My Second Trip to Chiapas — 2014

Post 1

A year has passed, I am back in Chiapas with Companeros en Salud, (a.k.a. Mexican Partners in Health)—welcome back dear reader. I have learned a lot this year–how to suture and intubate, how to set up an IV line, to listen more carefully to my patients and to ask more careful questions in my history. For those of you who do not know me my name is Kareem Raad and I am a fourth year medical student who will graduate in weeks from the Lebanese American University in Byblos, Lebanon. I originally visited Chiapas last year during the vacation time of my third year of medical school to understand how a good system of rural primary care ought to be run so that I can implement something similar in Lebanese communities.

My goal, as on my last trip, is to live in a rural community in Chiapas, serve the people, and reflect on this experience. If you want to understand what it is like to deliver healthcare and share the lives of the people of Chiapas then you need to come live in the community, but if you can’t, then the next best thing is to read this blog.

Last year I summarized “Histories and Stories from Chiapas” which goes into the anthropology, history, and culture of the people of Chiapas. This year I will focus on Christian spirituality by doing a summary-analysis of Gustavo Gutierrez’s “We Drink from Our Own Wells.” This 137 page book summarizes some of the defining ideas in a Christian spiritual movement called Liberation Theology, which influenced the philosophy of structural violence which has been written about in detail by Paul Farmer, the founder of Partners in Health. I am a simple medical student describing an experience, I do not represent Partners in Health in these writings, and I take full personal responsibility for the views expressed.

Fr. Gutierrez’s book begins with a question, “How shall we sing to the Lord in a foreign land?” reflecting the fact that the people of South America are living in soul-crushing poverty and so are faced with the question of what to be thankful for. This poverty is so great that forces the great majority to live in their own land as if they were on an alien planet, a foreign land, a place that destroys futures, culture, and ultimately amounts to death.

He quotes a Haitian community that is being threatened eviction:

“These fields are our entire life, our entire support. They give us food. Thanks to them we can send our children to school…Where can we go? If we move to Port-au-Prince our situation will only be worse, because there is such misery there. If we go to the mountains, what kind of land can we expect to till? Must we, then, leave Haiti—get on a boat in order to discover the misery in other places? We do not deserve this torture.”[1]

Setting the stage with this scenario of suffering, Gutierrez is now going to make a claim that Christian spirituality can no longer ignore others. Mirroring the Mahayana/Theravada Buddhist debate, he is saying that Christianity can no longer be geared to orders that wish to separate from the world in order to reach religious perfection, to go to monasteries deep in the mountains to be closer to God. God is among the suffering people. He makes a second claim, that spirituality is not an individualistic cultivation of values, an interior perfection, but requires action, a role in the world.

How does poverty manifest in Chiapas? Alcoholism and domestic violence, few options for young people the majority of whom want to leave the community, a diet mainly of beans and tortillas with few fresh vegetables or meat, four hour trips to the nearest hospital, inability to afford medications or tertiary care—even during delivery of a baby, rampant medical charlatanism, garbage scattered among streets and forest roads. These are the things I saw with my eyes. How do I respond to Gutierrez’s claim that we must pray not in isolation but among the people? I’m nowhere near a saint but at least I’m already in Chiapas, silly—you should come too!

Post 2

My first days back in Chiapas were spent in the “curso”, the medical conference for the pasantes. I attended a mind blowing series of dermatology lectures where, in two weeks, Monica, a visiting dermatologist based in Chicago, had photographed and presented cases from her time in Chiapas covering the entire breadth of dermatology and skin fungal infections, 156 slides of diagnosis and management.

There are a few old faces, but many more new ones. The same fire is there, the passion to make a change in people’s lives. To comfort patients, to care for each other as a team. A place where a few people really feel that they can change the world, step-by-step, with hard work, patience, perseverance, humor.

How much does a one-year community service commitment impact a doctor’s medical training, commitment to the poor, or the health of the community? To the first two questions it is still too early in my life to be able to say, but I can say with certainty that in the couple months that I have spent with pasantes I have seen lives radically improved, altered, saved. We are still far from getting to the root of social injustice and poverty, but as you will see in the upcoming posts the people in the communities I worked deeply appreciated and recognized the impact of an accessible physician with basic medication. A wise person once told me that if you want to figure out what organizations to empower or affiliate with in the community then you need to look at what the community itself values and considers effective.

Last night while driving home from Tuxtla where we had been accompanying a patient on a clinical visit, Valeria and I saw about eight cars and trucks parked to the side of the road. Approaching, we saw a boy lying in the road covered in blood, surrounded by ten men and women standing around him, some talking on cell phones calling for help and his family. He was talking and conscious, so we checked his pulse and pupils, got a bandage to put compression over his bleeding head wound. Several minutes later three other pasantes who by coincidence had been driving through and saw us stopped to help. Together we wrapped a towel around his neck to stabilize his cervical spine, and put him on a couple large pieces of cardboard to minimize bending of his spine while carrying him to the truck to be transported to the hospital. After an uneventful trip during which he remained conscious we got him to the hospital where the team immediately got an I.V. line running, confirmed acceptable vitals, and bandaged his head. He did receive dexamethasone which was in the past considered to be the standard of care in head trauma but which is no longer used. We decided not to try to correct the local doctor in front of her staff. Now stable, he was ready to be transported to a tertiary center for head CT. Arriving home at 11pm, I went to bed and set my alarm for 430am to take the bus to see another patient in Tuxtla Guttierez tomorrow.

I have been describing Gustavo Gutierrez’s book “We Drink from Our Own Wells” in the context of my experience in Chiapas. Last time we discussed Gutierrez’s description of the suffering and poverty in Latin America. Gutierrez describes a kind of Christian schizophrenia, a spiritual split—Christians on the one hand “feel the need of a sure spiritual way,” the classical individualistic spiritual life seeking perfection in an isolated dialogue with God. On the other hand, “daily life with its demands for commitment [in the context of bone-crushing poverty] seems to run on a tangential track.”[2] We said last time that to resolve this tension Gutierrez wants us to live and pray among the poor.

But how do we deal with this suffering? Is Gutierrez just going to depress us and leave us hanging? Hope, he says, arises in the context of a real lived experience with poverty, an experience that allows us to express ourselves through the psalms:

I will give thanks to the Lord with my whole heart;

I will tell of all they wonderful deeds.

I will be glad and exult in thee,

I will sing praise to thy name, O Most High

[Ps. 9:1-2]

And why do we live in a favorable time, a time of hope? Not because there is more or less suffering, but because for the first time the most oppressed are “beginning to grasp the causes of their situation of injustice and are seeking to release themselves from it.”[3] This historical perspective has a Hegelian flavor—Gutierrez describes a historical power of the poor to continue to evolve for the better in dialogue with the Lord and the social structures that contribute to their problems. Faith in the Lord is paired with a faith in a better world. What a beautiful combination!

But now Gutierrez is committed to his words, if he is arguing that social justice will prevail with faith in Jesus Christ then he has to show that this is in fact a historical reality, and not merely a theory. He goes on to discuss his lived experience with Christians in Peru and throughout South America, arguing that he has seen great outpourings of solidarity, prayer, and even martyrdom in dozens of countries, reminiscent of the sacrifices of the early Christian community. He steps from making too aggressive of a conclusion about what this all means, as he states that it is too early to understand the full ramifications of this martyrdom—we are too historically close. If I wanted to go into more detail I would have to copy and paste his book, so I will refer you to part 1, chapter 2 of We Drink From Our Own Wells for more of Gutierrez’s beautiful prose in which he describes to the reader a time “of salvation and judgment, a time of grace and stern demand—a time, above all, of hope.”[4]

Post 3

After a couple days accompanying patients at the hospital in Tuxtla Gutierrez, I was assigned to work in the small village of Laguna Del Cofre. I began my first couple days by taking vital signs and helping greet and triage patients, a great way to refresh ones medical Spanish and begin to connect to the community. In the afternoons I went with Alfredo, the local nurse, where we vaccinated 50+ children in the town square. With Azucena, the Pasante with whom I will work this month, I also began to observe her caring for patients in clinic and we discussed some of the difficult diagnoses. The best experience of the first two days was my first chance to pick coffee with a friend I had made last year, Don Ramiro.

A few days into the work we had the chance to go on four vacation days in the touristic city of San Cristobal, a great place to dance salsa and enjoy some of the best restaurants in Chiapas. The pasantes and I laugh often at Companeros en Salud, we really enjoy life. (If by now you are still wondering what a pasante is, it is a recently graduated doctor who is required by the government to do a 1 year medical service commitment in a rural setting—these are the people that Partners in Health is supporting with medication and training in 6 different rural communities.) And sometimes this happiness is mixed with guilt for me—should I be enjoyed dancing and art when doing this work, is this what real solidarity means? Isn’t solidarity sharing in the same conditions as the people with whom you work? How about if one decided to move to Laguna del Cofre and practice medicine in this community—your kids would have to go to worse schools and because of your limited income potentially have insufficient resources to go to university, limiting their future opportunities—is this something that solidarity with the poor requires of your children? In conversation with a wise friend the following view was defended: “anyone who does work to change the unjust structure of society for long periods of time suffers, but that is not a problem—the problem only exists if there is not enough love to match that suffering.” Maybe taking time as a team in a context outside the rural community, like San Cristobal, helps create the love that allows the pasantes to continue this difficult work.

Let us continue with Gustavo Gutierrez and maybe he will have something to say about this later… maybe he can give me some guidance about the meaning of solidarity. Today we get to the real meat of what Gutierrez discusses in his book, he describes a spiritual revolution in Latin America with the key component, the catalyst, the core being the poor. In a set of beautiful passages I think he answers the question “What is Liberation Theology?” in a succinct and straightforward way:

“In search of this utopia, an entire people—with all its traditional values and the wealth of its recent experience—has taken to the path of building a world in which persons are more important than things and in which all can live with dignity, a society that respects human freedom when it is in the service of a genuine common good, and exercises no kind of coercion, from whatever source.

All this we call the historical process of liberation, and with its ideas and impetuosity it is sweeping all Latin America. The process is only beginning. It is not advancing triumphantly and without obstacles to the applause of the entire world; […] nonetheless we are in the presence of a coherent and dynamic movement that is bringing out what is best and most promising in the peoples of Latin America.

The struggles of the poor for liberation represent an assertion of their right to life. The poverty that the poor suffer means death; a premature and unjust death.”[5]

Gutierrez closes this chapter by shifting from a historical description of Liberation Theology to what we ought to be doing as Christians. He points out a paradigm for Christians to practice, a dialectic that characterizes Liberation Theology: “The relationship between an oppressive system and the God who liberates, between death that seems to have the upper hand and the God of life, adumbrates a way of following Jesus and being his disciples under the conditions now prevailing in Latin America. Jesus is not to be sought among the dead: he is alive (Luke 24:5). To seek him among the living is to choose life…” In other words, Jesus is found in service to the living oppressed, not in a monastery deep in the woods or in isolated prayer, spiritually far from other human beings.

He continues to develop the depth of the Christian commitment that is required:

“This new reality invites Christians to leave the familiar world they have long inhabited, and leads many of them to reread their own spiritual tradition. Above all, it is a question of making our own the world of the poor and their manner of living out their relationship with the Lord and taking over the historical practice of Jesus. Otherwise we shall be traveling a road that simply parallels that taken by oppressed believers. Then we shall have to try to build bridges that connect these different roads: bridges of commitment to the exploited, friendly relationships with some of them, celebration of the Eucharist with them, and so on. All these would be meritorious efforts no doubt, but they are inadequate because such connections do not change the fact that the roads are only parallel. At the present time, the spiritual experience of the poor is too radical and too comprehensive in scope to merit only that kind of attention. That is why I have spoken here of making that experience our own. That is the issue. Any other response will be a halfway response.”[6]

This passage resolves the spiritual schizophrenia that was described in my first post, and a path has been laid out to live in a single, united Christian community, without “parallel roads”. To live in poverty is an extreme undertaking that can’t be taken lightly, and I still do not have answers to whether it is a breach of solidarity to be sending your kids to better schools or vacationing in San Cristobal. These are really tough questions I am still working on, but my instinct is that the answers require radically creative solutions.

Before I leave you, the expression “We Drink From Our Own Wells” will be explained: “The faith and hope in the God of life that provide a shelter in the situation of death and struggle for life in which the poor and oppressed of Latin America are now living—they are the well from which we must drink if we want to be faithful to Jesus.” And that, my friends, is the bedrock of Liberation Theology. When someone asks you what Liberation Theology is, you can tell them that we are living in a historical time in which we are called to serve, fight injustice with, and become enriched by the entire Christian community while bathing in the love of Jesus Christ.

Post 4

We are back in Laguna again and after stitching up the leg of a child who got cut running with a mirror, tending an infected wound, and washing out an eye that was splashed with gasoline, plus the standard battery of patients, we retired around 730 for a dinner of bread and coffee. How impersonal a description, listing patients in terms of anatomy. Certainly I have not remembered many names here, perhaps a reflection of depersonalization, more likely an absolutely terrible memory with names I brought with me from Lebanon.

Over dinner we debated the qualities of the perfect man, and I went to bed only to awake at 4am to vomit from probably S. aureus food poisoning in the bread. Azucena, my Pasante, motheringly made some electrolyte solution and after making sure I was fine headed off to work. With my halfday off from work I cleaned the entire house including the burning of the garbage, the traditional way to dispose of it. Part of my role working in Laguna del Cofre, in my eyes, is to support Azucena personally and professionally, to avoid her burning out, so that, as I talked about in my last post, the love she has for her work exceeds the suffering. This means taking care of her material comforts like making sure she has eaten enough, the house is clean, she gets enough sleep, etc. This is an indirect way of supporting the patients—a tired, hungry brain can’t make a good diagnosis, and ultimately the patient suffers. I also see this activity in the context of social medicine, or the nonmedical, social factors that impact patient care—doctor burnout and high physician turnover in rural settings being one such factor. By making sure Azucena is cared for I am helping the patient, my ultimate goal. I am certain that a doctor’s role goes beyond diagnosis and treatment—it has the right to expand to any and all factors that impact health, and my service to Azucena is a reflection of this.

In my last post we talked about Part 1, Chapter 2 of “We Drink from Our Own Wells” where the big picture in Liberation Theology was presented—the historical framework, the big brushstrokes of what it means to follow Jesus. We have been talking of Liberation Theology as a spiritual journey, and Gutierrez states the end destination: “the search for God is the ultimate meaning of any and every spirituality.” He gets more specific saying that its dimensions are “an encounter with Jesus Christ, life in the Spirit, and a journey to the Father.”[7] In Part 2 of the book Gutierrez is now going to go deep into the Bible to describe these dimensions that are still theological jargon to us. To understand what he means by these dimensions, let us journey on together. ;)

Encounter with the Lord: Gutierrez uses an elegantly simple passage to convey the encounter with Jesus and the birth of the Christian community:

The next day again John was standing with two of his disciples and he looked at Jesus as he walked, and said, “Behold the lamb of God!”

The two disciples heard him say this and they followed Jesus. Jesus turned, and saw them following, and said to them, “What do you seek?” And they said to him, “Rabbi” (which means Teacher), “where are you staying?” He said to them, “Come and see.”

They came and saw where he was staying; and they stayed with them that day, for it was about the tenth hour.

One of the two who heard John speak, and followed him, was Andrew, Simon Peter’s brother. He first found his brother Simon, and said to him, “We have found the Messiah” (which means Christ). He brought him to Jesus. Jesus looked at him, and said, “So you are Simon the son of John? You shall be called Cephas” (which means Peter) [John 1:35-42].

When I first read this passage I found it boring and meaningless. Little did I know how much amazingness was packed in these simple words.

First, Gutierrez describes the phrase that John uses to invite his disciples to follow Jesus, whose path he had been preparing: “Behold the lamb of God!” This refers to the Passover lamb of the old testament “whose blood freed the people from death”[8] The suffering that follows from following a lamb to the slaughter is not hidden from the disciples, but comes with the promise of final victory and the sovereign rule of the lamb as described in the Apocalypse.

Next the disciples follow Jesus in silence, but this following, as we have seen, is already heavy with meaning. One of the beautiful things of Gutierrez’s message is how he explains “following” as not only an obedience to the Lord, but also as an act requiring a creativity in the new way that must be travelled.

Jesus next asks “What do you seek?” (John 1:38) A direct question that is asking the disciples to define themselves, to explain their following. It is a test. The response of the disciples using the word “Rabbi”—which means someone who teaches by his manner of life—“Where are you staying?” implies the disciples want to go directly into sharing the way of life of Jesus (before hearing long philosophical treatises about what he represents). By asking where he lives they are inviting themselves to intimacy with him. Jesus invites the disciples to “Come and see,” and to accept the consequences. And why does the passage mention that “It was the tenth hour”? Gutierrez sees this detail as the very normal human reaction of remembering the details of the great events that change our lives, the color of the shirt someone was wearing at a wedding, the taste of the wine right before a first kiss. Biologically, there is evidence that strong emotions are associated with better memory of an event—but I don’t think I can go that far in the interpretation without putting words in Gutierrez’s mouth.

But where does Jesus live? “Foxes have holes, and birds of the air have nests; but the Son of man has nowhere to lay his head” (Mathew 8:20). Gutierrez sees the answer in John 1:14 “And the Word became flesh and dwelt among us.” Jesus dwells in the center of human history, living in the task of proclaiming the gospel. He lives among the people—not in a tower in the Vatican, in the waters of Lourdes, in an old cathedral in Jerusalem—among the people in service to others is where we find Jesus. Gutierrez later quotes Mathew 11:2-5 to emphasize this: “[John sends his disciples to ask Jesus] “are you he who is to come, or shall we look for another?” And Jesus answered them, “Go and tell John what you hear and see: the blind receive their sight and the lame walk, lepers are cleansed and the deaf hear, and the dead are raised up, and the poor have the good news preached to them”. Jesus answers not with words but with witnessed deeds, “For a tree is known by its fruit.” “Not everyone who says to me ‘Lord, Lord,’ shall enter the kingdom of heaven, but he who does the will of my Father who is in heaven” (Mathew 7:21).  “Orthodoxy, correct opinion, demands orthopraxis: comportment in accord with the opinion expressed.”[9] As a young man I realized this and tattooed the words “al-tafkeer” and “al-tasarruf”, “thought” and “action/behavior”, on my arms to remind me of this life-changing paradigm. ACTION! This is central to Gutierrez’s message.

This simple passage tells us of the birth of a Christian community. “Jesus and the two disciples, with others soon following, share a life. For all of them the following of Jesus entails a commitment to a mission that requires them, like their master to pitch camp in the midst of human history and there give witness to the Father’s love. […] The following of Jesus is not, purely or primarily, an individual matter but a collective adventure. The journey of the people of God is set in motion by a direct encounter with the Lord but an encounter in community: ‘We have found the Messiah’.”[10]

Gutierrez goes on to explain more about encountering Jesus, but for me this passage is the steak of the meal, the rest is carrots on the side. Hope you’re full, come back soon for more.

Post 5

Yesterday was Sunday, our “day off”, which we spent cleaning the storage room of the clinic, an area that had not been touched for 3 years, and earning me the role of spider killer. It was a tough marathon, and I decided to create a vegetable garden for Azucena the same day, adding more work to my plate. Great exercise and feeling of productivity, sad back. At night all the female relatives of our friend Lupita got together at her house to make tamales with chicken and mole or vegetables, kids playing in the corners of the dimly light and smoky room, family friends coming and going, and teenage girls gathering in groups to gossip before breaking off to wander home to start homework. This is what my grandma used to call “beit maftooh,” an “open house”.

Last time we talked about encountering Jesus and the beginning of a “following” or discipleship. The journey that follows from this encounter is called “walking according to the spirit” (Rom. 8:4) by St Paul. Let’s see if this walking is a casual stroll or more of a shake your butt power walk, that is, let’s see what it’s like.

Life in the Spirit: Drawing heavily on St. Paul, Gustavo is going to focus on three terms, “Flesh,” “Body,” and “Spirit,” and the spiritual life that follows from an understanding of these concepts. Flesh signifies the substance of which human beings are made, a material, corporeal, carnal creature. “To live in the flesh, is, therefore, to share the human condition.”[11] But Paul goes on to create a juxtaposition between the “flesh of sin” and the spirit, and behaviors associated with the flesh including “immorality, impurity, licentiousness, idolatry, sorcery, enmity, jealousy, envy, and so on” (Gal 5:19-21). Paul continues with this train of thought by arriving at a logical conclusion: “the flesh leads to death.” If the spirit is walking in the footsteps of Jesus Christ, who is life, then succumbing to the behaviors of the flesh represents the death of the person. Paul uses a strong image: “to serve their own belly” (Rom 16:18). Being preoccupied with filling your belly suggests a selfish self-centeredness.

Guttierez also puts a beautiful emphasis on passages in the Bible that warn about idolizing money: “You cannot serve God and Mammon [money]” (Matthew 6:24); Paul twice says covetousness is idolatry (Col 3:5, Eph 5:5); the scriptures portray oppressors as causing the death of the poor out of sheer voracity: “Have they no knowledge, all the evil-doers who eat up my people as they eat bread, and do not call upon the Lord?” (Ps 14:4); Ezekial says “the people of the land have practiced extortion and committed robbery; they have oppressed the poor and needy, and have extorted from the sojourner without redress (Ezek. 22:27, 29). I think this message is probably one of the most radical of all the concepts in liberation theology—for Christians to be committed to a life of simplicity and poverty is the greatest challenge most people will face in this message, the Christian concept that we most continue to live in denial about. Doing good and taking a vow of poverty are inseparable concepts—a person can be kind, loving, merciful, but also own a disproportionate amount of community resources, and this physical, material concentration of objects that this person owns that could help others become educated, get cleaner water and healthier food, and so forth, in fact causes more harm than all the kindness and goodness this person practices in their everyday interactions.

A classic example for me is those doctors who say “well I am a good pediatrician and treat my patients well” while participating in a corrupt medical system that is not built to serve the community well, and then goes home to a huge villa where they drink imported wine while watching TV on their big plasma screen and enjoying jet-skiing on the weekend…well this is pure hypocrisy. The doctor might actually have studied their butt off to be the best clinician they can be, their patients might objectively feel comfortable and well-served in this physician’s office—but my argument is that the pure material concentration of objects (wealth) that this individual has accumulated actually harms the health of the people in his or her community often just as much as the good deeds of service that the person does in the confines of the clinic. Someone who is a true doctor, someone who truly cares about health, must attack the root cause of poor health—poverty.

And how about the “Spirit”? The spirit signifies a life in accordance with God’s will, specifically that “the fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control; against such there is no law” (Gal. 5:22-23). In a word, the Spirit is life: “To set the mind on the flesh is death, but to set the mind on the Spirit is life and peace” (Rom. 8:6). Here I must emphasize an idea that is crucial to Gutierrez, that the flesh and the spirit do not split people into two entities, physical and mental, material and immaterial, a dualism. The flesh is not the stuff you can touch and the spirit equivalent to a soul. In fact Gutierrez wants to emphasize that the spirit and flesh act on the whole person, body and soul, leading all of the person to choose life or death. Gutierrez emphasizes this many times to avoid confusion about the concepts and probably also to avoid getting into philosophical debates that would side-track his message.

So what do the flesh and spirit act on? The answer is in a section entitled “The Body of Flesh”. The body is a neutral entity which constitutes each person upon which “the flesh as death-dealing power operates, but where at the same time the Spirit, the power that gives life, is also active.” And so Gutierrez opens up to us a spiritual body, not only something in the afterlife, but also here on Earth thanks to baptism and the ability to walk according to the spirit in this life. Finally, he describes the body of Christ as constituting the entire Christian community, body is a factor in solidarity.

In keeping with the tone of Gutierrez, he ends on a hopeful note: “if, because of one man’s trespass, death reigned through that one man, much more will those who receive the abundance of grace and the free gift of righteousness reign in life through the one man Jesus Christ” (Rom. 5:17). Without fear, Gutierrez continues to push us to change history for the better.

Post 6

On his visit to Laguna del Cofre, as part of a visit to Companeros en Salud Mexico I met Paul Farmer ten years after reading Mountains Beyond Mountains. I thought he would have a really alpha male personality and dominate the interaction but he had a gentle demeanor and spent most of the afternoon teaching us in the clinic. I went to the radio station in the center of town to call one of our patients in a neighboring community, a young girl who developed a huge lymph node in her groin after getting a cut on her foot. We wanted to invite her to the clinic as Dr. Farmer, a specialist in infectious diseases, could obviously help us make the diagnosis and help with treatment. After a continuous 15 minutes of the poor girls crying (she cried at the sight of my beard so I hid behind another doctor during the consult) Dr. Farmer considered it to be a common cellulitis and to begin with trimethoprim-sulfamethoxazole + clindamycin which are better absorbed by the gut and better concentrated at the sight of infection than the dicloxacillin we were giving. Dr. Farmer was so supportive, had such positive things to say about Azucena’s work and left us feeling like superstars.

Continuing on with my analysis of Gustavo Gutierrez’s “We Drink from Our Own Wells,” my last two posts described “an encounter with Jesus Christ” and “life in the Spirit” which are two aspects of the Christianity spirituality that Fr. Gutierrez is explaining. The encounter with Jesus Christ was the start of a journey of life in the spirit, which had a moral message of choosing the spirit and life over the flesh and death. Today we begin the “journey to the Father,” an amazing chapter that answers big questions about love, freedom, slavery, service to others, solitude, and “the way.”

Journey to the Father: Gutierrez describes the Christian way as a journey of a people that takes inspiration from the Exodus, in which the Jewish people fled from the fertile soils of Egypt to claim a new land. They broke away from slavery, which is death, and journeyed for forty years in the wilderness. “Why so long a route, why forty years?” asks Gutierrez. He answers that it was a test of the people, a time for God and the people to begin to know each other, and a chance for God to show his love to them by bringing them through it safely and providing for their day-to-day needs—like feeding them with manna from heaven. To Gutierrez, the current journey of the church can draw inspiration from this original journey.

It was a time of freedom! No pathways had yet been created in the wilderness, and it was not an easy journey, with the continuous attraction of the easy way back to slavery, to “the fleshpots of Egypt”. It was definitely a challenging two steps forward, one step back process. But the Jewish people succeeded in their journey so greatly that they speak to Jesus in the Gospel of John many years later saying:

“We are descendants of Abraham, and have never been in bondage to anyone. How is it that you say, ‘You will be made free’?” Jesus answered them, “Truly, truly, I say to you, everyone who commits sin is a slave to sin. The slave does not continue in the house for ever; the son continues for ever. So if the son makes you free, you will be free indeed.” [John 8:33-36].

In this conversation, as we have discussed, the Exodus of the Jewish people marks their freedom. In this passage Jesus goes another step further, responding to these Old Testament ideas by saying that there is a deeper understanding of freedom which is freedom from sin, which exists when a person does the right thing and approaches God. He compares freedom to the intimate relationship between God and his children, which lasts forever, unlike the temporary servitude of the slave.

But the journeying people will not remain in the wilderness forever, they arrive to the Promised Land:

For behold, I create new heavens

And a new earth;

And the former things shall not be remembered

Or come into mind.

But be glad and rejoice for ever

In that which I create;

For behold, I create Jerusalem a rejoicing,

And her people a joy.

I will rejoice in Jerusalem,

And be glad in my people;

No more shall be heard in it the sound of weeping

And the cry of distress.

No more shall there be in it

An infant that lives but a few days,

Or an old man who does not fill out his days,

For the child shall die a hundred years old,

And the sinner a hundred years old shall be accursed.

They shall build houses and inhabit them;
they shall plant vineyards and eat their fruit.

They shall not build and another inhabit;

They shall not plant and another eat;

For like the days of a tree shall the days of my

people be,

and my chosen shall long enjoy the work of their hands.

They shall not labor in vain,

Or bear children for calamity;

For they shall be the offspring of the blessed of the Lord,

And their children with them [Isa. 65:17-23].

This is a world of justice, where “They shall not build and another inhabit, they shall not plant and another eat.” It is a world without the suffering of “weeping and the cry of distress,” a healthy world where no longer is there an “infant that lives but a few days.” These are specific, concrete descriptions of what it means to create heaven on Earth, and Gutierrez is calling us on a historical march to justice and to work together to end suffering here on Earth, now. This is a journey in the wilderness requiring of us to create a new path, to be free, and not to succumb to the old ways, the temptations of Egypt, the easy lifestyle of the flesh that represents death. Next time we will talk about the single unique attribute that defines the Christian promised land, love. Until then, get your mother some flowers.

Post 7

Yes I am actually working, but what sticks in my mind this week has been hiking with our friend Lupita and picking flowers and making tamales and a little soccer and so forth. Somehow the days are melding together in a happy blur. This week was the Spring festival and all the young people had dances and songs and entertainment prepared for the town, Lupitas son won the “King of Spring” event, and there was a Spring dance where I danced with every girl in the town probably. It was in the coffee warehouse with disco lights and an acceptable speaker system, and teens and young adults visiting from surrounding villages, some more than an hour away. And that is the end of these semi-adolescent stream of consciousness musings.

We return to Gutierrez and our topic today, love. Gutierrez ends the “Journey to the Father,” or the final phase in the Christian spiritual journey, with some reflections on what Paul calls “a more excellent way” [Cor. 12:31] or, referred to simply as “the way.” Gutierrez does not explicitly tell us if “the way” represents Christians themselves, or whether it refers to Christian teaching. We go back to my tattoos, “al-tafkeer” (thinking) and “al-tasarruf” (acting), which resolve this dilemma by emphasizing the interconnectedness of thinking and acting—as Gutierrez puts it: “in short, a way of life. […] This manner of life singles out the Christian community in the Jewish and pagan world in which it lives and gives its witness.”[12]

So what is so unique about Christians? What is so defining? What makes “the way” so different that it led to the persecution of the early Christian community, which continues to the present day?

“For the way in question is in fact the way of love that shapes the whole of Christian life because love ‘bears all things, believes all things, hopes all things, endures all things, Love never ends’ [vv. 7-8]. The way of the spirit is the way of love (an idea) that expresses itself in deeds (an action).

But what does love mean exactly, is it like a set of rules that you have to follow mechanically like a computer program:

IF

“child x scrapes knee”

THEN say “it’s ok sweetie”

AND clean “wound”

AND put “Band-Aid”

AND kiss “booboo”

END

If you do the specific action, x, in the specific context, y, then you are loving?

No! To love is actually to be free from such laws, because “if you are led by the Spirit you are not under the law” (Gal. 5:18). You live in the regime of grace: “you are not under the law but under grace” (Rom. 6:14). “The regime of grace” is a place where you can act in love without worrying about if you are healing on the Sabbath and what the Pharisees, or authorities, will think about your behavior. “To follow the way is to love in Christ the Lord (Col. 2:6). For the Christian way is not directed by an external law; it is identified with a person, with Jesus, the free man.”[13]

We need to find creative ways to love by trying to understand the life of Jesus and walk in his footsteps, not by mechanically following laws set down by the church in 1234 A.D. by Pope blah the bloop in the reign of King Henry of Spain. It is a path we collectively create as a community now, in freedom; a movement of the young-minded, of the present; a movement to change history now, to creatively imagine, then take action to implement the kingdom of heaven on Earth. The importance of love in the Christian life and the practice of freedom (from B.S. laws) is so great that it allows Augustine to famously say “Love; then do what you want.” What a liberating statement! What an anxiety-destroying statement!

A wife wants to prepare her husband a lovely meal after work. She spends all day working and stressing, preparing an incredible meal, candles and so forth. The husband comes home tired from a long day at work dealing with an abusive boss and the only thing he wants is a little time alone. The wife is angry when her husband does not give her attention and affection, and takes it out further on her husband. Was it loving to create this beautiful meal? Wouldn’t love have actually been just to give her husband space? This is an example of flipping the conventional rule-based idea about love.

And do you have to be around people, loving all the time, in the community hugging and kissing and asking about each person’s day and how they are feeling constantly and continuously? Isn’t this draining after a while? Doesn’t it have the potential to create a kind of fake interest in others on those days when you are tired and honestly do not care, when you are feeling burnt-out? We are human beings after all, not love machines. Well Gutierrez allows us to “breath” spiritually by emphasizing again the importance of solitude in allowing us to love:

“Like the Jewish people in the wilderness, one traveling this road travels in the greatest solitude. Solitude, but not selfish withdrawal, is a central factor in every experience of God, for it is in the wilderness that God speaks to us: ‘I will allure her, and bring her into the wilderness, and speak tenderly to her’ (Hos. 2:14). Solitude thus understood has nothing to do with individualism.”[14]

This is not individualism he explicitly states, a selfish disconnection from others. Rather, solitude is a way to “create an authentic disposition” for communion. Without solitude we cannot find the natural hunger to be with others, to share their experiences. Solitude occurs in is this journeying into the wilderness that we saw in the Exodus that creates a freedom to follow a new path to love.

The heart of what we have just studied is this: “Every spirituality is a way that is offered for the greater service of God and others: freedom to love.”[15] Gutierrez has described a new spirituality based on his experience and the experience of many people surrounding him that offers a new way of being Christian, a new spirituality based on the experience of the poor in the present time. “Walking according to the Spirit” is a communal, not individual activity. This does not mean we no longer make personal decisions, but rather situates every person’s individual actions in the context of a historical, spiritual movement. We can change history, each of us, every day, in the choices we make.

A friend asked me what I think about Liberation theology. I replied that I would like to live this spirituality, but we have no such collective historical spiritual movement in Lebanon—although I have close friends in the Church, I am exploring the spirituality of Liberation Theology alone. Certainly many of my friends follow “the way,” sacrificing their weekends and working late into the night for others, but always in a historically unfocused way. I am writing these words in the hope that perhaps some seeds can be planted among readers in my country to begin a collective, organized, and historically grounded encounter with Jesus and journey of the Spirit. As I write these words in April 2014, with one million new Syrian refugees, the same political crises we have been dealing with for forty years, still no consistent electricity, water, sewage, rampant corruption and sectarianism pervading every aspect of public and private life, Lebanon needs all the love it can get.

Post 7

I have been transferred away from Azucena and Laguna del Cofre to work with Lizbeth in Reforma. As opposed to a 3 hour truck ride to get to Laguna from the nearest city, Reforma is only 40 minutes away from Jaltenango and this accessibility to the city meant that we could go there after work daily to check our email and work on the internet. This meant less time in the community, and being less integrated into the lives of the community was the biggest difference I felt between Laguna and Reforma. The Mexican “Secreteria de Salud” sets strict and extensive paperwork requirements for the pasantes, and this causes the pasantes great stress as their social service year is approved by the Secretaria. If they are perceived as doing a poor job their clinic might not be approved, theoretically wasting a year of their lives. After an inspector from the Secretaria came to inspect Lizbeth’s clinic and said that a lot of the paperwork was not in order, she asked me to come help sort through about 600 family files and review them to make sure there were no missing papers and that they were all signed. This task will occupy most of my last two weeks in Chiapas.

Continuing our academic journey, let us summarize what we’ve studied together in Gustavo Gutierrez’s “We Drink from Our Own Wells.” We started with a chapter where Gutierrez describes great poverty among the people of Latin America, stating that despite this suffering this is a time of hope. We read his exploration of the Bible to describe the three components of Christian spirituality, “Encounter with the Lord,” “Walking According to the Spirit,” “Journey to the Father,” that he will develop in his Theology of Liberation, a spirituality that he puts in the same family as the Ignatians, the Carmelites, the Franciscans and others. And now in the upcoming post we are ready to explore some of the most famous concepts in Liberation Theology such as the “Preferential Option for the Poor,” and some of the key concepts that underlie Paul Farmer’s theories about Structural Violence.

Father Gutierrez begins the third, and final section of his book with a liberating concept, being “Free to Love.” Let us say that you have gone along on this journey with me and accepted everything that Gutierrez has been writing. You are free to choose a path now in solidarity with the poor. This decision to practice solidarity with those facing death is not influenced by any external forces, it is a free choice made out of love, as Jesus did: “No one takes it [my life] from me, but I lay it down of my own accord” (John 10:18). Trying to understand this freedom, Gutierrez refers to St. Thomas Aquinas to distinguish between freedom from, and freedom for:

“Freedom from” refers to freedom from sin, from selfishness, from injustice, from need; all these are conditions that call for a liberation. “Freedom for” states the purpose of the freedom acquired: freedom for love, for communion; attainment of love and communion is the final stage in liberation. “Free to love”: this phrase, inspired by Paul (another text in the same line is that of 1 Cor. 9:19: “though I am free from all men, I have made myself a slave to all”), expresses the full meaning of the process of liberation to which many Latin American Christians are committed. In the final analysis, to set free is to give life—communion with God and with others.”[16]

Freedom for communion and love—sounds lovely, but practically what we are we going to do now Gustavo? On one hand you are free—you’re going to break from your old life by turning off your television, reevaluating priorities, reorganizing your personal space, etc.—on the other hand you are committed to traveling through the wilderness to begin a new journey. “Sell all that you have…and come, follow me” (Luke 18:22). This may be a bewildering, overwhelming situation…where to begin? Gutierrez is going to give us some concrete tips about what how to make use of our “freedom to love,” we will take the first concrete steps to walking this spiritual path together.

Acknowledgement of Sin: Gutierrez begins with a classic Christian starting point, the acknowledgement of the original sin of Adam and Eve, and of the personal need to acknowledge that every one of us sins and needs forgiveness. He quotes a Christian community in Peru who are able to publically express this: “There are defects in our lives. Sin is among us too, and we are not always faithful. We do not always live up to our commitments; there are little betrayals, acts of cowardice, falls, selfish and underhanded actions.”

He continues by describing sins of omission, in which we keep silent in the face of injustice. This goes back to the example I gave in the section about “Life in the Spirit” in which an average doctor at an average hospital who studied hard and treats his patients well in the clinic, still, to me, is failing because of all the things he is not doing. Of compartmentalizing injustice and working as if it can be contained and given a prescription for within a 30 minute clinical visit.

And the last type of sin is described as a social sin: “The luxury of a few becomes an insult to the wretched poverty of the vast masses. This is contrary to the plan of the Creator and to the honor that is due him. In this anxiety and sorrow the church sees a situation of social sinfulness, all the more serious because it exists in countries that call themselves Catholic and are capable of changing the situation” (PD, no. 28).[17] Archbishop Romero states it similarly: “Nowadays an authentic Christian conversion must lead to an unmasking of the social mechanisms that turn the worker and the peasant into marginalized persons. Why do the rural poor become part of society only in the coffee-and cotton-picking seasons?”[18] And here Gutierrez responds to these quotes with a beautiful insight that makes his theory so interesting and powerful to me:

“For a long time this perspective has perhaps been absent from the treatment of the theme in spiritual literature; today, however, it cannot be neglected. The encounter with the Lord in the inmost recesses of the individual does not exclude but rather calls for a similar encounter in the depths of the wretchedness in which the poor of our countries live. […] But how can we do this and achieve solidarity with the poor if we do not understand the structural causes of ‘this situation of pervasive extreme poverty’ that gives rise to the suffering?”[19]

BAM! To understand and respond to suffering we need to understand history, to understand economics, to educate ourselves about the world around us, and not to curl up into a fetal position of innocent silence. For me, claiming innocent silence amounts to a sin of omission, like an ostrich sticking its head in the ground and thinking it is safe. The world demands us to charge forward. To battle! Indeed, spirituality demands this!

And the personal and social are one interconnected structure: “The consequences of such a recognition are clear. It becomes necessary for us to examine our own responsibility for the existence of unjust ‘social mechanisms.’ In addition to calling for a personal transformation, the analysis will in many cases mean a break with the social milieu to which we belong.”[20] Poverty that results from our purchases, from the way we vote and the personal choices we make every day cause death—this is obvious in the clinic when we see someone dying because of a cheap medication that they could have taken if they just had the money for transportation to get to the clinic where the medication was being offered for free. And here I will make a small reminder of the future poverty we are choosing for our children every day based on the sustainability of our current lifestyles, which alters the planet they will one day inhabit. But do not be depressed and cynical, for the next section is entitled “The Way of Life.”

Post 8

After a long day with me reviewing paperwork and Lizbeth in the clinic, we would go to the city, Jaltenango, so Liz could use the internet. She needed to register for an exam she will take in August in order to apply for residency. With Liz I saw several patients with fungal ear infections because Reforma has a nearby river. We also saw a confusing case of a woman with a hard abdominal mass and nausea—after making our differential and analyzing the possibilities we performed an ultrasound under the supervision of Patrick, our clinical director—the obvious diagnosis, pregnancy! A third interesting case was a man who developed an itchy groin rash that sounded like a sexually transmitted infection immediately after having received the treatment for sexually transmitted infections. We just retreated and ran an HIV test to make sure we weren’t missing anything. This was the first patient in the more than 1 month that I’ve been in Chiapas who we considered ordering blood labwork for. Coming from Lebanon where we order a complete blood count for every patient with the common cold, this has been an amazing experience in respecting the value of a good history and physical exam.

Gustavo Gutierrez time. Last time Gustavo insisted we openly express the fact that we sin, including the “social sins” that we commit every day in our political and economic choices. Acknowledging all this sin was depressing, and today we will figure out how he suggests we act to deal with this big ball of sin and suffering.

The Way of Life: So we are sinners, and we openly admit it…now what? Gutierrez continues with a very classical Christian line of argument:

to acknowledge our sins implies the will to restore broken amity. […] The God of the Bible manifests fidelity and mercy in a permanent disposition to pardon: ‘The steadfast love of the Lord never ceases, his mercies never come to an end’ (Lam. 3:22-23).

This attitude of God must serve as a model for the people of God. […] Pardon is an inherent characteristic of the Christian community. To pardon means not to fixate the past, but to create possibilities for persons to change and to realign the course of their lives. […] Pardon forges community. […] Pardon implies forgetting, canceling out a past of death and initiating a new era characterized by life. […]

The Lord is the one to whom we say, “Thou dost show me the path of life” (Psalms 16:11). [21]

This personal journey that pardon opens up takes the form of “an option in behalf of life”21. And repeats many of the themes we saw earlier, for example that because we do not merely want to “build bridges” to being with the poor, with those that live with premature death, this option for life should occur in solidarity, by partaking in their social context—not for 3 hours on a medical mission on the weekend to help us deal with the guilt we feel in the face of injustice—but rather in our daily life choices. And returning to his emphasis on “the body of Christ,” the community of believers, and the importance of collective historical action, he says that “this way of solidarity is not to be undertaken by isolated individuals,” but rather by “the entire church.”[22]

To summarize we go to the words of Clergymen in Santiago, Chile, who Gutierrez quotes: “To give food to the hungry…drink to the thirsty…clothing to the naked…shelter to the homeless…and to welcome the stranger are actions so basic that at the end of time we shall have to render an account of them. Solidarity is written into the very substance of the church.”[23]

The Material and the Spiritual: Gutierrez discusses the importance of material things in the context of spirituality—specifically that the form our expression of love and life takes is often physical—food, clothing, healing bodies. What Gutierrez wants to argue is that this activity is more than an expression of the social dimension of faith, rather it is at the heart of the encounter with God, quoting Mathew 25:35-36:

“For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me. […] What you do to the most wretched you do to me.”

The fact that this type of work is an encounter not only with other human beings but also with God evokes our surprise,

“When did we see you hungry? […] It is a work of love that implies a gift of self and is not simply a matter of fulfilling a duty. […] The solidarity is not with ‘the poor’ in the abstract but with human beings of flesh and bone. Without love and affection, without—why not say it?—tenderness, there can be no true gesture of solidarity. Where these are lacking there is an impersonality and coldness (however well intentioned and accompanied by a desire for justice) that the flesh-and-blood poor will not fail to perceive. True love exists only among equals.”[24]

I want to add another dimension to Gutierrez’s idea about the material, and it is that providing clothing, food, healthcare, are all skill intensive processes—medicine, supply chains, the psychology of adherence to treatment, the anthropology of a community and how to work effectively in that community all require us to gain concrete skills, to strengthen our minds and bodies, and not simply to have good intentions. Our own personal growth in knowledge, physical strength, and life skills provide us with the opportunity to serve other people in ways that we could not otherwise do. This is the basis for a “calling” like being a physician, priest, or social worker. I’m arguing that spirituality demands specific skills to be effective.

Post 9

Along with a visiting doctor from Mexico City I visited the “urban village” today, a refugee housing project that was created after Hurricane Stan triggered huge mudslides and flooding in 2005. We talked to the representative of one of the largest communities, “Columbia,” that had moved there. The community of Columbia continue to travel up to their village in the mountains to farm coffee part of the season and return to the urban village in the city for the rest of the season as they feel there is a better education and lifestyle there. This is similar to the classic migration pattern of Lebanese people who live in their villages during the cool summer and Beirut during the cold winter.

It was a massive cash investment by the government, who basically built an entire community including schools, shops, water, electricity, sewer systems, garbage disposal and is still investing in the community to try to create jobs for people. The biggest and obvious critique is that the gorgeous looking solar-panel based street lights and electric taxi cars that the government provided so that people in the community could work as taxi drivers soon broke down and with no skilled people to repair them are now a pile of junk. Greenhouses that were built to farm vegetables were blown away in a storm, leaving only metal tubes like the bony carcass of a dead animal. On a positive note, there was a functioning chicken egg hatchery which was employing about a dozen men from the community (from a total population of 2,000).

When I compare this to the Syrian Refugee crisis I see that the people here in Mexico live so much better than the Syrians as a result of this project—but at what cost? I don’t have the numbers to analyze if this is cost-effective, to understand the full ramifications on sustainability and how moving people in this way will impact the economic and social health of the region—but my impression on the surface is that the Mexicans did better than anything I have seen yet in Lebanon, granted that it is on a far smaller scale compared to what the Lebanese are facing. It would be extremely interesting, for those interested in urbanization, to study what happens to the values of a village community when they are shifted to an urban setting in a single generation. Children from the community of Columbia are growing up like “city kids” according to what I heard from their leader.

We have been talking about Gustavo Guttierez’s concrete recommendations for how to live out Liberation Theology, how we deal with being “Free to Love.” The last section after acknowledging our own sins and acting for life is not to give up, also known as…

Consistency and Stubbornness: I will quote a couple paragraphs to summarize Gutierrez’s last thoughts on being “Free to Love”:

“The new way that we undertake and to which we are constantly being converted calls for constancy and deep conviction. […] Teresa of Avila says of those who would have such steadfastness:

It is most important—all-important, indeed—that they should begin well by making an earnest and most determined resolve not to halt…whatever may come, whatever may happen to them, however hard they may have to labor, whoever may complain of them, whether they reach their goal or die on the road…whether the very world dissolves before them.

This “determined resolve” is what I have been calling “stubbornness.” It is the steadfastness of those who are convinced, those who know what they want, those who put their trust in the Lord and devote their lives to others: “Those who trust in the Lord are like Mount Zion, which cannot be moved, but abides forever” (Ps. 125:1).

As a good friend recently told me here in Chiapas: “people who say that social workers do not need to suffer in order to do their work are people who have not done it for long periods of time—after long periods of time everyone who does this work suffers. But what is important is that your love is always greater than your suffering, for otherwise you get burned out, the quality of the work is affected, you become bitter.”

And that, my friends, is the end of the process of being “Free to Love”. The four steps include:

1)      Acknowledging our sin, which requires some education about history as well as an understanding of the network of social and economic relations in which we exist.

2)      The Way of Life, to go from these sins to concrete action for life.

3)      The Material and the Spiritual, in which we talk about concrete objects that we need to provide people like food and clothing, which entail skills we must acquire (this is a theme Gutierrez will develop a bit later.)

4)      Consistency and Stubbornness, where we persist on our path despite suffering.

So go love! See you soon.

Post 10

Today our journey together comes to an end. This last-mega post will summarize four final Gustavo Guttierez chapters and wrap up my final days in Chiapas.

After my time doing paperwork in Reforma I returned for a couple more days of clinical work in Laguna with Azucena. I also wanted to visit Luis, a pasante who completed his service year last year and was returning this year for social visits and to launch a home that would be controlled by the women in the community, a move to empower them. Part of his motivation was seeing so much alcohol-related domestic violence—for example, one of his patient’s last year had suffered a lot of sexual and physical abuse, frequently binge-drank (drinked?) and had several children that were not being cared for. When confronted with this fact the mother would automatically deliver a set of Christian quotes to appease the expectations of her interlocutor like “I believe in God, the savior. Thanks to the Virgin Mary I have life and thank her for her blessings and the church…” and repent but her behavior would not change… In the absence of an orphanage, government involvement, foster care, etc. I heard many other women complain about being beaten by their husbands or fathers. Perhaps Luis’ project will allow the women a safe space to help them deal with these sorts of problems. Interestingly, in Honduras the punishment for beating your wife is house arrest—obviously this means it usually goes unreported.

Seeing the rapport and relationship that Luis had with the community really inspires me as a role-model for what I want to do in Lebanon. He really connects to people, is greatly respected, and is deeply trusted by many despite being from Monterrey, many hours (or days?) bus ride away. When he spoke at a big public gathering it was inspiring to see the huge public support from the women in the community.

In this last, large post exploring Gustavo Gutierrez’s “We Drink from Our Own Wells” I will summarize the last four themes: “Joy,” “Spiritual Childhood,” “Community,” and an interesting concept called “Gratuitousness” with which we will begin.

Gratuitousness: Gratuitousness is the free love which God has given us, the encounter with Jesus—even Genesis and the creation of the universe were an act of love. But does this mean that it is enough to want to do good, to have good intentions, even when you suck at it?  Like the ostrich I described before, can we stick our heads under the “ground of good intentions” and say that our attempt to do good is enough? Or do we have to be effective? Is love “reducible to energy expended in the service of human development?”[25]

Gutierrez answers this with two main statements as I see it:

Statement 1: “Authentic love tries to start with the concrete needs of the other and not with the “duty” of practicing love.”[26]

Many people have asked me “why do you want to go practice medicine in Guatemala or Mexico?” It is not because I feel a duty to be good, to love, and I wake up in the morning looking for random people to give money to and hug…it is rather because after living in Guatemala and experiencing what the people there are experiencing—children without adequate nutrition, education, clothing, clean water—I wanted to participate in their communities and be a positive presence.

Would I go to Mexico or Guatemala if I was just a tourist, unable to make any positive contribution, ineffective at meeting any of the challenges the community is facing? Probably not. So if we actually care about the “concrete needs of the other” and not just about our “duty to Jesus” then, Gutierrez continues:

Statement 2: “Concern for effective action is a way of expressing love for the other.”

And this is not a balance between gratuitous “love energy” which flows from us and cold-hearted statistical effectiveness, but rather:

“Gratuitousness is an atmosphere in which the entire quest for effectiveness is bathed. It is something both subtler and richer than a balance maintained between two important aspects. [… This perspective] locate[s] efficacy in a comprehensive and fully human context that is in accord with the gospel. That context is the space of freely bestowed encounter with the Lord.”

Beginning with this perspective rejects the killing of one person to cure ten, it even rejects a debate about the subject, which might occur if we were to prioritize effectiveness or try to balance effectiveness and gratuitousness. And prayer can grow in the shadow of gratuitousness, because if we prioritized effectiveness then why would we waste our time praying when we could be feeding orphan babies? Prayer is a form of gratuitous love that we can spill out into the cosmos. And in the clinic listening to depressed patients I often relate to Gutierrez’s beautiful phrase that “Simple and silent presence is a touchstone of love”—gratuitous love can even take the form of silent presence.[27]

Joy: We will begin with Gutierrez’s poetically bleak description of poverty:

“It is a frightening and deeply saddening experience to come in contact […] with the miseries that descend upon the poor in an endless procession. There are countless small things: wants of every kind, the abuse and contempt that the poor endure, lives tormented by the search for employment, incredible ways of earning a living or—more accurately—earning a crust of bread, mean bickerings, separations of family members, sicknesses not found at other levels of society, infant undernourishment and death, unjust prices for products and commodities, total confusion about what is necessary for themselves and their families, delinquency springing from abandonment or despair, the loss of one’s own cultural values.”

So how does one feel joy in such a context? By drinking a bottle of tequila? By finding a woman, you lonely men? Escaping reality by reading fantasy novels and watching movies? And anyone who has been hungry knows the inner fatigue that chronic hunger does to a person, outside one may be smiling, but this is a performance as hunger sucks the inner pleasure out of life.

Gutierrez has observed a joy arising from hope. This hope arises in communities in their struggle for liberation from the conditions that lead to suffering, in the joy that arises from a deep knowledge of the Easter message, in the faith that Christ has been born again, in the knowledge that the universe is fundamentally a good place and that suffering will always be temporary. Whether temporary because joy will be found again in heaven, or because oppression will be wiped out here on Earth, the hope that goodness will prevail leads to a joy that creeps out in celebration and grows to efface day-to-day sadness.

And Gutierrez talks about martyrdom in this context, as many have lost their lives in the struggle for injustice in present day Latin America. Martyrdom is considered a good thing, but what does it mean? A friend of mine here in Chiapas and I were discussing ritualistic, non-fatal, self-crucifixion, a cultural component of some Mexican Christian communities (not here in Chiapas), and my immediate reaction was revulsion. “The way to give of yourself,” I said in that context, “is to work to serve other people, to direct your energy in a positive way, not to hurt yourself. I don’t think this is what God would want us to do.” Giving your life or hurting yourself for your faith is only done when necessary, not in a dramatic performance, but quietly. Gutierrez quotes Luis Espinal who says:

The faithful do not have a vocation to be martyrs. When they fall in the struggle, they fall with simplicity and without posing…. Light ought to be given by working, not be dying. Away with the slogans that create a cult of death! … The revolution calls for human beings who are lucidly conscious; realists who have ideals. And if the day comes when they must give their lives, they will do it with the simplicity of someone who is carrying out one more task, without melodramatic gestures.

In summary, Gutierrez situates joy in something I will call Christian historical realism (I made that label up) with phrases such as this: “Joy springs therefore from the hope that death is not the final word of history.”[28]

Enough about joy.

Spiritual Childhood: Gutierrez repeats many ideas he has already touched on, that it is not enough to build bridges to the poor, to see their communities as a place of work, but rather we need to take up these communities as a place of residence:  “It does not mean going into that world by the hour to bear witness to the gospel, but rather emerging from within it each morning in order to proclaim the good news to every human being.” (my italics)[29]

He goes on to call not only for material poverty, but also something he calls spiritual poverty: “Medellin … does not present spiritual poverty primarily under the aspect of detachment from material goods. … It identifies spiritual poverty with spiritual childhood.”[30] Gutierrez doesn’t go into a lot of detail about spiritual poverty, spiritual childhood and what they mean. I will hazard a guess from what I gathered from reading him that spiritual childhood is an attitude of humility that begins with saying “I do not claim to know, I look to God, my father, for guidance.” From this emptiness, this statement of openness to spiritual experience, one can grow in their interaction with others and with God. Without the humility of a child we may think we know better and close off a new path. Gutierrez emphasizes often that this spiritual childhood is just as central as material poverty, but he does not flesh out its details. We move on.

Community: In this last section Fr. Gutierrez again describes the relationship between solitude and community as he did earlier in section 2. Solitude is a deep aloneness that can be experienced even while completely surrounded by others, and a positive energy-recharging, decision-making in the uncharted desert time. It avoids individualism and selfishness, and allows an authentic experience of engaging in community. But I think in this section Gutierrez wants to give us direction and words of encouragement on a personal level that he did not focus on earlier in his book:

When they find themselves alone—and there are many kinds of solitude—many persons would like to rewrite their lives; they wish they had not done or said this or that. Not all wishes at such a moment are dictated by a healthy self-criticism; weariness plays a part, as does cowardice and even despair at the thought of the many obstacles and misunderstandings that must be overcome. There are also moments for great decisions in which nothing is clear, but a decision must nonetheless be made. There are no fixed points of reference. All that remains is the conviction that one wants to do the Father’s will and serve the people, but the moment is so filled with spiritual aridity that despite one’s conviction one’s tongue cleaves to the roof of one’s mouth (Ps. 137:6).

Gutierrez compares this later to living inside a tunnel in which we are journeying with no end in sight. This is the journey in the wilderness. This is the Exodus. We travel alone on uncharted paths, but eventually we reach the promised land. The escape from solitude is community. Community is the proclamation of the good news after the journey in the desert; we cannot experience community without an authentic experience of solitude. Through mass, communion, and just getting together with the people we love we experience hope and joy to warm us in the bitter night.

Thank you for sharing this journey with me. By exploration Gustavo Gutierrez’s words I have tried to deepen my understanding of “the good life,” and in the process hope that I have been able to share his beautiful ideas with you too. I leave you with a conclusion:

“Spirituality is a community enterprise. It is the passage of a people through the solitude and dangers of the desert, as it carves out its own way in the following of Jesus Christ. This spiritual experience is the well from which we must drink. From it we draw the promise of resurrection.”[31]

In his book Gutierrez states a bedrock concept of good theology: that theorizing comes after a lived experience. (Similarly, Paul Farmer’s structural violence is understood in the context of a lived experience with the poorest—theory grows from reflection on particular experiences). He cites such authorities as the Gospel of Luke, St. Anselm, and Thomas Aquinas who approached theology not as an academic exercise, but as a way of dealing with a lived experience. And so I encourage you, dear reader, to come visit Chiapas, or live with the communities that are most marginalized nearest you. I have learned more from the people of Chiapas than any textbook.

 

[1] “We Drink from Our Own Wells” page 10.

[2] “We Drink from Our Own Wells” page 17.

[3] “We Drink from Our Own Wells” page 20.

[4] “We Drink from Our Own Wells” page 25.

[5] “We Drink from Our Own Wells” page 27.

[6] “We Drink from Our Own Wells” page 31.

[7] “We Drink from Our Own Wells” page 34.

[8] “We Drink from Our Own Wells”, page 39.

[9] “We Drink from Our Own Wells”, page 50.

[10] “We Drink from Our Own Wells”, page 41, 42.

[11] “We Drink from Our Own Wells”, page 56.

[12] We Drink from Our Own Wells, page 81.

[13] We Drink from Our Own Wells, page 82.

[14] We Drink from Our Own Wells, page 86.

[15] We Drink from Our Own Wells, page 89.

[16] We Drink from Our Own Wells, page 92.

[17] We Drink from Our Own Wells, page 161.

[18] We Drink from Our Own Wells, page 98.

[19] We Drink from Our Own Wells, page 98-99.

[20] We Drink from Our Own Wells, page 99.

[21] We Drink from Our Own Wells, page 99-100.

[22] We Drink from Our Own Wells, page 101.

[23] We Drink from Our Own Wells, page 101.

[24] We Drink From Our Own Wells, page 104.

[25] We Drink from Our Own Wells, page 108.

[26] Ibid.

[27] We Drink from Our Own Wells, page 111.

[28] We Drink from Our Own Wells, page 118.

[29] We Drink from Our Own Wells, page 124.

[30] We Drink from Our Own Wells, page 126-7.

[31] We Drink from Our Own Wells, page 137.

Posted in Uncategorized | Leave a comment

Chiapas 15

(If this is the first time you see this blog I suggest starting to read from “Chiapas 1″ and onwards so that it all makes more sense.)

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town "Here the people order, and the government obeys."

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town “Here the people order, and the government obeys.”

A photo of where the pacifist resistance group Las Abejas was killed and buried.A photo of where the pacifist resistance group Las Abejas was killed and buried.

photo (5)

A Zapatista school

A Zapatista school

Lucky 13 will be my final post, and as I sit in the Jaltenango office waiting to fly home in a few days–doing hardcore Excel and Access manipulations to support the pasante’s information technology system and researching Chiapas history, I am enjoying a light 38C fever and stomach ache. After the course the team have each gone their separate ways, some back to work in their communities and some to vacation, and I am locked up in the office trying to accomplish something productive to contribute to the team.

This final post will focus on the Zapatista movement and its influence, and a brief note on the threat of mining corporations.

On January 1, 1994, rumors of war traveled throughout the Sierra Madre. It was said that “indigenous brothers” had taken over the municipal capitals of Altamirano, Chanal, Huixtan, Las Margaritas, Oxchuc, Ocosingo, and San Cristobal.1 That day the local radio station did not broadcast, and people would later learn that the indigenist radio station had been occupied by Zapatista troops and that technical problems had prevented them from broadcasting to borderland inhabitants “The First Declaration of the Lacandon Rain Forest,” a beautifully written document that summarizes some of the history we reviewed together in my posts:

TO THE PEOPLE OF MEXICO:

MEXICAN BROTHERS AND SISTERS:
We are a product of 500 years of struggle: first against slavery, then during the War of Independence against Spain led by insurgents, then to avoid being absorbed by North American imperialism, then to promulgate our constitution and expel the French empire from our soil, and later the dictatorship of Porfirio Diaz denied us the just application of the Reform laws and the people rebelled and leaders like Villa and Zapata emerged, poor men just like us. We have been denied the most elemental preparation so they can use us as cannon fodder and pillage the wealth of our country. They don’t care that we have nothing, absolutely nothing, not even a roof over our heads, no land, no work, no health care, no food nor education. Nor are we able to freely and democratically elect our political representatives, nor is there independence from foreigners, nor is there peace nor justice for ourselves and our children.

But today, we say ENOUGH IS ENOUGH.

We are the inheritors of the true builders of our nation. The dispossessed, we are millions and we thereby call upon our brothers and sisters to join this struggle as the only path, so that we will not die of hunger due to the insatiable ambition of a 70 year dictatorship led by a clique of traitors that represent the most conservative and sell-out groups. They are the same ones that opposed Hidalgo and Morelos, the same ones that betrayed Vicente Guerrero, the same ones that sold half our country to the foreign invader, the same ones that imported a European prince to rule our country, the same ones that formed the “scientific” Porfirsta dictatorship, the same ones that opposed the Petroleum Expropriation, the same ones that massacred the railroad workers in 1958 and the students in 1968, the same ones the today take everything from us, absolutely everything.

To prevent the continuation of the above and as our last hope, after having tried to utilize all legal means based on our Constitution, we go to our Constitution, to apply Article 39 which says:

“National Sovereignty essentially and originally resides in the people. All political power emanates from the people and its purpose is to help the people. The people have, at all times, the inalienable right to alter or modify their form of government.”

Therefore, according to our constitution, we declare the following to the Mexican federal army, the pillar of the Mexican dictatorship that we suffer from, monopolized by a one-party system and led by Carlos Salinas de Gortari, the maximum and illegitimate federal executive that today holds power.

According to this Declaration of War, we ask that other powers of the nation advocate to restore the legitimacy and the stability of the nation by overthrowing the dictator.

We also ask that international organizations and the International Red Cross watch over and regulate our battles, so that our efforts are carried out while still protecting our civilian population. We declare now and always that we are subject to the Geneva Accord, forming the EZLN as our fighting arm of our liberation struggle. We have the Mexican people on our side, we have the beloved tri-colored flag highly respected by our insurgent fighters. We use black and red in our uniform as our symbol of our working people on strike. Our flag carries the following letters, “EZLN,” Zapatista National Liberation Army, and we always carry our flag into combat.

Beforehand, we refuse any effort to disgrace our just cause by accusing us of being drug traffickers, drug guerrillas, thieves, or other names that might by used by our enemies. Our struggle follows the constitution which is held high by its call for justice and equality.

Therefore, according to this declaration of war, we give our military forces, the EZLN, the following orders:
First: Advance to the capital of the country, overcoming the Mexican federal army, protecting in our advance the civilian population and permitting the people in the liberated area the right to freely and democratically elect their own administrative authorities.
Second: Respect the lives of our prisoners and turn over all wounded to the International Red Cross.
Third: Initiate summary judgments against all soldiers of the Mexican federal army and the political police that have received training or have been paid by foreigners, accused of being traitors to our country, and against all those that have repressed and treated badly the civil population and robbed or stolen from or attempted crimes against the good of the people.
Fourth: Form new troops with all those Mexicans that show their interest in joining our struggle, including those that, being enemy soldiers, turn themselves in without having fought against us, and promise to take orders from the General Command of the Zapatista National Liberation Army.
Fifth: We ask for the unconditional surrender of the enemy’s headquarters before we begin any combat to avoid any loss of lives.
Sixth: Suspend the robbery of our natural resources in the areas controlled by the EZLN.

To the People of Mexico: We, the men and women, full and free, are conscious that the war that we have declared is our last resort, but also a just one. The dictators are applying an undeclared genocidal war against our people for many years. Therefore we ask for your participation, your decision to support this plan that struggles for work, land, housing, food, health care, education, independence, freedom, democracy, justice and peace. We declare that we will not stop fighting until the basic demands of our people have been met by forming a government of our country that is free and democratic.

JOIN THE INSURGENT FORCES OF THE ZAPATISTA NATIONAL LIBERATION ARMY.
General Command of the EZLN2

Where did this movement that burst forth in 1994 come from? Apparently in the 1970s indigenous people from all over the state were gathering together to colonize a rain forest East of the Sierra area where our medical team works. Immigrant Guatemalans and mestizo peasants converged with indigenous people of many ethnicities along with a Maoist organization called Popular Politics. The exchange of experiences has allowed many global perspectives and political and religious ideologies to coalesce into a political-military movement.3 After the Zapatista uprising the government set up a huge military base nearby, but this did not deter local communities who now felt a radical sense of empowerment. On January 27, 1994, the Mam Supreme Council of the lowlands led a demonstration in front of the local office of the Ministry of Agrarian Reform, demanding restitution of the lands of Finca La Patria (remember Fincas are the old farms that began during plantation times, 1910-1930s): “If you are not going to grant us the rights over our ancestral lands, then make the necessary formalities so that our fifty families can have passports to go work in the United States, for we are already foreigners in our own territory, being displaced by finqueros from other countries who have become lords of the Soconusco.”4 (Recall the finqueros that started in plantation time 100 years ago were American, German, Swiss, Italian, Ladino, and of other international origins, and apparently the people see this as unchanged to this day.) A flurry of peaceful civil protests supporting the Zapatista cause began throughout Mam and Sierra populations, causing friction in indigenous organizations when some members chose to support the cause while others preferred to stay out of the conflict. “The organization, the religious group, the community, and even the family are now crossed over by a line dividing those who favor the Zapatistas and those who favor the government[!]“5

Since the first violent conflict with the government, which became a ceasefire within weeks due to international pressure, the Zapatistas have operated peacefully and are actually running the government instead of the federal government in several municipalities in the area. In December, 2012 a silent march demonstrated to the world that the Zapatista are still active, still working hard in their communities. To quote Roar Magazine: “The Story of the Sword” is an ancient parable that demonstrates how the indigenous peoples of Mexico can finally defeat the European invader. “The tree”, says Subcomandante Marcos when narrating the story, “tried to fight the sword, but was defeated. The stone likewise.” But not the water. “It follows its own road, it wraps itself around the sword and, without doing anything, it arrives at the river that will carry it to the great water where the greatest of gods cure themselves of thirst, those gods that birthed the world, the first ones.”6

I asked a friend I met who had visited Zapatista areas to get a personal account of a Zapatista’s life:  “The Zapatistas are campesinos. They work in their lands. They suffer a lot because they are separate from the system. Both men and women work hard, and they share food–they barter e.g. jam for coffee. They feel that they are a different community because they have dignity–and this comes from having autonomy. They have a hospital and clinics in each town served by health promoters. The level of education of these medical personnel is not the highest but they are open to any volunteer who wishes to teach. Preventive care did not seem to be prominent, but they seemed to have the same medications as the government hospital.”

When I asked this friend about a critique of the Zapatistas, that the community is very hierarchical, that Sub Commandante Marcos and his colleagues are very controlling of the population, he responded: “In fact I was told that the government is a direct democracy: all decisions are made by every member of the community, both men and women. In Zapatista communities the women’s voice is more heard and respected, and they are leaders in feminist thought. Zapatista feminist claims have trickled into other communities of Chiapas. When the decision requires coordination between many municipalities a representative is chosen to represent the opinion of the town. If this representative gives his own opinion instead of the communities opinion she or he is immediately deposed.” When someone asks them “Can I work with you?” The answer was “We are not looking for people to join us. We are asking people to join the revolution. We don’t need more people.”

A final challenge to the Zapatista model is their application of communism. So if someone works hard he or she does not receive more, he still needs to distribute his production to his neighbors. If a Coca-Cola is being drunk, everyone has to drink it together… Some people have emigrated to the United States when given the opportunity because of their distaste for this system. Let me end this summary of the Zapatistas by saying that first, to be clear Companeros en Salud is not affiliated with this group, that the Zapatista communities work very hard and suffer, and that their lives are not a romantic vacation in the jungle. Perhaps this is the cost of human dignity, and perhaps it is too high a price for most people to pay. The comforts that the mass market and multinational politics can bring are tempting.

Before ending I will describe a new controversy with the government pushing privatization of ejido land (land that began to be distributed by the government starting in the 1930s) that would allow multinational corporations to buy pieces of land in the community. When you purchase any piece of land in Chiapas the first 20m are owned by the land-owner, but deeper than that the land is owned by the federal government. Thus if a single piece of land is purchased and mining rights are given the company can dig deep under other community lands until the soil is polluted and entire communities stop being able to produce coffee. This is scary, but so far the communities in which we are working are fiercely opposed to these mining operations, which limits the government’s ability to give mining rights.

Although violent gangs still exist, the communities in which Companeros en Salud operates are peaceful and not sites of active conflict. So do not start panicking with all these stories of guerrilla warfare and mining.

I am going to end these thoughts with an invitation to support the wonderful team here doing excellent preventive medicine and primary care in isolated communities throughout Chiapas, to do so with a deep knowledge of the people and their experiences, their feelings, thoughts, and beliefs. In the month I was here I did no more than learn how little I know. If your experience is anything like mine, you will laugh often, eat well, work too hard, be touched by the stories of people’s lives and a shared humanity that has been oppressed in the most inhumane ways. This is one of the places where I can express my solidarity with those who wish to work the land free from oppression, as I work to fulfill my childhood aspiration to become a member of an international community of people that sustainably live off the land.

1: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.204
2: http://flag.blackened.net/revolt/mexico/ezln/ezlnwa.html
3: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.206
4: ibid. pp. 208.
5: ibid. pp. 214.
6: Roar Magazine: http://roarmag.org/2012/12/zapatistas-march-chiapas-mayas/

Posted in Mexico | Leave a comment

Chiapas 14

We are back in Jaltenango, the city where Companeros en Salud is based for 3 days of coursework on topics in global health, case presentations, and support of pasante’s research projects in the communities. These 3 days have been one of the most incredible learning experiences of my life. In addition to learning about how to design a public health project and learning about challenges pasantes face in navigating their health care system, I had the opportunity to present the Lebanese healthcare system and get feedback on ideas for public policy, I was impressed by how quickly, with only my brief introduction, the team picked up on subtle problems Lebanese face and proposed many of the solutions I have been thinking about for months. With many warnings about things to watch out for, it was a productive exchange of ideas about how the model they are working on in Mexico would translate to Lebanon, and I am confident that it is a promising way forward to developing primary care in my country.

Presenting Lebanon

Presenting Lebanon

We watched “Rojo Amanecer” to end the conference, a movie describing the daily life of a family that died in the Tlatelolco massacres of students that I previously described as undermining the people´s trust in the national government. A difficult discussion occurred during the feedback as several pasante´s expressed a variety of concerns about the student´s lack of interest in coursework, a reminder of how to maintain respect for the members of the communities in which we are working (don´t speak in English in their homes, don´t treat people that host you in their homes as if you have any entitlement for their service and also with deep humility and gratitude,) and other concerns regarding division of responsibility for cleaning as we are 15 people living in this home.

Abusing Abelardo

Abusing Abelardo

SAM_6672

Everyone at the beach!

Everyone at the beach!

Pasantes brought everything from candy to these blowing things to spice up their presentations

Pasantes brought everything from candy to these blowing things to spice up their presentations

Late at night Gaby and I decided to play the “put toothpaste on your hand and tickle your ear prank” on a couple of the pasantes who had to wake up at 6am the next morning. Almost everybody found it funny. ;-)

Last time we talked about religion in Chiapas and the cultural changes that began in the 1970s with participative indigenism. Today we will talk about the COPLAMAR program, the first program to support rural development in marginalized communities. You will see IMSS-OPORTUNIDADES if you visit a Chiapas clinic, and this is a direct descendant of COPLAMAR. To quote from the government’s website:1

“IMSS-Oportunidades is a Federal Government Health Care Program administered by the Mexican Institute of Social Security (Seguro Populare). The Program provides health services to the uninsured population, promoting the comprehensive development and equality of opportunities for all Mexicans, as well as fulfilling their Constitutional right to health care.

The Program operates thorugh a Comprehensive Health Care Model (CHCM) based on Medical Care and Community Action. Medical Care functions by means of 3,594 Rural Medical Units, 225 Mobile Health Teams, 270 Urban Medical Units, and 79 Rural Hospitals and is responsible for providing health care services and mounting epidemiological vigilance programs. Community Action (CA) incorporates individuals and communities in the practice of healthy habits to improve their long-term quality of life. CA work is done through medical staff and more than 309 thousand health volunteers originating from within the populations served by IMSS-Oportunidades.”

To quote Wikipedia:

“It is designed to target poverty by providing cash payments to families in exchange for regular school attendance, health clinic visits, and nutritional support. Oportunidades is credited with decreasing poverty and improving health and educational attainment in regions in which it has been deployed.

Key features of Oportunidades include:

  • Conditional Cash Transfer (CCT) – To encourage co-responsibility, receipt of aid is dependent on family compliance with program requirements, such as ensuring children attend school and family members receive preventative health care
  • “Rights holders” – Program recipients are mothers, the caregiver directly responsible for children and family health decisions
  • Cash payments are made from the government directly to families to decrease overhead and corruption
  • A system of evaluation and statistical controls to ensure effectiveness
  • Rigorous selection of recipients based on geographical and socioeconomic factors
  • Program requirements target measures considered most likely to lift families out of poverty, focusing on health, nutrition and children’s education.

Many pasantes like the program, especially because it improves chronic patient’s clinic attendance, but others mentioned some challenges:

“Rigorous selection of recipients based on geographical and socioeconomic factors”: “One problem is that people who need Oportunidades do not receive it. Why? Because people who need it sometimes don’t receive it–the criteria for selection are having a big house or not–sometimes people go to America and make money and build a big house but now they don’t have money.”

“Rights holders” – Program recipients are mothers, the caregiver directly responsible for children and family health decisions: “Some mothers are expected to buy food to secure children’s nutrition, but many spend the money on other things and end up having more debt. They then use Oportunidades money for paying their debts.”

Program requirements target measures considered most likely to lift families out of poverty, focusing on health, nutrition and children’s education:Another problem is rural communities have Oportunidades–they have to get their children to school and to a health center, but then their is no health center or doctor. So what is the point of making these payments if there is no teacher or doctor?

To quote a report I found on the World Bank website from “the Shanghai Poverty Conference” that describes the program:2

The program design was based on the idea that poor families do not invest “enough” in human capital and are thus caught in a vicious circle of intergenerational transmission of poverty. According to Oportunidades’s vision, poor families are aware of the benefits of investing in their children but cannot afford the monetary costs of attending school or the opportunity costs of sending children to school (the income or value of income that children would earn if they were working, rather than attending school). Since families need this income for current consumption, they take their children out of school at early ages and send them to work. Thus, the idea of Oportunidades is to provide parents the equivalent of that income to send their children to school instead.

The amounts of the monthly grants range from about $10.50 (105 pesos) in the third grade of primary to about $58 (580 pesos) for boys and $66 (660 pesos) for girls in the third year of high school. The health component provides basic health care for all members of the family, with a particular emphasis on preventive health care. This service is provided by government public health institutions. The nutrition component includes a fixed monetary transfer, equal to about $15.50 (155 pesos) monthly, for improved food consumption, as well as nutritional supplements for children between the ages of four months and two years, malnourished children aged 2 to 4, and pregnant and lactating women.

This is the briefest of introductions and doesn’t sufficiently analyze the program, read a few books and visit the communities to make your own educated judgments.

1: http://www.imss.gob.mx/english/Pages/IMSS_Op_Introduction.aspx

2: http://info.worldbank.org/etools/docs/reducingpoverty/case/119/summary/Mexico-Oportunidades%20Summary.pdf

Posted in Mexico | Leave a comment

Chiapas 13

This brief post describes pasante’s responsibilities in Motozintla, the capital of the county in which they are working. Each month they go to a central health administration office in their county and deliver information on child and maternal health, chronic diseases, and the number of patients they’ve seen and other clinical statistics.

20130324_161041

A gang of kids had a chain raised in front of the car and asked for money (a common practice done when someone repairs the road, but these kids wanted a freebie!)

20130325_115205

Apparently the town name means “squirrel”

20130325_120743

Motozintla’s hilly streets

20130325_121025

The health center where people clamor for benefits and doctors fill their paperwork in the government bureaucracy upstairs

20130325_121143

One of 16 offices that the pasantes enter to get their paperwork signed. This is a half-day process every month.

20130325_122934

Motozintla town square

20130325_161615

Stark contrast of a high-end supermarket with the rest of the area

20130325_161619

Stark contrast of a high-end supermarket with the rest of the area. Buying the ingredients for mango ice cream!

Posted in Mexico | Leave a comment

Chiapas 12

Today was palm Sunday and we did a procession through town to the church, after which the priest delivered one of the most beautiful masses I have heard. The two most beautiful ideas were developed from the passage in the last supper where Jesus talks about being served at the dinner table. He asks his disciples “who is more important, he who is at the table being served or he who is serving?” And he responds (these quotes are rough, from memory) “I am sitting at the table, I am the greatest, and yet I sit in the middle of you serving you.” And in our hearts this is an idea we reject, because we do not tell the person who we pay to work for us in the fields (and many members of the congregation hire Guatemalans to harvest coffee): please, let me serve you. Instead we say “do your work and I will compensate you.” Serve me first! But if you are tired one day then you say “ok, this is where I draw the line of serving others.” But then the priest held up the ideal of Mother Theresa as someone who begged in her right hand for her own bread, and then begged for the poor with the left hand. She had this Christian balance–how wonderful would it be to be able to hold up both the ideal of self-service and community-service? And beyond the theory, he gave a few practical examples–the good husband is the one who on Sunday says “honey, today the housework is mine,” as well as the wife who says “after a long day of work I cooked you a special dinner.” Service in a relationship, the priest described, is love. Challenging patriarchy, he emphasized the importance of service as leadership in the tradition of “the Promisekeepers,” a religious group worth googling that I studied back in the undergraduate days. And this is a radical Christian idea–when everyone in society says “this is good,” the Christian always has to go through the hard work of defying the norm and saying–actually, I have a different ideal.

Honduras Catholic church

Honduras Catholic church

Flowers for Palm Sunday procession. (Everyone carries leaves or flowers)

Flowers for Palm Sunday procession. (Everyone carries leaves or flowers)

The second place where he developed the concept of service as described in the last supper was in government. When the government does something good for the community they say “I am doing you a favor. Look how good I am.” When in fact leadership, as we discussed, is a type of service. Again, who is greater, he who serves or he who is being served? And if one can balance the two entities, the servants and Jesus and his disciples, one sees those in government not as the most important, but rather to provide for the basic human needs of the community is their right. Health as a human right, I was later told in coursework on Mexican public health, was written into Mexican law in 1977 into Article 4 of the constitution. What a beautiful message in advocacy drawing on the rich tradition of the Bible. We are driving to Motozintla, the government offices where paperwork is completed every month by Juan Carlos and Valeria to document all the work they are doing and inventory and order the medications they use in the communities.

I went online to learn more about religion in Chiapas and found an interesting article1 by a writer from the Casa collective, a local NGO:

“To begin to understand religion in Chiapas or Mexico at large, it is essential to realize the central role it plays in community life. In small communities or neighborhoods in urban areas, the festival of the Church’s patron saint is the most important time of year, and organizing and paying for the party, the most important cargo (communal duty, service). Typically, the people who fund and host the saint festival are among the wealthiest and most powerful in village and municipal political bodies. That is to say, religious, economic, and political power in small communities often overlaps. When a family removes themselves from the Church by converting to a different faith it is an affront not just to the religious uniformity of a village, but also to community social and political life. In some areas, these tensions become very real power struggles in which converted Protestants are expelled from the community, or if Protestants reach a majority, Catholics are expelled. In Chiapas, religion is an explosively divisive issue and religious refugees in the state’s major cities number in the thousands.

These conflicts are in the minority, however compared to the religiously divided communities that coexist with little or no discord. Furthermore, the healing and empowering aspects of religion are sometimes overlooked. For example, many women attribute their conversion to Protestant faiths to the prohibition of alcohol, which for many means the recovery of an alcoholic husband, more family stability and less domestic abuse. A Mayan Christian movement (resurrecting traditional Indigenous theology within a Catholic context, exploring the syncretism in the faith of present day Indigenous Catholics) is a growing force for ethnic empowerment, spiritual healing, unity and dignity in communities. Liberation theology (a reorientation of the Catholic Church in the late 60s and 70s to the empowerment and spiritual needs of the worlds oppressed peoples) and its’ defender in Chiapas, Bishop Samuel Ruiz, was incredibly successful in creating Indigenous leadership, mobilizing communities for dignity and justice and allowing space for an Indigenous theology that renewed cultural traditions and pride. It is thought that the religious and leadership training that Indigenous catechists received laid the groundwork for an Indigenous movement demanding rights, justice and dignity in the mid-80s; the fledgling Zapatista Liberation Army.”

1: CASA Collective, accessed March 30, 2013. http://www.casacollective.org/story/analysis/analysis-believing-a-better-tomorrow-religion-chiapas

Posted in Mexico | Leave a comment

Chiapas 11

Saturday evening Valeria and I did two home visits: the first was to a patient with suspected pulmonary fibrosis, a disease where the lungs basically become non-functional for a variety of reasons, most still not properly understood. There was also a suspicion of right heart failure, and the patient had been complaining of a night-time cough that was making it impossible to sleep. In addition to following up on his medications and adjusting dosages, we suggested raising the head of the bed or putting pillows under his back to avoid pulmonary edema (water in the lungs) that can be caused by the heart failure that might be causing the cough. We also diagnosed what appears to be an oral candidiasis from his prednisone and promised to deliver a nystatin gargle in the morning.

The second patient was a difficult patient that had been prescribed anti-depressants which he did not like to take, and who was confusing because he had episodes of depression and insomnia by history but was completely normal on the depression screening test we use (the “PHQ9″). He also had an addiction to sleeping medication (clonazepam) without which he did not sleep for several days at a time but had normal function. His insomnia, pressured speech, and his history of depression with a normal to elevated mood on admission put both anxiety and bipolar disorder high on the list of diseases I suspected he might have. So we went to see his wife and family to see what they knew–and indeed after about an hour of patiently probing conversation his wife spontaneously started telling us about a history of grandiosity associated with hyperactivity that lasted for several months–he was going to build a ranch (despite being economically challenged), and have lots of horses and buildings on it, and indeed woke up in the middle of the night to work on this project getting little to no sleep. He also talked about episodes of how he would speak a little too openly to other men’s wives and spent money freely, disinhibitions that, along with his other symptoms, were enough for me to consider the diagnosis of bipolar disorder. Typically bipolar disorder is a diagnosis that is referred to psychiatry, but this may not be possible in the context in which we are working. We left with the proposal that we switch to a mood stabilizer instead of his addictive / not recommended for long term use sleep medication, and will probably refer to the healthcare team for advice about the case before making any definitive decisions.
 
Today we will introduce the Instituto National Indigenista, and elaborate on the discussion of the 1970s cultural changes pushed by the government and discussed in my post “Chiapas 7.” In the 1970s, after the Tlatelolco massacre (the killing of students by the police forces at a demonstration,) and a series of land distributions that favored a few wealthy families, the Confederacion Nacional Campesina [CNC] created in 1938 to defend peasant rights and end plantation conditions began to lose its credibility. A political vacuum developed between the government and indigenous community, and so after the Indigenous Congress in San Cristobal sixty regional congresses were organized to represent the different communities of the region. It is in this context that we see the emergence of government initiatives to recognize “ethnic groups” as state interlocutors and to create institutional spaces for their representation.1 The shift to a multicultural Mexico where the government would encourage a certain conception of ethnicity began in the Instituto National Indigenista, the government organization that was composed of anthropologists and other academics and previously responsible for salvaging the traditions of a dying indigenous culture while simultaneously promoting integration into a unified Mexican culture. This changed in the following way: before the government wanted to integrate; now they wanted to promote a certain conception of ethnicity that could be used to communicate with and, arguably, use to have a hegemonic influence on indigenous culture: participative indigenism. In this model the state related to ethnic groups through programmed investments in cultural activities. 
 
One such investment spurred the creation of the Mam dance groups, a way in which contemporary Mam have imagined their history. Dramatizations by Mam dance groups serve as a collective reconstruction of a prohibited past that now includes memories of the “Law of Government,” the “burning of the costumes,” the suffering of the finca, and the years of the purple disease. All these historical discourses have been confined into a myth of origin with which the Mam identify themselves before large audiences.2
 
As of 2002, when the book I borrow heavily from in this blog was created, the following could be said: “One of the main weaknesses of the participative model was that policies were still being created in the country’s capital by urban intellectuals and civil servants with little knowledge of indigenous reality. As of 1994, out of the sixty Centros Coordinadores Indigenistas [regional congresses] that were created, not one was under indigenous management. The few indigenous personnel in the CCI were at best hired as “research assistants,” which meant basically being translators for the local anthropologist. Most INI employees were in fact drivers or janitors. These personnel policies, which in any other context would be called racist, have not been challenged, not even by the most critical sectors of Mexican society. Only since 1994, after the Zapatista uprising, has institutional racism been discussed in the political debate of the Mexican left. The Community Committees, which should have functioned as advisers for indigenist civil servants, were rather an administrative space in which local INI officials met “community representatives” monthly to inform them of the projects that were already being developed or decisions that had usually already been taken.”
 
The following link shows the different “centros coordinadores para el desarrollo indígena,” some of which exist in the communities served by the health centers I visited: http://sic.conaculta.gob.mx/index.php?table=centro_desarrollo_indigena&disciplina=&estado_id=7&municipio_id=0
Hopefully the modern reality is different from the textbook I am using, and I will leave it to you to explore this issue further.
1. R. Aida Hernandez Castillo. Histories and stories from Chiapas; Border identities in Southern Mexico; pp.103.
2. ibid. pp. 137
Posted in Mexico | Leave a comment

Chiapas 10

Last time Valeria, the pasante with whom I am working and I went to a local hospital to care for a teenager with renal failure. At 12:30am the local doctor came to give his orders for the patient, and I was confronted with how to convey to this doctor the right medications for this patient so that he does not compromise the child´s renal function, which Valeria had been working to improve for months. At first in my mind I was panicking–how am I going to convey information to this doctor with my limited Spanish? If things go sour how am I going to call Valeria and from which phone? But I tried not to show this and tried to stay cool and confident: the first problem we have here is a power struggle; how am I going to convey that Valeria and I, despite being inferior in the medical hierarchy, know what is medically best for this child? Previously I hadn’t participated in any of the conversation, so I began by introducing myself to the doctor as “Kareem, a doctor from the United States who is assisting Valeria this week in her medical work.” (Saying from the United States was easier than explaining where and what Lebanon is.) I explained that she is a pasante (a medical graduate doing a mandatory public service year) working with Partners in Health, an international organization that supports rural medicine in countries around the world (again, PIH is not strictly a rural organization, but close enough…). This introduction with a few words of English thrown in seemed to impress my colleague, but I immediately followed up this introduction with a move to negate any upcoming power struggle: “We are here in this hospital as your guests and the decisions are yours. We are a team caring for this child, but my role is only to support and give advice–ultimately, the decision is yours. So what do you want to do?”

image

Random images of Chiapas: road destroyed by mudslides

The doctor then explained each step in his plan and his reasoning (which prompted me to share the following ideas in brackets): an ACE inhibitor or nifedipine to lower the blood pressure (ACE inhibitors would decompensate and cause hypoperfusion in this child with creatinine of 1.7; Harriet Lane, a pediatric textbook, suggests that nifedipine causes too rapid a drop in blood pressure in children with urgent hypertension; and the blood pressure was only high (~150 systolic) because the doctor had told the mother not to give the child’s normal amlodipine dose in the first place, perhaps we could consider keeping the child on his regular medication to avoid reflex tachycardia of discontinuing a calcium channel blocker), to start diuretics, furosemide and spironolactone (the risk of direct damage from dehydration and the diuretics exceeded the risk of fluid overload in this child (he was 52kg with an ideal weight of 47kg–uptodate suggests dialysis when >15% ideal weight–but I don’t know what the right call is here), and discussed with the mother if the child could be monitored at the hospital for the next few days (since they couldn’t measure electrolytes here it would be better to refer to tertiary care).

image

The town of Siltepec, where this story happened

Valeria’s suggestions for the management of this child were based on a phone conversation with a pediatric nephrologist who had gone over with her the indications for admission, best antihypertensives (terazosin or hydralazine), and so forth, and apparently this nephrologist was the professor of the young doctor at the hospital and commanded his respect. Eventually he agreed to hold off on prescribing medication till the morning since the child was stable so we could consult the specialist and refer to tertiary care so they could make these decisions, seeing as the child was stable. At 3am his blood pressure was 150 and we gave 5 drops of nifedipine, which in hindsight may not have been the best call since the rapid decrease in blood pressure could provoke more hypoperfusion and acute kidney injury than the problems the 150 systolic was going to cause. The next morning at 6am Valeria and the local doctor had a very conciliatory conversation and bonded, and the doctor shared the idea that it would be best to refer to tertiary care since there are actually no doctors at this health facility over the weekend, and that there are many lab tests that could not be done with the local laboratory. This gave us confidence that the doctor was going to put our patient in a tertiary care facility, and after exchanging numbers and information about the local health system Valeria and I ended up having an excellent relationship with the local doctor. We also learned that in the neighboring town we could send our pregnant patients for free ultrasounds, an important piece of knowledge for the three pasantes working in our area. We drove back to the Honduras clinic and Valeria saw her patients that morning while I slept… We are still concerned that the prednisone has been stopped [Update: it wasn't and so far patient doing great!] –which would be unfortunate seeing as it was keeping his creatinine under 2 –and know that the mother needs support to navigate the medical system which Valeria was providing but (of course) was unable to devote herself to full-time, but ultimately we cannot follow this patient at the expense of all the others and have to trust in the system. (No history this time as well…stay tuned!)

image

Epic (and typical) breakfast while staying Jaltenango. Beans, eggs, tortilla, papaya juice

Posted in Mexico | Leave a comment