When you think about the last time you gave someone a gift, what feelings do you remember? Maybe it was for a holiday, or a birthday, or just a no-reason way of showing appreciation to someone you care about. For me, it was my dad’s birthday, late last month. There is always a bit of trepidation and uncertainty around whether or not the gift will be useful to the recipient, or if they even like it. And while you’re giving this gift without really expecting anything in return, there is always an expectation, or at least a hope, that the recipient will show their gratitude. After all, you’re doing something nice for them! 

Receiving a present is also tricky. I always feel nervous about whether or not I will like the gift, or if it will end up sitting unused, collecting dust. But regardless of whether we like the present or not, we feel an obligation to show our thankfulness in an authentic way, to show that this expense taken on our behalf was not done without reason. 

Gift-giving thus becomes its own kind of awkward social dance. So how does this look on a widespread scale – even globally? This was one of the topics that Dr. Holman and I explored in our discussion on Friday. Last week, I finished reading her book Beholden: Religion, Global Health, and Human Rights. The final chapter is on the concept of the gift, and what gift-giving might look like in global health contexts. 

A gift is different from charity. Charity, while not all bad, implies some patronization and an attitude of “helping” those who are helpless. Gift-giving emphasizes the fact that everyone has something to offer. In gift-giving, while the giver still does not expect anything in return from the recipient, they also look out for ways that they can learn from the recipient. It places both the giver and recipient on equal footing. For gift-giving, picture an image of two people walking alongside each other, learning from each other. Charity would be more like the image of one person deigning to lean down and pull up the other. 

While gift-giving is a sort of exchange, the people involved still do not have any expectation of being “repaid.” It is a tricky balance, and requires both vulnerability and an unwavering focus on the dignity of all people. 

This week, I also read some selected chapters from an anthology book honoring the late Dr. Paul Farmer, a pioneer in global health. Dr Farmer established multiple hospitals in low-income nations, giving care and training to new generations of local doctors. He also challenged notions about what global health interventions were possible, often seeking after the seemingly lost-cause cases. 

One chapter in this book, “Liberating Theological Ethics from the Invisible Hand,” discussed how the economic principles of neoliberalism have seeped into global health. This process has made patients “consumers” and services “products.” In our market-infused health system, nothing is given without something else being expected in return. “Cost-effectiveness” and “efficiency” are the gold standard, prioritized above impact on human health and wellbeing. If money is being invested into a project, that project better have some sort of financial benefit to show for it. 

Gift-giving is a way to challenge this market-driven approach to health. Profit is not the ultimate goal, but the wellbeing of each person, no matter how disadvantaged, is. 

Most importantly, this gift exchange goes both ways. As Christians, we are reminded of the ultimate, selfless gift of grace and how there is nothing that we, as humans, can do to “repay” or reciprocate that gift. This gift-exchange mindset means being willing to give what you are able without a sense of being owed something in return. It also means being open to receiving gifts ourselves without feeling a need to repay it, as we have received grace. Gift-giving in global health means that our main goal is to emphasize the dignity of each person as a child of God, instead of as a potential revenue source. This might look like providing services without any requirement of payment from patients. Or it could look like walking 6 hours to make a home visit, as Dr. Farmer often did. 

This is a wonderful ideal to aspire to. But most of us are not charismatic, trained medical doctors who can pause our lives to start building a hospital in Haiti. Still, there is need everywhere, and it is oftentimes right on our doorstep. My work this summer, at Bread for the City and Catholic Charities of D.C, has been centered around this type of gift-giving. Both organizations provide free health and social services to the community – work that isn’t very “cost-effective” or “profit-driven.” It is easy to slip into a mentality of “helping” our disadvantaged “consumers.” But as I’ve found through experience, this closes the door on seeing the whole person with whom I am interacting. It both closes the door on learning anything from them, and makes me more impatient.

When we feel as though we have nothing to give, or don’t know what to give, a listening ear and some time is all we need. A later chapter in the Paul Farmer book, “Practicing Local Listening with Village Midwives in Sudan,” highlights the title’s case study. Truly listening to what people have to say about their lived experiences – and not just hearing what we want to hear! – is the mark of a mutual gift giving. It reflects a just and fair community partnership, in which services and knowledge are given freely, and all community members walk together in solidarity on the road to better health. 

This is one in a series of post by Elizabeth Rambo, on her 2024 PLT summer internship experience.

Readings:

Clark, M. (2023). Practicing local listening with village midwives in Sudan: A case study for theological ethics. In J.W. Block, M.T. Lysaught, and A.A. Martins (eds.), AA Prophet to the Peoples: Paul Farmer’s witness and theological ethics. Pickwick Publications. 

Holman, S.R. (2015). Beholden: Religion, global health, and human rights. Oxford University Press. 

Lysaught, M. (2023). Liberating theological ethics from the invisible hand: Paul Farmer, the world’s poor, and the quandaries of the fortunate. In J.W. Block, M.T. Lysaught, and A.A. Martins (eds.), A Prophet to the Peoples: Paul Farmer’s witness and theological ethics. Pickwick Publications. 

The Project on Lived Theology at the University of Virginia is a research initiative, whose mission is to study the social consequences of theological ideas for the sake of a more just and compassionate world.

I didn’t notice it at first – my second coffee of the morning probably hadn’t kicked in yet. Most mornings, I sort all of the mail that has come into Bread for the City for their representative payee clients. These are consumers who have been declared mentally unable to take care of their own finances by a judge or doctor. BFC is one of a few organizations around the city that manages the consumer’s money to pay their bills and give them a weekly allowance. Sorting this mail requires looking up the recipient’s name and categorizing them according to what “group” the recipient is labeled as. 

After I got about halfway through the pile, I realized a lot of them were going to various teams at Anchor Mental Health – the building in which I work for Catholic Charities on Wednesdays and Thursdays. Anchor is the headquarters for all of Catholic Charities’ mental health and psychiatric care – which is a lot. They have about a half-dozen teams responding to various groups’ needs, with school interventions, crisis response, and counseling. The biggest recipient of the mail I was sorting was the ACT team. ACT, or Assertive Community Treatment, is for people who have severe, untreated mental illness. 

Dozens of these mail recipients, who were clients of Bread, were also clients of Catholic Charities. I guess I should not have been surprised by this, because both organizations provide similar but complementary social services. There is a lot of overlap in the groups of people who seek out their services. 

If someone is severely mentally ill, chances are they have a hard time keeping a job. That affects their ability to pay bills or get food, which Bread helps with. It also affects their ability to function independently, which Catholic Charities would help with. I mentioned what I had noticed to Ms. Kesara, my supervisor, and she explained it much more succinctly: “We help with the money and the food, they [Catholic Charities and other nonprofits] help with the other stuff.” 

This realization got me thinking more about how various social determinants of health overlap and feed off of each other. In the public health sphere, social determinants of health, in a broad sense, are the various nonmedical factors that affect health. These are the environments and conditions in which one grows up and lives in. Access to nutritious food is a good example, as are water and air quality, safe housing and transportation, exposure to trauma and violence, and financial stability. And a lot of times, these overlap. A child born in poverty lives in a rough neighborhood near an industrial park. The pollution he grows up breathing, coupled with the fact that there are no safe parks nearby to run around in, means that he has a vastly greater chance of developing asthma or other health issues.

Just by sorting the mail, I was seeing some of these social determinants play out in real life. Financial struggles were connected to physical health struggles were connected to mental health struggles were connected to food struggles were connected to… you get it. 

Local nonprofit organizations are uniquely able to get to know their clients and work with them on specific issues. They’re generally best suited to address the needs of consumers for whom the social determinants of health have overlapped in difficult ways. Picture an archetypal homeless person. Probably influenced as much by stereotypes as by lived experience, this is probably a drinking, smoking, guy talking loudly to himself. You (and me, too) start mentally preparing to look straight ahead and give him a wide berth as soon as you hear him down the block. Bread for the City might help him pay his bills if he is unable to. Catholic Charities might help him with psychiatric care and substance abuse recovery. Another organization might assist with finding a job.

Local, specialized NGOs can understand the local environment and residents far better than a statewide, national, or even international effort can. But it also means that there are that many more opportunities for information – and people – to slip through the cracks. Here we find a very fine balance between specialization and complication. 

Global public health at large faces the same difficulties. This week, I have continued reading Ellen Idler’s Religion as a Social Determinant of Public Health. In his chapter, “Religion and Global Health,” Peter Brown writes that global health is “fragmented, complicated, and inadequately tracked.” A pretty condemning description! In this chapter, Brown writes about how nationally- or internationally-funded programs work best when enacted by local actors. Instead of outsiders entering a community and attempting to run (usually very well-intentioned) initiatives, these initiatives should be run by those who they would benefit. Community leaders better understand the culture, the issues affecting the residents, and what solutions might work best. 

However, these locally-run initiatives often struggle to communicate with each other and as a group. This damages both day-to-day logistics as well as prevents everyone from learning what works and what doesn’t. 

In our conversation last Friday, Dr. Holman and I discussed these issues of autonomy, locality, communication, and consistency of care. Ultimately, it comes down to a balance between effectiveness and efficiency. Balancing the scale requires both being fair to local needs and emphasizing quality assessment. Yes, public health initiatives should be locally-run as much as possible if (!) they are consistently assessed to be working. 

It’s difficult to measure the costs and benefits of this fragmented approach to holistic public health. How many bills were late because a Catholic Charities intern took too long to sort the mail forwarded to another organization? How many people had to rethink their whole schedule because Bread changed their food pantry hours? But also: how many mentally disabled people are able to lead more independent lives with fewer financial burdens? How many meals have been distributed to those who would have otherwise not eaten? 

These next two weeks, I will be reading Bread for the World by Arthur Simon and the chapter “Toward a Theology of Medicine,” in Hostility and Hospitality by Michael and Tracy Balboni, and am looking forward to finally getting to My Year of Rest and Relaxation (the book, but maybe it’ll also spark a very mellow next 365 days). 

This is one in a series of post by Elizabeth Rambo, on her 2024 PLT summer internship experience.

The Project on Lived Theology at the University of Virginia is a research initiative, whose mission is to study the social consequences of theological ideas for the sake of a more just and compassionate world.

It has been almost three weeks since I started my internships at Bread for the City and Catholic Charities. I’ve started to get a view of what my work looks like, and how it fits into both each organization’s mission and public health in D.C. My days at Bread usually consist of helping organize and run their extensive food pantry, which serves hundreds of people a day. This is a lot of on-the-ground, with-the-people work, and it is as exhausting as it is rewarding. 

Recently, a lot of my time at Bread has involved making calls. Because of a lack of funding, the organization has had to cut their food delivery program. For the past few years, since the beginning of the pandemic, they have delivered monthly groceries to many clients around the city. The program is shuttering on July 1, and we have to call all 1,500 (yes) recipients before then to let them know. I have the script practically memorized at this point: We have to end the delivery program, no, there is not enough money for it, yes, the pantries will still be open, yes, from Monday through Thursday, 9 am to 3 pm. The phrasings of “this number is no longer in service,” or “this number cannot accept calls” are ingrained in my mind at this point. 

Nearly everyone was very understanding, although I’m sure this created a considerable disruption to their food supply. The monthly deliveries are not meant to provide every single meal for a whole month, but they are a significant supplement. They are often part of a puzzle, put together with other pieces from other nonprofits, services and purchased food. People were sympathetic about the financial constraints and made plans to come in-person, and lots were thankful I let them know. A few people were upset, and I was hung up on a few times. 

The calls that have stuck with me, though, are the ones of older people who are homebound, from illness, immobility, or both. And when I go into the next part of my spiel – don’t worry! If they can’t get to us, they can send someone to pick up their groceries for them! – these callers have responded with “well, I don’t have anybody.” Nobody – no family or friends, no caretaker or assistant, no neighbor or random neighborhood acquaintance. They “don’t have anybody” to pick up their food, their medication, help them get dressed, or just to sit and spend time with them. 

I am especially struck by this loneliness when I think about all of the people I have interacted with today. I called my parents and brother, who are all interested in my summer. I played pickleball and went to a museum with my friend Caroline. I went to church with my great aunt and uncle (with whom I am living) and chatted with the pastor afterwards. All of those people would help me if I needed it – and these are only the people I saw today. Being confined to bed would be immensely difficult for anyone, even if they were well-connected. But to go at it alone – I’m embarrassed to say that it is difficult for me to comprehend and it is mind-boggling in its emptiness. This is a loneliness that stands apart, and is far deeper than any of my dabblings during my first semester of college. 

From my reading list, provided by Dr. Holman, I have begun Religion as a Social Determinant of Public Health,by Ellen Idler. In it, she describes how there is something about religion that is good for health.¹ Even when controlling for related variables (like being married or drinking less), the uplifting community that religion creates consistently predicts a longer lifespan. Being with other people and feeling connected to them is not only good for the soul, but also good for the body. So in a way, facilitating connection is one of the ultimate public health interventions. It’s probably why the surgeon general called our nation’s loneliness “an epidemic.”² 

When I read this information today, I couldn’t help but think about Alice*, who sounded as though she might be about to cry when she said she didn’t have anyone to get her groceries for her. Her voice sounded like my grandmother’s as she described how she is bedridden. Or about Cassandra*, who was struggling to think of someone to do her pickup after her son passed away on Friday. There is a depth to this loneliness that touches on a spiritual level, but hurts physical health, too. 

This (very) windy thought tangent has started to nudge me outside of what I typically picture as public health interventions. This is beyond the typical vaccinations and seatbelts – how can we prescribe something so intangible as connection, to a culture so desperately in need of a cure? My normal knee-jerk response of “public policy” is limited here. The types of community interventions, as well as the layered complexities of social determinants of health, are something I will enjoy diving into with Dr. Holman during our next meeting.

As I begin to think about what it means to be a Christian in public health spaces, and to serve others through faith, I think about Ms. Jeanette, one of my supervisors at Bread. During some of the busiest parts of the day – when the line of customers keeps growing, the grocery bags keep tearing, and my feet are sore – is when she likes to play her gospel music. It isn’t a dramatic singalong, but an underlying soundtrack that everyone who enters the food bank can hear. 

Her music is not just some silly, platitudinous attempt to tell the people coming in for food to “not worry, because God has a plan!” I don’t think that’s comforting, and I doubt many other people think it is, either. Somehow Ms. Jeanette finds additional room for praise in the midst of need. But there is also grief: “in the darkest night you are close like no other,” one song says. There is both praise and lament in this space, where the hungry are lonely, and somehow there is still a God walking alongside. 

This is one in a series of post by Elizabeth Rambo, on her 2024 PLT summer internship experience.

The Project on Lived Theology at the University of Virginia is a research initiative, whose mission is to study the social consequences of theological ideas for the sake of a more just and compassionate world.

¹ Idler, Ellen L. (2014). Religion as a social determinant of public health. Oxford University Press.

² Murthy, Vivek H. Office of the Surgeon General. (2023). Our Epidemic of Loneliness: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community. https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf