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.
