Accompaniment

Paul Farmer has a piece in Foreign Affairs titled “Partners in Help”. Much of it is a re-telling of stories and ideas Farmer has used before (to great effect, of course), focusing largely on the idea of ‘accompaniment.’ I especially like (and wish he would expand on) this ending section:

Another way of putting this is: Beware the iron cage. About 25 years ago, when I was a graduate student at Harvard, I bought a copy of sociologist Max Weber’s collected works. It hurt my back and brain to even look at this giant tome, but his topic — how the “iron cage” of rationality comes to suppress innovation — remains relevant to this day. It occurs through “routinization,” a process by which rationalized bureaucracies gradually assume control over traditional forms of authority. This is often a good thing: Rationalized procedures can improve efficiency and equity. (Atul Gawande made this insight the core of his “checklist manifesto.”) When the World Health Organization launched its directly-observed therapy protocol for tuberculosis, many countries, such as Peru, made great strides against the ancient scourge.

But exceptional events — black swans, in popular parlance — expose the limits of this form of efficiency. When patients began falling ill with drug-resistant strains of tuberculosis, WHO guidelines suggested they be treated with the same first-line drugs as non-resistant patients. Yet treating patients with the very drugs to which their disease had developed resistance not only failed to help them; it enabled the worse strains to spread unchecked among patients’ families and co-workers. This is the double-edged sword of routinization: Rationalized treatment protocols first helped health providers increase the effectiveness and reach of treatment but later prevented them from taking necessary steps to curb the spread of drug-resistant strains. Increases in bureaucratic efficiency can come at the price of decreased human flexibility. In other words, as institutions are rationalized, and as platforms of accountability are strengthened, the potential for accompaniment can be threatened, since it is open-ended, elastic, and nimble.

When the iron cage of rationality leads to a poverty of imagination, cynicism and disengagement follow. It is easy to be dismissive of accompaniment in a world in which arcane expertise is advanced as the answer to every challenge. But expertise alone will not solve the difficult problems ahead. This was the long, hard lesson of the earthquake: We all waited to be saved by expertise, but we never were. True accompaniment does not privilege technical expertise above solidarity, compassion, and a willingness to tackle what may seem insuperable challenges. It requires cooperation, openness, and humility; this concept may, I hope, infuse new vitality into development work.

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08 2011

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