Liberation Medicine: Health & Justice


By Lanny Smith, MD, with Ken Hilsbos, MD


I was searching for an adequate definition for the kind of medicine we had been practicing in El Salvador for a presentation at the Second International Conference on Health and Human Rights to be held in September of 1996. I also wanted to include the larger component of local and international education and solidarity that our work had come to involve. The defining word came to me while reading Father Ignacio Martin-Baro’s book, Writings for a Liberation Psychology. While ostensibly about psychology, I found the book’s message applicable to medicine as a whole. Fr. Martin-Baro wrote, "In our case more than anyone else’s, the principle holds that the concern of the social scientist should not be so much to explain the world as to change it."


In his book, Martin-Baro urged that Liberation Psychology explore new horizons, a new way of seeking knowledge, and a new way of acting. As an example of what needed to be done to accomplish this, he referenced Paulo Freire, the Brazilian who developed a method of teaching literacy for impoverished adults based on dialogue and sought to break "the chains of personal oppression as much as the chains of social oppression."
It seemed to me that Martin-Baro was describing the kind of medicine we had been attempting to pursue in Morazán. Thus came the definition of Liberation Medicine that we at DGH have been using: "The conscious, conscientious use of health to promote human dignity and social justice."


This definition was the springboard for two group discussions in the Fall of 1996, which lead to the creation of the Liberation Medicine Working Group, a group of health professionals dedicated to exploring and pursuing this concept. The first discussion was held in a workshop setting at the Conference that had spurred my search, which took place at the François-Xavier Bagnoud Center for Health and Human Rights of the Harvard School of Public Health. The second group discussion on the subject was in a non-official workshop two months later, as described in the following vignette by Dr. Ken Hilsbos: "I first heard of Liberation Medicine when I saw a hand-written sign taped up on a fancy glass case outside a meeting room at the 1996 American Public Health Association (APHA) meeting in New York City. The sign announced a workshop on Liberation Medicine. Twenty or so people attended. We rearranged our chairs to form a circle. The process and the content were very democratic. Lanny gave his definition of Liberation Medicine. Each of us talked about what we thought Liberation Medicine might be about and how the idea related to our experiences. I introduced my short essay Caring, Compassion and Humility: A Proposed New Model for Medicine Closer to the Heart, which I had brought: ‘Compassion means empathy and kindness. Caring is fundamental to good medicine. Humility is the most difficult, especially for doctors, but can best be described as a radical equality with those whom we accompany. In other words, the person seeking my help might have a third grade education, or Down’s syndrome, or an annoying lack of access to soap and water, but they don’t really understand any less than I do the mystery of death, or of birth, or the other great mysteries.’ The group agreed that these three values, so little found in clinical medicine and medical teaching, are essential to the practice of Liberation Medicine."


Liberation Medicine immediately brings to mind Liberation Theology, the movement that interpreted Jesus’ teaching as a radical call for the equality of all people and to caring for one another, which began in the 1960’s within the Catholic Church after Vatican II and the Bishops’ Conference in Medellin, Colombia. Martin-Baro was greatly influenced by the Liberation Theology movement and pointed to it as his inspiration for Liberation Psychology. A useful methodology with or without the religious angle, Liberation Theology calls for observation, reflection and action. Whenever possible this process should be done through accompaniment of the disempowered, those whom Archbishop Romero (the Salvadoran clergyman who was assassinated soon after calling on soldiers to stop killing their brothers and sisters), referred to as the "voiceless."
Of course, people have been practicing Liberation Medicine for a long time without necessarily calling it that. One example is the Jamkhed project in India, ongoing for 28 years now, led by Drs. Raj and Mabele Arole. The humility they describe in sitting together in a circle to eat and the equality they promote with the untouchable women as Health Promoters, is Liberation Medicine in action. Just as is the social medicine tradition of Chile, continued in another form in Cuba, and the accompaniment of Charlie Clements, MD, MPH, in his book Witness to War, where he documents the suffering reality of the Salvadoran people. Another example of Liberation Medicine under a different name is what David Hilfiker, MD, describes as "poverty medicine" in Not All of Us Are Saints: A Doctor’s Journey With the Poor. Responding to a physician in a conference who asked, "I can only applaud your commitment to the poor, Dr. Hilfiker, but don’t you think it’s a waste of your professional education?" Dr. Hilfiker wrote, "It takes all the medical judgement we possess to discern when to let go and when to press a homeless patient. It takes every bit of our medical authority to get such patients into the health care system. It takes as much medical knowledge as we can muster to diagnose across cultural barriers. But—since our work is so different from a doctor’s standard routine—it is easy, from the medical point of view, to mistake it for no work at all...Medical practice in a community of poor people often seems a solitary specialty without research, common cause or shared experience."


One of the goals of DGH in promoting the concept of Liberation Medicine is to address and remove the isolation described by Dr. Hilfiker. Drawing on his example, and aware that we must walk with humility in this endeavor, we would like to help people see the inter-relatedness of life and the need to address the issues of the poorest if we are to have full lives ourselves. As Rev. Martin Luther King, Jr. once put it, "As long as there is poverty in this world I can never be rich, even if I have a billion dollars. As long as diseases are rampant and millions of people in this world cannot expect to live more than twenty-eight or thirty years, I can never be totally healthy even if I just got a good check-up at the Mayo Clinic. I can never be what I ought to be until you are what you ought to be. This is the way our world is made. No individual or nation can stand out boasting of being independent. We are interdependent."


Of course, this means that we must strive to work within the context of community, for liberation is a community exercise as well as an individual one. In The Virtues in Medical Practice, Edmund Pellegrino, MD and David Tomasma, PhD, present the concept of medicine as a moral community, "These three things—the nature of illness, the nonproprietary character of medical knowledge, and the oath of fidelity to the patient’s interests— generate a strong moral bond and a collective responsibility...Medicine cannot, and should not, undertake all of this alone. It can join with other health professionals, concerned people and legislators."


In addition to the many examples of Liberation Medicine that do not define themselves as such, we have also found some references to liberation and medicine together. In Liberating Medicine, David Seedhouse asks physicians to enable their patients’ potentials, help them to overcome obstacles and honor their oath to "First, do no harm." He also seeks a new definition of "health" as optimal patient autonomy, and the reform of medical education to embrace what he terms the "rings of uncertainty" theory—a call for humility in medical training and practice.


Similarly, a Mexican physician, Agustin Sangines, in Medicina Liberadora, applies a Marxist interpretation to elucidate the social causes of disease and explore what he calls "oppression medicine." A home-grown example of oppression medicine is California’s Proposition 187, which would have required health professionals to report "illegal" immigrants to the Immigration Service— as if any human could be illegal. Another less overt but more appalling look at oppression medicine—including the role of physicians as torturers—can be found in the British Medical Association’s Medicine Betrayed.
Likewise, Health as Liberation: Medicine, Theology and the Quest for Justice, by Professor Alastair Campbell, defines health as freedom. Outlining his plan in the book, Professor Campbell writes, "First, in every chapter I will introduce some of the ‘voices of the oppressed’ and try to give these a normative place in determining how health may be more richly understood. Second, I acknowledge that hearing these voices demands a critical stance toward the social structures within which the oppression occurs. When we are willing to listen to the experience of the oppressed, we begin to see how injustice has become institutionalized in those very social structures that claim to be concerned only with human well-being." Despite such a brutally honest vision, Professor Campbell offers hope in the form of a quest: "Here, I think, we must try to distinguish between dreams of utopia and a hope based on a refusal to accept that we have no power to change things...One thing is for sure: if we do not take such risks, our attempts at health care will be little more than the echoes of our own ill-founded complacency."


What we in DGH are looking to do with Liberation Medicine is forge a path for hope, a way to build upon the energy found in the people of Morazán and around the world who, despite suffering horrible injustice, have the strength to rebuild and the vitality to believe that they can. Like the hope found in Paulo Freire’s Pedagogy of the Oppressed, "The dehumanization resulting from an unjust order is not a cause for despair but for hope, leading to the incessant pursuit of the humanity denied by injustice. Hope, however, does not consist in crossing ones arms and waiting." This quest is put most eloquently by Dr. Nancy Scheper-Hughes in Death Without Weeping: The Violence of Everyday Life in Brazil: "Medicine, the hospital, and the clinic can be isolated, closed off, from the experiential world of patients. Or, they can provide a space where new ways of addressing and responding to human misery are worked out...We might conclude by asking what medicine might become if, beyond the humanitarian goals it espouses, it could see in the suffering that enters the clinic an expression of the tragic experience of the world. We might have the basis for a Liberation Medicine, a new medicine, like a new theology, fashioned out of hope."


The Father of Liberation Theology: Gustavo Gutiérrez


Reverend Gustavo Gutiérrez, a Peruvian theologian who lectures in theology and social sciences at the Catholic University of Lima, is considered the father of Liberation Theology by many scholars. Best known for his 1971 groundbreaking book, A Theology of Liberation (published in Spanish and English), Gutiérrez drew international attention to the plight of the poor in Latin America when he challenged his church to work for liberation and justice by identifying and changing the social, political and economic structures that create and perpetuate oppression.


His theology of liberation— later termed Liberation Theology— influenced religious scholars around the world and became one of the most influential movements in contemporary theology. After calling the world’s attention to the oppressive structures that victimize the poor in Latin America, theologians began applying Liberation Theology to liberation movements for women, for developing countries, for African- Americans and other oppressed groups.


Born in Lima, Peru, in 1928, Gutiérrez grew up among the poor. After studying in both Rome and France, he returned to Peru to teach at the University of Lima, but chose to live in the slums of the city rather than the more comfortable neighborhood surrounding the university.


Gutiérrez received The Marianist Award from the University of Dayton in 1997 for outstanding scholarship by a Catholic. The University’s chancellor, Rev. James L. Heft, said, "It is significant that Father Gutiérrez’s thought has never been criticized by the Vatican, I believe, because his thought is so clearly rooted in the Gospel. He has taught us that the Gospel should never be reduced to politics, but that the Gospel, fully lived, always has political consequences."