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

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.

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.

March 5, 2014

Recently, I was back in court again with Safine. It turns out that her first trip to Judge Patrick’s courtroom did not solve her problems with Maxo, the father of her two youngest children. This time, she was the one filing the complaint. Maxo attacked her, hurting her badly enough that she had to go to the hospital. Normally, her case manager, Hilaire, would have accompanied her through this process, but he had been called away first thing in the morning to help another CLM member, so he asked me to fill in for him.

The woman he needed to help lives in the farthest pocket of Mazonbi, a secluded area in the southwest corner of our territory. Her name is Mimose, and her home is remote even within Mazonbi. Invisible from the narrow footpath that runs about 100 feet above it, you have to know where to step into a field of pigeon peas to find the trace of a path that winds downward through a series of jagged boulders to the small yard.

Mimose had borrowed a telephone the night before to call Hilaire. She was terribly distressed. A neighbor name Marc had killed two of her goats – large, healthy, pregnant ones – when they wandered into his unplanted garden. It was a huge setback.

So Hilaire got on his motorcycle early on a Thursday morning, and went off to see what he could do. When he got to Mazonbi, he found the beheaded goats hanging from a tree at the edge of Marc’s field. He tried talking to Marc about it, but Marc wouldn’t give him the time of day.

So he went to Dumisso. He is the secretary of the Village Assistance Committee for Mazonbi and Laferyè, a neighborhood along a ridge just east of the ridge the Mazonbi sits on. Dumisso told Hilaire that they really needed to do something. He had heard that community members in Mazonbi who had not been selected for CLM were jealous of the CLM members’ progress, and were saying that they would kill any of the goats they got their hands on. Dumisso felt that if we did not take a stand, our members’ losses would start piling up.

Hilaire went from Dumisso to the KASEK. A KASEK is a local elected official. In rural areas, they employ assistants, who are paid a couple of dollars to deliver messages, bring people the KASEK wants to see to him or her, or perform other minor duties. In this case, the KASEK sent his assistant to the man to let Marc know he wanted to see him. Marc responded that the KASEK should mind his own business.

Hilaire then took the assistant to see where the goats’ carcasses were hanging in the tree, and put him and Mimose on the back of his motorcycle so that Mimose could file a complaint in Judge Patrick’s court.

This is where things first got complicated. Our motorcycles are designed to take a passenger, but they are not designed for two. Hilaire is a very strong man, and he has a lot of experience with a motorcycle on bad roads, so he took a chance. He managed to get them up the terrible rocky road that leads out of Mazonbi and down to the highway in Fon Cheval. Going down from Fon Cheval to the courthouse in Trianon should have been much easier. But Hilaire hit a small patch of loose gravel on a sharp curve in the road, and because of all the extra weight behind him, the wheel slid out from under him. He and Mimose were both scraped up in the fall. Nothing too serious, but their wounds needed some attention. He got them to a small clinic just downhill from the courthouse.

By the time they got to the courthouse, we were finishing up Safine’s case against Maxo. Judge Patrick was instructing us all to go to the higher court in Mirebalais the next day. Since blood had been drawn, he said, the case went beyond his authority as justice of the peace. He would prepare a document for the higher judge in Mirebalais, and have us take it down the next day.

When Hilaire and Mimose arrived, Judge Patrick listened to them and agreed to go up to Mazonbi with his security guard and have a look. Hilaire was very sore, but he immediately agreed to lead them there. He asked me to switch motorcycles with him. His clutch had been damaged, and it would have been hard for him to negotiate the Mazonbi road whereas I would just have to coast downhill. So he took my bike, and they went back up the hill.

That evening, I heard from him that things had gone poorly. Marc and his friends had intimidated the judge and his security guard. They had been forced to leave the scene rather than risk a conflict. When Judge Patrick formally invited Marc to a hearing, Marc refused. So Judge Patrick, Hilaire, and the security guard returned to Trianon.

Hilaire was furious. He couldn’t understand why a representative of the government would let himself be chased away by threats. But there wasn’t much he could do. Judge Patrick filled out a warrant for Marc’s arrest, and gave it to Hilaire to bring to the police station down in Mirebalais.

Hilaire took the warrant to the station the next morning while I continued to follow-up with Safine. When we talked midday, he told me that the police had said that they didn’t right then have anyone available whom they could send after the guy.

In the meantime, Marc must have had second thoughts, because when the KASEK sent for him again, he had disappeared. An older relative of his – actually his wife’s cousin – sent word that she wanted to resolve things. She would give Mimose two of her goats if Mimose would let the matter drop.

So Hilaire and I went to Mazonbi with the KASEK, whose name is Lenèl, and Dumisso. Madanm Tibèt was the cousin trying to resolve things. Mimose came with her husband and Madanm Tibèt’s two goats, which her husband, Ozlèn, had already been watching for the older woman.

Madanm Tibèt explained that she couldn’t see why everyone was pursuing Marc. He is a poor man who had killed the goats because they threatened his farmland, which is his livelihood. We explained – with Lenèl’s help – that there are ways to go about things. Haiti’s rural legal code, which dates from the Duvalier years, does allow farmers to kill goats they find eating their crops. But the farmer is supposed to find a local authority to serve as a witness when he or she does so. The thought – I suppose – is that a witness can help a farmer cool down enough to accept monetary damages rather than the life of the goat, which is generally worth much more than the crops that it eats. Marc didn’t bother seeking a witness. He just killed the goats, singling out CLM goats in particular among several goats that were in his garden, and strung them up.

Madanm Tibèt wanted the matter settled because, first, she values peace and her neighborhood and, more importantly, she is a single mother who counts on Marc to farm her land for her. His arrest would be a direct threat to her livelihood.

But there was a problem. Mimose and Ozlèn didn’t want to accept her offer. They gave two reasons. On one hand, the goats Madanm Tibèt was offering were much less valuable than the goats Marc had killed. Their two, large, pregnant goats could have sold for over $70 each. The small mother that Madanm Tibèt wanted to give them with its kid couldn’t have sold for that much combined. On the other hand, Mimose and Ozlèn feel that they’ve had a good relationship with their wealthier neighbor. The fact that she has let Ozlèn care for her goats is good evidence of that. They are worried that her sacrifice will leave a bitter taste in her mouth, that she might come to hold it against them.

Eventually, however, they agreed. Partly, it was because they too wanted the matter settled. Partly, they were convinced when Madanm Tibèt reminded them that she had already lost a goat in their hands. She had left another female for Ozlèn to care for, and it had disappeared. She asked them whether she had ever bothered them about the lost goat, and they had to agree that she hadn’t.

So Lenèl drew up a formal agreement in which Mimose accepted three of Madanm Tibèt’s goats – the two that had been brought to the hearing and the one Ozlèn had lost – in exchange for her two. It was still a loss for her, but it was the best we thought she’d be able to do under the circumstances. So Hilaire encouraged her to sign. Lenèl pleased her by complimenting her for the way she signed her name to the agreement. It’s something she’s learned from Hilaire.

The hearing, held under a tree by the side of the road at the entrance to Mazonbi, took over two hours. It involved a lot of conversation. Much of it was related to the complexity of the problem involved. Some of it related to Dumisso’s desire to make the KASEK, who lives in a distant part of the region, recognize that he wasn’t spending enough time in their neck of the woods. He felt that Lenèl’s inattention was partly responsible for Mimose’s loss, and he said so clearly and at length.

I visited Mimose and Ozlèn a few days later, and they seemed at ease about by the way things had turned out. They were miserably poor when we first found them, but because they work hard and together, they’ve already come a very long way. As such, they present a stunning contrast to Safine, who has to waste a lot of time just working out her final separation from Maxo, a man who doesn’t do the simplest things she would need a partner to do. If this turns out to be their biggest setback, the Mimose and Ozlèn are very likely to be just fine.

Michaël and Heleine live within a few feet of each other in Domon, a remote village far off the main road in southeastern Mirebalais. They joined CLM together three months ago, as part of a group of 150 women. Both were struggling to support their families when they joined the program. They would take the long walk into Mirebalais, and spend a long day doing laundry by hand for wealthier families. They might earn two dollars in a day, once or twice a week, but the work was irregular, and the women who hired them would treat them poorly.

Michaël is a young mother of three. She was excited when she learned that she qualified for the CLM program. “I had lots of problems. I wanted to sent my two older children to school but I didn’t have the money”

But to succeed in the program, she would need to solve one problem first. The problem was her husband. “He never wanted me to participate in anything that outsiders do where we live. When Mercy Corps and World Vision gave away stuff in Domon, he wouldn’t let me take any of it.”

So Michaël took a chance. She joined the program without telling him. She sneaked to her six days of enterprise training and to the launching ceremony, and she managed to start receiving her weekly visits from her case manager, Mahotière, without tipping her husband off. She chose goats and a pig as her two enterprises. “I hid the animals back away from the house.”

But her husband was bound to find out eventually, and when he did he was very angry. Mahotière got a call from a crying Michaël one evening, telling him that he’d have to come by the next day to take back her animals. Her husband was making her drop out of the program. So Mahotière called a member of the local Village Assistance Committee, and asked him to go over and collect the animals right away. He didn’t want to take the chance that the husband’s anger would bring the animals to harm.

The next day, he went to talk to the man. He took the committee member with him. They spent some time with the guy, who was initially hostile but was willing to listen because of the committee member’s presence. Mahotière was friendly, but very frank. “I told him that his wife and children were living very badly, and that I was there to help him change that. I told him that if he didn’t want outside help he should say how he was going to send his kids to school.” It took some time, but eventually the man came around.

Now Michaël is starting to move forward. The progress she is proudest of is her small commerce.

She didn’t get it started with merchandise we gave her. Instead, she started it with money from her sòl. A sòl is a traditional Haitian kind of savings club. Its members make a set daily, weekly, or monthly contribution, and one member then gets the whole pot. CLM case managers help members organize the clubs as a way to help them learn financial planning. Michaël took 1250 gourds of her sòl money when her turn came, and invested it in the kinds of things she could sell right out of her home: rice, cooking oil, laundry soap, etc.

And her business has taken off. She has 1500 gourds in it now, even though she has been using profit to keep her children fed.

Her neighbor, Heleine, has been having a harder time of it, and it is easy to understand why. Her life has been difficult for a very long time. “Before I joined CLM,” Heleine says, “I couldn’t even feed my kids. I couldn’t always send them to school.”

She has had twenty. “I had them by twos and threes.” She’s had three sets of twins, and two sets of triplets. Only five of her twenty children survive. She now lives with her two youngest boys and two grandchildren who were left to her when their mother, who was her daughter, died. “I’m the only mother those little girls know.”

Heleine is raising the children by herself. She’s never had a steady husband. “When you’re living in real misery,” she explains, “you have children with the husbands of other women.”

She’s committed to taking good care of her CLM livestock. “Sunrise doesn’t find me in bed. I get up early to make sure the pig has food and the goats are tied somewhere where they can graze.”

But though she too started a small commerce with sòl money, she hasn’t had Michaël’s success. One of her boys is supposed to take the national primary school graduation exam this year. He finally made it to sixth grade. But his teacher sent him home from school because Heleine hadn’t been able to buy him the books he needs. So she felt she had no choice. She sold out her merchandise, and used the money to buy books. Her commerce disappeared.

She lost 1000 gourds. Though both women received 1500 gourds from the sòl, Mahotière encouraged Heleine to put 500 gourds in the bank. Michaël deposited only 250. That might not seem like a big difference. It’s less than $6. But 500 is easily enough to start a very small business. With only 250, it would be much harder.

Mahotière is clear about his reasons for advising the two women differently. He didn’t think that Heleine was ready to make the sacrifices she would need to make for a business to succeed. So he let her take a chance, but had her keep something in reserve so she’d be able to make a second attempt. If it was up to her, she would be trying again already, but Mahotière wants to take things slowly. “I don’t want to authorize her to withdraw her money until I think she understands what small commerce requires.”

With only three months in the program, it is hard to get either woman to look to the future. Women living in extreme poverty tend to struggle so much with day-to-day issues that they don’t articulate their ambitions. When I asked them what they would like to achieve while they are in the program, they both said that they want to do what Mahotière decides.

But Heleine is a older woman. I told her that I know that young people fall asleep quickly, but that the older you get the more you lie awake, thinking. I asked her to tell me what she dreams of when she lies awake. She smiled. She knew about lying awake. Then she gave me a simple answer. “I don’t want to do laundry for other women any more.”

She wants to feed and educate her children. But more than anything, she just wants an end to the indignities she suffers as she lives the only life she has known.

Dealing with marital relationships, or the relationships between partnered but unmarried women and men, is one of the critical parts of a CLM case manager’s work. Safine’s struggle out of extreme poverty, and that of other women like her, is made more difficult by the drag on their progress that uncooperative partners create. (See: Complex Relationships.) Other women have a much more reasonable chance at success, in part because of husbands or partners who are willing to work hard beside them. (See: Elienne and Odak for an example.)

So we try to to help couples establish good relationships. But I never would have expected that our efforts would lead me to spend part of Sunday evening in a beauty salon in downtown Mirebalais.

I went to the beauty salon with two case managers, Christian Louizia and Sandra Julien. We had gone to ask for help dealing with one of Christian’s CLM members, a woman named Memène, who lives in Demare, a farming community behind the Labasti market. The relationship between Memène and her partner Chiver has been a key issue for Christian for several months, and we do not feel as though we have made much progress.

They are a young couple. Memène is 22, and Chiver is a few years older than that. Each has a small child, but both children are from previous relationships. They do not yet have a child together. When we met them, they were living in a very dilapidated shack with a roof of dried, cracked palm fronds, on a plot of Chiver’s father’s land. The land has several equally dilapidated homes on it, including the father’s, and more than one of the households qualified for CLM. It is an especially poor little neighborhood.

We were troubled when, early on in our engagement with the couple, we heard reports of violence. Chiver was beating Memène severely enough that their neighbors were worried. Tikomè, another CLM member who lives just down the path from them, had pulled Christian aside. Tikomè is the members’ representative on the Village Assistance Committee, and she has started taking her responsibilities seriously. She asked Christian to do something. “He’ll kill her,” she said.

Christian rushed to meet with Memène, and she explained how it was that Chiver ended up losing his temper most recently. He spoke with Chiver as well. After some conversation, Memène decided to leave Chiver. She’d move back in with her mother, who is also a CLM member. It seemed like the obvious thing to do. They would be able to build their houses next to each other on the mother’s land. But Memène didn’t want Chiver prosecuted. Maybe it had to do with the fact that what separated her from her daughter’s father was that he had been sent to prison for theft. Maybe she was afraid of what he might do if he was arrested but wasn’t sent to jail. We were sorry that she wasn’t willing to press charges, but saw it as her choice. Christian planned the move with them both, and Chiver agreed to turn over the livestock CLM had given her, which he had been caring for.

Christian was surprised when he went by a few days later and found Memène back in the house with Chiver. He made sure it was what she wanted. That was about all that he could do. But hearing her say that it was, he talked to Chiver about how important it was that he stop using violence. Christian asked me to come talk to them, too.

So I went by and we had a long conversation. I quick got the impression that they really did want to stay together. Memène talked about the one time that someone from Chiver’s family had been nasty to her. One of his sisters had said some really ugly things that culminated in her naming a pig with an unflattering nickname she had used for Memène. When Chiver came home after his day in the fields and heard what had happened, he was furious, screaming at his sister and mother, who had taken sides with her daughter, and threatening to kill the pig. His father took up Chiver’s side of the argument, and the two women agreed that they had been wrong. They apologized to Memène. But the crucial thing was that Chiver had stuck up for her. And Memène was the one who told me the story. Chiver, for his part, kept insisting that Memène could go if she wanted to, but he was near tears. You could tell he didn’t really mean it.

When I told Chiver that hitting his wife could get him arrested, he started talking about all the things she does to make him lose his temper. Some of those things would have made me mad, too.

I do not blame the victim. All the violence is entirely his fault. She doesn’t force him to hit her. But Memène says some very mean things.

So I cut him off. I put my arm around him because I wanted to ensure that I had his full attention and I wanted him to feel that my intentions were friendly. And I told him that he needed to understand that if he was arrested for hitting his wife, the judge would not listen to his story about the things Memène had said or done. I wanted him to understand that, as soon as he hit her, the court would automatically look at him as the one in the wrong. Even if he was right to be angry – and I didn’t doubt that he sometimes was – he was always wrong to be violent. And I added that he didn’t need to take my word for it. He could ask any of his friends or neighbors. One of the members of our Village Assistance Committee was there, a man not much older than Chiver, and he chimed in to support what I was saying.

I tried to keep my tone friendly but unambiguous. As long as Memène chose to stay with Chiver, I couldn’t let him think of the CLM program as a threat because she and the children would be better off if he continued to collaborate well with Christian. I was inclined to think that she should get out of the house, but it had to be her decision, and she wasn’t making it.

The peace we established that day held up for almost six weeks. And the couple accomplished a lot during that time. They installed their latrine, they put the tin roof on their house, and they began to build up their wealth by taking very good care of their livestock. Chiver added a pig to what we had given them. He bought with money he earned through day labor. The six months of weekly stipends that we gave them took enough pressure off his meager earnings that he was able to invest some of what he brought in.

I went by every week or so just to check in and to see how they were doing, and I always got friendly greetings from both. They were still arguing, but Chiver would call Christian whenever he felt he was losing his temper. He knows he is hot-headed. Christian would go help them work things out. Their relationship was becoming a big part of his job.

But about a week ago, Christian got word that Chiver had attacked Memène again. Memène told him that Chiver had hit her and kicked her. This time, she said she really wanted to leave him. Christian talked with them both to arrange the separation because he wanted to ensure both that Memène would feel safe and that she would keep all the assets we had helped her accumulate.

By this point, however, things had gotten a little complicated. For example, the couple had built their house by putting her roofing material on a structure that was already his, on land that belongs to his family. They had also used CLM money to pay the skilled labor that installed the roof and built up the stone walls which replaced the original mud-and-sticks ones. We couldn’t get the skilled labor back. That money had been spent. But Christian and Chiver calculated how much Chiver would have to pay Memène if he kept the roofing material, and he agreed to the sum. It would be more sensible that removing the roof and returning the material to her. Chiver and Christian even created a realistic payment plan.

We thought we had things worked out. But when push came to shove, Memène decided, once more, to stay with Chiver. This only proved that Christian and I were in over our heads, that we didn’t know how to help Memène.

And it’s why we ended up in a beauty parlor. The beauty parlor’s owner and head beautician is Minouche, and she is the one we had come to see. The Haitian government includes an important ministry that is especially charged with seeing to the affairs of women. It’s called the Ministère des Conditions Féminines, and it has representatives throughout Haiti. They organize women’s groups and special activities and celebrations for women. They advocate for issues especially important to women. And they work closely with local police and courts to protect women from abuse. We needed both expertise and clout, and we went to Minouche hoping that she’d be able to provide them.

She said that she’d be happy to help out. She’d had heard of our work, had been admiring it from a distance, and was glad contribute.

Christian made sure that Memène and Chiver would be a home Tuesday afternoon, and we brought Minouche to their home in Demare in a CLM truck. She spent almost three hours with the couple.

She began by introducing herself, her office, and her role. She was there, she said, neither for Memène nor for Chiver. Her job was to help them both solve the problems they had with each other. If the solution was separation, she would help them through that process step-by-step, guaranteeing the Memène would get all the protection she needed. If they wanted to stay together, she would help them figure what they each would need to do to make that work.

One of the issues we regularly face in dealing with the two of them is that Chiver is very comfortable talking and Memène is not. He is both friendly and outgoing. Though he started angrily, showing that he resented our having turned him in, that anger passed before he even finished his first set of explanations. To Minouche’s pointed question as to whether he wanted Menène to stay with him so that they could spend the rest of their lives together, he finally said that he did, though it took him a lot of avoidance before he could get to that point. When she asked him what Memène would have to change for him to feel as though he could make their partnership work, he said that the only thing about her that he could not accept is that she leaves the house for hours at a time with letting him or anyone else know where she is going. He repeated several times that this was the only thing. Minouche was careful to say that she agreed with him that neither husband nor wife should wander off without letting the other know.

Minouche now passed to Memène, and this is when her work started to get hard. Memène is shy. She still has trouble even looking at people whom she isn’t used to, let alone talking to them. But Minouche persisted. When she asked Memène whether she wanted to stay with Chiver, Memène initially said that she didn’t. Asked to explain, she said that he kept hitting her. Minouche then asked her whether, if we could change that about him, she would want to stay with him. And she said that she did.

This took some persuasion on Minouche’s part. She talked about Chiver’s good qualities, and how easily Memène could end up with a partner who was much worse, always agreeing, however, that Chiver would have to stop hitting her.

Talking to Memène took a lot of time, both because she was reluctant to speak and because Chiver kept interrupting to defend himself. The more he defended himself, the more heated he became. And as he became heated and louder, a crowd of neighbors began to gather, ready to enjoy the spectacle. Minouche started to get frustrated, put off by the regular interruptions our spectators’ laughter and commentary produced, so she had us move into the one-room house. There was no space for chairs inside, but there is a larger bed for the two of them and a smaller one for the kids. We sat on the beds and continued to talk.

The more we talked, the more we learned that there were issues we needed to face beyond what they each were initially willing to admit. On Chiver’s side, the most serious thing was that Memène was always hurting his feeling with things she would say. He didn’t put things that way, but he didn’t need to. He was on the verge of tears several times as he talked of times that her words had cut him to the quick. On Memène’s side, she talked more and more of her little girl. Though Chiver repeated said he had two children in the home – his son and Memène’s daughter – and that both felt like his, Memène complained that he didn’t treat them equally, and that when he was angry he would use terribly ugly words to yell at her girl.

Minouche had succeeded at getting to a deeper layer of their conflict, so she asked them once more, at this more serious level, whether they wanted to spend their lives with each other. Chiver affirmed that he did, but Memène had a hard time answering.

Here I interrupted to ask her and Minouche whether it might be better if Chiver and I left so that they could talk privately, woman to woman. Minouche thanked me, and so I led Chiver back out of the house. He took me down to look at their pigs.

When Minouche call us back in, she said that Memène had agreed to stay with Chiver. She explained that she would create an agreement between them, specifying the conditions each would have to respect in order to make their relationship work. They each would sign the agreement and she would file it in her office and in the courthouse in Mirebalais. This took a few more minutes. It was getting dark as we got in the truck to head back to Mirebalais.

We don’t know whether Minouche’s intervention will prove successful. We have our doubts. Christian believes that the couple will split eventually, and we just hope that, if they do, we can facilitate a split that is safe and that leaves Memène the best possible chance at future success. We hope that making them feel that they live in a community with laws they must abide by will help them find their way to a good future, whatever that future might turn out to be.