Medicine and social justice
Proponents of liberation theology have maintained for decades that people of faith must make a preferential option for the poor. As discussed by Leonardo Boff of Brazil, a leading contributor to the movement, "the church's option is a preferential option for the poor, against their poverty." The poor, Boff adds, "are those who suffer injustice. Their poverty is produced by mechanisms of impoverishment and exploitation. Their poverty is therefore an evil and an injustice."
To those concerned with health, a preferential option for the poor offers both a challenge and an insight. It challenges doctors and other health providers to make an option for the poor by working on their behalf. The insight is, in a sense, an epidemiological one: most often, diseases themselves make a preferential option for the poor. That is, the poor are sicker than the non-poor. They are at heightened risk of dying prematurely, whether from increased exposure to pathogens (including pathogenic situations) or from decreased access to services or, as is most often the case, from both of these "risk factors."
Liberation theology, which argues that genuine change will be rooted in small communities of poor people, advances a simple three-part methodology--observe, judge, act. The observe part of the formula implies analysis. It is perhaps surprising that the Catholic bishops of Latin America, traditionally allied with the elites of their countries, have more recently chosen to favor hard-bitten social analysis when examining their societies. Many would argue that liberation theology's key documents were hammered out at the bishops' meetings in Medellin in 1968 and in Puebla in 1978. In both instances, progressive bishops, working with like-minded theologians, such as Peru's Gustavo Gutierrez, deplored the political and economic forces that bring misery to so many Latin Americans. The bishops did not mince words: "The Puebla document," Boff remarks, "moves immediately to the structural analysis of these forces and denounces the systems, structures, and mechanisms that 'create a situation where the rich get richer at the expense of the poor, who get even poorer.'
The judge part of the equation is important and, in one sense, pre-judged. We look at the lives of the poor and are sure, as they are themselves, that something is wrong. Structural violence is being done to them. (Some of the bishops termed this "structural sin".)
In the wealthy countries of the northern hemisphere, the relatively poor often travel far and wait long for health care inferior to that available to the wealthy. In the third world, where conservative estimates suggest that one billion people live in poverty, the plight of the poor is far worse. How do they cope? Often enough, they are unable to. The poor there have short life expectancies, often dying of preventable or treatable diseases or from accidents. In fact, most of the third world poor receive no effective biomedical care at all For many people, there is no such thing as a polio vaccine. Tuberculosis is as lethal as AIDS. Childbirth involves mortal risk. In an age of explosive development in the realm of medical technology, it is unnerving to find that the discoveries of Salk, Sabin and even Pasteur remain irrelevant to much of the human population.
There are important corollaries to this sense that injustice is being done. One is that the viewpoints of poor people will inevitably be suppressed or neglected as long as elites control most means of communication. Thus the observation and judgment steps will usually be difficult, because vested interests, including those controlling development efforts, have an obvious stake in shaping observations and in attenuating harsh judgments about deplorable conditions.
Finally, the liberation theologians and the base communities from which they draw their inspiration agree that it is necessary to act on these reflections. The act part of the formula implies much more than reporting one's findings. Jon Sobrino, a Jesuit theologian in EI Salvador, has put it this way: "There is no doubt that the only correct way to love the poor will be to struggle for their liberation. This liberation will consist, first and foremost, in their liberation at the most elementary level-that of their simple, physical life, which is what is at stake in the present situation." Father Sobrino's assessment is consonant with my own experiences in Haiti and elsewhere, including the streets of some of the cities of the United States. What is at stake, for many of the hemisphere's poor, is often physical survival.
Tuberculosis' Own Preferential Option for the Poor.
To act as a physician in the service of poor or otherwise oppressed people is to prevent, whenever possible, the diseases that afflict them-but also to treat and, if possible, to cure. So where is the innovation in that? How would a health intervention inspired by liberation theology be different from those with more conventional underpinnings? Over the past decade, Partners in Health has joined local community health activists to provide basic primary care and preventive services to poor communities in Mexico, Peru and especially Haiti-offering what we have termed pragmatic solidarity. As often as not, our medical efforts have been informed by certain insights from liberation theology.
Take tuberculosis, probably the leading cause of preventable adult deaths in the world. How might one observe, judge and act in pragmatic solidarity with those who are likely to acquire or who are already suffering from TB? The observation part of the formula is key, for it involves careful review of a large body of literature seeking to explain the distribution of the disease within populations, to explore its clinical characteristics and to evaluate TB treatment regimens. This sort of review is standard in all responsible health planning, but liberation theology would push analysis in two directions: first, to seek the root causes of the problem; second, to elicit the experiences and views of poor people and to incorporate these views into all observations, judgments and actions.
Careful review of the biomedical and epidemiological literature on TB does permit certain conclusions. First, it is clear that the incidence of the disease is not at all random. TB has had its victims among the great, but it is a disease that from time immemorial has ravaged the economically disadvantaged. This is especially true in recent decades. With the mid-century development of effective therapy came high cure rates-over 95 percent-for those with access to the right drugs for the right amount of time. Thus TB deaths now occur almost exclusively among the poor, whether they reside in our own inner cities or in the poor countries of the southern hemisphere.
The latest twists to the story-the resurgence of TB in the United States, the advent of H.I.Y.-related tuberculosis and the development of strains of TB resistant to all of the "first-line" therapies developed in recent years-serve to reinforce the thesis that Mycobacterium tuberculosis, the causative organism, makes its own preferential option for the poor.
Many consider it scandalous that the world's leading cause of preventable adult deaths is a disease that, with the exception of the new resistant strains, is more than 95 percent curable with standard therapy. (Measles and malaria, the one wholly preventable and the other treatable, also kill millions each year.) Others express distaste for a disease partial to poor and debilitated hosts and judge unacceptable the lack of readily available therapy for those most likely to become ill with TB. In a very real sense, poverty puts people at risk of TB and then bars them from access to effective treatment.
The recrudescence of TB is rarely blamed on the inequalities native to our society. Instead we hear about biological factors (the advent of H.I. Y., the emergence of drug resistance) or about cultural and psychological barriers to compliance. Through these two sets of mechanisms, high rates of treatment failure may be expediently attributed to either the organism or to uncooperative patients.
There are costs to seeing the problem in this way. If the resurgence of TB is viewed as an exclusively biological phenomenon, then available resources will be shunted to, say, pharmaceutical and immunological research. If the problem is primarily one of patient compliance, then plans to address TB are necessarily grounded in plans to change the patient, not the poverty-related forces that are, in my opinion, demonstrably the root causes of the modem TB pandemic.
How about the act part of the formula? In a sense, it is simple: heal the sick. Most studies of TB in Haiti reveal that the vast majority of patients do not complete treatment. This explains in part why TB is the leading cause of adult deaths in rural areas. In the country's central plateau, we worked with our sister organization, Zanrni Lasante, to devise a TB treatment effort that borrows a number of ideas, and also some passion, from liberation theology. Although the Zanmi Lasante staff had effectively identified and referred patients with pulmonary TB to the clinic in its first few years of operation, it gradually became clear that detection of new cases did not always lead to cure, in spite of the fact that all TB care, including medications, was free of charge. Procedures were thoroughly reexamined in 1988, after three young adults died from old-fashioned pulmonary TB in the space of a few months.
What had gone wrong? A group of community health workers and physicians met together to address this question. (The discussion sessions were modeled on the practice of base communities.) Many in the group pointed to patient factors. Those who had died were said to have been non-compliant or superstitious. Others felt that structural factors were more to blame: Patients had difficulty keeping appointments or finding someone to give them injections. One village health worker pointedly noted that "only the hungriest ones die."
After a lengthy study of two groups in the central plateau area, we concluded that removing structural barriers to compliance, when coupled with financial aid, dramatically improved outcome in poor Haitians with TB. This insight cuts straight to the heart of the compliance question. Certainly, patients may be non-compliant, but how relevant is such a notion in rural Haiti? Patients may be instructed by doctors to eat well. They will "refuse" if they have no food. They may be told to sleep in an open room and away from others. Here again, forced by their poverty to live in crowded conditions, they will be considered non-compliant. They will be instructed to go to a hospital. Again, "gross negligence" will follow if medical care must be paid for in cash, as is the case in most of Haiti.
Although anthropologists are expected to underline the importance of culture in determining the ultimate efficacy of efforts to combat disease, we learned that in Haiti many variables-initial exposure to infection, reactivation of quiescent TB, length of convalescence, development of drug resistance, degree of lung destruction and, most of all, mortality-are all strongly influenced by economic factors. In a study published in collaboration with Zanmi Lasante, we concluded that "the hoary truth that poverty and TB are greater than the sum of their parts is once again supported by data, this time coming from rural Haiti and reminding us that such deadly synergism, formerly linked chiefly to crowded cities, is in fact most closely associated with deep poverty."
Similar scenarios might be described concerning other diseases, ranging from typhoid to AIDS. In each case, poor people are at higher risk for the disease and also less likely to have access to care. And in each case, analysis of the problem may lead researchers to focus on the patients' shortcomings (e.g., failure to drink pure water,
failure to use condoms, ignorance about public health and hygiene) or on the conditions that structure people's risk (e.g., lack of access to potable water, lack of economic opportunities for women, unfair distribution of the world's resources).
One of the chief benefits of analysis of this kind is that it encourages physicians and others concerned with protecting or promoting health to make common cause with people who are both poor and sick. This is especially important in areas where austerity measures imposed by international financial agencies are making health care even less accessible to poor people. Indeed, the emergence of a World Bank-endorsed "new world order" will surely test our commitment-and not just in places like Haiti and Peru. The passage of Proposition J 87 in California could compromise medical care (and education) for tens of thousands of residents, especially Latino children. To their credit, many California providers have simply pledged to resist efforts to deny services to people based on their immigration status. A similar pledge of resistance may become necessary for those concerned about the millions of Americans who have no health insurance.
An Option for the Poor in Health Care.
Tuberculosis aside, what follows next from a liberation theology perspective on medicine? For me, applying an option for the poor has never implied advocacy of a particular strategy for a national economy. It does not mean preferring one form of development or social system over another (although some economic systems are patently more marked by structural violence than others). Nor does recourse to the central ideas of liberation theology necessarily imply a commitment to a particular body of religious beliefs. Partners in Health, the community organization I represent, is completely ecumenical.
Liberation theology's first lesson is similar to that usually confronting healers: namely, that there is something terribly wrong. Things are not the way they should be. But in this view the problem is with the world, even though it may be manifested in the patient. As Robert McAfee Brown, paraphrasing the Uruguayan Jesuit Juan Segundo, has noted: "Unless we agree that the world should not be the way it is, there is no point of contact, because the world that is satisfying to us is the same world that is utterly devastating to them."
The second lesson is that there is much to be learned from reflecting upon the lives and struggles of poor or otherwise oppressed people. How is suffering, including that due to sickness, best explained? How is it to be addressed? These questions are as old as humankind. We have had millennia in which to address-societally, in an organized fashion-the suffering that surrounds us. In looking at approaches to this problem, one can easily discern three main trends: charity, development and social justice.
Each of these might have much to recommend it, but it is my belief that the first two approaches, charity and development, are deeply flawed. Those who believe that charity is the answer to the world's problems often tend to regard people who need it as somehow intrinsically less than themselves. This is different from regarding the poor as disempowered or impoverished through historical processes and events, like the flooding of a valley. There is an enormous difference between seeing poor men and women as victims of innate shortcomings and seeing them as victims of structural violence.
Charity further presupposes that there will always be those who have and those who have not. This may or may not be true, but again, there are costs to seeing the problem in this light. In Pedagogy of the Oppressed, Paulo Freire put it this way: "In order to have the continued opportunity to express their 'generosity,' the oppressors must perpetuate injustice as well. An unjust social order is the permanent fount of this 'generosity,' which is nourished by death, despair, and poverty." Freire's conclusion follows naturally enough: "True generosity consists precisely in fighting to destroy the causes which nourish false charity." Given the 20th century's marked tendency toward increasing economic inequity in the face of economic growth, there will be plenty of false charity in the future.
In medicine, charity underpins the often laudable goal of addressing the needs of underserved populations. In this view, second-hand, castoff services and leftover medicine are doled out. Many of us have been involved in these sorts of good works, and have often heard their motto: "The homeless poor are every bit as deserving of good medical care as are the rest of us." The notion of a preferential option for the poor challenges us by reframing the motto: "The homeless poor are more deserving of good medical care than are the rest of us."
What about development approaches? Often, this perspective seems to regard progress and development as almost natural processes. The technocrats who design development projects-like the U.S.-planned and financed Peligre dam that displaced and thus impoverished tens of thousands of Haitian peasant farmers in 1956-plead for patience. "In due time," they say, "you too will share our standard of living, or, if not you, your children." And certainly, looking around us, we see everywhere the tangible benefits of scientific development. So what is wrong with that? In his introduction to A Theology of Liberation, Gustavo Gutierrez argues that we assert our humanity in "the struggle to construct a just and fraternal society, where persons can live with dignity and be the agents of their own destiny. It is my opinion that the term development does not express these profound aspirations." He continues his comments by noting that the term "liberation" expresses the hopes of the poor much more succinctly.
In examining medicine, one sees the impact of developmental thinking not only in the planned obsolescence of medical technology, but also in influential analytic constructs such as the health transition model. In this view, societies as they develop are making their way towards that great transition when deaths will no longer be caused by infections such as TB, but will occur much later and be caused by heart disease and cancer. But this model masks interclass differences within a particular country. For the poor, wherever they live, there is no health transition. In other words, wealthy citizens of underdeveloped nations (those that have not yet experienced their health transition) do not die young from infectious diseases, but rather later and from the same diseases that claim similar populations in wealthy countries. In parts of Harlem, in contrast, death rates in certain age groups are as high as those in Bangladesh; in both places, the leading causes of death in young adults are infections and violence.
The leaders of countries are impatient with such observations, and respond, if they respond at all, with sharp reminders that it is the overall trends that count. But if you happen to work in the service of the poor, what is taking place within that particular class-whether in Harlem or in Haiti-always counts a great deal. In fact, it counts most.
In summary, then, the charity and development models, though perhaps useful at times, are found wanting when it comes to rigorous and soul-searching examination. That leaves the social justice model. In my experience, people who work for social justice, regardless of their own stations in life, tend to see the world as deeply flawed. They see the conditions of the poor not only as unacceptable, but as the result of structural violence that is human-made. Often, if they are privileged people like me, they understand that they have been implicated, directly or indirectly, in the creation or maintenance of this structural violence. They then feel indignation, but also humility and penitence.
This posture of penitence and indignation is critical to effective social justice work. Alas, it is all too often absent or, worse, transformed from posture into posturing. And unless the posture is linked to much more pragmatic interventions, it usually fizzles out.
Fortunately, embracing these concepts and this posture has very concrete implications. Making an option for the poor inevitably implies working for social justice, working with poor people as they struggle to change their situations. In fact, in a world riven by inequity, medicine could be viewed as social justice work, and most of what we do could be seen in this light. In Haiti and Peru and Chiapas, we have found, it is often less a question of development, and more one of redistribution of goods and services, of simply sharing the fruits of science and technology. The majority of our efforts in the transfer- of technology-medications, laboratory supplies, computers and training-are conceived in just this way.
A preferential option for the poor also implies a mode of analysis. In examining TB in Haiti, our analysis must be historically deep: not merely deep enough to remind us of the Peligre dam project that depeived the majority of my patients of their land, but deep enough to make us remember that modem-day Haitians are the descendants of a people kidnapped from Africa in order to provide us with sugar, coffee and cotton.
Our analysis must also be geographically broad. Many believe that the world as we know it is becoming increasingly interconnected. A corollary of this belief is that what happens to poor people is never divorced from the actions of the powerful. Certainly, people who define themselves as poor may control to some extent their own destinies. But control of lives is related to the control of land, systems of production and the formal political and legal structures in which lives are enmeshed. There has come, with time, an increasing concentration of wealth and control in the hands of a few. The very opposite trend is desired by people working for social justice.
For those who work in Latin America, the role of the United States looms large. Jim Carney, a Jesuit priest who worked with the poor of Honduras, put it starkly:
"Do we North Americans eat well because the poor in the third world do not eat at all? Are we North Americans powerful because we help keep the poor in the third world weak? Are we North Americans free because we help keep the poor in the third world oppressed?" (Father Carney, who attempted to live his option for the poor to the fullest, was killed by U.S.-trained Honduran security forces in 1983.)
Granted, it is difficult enough to think globally and act locally. But perhaps what we are really called to do, in efforts to make common cause with the poor, is to think locally and globally, and to act in response to both levels of analysis. If we fail in this task, we may never change the structures that create and maintain poverty, structures that make people sick.