"O" FOR THE "P"

a sermon preached by
the Rev. Dr. Tim W. Jensen
at the First Religious Society in Carlisle, Massachusetts Sunday February 25th, 2007


I know I’ve told this story here before, but it’s been awhile and it bears repeating. But about a month after I first saw this fresco of the Good Samaritan in the Unitarian Church in Copenhagen, I had a very vivid lesson in the ethical challenge offered by this parable. My mother was visiting me in Denmark for a few weeks, and we were headed to the train station early in the morning, on our way to do some sightseeing, when a rather frail, elderly woman came up to us started jabbering at me in very rapid, heavily accented Danish. And I was trying to explain to her that we were in a hurry, and that I didn’t really understand what she was saying, but she didn’t seem to understand me either; instead, she just kept grabbing at my arm and pointing to a nearby bus shelter. So I looked over at where she was pointing and saw a person, this body, really, seated on the bench and slumped over against the glass wall on the side of the shelter, with a thin trickle of blood running down the side of his face....

And at that point the conversation suddenly got very animated. I was trying to tell this woman (in a jumble of Danish, English, French, German, Greek and Latin all at once) that she needed to call the police, but she wasn’t having any of it. She’d shown the body to me, an obviously competent and responsible younger person, and now she had to catch her bus, “Tak skal du have” and away she went.

And there I was.

Now this particular bus shelter was right outside a government hospital that had recently closed due to budget cuts, so naturally, being an American, I assumed that this young man had been shot or beaten up in some sort of gang-related drug deal and then dumped by his buddies outside the hospital because they didn’t want to risk involvement with the authorities. I tried to rouse him, just like I had been taught in the Boy Scouts, but I got no response, so I went inside the hospital just to see if I could find anyone there who could help me. Eventually I found a caretaker, who explained to me (in English) about the hospital being closed, and then agreed to accompany me back outside to see the body for himself.

He also tried to rouse this fellow, a little more loudly and aggressively than I had, and sure enough, the body responded... and after a brief conversation between the two of them, the caretaker assured me that the gentleman in question was merely someone who had stayed out a little too late the night before, and had fallen asleep while waiting for his bus, having fallen down and banged his head against something hard earlier in the evening... but not to worry, because [wink,wink] he was feeling no pain. So I was able to explain all this to my mother, who of course had also seen the body, but basically understood nothing else of what had been going on, that everything was OK and that we could continue on our way.

And I honestly don’t know to this day whether or not I would have spent as much time I did trying to help this stranger if I hadn’t seen the fresco of the Good Samaritan in the Unitarian Church just a few weeks earlier. But I do know this...having just seen that fresco, only a few blocks from that bus shelter, I would have felt like a terrible hypocrite if I had simply passed him by.

As a general rule, we Unitarian Universalists don’t ordinarily put much stock in guilt and shame as spiritual and ethical motivators, but I suppose there’s a time and a place for everything. Because yes: I was confused, and also a little afraid, far from home on unfamiliar ground, and in many ways it would have been a lot easier for me to turn my back and walk away. But how was I going to explain that behavior to my mother? (who, in all honesty, would have probably just as soon walked away herself). And, more importantly, how was I going to live with myself afterwards?

And since that day, which was almost seven years ago now, I’ve often thought about just how appropriate a fresco of the Good Samaritan is for a Unitarian Church -- so much more appropriate than so many other stories from the Bible that might have been chosen instead. Even if we weren’t raised in the Christian tradition, we’ve all known the story since we were children. It’s part of our cultural lexicon. A Samaritan is someone who does good deeds, who helps others in need, even if they happen to be strangers. In fact, especially if they happen to be strangers....

But it’s also easy for children to miss the real message of this story, and even for adults the actual context is often a little obscure. A traveler is attacked, robbed, and left for dead at the side of the road. A Priest and a Levite (which was basically just another kind of priest) see him there but pass him by...not necessarily because they are bad people, or even because they are afraid of being robbed themselves, but most likely simply because they assumed he is already dead, and knew that touching a corpse would leave them ritually unclean and therefore incapable of performing their religious duties. In other words, their positions of social privilege and their responsibilities for community leadership caused them to look past the immediate and pressing need right in front of their own eyes, and to continue on their way.

But then a Samaritan -- an outsider, an outcast -- sees the body and takes the time to investigate. He’s not worried about his formal religious duties interfering with his compassion for another human being, nor is he afraid to take the risk of becoming a victim himself. Or at the very least he is willing to face that fear. And all this in the context of the one Great Commandment of both Christianity and Judaism: “Love the Lord Your God With All Your Heart (and all your Soul and all your Strength and all your Mind), and Love Your Neighbor As Yourself.” The lawyers, the priests, the Levites and the Pharisees may wish to quibble about the precise definition of neighbor, if only to reassure themselves of their own wisdom and importance. But the Samaritan knows that if you happen to be in the neighborhood, whoever you see there is your neighbor. Even if he happens to be a stranger, and you yourself are traveling far from home.

In many ways, Dr Paul Farmer is a perfect example of a modern day Samaritan, yet in other ways he is exactly the opposite. “Doktè Paul” (as he is known in Haiti) is a Harvard-educated physician and anthropologist who has essentially devoted his entire adult life to pursuing his compelling mission of providing first world health care to third world people. The Cambridge-based not-for-profit “Partners in Health” and its Haitian counterpart “Zanmi Lasante,” which he founded while still a medical student in the 1980’s, are now the much-admired working paradigms for his philosophy of “solving global health problems through a clear-eyed understanding of the interactions of politics, wealth, social systems, and disease.”

In more specific terms, Farmer’s philosophy combines the scientific discipline and humanitarian concern of the very best of modern medical practice with Liberation Theology’s “preferential Option for the Poor,” and it’s “powerful rebuke to the hiding away of poverty, a rebuke that transcends scholarly analysis.” Farmer’s extraordinary combination of scientific excellence and spiritual commitment in many ways simply reflects the profound contrast between the two worlds of Harvard and Haiti.

“The fact that any sort of religious faith was so disdained at Harvard and so important to the poor -- not just in Haiti but elsewhere too -- made me even more convinced that faith must be something good,” he once explained to author and friend Tracy Kidder. He amplified these sentiments on another occasion while trying to explain why he lives the life he lives. “If you’re making sacrifices, unless you’re automatically following some rule, it stands to reason that you’re trying to lessen some psychic discomfort. So, for example, if I took steps to be a doctor for those who don’t have medical care, it could be regarded as a sacrifice, but it could also be regarded as a way to deal with ambivalence.... I feel ambivalent about selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent....”

If you want to know the entire story of Paul Farmer’s remarkable medical career, I’m afraid you’re going to have to read the book yourself. It’s not that I don’t want to tell you about it; it’s just that I can’t. Paul Farmer defies easy summarization; even Kidder’s 300 page New York Times bestseller often seems only to scratch the surface of this incredibly talented and complex individual. He also defies imitation. As his colleague at PIH, Jim Kim, once put it “Paul has created technical solutions to help the rest of us get to decency, a road map to decency that we can all follow without trying to imitate him.... Paul is a model of what should be done. He’s not a model for how it has to be done. Let’s celebrate him. Let’s make sure people are inspired by him. But we can’t say anybody should or could be just like him...because if the poor have to wait for a lot of people like Paul to come along before they get good health care, they are totally....” (and I’ll just leave you to fill in that last word for yourselves).

But this notion of a “road map to decency” is a very intriguing and provocative one. What does it take to inspire brilliant and talented people like Paul Farmer to step off the fast track to wealth and power and privilege, and instead become successful and accomplished on their own terms, by turning their attention to those who have been robbed, beaten and left helpless along the side of the road? How would the World be different if we all shared the assumption that our highest priority should be those with the greatest need? It’s hard to imagine, but it might look a little like this. During a trip to Moscow to consult with Russian doctors about the epidemic of Multi-Drug Resistant Tuberculosis in that country, Farmer shared this anecdote about himself:

“I have been working in Haiti for almost twenty years, ever since I was a young chap, and some years ago I was asked by the state of Massachusetts to be a TB commissioner, and I said ‘What the hell do we do?’ I was in Haiti and I had a couple of MDR-TB patients and I took sputums and I brought them to Boston. And I took them into the lab and I wrote, ‘Paul Farmer, Sate TB Commissioner.’ I wanted them to process my samples from Haiti and they did and never asked any questions, so I did it more and more and then I did it with sputums from Peru, and of course, eventually they asked me why. I said, ‘Massachusetts is a great state, it has a big TB lab, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. It lacks only one thing. Tuberculosis.’ “

Tuberculosis, as Farmer likes to say, asserts its own preferential option for the poor. On the wrong side of what he calls “the great epi divide,” that portion of the epidemiological map where poverty and its associated hunger and malnutrition, overcrowding, poor hygiene, violence and preventable infectious disease reduce average life expectancies by anywhere from a third to a half, TB still kills more people than any other disease but AIDS (with which it shares, in Farmer’s words, a “noxious synergy”), while in more affluent parts of the world, such as here in Massachusetts, it is easily treatable and has all but disappeared. On Paul Farmer’s roadmap, patients always comes first, no matter where they live, just as we would hope we would be treated if we were the patients in question. But this is only the first step.

To borrow terminology from the 19th century German physician Rudolph Virchow (whose writings Farmer first discovered when he was an undergraduate at Duke), it also involves embracing the Politics of Prophylaxis rather than the Politics of Palliation; of practicing real prevention, and not just alleviating suffering. According to Virchow, “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation” and “medical education does not exist to provide students with a way of making a living, but to insure the health of the community.”

In other words, good medicine, even (and perhaps even especially) in a third world country like Haiti, is not simply about passing out bigger band aids. It involves addressing the underlying economic and public health issues which create the conditions for disease in the first place, as well as confronting the overarching political power structures which keep those conditions in place. It means creating clean and reliable public water supplies, and adequate sewage treatment, training cadres of local public health care assistants, who understand the culture as well as the medicine, and developing top quality medical facilities where they are most urgently needed, rather than merely where they are most easily afforded.

And yet, on Paul Farmer’s roadmap, the distinction between “prevention” and “treatment” doesn’t really exist, and is often just an excuse used by Public Health officials to justify their own inaction. Of course an ounce of prevention worth a pound of cure. But if the patient already has the disease, and the means to cure it exist, the relative cost of these two options is and ought to be essentially irrelevant. This is one of Farmer’s many AMCs (or “areas of moral clarity”). Strictly speaking, as he is fond of saying, all resources everywhere are limited. “But they’re less limited now than ever before in human history,” he continues. It’s just a matter of moving away from an analysis of cost effectiveness to one which puts the needs of the patients first.

His colleague Jim Kim amplifies this sentiment. “There have been fundamental frame shifts in what human beings feel is morally defensible, what not. The world doesn’t bind women’s feet anymore, no one believes in slavery. Paul and I are anthropologists. We know that things change all the time. Culture changes all the time. Advertising people force changes in culture all the time. Why can’t we do that?”

It’s a provocative challenge, not unlike the challenge of the Good Samaritan. But rather than trying to imagine all the details, simply imagine this: how would the United States be viewed differently in the world if our Foreign policy was based on eradicating global poverty and treating endemic communicable diseases like AIDS and tuberculosis and malaria, rather than defeating terrorism of global reach, and defending easy access to Middle Eastern oil?

And perhaps more to the point, how would we feel differently about ourselves?

****

READING: from Mountains Beyond Mountains by Tracy Kidder

The term [triage] comes from the fourteenth-century French trier, “to pick or cull,” and was first used to describe the sorting of wool according to its quality. In modern medical usage, triage has two different meanings, nearly opposite. In situations' where doctors and nurses and tools are limited, on battlefields, for instance, one performs triage by attending first to the severely wounded who have the best chance of survival. The aim is to save as many as possible; the others may have to die unattended. In the peacetime case, however, in well-staffed and well-stocked American emergency rooms, for example, triage isn’t supposed to imply withholding care from anyone; rather, it’s identifying the patients in gravest danger and giving them priority.

[Paul] Farmer has constructed his life around this second kind of triage. What else is a “preferential option for the poor” in medicine. But Haiti more nearly resembles a battlefield than a place at peace. Walking behind him, I say there must always be situations here where the choice to do one necessary thing also means the choice not to do another -- not just to defer the other but not to do it.

“All the time,” he says.

“Throughout your whole career you’ve had to face this, right?”

“Yes. I do it every day. Do this instead of that. Every day all day long, that’s all I do. Is not do things....

“...I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat?”

“A long defeat.”

“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory. You and I have discussed this so many times.”

“Sorry.”

“No, no, I’m not complaining” he says. “you know, people from our background -- like you, like most PIH-ers, like me -- we’re used to being on a victory team, and actually what we’re trying to do in P[artners] I[n] H[ealth] is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat....”

“...I like the line about the long defeat, “ I tell him.

“I would regard that as the basic stance of O for the P,” he replies. “I don’t care if we lose. I’m gonna try to do the right thing.”

“But you’re going to try to win.”

“Of course!...”