Lessons for Practice-- Re: Haiti After the Earthquake

            The further I get in my education, the more I realize that learning is a never-ending process. A salient lesson I have encountered in my last semester of college has taken place in a final reflective sweep of my education at the University of Montana. I have recognized that any subject of any discipline can be viewed as the interaction of interdependent and cyclical forces. It is with this perspective that I approach Paul Farmer’s book, Haiti After the Earthquake (2011), in an attempt to siphon out lessons for practice in international social work from Farmer’s medical jargon and clinical mindset. Farmer’s account of pre and post-earthquake Haiti illustrates an exemplary case study for many issues of social work; in this essay I will focus on lessons of ‘acute-on-chronic,’ local expertise, transformation of worldviews, and assuaging the unremitting contradictions of humanitarian being.

            Paul Farmer eloquently weaves top-tier and on-the-ground perspectives through a handful of coined phrases, my favorite being ‘acute-on-chronic.’ As a medical professional, he reminds us that immediate illnesses and social ills alike must be viewed in terms of the chronic history of symptoms and infrastructural fragility facilitating the onset of struggle. With this, Farmer reminds us to always contextualize the present issue with knowledge of history, systemic injustice, generational trauma, and other contributions to the social mélange. In essence, Farmer reminds practitioners to confront problems with a holistic lens—to account for the delicate ecological nature of social ills and not attribute blame to any one cause or propone any one solution.

            The idea of ‘acute-on-chronic’ segues into Farmer’s dialogue about the importance of language in our conceptualizations of practice. Through language, ‘experts’ construct certain realities. Farmer uses the example of the use of  ‘natural disaster’ to describe the earthquake in Haiti. He claims that the disaster in Haiti was in no way ‘natural,’ but was a social disaster resulting from, “policy decision[s] made far from the…affected areas,” (213). Farmer challenges the reader to recognize who is present at the table when big decisions or definitions are made; we should always question the agenda at hand, examining who is benefiting from the policy prescriptions. Furthermore we should identify whose perspectives are missing from the equation and “[seek] to echo and amplify the voices of those we encountered as well as those silenced,” (2).

            As Farmer stresses in the aforementioned quote, and to continue with the role of language in social work practice, I am learning that it is essential to let those affected define their experiences, problem, and solutions. It is necessary to vouch for the inclusion of locals into the decision-making and implementation process. As Farmer quotes Hillary Clinton, “we cannot any longer in the twenty-first century be making decisions for people and their futures without listening and without giving them the opportunity to be as involved and make as many decisions as possible,” (90).

The case study of Haiti honestly examines the role of humanitarian aid in the development process. His account attests to the fact that ingenuity and hard earned experiential knowledge should not be wasted on top-down innovation and implementation, as this route often proves futile. There is a vast potential of local expertise that often goes untapped. Our role as social workers should be to crack the well—organize an efficient means of fostering the flow.

             Even on an interpersonal level, I must practice letting go of a solution-driven mindset and recognize when bearing witness is the deficient resource. As well-to-do Americans, in the words of Farmer, “it’s tempting to focus on immediate clinical questions,” (118) and facilitate the urge to ‘fix,’ as opposed to recognizing the value of inaction. As a westerner I put a premium on visible progress, but there are times when my agenda does not suit the present situation and in fact can stifle change. I have to remember to let go of my way of doing things and practice holding the uncomfortable space, allowing for a humble exchange of knowledge and experience.

            Farmer speaks to the interplay of praxis and policy in one of his chapters; I can also apply this to the conceptualization of opposing tensions within the self—that social work is the interplay of action and reflection. As social workers, our engagement with individuals or communities has reciprocal, and indeed transformational, effects on our personal selves. It is essential to examine the push/pull factors within our own selves in order to explore the motives behind our participation in this work.

            Taking from Fetcher’s Professional is Personal, one can recognize that our work is not passive. Social workers are racialized, socialized, historicized creatures who cannot help the tides of sociopolitical time nor check our worldviews at the door. Personally, I must be aware of the deep-seated guilt that accompanies my status as a privileged white American. I must also reconcile with the fact that people may only view me as a potential dollar sign, temporarily invested in a project for self-centered gains. As Isla asked recently in a class lecture, “how do we balance the responsibility of coming from a country that has access to virtually all of the world’s resources,” and in contrast practice being present with a humble spirit?

            In learning from Farmer, my classmates, and various voices from the readings over the semester, I believe this is answered in the process. To paraphrase Rilke, we must live the questions themselves. We must also learn to balance the fundamental tensions between being, at all times, the learner and the teacher, the researcher and the subject, the doctor and the patient, the sojourner and the native. Likewise at the micro-level are macro-level tensions between relating international experiences back to local issues in our home communities. How can we transform the vision of globalization to facilitate connections in terms of promoting social justice?  

            Social work is a balancing act; we straddle incongruous paths, digging for a nugget of change out of obstinate soil. Farmer’s book has reminded me to always remain a humble learner, even if social norms label me ‘the expert.’ Every human’s individual experience is incomprehensible, yet it is through the power of human stories that I believe we can reconcile coming home to advocate the process of reverse mission and accompaniment. In the end, as Farmer alludes to, we must put our energy in drawing out people’s stories—look for shared patterns, themes, to develop deeper discussion that probes into peoples’ experience so that we can extract, expand, and humanize the struggles against injustice abroad and at home.

           

Paul Farmer on Charity, Development, and Justice – From “America” magazine - 1995

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 deprived 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.
Paul Farmer, M.D., a physician and anthropologist, has worked as a volunteer in rural Haiti for over a decade and is the author of AIDS and Accusation and The Uses of Haiti. He teaches at Harvard Medical School and the Brigham and Women's Hospital. This essay is based on a talk recently delivered at Creighton University in Omaha, Neb.

Women in Development

 

As an integrated global community, it is essential to examine alternative development models outside of neo-liberal ideals. My position is one of advocacy in an effort to spark consciousness within the individuals and governments who sign off on top-down development programs and fund the research that makes progress possible. My postulate is one that emphasizes the importance of viewing global injustice as fundamentally gendered. This essay will seek to examine the nascence and burgeoning centrality of women’s struggle in the globalized world. The purpose of this paper is to propone women’s prodigious roles in sustainable development from top-tier decisions, to on-the-ground pragmatic implementation.

            To contextualize women’s struggles in development discourse, I cite Finn, Perry, and Karandikar (2012), who speak of the gendered nature of globalized oppression and emphasize the need to analyze issues of social justice through feminist discourse. Despite a dearth of research examining the gendered hue of global injustice, it is intuitively clear that women are among the most vulnerable populations to a myriad of human rights violations and general malfeasance (pgs. 2-4).

Citing some statistics from the UN report, The World’s Women (2010) illustrates this fact: nearly 70% of impoverished people on the planet are women; between 75-80% of the world’s refugees are women; women make up less than 10% of the world’s leaders and less than 1 in 5 members of global parliaments are women; only 13 of the 500 largest corporations in the world have a female CEOs; two-thirds of the world’s illiterate adults are women; women are concentrated in insecure jobs in the informal sector with low income and few rights; women’s nominal wages are 17% lower than men’s on average; the value of women’s unpaid housework amounts to 10-35% GDP worldwide, a number in the trillions; women are being increasingly affected by HIV and are more likely to suffer maternal health complications in developing countries; the primary victims of today’s wars are not soldiers, but civilian women and children; the use of rape as a weapon of war has become increasingly evident; violence against women is a near-universal phenomenon.

While these statistics are certainly disheartening, as Sheryl Wu Dunn, a renowned advocate for the global advancement of women and co-author of Half the Sky, describes in her TED-talk (2010), “women are not the problem, they are the solution.” Sheryl speaks to the need to shift examination from the extent of quandary to the nascence of the problem.

If an earthquake happens, we call it a ‘natural disaster;’ similarly when a woman is raped, physically or psychologically, we call this a ‘tragedy.’ In borrowing from Dr. Paul Farmer’s (2011) examination 2010 earthquake that devastated Haiti, he ruminates that natural disasters are only as much of a disaster as the pre-existing social vulnerabilities allow (pg. 117-118). Similarly, tragedies suffered by women are only the result of a social milieu that fosters injustice. Using passive language to describe gendered issues negates the opportunity for examining overarching structures of oppression. 

Remer and Worell (2002) describe Kimberlé Crenshaw’s concept of ‘intersectionality’—a feminist framework for examining structures of oppression as a wheel within which interdependent axes of vulnerability operate. This model emphasizes that all oppressed populations form unique identities through individual experience in the context of complex umbrella of social power dynamics (pg. 30-32). Intersectionality speaks to the labyrinthine nature of oppression and the experiences of women in the context of goliath mechanisms of globalization. 

Feminist lenses of analysis make it clear that women’s issues are global issues. In the words of UN Executive Women Director and former president of Chile, Michele Bachelet, “where we fail to capitalize on the potential and talents of one half of the population, we also squander the potential to reduce poverty, hunger, disease, environmental degradation and violence,” (UN News Centre, 2011).

I believe women’s empowerment is the key to sustainable development and the amelioration of global injustice. The UNFPA and RAFAD (2010) defines empowerment as: 1) the right to have the power to control their own lives--within and outside the home 2) the right to have access to opportunities & resources 3)the right to have & to determine choices 4)a sense of self worth. As expanded upon by Bisnath (2001), embedded in these rights are facets of cognitive, economic, political, psychological, and sexual empowerment.

Empowerment of women is imperative for the betterment of any society for numerous reasons. Some specific examples include women’s responsibility for socializing future generations; if women are devalued and trying to thrive in a system that has set them up to fail, chances of successfully rearing children or lifting a family out of poverty are very slim. In economic terms, Women can provide the human capital necessary to stimulate local economies and are also known to invest a higher percentage of their obtained resources back into the long-term welfare of their family (UN News Centre, 2011). If women are continually denied access to the market, they cannot contribute all of their valuable perspective, skills and personalities to global progress. Engaging in global discourse that subtly ‘gender-blind’ results in policies and projects missing half the story.

There are numerous examples of ‘broken’ countries ‘building back better,’ in the words of Dr. Paul Farmer (2011), by placing women at the center of reconstruction. An excerpt written by Didi Bertrand Farmer, wife of author Dr. Farmer, in Haiti: After the Earthquake, describes the national trauma while also emphasizing the exacerbated jeopardy of sexual violence and exploitation women and girls faced in the temporary settlements of this devastated country (pg. 301). Her words exemplify the cognitive process I believe should be institutionalized in development rhetoric, “women are the centerpost…of our families and society. The reconstruction of Haiti will succeed only if we strengthen its centerpost by educating and empowering our country’s women and girls,” (pg. 303).

Pragmatically, Farmer suggests leadership quotas and an emphasis on female involvement in local and bureaucratic decision-making, as well as decentralized efforts with a national goal towards gender equality (pg. 305). I also believe sustainable development should focus efforts on the elements of women’s lives pivotal to struggle or success: economic factors such as access to credit, stable jobs, microfinance programs and small business initiatives, increased education efforts—such as sexual education, language immersion, and literacy, health resources centered on maternal health, preventative care, and financial support for receiving said services, local agricultural involvement and/or education about how to incorporate sustainable resources back into a drained community, advocating for the amendment of property rights to include women, providing incentives for political participation, et cetera. As a student, I also recognize the premium institutions place on quantifiable data; I therefore vouch for the government and other academic organizations to fund research that, echoing Bisnath (2001), acknowledges differential factors of race, gender, and economic standing, among other axes of oppression. Theoretical models for analyzing the forces of globalization and development have to be revamped by research that views these issues as inherently gendered.

Farmer looks to her experience in Rwanda as a model for development centered “on the backs of…women—victims of rape and physical violence, wives abandoned by husbands imprisoned or fleeing imprisonment, women who had lost family members, friends, neighbors, lovers, children,”(pg. 305). This quote illustrates an idea I encounter daily in my local community, as well as in my studies of international social work— women are resilient creatures.

Although women continue to struggle for justice, it is the feminine perseverance for the sake of bettering future generations that should be capitalized on as our world moves forward with an eye on sustainable development. So much of the current paradigm of globalization is about violence, dominance, and control. Patriarchy can be equated with violence—men against women, institutions against communities, government against people, individual against individual, humans against nature. On a more philosophical level, if characteristics of femininity are incorporated as valuable tools of the global decision making process, the result may be a ‘kinder and gentler’ version of globalization. It is for these reasons that I urge all development agencies and governmental institutions to plug women back into the equation; embracing femininity, literally and figuratively as a mode for behavior and expression, will be transformative for all.

 

References

Bisnath, S. (2001, November 26-29). Globalization, Poverty and Women’s Empowerment. UN Division for the Advancement of Women (DAW) Group Meeting on "Empowerment of Women Throughout the Lifecycle as a transformative strategy for poverty eradication." New Delhi, India.  

Farmer, P. (2011). Haiti After the Earthquake. New York, NY: PublicAffairs.

Finn, J.L., Karandikar, S., & Perry, T. (2012). Gender Oppression and Globalization: Challenges for Social Work.

Remer, P. & Worell, J. (2002). Feminist Perspective’s in Therapy: Empowering Diverse Women. Hoboken, NJ: John Wiley & Sons, Inc.

United Nations Department of Economic and Social Affairs. (2010). The World’s Women 2010: Trends and Statistics. New York, NY: United Nations Publication. Retrieved from <http://unstats.un.org/unsd/demographic/products/Worldswomen/WW_full%20report_BW.pdf>

United Nations Population Fund (UNFPA) and Research and Applications for Alternative Financing for Development (RAFAD). (2010). Exploring Linkages: Women’s Empowerment, Microfinance and Health Education. United Nations Population Fund. Retrieved from http://www.unfpa.org/webdav/site/global/shared/documents/publications/2011/Exploring%20Linkages%20-%20Women%27s%20Empowerment,%20Microfinance%20and%20Health%20Education.pdf

UN News Centre. (2011, June 27). Empowering Women Helps Fight Poverty and Other Social Ills, UN Official Stresses. Web. 25 Nov. 2012. Retrieved from <http://www.un.org/apps/news/story.asp?NewsID=38863&Cr=gender+equality&Cr1#.UMTZ3oVA7n4>.

WuDunn, S. (2010, July). Our Century’s Greatest Injustice. In TEDGlobal 2010. Oxford, England.