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Ethics For A Global Partnership
A group of Yale students travel to El Salvador to encourage health empowerment
By Justin M. List |
In March of 2003, a group of graduate students from the Yale Epidemiology and Public Health Department, Divinity, and Law schools traveled to Isla de Mendez, El Salvador on a student-led public health outreach trip. A non-governmental organization, Foundation for Self-Sufficiency in Central America, coordinated the group's logistics there. Over the next eight days, I witnessed health and education as liberating conduits for improving lives in a low-income country context. It was an amazing practical hands-on experience, my reflections on our group's experiences there provided me glimpses into a variety of ethical and public health frameworks ideal for promoting community empowerment through health.
One of the most important concepts I explored in El Salvador involved relational ethics, defined as ethics that encourage moral and cross-cultural discourse between persons. In Isla de Mendez, a small, financially impoverished town of 400 families, decisions made in the community to mobilize limited resources are shared among leaders and residents. Ethical discourse functions there as a tool for making pragmatic decisions about basic issues such as waste disposal, water treatment, employment and healthcare access Ð issues that are rarely on the minds of residents of higher-income counties. As a result, our presence in the town put a cross-cultural slant on relational ethics, as we considered the cultural, economic, and health contexts of the people.
When our group arrived, we had an agenda of things to accomplish in the community. The "to do" list was based upon needs we thought they had; however, we quickly learned that certain aspects of this approach would not best benefit the Isla de Mendez community. We learned from the community members that there were public health problems in the village that we hadn't thought of. Chickens, pigs, cats, and dogs not only roamed not only the streets and yards but also would casually walk inside and outside of the largely unsecured homes. We were told that water was not consistently treated in the well, as our Yale-group conducted demographic survey results later confirmed. Animal feces and trash littered the dusty streets, and garbage was burned, buried, or thrown in the bay where residents caught fish for food. To remedy these problems, we provided education about some of these troubles and worked toward designing feasible solutions with the community leaders and residents.
The discourse between our group and community members established a cross-cultural framework for transforming pragmatic, yet harmful, solutions to pollution and water treatment issues into improved health practices. For example, our group designed a school module for educating local students about the benefits of proper garbage disposal. Foreshadowing an upcoming NGO-sponsored rudimentary recycling and trash program the community was about to receive, our group educated the students about the aesthetic, health, and environmental benefits of improved trash disposal in the community. We then tested the students on what they had learned through a clever word find game in which students located and then explained the importance of certain key words and concepts from our presentations. The session concluded with a cooperative garbage pickup between our group and the local students, yielding immediately visible results. Community members shared their gratitude for the tangible and basic improvements to their environs.
During this trip, I lived in the home of the equivalent of a town mayor. The mayor had a cadre of local men and women come over one of the last evenings to discuss the state of their community. My roommate and I heard their conversation from our rooms, and we were excited to hear them discussing improvements and the notion of partnering with a university in a long-term relationship. By reframing our agenda with the community's perceived needs and wants, our partnership with the community was more beneficial than if we had merely acted independently to "clean up" their community for a week.
Our involvement in the Isla de Mendez community demonstrated the distributive justice of ideas and services embedded within the process of globalization. Globalization in this sense refers to the forces that impact all lives in some way, either by way of omission from or increased access to all forms of information, trade and economic power, or governance ideologies. On a more local level, globalization refers to the questions of equity and cultural sensitivity that arise when people working from one context evaluate and engage with a different context. We needed to be sensitive about which perceived goods (i.e., health information) the community of Isla de Mendez wanted, and how our group could share that good keeping in mind their cultural and religious context. We hoped that the presence of our group altered the local community Ð we hoped for empowerment in their society through health. However, even the best of intentions from more empowered groups such as our own have the potential and in some degree erode and transform certain aspects of another group's cultural framework.
The forces of globalization affect all cultural contexts. Health can be a particularly difficult context, because of other social norms within a group not understood from an outsider's perspective. The community may have particular social justifications unknown to us for their sanitation and hygiene practices. However, information from previous groups in the community and from the demographic survey we conducted both suggested this was not the case. The residents of Isla de Mendez suffered from a lack of resources and a lack of access to others.
Our group, which had access to goods, services, and education in the U.S., worked alongside members of a more disadvantaged Latin American society with a limited access to these same things. By seeking to understand the concerns of community members, we worked together to form solutions that would improve the community's standard of living through empowerment from health education and "train-the-trainer" sessions regarding sanitation and hygiene. In distributing our knowledge, we intended to extend certain benefits enjoyed in the U.S. to the local people in their cultural context, and in a sensitive manner.
Considering the cultural context is an essential responsibility. Though it is difficult to avoid, we must try not to impose our own culture on other peoples. In this regard, Jan Scholte asks a crucial question about the value of global forces and cross-cultural dialogue: Does globalization enhance or detract from the human condition? The answer to this question in part hinges on how one construes the meaning and importance of freedom. Under the premise that providing the means for better health and attitudes towards the environment would provide more freedom for community development, we felt and heard from the community that our requested presence and ability to share health ideas were important to them.
The partnership model we utilized created a space for dialogue that we found effective for improving the local health situation. Two considerations that were useful for framing this type of partnership are discussed in the work of the economist Amartya Sen. First, we took account of the results of the present social and health arrangements. Second, we paid attention to the well-being of the people when judging their social arrangements and the results produced by these social arrangements. In essence, our group acted as a consultant group as well as a humanitarian agent.
Among the most crucial lessons I learned from my public health development work in El Salvador revolved around the relationship between empowerment and ethics. Our group did not come to Americanize the local people, but to provide conceptual tools that would empower them to improve their standard of living on their own terms. The immediate kindness of the inhabitants and the families' eagerness to learn foreshadowed their active involvement working towards a healthier community. Community members accompanied the survey teams, which enhanced survey participant involvement. As a result of their words of gratitude, both our group and the local leaders discussed the power of partnership for sustainable change.
Some of these positive changes have already taken place. For example, community attitudes towards women were pleasantly surprising: "International Women's Day" was celebrated at the local school. The presence of and support from local men reflected burgeoning support for a community ethic of reducing gender inequality. Globalization forces impact how a community understands gender relations. The public reading of the United Nations Declaration of Human Rights and public recognition of what women did for the community suggested some other benefits the globalization of ideas rendered in this community in terms of freedom.
Many warn that present globalization forces continue to enlarge disparities between so-called developed and developing countries. While these disparities arguably exist in some contexts, the forces of globalization also provide the means to empower disadvantaged populations, as high- and middle-income nations work toward a more equitable distribution of resources and ideas. Such action enables communities and individuals to contribute more to their society, rather than leave fellow global community members in the dust as their own nations continue to reap new benefits. Access to health and education are two essential components for such empowerment.
NOTES/ADDITIONAL READING
For more ideas read: Bower, Bill and David Werner. Helping Health Workers Learn: A Book of Methods, AIDS, and Ideas for Instructors at the Village Level. Hesperian Foundation, 1982.
Scholte, Jan Aart. Globalization: a critical introduction. New York: Palgrave, 2000.
Campbell, Alastair V. Health as Liberation: Medicine, Theology, and the Quest for Justice. Cleveland: Pilgrim Press, 1995.
Sen, Amartya. Development as Freedom. New York: Alfred A. Knopf, 1999.
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