Jun
19

Introducing Liberation Theology

Over the last decades, one of the sources of inspiration for new thinking in development practice has been liberation theology. Dr. Paul Farmer has utilized the ideas (in a less overtly religious form) and conveyed them to a broader audience, as the preferential option for the poor. What is liberation theology? Leonardo Boff and Clodovis Boff (1986, first in English 1987) authored "Introducing Liberation Theology" to provide insight. The book itself focuses quite a lot on the Biblical foundation, justification and purpose, while in this point I draw upon some of the practice-oriented lessons:

"The poor can break out of their situation of oppression only by working out a strategy better able to change social conditions: the strategy of liberation. In liberation, the oppressed come together, come to understand their situation through the process of conscientization, discover the causes of their oppression, organize themselves into movements, and act in a coordinated fashion. First, they claim everything that the existing system can give: better wages, working conditions, health care, education, housing, and so forth; then they work toward the transformation of present society in the direction of a new society characterized by widespread participation, a better and more just balance among social classes and more worthy ways of life." (p. 5)

"The first step for liberation theology is pre-theological. It is a matter of trying to live the commitment of faith: in our case, to participate in some way on the process of liberation, to be committed to the oppressed. Without this specific precondition, liberation theology would be simply a matter of words. So it is not enough here only to reflect on what is being practiced. Rather we need to establish a living link with living practice. If we fail to do this, then "poverty," "oppression," revolution," "new society" are simply words that can be found in a dictionary." (p. 22)

"liberation theology longs and fights for a new society in this world: an alternative society to capitalism, but really an alternative and therefore going beyond socialism as it exists today, embodying the hopes and needs of the least of all peoples and their intrinsic potential, a project with amble resonance in the tradition of faith." (p. 92)

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Nov
14

Pathologies of Power

Paul Farmer's (2005) "Pathologies of Power: Health, Human Rights, and the New War on the Poor" is a "physician-anthropologist's effort to reveal the ways in which the most basic right – the right to survive – is trampled in an age of great affluence" (p. 6). However, Farmer covers much more than the right to survive, this book "is about the struggle for social and economic rights, the neglected stepchildren of the human rights movement. Because social and economic rights include the right to health care, housing, clean water, and education, they are sometimes called the "the rights of the poor."' (p. xxiv). It is highly recommended for academics and practitioners, and I also highly recommend Farmer's book Infections and Inequalities.

For those new to development studies, academics who assume development practitioners are non-reflexive positivists, and for practitioners looking to be more critical of the processes within international development, Farmer's books are essential reads. In the opening pages he sets the tone: "It was not the silence that rankled. It seemed to us that the exercise was demeaning – the participants, having survived genocide and displacement, were now being treated like children. They were being asked to respond to an agenda imported from capital cities, from do-gooder organizations like ours, from U.S. universities with the "right" answers to their every question. No harm done, perhaps, and the topic was important – but how helpful was this exercise, with its aim of changing the mentality of the locals, who were, after all, the victims of the previous decades of violence? A change in mentality was needed, certainly, but it was needed in the hearts and minds of those with power – and they were not here" (p. 3-4).

It is not just the 'others' with power; as a physician, Farmer writes that many "physicians are uncomfortable acknowledging these harsh facts of life and death. To do so, one must admit that the majority of premature deaths are, as the Haitians would say, "stupid deaths." They are completely preventable with the tools already available to the fortunate few" (p. 144). Yet, it is not simply more "development" that is required: "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 approaches must acknowledge their failure to help the poor" (p. 155)

Weaved throughout the book, Farmer expresses his concern with a changing set of norms and values: from rights, respect and dignity to costs and value for money. He writes: "many of the concepts currently in vogue in public health – from "cost-effectiveness" to "sustainability" and "replicability" - are likely to be perverted unless social justice remains central to public health and medicine. A human rights approach to health economics and health policy helps to bring into relief the ill effects of the efficacy-equity trade-off" (p. 18). This view is not just challenged as an opinion, but as an affront to the practice of health care: "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 this witness to stupid deaths from infection, or sitting in an emergency room in a U.S. city, and this the provider of first resort for forty million uninsured, you must acknowledge that the commodification of medicine invariably punishes the vulnerable" (p. 152). This book was published in 2005, and parts published earlier, and Farmer foresaw a challenge that has grown (while also shifting names from cost-effectiveness to value for money, to assessments of quality-adjusted life years, and as metrics in results and impact reporting): "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" (p. 159).

For those who work with marginalized and vulnerable people, who voices are excluded, it is challenging to convey experiences to others. In Farmer's earlier book Infections and Inequalities he used vignettes of people's lives as an attempt. In this end, however, "the experience of suffering, it's often noted, is not effectively conveyed by statistics or graphs. In fact, the suffering of the world's poor intrudes only rarely into the consciousness of the affluent, even when our affluence may be shown to have direct relation to their suffering. This is true even when spectacular human rights violations are at issue, and it is even more true when the topic at hand is the everyday violation of social and economic rights" (p. 31). It is both a depressing conclusion – the reality of a lack of concern – and a call to action. The systems that create and entrench poverty, as well as those that ignore suffering when plan to see, will continue lest things change, and change necessitates informed, critical engagement.

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Jun
28

Infections and Inequalities

An essential read, whether you are in development studies, anthropology or medicine, is Paul Farmer's Infections and Inequalities (1999). "This book examines inequalities in the distribution and outcome of infectious diseases. It asks why people like Annette Jean and her siblings are likely to die of infections such as tuberculosis and AIDS and malaria, while others are spared this risk. It explores the creation and maintenance of such disparities, which are biological in their expression but are largely socially determined" (p. 4). Parts of the book reflect the moment(s) in which it was written, much of it offers insight that will apply well beyond the specifics of drug resistant TB and HIV treatment in the 1990s. In re-reading this book I am struck by the passion that comes through the pages, a powerful voice driven by a strong sense of social justice. He writes: "Our challenge, therefore, is not merely to draw attention to the widening income gap, but also to attack it, to dissect it, and to work with all our capacity to reduce this gap" (p. xxvi) and that only "by struggling for higher standards for the destitute sick will we avoid another unappealing role – that of academic Cassandras who prophesy the coming plagues, but do little to avert them" (p. xxviii).

Opposition to offering high-cost treatment in developing countries, Farmer argues, "may be justified as 'sensible' or 'pragmatic,' but as a policy it is tantamount to the differential valuation of human life, for those who advocate such a policy, regardless of their nationality, would never accept such a death sentence themselves" - it is only because the "victims tends to be poor, and thus less valuable, that such policies appear reasonable" (p. 278). He writes, "it slowly became clear to me that I'd been taken in by some of the pieties of development work. Talk of "appropriate technology" and "sustainability" had sounded good to me, at least initially. The problem was that these sounded silly, even sinister, to the landless peasants with whom I worked" (p. 21).

"Market utilitarianism" Farmer writes, "is a strange beast, since it seems to permit all sorts of inefficiencies as long as they benefit the right people – namely the privileged… confident claims about what is cost effective and what is not should be viewed with some suspicion" (p. xxiv). Another of the justifications is not imposing "standards of care" upon others, the "irony of which will not be lost on those whose experiences are described in this book. Americans may impose – through the World Bank or the International Monetary Fund, say, or through foreign policy writ large – social and economic policies that drive up inequalities, leaving the destitute sick out of the frame of analysis. But heaven forfend that we should require that the Third World poor be subjected to "culturally inappropriate" medical standards" (p. 35). Throughout the book Farmer deconstructs this discourse as illogical and "morally unsound" (p. 278).

Farmer wages a critique against the emphasis upon individual agency, one which remains valid in 2016: "In each of the sociomedical studies I have critiqued, a well-intentioned effort to incorporate the patients points' of view has served, paradoxically, to shift the blame onto the sick-poor by exaggerating their agency" (p. 254). In doing so, programs offer 'culturally sensitive education' and through "this cognitivist legerdemain, we have expediently moved the locus of the problem – and this the focus of the interventions – away from certain features of an inegalitarian society toward the women deemed "at risk"" (p. 86).

On the gendered experience:

  • "Among the myriad mystifications that obscure the nature of women's risk, three are recurrent and important. One is the focus on local factors and local actors to the exclusion of broader analyses that would implicate powerful forces and powerful actors outside the field of view. A second is the conflation of structural violence and cultural difference. A third, centrally related to the others, is the absence of series consideration of social class" (p. 84-85).

On anthropology and anthropologists, he writes:

  • "For many physicians and public health specialists, anthropologists are expected to "do the culture piece." We're expected to elicit the local beliefs and customs that hamstring sensible efforts to treat or prevent illness; we've supposed to reveal what it is that makes the natives tick… And very often, we have been willing to fill this restricted role, even if it means not talking about the forces and structures that ultimately determine tuberculosis outcomes" (p. 254)
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