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.