by Dionissi Aliprantis
Dionissi Aliprantis is a Research Associate at the Inter-University Institute for Research and Development (INURED) in Port-au-Prince, Haiti.Â The research discussed in this blog post was conducted with support from the Inter-American Development Bank. In the years before he began working for the INURED, Dionissi worked with Dr. Chuck to help found one of Timmy Global Health’s first student chapters at Indiana University. As a Timmy alum he is a shining example of how Timmy students continue to engage in research, service and development in the movement to end health disparities–even after they graduate.
Most of the choices we make imply tradeoffs between competing objectives we hold.Â Consider a seemingly innocuous choice I face every day â€“ the temperature at which to set my thermostat. I want to be comfortable in my apartment (at least enough so to write my Timmy blog post!), but my physical comfort is not the only thing affected by my choice. On the positive side, increasing the temperature will lead me to pay a higher heating bill, which helps provide jobs to those operating the power plant, and contributes to my cityâ€™s tax base for things like roads and schools. But on the negative side, increasing the temperature will lead me to pay a higher heating bill, which comes out of my paycheck. And since my heat comes from a coal-fired power plant, heating my apartment contributes to global warming and increases cancer and asthma rates in my city.
Ultimately, my choice will weigh my physical comfort against the other effects from heating my apartment. If schools will close without the tax revenue from my heating bill, I might be convinced to crank up the heat. But if CO_2 emissions are wrecking the planet, it might make more sense for me to put on a sweater during the winter months. Knowing the precise tradeoffs my choice represents will help me to make a better decision.
Now, if you work with Timmy, it may be old news that many of your everyday choices have these kinds of tradeoffs, and you may have already spent a lot of time thinking about those tradeoffs you are willing to accept in your own life. Iâ€™m writing this blog post not just about these individual-level choices, but about a very specific group-level choice we might face: If we were to intervene to help communities in rural Haiti gain access to safe water, what strategy or approach should we adopt (â€œWeâ€ can be a lot of people â€“ Timmy, the Haitian government or a Haitian NGO, etc.)?Â Â To be even more specific, I am thinking about two particular approaches to improving access to safe water in rural Haiti.Â The standard approach is to drill wells and give all community members access to them, and the community-based approach is to drill wells only after training community members to manage the wells for themselves.
To aid those working to provide water in rural Haiti in making better decisions, I have done some research to try to characterize the precise tradeoff made when choosing between these two types of interventions.Â The strength of the standard approach is that it provides water for all community members when wells are functioning, but its weakness is that its wells arenâ€™t always functioning.Â The strengths of the community-based approach are that wells tend to function better under this approach, and that it can help build political institutions. The main weakness of the community-based approach is that it might limit access to water for the very poorest members of a community.
After thinking about these tradeoffs for a couple of years, I now believe the community-based approach is a hands-down, clear improvement over the standard approach. But I didnâ€™t always think this way. In fact, when I began my project in the summer of 2010, I actually had very strong views in favor of the standard approach. The main reason is that I am interested in improving the outcomes of the poor, and there is research showing that programs similar to the community-based approach for well maintenance can hurt access of the very poorest community members. Well-known examples in economics are studies of two programs, one designed to distribute de-worming drugs to school children, the other to distribute Insecticide-Treated Bed Nets (ITNs) to combat malaria. It was shown that when participants were charged even the most modest user fees for these programs, participation dropped dramatically as compared to programs with free distribution.Â
So when I met Neil Van Dine in Haiti and heard him describe the management program for wells he and his organization had developed, it all sounded very well and good to me except one detail: After his group has helped to organize a community, those communities almost always decide to charge for access to their wells. I could tell Neil was working hard to improve the situation in Haiti, and I could tell he had the best of intentions. But there are a lot of people working in Haiti today with good intentions, and if you are to judge a tree by its fruit, wellâ€¦ looking at Haiti today, I would simply have to conclude that good intentions arenâ€™t enough.Â The community-based approach seemed to offer some advantages, but I initially thought the tradeoff in terms of access for the poor was too high to justify the approach.
Two things changed my mind. First, I listened to Neil tell me about his experience working on development projects in rural Haiti.Â Neil has been involved in these types of projects since the 1980s, and he and his colleagues didnâ€™t just arrive at the community-based approach because they were trying to make money or restrict access of the poor. I realized there is a case for user fees in some contexts, especially when it comes to maintaining infrastructure.
In the case of water infrastructure, Neil told me about lessons he had learned the hard way. He told me about the water system he had worked to construct together with over 500 unpaid community volunteers per day over the course of a summer.Â It sounded like a religious experience â€“ so much goodwill, so much hard work for the good of the community. But because no institutional structure was established to maintain the system after it was constructed, it quickly fell into disrepair.Â All of that goodwill and hard work, and in the end the community still didnâ€™t have access to safe water.
He told me about a realization he had while traveling to the US. He noticed that after all the progress he thought his organization had made, he would leave for a few weeks, and everything would fall apart. Wells would stop working, and things would be right back at square one. After an honest look in the mirror, he came to conclude that even after his organization had worked in communities, they were still dependent on outsiders for access to safe water. The community-based approach was developed around the idea of doing something different, an intervention that would leave communities more self-sufficient than before.Â
Briefly, Haiti Outreachâ€™s community-based approach is designed around the end goals of organizing communities to make collective decisions, and then helping to train community members in making those decisions a reality. HO works with the local government to establish a committee whose members will oversee the operations and maintenance of the well, making sure that at least $5 are deposited in the wellâ€™s bank account each month.Â These committees have a variety of responsibilities, and HO requires that they have a series of public meetings to ensure the dissemination of information and transparency in their operation. If the committee is functioning properly, HO will drill or refurbish the communityâ€™s well and build a shelter around it (I discuss these issues in greater detail, including exactly how HO experimented their way onto their current approach, in Section 3 of my paper.)
The second thing that changed my mind was looking at the evidence.Â Although the standard approach provides water to all, including the poorest, since communities do not manage the wells for themselves, they tend to break down relatively often. As a result, the provision of water is relatively sporadic. Remember that while the community-based approach solves this problem by providing water more consistently, the tradeoff is that it might exclude the poorest members of the community due to the user fees it charges. In my research paper I developed a way to quantify this tradeoff, and I collected data and crunched the numbers in order to do so. The baseline results I got were determined under assumptions strongly favorable to the standard approach. According to these results, in order to prefer the standard approach over the community-based approach you would have to be willing to trade the provision of A LOT of water to the average rural Haitian in exchange for providing water to the poorest.
One of the strong assumptions of these baseline results is that the only reason community members donâ€™t subscribe to a well is because they canâ€™t afford the user fees. But this assumption is quite unrealistic. First of all, by the standards of rural Haiti, the subscription fees arenâ€™t exorbitant (typically about 50 cents per month), and committees can grant discounts to families too poor to afford the full price. This is supported by the fact that 64 percent of households in the median wellâ€™s community were subscribers.Â Second, there are all kinds of other reasons families might not subscribe. They might prefer to get water from a river if they live near one, or they might simply choose to buy it elsewhere. They might also be jealous of those on the committee, and want the project to fail.Â Once you relax this assumption to something more realistic about the access denied to the poor through user fees, the tradeoff is no longer even close. To prefer the standard approach, you would need to essentially ONLY care about the very poorest in communities, being close to indifferent to whether anyone else has access to safe water.
Now I take this as really strong evidence that my initial concerns were misplaced, but this is not yet the end of the story (I know itâ€™s a long post, sorryâ€¦). We have gotten to this point, and I have yet to say anything about Haitian history, which is amazing, because it is amazing. It is important to recognize Haitiâ€™s role in the development of the Western hemisphere, with particular attention as an American on the Louisiana Purchase. Thinking as a citizen of the world, it is important to recognize what Haiti has done for freedom.Â After it gained independence, Haiti supported groups like Simon Bolivar and his troops, and even the Greek Revolution, with weapons, troops, and other resources. Haiti gave only one condition for its support:Â whatever new countries those groups started, they had to abolish slavery there. How can you not want to jump in to support that cause?
The reason I bring up Haitian history here is because so far I have only spoken in terms of water (This is also the focus of my research paper.), but Haiti currently being the poorest country in the Western hemisphere is not unrelated to it also being the first free country in the Western hemisphere. Given this history, I think it can be easy for people to focus on Haitiâ€™s history and to see Haitians as victims. It is easy to see that Haiti is still paying a heavy price today for standing up for freedom at a time when it wasnâ€™t acceptable to the worldâ€™s powers. I donâ€™t want to minimize this point, because there is no question the past is silenced way too often when people talk about Haiti. But I think there is an opposing danger in focusing on this too much, because Haitians are much more than just victims. Just because Haiti has suffered from problems beyond its control, it does not mean that Haitians do not have the capacity to make positive changes in their lives. However much we might blame the current situation on history, it doesnâ€™t change the fact that the problem we have inherited is ours; we have to find a way to address it. Focusing so much on Haitiâ€™s history has at times taken my focus away from finding solutions, and I think others have fallen into this mentality as well.
Just like Jacques Roumainâ€™s classic â€œMasters of the Dew,â€ I think Haiti Outreachâ€™s work is in the end about much more than just water. It is about realizing the problem is ours, and that we have the power to actually do something about it. From its years of experience, Haiti Outreach now views its work as helping to make communities responsible for moving themselves forward. Once communities become collectively responsible, projects become more effective. This realization has become so deep that Neil is now spending most of his time to initiate a group called Develop Haiti, which is about creating this sense of responsibility on a broader scale than water alone. Develop Haitiâ€™s goal is to create programs that help people realize their language, attitude, and actions have a direct impact on the quality of life they lead.
What does any of this have to do with Haiti becoming a â€œdevelopedâ€ country?Â One big problem Haiti has inherited from its history is that it is a country where social and political institutions have had little room to grow (One illustrative example Dr. Chuck and I like to cite:Â Papa Doc Duvalier was so paranoid about any potential leaders threatening his power that he even disbanded the Boy Scouts! Click Here for details). As a result, there is a clear need for building local capacity and institutions to move from simply providing relief in Haiti to actually helping the country to develop. I think the work done by Haiti Outreach and Develop Haiti is THE precise work that has to be done in order for it to be possible to build local capacity and local institutions. From my experience, I think a focus on building physical infrastructure alone, whether used to provide water or for any other purpose, can distract from this even more fundamental work of building the social infrastructure that is ultimately necessary for the long-term development of Haiti.
Alright, you have finally reached the end!Â But before I go, I should say a few words about my connection to Timmy.Â It just so turns out that I became interested in Haiti after I went on a Timmy trip there in March of 2000. I think my case is a clear example of the seeds Timmy trips can plant in students. After our experience in Haiti, some friends and I started bugging Dr. Chuck until he would let us hang out in his clinic with him. Eventually I became involved with the group that got the IU chapter going, and in so doing I got to spend some time in Ecuador, Honduras, and at CHAMP Camp. Our group at Indiana was really lucky â€“ not only did we have great support from people at Timmy (Chuck, Scott, Darrell, Jess, and others), but we were also at IU, which was filled with people who had the vision to support us (people at the Honors College, the IU Foundation, as well as alumni and individual faculty members). And I would like to think we had a pretty cool group of students working together, too.
I have been extremely impressed both with the overall direction Timmy is taking and with the current Timmy students I have met â€“ they all seem to be well-rounded and thinking about the right issues. If I had any advice for students involved with Timmy, it would be to keep at it even when things are tough, and to remember that Timmy is a vehicle for creating the kind of world we want not only in terms of global health, but also in the most basic terms of how we interact with each other here in the US and all around the world.
DISCLAIMER:Â The author is a Research Associate at the Inter-University Institute for Research and Development (INURED) in Port-au-Prince, Haiti.Â The research discussed here was conducted with support from the Inter-American Development Bank, and was conducted while the author was on leave from the Federal Reserve Bank of Cleveland.Â The views stated here are those of the author alone, and do not represent the views of Haiti Outreach, Develop Haiti, INURED, the Inter-American Development Bank, the Federal Reserve Bank of Cleveland, or the Board of Governors of the Federal Reserve System.
If you are interested in studying in Haiti, I would strongly recommend you study with the Haiti Today program run by the Haitian Studies Association at the University of Massachusetts Boston.
Two quick links on Haitian history:
And a short list of other organizations doing great work in Haiti includes