Capstone Reflection: The Violence of Hope
As Doctor James Kim describes, “optimism is a moral choice” (1:30:13 in Davidson & Kos, 2017). How important is hope to the global healthcare initiative? How might we reconcile the asymmetry of the qualitative benefits hope brings to suffering and mental health with the structural violence which causes optimism to erode in patients? Hope is a key measure of qualitative success on the ground, but challenging to quantify in upstream decisions focused on the economics of how that same hope might be delivered. Asymmetrical hope-destroying decisions of discrimination, hidden suffering, shame, and human rights abuses are characteristics of lowered life expectancy, driven by inequities in global mental healthcare, and have motivated Dr. Vikram Patel to describe it as a human rights crisis (9:21-12:11 in Patel, 2012). Citing Kleinman, who expresses it as a failure of humanity, both argue there is no greater failure than removing an individual’s hope of recovery (Kleinman, 2009). Both ask where the outrage is in rebalancing the moral imperative to help those who suffer in a world increasingly treating mental illness with pharmaceutical solutions and imposing healthcare decisions upon those without a seat at the table (Patel & Farmer, 2020).
This remoralization of hope is one which seeks to include qualitative measures of patient optimism into economic decisions of mental health, and dismantle the structural violence which would seek to remove it (Farmer, 1996). Such remoralization still asks us to make choices and determine hierarchy, but the inclusion of hope as a measure demands we bring the patient into the mathematics. It forces us to see patients not data (Krol in Petryna, 2013). Who gets to extend hope to whom is still a privilege of those making choices upstream of the very suffering they seek to alleviate. As Kleinman describes, the goal of such remoralization is to destigmatize mental health and to improve morale in the patient, but we still return to a central problem of the cost of care (Kleinman, 2009). As Fassin describes, "what we're looking at here is the worth of lives versus the value of life" (Fassin in Joiner, 2024). If we morally assert that all life has value, as Patel argues, then we must also make the economic argument that all lives have worth and that hope as a dimension of dignity in suffering is critical to care (Patel, 2012). The moral argument to introduce hope as a measure appeals to an emotionally positive outcome, but still cries out for an economic reconciliation.
The ancestry of suffering is often informed by a constellation of social, economic and political forces which over time coalesce around the destructive, hopeless structural violence of poverty. As The World Health Organization describes, “poverty wields its destructive influence at every stage of human life” (Farmer, 1996). But poverty goes beyond the economic asymmetry of structural violence. It robs those who suffer of hope, where the moral imperative to help is often fatally hampered by delay, which itself erodes optimism. Agency, access, and an disproportionate relationship between traditional and modern healing methods, both of which are paths to hope, collide to exacerbate suffering in the rural poor. In the film Bending The Arc (37:48-39.52 in Davidson & Kos, 2017), a young patient, Melquiades, lingers with long-term multi-drug resistant tuberculosis, but also chronic despair and exhaustion. A victim of disease, but also the structural violence imposed upon poor countries by economic administrations which withhold multi-drug resistant medication as ‘an expensive luxury’ and assign the violence of value to a hierarchy of human life. Melquiades’ loss of hope accelerates his decline. A fatal violence which creates winners who get to hope and losers who don’t.
Patients suffering from hopelessness also exhibit reduced agency through the structural violence of a lack of education, and from distant administrative decisions prioritizing market forces over individual suffering (Farmer, 1996). This is compounded by a lack of communal access to modern medicine, which drives patients towards supernatural healing methods, and where the only modern available alternative is unregulated. Both traditional methods and unregulated modern care bridge the gap of hope between suffering and recovery (Banerjee, 2013). They offer an optimism which comes from treatment irrespective of origin. The faith patients place in their localized methods of healing are often their only, uneducated, ineffective hope, where the unquestioning faith we place in western medicine similarly immunizes us from the kind of suffering which results from a lack of hope. The privilege of medical hope being within reach asserts itself over faith-based treatments, but is also a delineation across social and economic means. Those with means are afforded hope. It causes us to construct a perspective where the supernatural mysticism valued by suffering communities in less developed parts of the word is viewed as as less hopeful than the science of western medicine. A value system which prejudices western medicine over mysticism, and discards the hundreds of years of lived experience for which such methods have been in practice. It’s not that we seek to enlighten the traditional with scientific method, but seek more inclusive pathways for them to coexist within a sensitive, dignified lens of optimism for the sufferer.
Reframing optimism is a moral choice, but also one of economics (Kleinman, 2009). One which places accountability on a system which takes the hopeless environment of suffering and applies qualitative solutions to it through quantitative resourcing. Hope is not cure, but it is life-giving to those who suffer. Hope is a key counter-measure to structural violence and negative illness narratives (Kleinman, 1989). As Doctor James Kim describes, “the key is to have a pessimism of the intellect, but an optimism of the will” (1:32:29-1:32:56 in Davidson & Kos, 2017). The economic approach itself must be infused with hope. As Kim’s program proved successful on the ground in developing countries, it empowered Kim and his colleagues to make the argument for investment at the economic source of the violence, but also to place hope at the center of their treatment. When Melquiades recovers, Kim becomes emotional. “To think we almost let him die. Just because we didn’t think he deserved it” (40:08-41:32 in Davidson & Kos, 2017). It’s optimistic treatment on the ground paired with economic argument grounded in hope at the source which bends the moral arc of history towards a more hopeful future.
References:
Banerjee, A. (2013). The Name of the Disease. [Video File]. YouTube.com. Retrieved from: https://www.youtube.com/watch?v=rOenEuclS30.
Davidson & Kos. (2017). Bending The Arc. [Video File]. Retrieved from: https://video-alexanderstreet-com.proxy.library.upenn.edu/watch/bending-the-arc.
Farmer, P. (1996). On Suffering and Structural Violence. Daedalus , Winter, 1996, Vol. 125, No. 1. [Digital File]. Retrieved from https://www.jstor.org/stable/pdf/20027362.pdf.
Joiner, M. (2024). Week 4 Required Lecture. [Digital File]. Retrieved from: https://canvas.upenn.edu/courses/1781220/pages/week-4-required-lecture-47-00?module_item_id=29900561.
Kleinman, A. (1989). The Illness Narratives: Suffering, Healing, And The Human Condition. Basic Books. [Digital File]. Retrieved from: https://canvas.upenn.edu/courses/1781220/files/133613891?module_item_id=29900548.
Kleinman, A. (2009). Global mental health: a failure of humanity. The Lancet. Vol. 374. August 22 2009. Retrieved from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61510-5/fulltext.
Patel, V. (2012). Why Mental Health Matters to Global Health. McGill Transcultural Psychiatry. [Video File]. Retrieved from: https://vimeo.com/48897107.
Patel, V. & Farmer, P. (2020). The moral case for global mental health delivery. The Lancet. Vol. 395. January 11 2020. Retrieved from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33149-6/abstract.
Petryna, A. (2013). The Right of Recovery. Current Anthropology. Volume 54, Supplement 7, October 2013. [Digital File]. Retrieved from: https://www.journals.uchicago.edu/pb-assets/docs/journals/CA_S7_v54nS7_potentiality_supplement-1593017836633.pdf.
