case managers began working with them. We occasionally heard from Jean Hilaire because one of our other case managers hosts a evangelical call-in show on a local radio station, and Jean Hilaire would call him now and again just to say, “Hi.”

Then he disappeared. As it turned out, the phone he had been using to call us gave out and he couldn’t afford to replace it. Then he went to Port au Prince. His brother-in-law, a young man not much older than he, convinced him to join him there. The brother-in-law would look for work to support his wife and kids, and Jean Hilaire would try to learn a trade. He signed up for a plumbing class.

That was at the beginning of the fall.

Every three months, we bring together all our members for a three-day workshop. They talk about the successes and the failures they’ve encountered over a three-month period. It is a way to build the confidence of members who are moving forward while it motivates those who are lagging behind. It also enables them to share advice about problems that they may share. In late March, I was at the session near Pyèrèt, and I saw Melisiane, Jean Hilaire’s mother. Naturally, I asked for news of Jean Hilaire.

“He’s really sick. Hadn’t you heard?”

I hadn’t heard. So I went by Melisiane’s house to see him after I had done what I wanted to do at the workshop.

It turned out, Jean Hilaire had returned sick from Port au Prince. He was coughing and feverish. He had no appetite. He had spent more than a month, lying in his mother’s house, wasting away. When I found him, he was in a bed hidden behind a curtain, in his mother’s back room. I pushed the curtain to the side, and sat on the edge of the bed with my hand on his forehead. He wanted to sit up to talk to me, but he just couldn’t. He was too weak. I asked him why he hadn’t sent word to me to let me know that he was sick. Didn’t he know how important he was to me? He turned his face away from to the wall and wept. He didn’t know, he said.

Melisiane had made three trips with him to see a local healthcare provider named Mis Marie, but he had only grown worse, despite the medications she prescribed. In Créole, a “mis” is a nurse. But Mis Marie is not a nurse. She has a small business prescribing and then selling simple medications for basic complaints. She lives in downtown Saut d’Eau, and has a wide reputation throughout the county. She probably does a fair amount of good, helping people with minor aches and pains and the sorts of standard illnesses that can be easily diagnosed and treated with simple antibiotics or other straightforward medications.

But she’s a problem, too.  Melisiane was going back and forth to Saut d’Eau, spending money on the motorcycle taxis, the consultations, and the medications, money that she needed to feed her kids. Yet Mis Marie could not treat Jean Hilaire, and she never said anything as simple as, “This case is beyond what I can treat.” She never told Melisiane to take her boy to the hospital, even as Jean Hilaire got worse. He grew weaker and weaker, unable to get out of bed most days. And even when he could have gotten out of bed to sit in the sun, he preferred not to. He was ashamed of his weakness, ashamed of how thin he had become, so ashamed that he was afraid to bathe in the nearby stream, for fear neighbors would see his ravaged body, so ashamed that he had hidden even from Melisiane’s case manager, Zetrenne.

So when I saw him, I told him he had to go to the hospital, and I arranged for him to go the next day. That meant giving them some money to make the trip. Melisiane was still at our workshop, so she sent Jean Hilaire with his younger brother, a teenager named Abraham. Seeing Abraham and Jean Hilaire together was painful. Abraham is not a lot younger than Jean Hilaire, and though their faces are very different, their body types are more or less the same. They are both very thin. But Abraham is healthy, and looking at him next to his older brother made it easier to see just how much weight Jean Hilaire had lost.

They went to the Partners in Health hospital in Mirebalais the next day. It’s a wonderful facility, designed to be Haiti’s premier teaching hospital. It offers first-class care for virtually nothing to anyone who can get there. But it is a little overwhelmed by the number of people it attracts, and so it can be challenging for sick people to navigate. When we have CLM members who need services, we try to accompany them, helping them figure out the series of lines they must stand or sit in. The lines can be confusing. Our close relationship with Partners in Health – it has been our principal partner in the field since the start of CLM – means that PIH staff will go out of their way to help our members. But only if we are there to ask them for extra help. And what they can do, even by going out of their way, is sometimes limited by the strain that a whole nation in need of their services can put on their system.

But the minute Jean Hilaire got to the front of the line, the hospital staff knew what they should be looking for: his cough, his fever, his loss of weight all suggested tuberculosis. The older novels I like to read call the disease “consumption,” and it’s easy to see why. Jean Hilaire had wasted away to almost nothing.

The first thing that the PIH doctor did for him was to prescribe a series of tests: blood tests, but also a chest x-ray and a series of sputum samples. For the latter, Jean Hilaire was told to come to the hospital three times on consecutive days. But the first trip to the hospital wore him out so terribly that it was a couple of days before he could make his second trip. He just couldn’t get out of bed.

But the tests eventually showed clearly enough that Jean Hilaire was suffering from tuberculosis, and PIH immediately put him on a multi-drug regimen that will last six months. He’ll have to come into the hospital every month for refills, and we’ll need to follow him closely to ensure that he stays with the treatment.

We’ll need to keep an eye on his family as well. Between his mother, his siblings, and his two nephews, there are nine people crowded into a two-room house. And the PIH doctor’s instructions that tell him to stay someplace well ventilated only mock the reality that the family faces. We think it is perfectly likely that others will start to show symptoms, and then it will be our job to get them to the right care – not from Mis Marie, but from the fine PIH hospital – right away.

But things are looking up. Jean Hilaire has started to feel up to getting up and about. He needed a pair of sandals, and when Zetrenne gave him a few gourds to buy a pair, he wanted to go to the local market himself. We asked him not to. The crowded market is the last place we should be sending a young man with TB.