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health, healing, and social Justice Insights from Liberation Theology

P a u l F a r M e r

If I define my neighbor as the one I must go out to look for, on the highways and byways, in the factories and slums, on the farms and in the mines—then my world changes. This is what is happening with the “option for the poor,” for in the gospel it is the poor person who is the neighbor par excellence. . . .

But the poor person does not exist as an inescapable fact of des- tiny. His or her existence is not politically neutral, and it is not ethically innocent. The poor are a by-product of the system in which we live and for which we are responsible. They are marginalized by our social and cultural world. They are the oppressed, exploited pro- letariat, robbed of the fruit of their labor and despoiled of their hu- manity. Hence the poverty of the poor is not a call to generous relief action, but a demand that we go and build a different kind of social order.

—Gustavo Gutiérrez, The Power of the Poor in History

Not everything that the poor are and do is gospel. But a great deal of it is.

—Jon sobrino, Spirituality of Liberation

This chapter originally published in Paul e. Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley: university of California Press, 2004). reprinted with permission.

The Preferential Option for the Poor Beyond Theology, edited by Daniel G. Groody, and Gustavo A. Gutierrez, University of Notre Dame Press, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/seattleu/detail.action?docID=3441153. Created from seattleu on 2018-11-01 14:49:47.

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M a k i n G a P r e F e r e n T i a l O P T i O n F O r T h e P O O r

For decades now, proponents of liberation theology have argued that people of faith must make a “preferential option for the poor.” as dis- cussed by Brazil’s leonardo Boff, 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 pov- erty is produced by mechanisms of impoverishment and exploitation. Their poverty is therefore an evil and an injustice.”1 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—a choice—for the poor, to work on their behalf.

The insight is, in a sense, an epidemiological one: most often, dis- eases themselves make a preferential option for the poor. every careful survey, across boundaries of time and space, shows us that the poor are sicker than the nonpoor. They are at increased 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” working together.2 Given this in- disputable association, medicine has a clear—if not always observed— mandate to devote itself to populations struggling against poverty.

it is also clear that many health professionals feel paralyzed by the magnitude of the challenge. where on earth does one start? we have re- ceived endless, detailed prescriptions from experts, many of them mani- festly dismissive of initiatives coming from afflicted communities them- selves. But those who formulate health policy in Geneva, washington, new york, or Paris do not really labor to transform the social conditions of the wretched of the earth. instead, the actions of technocrats—and what physician is not a technocrat?—are most often tantamount to managing social inequality, to keeping the problem under control. The limitations of such tinkering are sharp, as Peruvian theologian Gustavo Gutiérrez warns:

latin american misery and injustice go too deep to be responsive to pal- liatives. hence we speak of social revolution, not reform; of liberation, not development; of socialism, not modernization of the prevailing sys-

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tem. “realists” call these statements romantic and utopian. and they should, for the reality of these statements is of a kind quite unfamiliar to them.3

liberation theology, in contrast to officialdom, argues that genuine change will be most often rooted in small communities of poor people; and it advances a simple methodology—observe, judge, act.4 Throughout latin america, such base-community movements have worked to take stock of their situations and devise strategies for change.5 The approach is straightforward. although it has been termed “simplistic” by technocrats and experts, this methodology has proved useful for promoting health in settings as diverse as Brazil, Guatemala, el salvador, rural Mexico, and urban Peru. insights from liberation theology have proved useful in rural haiti too, perhaps the sickest region of the hemisphere and the one i know best. with all due respect for health policy expertise, then, this chapter explores the implications—so far, almost completely over- looked—of liberation theology for medicine and health policy.6

Observe, judge, act. The “observe” part of the formula implies analysis. There has been no shortage of analysis from the self-appointed apostles of international health policy, who insist that their latest recipes become the cornerstones of health policy in all of latin america’s nations.7 within ministries of health, one quickly learns not to question these fads, since failure to acknowledge the primacy of the regnant health ideology can stop many projects from ever getting off the ground. But other, less con- ventional sources of analysis are relevant to our understanding of health and illness. it’s surprising that many Catholic bishops of latin america, for centuries allied with the elites of their countries, have in more recent decades chosen to favor tough-minded social analysis of their societies. Many would argue that liberation theology’s key documents were ham- mered out at the bishops’ conventions in Medellín in 1968 and in Puebla in 1978. in both instances, progressive bishops, working with like- minded theologians, denounced the political and economic forces that immiserate so many latin americans. regarding causality, the bishops did not mince words:

let us recall once again that the present moment in the history of our peoples is characterized in the social order, and from an objective point of

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view, by a situation of underdevelopment. Certain phenomena point an accusing finger at it: marginalized existence, alienation, and poverty. in the last analysis it is conditioned by structures of economic, political, and cultural dependence on the great industrialized metropolises, the latter enjoying a monopoly on technology and science (neocolonialism).8

what began timidly in the preparation for the Medellín meeting in 1968 was by 1978 a strong current. “The Puebla document,” remarks Boff, “moves immediately to the structural analysis of these forces and denounces the systems, structures, and mechanisms that ‘create a situ- ation where the rich get richer at the expense of the poor, who get even poorer.’”9 in both of these meetings, the bishops were at pains to argue that “this reality calls for personal conversion and profound structural changes that will meet the legitimate aspirations of the people for authen- tic social justice.”10

liberation theology has always been about the struggle for social and economic rights. The injunction to “observe” leads to descriptions of the conditions of the latin american poor, and also to claims regarding the origins of these conditions. These causal claims have obvious implica- tions for a rethinking of human rights, as Gutiérrez explains:

a structural analysis better suited to latin american reality has led certain Christians to speak of the “rights of the poor” and to interpret the defense of human rights under this new formality. The adjustment is not merely a matter of words. This alternative language represents a critical approach to the laissez-faire, liberal doctrine to the effect that our society enjoys an equality that in fact does not exist. This new formulation likewise seeks constantly to remind us of what is really at stake in the defense of human rights: the misery and spoliation of the poorest of the poor, the conflictive character of latin american life and society, and the biblical roots of the defense of the poor.11

liberation theologians are among the few who have dared to under- line, from the left, the deficiencies of the liberal human rights movement. The most glaring of these deficiencies emerges from intimate acquain- tance with the suffering of the poor in countries that are signatory to all modern human rights agreements. when children living in poverty die of

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measles, gastroenteritis, and malnutrition, and yet no party is judged guilty of a human rights violation, liberation theology finds fault with the entire notion of human rights as defined within liberal democracies. Thus, even before judgment is rendered, the “observe” part of the for- mula reveals atrocious conditions as atrocious.

The “judge” part of the equation is nonetheless important even if it is, in a sense, prejudged. we look at the lives of the poor and are sure, just as they are, that something is terribly wrong. They are targets of structural violence. (some of the bishops termed this “structural sin.”)12 This is, granted, an a priori judgment—but it is seldom incorrect, for analysis of social suffering invariably reveals its social origins. it is not primarily cata- clysms of nature that wreak havoc in the lives of the latin american poor:

all these aspects which make up the overall picture of the state of hu- manity in the late twentieth century have one common name: oppression. They all, including the hunger suffered by millions of human beings, re- sult from the oppression of some human beings by others. The impotence of international bodies in the face of generally recognized problems, their inability to effect solutions, stems from the self-interest of those who stand to benefit from their oppression of other human beings. in each major problem there is broad recognition of both the moral intolerable- ness and the political non-viability of the existing situation, coupled with a lack of capacity to respond. if the problem is (or the problems are) a conflict of interests, then the energy to find the solution can come only from the oppressed themselves.13

rendering judgment based on careful observation can be a powerful experience. The Brazilian sociologist Paulo Freire coined the term consci- entization, or “consciousness raising,” to explain the process of coming to understand how social structures cause injustice.14 This “involves discov- ering that evil not only is present in the hearts of powerful individuals who muck things up for the rest of us but is embedded in the very struc- tures of society, so that those structures, and not just individuals who work within them, must be changed if the world is to change.”15 libera- tion theology uses the primary tools of social analysis to reveal the mecha- nisms by which social structures cause social misery. such analysis, unlike many fraudulently dispassionate academic treatises, is meant to challenge

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the observer to judge. it requires a very different approach than that most often used by, say, global health bureaucrats. it requires an approach that implicates the observer, as Jon sobrino notes:

The reality posed by the poor, then, is no rhetorical question. Precisely as sin, this reality tends to conceal itself, to be relativized, to pass itself off as something secondary and provisional in the larger picture of human achievements. it is a reality that calls men and women not only to recog- nize and acknowledge it, but to take a primary, basic position regarding it. Outwardly, this reality demands that it be stated for what it is, and de- nounced. . . . But inwardly, this same reality is a question for human be- ings as themselves participants in the sin of humankind. . . . the poor of the world are not the causal products of human history. no, poverty re- sults from the actions of other human beings.16

how is all of this relevant to medicine? it is more realistic, surely, to ask how this could be considered irrelevant to medicine. 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 1 billion souls live in dire poverty, the plight of the poor is even worse. how do they cope? They don’t, often enough. The poor there have short life expectan- cies, often dying of preventable or treatable diseases or from accidents. Few have access to modern medical care. in fact, most of the Third world poor receive no effective biomedical care at all. For some people, there is no such thing as a measles vaccine. For many, tuberculosis is as lethal as aiDs. Childbirth involves mortal risk. in an age of explosive develop- ment 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 humanity.

Many physicians are uncomfortable acknowledging these harsh facts of life and death. To do so, one must admit that the majority of prema- ture deaths are, as the haitians would say, “stupid deaths.” They are com- pletely preventable with the tools already available to the fortunate few. By the criteria of liberation theology, these deaths are a great injustice and a stain on the conscience of modern medicine and science. why, then, are these premature deaths not the primary object of discussion and debate

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within our professional circles? again, liberation theology helps to answer this question. First, acknowledging the scandalous conditions of those living in poverty often requires a rejection of comforting relativism. so- brino is addressing fellow theologians, but what he writes is of relevance to physicians, too:

in order to recognize the truth of creation today, one must take another tack in this first, basic moment, a moment of honesty. The data, the sta- tistics, may seem cold. They may seem to have precious little to do with theology. But we must take account of them. This is where we have to start. “humanity” today is the victim of poverty and institutionalized violence. Often enough this means death, slow or sudden.17

a second reason that premature deaths are not the primary topic of our professional discussion is that the viewpoints of poor people will in- evitably be suppressed or neglected as long as elites control most means of communication. Thus the steps of observation and judgment are usually difficult, because vested interests, including those controlling “develop- ment” and even international health policy, have an obvious stake in shaping observations about causality and in attenuating harsh judgments of harsh conditions. (This is, of course, another reason that people living in poverty are cited in this book as experts on structural violence and human rights.)

Finally, the liberation theologians and the communities from which they draw their inspiration agree that it is necessary to act on these reflec- tions. The “act” part of the formula implies much more than reporting one’s findings. The goal of this judging is not producing more publica- tions or securing tenure in a university: “in order to understand the world, latin american Christians are taking seriously the insights of social scien- tists, sociologists, and economists, in order to learn how to change the world.”18 sobrino puts it this way: “There is no doubt that the only cor- rect 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.”19 i could confirm his assessment with my own experiences in haiti and elsewhere, including the streets of some of the cities of the hemisphere’s most affluent country. what is at stake, for many of the poor, is physical survival.

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The results of following this “simple” methodology can be quiet and yet effective, as in the small-scale project described in the next section. But careful reflection on the inhuman conditions endured by so many in this time of great affluence can of course also lead to more explosive ac- tions. retrospective analysis of these explosions often reveals them to be last-ditch efforts to escape untenable situations. That is, the explosions follow innumerable peaceful attempts to attenuate structural violence and the lies that help sustain it. The zapatistas, who refer often to early death from treatable illnesses, explain it this way in an early communiqué:

some ask why we decided to begin now, if we were prepared before. The answer is that before this we tried other peaceful and legal roads to change, but without success. During these last ten years more than 150,000 of our indigenous brothers and sisters have died from curable diseases. The fed- eral, state, and municipal governments’ economic and social plans do not even consider any real solution to our problems, and consist of giving us handouts at election times. But these crumbs of charity solve our prob- lems for no more than a moment, and then, death returns to our houses. That is why we think no, no more, enough of this dying useless deaths, it would be better to fight for change. if we die now, we will not die with shame, but with the dignity of our ancestors. another 150,000 of us are ready to die if that is what is needed to waken our people from their deceit-induced stupor.20

a P P ly i n G P r i n C i P l e s O F l i B e r aT i O n T h e O l O G y TO M e D i C i n e

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’s the innovation in that? how would a health intervention inspired by liberation theology be dif- ferent from one 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, the united states, and, especially, haiti—offering what we have termed “pragmatic solidarity.” Pragmatic solidarity is different

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from but nourished by solidarity per se, the desire to make common cause with those in need. solidarity is a precious thing: people enduring great hardship often remark that they are grateful for the prayers and good wishes of fellow human beings. But when sentiment is accompa- nied by the goods and services that might diminish unjust hardship, surely it is enriched. To those in great need, solidarity without the prag- matic component can seem like so much abstract piety.

lest all this talk of structural violence and explosive responses to it seem vague and far-removed from the everyday obligations of medicine, allow me to give examples from my own clinical experience. how does liberation theology inform medical practice in, say, rural haiti? Take tuberculosis, along with hiv the leading infectious cause of preventable adult deaths in the world. how might one observe, judge, and act in pragmatic solidarity with those most likely to acquire tuberculosis or already suffering from it?

The “observation” part of the formula is key, for it involves careful review of a large body of literature that seeks to explain the distribution of the disease within populations, to explore its clinical characteristics, and to evaluate tuberculosis treatment regimens. This sort of review is stan- dard in all responsible health planning, but liberation theology would push analysis in two directions: first, to seek the root causes of the prob- lem; second, to elicit the experiences and views of poor people and to in- corporate these views into all observations, judgments, and actions.

ironically enough, some who understand, quite correctly, that the underlying causes of tuberculosis are poverty and social inequality make a terrible error by failing to honor the experience and views of the poor in designing strategies to respond to the disease. what happens if, after analysis reveals poverty as the root cause of tuberculosis, tuberculosis con- trol strategies ignore the sick and focus solely on eradicating poverty? elsewhere, i have called this the “luddite trap,” since this ostensibly pro- gressive view would have us ignore both current distress and the tools of modern medicine that might relieve it, thereby committing a new and grave injustice.21 The destitute sick ardently desire the eradication of pov- erty, but their tuberculosis can be readily cured by drugs such as isoniazid and rifampin. The prescription for poverty is not so clear.

Careful review of the biomedical and epidemiological literature on tuberculosis does permit certain conclusions. One of the clearest is that

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the incidence of the disease is not at all random. Certainly, tuberculosis has claimed victims among the great (Frederic Chopin, Fyodor Dostoy- evsky, George Orwell, eleanor roosevelt), but historically it is a disease that has ravaged the economically disadvantaged.22 This is especially true in recent decades: with the development of effective therapy in the mid- twentieth century came high cure rates—over 95 percent—for those with access to the right drugs for the right amount of time. Thus tuberculosis deaths now—which each year number in the millions—occur almost ex- clusively among the poor, whether they reside in the inner cities of the united states or in the poor countries of the southern hemisphere.23

The latest twists to the story—the resurgence of tuberculosis in the united states, the advent of hiv-related tuberculosis, and the develop- ment of strains of tuberculosis resistant to the first-line therapies devel- oped in recent decades—serve to reinforce the thesis that Mycobacterium tuberculosis, the causative organism, makes its own preferential option for the poor.24

what “judgment” might be offered on these epidemiological and clinical facts? Many would find it scandalous that one of the world’s lead- ing causes of preventable adult deaths is a disease that, with the possible exception of emerging resistant strains, is more than 95 percent curable, with inexpensive therapies developed decades ago. Those inspired by lib- eration theology would certainly express distaste for a disease so partial to poor and debilitated hosts and would judge unacceptable the lack of ther- apy for those most likely to become ill with tuberculosis: poverty puts people at risk of tuberculosis and then bars them from access to effective treatment. an option-for-the-poor approach to tuberculosis would make the disease a top priority for research and development of new drugs and vaccines and at the same time would make programs to detect and cure all cases a global priority.

Contrast this reading to the received wisdom—and the current agenda—concerning tuberculosis. authorities rarely blame the recrudes- cence of tuberculosis on the inequalities that structure our society. in- stead, we hear mostly about biological factors (the advent of hiv, the mutations that lead to drug resistance) or about cultural and psycho- logical barriers that result in “noncompliance.” Through these two sets of explanatory mechanisms, one can expediently attribute high rates of treatment failure either to the organism or to uncooperative patients.

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There are costs to seeing the problem in this way. if we see the resur- gence or persistence of tuberculosis as an exclusively biological phe- nomenon, then we will shunt available resources to basic biological research, which, though needed, is not the primary solution, since almost all tuberculosis deaths result from lack of access to existing effective ther- apy. if we see the problem primarily as one of patient noncompliance, then we must necessarily ground our strategies in plans to change the patients rather than to change the weak tuberculosis control programs that fail to detect and cure the majority of cases. in either event, weak analysis produces the sort of dithering that characterizes current global tuberculosis policy, which must accept as its primary rebuke the shameful death toll that continues unabated.

how about the “act” part of the formula advocated by liberation the- ology? in a sense, it’s simple: heal the sick. Prompt diagnosis and cure of tuberculosis are also the means to prevent new infections, so prevention and treatment are intimately linked. Most studies of tuberculosis in haiti reveal that the vast majority of patients do not complete treatment— which explains why, until very recently, tuberculosis remained the leading cause of adult death in rural regions of haiti. (it has now been surpassed by hiv.) But it does not need to be so. in the country’s Central Plateau, Partners in health worked with our sister organization, zanmi lasante, to devise a tuberculosis treatment effort that borrows a number of ideas— and also some passion—from liberation theology.

although the zanmi lasante staff had, from the outset, identified and referred patients with pulmonary tuberculosis to its clinic, it gradu- ally became clear that detection of new cases did not always lead to cure, even though all tuberculosis care, including medication, was free of charge. in December 1988, following the deaths from tuberculosis of three hiv-negative patients, all adults in their forties, the staff met to re- consider the care these individuals had received. how had the staff failed to prevent these deaths? how could we better observe, judge, and act as a community making common cause with the destitute sick?

initially, we responded to these questions in differing ways. in fact, the early discussions were heated, with a fairly sharp divide between com- munity health workers, who shared the social conditions of the patients, and the doctors and nurses, who did not. some community health work- ers believed that tuberculosis patients with poor outcomes were the most

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economically impoverished and thus the sickest; others hypothesized that patients lost interest in chemotherapy after ridding themselves of the symptoms that had caused them to seek medical advice. Feeling better, they returned as quickly as possible to the herculean task of providing for their families. still others, including the physicians and nurses, attributed poor compliance to widespread beliefs that tuberculosis was a disorder inflicted through sorcery, beliefs that led patients to abandon biomedical therapy. a desire to focus blame on the patients’ ignorance or misunder- standing was palpable, even though the physicians and nurses sought to cure the disease as ardently as anyone else involved in the program.

The caregivers’ ideas about the causes of poor outcomes tended to coalesce in two directions: a cognitivist-personalistic pole that emphasized individual patient agency (curiously, “cultural” explanations fit best under this rubric, since beliefs about sorcery allegedly led patients to abandon therapy), and a structural pole that emphasized the patients’ poverty. and this poverty, though generic to outsiders like the physicians from Port-au-Prince, had a vivid history to those from the region. Most of our tuberculosis patients were landless peasants living in the most dire pov- erty. They had lost their land a generation before when the Péligre Dam, part of an internationally funded development project, flooded their fer- tile valley.25

More meetings followed. Over the next several months, we devised a plan to improve services to patients with tuberculosis—and to test these discrepant hypotheses. Briefly, the new program set goals of detecting cases, supplying adequate chemotherapy, and providing close follow-up. although they also continued contact screening and vaccination for in- fants, the staff of zanmi lasante was then most concerned with caring for smear-positive and coughing patients—whom many believed to be the most important source of community exposure. The new program was aggressive and community-based, relying heavily on community health workers for close follow-up. it also responded to patients’ appeals for nu- tritional assistance. The patients argued, often with some vehemence and always with eloquence, that to give medicines without food was tanta- mount to lave men, siye atè (washing one’s hands and then wiping them dry in the dirt).

Those diagnosed with tuberculosis who participated in the new treat- ment program were to receive daily visits from their village health worker

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during the first month following diagnosis. They would also receive fi- nancial aid of thirty dollars per month for the first three months; would be eligible for nutritional supplements; would receive regular reminders from their village health worker to attend the clinic; and would receive a five-dollar honorarium to defray “travel expenses” (for example, renting a donkey) for attending the clinic. if a patient did not attend, someone from the clinic—often a physician or an auxiliary nurse—would make a visit to the no-show’s house. a series of forms, including a detailed initial interview schedule and home visit reports, regularized these arrangements and replaced the relatively limited forms used for other clinic patients.

Between February 1989 and september 1990, 50 patients were en- rolled in the program. During the same period, the clinical staff diag- nosed pulmonary tuberculosis in 213 patients from outside our catchment area. The first 50 of these patients to be diagnosed formed the comparison group that would be used to judge the efficacy of the new intervention. They were a “control group” only in the sense that they did not benefit from the community-based services and financial aid; all tuberculosis pa- tients continued to receive free care.

The difference in the outcomes of the two groups was little short of startling. By June 1991, 46 of the patients receiving the “enhanced pack- age” were free of all symptoms, and none of those with symptoms met radiologic or clinical diagnostic criteria for persistent tuberculosis. There- fore, the medical staff concluded that none had active pulmonary tuber- culosis, giving the participants a cure rate of 100 percent. we could not locate all 50 of the patients from outside the catchment area, but for the 40 patients examined more than one year after diagnosis, the cure rate was barely half that of the first group, based on clinical, laboratory, and radiographic evaluation. it should be noted that this dismal cure rate was nonetheless higher than that reported in most studies of tuberculosis out- comes in haiti.26

Could this striking difference in outcome be attributed to patients’ ideas and beliefs about tuberculosis? Previous ethnographic research had revealed extremely complex and changing ways of understanding and speaking about tuberculosis among rural haitians.27 Because most physi- cians and nurses (and a few community health workers) had hypothesized that patients who “believed in sorcery” as a cause of tuberculosis would have higher rates of noncompliance with their medical regimens, we took

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some pains to address this issue with each patient. as the resident medical anthropologist, i conducted long—often very long—and open-ended in- terviews with all patients in both groups, trying to delineate the domi- nant explanatory models that shaped their views of the disease. i learned that few from either group would deny the possibility of sorcery as an etiologic factor in their own illness, but i could discern no relationship between avowal of such beliefs and compliance with a biomedical regimen. That is, the outcomes were related to the quality of the program rather than the quality of the patients’ ideas about the disease. suffice it to say, this was not the outcome envisioned by many of my colleagues in anthro- pology.

although anthropologists are expected to underline the importance of culture in determining the efficacy of efforts to combat disease, in haiti we learned that many of the most important variables—initial exposure to infection, reactivation of quiescent tuberculosis, transmission to house- hold members, access to diagnosis and therapy, length of convalescence, development of drug resistance, degree of lung destruction, and, most of all, mortality—are all strongly influenced by economic factors. we con- cluded that removing structural barriers to “compliance,” when coupled with financial aid, dramatically improved outcomes in poor haitians with tuberculosis. This conclusion proved that the community health workers, and not the doctors, had been correct.

This insight forever altered approaches to tuberculosis within our program. it cut straight to the heart of the compliance question. Cer- tainly, patients may be noncompliant, but how relevant is the notion of compliance in rural haiti? Doctors may instruct their patients to eat well. But the patients will “refuse” if they have no food. They may be told to sleep in an open room and away from others, and here again they will be “noncompliant” if they do not expand and remodel their miserable huts. They may be instructed to go to a hospital. But if hospital care must be paid for in cash, as is the case throughout haiti, and the patients have no cash, they will be deemed “grossly negligent.” in a study published in col- laboration with the zanmi lasante team, we concluded that “the hoary truth that poverty and tuberculosis 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.”28

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similar scenarios could be offered for diseases ranging from typhoid to aiDs. in each case, poor people are at higher risk of contracting the disease and are also less likely to have access to care. and in each case, analysis of the problem can lead researchers to focus on the patients’ shortcomings (for example, failure to drink pure water, failure to use con- doms, ignorance about public health and hygiene) or, instead, to focus on the conditions that structure people’s risk (for example, lack of access to potable water, lack of economic opportunities for women, unfair distri- bution of the world’s resources). in many current discussions of these plagues of the poor, one can discern a cognitivist-personalistic pole and a structural pole. although focus on the former is the current fashion, one of the chief benefits of the latter mode of analysis is that it encourages physicians (and others concerned to protect or promote health) to make common cause with people who are both poor and sick.

a s O C i a l J u s T i C e a P P rOa C h TO a D D r e s s i n G D i s e a s e a n D s u F F e r i n G

Tuberculosis aside, what follows next from a perspective on medicine that is based in liberation theology? Does recourse to these ideas demand loy- alty to any specific ideology? For me, applying an option for the poor has never implied advancing a particular strategy for a national economy. it does not imply preferring one form of development, or social system, over another—although some economic systems are patently more patho- genic than others and should be denounced as such by physicians. re- course to the central ideas of liberation theology does not necessarily imply subscription to a specific body of religious beliefs; Partners in health and its sister organizations in haiti and Peru are completely ecu- menical.29 at the same time, the flabby moral relativism of our times would have us believe that we may now choose from a broad menu of approaches to delivering effective health care services to the poor. This is simply not true. whether you are sitting in a clinic in rural haiti, and thus a witness to stupid deaths from infection, or sitting in an emergency room in a u.s. city, and thus the provider of first resort for 40 million uninsured, you must acknowledge that the commodification of medicine invariably punishes the vulnerable.

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a truly committed quest for high-quality care for the destitute sick starts from the perspective that health is a fundamental human right. in contrast, commodified medicine invariably begins with the notion that health is a desirable outcome to be attained through the purchase of the right goods and services. socialized medicine in industrialized countries is no doubt a step up from a situation in which market forces determine who has access to care. But a perspective based in liberation theology highlights the fundamental weakness of this and other strategies of the affluent: if the governments of scandinavian countries and that of France, for example, then spend a great deal of effort barring noncitizens from access to health care services, they will find few critics within their bor- ders. (indeed, the social democracies share a mania for border control.) But we will critique them, and bitterly, because access to the fruits of sci- ence and medicine should not be determined by passports, but rather by need. The “health care for all” movement in the united states will never be morally robust until it truly means “all.”

liberation theology’s first lesson for medicine is similar to that usu- ally confronting healers: There is something terribly wrong. Things are not the way they should be. But the problem, in this view, is with the world, even though it may be manifest in the patient. Truth—and libera- tion theology, in contrast to much postmodern attitudinizing, believes in historical accuracy—is to be found in the perspective of those who suffer unjust privation.30 Cornel west argues that “the condition of truth is to allow the suffering to speak. it doesn’t mean that those who suffer have a monopoly on truth, but it means that the condition of truth to emerge must be in tune with those who are undergoing social misery—socially induced forms of suffering.”31

The second lesson is that medicine has much to learn by reflecting on the lives and struggles of poor or otherwise oppressed people. how is suffering, including that caused by sickness, best explained? how is it to be addressed? These questions are, of course, as old as humankind. we’ve had millennia in which to address—societally, in an organized fashion— the suffering that surrounds us. in looking at approaches to such prob- lems, 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 are deeply flawed. Those who believe that

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charity is the answer to the world’s problems often have a tendency— sometimes striking, sometimes subtle, and surely lurking in all of us—to regard those needing charity as intrinsically inferior. This is different from regarding the poor as powerless or impoverished because of his- torical processes and events (slavery, say, or unjust economic policies propped up by powerful parties). There is an enormous difference be- tween seeing people as the victims of innate shortcomings and seeing them as the victims of structural violence. indeed, it is likely that the struggle for rights is undermined whenever the history of unequal chances, and of oppression, is erased or distorted.

The approach of 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 viewing the problem in this light. in Peda- gogy of the Oppressed, Paulo Freire writes: “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.”32 Given the twentieth century’s marked tendency toward increasing economic in- equity in the face of economic growth, the future holds plenty of false charity. all the recent chatter about “personal responsibility” from “com- passionate conservatives” erases history in a manner embarrassingly expe- dient for themselves. in a study of food aid in the united states, Janet Poppendieck links a rise in “kindness” to a decline in justice:

The resurgence of charity is at once a symptom and a cause of our society’s failure to face up to and deal with the erosion of equality. it is a symptom in that it stems, in part at least, from an abandonment of our hopes for the elimination of poverty; it signifies a retreat from the goals as well as the means that characterized the Great society. it is symptomatic of a pervasive despair about actually solving problems that has turned us to- ward ways of managing them: damage control, rather than prevention. More significantly, and more controversially, the proliferation of charity contributes to our society’s failure to grapple in meaningful ways with poverty.33

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it is possible, however, to overstate the case against charity—it is, after all, one of the four cardinal virtues, in many traditions. sometimes holier-than-thou progressives dismiss charity when it is precisely the vir- tue demanded. in medicine, charity underpins the often laudable goal of addressing the needs of “underserved populations.” To the extent that medicine responds to, rather than creates, underserved populations, charity will always have its place in medicine.

unfortunately, a preferential option for the poor is all too often ab- sent from charity medicine. First, charity medicine should avoid, at all costs, the temptation to ignore or hide the causes of excess suffering among the poor. Meredeth Turshen gives a jarring example from apart- heid south africa:

south african paediatricians may have developed an expertise in the understanding and treatment of malnutrition and its complications, but medical expertise does not change the system that gives rise to malnutri- tion nor the environment to which treated children return, an environ- ment in which half of the children die before their fifth birthday. Mal- nutrition, in this context, is a direct result of the government’s policies, which perpetuate the apartheid system and promote the poor health con- ditions and human rights violations.34

second, charity medicine too frequently consists of secondhand, castoff services—leftover medicine—doled out in piecemeal fashion. how can we tell the difference between the proper place of charity in medicine and the doling out of leftovers? Many of us have been involved in these sorts of good works and have often heard a motto such as this: “The homeless poor are every bit as deserving of good medical care as 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 the rest of us.35 whenever medicine seeks to reserve its finest services for the destitute sick, you can be sure that it is option-for- the-poor medicine.

what about development approaches?36 Often, this perspective seems to regard progress and development as almost natural processes. The technocrats who design development projects—including a certain Péli- gre Dam, which three decades ago displaced the population we seek to

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serve in central haiti—plead for patience. in due time, the technocrats tell the poor, if they speak to them at all, you too will share our standard of living. (after a generation, the reassurance may be changed to “if not you, your children.”) and certainly, looking around us, we see everywhere the tangible benefits of scientific development. so who but a luddite would object to development as touted by the technocrats?

according to liberation theology, progress for the poor is not likely to ensue from development approaches, which are based on a “liberal” view of poverty. liberal views place the problem with the poor them- selves: these people are backward and reject the technological fruits of modernity. with assistance from others, they too will, after a while, reach a higher level of development. Thus does the victim-blaming noted in the earlier discussion of tuberculosis recur in discussions of underde- velopment.

For many liberation theologians, developmentalism or reformism cannot be rehabilitated. Jorge Pixley and Clodovis Boff use these terms to describe what they consider an “erroneous” view of poverty, in contrast to the “dialectical” explanation, in which the growth of poverty is depen- dent on the growth of wealth. Poverty today, they note, “is mainly the result of a contradictory development, in which the rich become steadily richer, and the poor become steadily poorer.” such a poverty is “internal to the system and a natural product of it.”37 Developmentalism not only erases the historical creation of poverty but also implies that development is necessarily a linear process: progress will inevitably occur if the right steps are followed. yet any critical assessment of the impact of such ap- proaches must acknowledge their failure to help the poor, as leonardo and Clodovis Boff argue:

“reformism” seeks to improve the situation of the poor, but always within existing social relationships and the basic structuring of society, which rules out greater participation by all and diminution in the privileges en- joyed by the ruling classes. reformism can lead to great feats of develop- ment in the poorer nations, but this development is nearly always at the expense of the oppressed poor and very rarely in their favor. For example, in 1964 the Brazilian economy ranked 46th in the world; in 1984 it ranked 8th. The last twenty years have seen undeniable technological and industrial progress, but at the same time there has been a considerable

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worsening of social conditions for the poor, with exploitation, destitution, and hunger on a scale previously unknown in Brazilian history. This has been the price paid by the poor for this type of elitist, exploitative, and exclusivist development.38

in his introduction to A Theology of Liberation, Gustavo Gutiérrez concurs: we assert our humanity, he argues, 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 well express these profound aspirations.”39 Gutiérrez continues by noting that the term liberation expresses the hopes of the poor much more succinctly. Philip Berryman puts it even more sharply: “‘liberation’ entails a break with the present order in which latin american countries could establish sufficient autonomy to reshape their economies to serve the needs of that poor majority. The term ‘liberation’ is understood in contradistinction to ‘development.’”40

in examining medicine, one sees the impact of “developmental” thinking not only in the planned obsolescence of medical technology, essential to the process of commodification, but also in influential ana- lytic constructs such as the “health transition model.”41 in this view, so- cieties as they develop are making their way toward that great transition, when deaths will no longer be caused by infections such as tuberculosis 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, often enough, no health transition. in other words, wealthy citizens of “underdeveloped” nations (those countries that have not yet experienced their health transition) do not die young from infectious diseases; they die 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 Bang- ladesh; in both places, the leading causes of death in young adults are in- fections and violence.42

The powerful, including heads of state and influential policymakers, are of course impatient with such observations and respond, if they deign to respond, with sharp reminders that the overall trends are the results that count. But if we focus exclusively on aggregate data, why not declare public health in latin america a resounding success? after all, life expec-

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tancies have climbed; infant and maternal mortality have dropped. But if you work in the service of the poor, what’s happening to that particular class, whether in harlem or in haiti, always counts a great deal. in fact, it counts most. and from this vantage point—the one demanded by libera- tion theology—neither medicine nor development looks nearly so suc- cessful. in fact, the outcome gap between rich and poor has continued to grow.

in summary, then, the charity and development models, though per- haps useful at times, are found wanting in rigorous and soul-searching examination. That leaves the social justice model. in my experience, people who work for social justice, regardless of their own station 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. as robert Mcafee Brown, paraphrasing the uruguayan Jesuit Juan segundo, observes, “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.”43 Often, if these individuals are privileged people like me, they understand that they have been implicated, whether directly or indirectly, in the cre- ation or maintenance of this structural violence. They then feel indigna- tion, but also humility and penitence. where i work, this is easy: i see the Péligre Dam almost every week.

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 does have very concrete implications. Making an option for the poor inevitably im- plies working for social justice, working with poor people as they struggle to change their situations. in a world riven by inequity, medicine could be viewed as social justice work. in fact, doctors are far more fortunate than most modern professionals: we still have a sliver of hope for mean- ingful, dignified service to the oppressed. Few other disciplines can make this claim with any honesty. we have a lot to offer right now. in haiti and Peru and Chiapas, we have found that it is often less a question of “de- velopment” and more one of redistribution of goods and services, of simply sharing the fruits of science and technology. The majority of our

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efforts in the transfer of technology—medications, laboratory supplies, computers, and training—are conceived in just this way. They end up being innovative for other reasons: it is almost unheard of to insist that the destitute sick receive high quality care as a right.

Treating poor Peruvians who suffer from multidrug-resistant tuber- culosis according to the highest standard of care, rather than according to whatever happens to be deemed “cost-effective,” is not only social justice work but also, ironically enough, innovative. introducing antiretroviral medications, and the health systems necessary to use them wisely, to aiDs-afflicted rural haiti is, again, viewed as pie-in-the-sky by inter- national health specialists but as only fitting by liberation theology. For example, operating rooms (and cesarean sections) must be part of any “minimum package” of health services wherever the majority of maternal deaths are caused by cephalopelvic disproportion. This is obvious from the perspective of social justice but controversial in international health circles. and the list goes on.

a preferential option for the poor also implies a mode of analyzing health systems. in examining tuberculosis in haiti, for example, our analysis must be historically deep—not merely deep enough to recall an event such as that which deprived most of my patients of their land, but deep enough to remember that modern-day haitians are the descendants of a people enslaved in order to provide our ancestors with cheap sugar, coffee, and cotton.

Our analysis must be geographically broad. in this increasingly inter- connected world (“the world that is satisfying to us is the same world that is utterly devastating to them”), we must understand that what happens to poor people is never divorced from the actions of the powerful. Cer- tainly, people who define themselves as poor may control their own desti- nies to some extent. But control of lives is related to control of land, systems of production, and the formal political and legal structures in which lives are enmeshed. with time, both wealth and control have be- come increasingly concentrated in the hands of a few. The opposite trend is desired by those working for social justice.

For those who work in latin america, the role of the united states looms large. Father James Guadalupe Carney, a Jesuit priest, put his life on the line in order to serve the poor of honduras. as far as we can tell, he was killed by u.s.-trained honduran security forces in 1983.44 in an

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introduction to his posthumously published autobiography, his sister and brother-in-law asked 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?”45

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 be able to con- tend with the structures that create and maintain poverty, structures that make people sick. although physicians and nurses, even those who serve the poor, have not followed liberation theology, its insights have never been more relevant to our vocation. as international health experts come under the sway of the bankers and their curiously bounded utilitarianism, we can expect more and more of our services to be declared “cost- ineffective” and more of our patients to be erased. in declaring health and health care to be a human right, we join forces with those who have long labored to protect the rights and dignity of the poor.

n OT e s

1. leonardo Boff, Faith on the Edge: Religion and Marginalized Existence, 1st ed. (san Francisco: harper and row, 1989), 23. 2. The literature on the correlation between poverty, inequality, and in- creased morbidity and mortality is massive. For reviews, see, for example, P. e. Farmer, Infections and Inequalities: The Modern Plagues (Berkeley: university of California Press, 1999); J. y. kim, J. v. Millen, a. irwin, and J. Gershman, eds., Dying for Growth: Global Inequality and the Health of the Poor (Monroe, Maine: Common Courage Press, 2000); and r. G. wilkinson, Unhealthy Societies: The Afflictions of Inequality (london: routledge, 1996). Other major reviews include a. leclerc, D. Fassin, h. Grandjean, et al., eds., Les inégalités sociales de santé (Paris: éditions la Découverte et syros, 2000); world health Organization, World Health Report 1999—Making a Difference (Geneva: world health Organi- zation, 1999); World Health Report 2000. Health Systems: Improving Performance (Geneva: world health Organization, 2000); world Bank, The Burden of Dis- ease among the Global Poor: Current Situation, Future Trends, and Implications for Strategy (washington, D.C.: world Bank, 2000); M. Bartley, D. Blane, and

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G. D. smith, “introduction: Beyond the Black report,” Sociology of Health and Illness 20:5 (1998): 563–77; a. sen, “Mortality as an indicator of economic suc- cess and Failure” (text of the innocenti lecture of uniCeF, delivered in Flor- ence, March 1995), Economic Journal 108:446 (1998): 1–25; D. Coburn, “in- come inequality, social Cohesion, and the health status of Populations: The role of neo-liberalism,” Social Science and Medicine 51:1 (2000): 135–46; and k. Fiscella, P. Franks, M. r. Gold, et al., “inequality in Quality: addressing socioeconomic, racial, and ethnic Disparities in health Care,” Journal of the American Medical Association 283:19 (2000): 2579–84. Other articles review case studies of inequality in access to treatment of specific diseases; see, for ex- ample, s. s. rathore, a. k. Berger, k. P. weinfurt, et al., “race, sex, Poverty, and the Medical Treatment of acute Myocardial infarction in the elderly,” Circula- tion: Journal of the American Heart Association 102:6 (2000): 642–48; and of course the sizable body of literature on inequality of access to hiv therapy. 3. Gustavo Gutiérrez, The Power of the Poor in History (Maryknoll, n.y.: Orbis Books, 1983), 44. 4. For a concise history of liberation theology, its historical relevance, and an explanation of key themes and motivations, see leonardo and Clodovis Boff ’s slim and helpful volume Introducing Liberation Theology (Maryknoll, n.y.: Orbis, 1987). 5. Base-community movements, also known as “basic ecclesial communi- ties,” are disparate and sociologically complex, and i do not aspire to review their idealized or actual impact. But, as this movement has been felt throughout latin america, i would encourage further reading. For an insider account, see the vol- ume by Father Álvaro Barreiro, Basic Ecclesial Communities: The Evangelization of the Poor (Maryknoll, n.y.: Orbis Books, 1982). a study by John Burdick, Look- ing for God in Brazil: The Progressive Catholic Church in Urban Brazil’s Religious Arena (Berkeley: university of California Press, 1993), contains a complemen- tary, scholarly examination of such communities in urban Brazil. 6. There are other clues that liberation theology might have something to offer the healing professions: for one, the more destructive forces hate it. in 1982, for example, advisers to u.s. president ronald reagan argued that “ameri- can foreign policy must begin to counterattack (and not just react against) libera- tion theology” (quoted from the santa Fe document, a reagan administration working paper; cited in Boff and Boff, Introducing Liberation Theology, 86). 7. recent health care “reforms” in latin america and other developing re- gions have followed a neoliberal framework that favors commercialization, corpo- ratization, and privatization of health and social welfare services. Most notable is the enthusiastic exportation of the u.s. model of “managed care.” as neill notes in his critique of these developments, “Managed health care is touted by many experts—usually found in usaiD, the world Bank, and various havens of aca- demia—as a tangible model which can be of immense value to developing coun-

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tries if applied wisely and efficiently.” see k. G. neill, “Dancing with the Devil: health, human rights, and the export of u.s. Models of Managed Care to Developing Countries,” Cultural Survival Quarterly 24:4 (2001): 61–63. This position, of course, ignores the growing body of evidence challenging the un- abashed claims that managed-care organizations (MCOs) provide quality care with efficiency and cost-effectiveness—evidence that also points to managed care’s role in exacerbating the already large inequities that characterize health care in the united states; see G. anders, Health against Wealth: HMOs and the Breakdown of Medical Trust (Boston: houghton Mifflin, 1996); D. P. andrulis and B. Carrier, Managed Care in the Inner City: The Uncertain Promise for Providers, Plans, and Communities (san Francisco: Jossey-Bass, 1999); P. e. Farmer and B. rylko- Bauer, “l’ ‘exceptionnel’ système de santé américain: Critique d’une médecine à vocation commerciale” [The “exceptional” american health care system: Critique of the for-profit approach], Actes de la Recherche en Sciences Sociales 139 (2001): 13–30; e. Ginzberg, “The uncertain Future of Managed Care,” New England Journal of Medicine 340:2 (1999): 144–46; D. himmelstein, s. woolhandler, and i. hellander, Bleeding the Patient: The Consequences of Corporate Health Care (Monroe, Maine: Common Courage Press, 2001); M. e. lewin and s. altman, eds., America’s Health Care Safety Net: Intact But Endangered (washington, D.C.: national academy Press, 2000); J. Maskovsky, “‘Managing’ the Poor: neoliberal- ism, Medicaid hMOs, and the Triumph of Consumerism among the Poor,” Medical Anthropology 19 (2000): 121–46; e. Pellegrino, “The Commodification of Medical and health Care: The Moral Consequences of a Paradigm shift from a Professional to a Market ethic,” Journal of Medicine and Philosophy 24:3 (1999): 243–66; M. a. Peterson, “Managed Care Backlash,” Journal of Health Politics, Policy, and Law 24:5 (theme issue) (1999): 873–1218; e. C. schneider, a. M. zaslavsky, and a. M. epstein, “racial Disparities in the Quality of Care for en- rollees in Medicare Managed Care,” Journal of the American Medical Association 287:10 (2002): 1288–94. in fact, h. waitzkin and C. iriart, in “how the united states exports Managed Care to Developing Countries,” International Journal of Health Services 31:3 (2001): 495–505, note that, as the u.s. market has become saturated and MCOs face growing criticism, these corporations

have turned their eyes toward developing countries, especially those in latin america. in the tradition of tobacco and pesticides, u.s. corporations are exporting to developing countries—in the form of managed care—products and practices that have come under heavy criticism domestically. The expor- tation of managed care is also receiving enthusiastic support from the world Bank, other multilateral lending agencies, and multinational corpora- tions. . . . developing countries are experiencing strong pressure to accept managed care as the organizational framework for privatization of their health and social security systems. . . . this experience is serving as a model for the exportation of managed care to africa and asia. (497)

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There is, of course, much money to be made by tapping into the health care and social security funds of the public sector even in poorer developing nations, under the guise of rescuing these countries from inefficient bureaucracies and rising costs by importing neoliberal managed-care solutions. large segments of the population in latin america live in poverty and often have minimal or no access to formal health care. The consequences of such health care transforma- tions for the poor and the oppressed in developing countries, as well as for the public health systems they might rely on, are dire, to say the least. “as public health systems are dismantled and privatized under the auspices of managed care, multinational corporations predictably will enter the field, reap vast profits, and exit within several years. Then developing countries will face the awesome pros- pect of reconstructing their public systems” (waitzkin and iriart, 498). For more on health care reforms in latin america, see F. armada, C. Muntaner, and v. na- varro, “health and social security reforms in latin america: The Convergence of the world health Organization, the world Bank, and Transnational Corpora- tions,” International Journal of Health Services 31:4 (2001): 729–68; M. Barraza- lloréns, s. Bertozzi, e. González-Pier, et al., “addressing inequality in health and health Care in Mexico,” Health Affairs 21:3 (2002): 47–56; C. iriart, e. e. Merhy, and h. waitzkin, “Managed Care in latin america: The new Common sense in health Policy reform,” Social Science and Medicine 52 (2001): 1243– 53; a. C. laurell, “health reform in Mexico: The Promotion of inequality,” International Journal of Health Services 31:2 (2001): 291–321; e. J. Pérez-stable, “Managed Care arrives in latin america,” New England Journal of Medicine 340:14 (1999): 1110 –12; and k. stocker, h. waitzkin, and C. iriart, “The ex- portation of Managed Care to latin america,” New England Journal of Medicine 340:14 (1999): 1131–36. 8. J. l. segundo, Our Idea of God (Dublin: Gill and Macmillan, 1980), 16; quoted from segunda Conferencia General del episcopado latinoamericano, Medellín 1968. 9. l. Boff, Faith on the Edge: Religion and Marginalized Existence, 20. 10. J. eagleson and P. sharper, eds., Puebla and Beyond: Documentation and Commentary (Maryknoll, n.y.: Orbis Books, 1979), 128. 11. Gutiérrez, The Power of the Poor in History, 87. 12. J. sobrino explains, in Spirituality of Liberation: Toward Political Holi- ness (Maryknoll, n.y.: Orbis Books, 1988), 15, the link between structural vi- olence and structural sin: “God’s creation is being assaulted and vitiated. . . . because this reality is not simply natural, but historical—being the result of action taken by some human beings against others—this reality is sinful. as absolute negation of God’s will, this sinfulness is very serious and fundamental.” 13. J. v. Pixley and C. Boff, The Bible, the Church, and the Poor (Mary- knoll, n.y.: Orbis Books, 1989), 242.

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14. in the english translation of Pedagogy of the Oppressed, the original Por- tuguese term is retained. in P. Freire’s own words, “Conscientização is the deepen- ing of the attitude of awareness characteristic of all emergence”—in other words, critical consciousness (new york: Continuum, 1986), 101. 15. r. M. Brown, Liberation Theology: An Introductory Guide (louisville: westminster John knox Press, 1993), 45. 16. sobrino, Spirituality of Liberation, 31. 17. ibid., 13, 15. 18. Brown, Liberation Theology, 45. 19. sobrino, Spirituality of Liberation, 32. 20. “Communiqué from the CCri-CG of the ezln, January 6, 1994,” in s. Marcos and the zapatista army of national liberation, Shadows of Tender Fury: The Letters and Communiqués of Subcomandante Marcos and the Zapatista Army of National Liberation (new york: Monthly review Press, 1995), 58. 21. see Farmer, Infections and Inequalities: The Modern Plagues, chap. 1; and P. e. Farmer and e. nardell, “nihilism and Pragmatism in Tuberculosis Control,” American Journal of Public Health 88:7 (1998): 4–5. 22. even at the dawn of the era of antibiotics, when streptomycin was al- ready available, class divisions were sharp inside europe’s sanatoriums. George Orwell’s journal entries from the year before his death of tuberculosis are telling:

Curious effect, here in the sanatorium, on easter sunday, when the people in this (the most expensive) block of “chalets” mostly have visitors, of hearing large numbers of upper-class english voices. i have been almost out to the sound of them for two years, hearing them at most one or two at a time, my ears growing more & more used to working-class or lower- middle-class scottish voices. in the hospital at hairmyres, for instance, i literally never heard a “cultivated” accent except when i had a visitor. it is as though i were hearing these voices for the first time. and what voices! a sort of over-fedness, a fatuous self-confidence, a constant bah-bahing of laughter abt [sic] nothing, above all a sort of heaviness & richness com- bined with a fundamental ill-will—people who, one instinctively feels, without even being able to see them, are the enemies of anything intelli- gent or sensitive or beautiful. no wonder everyone hates us so. (G. Or- well, The Collected Essays, Journalism, and Letters of George Orwell, vol. 4, In Front of Your Nose, 1945–1950 [new york: Penguin Books, 1968], 578; journal entry from april 17, 1949)

For more on the history of tuberculosis in north america, see Georgina Feld- berg’s helpful review, Disease and Class: Tuberculosis and the Shaping of Modern North American Society (new Brunswick, n.J.: rutgers university Press, 1995);

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see also the classic study by r. Dubos and J. Dubos, The White Plague: Tubercu- losis, Man, and Society (Boston: little, Brown, 1952). unfortunately, little has been written of the history of tuberculosis in the regions of the world where it has taken its greatest toll. 23. For an overview of the burden of disease and death caused by M. tuber- culosis, see P. e. Farmer, D. a. walton, and M. C. Becerra, “international Tuber- culosis Control in the 21st Century,” in Tuberculosis: Current Concepts and Treat- ment, 2nd ed., ed. l. n. Friedman (Boca raton, Fla.: CrC Press, 2000), 475–96. 24. These “twists” are reviewed in Farmer, Infections and Inequalities: The Modern Plagues, chap. 9. 25. This story is told more fully in P. e. Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: university of California Press, 1992), 19–27. 26. For a more detailed discussion of this study, see Farmer, Infections and Inequalities, 217–25. 27. P. e. Farmer, “sending sickness: sorcery, Politics, and Changing Con- cepts of aiDs in rural haiti,” Medical Anthropology Quarterly 4:1 (1990): 6–27. 28. P. e. Farmer, s. robin, s. l. ramilus, et al., “Tuberculosis, Poverty, and ‘Compliance’: lessons from rural haiti,” Seminars in Respiratory Infections 6:4 (1991): 260. For more on this project, see Farmer, Infections and Inequalities, chap. 8. 29. indeed, one does not need to subscribe directly to the religious tenets of liberation theology in order to make a “preferential option for the poor.” Pixley and Boff summarize the widespread starvation, malnutrition, and poverty that are a daily reality for millions (remarking that one does not need “socio-scientific instruments” to prove this) and conclude that “this state of affairs is morally intol- erable, for those who do not believe in the God of the Bible as much as for those who do” (Pixley and Boff, The Bible, the Church, and the Poor, 238, 239). They note the simple facts of the situation and what our response—whether one im- bued with faith, or one relying solely on reason—must logically be:

The energy to find the solution can come only from the oppressed them- selves. wherever there is oppression, there will be struggles to win life- sustaining conditions—struggles between classes, between races, between nations, between sexes. This is simply an observable fact, not a moral im- perative or a scientific conclusion. we can see the just struggles of the op- pressed going on around us, and we cannot see any other way out of the vast problems that afflict humanity at the close of the twentieth century. (242)

For a more in-depth discussion of these matters, refer to the full argument made by Pixley and Boff (The Bible, the Church, and the Poor, 237–43). 30. Perhaps it goes without saying that no physician who bases his or her practice on clinical trials can in good faith buy into the postmodern argument that all claims to truth are merely “competing discourses.” But, as Christopher

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norris writes, in both the social sciences and the humanities, the conviction that we ought to find out what really happened is proof

that we hadn’t caught up with the “postmodern” rules of the game, the fact that nowadays things have moved on to the point where there is no last ground of appeal to those old, self-deluding “enlightenment” values that once possessed authority (or the semblance thereof ), at least in some quar- ters. anyone who continues to invoke such standards is plainly in the grip of a nostalgic desire for some ultimate truth-telling discourse—whether Pla- tonist, kantian, Marxist or whatever—that would offer a delusory refuge from the knowledge that we are nowadays utterly without resources in the matter of distinguishing truth from falsehood. (C. norris, Uncritical Theory: Postmodernism, Intellectuals, and the Gulf War [amherst: university of Mas- sachusetts Press, 1992], 13)

norris’s devastating account of intellectuals and the Gulf war (1992) is one of the best critiques of the postmodern foolishness that has gained quite a foothold in universities on both sides of the atlantic. see also C. norris, What’s Wrong with Postmodernism: Critical Theory and the Ends of Philosophy (Baltimore: Johns hopkins university Press, 1990). 31. C. west, Prophetic Thought in Postmodern Times (Monroe, Maine: Common Courage Press, 1993), 4. 32. Freire, Pedagogy of the Oppressed, 29. 33. J. Poppendieck, Sweet Charity? Emergency Food and the End of Entitle- ment (new york: viking Press, 1998), 5. 34. M. Turshen, “health and human rights in a south african Bantu- stan,” Social Science and Medicine 22:9 (1986): 891. 35. samuel Johnson once observed that “a decent provision for the poor is the true test of civilization.” surely this is true, and it serves as an indictment of affluent society. But liberation theology delivers an even more damning indict- ment, since its proponents argue that we should reserve our highest standards for the poor. 36. My critique of development is by no means original; it draws heavily on a very large literature reaching back almost thirty years. From andré Gunder Frank to immanuel wallerstein, the more refined versions of dependency theory cannot be lightly dismissed. For more recent reviews of the limitations of de- velopment approaches to health care, see Meredeth Turshen’s wonderful book Privatizing Health Services in Africa (new Brunswick, n.J.: rutgers university Press, 1999). 37. Pixley and C. Boff, The Bible, the Church, and the Poor, 6–7. 38. Boff and Boff, Introducing Liberation Theology, 5. 39. G. Gutiérrez, A Theology of Liberation: History, Politics, and Salvation (Maryknoll, n.y.: Orbis Books, 1973), xiv.

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40. P. Berryman, Liberation Theology: Essential Facts about the Revolutionary Movement in Latin America and Beyond (new york: Pantheon Books, 1987), 91. 41. For an introduction to the notion of health transition, see J. C. Cald- well, s. Findley, P. Caldwell, et al., eds., What We Know about Health Transition: The Cultural, Social, and Behavioural Determinants of Health. The Proceedings of an International Workshop, Canberra, May 1989 (Canberra: health Tran sition Centre, australian national university, 1990); Gutiérrez, zielinski, and kendall have more recently qualified this concept by placing it in broader social context. see e. D. Gutiérrez, C. zielinski, and C. kendall, “The Globalization of health and Disease: The health Transition and Global Change,” in The Handbook of Social Studies in Health and Medicine, ed. G. albrecht, r. Fitzpatrick, and s. scrimshaw (london: sage, 2000), 84–99. see also the discussion by w. h. Mosley, J. l. Bobadilla, and D. T. Jamison on the implications of this model for developing countries in “The health Transition: implications for health Policy in Developing Countries,” in Disease Control Priorities in Developing Countries, ed. D. T. Jamison, w. h. Mosley, a. r. Measham, and J. l. Bobadilla (new york: Oxford Medical Publications, 1993), 673–99. 42. C. McCord and h. Freeman, “excess Mortality in harlem,” New En- gland Journal of Medicine 322:3 (1990): 173–77. 43. Brown, Liberation Theology: An Introductory Guide, 44. 44. Carney is said to have been killed after being captured when he partici- pated in an ill-fated guerrilla incursion from nicaragua into Olancho Province, honduras. 45. J. G. Carney, To Be a Revolutionary (san Francisco: harper and row, 1987), xi. Carney goes on to criticize the united states directly, citing the u.s.- backed 1973 military coup d’état in Chile, in which tens of thousands were killed, as his own moment of realization about the extent of the often brutal u.s. involvement in the political and economic affairs of the region: “after the bloody military coup of 1973 in Chile, it was obvious that the United States would never allow a country that is economically dependent on it to make a revolution by means of elections—through the democratic process directed by the majority—at least as long as the country has an army that obeys the capitalist bourgeoisie of the coun- try” (311). For an examination of u.s. policy toward progressive movements in Guatemala, el salvador, and haiti in a similar light, see P. e. Farmer, The Uses of Haiti (Monroe, Maine: Common Courage Press, 1994).

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