Daniel Palazuelos: Whose community is it anyway?

Daniel PalazuelosThere is no magic formula for how to work with communities in a way that perfectly balances power sharing with meaningful change.[1]  Many of the experiences that I have had in the Partners In Health supported projects in Mesoamerica have been incredible reminders of just how complicated this work can be.  Nevertheless, like the practice of medicine, there is both a science and art to the vocation.  Inspired by my readings and experiences, I offer a few key considerations, certainly not exhaustive, for those who may find themselves in the tumult of community participation:[2]

 1.     Communities are people, so don’t forget you are too:

If you want to work with communities, you have to work in communities.  This means being present, eating what they eat, sleeping where they sleep, sharing with the community members both the joys and difficulties of everyday life.  White 4×4 trucks that allow for easy access and egress can be destructive if they are used as a means of separating ourselves from the challenges that our local partners live every day.  Personal safety is certainly paramount, but we should be careful to not fool ourselves about what is safe and what is merely comfortable privilege. 

2.     People often prefer accompaniment to overt leadership:

Your partners on-site have thought and acted before you ever came, and will continue to think and act long after you’ve left.  Each one has a personal understanding of their own world, and of the logic that connects them too it.  If we are outsiders bringing in new elements, albeit positive elements, the onus is on us to understand how this element fits within established paradigms.  By hoping to accompany local processes as a truly humble partner, we can hopefully meet the inevitable challenges with a spirit of compassion, ingenuity, and equal collaboration.

3.     Communities are actually made up of many communities:

When many people think of the good community, they often envision a collection of quaint houses along a mountain’s edge where everyone comes together on Sundays to democratically arbitrate disputes and then celebrate life.  If this evokes in you a warm and fuzzy feeling, then you simply don’t know communities.  They aren’t perfect, and they certainly aren’t singular entities that share one mind and speak with one voice.  This is most true in modern communities, such as in urbanised areas and slums, where people are forced to live next to each other as economic refugees.  We need to accept that community work may mean long conversations with different factions, trying to sort out who is working well together and who is gearing up for battle.  All community participatory work runs the risk of what has been called “elite capture” – a process by which the locals that are relatively more well off, usually men and majority groups, influence resources and projects such that they make out with more of the benefits.[3]  Knowing this ahead of time, you can work towards creating systems that minimise this corrosive process.

4.     Participation needs investments:

Community participation is sometimes seen as a “cost-effective” panacea: a yellow brick road to empowerment and sustainability that presents little need for increased material resources.  This is wrong, because even the most organised and active communities can always do more with new tools and new initiatives.  Without tools, the glass ceiling of achievement will be low; but once the tools are available, an engaged and involved community has the possibility of adapting them to local needs.  Equity in action is the sharing and redistribution of resources, good resources.  One can see this taking shape in initiatives such as improved housing, quality HIV care, electronic medical records, etc.  In our work, as one of many examples, we are piloting the use of original computer applications, programmed on cell phones, as decision support tools for village health workers. 

5.     Hierarchies only crush those at the bottom:

Whether they are liberators or lackeys, if village health workers are only the last rung on a steep ladder of participation, they will be crushed by the weight of those above them. It sends the wrong message. Initiatives are better managed horizontally, and incentives have to be distributed transparently and equitably.

6.     Communities exists in a context:

Even the most isolated and marginalised communities exist within countries, and countries almost always have governments.  Even if communities decide not to work directly with government services because of past abuses, efforts should still be made to encourage communities to envision how local efforts will exist within the larger context of government programs.  This is not only to prevent parallel services that waste resources through duplicate efforts, but also to potentially strengthen the rights afforded to them that only governments can supply. There are many different mechanisms by which this can occur, and a number of studies have looked at which are more effective then others[4], but the first step is to recognise that while completely rejecting government services may be appealing to some in the short run, this strategy threatens to undermine the very foundation of peoples’ rights in the long term.

In Short, they decide, and we participate:

Community participation is actually not only about communities; it is also about us, the privileged who hope to help them.  It is: a constant reassessment of what drives our motivations, and how we are interacting with our on-site colleagues; a daily practice of active patience and cultivated humility; a gentle reminder that while we bring new tools and materials, we will always have yet more to learn about how to use them best on-site.  As a personal barometer, I regularly ask myself: who’s deciding and who’s participating.  I know I’m getting close to being right when I find myself participating in and accompanying initiatives that our colleagues have decided upon themselves, hopefully, as a community.  We all have our part to pull. 

[1] Rifkin, SB. Paradigms Lost: Toward a new understanding of community participation in health programmes. Acta Tropica. 1996: 61;79-92.

[2] Kahssay HM, Oakley P. Community Involvement in Health Development: a review of concept and practice.  Geneva: WHO; 1999.

[3] Platteau JP. Monitoring Elite Capture in Community-Driven Development. Development and Change. 2004 April; 35(2): 223–246.

[4] The Poverty Action Lab at MIT has done a particularly nice job in this.

Daniel Palazuelos is an associate physician at the Brigham and Women’s Hospital, and an instructor of medicine at Harvard Medical School. He is the clinical director of the Partners In Health-supported projects in Chiapas, Mexico and Guatemala. Partners In Health is a US-based NGO working to bring advanced medical care to the world’s sickest and poorest people. In this role, he lives for half of the year in isolated communities in the Sierra Madre Mountains, training local community health promoters, providing medical care, conducting research, hosting medical student projects, and creating original curricula. For the other half of the year, he lives in Boston and practices inpatient medicine with the hospitalist group at the Brigham.

Competing interests: DP does pro-bono work for Partners for Health, a Boston-based NGO and they assist him with travel support to work abroad.