'In the Company of the Poor': Book by Paul Farmer and Fr. Gustavo Gutiérrez

Partners In Health’s mission is to provide a “preferential option for the poor” in health care. The phrase—which means to make an option for poor people and to work on their behalf—is articulated in the liberation theology of Father Gustavo Gutiérrez, a Peruvian priest and longtime mentor and friend to PIH co-founder Dr. Paul Farmer.

The two men have co-authored a book, In the Company of the Poor, in which they discuss their shared commitment to a “theology of accompaniment”—a lifelong practice of not only walking with people who are poor, but working to change the conditions that keep them poor. In the following chapter, Farmer tells us about his introduction to Gutiérrez and how his writing came to provide the intellectual framework for PIH’s work.

Reimagining Accompaniment: A Doctor's Tribute to
Father Gustavo Gutiérrez

In 1971, when Gustavo Gutiérrez published A Theology of Liberation, I was eleven years old and living in small-town Florida. To me, and to my siblings, church was a place one went to fulfill obligations to parents and grandparents: First Communion, Confirmation, high holy days. It meant sitting through homilies—often boring ones, I’m sorry to say, and almost always remote from our experience. Perhaps the priests made too little effort, or felt little need to make the effort, to address people our age; more likely, we made too little effort ourselves. The arcana of theology were of course completely beyond us. Once we had advanced to high school, we saw little reason to continue going to Mass. Our parents, who shared our ambivalence, did not insist.

A few years later, the boundaries of my world had expanded significantly. I was a college student in Durham, North Carolina, and learning at last about the world we inhabited, pushing back the boundaries so that more and more of this very real world was revealed to me. I learned about conflicts taking place in Central America. For me and most of my college peers, those conflicts were remote and hard to understand. But in fact they were so profoundly connected to our world that a journalist reporting the Salvadoran army’s massacre of an entire village in that beleaguered nation would discover that the headstamps on the bullets read Lake City, Missouri. I learned about the resistance to tyranny and violence offered by many members of the church and thought: same church, same world. Not two or three worlds, but one. I stood in front of the Duke Chapel with more than a hundred fellow mourners, gathered in shock to grieve for the murder of Archbishop Romero of San Salvador. He had been cut down in the middle of Mass while intoning the very words, no doubt, that had recently seemed to me so dull and uninspiring.

After graduation, I spent the better part of a year in Haiti. If conflicts in distant countries were what it had taken to revive my interest in Catholic social teaching, proximity to suffering and poverty taught me even more about what these lessons might mean in the last years of the twentieth century. And it was the patient, scholarly work of Gustavo Gutiérrez that helped me make sense of the poverty I saw around me in Haiti, elsewhere in Latin America, and back home in the United States.

Understanding poverty as “structured evil,” and understanding how it is perpetuated, is not the same as fighting it. But if we believe that knowledge can inform practice—if we believe in pragmatic solidarity as the best confirmation of theory—then it is best to have intellectual accompaniment. I have had Father Gustavo as my accompagnateur for many long years, including the decade before I had the chance to meet him in person.

A preferential option for the poor informs our clinical work and also our efforts to move beyond individual patients to remedy inadequacies, inefficiencies, and gaps in health systems.

Let me give an example. One day, early in my stay in rural Haiti, I was in my room in the rectory of an Episcopal Church in Mirebalais, a market town in the center of the country. I’d spent the day in a hot, overcrowded clinic. My job was to take vital signs, and to give moral support to the beleaguered young Haitian physician in charge. We quickly became good friends. In time he confessed how much he hated the work he had been called to do: “It’s like a mediocre medical factory. No lab. No real chance to examine the patients or do more than the most perfunctory work.” But he never did much to change it. These conditions were seemingly as immovable as fate. Not yet thirty, the doctor had been socialized for scarcity and failure, I came to understand, even as I had been socialized for plenty and success.

In other words, poverty had worked its way into the doctor’s life too, even though he was not poor. This is exactly what is meant by the concept of structural violence: inequity that is “nobody’s fault,” that is just “the way things are,” that we live with because we cannot or will not or do not know how to address the conditions that create unequal outcomes for rich and poor. This idea, of an unjust social order that was in itself a form of structured violence, seeped into my consciousness throughout that year. It was, incidentally, one of the last years of the Duvalier family dictatorship.

Late on that Wednesday afternoon, after a copious meal (the two of us never lacked for food and clean water), we repaired to our rooms to read. I heard a ruckus outside. A crowd was chanting, marching down the street. The food riots and political demonstrations that would bring down the dictatorship were still more than a year away, and noises like this were almost always associated with some sort of local unpleasantness.

I could hear the crowd very well.

Madame Providence manje de ti moun.

I knew enough Creole to know that the crowd was singing, “Mme Providence ate two children,” and had read enough about Haiti to know that this was likely a sorcery accusation. I looked out and saw a crowd of people, pushing and pummeling a woman as they paraded her down the street toward the police station and could envision the fate reserved for her. I learned later that she was arrested on God-knows-what charges, and her beatings continued in the foul jail down the road. The brutality of it all revolted me. And what made me feel really lonely was that almost everyone I worked with, including the talented young doctor, seemed to take it all in stride, or to agree that Mme Providence might indeed have performed some sort of magical poisoning that felled a neighbor’s two previously healthy children. “Who knows?” he asked, an eyebrow arched.

I did not, and still do not, believe in sorcery; I see accusations of sorcery as one outcome of injustices that people endure until they can endure them no longer. By then I had seen kids die of malaria and of other acute infections. But how to explain all of this to myself or to others? The Haitian priest with whom I worked, and still work, dismissed the sorcery accusation as “peasant superstition” with a gruff and somewhat embarrassed wave. That was the end of that conversation. For my part, I read about history, anthropology, demographics, cosmology, and anything else that might clarify Haiti. Even though I didn’t know Mme Providence, much less believe her capable of magical poisoning, I understood why such modes of explaining misfortune flourished in Haiti and even, to some extent, where they’d come from. Similar forms of accusation and symbolic reparation flourished across the plantation economies of the Caribbean and southern United States and parts of Latin America. These attitudes, although they might be nonsense etiologically, made sense to me as a certain reflection of social conditions in rural Haiti.

Extending a hermeneutic of generosity to those who rely more on a hermeneutic of suspicion (like the suspicion to which Mme Providence was subjected) has been an enduring intellectual and personal project for me. Those first years in Haiti taught me to understand the force that sorcery allegations, and rumor and umbrage of all sorts, can have. Like the doctor’s resignation, it was a response to being socialized for scarcity, to zero-sum solutions and diminishing returns. It was then that I began reading the work of Gutiérrez and others seeking to interpret not only scripture but its meaning in Latin American contexts. Recently, a fellow physician-anthropologist and friend asked me how Paul Ricoeur’s work had informed my own passing commentary on hermeneutics. It was true that I’d slogged through three volumes of Ricoeur’s book on time and narrative—in French no less—in graduate school. But that wasn’t what hermeneutics meant for me. I saw it, in the spirit of Gutiérrez, as a much older endeavor, and one predicated on an ethical stance. What I learned from Gutiérrez above all was that hermeneutics was praxis. He’d taught me to look for the hermeneutics of hope that might follow the hermeneutics of generosity I’d sought to extend to my hosts.

Liberation theology continues to be, for me, an inexhaustible font of inspiration. I see the spirituality associated with it as, at the very least, aspirational: any of us can aspire to be better—but only if all of us seek to attack contemporary poverty and to remember that we live in one world, not three. Nothing that I’ve seen, from plague to famine to flood to quake, could persuade me otherwise.

***

Later, Gutiérrez himself inspired me. On one of my early trips to Lima in the early 1990s, the first person I wanted to meet, beyond my new hosts and patients in a squatter settlement north of Lima, was Father Gustavo. Although he did not know me, a newly minted gringo doctor, I came with a friend and colleague, Dr. Jaime Bayona, the founder of Socios En Salud, as Partners In Health is called in Peru, and with Dr. Jim Kim. I brought Father Gutiérrez copies of my first two books, works of medical anthropology that drew heavily on his thinking. He received us in Rimac, where he was a parish priest and running a center for study and reflection. It was a tough time in Peru: the tail end of a huge cholera epidemic, itself the tail end of a civil war. Fujishock was what our hosts termed the fiscal austerity programs of the government. There was ill will to spare. Our first project in the slums of Lima, a pharmacy for poor people, had just been blown up by a pipe bomb.

Poverty is not some accident of nature but the result of historically given and economically driven forces.

The core of Father Gustavo’s teaching has always been that we must make a preferential option for the poor. I distill this teaching into three simple points: first, that real service to the poor involves understanding global poverty. (The converse is also sometimes true.)

Poverty is not some accident of nature but the result of historically given and economically driven forces. Human beings constitute the social world, and we will always shape it. Understanding poverty and inequality requires multiple disciplines: economics, ethics, law, sociology, anthropology, epidemiology, and so forth. Most of all, it requires listening to those most affected by poverty, which is to say the poor and otherwise marginalized. Listening is also a significant part of accompaniment, and of clinical medicine. Listening is thus both engagement and research. It would not be remiss to think of reverent listening as encompassing the four traditional pillars of Dominican life: prayer, study, service, and community. “Your desk is your prayer bench,” as Dominic said. This academic, information-seeking approach is how option-for-the-poor medicine should work, too. If there is anything that distinguishes Partners In Health from other nongovernmental organizations, it is less an insistence on social justice—many organizations make similar claims—and more an insistence on linking our service work to training and to research. It is why our efforts are so often linked to a research university.

Father Gustavo’s theology stems from a similar conviction, even though he wasn’t always rewarded for it. Until less than a decade ago, he’d never had an academic appointment; his research and writing were additions to his priestly vocation. Yet this has not resulted in an intellectual profile that anyone would call amateurish. As Father Dan Groody puts it, “Gutiérrez would bring his claims of faith into dialogue with such thinkers as Albert Camus, G.W.F. Hegel, Jean-Paul Sartre, and Gabriel Marcel; film directors such as Luis Buñuel and Ingmar Bergman, and writers such as Peruvians José María Arguedas, Felipe Guaman Poma de Ayala, and César Vallejo.” Along the same lines, we succeeded, in 1995, in bringing Father Gustavo together with Noam Chomsky for a day-long, wide-ranging conversation. Somewhere, I hope, this conversation has been taped and archived.

Second, an understanding of poverty must be linked to efforts to end it. Father Gustavo has often noted, in his writing and in his speaking, that poverty means death. Nowhere is this more evident than in medicine; and most medical specialists and institutions are aware of the need to do something about it. Imagine trying to do clinical research in an American teaching hospital without providing any clinical services. The study of poverty without an expressed concern with ending it is seen with a hermeneutic of suspicion by most of the people with whom I’ve lived and worked.

A preferential option for the poor informs our clinical work and also our efforts to move beyond individual patients to remedy inadequacies, inefficiencies, and gaps in health systems. To show how much we’ve been influenced by this and related notions, let me go back to 1987, when we founded Partners In Health. Our mission statement, duly filed with public authorities in order to start a public charity, reads as follows:

Our mission is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, Partners In Health strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. We draw on the resources of the world’s elite medical and academic institutions and on the lived experience of the world’s poorest and sickest communities. We are dedicated to providing the highest level of clinical care possible while alleviating the crushing social and economic burden of poverty that creates obstacles to health. At its root, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When our patients are ill and have no access to care, our team of health professionals, scholars, and activists will do whatever it takes to make them well—just as we would do if a member of our own families—or we ourselves—were ill. We stand with our patients, some of the poorest and sickest victims of poverty and disease, in their struggle for equity and social justice.

In the intervening quarter of a century, our mission has spread to a dozen countries. But it’s the same mission. Only the word “elite” has been dropped from our description of the institutions from which we channel resources. It was replaced with “academic.”

Third, as science and technology advance, our structural sin deepens. This is no Tea-Party assertion; we love science and technology. It is just an observation to the effect that our increase in knowledge and power brings an increase in responsibility.  As the effectiveness of medical interventions grows, our failure to use such interventions justly widens the “outcome gap.”

Let me take cholera as an example. I have already mentioned Peru’s cholera epidemic. The decades since that epidemic have brought new medical developments: new antibiotics, better formulations of oral rehydration salts, and new preventives, including safe vaccines. There have been new developments in water purification and sanitation, and new communications platforms have altered the way we report epidemics.

Despite these advances, in 2010 cholera appeared for the first time ever in Haiti, introduced inadvertently by a soldier from a region of the world where the disease is endemic. Cholera exploded like a bomb in Haiti, becoming the world’s largest epidemic—both in absolute terms and proportionally. Yet with more than half a million sick and thousands dead, relief agencies still haggled over whether or not to use the vaccine, which was not available during the previous Latin American epidemic but has since gone through trials showing it to be safe.

The harm done by this twenty-first-century epidemic is worse in some ways than any of the larger ones that may have preceded it, for cholera is now, in contrast to nineteenth-century epidemics, a disease exclusively of the poor. In other words, the pathogen has made a far more radical preferential option for the poor than have those fighting it.

***

“Structural violence,” “immodest claims of causality,” and “a hermeneutic of generosity”—these concepts figure heavily in my written work, even when they are not called out by name. Far from suffering from the “anxiety of influence,” I am proud of my debt to Gustavo Gutiérrez and to liberation theology.

Making a preferential option for the poor ought to be easy in medicine—just follow the pathology, and that’s where it leads you—but it’s not. There are a million traps, so many of them analytic, but the most cunningly laid traps are perhaps best termed spiritual ones: failures of imagination, failures to extend a hermeneutic of generosity (or suspicion) when warranted, failure to listen patiently, much less reverently. These failures afflict all of us, which is why, no doubt, all of Father Gustavo’s work can be seen as spiritual. Father Groody put it this way in introducing Gutiérrez as a “spiritual master” when compared to many less humble proponents of liberation from poverty: “Beneath the theological words and the social analysis were attitudes of self-righteousness, judgmentalism, and aggressiveness that left me wanting to fight for liberation from a deeper place. I began to appreciate not only that one fights for liberation but how one does it. I was drawn particularly to those whose fight for justice emerged from a quality of soul and deep spirituality.”

As long as poverty and inequality persist, as long as people are wounded and imprisoned and despised, we humans will need accompaniment—practical, spiritual, intellectual.

One could paraphrase: the self-styled liberators from poverty are too often those who want to preach, rather than listen, to the poor. The theme of receptive hearing as linked to humility runs throughout Father Gutiérrez’s work as both pastor and as a theologian. “Working in this world [of the poor] and becoming familiar with it, I came to realize, together with others, the first thing to do it to listen.” Gutiérrez wrote these words in 2009, but has instantiated them throughout his five decades as a priest and theologian. Listening might seem easy in a classroom at Harvard or Notre Dame, or in a rectory in Rimac or in Rome. It isn’t. Among the poor, especially those who are sick, it’s hard and often painful.

My experiences in Mirebalais and elsewhere in Haiti, including those registered after the January 2010 earthquake, tried me in ways I would not have anticipated. Regarding Mme Providence, I was appalled that a woman could be publicly excoriated and worse for “eating” two children, but I was determined to understand how such explanatory models might come about. I tried not to turn away. I still work in Mirebalais, as do Ophelia Dahl and so many of our co-workers, including a new generation of physicians and nurses and a host of partners that has grown quickly since the earthquake. Soon we will open what will be Haiti’s largest teaching hospital, not more than a few hundred yards from where the unfortunate Mme Providence was jailed and beaten. The prison still stands and has not been much improved over thirty years, as we discovered to our great shame when cholera ripped through it, killing several prisoners before we acted with sufficient force to end the epidemic behind bars.

As long as poverty and inequality persist, as long as people are wounded and imprisoned and despised, we humans will need accompaniment—practical, spiritual, intellectual. It is for this reason, and for many others, that I am grateful for Father Gustavo’s presence on this wounded but beautiful earth.