Module 2: Why Bottom Up Instead of Top Down?

"The most critical issue with international development is getting the right resources to where they are needed most and ensuring those resources are being integrated in a sustainable manner. The greatest failure of international development to this day is the wasting of resources due to a lack of comprehensive knowledge of the realities on the ground.”(1) It is this lack of accountability and meaningful investment—“the tragedy of aid”—that William Easterly denigrates in his book The White Man’s Burden. He contends that while a lot of money has been allocated to developing country projects, there is “shockingly little” growth to show for it.(2) This can occur when bureaucratic interventions by governments, foreign agencies, or transnational conglomerates impose “top-down” solutions that fail to take into account both the needs and wishes of the bottom. Conversely, if solutions to community issues are identified and rectified by community-developed remedies—ones that better understand the delicate intricacies of local issues—success and sustainability are much more likely.

Case Study #1: A Successful Bottom-Up Approach

Ban Vinai, a 400-acre refugee camp perched in the remote, hilly region of northeast Thailand, has been home to more than 48,000 residents since the Vietnam War. Residing in the overcrowded, dilapidated camp hovels are primarily the Hmong, an ethnically unique hilltribe people originating in the mountains of Laos.(3) Before the war, the Hmong generally cloistered themselves off from Laotian society, preferring a solitary, exclusionary lifestyle of subsistence farming and distinctive cultural and religious tradition. In the late 1960s when the Vietnam War crept into Laos, however, the United States recruited thousands of Hmong fighters, who felt that their land and independence were threatened by communism. Displaced by the bombings of the North Vietnamese and Lao regime, the Hmong were forcibly relocated to state-run collective farms, or they voluntarily migrated to Thailand.(4) Ban Vinai, one of the biggest Thai camps, was riddled with disease as a result of open sewage and high population density.

In 1985, the International Rescue Committee appointed ethnographer Dwight Conquergood as the coordinator for an environmental health program in Ban Vinai. Instead of commuting to the camp daily, like the other expatriate researchers, Conquergood insisted on living in a thatched hut like the other Ban Vinai residents.(5) Drawing on inspiration from Pedagogy of the Oppressed by Paulo Freire, an influential Brazilian philosopher, as well as Where There Is No Doctor: A Village Health Care Handbook, Conquergood was interested to see if theories of Third World performance art and village theater could be applied in Ban Vinai to raise awareness about health issues.(6) One day, he noticed a Hmong woman humming folk songs on a bench.

“Her face was decorated with little blue moons and golden suns, which he recognized as stickers the camp clinic placed on medication bottles to inform illiterate patients whether the pills should be taken morning or night. The fact that Conquergood considered this a delightful example of creative costume design rather than an act of medical noncompliance suggests some of the reasons why the program he designed turned out to be the most (indeed, possibly the only) completely successful attempt at health care delivery Ban Vinai had ever seen.”(7)

The first dilemma Conquergood encountered was a failed attempt by the medical staff to vaccinate all the camp dogs after a rabies outbreak. In an effort to discover why so few Ban Vinai inhabitants brought their dogs to the clinic to be inoculated, he said that he found that Hmong expressed much distrust toward local hospitals, which were primarily run by overly zealous foreigners from Christian charitable foundations. The hospital volunteers disrespected their traditional beliefs, cutting spirit-strings from their wrists because they were thought to harbor germs, removing neck-rings that Hmong believed protected the souls of small children, and denouncing Hmong confidence in shamans and herbalists. With these beliefs and perceptions in mind, Conquergood designed a “Rabies Parade.”

It was “a procession led by three important characters from Hmong folktales—a tiger, a chicken, and a dab—dressed in homemade costumes. The cast, like its audience, was one hundred % Hmong. As the parade snaked through the camp, the tiger danced and played the qeej, the dab sang and banged a drum, and the chicken … explained the etiology of rabies through a bullhorn.” (8)

All three figures were strategically chosen to appeal to Hmong’s cultural ideologies. The tiger, a guileful creature in Hmong mythology, drew attention and inspired awe. The commotion of the singing and drumming of the dab, a supernatural spirit, drew people out of their huts and into the streets. The chicken implored the parents to vaccinate their dogs to protect their children. The adults, aware of the chicken’s divine status in Hmong folklore, listened attentively.(9)

“The next morning, the vaccination stations were so besieged by dogs—dogs carried in their owners’ arms, dogs dragged on rope leashes, dogs rolled in on two-wheeled pushcarts—that the health workers could hardly inoculate them fast enough.”(10)

Equally successful was Conquergood’s “Garbage Theme” month.

“Drawing on the evil ogre character from Hmong folklore (poj ntxoog), we created an ugly Garbage Troll in soiled ragged clothes and a mask plastered with bits of garbage and dirt. The Garbage Troll would lumber into the centre of the playing space and begin dramatizing the behavior to be discouraged—peeling eggs and other food and throwing the waste on the ground, picking up dirty food from the ground and putting it into his mouth, and so forth.”(11)

Then “Mother Clean,” an eight-foot dancing puppet on a bamboo frame would sing a song with the following lyrics: “When you lived in the mountains, the wind and the rain cleaned the garbage. Now with so many people in Ban Vinai, we all must be careful to clean up the garbage.”(12)

Conquergood’s detailed investigation of the local cultural landscape, as well as his integration of Hmong practices and beliefs into the program’s architecture, resulted in widespread conscientization of the public about the perils of pollution and poor sanitation. The resulting behavioral change suggests that development organizations must engineer programs that are culturally sensitive, as well as locally endorsed and conducted, if improvements are to be made.

Case Study #2: An Unsuccessful Bottom-Up Approach

Grassroots development is seen by many as the means by which underserved communities can “have a voice, invested interest, and ownership in the development of their land, economy, education, rights, and values.” The Foundation for Sustainable Development claims that “[t]hrough listening to [community members’] needs, empowering their belief in change, and working beside them to implement practical solutions, real progress can be made that does not result in donor reliance and further disempowerment. Cultivating a thorough understanding of the complex realities ‘on the ground’ is the key to empowerment and collective action.”(13) Sometimes, however, as seen in the following case study, even those involved in development work “on the ground” can be ineffective if the right questions are not asked.

Before a strong stance on HIV education was adopted by governmental leadership in Thailand in the early 1990s, HIV/AIDS severely threatened national health infrastructure and general stability. Even after the implementation of a pervasive public information campaign and condom distribution plan, the country still battles to keep its prevalence rate low.(14) It was in this environment that Peace Corps volunteers tried to do condom demonstrations for villagers in an effort to contribute to the national goals of HIV-transmission reduction.

“In the old days volunteers used bananas in the demonstration but switched to wooden replicas when they discovered that some participants went home and actually put condoms on bananas thinking it had some sort of power to keep them safe.”(15)

HIV/AIDS education and prevention is a large part of the work carried out by Peace Corps volunteers working in health sectors of Africa, the Caribbean, Eastern Europe, and Central Asia.(16) While encouraging condom use “is a critical element in a comprehensive, effective and sustainable approach to HIV prevention and treatment,” how the educational material is communicated to its target audience must be adapted to local cultural circumstances to avoid ineffectiveness in health programs.(17) A document published by the United Nations Population Fund, UNAIDS, and the World Health Organization states that:

• “Condoms must be readily available universally, either free or at low cost, and promoted in ways that help overcome social and personal obstacles to their use.”

• “HIV prevention education and condom promotion must overcome the challenges of complex gender and cultural factors.”(18)

Recognition of and respect for such cultural factors and social obstacles can be achieved through “cultural competence.” Achieving this competence “implies having the capacity to function effectively as an individual and an organization within the context of cultural beliefs, behaviors, and needs presented by consumers and their communities.”(19) This includes involving the community in pinpointing issues and generating solutions, collaborating with other local agencies to determine best practices, and evaluating receptivity to and outcomes of community-based endeavors. In addition to a more meticulous examination of the culturally acceptable methodologies of knowledge dissemination, a “cultural broker”—a liaison between outsiders and insiders who understands “the health values, beliefs, and practices within their cultural group or community”—might have been helpful in the Peace Corps volunteers’ situation as well.(20)

As a brief counterexample of how community health education about sexually transmitted diseases can be done effectively, we look to a case study from the Asaro Valley of the Eastern Highlands Province of Papua New Guinea. In their preliminary investigation, researchers found that while the national prevalence of some STDs is high—with 25% of both men and women having Chlamydia and 45% of women suffering from trichomonal vaginitis—knowledge about how STDs are transmitted is low. Before they started their health education workshops, researchers sought the guidance of a professional health educator from the country’s Division of Health. The native specialist shared the teaching techniques to which she thought Papua New Guineans would best respond. These included lectures, visual aids, group discussions, one-on-one health education, interviews, and demonstrations. These techniques were then tested and evaluated in various community settings to determine which were most well-received.

In the beginning, teaching aids included “cardboard models and puppets, line drawings of basic reproductive anatomy and drawings of people engaging in various activities or showing signs and symptoms of disease.” Also, educators utilized both bananas and wooden penis models for condom demonstrations. When villagers voiced discontent about the explicit nature of the materials, researchers adapted by asking village representatives to preview the materials before they were used in the workshops.(21) This action expressed to the villagers that the researchers were flexible in their methods, accommodating to cultural beliefs about sexuality, and sensitive to participants’ discomfort. “[E]nthusiastic support from the leaders” also helped augment the researchers’ credibility.(22) Researchers found that the majority of women had never seen nor used a condom. Hence, it was “important to demonstrate their use, and also to get the participants to handle them and, if possible, practice putting them on the models.” Contrary to the changes that were necessary in Peace Corps condom demonstration protocol, “bananas worked better than wooden penis models, because the women were less embarrassed about handling them.”(23)

The lesson that can be learned about the difference between the one group's approach in Thailand and the approach of researchers in Papua New Guinea is simple: merely working “on-the-ground” is not enough to create a successful bottom-up approach. It takes cultural competence, intensive assessment of community values, adjustment to cultural preferences, and space for open dialogue and feedback to implement an efficacious health education campaign.

Case Study #3: A Successful Top-Down Approach

While spontaneous grassroots initiatives and decentralized community-based organizations are often more successful at engaging community member participation in and ownership of progress because of their knowledge of local realities, outside agencies can still play a role in improving the well-being of individuals living in poverty.(24), (25) The Carter Center, a non-governmental not-for-profit organization founded by former US president Jimmy Carter and former First Lady Rosalynn Carter, is trying to do just this. Their mission, “in partnership with Emory University, is guided by a fundamental commitment to human rights and the alleviation of human suffering; it seeks to prevent and resolve conflicts, enhance freedom and democracy, and improve health.” The Center functions by “both engaging with those at the highest levels of government and working side by side with poor and often forgotten people” in more than 80 countries.(26) In doing so, the Center has accomplished much for the causes of equality and sustainability. Some of their successes include:

• Strengthening governmental competency by overseeing 113 democratic elections in Asia, Latin America, and Africa.

• Helping farmers double or triple their grain yields in 15 African countries.

• Mediating or working to prevent civil and international conflicts.

• Preventing unnecessary or neglected diseases in Latin America and Africa.

• Striving to diminish the stigma against mental illness.

• Leading a coalition that has reduced incidence of Guinea worm disease by 99.99 percent, making it the first parasitic disease likely to be eradicated.(27)

• Establishing a village-based health care delivery system in thousands of African communities

Unlike some less effective foreign agencies, The Carter Center is in the business of helping people improve their own lives by their own methods by providing the necessary skills, knowledge, and access to resources.(28) Take, for example, The Carter Center’s Guinea Worm Eradication Program. Guinea worm is a disease contracted by drinking stagnant water contaminated with the infectious larvae of microscopic water fleas. Once inside an individual’s body, the larvae incubate and grow to as long as three feet for about a year, and then slowly emerge from painful skin blisters. People with existing worms should not bathe or step in sources of drinking water, because doing so allows worms the opportunity to lay hundreds of eggs on which the water flies feed, thus tainting unfiltered pond water, and stimulating the cycle of infection again. The agonizing and incapacitating process of eliminating a worm from one’s body, which must be completed by wrapping the live worm around an object and gradually extracting it, inhibits children from attending school and farmers from cultivating their crops. The magnitude of impact of lost productivity due to Guinea worm is devastating in poor communities—in southeastern Nigeria, rice farmers in just one county lost $20 million in a single year due to high prevalence of Guinea worm disease.(29)

Between 1986 and today, The Carter Center’s measures have reduced the total caseload of Guinea worm from 3.5 million in 21 countries across Africa and Asia to 27 remaining in Chad, Ethiopia, South Sudan, Angola, Mali, and Cameroon. From 2019 to 2020 alone, there was a 75% drop in cases in Chad, and animal cases fell 20%.(30) Through health education and low-technology interventions, The Carter Center has empowered families to take control of their own protection. This has involved providing filter cloths for clay water-holding pots and distributing personal filters straws that can be worn around the neck (enabling people, especially nomadic tribes, to drink safely no matter where they are). The Carter Center also trains locals to use ABATE, a chemical larvicide donated by BASF Corporation, to purify pond water (and kills the guinea worm larvae). They have also erected deep wells and boreholes in hopes of banishing the disease completely.(31)

For a more poignant understanding of the risks and repercussions of Guinea worm, and how The Carter Center is working to eradicate it, please watch this video.

At the baseline, while The Carter Center does work on a rather large scale, transplanting effective methodologies to various countries around the world, their efforts are highly impactful. By accessing power networks and world leaders, “mobilizing government officials,” and collecting millions of dollars in aid—actions characteristic of top-down development agencies—the Carter Center works to “empower and educate communities to take simple measures to prevent the disease from recurring.”(32) This is the fundamental difference that separates the Carter Center from some other top-down agencies: the intimate involvement of community beneficiaries in the problem-solving process and the positive engagement of “voices that are seldom heard.”(33) When these voices are not engaged, as seen in the next case study, problems in effectiveness can arise.

Case Study #4: An Unsuccessful Top-Down Approach(34)

Insufficient sanitation systems, coupled with lack of access to clean water, constitute a lethal combination in developing countries, where diarrheal diseases, dysentery, hepatitis, typhoid, cholera, parasitic infections, and skin rashes ravage populations living in poverty. Public waste containment can dramatically reduce exposure to these diseases. Access to a basic pit latrine, on average, results in a 30% reduction in child mortality. The implementation of flush toilets precipitates a 60% decrease. The United Nations Development Program states, however, that “inadequate financial resources and technical capacity, allied in some cases with water shortages, make it unrealistic to assume that a developed country model could be extended rapidly across the developing world.” Thus, when donor foundations, health organizations, or national governments fail to invest in sanitary infrastructure, cost-effective “sanitary makeshifts” are transfigured into “appropriate technologies,” consequently validating a double-standard of quality between developed and developing nations.

To demonstrate this, Eric A. Stein explored the expectations, motives, and outcomes of a sanitation intervention in rural Central Java, Indonesia. Throughout the 19th and early 20th centuries, most colonial public health services were designed to solely cater to the European colonists in ports, cities, army outposts, and plantation estates. The Dutch generally believed that providing hygiene education to native populations in the East Indies was financially unintelligent. Consequently, the Netherlands was initially offended when a foreign foundation proposed a hookworm prevention campaign in 1924 because they saw the proposal as a threat to their medical sovereignty. The foundation was able to convince the colonizers, however, that this easily preventable, tropical disease hindered worker productivity, and that its eradication was in fact monetarily responsible.

The goal of the foundation’s “Intensive Rural Hygiene” project was to achieve compliance with Western standards of hygiene through the cheapest possible means. Central to the realization of this goal were the hygiene mantri, or hygiene “technicians”—local elites who, theoretically, were supposed to “cultivate desires among villagers to participate in and pay for the construction of their own sanitary infrastructure” via films, speeches, and sanitary inspections in homes. Decision-makers decided that, in order to abide by the expectations of frugality, impoverished villagers should be encouraged to construct rudimentary pit latrines using the plentiful natural resources surrounding them. While this model of community involvement and participation seems empowering, Stein reports that it ultimately failed to produce any significant change, for several reasons:

• Despite an emphasis on low-cost material and construction, only the wealthy could afford to construct latrines.

• For the poor who did manage to start latrine construction, the intensive labor investment resulted in lost productivity in their actual jobs and, accordingly, lost income.

• The mantri were adamantly avoided and feared by villagers because of their elite status, consequently infusing “health work with malevolent power dynamics of indirect rule within highly stratified village societies.”

• The cursory investigation of local demographics by public health officials allowed village gatekeepers—ashamed of the existing state of poverty and protective of their development rankings—to lie about the state of their sanitation system.

• For many of the poor, defecating in rivers and ponds was considered considerably more refreshing and comfortable that doing so over a hole or indoor toilet.

• Small-scale fish farmers encouraged locals to use latrine platforms constructed over ponds because catfish feed on human feces. Contaminated fish sold in local markets transmit typhoid fever caused by Salmonella typhi bacteria. Local health professionals made little connection, however, between typhoid and insufficient sanitation. The disease was often passed off as a minor gastrointestinal disturbance caused by eating excessively spicy foods.

While the motives behind the intervention were well-intentioned, the methods were misinformed. The project’s shortcomings could have potentially been avoided if developers had examined local power dynamics, illness orientations, cultural practices and preferences, and economic forces before pursuing an intervention.

Footnotes

(1) “Why Grassroots Development?” The Foundation for Sustainable Development.http://www.fsd.org/.

(2) Howes, S. (2009). The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good. Economic Record (The Economic Society of Australia). 85.271: 488.

(3) Cohen-Cruz, J. (Ed.). (2013). Health Theatre in a Hmong Refugee Camp: Performance, Communication, and Culture. Radical street performance: An international anthology. Routledge. 220-229.

(4) “The Journey.” Pbs.org. https://www.pbs.org/splithorn/story1.html.

(5) Fadiman, A. The Spirit Catches You and You Fall Down. (Macmillan, 1998): 35-36.

(6) Cohen-Cruz, J. (Ed.). (2013). Health Theatre in a Hmong Refugee Camp: Performance, Communication, and Culture. Radical street performance: An international anthology. Routledge. 222.

(7) Fadiman, A. The Spirit Catches You and You Fall Down. (Macmillan, 1998): 36.

(8) Ibid, 36-37.

(9) Cohen-Cruz, J. (Ed.). (2013). Health Theatre in a Hmong Refugee Camp: Performance, Communication, and Culture. Radical street performance: An international anthology. Routledge. 226.

(10) Fadiman, A. The Spirit Catches You and You Fall Down. (Macmillan, 1998): 37.

(11) Cohen-Cruz, J. (Ed.). (2013). Health Theatre in a Hmong Refugee Camp: Performance, Communication, and Culture. Radical street performance: An international anthology. Routledge. 226.

(12) Fadiman, A. The Spirit Catches You and You Fall Down. (Macmillan, 1998): 268.

(13) “Why Grassroots Development?” The Foundation for Sustainable Development.http://www.fsd.org/.

(14) “HIV & AIDS in Thailand.” AVERT.org. https://www.avert.org/professionals/hiv-around-world/asia-pacific/thailand.

(15) Schimmelpfennig, S. “Mosquito nets, condoms and recycling.” Good Intentions Are Not Enough: An honest conversation about the impact of aid. https://informationincontext.typepad.com/good_intentions_are_not_e/2009/09/mosquito-nets-condomns-and-recycling.html.

(16) Peace Corps. “HIV/AIDS.”  https://www.peacecorps.gov/educators/resources/all-about-hiv-and-aids/.

(17) “Position Statement on Condoms and HIV Prevention.” UNAIDS, WHO, UNFPA. July 2004, page 1. https://www.who.int/hiv/pub/prev_care/en/Condom_statement.pdf?ua=1..

(18) Ibid, 1-2.

(19) “Cultural Competence.” National Prevention Information Network. https://npin.cdc.gov/pages/cultural-competence#:~:text=Cultural%20competence%20requires%20that%20organizations,to%20work%20effectively%20cross%2Dculturally..

(20) Georgetown University Center for Child and Human Development. “Who Is the Cultural Broker?” National Center for Cultural Competence. https://nccc.georgetown.edu/culturalbroker/2_role/2_role.html.

(21) Horton, K., Lupiwa, S., Passey, M., & Suve, N. (1996). Knowledge about sexually transmitted diseases in rural and periurban communities of the Asaro Valley of Eastern Highlands Province: the health education component of an STD study. Papua New Guinea Medical Journal. 39.3: 244.

(22) Ibid, 245.

(23) Ibid.

(24) Lewis, D., and Wallace, T. New Roles and Relevance: Development NGOs and the Challenge of Change. (Kumarian Press, 2000).

(25) Willis, K. Theories and Practices of Development. (Routledge, 2005).

(26) “About the Center.” The Carter Center. https://www.cartercenter.org/.

(27) Barry, M. (2007). The tail end of guinea worm—global eradication without a drug or a vaccine. New England Journal of Medicine, 356(25), 2561-2564.

(28) Ibid.

(29) “Guinea Worm Eradication Program.” The Carter Center. https://www.cartercenter.org/health/guinea_worm/index.html.

(30) "Guinea Worm Cases Fell 50% in 2020, Carter Center Reports." The Carter Center. https://www.cartercenter.org/news/pr/2021/guinea-worm-worldwide-cases-announcement-012621.html.

(31) Ibid.

(32) Ibid.

(33) “Access to Information.” The Carter Center. https://www.cartercenter.org/.

(34) Stein, E. A. “’Sanitary Makeshifts’ and the Perpetuation of Health Stratification in Indonesia.” Anthropology in Public Health. (Oxford University Press, 2009): 541-565.