We Are All Accompagnateurs

Author: Steve Reifenberg ’81

“When I was in high school I was much more optimistic about being able to change the world,” a Notre Dame undergraduate recently said in my class on international development. “However, the more I study about development, the more I realize how hard and complicated making change is . . . and even with the best of intentions, there are just so many ways things can go wrong.”

Some international development statistics support this student’s assertion — and can be downright depressing. Almost half of the world’s 2.2 billion children live in poverty. And more than 29,000 children die every day, according to UNICEF, most from diseases that are simple and inexpensive to treat.

A lot of recent international development literature, with titles like Dead Aid by Dambisa Moyo and The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good by William Easterly, suggests that much international development aid, especially in Africa, has not only been ineffectual but often has made things worse, sometimes by promoting corruption.

Photo by Matt Cashore '94

Global challenges of poverty, poor health and early death are enormous and will likely only increase with world population growth. That world population — 2.5 billion people in 1950 — has now passed 7 billion and is expected to exceed 9 billion by 2050. Most of the expected growth in population will come from the poorest countries — the places least able to absorb the increase — such as those in sub-Saharan Africa.

Development aid, some argue, has historically had little impact on improving people’s lives: Governments of poor countries become dependent on foreign aid, which drives a wedge between them and their citizens, and allows corrupt and repressive governments to remain in power. Layering on the realities of violence, political instability, inequality and environmental degradation only adds to the sense of despair.

In the face of such realities, where can one even start? Might we quote Jesus, who said, “The poor you have with you always,” accept that reality and leave it at that?

An alternative does exist — a different telling of the development story that encourages us to remain actively, even enthusiastically, engaged. It is a story not of isolated examples of hope but of rapid, historically unprecedented progress in quality of life.

A century ago, the United States had an infant mortality rate of nearly 15 percent — meaning that 15 out of every 100 babies died before their first birthday despite a national income level that was one of the highest in the world. Today no country in the world has infant mortality rates that high, although a couple approach that percentage. Incredible advances in public health, dramatically expanded access to education, the green revolution in agriculture and diffusion of technology more generally have brought about unprecedented progress — even though the benefits of these advances are often distributed in wildly uneven patterns within countries, leading some to have incredible opportunities and others almost none.

What sometimes gets lost in the complex and at times contradictory telling of the human development story is that some real lessons are emerging — both about what works in development as well as how to do development well. Research universities such as Notre Dame have an enormous opportunity to contribute to these conversations.

Across the Notre Dame campus — in fields ranging from global health to economics, from peace building to engineering, from anthropology to theology — deep questions are being asked and contributions being made on both fronts, the what and how of these critically important development questions. By drawing on the rich resources of Catholic intellectual and moral traditions, and on the enormous practical experience of the Church in its human development work throughout the world, Notre Dame as a Catholic research university can bring a distinctive voice to the field and make an important contribution to understanding human development for the benefit of the entire human family.

At Notre Dame International Development in Practice: What Works in Development? undergraduate class links development theory with actual practice and explores what we have learned over the past decades about what actaully works.

What is so invigorating about teaching this class is how motivated students are to try to make sense of — and contribute to — a complicated world. The majority of my students have already engaged in some kind of work, service or research in Asia, Latin America or Africa. Some have volunteered at an orphanage in South Africa or with Mother Teresa’s Missionaries of Charity in India, while others have interned on community engagement projects in Uganda or helped with a business course in Costa Rica.

Students often come back from these international experiences enthusiastic but chastened, aware that the sustained positive change they hoped for is more elusive than they first imagined. Theory has met practice; idealism has met the real world. Some find organizations in disarray (despite beautiful mission statements), with endemic self-interest and political agendas carrying the day (possibly not unlike students who intern in Washington, D.C.). We grapple with such tensions in class and then try to ground the discussions in hands-on projects. Students form teams and work long-distance over the semester with clients in development organizations — in places such as Argentina, Bangladesh, Chile, Colombia, Haiti, India, Kenya, Mali and Zambia — to address a problem or opportunity their client has identified.

We examine insights from inspiring stories of success as well as from devastating failures. We look for evidence of positive impact: how a focus on girls’ education can benefit the whole society; how cell phones have become savings banks in rural areas where there are none; and why, in the same poor community, some children fail to survive while others flourish.

These are complicated issues, with sometimes conflicting theories and data, and it’s not just students who sometimes feel overwhelmed. Amid the complexity, together we try to distill some lessons in development. Here are four works in progress:

Some things do “work”

One of the first things students do in the class is identify an international development intervention they think “works.” They look for a bright spot, an example that shines through and serves as model. It’s not hard to find an inspiring story, yet students sometimes struggle to marshal the evidence behind the rhetoric that demonstrates this particular intervention has made a significant positive contribution.

In certain areas, though, the evidence is clear. There have been huge advances in recent decades in learning how to avoid unnecessary deaths, especially of children. One is investing in universal immunization of children against diseases such as diphtheria, measles and tetanus. For a child with severe, life-threatening diarrhea (still one of the biggest killers in the world), a mixture of a pinch of salt and a handful of sugar in clean water — oral rehydration therapy — can often be the difference between life and death.

Focusing on universal immunization, oral rehydration therapy, breast feeding and a few other simple interventions, UNICEF, governments and charity organizations around the world coordinated a “child survival campaign” that in a period of 15 years during the 1980s and ’90s likely saved the lives of some 25 million children.

Different types of organizations make different contributions. Most international development institutions are organized to respond to immediate life-or-death problems. Development agencies such as Catholic Relief Services, Save the Children or Mercy Corps must, by definition, be focused primarily on “doing.” Long-term systematic research is rarely part of their mission or capacity. Research universities, on the other hand, have the privilege and opportunity to take the long view, to ask the right questions, to study and evaluate what works (and what doesn’t), and, ideally, to partner with others to put what they learn into action.

Rigorous, scientific analysis matters

We all want to believe that heartfelt interventions addressing critical social issues contribute to solving them. However, just because a program addresses an important problem and people like it doesn’t mean it works.

It is difficult to know if our well-intentioned efforts make a contribution unless we do systematic research. Just as testing whether a particular drug “works” requires a placebo and a control group to isolate and measure its impact, this same rigorous analysis can help evaluate the effectiveness of international development initiatives as well.

Increasingly, we are seeing the tools of science being brought to the world of international development. A new generation of researchers in health, economics and other social science fields are spending extensive time in the field using “experimental design” or randomized control trials to better understand how best to address specific problems in developing countries. Such trials can demonstrate whether positive changes can be attributed to the development intervention as opposed to other external factors.

Photo by Matt Cashore '94

Is it more effective, for example, to give away bed nets to prevent mosquito-borne malaria (to distribute them to the most people possible) or to charge a small fee (so people value them and use them properly)? The evidence shows that even a cost of a few pennies per bed net will dramatically reduce usage in poor communities.

What’s the most cost-effective intervention in education for children in low-income countries? Surprisingly, it’s probably deworming kids. In many parts of the world, most kids have intestinal worms, leaving them sick and anemic, and regularly missing school. Studies show that a single pill, costing a few pennies, decreases school absenteeism dramatically.

Our class also analyzes a development intervention right here in the United States that most students experienced as middle school students and know first-hand. The Drug Abuse Resistance Education (DARE) program aspires to help young people avoid the scourge of drug abuse. Teachers, administrators, law enforcement officials and parents are overwhelmingly enthusiastic about the program. Students consistently say they enjoy participating in it. The information the DARE programs shares on the impact of drugs on one’s health is based on good science.

However, systematic research shows that the classroom-based DARE program is ineffective and in some cases may even heighten drug use. How could that be? Studies found that the combination of providing extensive information on the effects of drugs with children of a certain age may simply raise curiosity, and charismatic police officers admonishing middle-school students “Just say no!” can lead some students to say yes. Research can both raise cautionary tales about interventions that don’t work, as well as renew our commitment to those that do.

At Notre Dame, professors are using rigorous analytical tools to address pressing development problems. For example, economist Joseph Kaboski, partnering with Catholic Relief Services, draws lessons on how to effectively promote “self-help group” microfinance services among poor people in East Africa. Engineers Tracy Kijewski-Correa and Alex Taflanidis have worked since the 2010 Haiti earthquake to understand how to build cost-effective, sustainable housing, using local material consistent with local aesthetics and concerns, that withstands the seasonal tropical storms and hurricanes, as well as earthquakes.

Good analysis addresses two main pitfalls that get in the way of effective development: irresponsible if well-intentioned programs that can cause more harm than good, and the cynicism that keeps people from trying at all.

International development is not just economic development

Development specialists, especially economists, had long focused on “economic” development and income as the measure of human development. However, increased Gross Domestic Product (GDP) does not always correlate with improved quality of life. GDP is a useful gauge of economic activity and, while an important metric, does not measure human well-being or happiness, nor the planet’s capacity to handle the consequences of all that economic activity, for as countries develop more they inevitably use more natural resources and create more pollution. In fact, GDP does not distinguish between kinds of economic activity. Spikes in crime and violence, for example, may stimulate the economy by creating jobs for more security firms and the building of more prisons, but this isn’t a great indicator of how well people are thriving.

In his book, Getting Better: Why Global Development is Succeeding — and How We Can Improve the World Even More, Charles Kenny presents compelling evidence from across the globe on the improvement of the quality of life for the majority of people. “Looking at almost any measure of the quality of life except income suggests ubiquitous improvement,” writes Kenny. “The general picture is of rapid, historically unprecedented progress in quality of life — progress that has been faster in the developing world than in the developed. This is true for measures covering health, education, civil and political rights, access to infrastructure.”

For example, over the past decades, even in the parts of sub-Saharan Africa that have experienced economic stagnation or worse, more children are surviving to adulthood and adults are living longer than ever before. What accounts for this? Technology, health improvements such as immunizations and clean water, and greatly expanded access to education, especially for girls, are among the main causes.

Furthermore, development specialists are increasingly focusing on more than just material development. In systematic ways that were once completely the domain of experts measuring economic growth, rigorous studies of human flourishing and happiness are becoming mainstays in international development.

Nobel Prize-winning economist Amartya Sen, who spoke in 2012 at Notre Dame, has described development as understanding and promoting conditions that allow people to participate fully in shaping their own futures while living in dignity and freedom. This idea of integral human development has long been central to Catholic social thought. Such thinking can be seen in a current Notre Dame project: Through its engagement and partnership with poor communities in Kenya and Uganda, the Kellogg Institute’s Ford Family Program in Human Development Studies and Solidarity aspires to learn what difference it makes when local communities play critical leadership roles in setting their own development agenda.

Studying human development in ways that combine rigorous science, and important ethical and normative questions are exactly the arenas where Notre Dame has an opportunity to advance both its scholarly excellence and concrete, real-world impact.

It’s not just what we do but how we do it

Some in the development field had long believed that successful solutions could be imposed if one simply got the formulas right. Unfortunately, the development landscape is littered with abandoned water wells covered in weeds, computer labs with no electricity and empty classrooms where no learning takes place.

Even the term, “international development” sets up a dynamic tension about the rich side — “us” — helping the poor-over-there side — “them.”

It is important to think about not just the what of development — but also the how. A starting point is avoiding the “us and them” dichotomy, instead framing the multiple ways we’re all in it together. Father Gustavo Gutiérrez, a Peruvian priest referred to by many as the father of liberation theology, and the John Cardinal O’Hara Professor of Theology at Notre Dame, often addresses this dichotomy, as well as the unjust social structures that marginalize the most vulnerable and the need for a preferential option for the poor.

Now in his 80s, Gutiérrez, who divides his time between Notre Dame and Peru, also writes about the concept of accompaniment that is having a major impact on how to do effective development today. We accompany one another when we walk a path together. This theological concept reframes our understanding of working to help people by dissolving the lines of us and them, donor and recipient. Instead, the two groups are partners working for the common good. Gutiérrez argues that the attitude of God must serve as a model for the people of God — walk humbly together, with God and with one another, in search of justice and mercy.

Paul Farmer, the subject of Tracy Kidder’s book, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, the Man Who Would Cure the World, has been deeply influenced by Gutiérrez’ work, and the idea of accompaniment permeates Farmer’s organization, Partners In Health (PIH). The two collaborated on a book, In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez (Orbis Books), based on their dialogues in 2011 when Farmer visited Gutiérrez at Notre Dame.

Over the past two decades — challenging the conventional wisdom that it was impossible to treat poor people with “expensive” diseases — PIH demonstrated that such devastating diseases as multidrug-resistant tuberculosis, HIV/AIDs and cancer could be successfully treated in some of the poorest communities in the world, and that people in those communities, who had once simply suffered and died, could flourish.

Central figures in the success of PIH’s work have been the community health workers, accompagnateurs, locally trained workers who see accompaniment as central to their work: visiting people in their homes, making sure pregnant women get routine prenatal care, that HIV and TB patients take their daily medications, and that children get immunized. These are all basic steps that reduce the threat of serious illness as well as prevent the higher costs of later treatment.

A study of 1,000 HIV patients in Rwanda who received daily visits from community health workers showed a 92 percent success rate in sustaining treatment two years after they were enrolled, compared to a more general retention rate of 70 percent for patients in sub-Saharan Africa. The rationale for these community health workers’ service as accompagnateurs is not just a moral one; it’s also that they are particularly effective interventions.

Nearly two-thirds of 13,000 people working for Partners In Health in Rwanda, Haiti, Peru and elsewhere around the globe are community health workers, weaving their lives with those they visit daily. Many have only a few years of education and were former patients themselves. In their roles as community health workers, they now have jobs, which in and of itself is transformative, and through their accompaniment work, they transform the lives of others.

“True accompaniment does not privilege technical expertise above solidarity, compassion, and a willingness to tackle what may seem insuperable challenges,” writes Farmer. “It requires cooperation, openness, and humility; this concept may, I hope, infuse new vitality into development work.”

Accompaniment, not just aid, says Farmer, is a game changer in the “how” of human development, underlining the idea that by walking together, we can change the world.

If you begin with the question “What’s wrong with development?” you can certainly find a wealth of examples. You could easily spend a career cataloging development failures in just one country, carrying out sophisticated and nuanced analysis of why things are so bad. But a more useful question to start with is “_What works?_” Even in tough situations, where is progress being made? Where are the bright spots? I often tell students that development is about addressing complex and difficult problems. There are rarely one-shot solutions to complex problems. Good intentions are not enough. But the fact that you can’t solve everything doesn’t mean you shouldn’t do anything.

Reimagining international development as accompaniment provides a powerful focus for the work. “We must always consider the person,” Pope Francis said recently. “Here we enter into the mystery of the human being. In life, God accompanies persons, and we must accompany them, starting from their situation. It is necessary to accompany them with mercy.”

While science and research devoted to pressing problems of human flourishing help us learn more about what works, the accompaniment model provides great insights into the how.

When Jesus said, “The poor will always be with you,” he was quoting a verse some of his listeners would have recognized from Deuteronomy, “Do not be hard-hearted or tight-fisted toward your needy neighbor. Rather, open your hand and meet the need, whatever it may be. . . . Since the poor will always be with you, I therefore command you to open your hand to the poor.”

The challenge is to not only open your hand and your heart to the poor but also to open your mind to think seriously and rigorously about ways that in accompanying each other we might, walking together, build something better.

Steve Reifenberg has worked on international education and development issues for the past 30 years, living more than a decade in Latin America. Since 2010 he has been the executive director at Notre Dame’s Kellogg Institute for International Studies, which focuses on issues of democracy and human development. He is working on a book with Paul Farmer and Jennie Block, tentatively called From Aid to Accompaniment.