Whom Should We (Try to) Help, and How? Reflections after Fleck
In the last issue of The Medical Humanities Report, Len Fleck wrote about the complexities in deciding who to help. Identifying the “least well off,” he wrote, is not all that matters; there are also questions about how much good will be accomplished. His discussion of finite health care resources has echoes throughout all “helping” spheres: there is only so much time, attention, energy, and money. The contributors to today’s InkLinks have extensive experience in community and international development. They share their own reflections on choosing what to do.
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—JA
Working in Africa: Whom to Help, and How?
Reading Fleck’s essay about our obligation to provide assistance to the medically least well-off is intriguing to those who deal with international development because the issues of how to use limited resources to assist those least well-off (in the third world as well as in our poorer communities) is the same. We struggle with moral claims around which least well-off take priority and how best to help them.
Large scale humanitarian efforts in countries or locations that lack social infrastructure or capacity have a lot of competing claims for assistance. Many organizations use a triage system whereby those “least well off” are prioritized for help. We make pragmatic decisions to alleviate famine, provide disaster relief, etc. But in the day-to-day work of development, women and children are the least well-off (according to UN indicators) and so programs focus on them. In situations of conflict, some aid organizations have begun to prioritize aid to those victimized the most and deny it to those who engage in violence (which is probably easier in theory than to see or control on the field).
As we see from this example, who we focus on also significantly impacts how we help them. Here is where Fleck raises an interesting point—he suggests that the effectiveness of the aid is part of the moral question. In effect, he suggests that it is morally permissible to provide aid only to those that the aid can help—which is a reverse of the usual aid mantra to find ways to provide aid that does help. If we consider it a moral imperative that the aid be effective, that it help move those least well-off to a better place, then humanitarian aid that helps the perpetrators of violence more than the victims is actually morally reprehensible.
But what about more mundane situations? Let’s return to the women and children example. Over the years, development programs have moved from programs that specifically provide services to the poor to those that attempt to help the poor access more resources. When focused on women, this quickly becomes a social structure issue: it isn’t whether there is enough food in the household to feed women, it is convincing male house heads that women deserve an equal share of the food there is. Pragmatic developers soon realize that women and children are marginalized because of complex social processes and structures that limit not just women’s roles but also those of men. Therefore fundamental changes in women’s social conditions, rights and abilities are required to improve their lives materially. In effect, women’s role in society must be changed—we are calling for a social revolution. Suddenly we discover that helping the least well-off is deeply challenging.
What is most interesting in terms of the question of helping the least well-off is the concept that aid is only morally justified if it is effective. We see that just doing “something” to help isn’t sufficient to fulfill our moral obligations—we have to do something effective, or we simply cause more damage.
Lexine Hansen
Master’s Candidate in Resource Development
Former Peace Corps Volunteer, Morocco
Working in North America: Worries about Worrying
I worry about three things when I think about treating the poor: First, that the implied separation between us and them when talking about treatment will go unnoticed and unaddressed; second, that most such discussions simply intensify efforts to preach to the converted; and third, that agonizing about how we (and others) should go about it will in the end paralyze all efforts.
First, the question “How ought we treat the poor?” implies an unhealthy separation between the poor and us. Of course there is a difference between people who are poor and people who are not poor, but differences in responsibility are not so clear. We create and perpetuate the conditions that result in poverty—in poor people. We cannot separate ourselves and our actions from conditions of poverty as easily as one might from someone who has a broken arm. There, one’s obligations could be only to treat the injury. Treating the poor as an overarching goal helps to distance us far too much from our culpability for what we treat. We need to ask how to eliminate the conditions that result in there being a separation between the ultra-poor and the well-off.
At this point my second concern crops up. People who are devoted to treating the poor understand both the need and the complexities involved in meeting the need. So discussions about it may not be helpful. The International Committee for the Red Cross is not naive in its traditional commitment simply to helping those who were suffering without concerning itself with guilt, innocence, or root causes. Sometimes treatment is the best one can do and in order to treat one will have to remain neutral, or even subjugate oneself to local powers.
My third concern is this. If you find yourself “merely” treating the poor, or “merely” making people aware of the roots of the problem, do not stop! Strategically, it makes sense that some of those who want to help act as neutral parties devoted to triage while others engage in activism against the source of the problem.
To achieve the goal of eliminating poverty we have to stop preaching to the converted and continue with the efforts we are currently involved in. Apathy is often blamed for inaction, but paralysis stemming from “but what can I do?” must be addressed. The challenge is to educate and motivate those who are doing nothing, while making more pluralistic our own efforts.
Bill Hannah
Doctoral candidate, Philosophy
Community activist, Canada