Alexandre A. Martins, OSCam.
Marquette University
Milwaukee
[email protected]
Editor's Note: The following essay was the second of two winners of the graduate student essay contest sponsored by CHA. It was delivered at the CHA Theology and Ethics Colloquium on March 20, 2014. Alexandre A. Martins is a Religious of the Order of St. Camillus from Brazil, and a Ph.D. student in health care ethics at Marquette University.
Introduction
Without social justice, we cannot promote population health nor a universal public health system necessary to support it. In the words of Norman Daniels "social justice is good for our health."1 Catholic social teaching has important insights to contribute to the social justice debate in health and public health care. Drawing upon this tradition, I will explore the concepts of justice and the common good and their implications for justice in health care.
Lisa Cahill proposes that theological bioethics should make justice in access to health care resources its first priority.2 This is my point of departure. Along with the notion of the preferential option for the poor, one of the basic principles of the Catholic social tradition, this is an option that comes from Christological faith.3
This option challenges us to look at reality, analyze it, and act in the world from a perspective that rises from below. This challenge begins with two invitations: first, it invites us to join with the poor and marginalized to share their lives and see reality from their perspective. Second, it invites us to understand suffering and poverty from the perspective of those who are poor and carry great burdens. If we accept these two invitations, we will discover what the suffering of the poor concretely means and how can it open our eyes to a new understanding of unfair social relations which create exclusion and exploitation of the weakest ones. Only among the poor, can we live the preferential option for the poor.4 This option leads us to realize that the poor are human beings and not a sociological concept, nor an abstract Christian principle. In addition, it stresses that the poor have their power in history; they are not simply masses that can be manipulated or a context to apply our theories. If we want a real transformation of reality, we need to act with the poor, from below.
The preferential option for the poor impacts the way in which to do theological bioethics. It forces theologians to turn from a bioethics from above to a bioethics from below. Therefore, this way of doing bioethics will be from the perspective of the poor in which issues such as justice, health, and universal health care will be a priority. From the perspective of the poor, it is possible to empower the poor and propose actions to promote justice in health in a participatory way.
My approach to justice in health and public health care is a dialogical process that begins with those who are excluded in order to empower them to participate in the decision-making process in the social and political arena. Thus, dialogue is an intrinsic aspect in the sense of a broad participation that includes the poor and all those who do not have a voice in the social arena. Hence, I divide my discussion into three topics. First, I present the issue of justice in public health. Second, I define social justice and the common good as they are expressed by the Catholic social tradition. Third, I show how the moral imperative of justice in health care (preventive and curative) and in the Catholic social tradition offers some insights to promote population health.
1. Health: Justice in Public Health5
Justice in health promotion and health care does not exist on its own. It needs a fair society. In other words, social justice is absolutely essential to population health. Many situations that put population health at risk are linked to the social conditions of life.6 Poverty is the number one cause of individual and social vulnerability and early death. Therefore, actions to promote social justice that address poverty and struggle against social inequalities are indispensable to promote justice in health. Unfortunately, the health sector itself does not have enough power to promote justice in health care in order to support population health. Inequalities in health care are a consequence of an unequal society that creates unfair structures to benefit a small and privileged group in the world. At the same time, these inequalities cause massive suffering among the greater part of the world's population. Those who are forced to live a miserable life and are without opportunities are vulnerable to all kinds of diseases and social insecurity.
These vulnerable people are the poor who do not have a face. The privileged ones do not see them, except as an undefined mass of misery. In theological language, these are crucified people who are abandoned to their crosses without hope of social redemption. It is not possible to promote social justice if we do not know who these suffering people are. We cannot promote justice in health promotion and health care if we do not know the suffering of this crucified people; if we do not know that they have faces, families, and dreams; if we do not know their names. They are José, Maria, Dominique, Julia, Tú, Jun, Bambam, Shinbin, Michael, Bryan, Samantha. They are human beings as you and I. Humans who think and feel, smile and cry, enjoy and suffer; who need to drink clean water and eat healthy food; who need clothes and a home; who need to grow and die after a life lived according to their beliefs, principles, and culture. They are human beings who want to develop their full humanity and expand their world through education and work as all children of Adam. They are people who are fragile and affected by death, who get sick and need health assistance. Again, these crucified people are worthy people like you and I.
The first step to promote social justice is to recognize that the poor have faces and lives. Simone Weil, the French philosopher, affirmed that the poor are invisible to those in society who are not poor and who have power in their hands. According to her, the world never will be better until we recognize the poor as individuals who share the common human condition of fragility. This recognition can only happen in two ways. The first is through our own experience of suffering that happens through a deep spiritual experience of meeting Jesus in his cross or our own social poverty. Both of these reveal the contingency and the fragility of our human lives. The second is through our courage to live with the poor and share their lives.7
Norman Daniels affirms that a theory of justice is the first step to promote justice in health care and population health because a theory of justice "can guide our practice with regard to health."8 But if we begin with a theory of justice, we might make abstract statements that are so beautiful and logical from a philosophical perspective, but remain far from reality and be impossible to apply realistically. Daniels' approach also proposes to address a virtual reality that is disconnected from the real needs of those we aim to help. In addition, beginning with a theory of justice from above to solve problems from below does not require democratic participation, does not recognize the faces of those who should benefit from it, and might be authoritarian when applied as well.9
I appreciate Daniels' theory of justice, but it is insufficient. He forgets the poor people who are suffering in an unjust reality that he wants to fix with a theory. Daniels does not analyze the mechanisms of oppression that prevent the poor from living a worthy life and having opportunities to flourish. Consequently, he thinks that the liberal model of development is sufficient to promote justice in health, and a reform is sufficient to join market freedom with economic growth and equality with social development.
A theory of justice could be a second or third step. The first step should be to recognize the face of the poor, to understand their suffering and share their lives. Thus, the analysis of the social reality must arise from the locus of the poor. Social transformation requires empowering the poor to participate in the decision-making process. In this way, we will know their health needs. Then, we can move to a theory of social justice in dialogue with the whole society. A theory may be useful, not because it has the solution for all social problems, but as another interlocutor in a dialogic construction. Hence, a dialectical approach from below respects the particular specificities of the local context, the particularities of cultures, and international relations. As dialectic, it begins giving voice to those who do not have one.
Nevertheless, among poor people we need instruments to analyze reality. We need to interact with the poor with a greater understanding of the mechanisms of oppression, exclusion, social injustice, and health inequalities. Social sciences provide these instruments. It is our responsibility to use them for analyzing the reality and translating the results into a language that the poor can understand. This must be a dialogic process with the poor within their reality and not in a seat of a university where the poor do not yet have a place.
Social analysis cannot be something given by scientists, intellectuals, or theologians to the poor because they do not have anything to offer, but only need to learn. It is necessary to recognize that the poor are not only passive receptors of a dominant mentality without any knowledge. The poor have their very specific kind of knowledge that keeps them standing amid situations of oppression and marginalization. This knowledge is not systematic as is scientific knowledge. It is fragmented and scattered, but it reveals a popular wisdom. It shows the power of the poor in history. Hence, dialogue and dialectical dynamics are indispensable requirements for bioethical praxis as well as virtues such as humility and prudence.
Paul Farmer exemplifies this approach. In his book Pathologies of Power, in dialogue with liberation theology, he talks with the poor in their locus of suffering in a concrete place, Haiti. There, as a physician, he worked with the poor. This experience gave him a perspective to understand the suffering of the poor and its causes. Sharing his medical gifts with the poor around the world, he noted that there are structures that cause suffering among the poor and prevent them from accessing a life with dignity. Farmer encourages a pragmatic solidarity.10 He invites people to leave their comfort zone and to join the poor working with them toward a better world. He also affirms that "the silence of the poor" must be broken and that this requires compassion and solidarity.11
Breaking the silence of the poor is necessary to meet those who are poor, listen to them, and give them voices. We will never break this silence if we are far from the poor. Without interaction with the poor, we see them only as a passive mass that merely receives a theory of justice that aims and promotes reforms while supporting the neoliberal economic model. Any neoliberal model is from above and marginalizes human lives that cannot compete in the marketplace. Giving voice to the poor requires knowing who the poor are and, at the same time, our compassion and solidarity move us to be with the poor. Among the poor, we realize that our intellectual instruments must be recreated to address their reality. The poor have something to offer to recreate a new world. We need to dialogue with them. I argue for pragmatic solidarity, humility, and creativity together with the poor.
Structural violence is a key concept to understand the suffering of the poor. Farmer affirms: "Today, the world's poor are the chief victims of structural violence — a violence that has thus far defied the analysis of many who seek to understand the nature and distribution of extreme suffering. ( ... ) The task at hand, if this silence is to be broken, is to identify the forces that conspire together to promote suffering, with the understanding that these are differentially weighted in different settings."12
Social analysis far from the poor tends not to see the poor themselves and believes that reforms are enough to promote social justice and justice in health care. In addition, this approach supports the status quo of those who are in a privileged situation. Theories of justice that are not situated in the locus of the poor are neither dialogic, nor democratic because they dispense the contribution of the poor. Consequently, they are elitist and support welfarist policies as a way to combat poverty and promote justice. Welfarism only ensures that the poor are able to survive and do not die of hunger quickly. It is necessary as an immediate action, but it must be overcome as soon as possible in order to empower the poor. Welfarism makes the poor dependent upon the neoliberal system in a cruel relationship between welfare and exploitation.13
Promoting justice in health promotion and health care requires struggling against the inequalities in health care that are the consequences of social injustice. Therefore, justice in health care requires social justice. In addition, justice in health care is not only to distribute health care; rather it requires promoting population health necessary to create possibilities for people to improve their lives. There are two ways of considering population health. First, it addresses social justice, it empowers people to live in good social conditions, it helps them to develop their lives with dignity. Justice in health care must be viewed as a societal issue and not isolated from it.14 In order to achieve justice, it is necessary to value justice in some "spaces" such as health care.15 Second, justice must be viewed in the specific context of health, as a precondition that enables people to develop their lives. Hence, it is crucial to address challenges of distribution of health and health care, the social determinants of health, and the allocation of resources in health care. This will foster the social arrangements that will strengthen social opportunities and break structural violence. These challenges should be met in a dialogic way with the poor to break through their silence and to empower their working collaboratively, creatively, and prophetically.
2. Theology: Justice and the Common Good in the Catholic Tradition
The Catholic social tradition offers us a contribution to promote social justice and justice in health promotion and health care. First of all, this teaching should be used dialogically among the poor. Catholic social teaching must allow itself to be confronted by the poor and their experience of structural violence and also to be recreated in light of this interaction. Otherwise, Catholic social teaching runs the risk of becoming just another abstract theory of justice. On the other side, Catholic social teaching, through prophetic voices, should dialogue with the secular world to advocate for the poor. Theologians must act as a bridge between the poor and the secular arena in order to give voice to the poor.
Shortly, I will explain a few elements that shape Catholic social teaching about justice and the common good. However, I will not accomplish this through conceptual explanations alone. Rather, I will do it from the standpoint of my experience working with the poor in grassroots communities in Brazil, particularly with volunteers of Pastoral of Health to promote a universal health care system. Justice and the common good in Catholic social tradition are social principles that arise from an experience of faith and a theological space. This space is the reality of the poor. Jon Sobrino affirms that the reality of the poor is the theological space of Christology in which we contemplate the face of the crucified Jesus in the face of crucified people.16 These faces of suffering invite us to proclaim: "Blessed are the poor because they belong to the Kingdom of God" (Lk 6:20). This blessing is Jesus' appeal to struggle for justice in our historical time with those who are crying out for justice. Therefore, justice is grounded in our faith in Jesus that leads us to struggle for social justice from the perspective of the poor. Joining with the poor is a precondition for justice and articulating a theological bioethics from below.
The common good is grounded in the fact that all human beings belong to the same human community and have the right to enjoy all the goods that nature can offer in order to develop their lives.17 The good of all human persons is connected to each person's ability to participate in the common good in the world that is God's gift. The Second Vatican Council affirms that the common good is "the sum of those conditions of social life which allow social groups and individual members relatively thorough and ready access to their own fulfillment."18 Thus, the fair distribution of the common good is the duty of all members of the civil society.
The integral development of the human being depends upon each person having the opportunity to participate in the common good and, at the same time, to collaborate in the development of goods and their just distribution. Participation in the common good requires both contribution and distribution in order to make goods available for all to promote social justice.19 There is a circular relationship between contribution and distribution of the common good for social justice that requires a conception of humanity as a community of solidarity. "From a common good perspective, therefore, justice calls for the minimal level of solidarity required to enable all societies to live with basic dignity."20
Pope John Paul II presents the principle of solidarity as a moral and social virtue necessary to social justice. He affirms that solidarity "is not a feeling of vague compassion or shallow distress at the misfortunes of so many people, both near and far. On the contrary, it is a firm and persevering determination to commit oneself to the common good; that is to say, to the good of all and of each individual, because we are all really responsible for all."21 Catholic social teaching has a communal vision of humanity and the relationship between people at local and global levels in its purview. As a community, all participate in the same human condition in which all are invited to collaborate with each other. The goal is an integral development of each person and of the whole community. Solidarity strengthens people in their active social involvement and recognizes the needs of each one leading to a mutual construction of a society that allows for integral human development.
Solidarity is necessary in order to share goods in which all can participate in the common good and build a good life in a just society. Catholic social teaching affirms that social justice requires commutative justice and distributive justice in order to empower all people to be able to participate in the common good.22 Commutative justice is the contribution that all people are invited to give towards developing and strengthening the common good. All people have a duty to contribute towards building the social life in which all are able to participate in social goods. Social institutions are responsible for organizing social goods and making them available to all. Each person contributes to the common good according to his/her conditions and from his/her social space. Distributive justice answers to commutative justice by making the goods created available to all members of the civil society so they can meet their needs to construct a life with full dignity. Solidarity requires us to address social justice in terms of commutative and distributive justice. Without solidarity, it is not possible to empower those who are currently prevented from participating in the common good and who suffer "exclusion from social life and from participation in the common good of the human community."23
Solidarity leads us to join the poor in their own locus. Social justice should empower them to participate and contribute to the decision-making process of public political life that will make the common good accessible for all.
The preferential option for the poor gives us a perspective that touches the reality of the poor in a way that empowers them to be agents of justice. Justice means that all members of civil society participate in the common good in a circular relationship between contribution and distribution (justice as a means) toward social justice (justice as an end). Everybody is called to give his/her contribution to growing the common good at the individual, political, and institutional levels of society.
The common good is a public good because it addresses the basic needs of human beings. In light of the preferential option for the poor, distributive justice makes the goods accessible to all through actions that begin from below, from those who suffer due to a lack of goods to meet their basic needs.
Justice and the common good are directly connected with the preferential option for the poor and solidarity. Among the poor, it is possible to see the harms that social injustice causes to human lives. With the poor, the first experience of solidarity is to share what they do not have. The situation of suffering and oppression draws the poor into a community united by their common experience of vulnerability and misery. They share their lives, sufferings, problems, and whatever crumbs they have available in order to keep the weakest ones alive. This is the first thing we learn with the poor. The poor live their lives full of insecurity due to the way in which social injustice prevents them from participating in the common good.
Catholic social teaching aims to promote the integral development of human beings in a communal perspective. It does not provide a framework to be applied, but offers some principles for dialogue. Justice and the common good are human values that point to any social contexts where all share the same human condition and dignity. They are completed by the preferential option for the poor that reveals the faces of those who are prevented from participating in the common good. The poor cry out for justice, freedom, and for conditions which enable them to participate in the common good. The preferential option for the poor brings the principle of social justice and the common good into dialogue with the poor and their reality to foster social transformation.
3. Health and Theology: An Approach between Catholic Tradition and Public Health
Lisa Sowle Cahill affirms that theological bioethics should reach beyond national health care reforms "to urge responsibility for global health inequities."24 I stated before that reforms are not enough to foster social transformation. It is necessary to promote social justice and justice in health. Reformist mentalities hold the status quo of elites and support the neoliberal model of development that history has proven is not fair. This model has created more inequalities by perpetuating and generating structures of violence that act against the poor and do not provide opportunities for them to participate in political and social arenas as agents. The reformist model keeps the poor as a mass to be manipulated in ways that serve the interests of those with economic power. A theological bioethics that focuses on inequalities in health at local and global levels should be prophetic and struggle for social transformation together with those who are the last ones of societies. For that, it is essential to go to the locus of the poor and work together in creative ways.
Among the poor, as the Brazilian pedagogue Paulo Freire states, the world must be re-read in context to recreate the world.25 The poor have a knowledge that can help them to recreate the world. A dialogical interaction must happen between those who have systematic knowledge, as scientists and theologians, and those who have a popular, fragmented, and experiential knowledge, that is, the poor. The synthesis of this dialogue allows creative ways to recreate the world and presents alternatives for a new society.
The knowledge of the poor is from resistance to structural violence. It is also a creative knowing that allows the poor to adapt to situations of marginalization and insecurity. The poor might know that they are victims of social injustice, but their popular knowledge is limited in its ability to explain the mechanisms of oppression. Theological knowledge by itself is also insufficient to explain these mechanisms, even when it explains these mechanisms from categories such as 'social sin' and 'structural sin'. Social sciences provide tools to understand them. The dialogue between theology and social sciences must include the poor.
An approach between Catholic social teaching as it relates to public health first leads us to join the poor by sharing their lives. According to the principles of justice and the common good, health is a good to be shared by all. Moreover, social justice requires solidarity in a way that addresses commutative and distributive justice.
Paul Farmer affirms the role of health professionals in promoting justice in health and proposes that the preferential option for the poor challenges these professionals to work with the poor.26 As one health worker, Farmer affirms that health care cannot be subjected to the laws of the market and become a commodity. Prophetic voices in health care are necessary to act against structural violence.27 Dialogue with the poor works towards meeting their lives as they experience them and guides us to struggle with them for social justice and justice in health care. These are requirements to foster prophetic voices.
On the one hand, social justice is necessary to address the social determinants of health to promote population health. On the other hand, a solid universal public health system — that works together with other social areas and supports population health — is also essential. This public health system must focus on primary care with actions that include education in health, prevention, and early diagnosis and treatment.
Primary care should work in interaction with the local population such as health professionals working as a team which has contact with the community and knows the local epidemiological reality. Small nuclei of health care centers or clinics among communities are a way to allow access to health professionals as well as to foster interactions between communities and professionals. The central government is responsible for financing these small nuclei of health centers that can act as part of a broad national system that also provides other health care institutions for health needs that cannot be handled in these small nuclei (e.g. hospitals and rehabilitation centers).28
These small nuclei of health care centers or clinics open the doors to the local communities and promote their participation in the decision-making process to promote health and health care in particular realities; hence, they connect health care providers to people. This approach facilitates the identification of the most vulnerable citizens. Theological reflection challenges health workers and administrators to approach the people where they live.29 Religious traditions are networks that join people and allow them to interact with each other by sharing their wisdom and being more involved in the political and social arena.30
Conclusion
Struggling against social unfairness and inequalities in health care to promote population health is a battle that must begin from below to be consistent, concrete, and democratic. The preferential option for the poor challenges us to join with the least of society and work with them to change structures of violence that are responsible for social unfairness and inequalities in health. By living with the poor, we recognize their power in history and their capacity to resist as well. The poor are not mere recipients of dominant knowledge; they have their own knowledge that helps them to keep going with faith and hope amidst their suffering. Dialogue builds a democratic participation that holds the possibility of transforming social reality. The dialogue between intellectual knowledge and the poor generates a new strength that encourages us to struggle against oppression and injustice.
Being with the poor in a humble action of creative dialogue and participatory construction of alternative ways, we recreate the world. Catholic social teaching is an open knowledge to dialogue with the poor in their locus. This dialogue is open to more agents, such as scientists, philosophers, and sociologists who help theological bioethics and the poor to understand the mechanisms of structural violence. Together with the poor, we struggle to transform society and promote social justice and justice in health care. In this dialogic relationship, we can build solid ways that promote social justice, a requirement for population health. At the same time, we support a public health system with universal assistance that works with other social sectors and focus on primary care with participation of the local community in the decision-making process.
Endnotes
1 Norman Daniels, Just Health: Meeting Health Needs Fairly (Cambridge — New York: Cambridge University Press, 2008): 6.
2 Lisa S. Cahill, Theological Bioethics: Participation, Justice and Change (Washington, DC: Georgetown University Press, 2005): 1.
3 Conferência Episcopal Latino Americana — CELAM, Documento de Aparecida (São Paulo; Brasilia: Paulus; Edições CNBB, 2007) no. 392.
4 Gustavo Gutierrez, "Memory and Prophecy," in The Option for the Poor in Christian Theology, D. Groody, ed. (Notre Dame, Indiana: University of Notre Dame Press, 2007): 18.
5 I would like to explain why I chose "justice in public health" as the title for this part rather than only "justice in health". Promoting justice in health, in a way that addresses both local and global population health, requires a robust public health system. This system should be universal and has as a starting point a broad and efficient web of primary care that focuses on health education, prevention, and early diagnosis (See World Health Organization, The World Health Report 2008: Primary Health Care, available online at: http://www.who.int/whr/2008/en/index.html). The first goal of a public health system should be the promotion of population health rather than simply being curative. Primary care will shape the politics of allocation of resources in health. However, for a system like that to be fair and to work, it must be supported by just social structures and democratic participation.
6 It is not necessary to provide a lot of dates as proof to find out that poverty is the number one cause that affects population health in the world. To see data, the World Health Organization provides annual reports about health in the world (available online at http://www.who.int/whr/en/) in which you can verify the connection between poverty and health. See also World Health Organization, Closing the gap: Policy into practice on social determinants of health-Discussion Paper, available online at: http://www.who.int/sdhconference/discussion_paper/en/
7 See Simone Weil, Attente de Dieu (Paris: La Colombe, 1950): 130-135.
8 Daniels, Just Health, 1. Mr. Daniels is a philosopher and bioethicist at Harvard University who has written about issues of justice in health care. He supports the view that a theory of justice is the first step to promote justice in health care.
9 There are many theories of justice that have been formulated since Plato and Aristotle. I recognize the importance of these theories. I do not simply refuse them to replace them with the Catholic social tradition's theory of justice. Although, I refuse a theory of justice as a starting point because it risks creating a perfect society for imperfect human beings who live in problematic contexts. Instead, we need to begin from real, concrete circumstances, suffering, and needs.
10 See Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley: University of California Press, 2003): 26, 146.
11 Farmer, Pathologies of Power, 50.
12 Farmer, Pathologies of Power, 27.
13 This strategy configures a peaceful face of the neoliberal system and of the elites by showing them as charitable and kind. On the one hand, the goal seems to be keeping poor people calm and believing that if they are still miserable, it is their fault because the system is good. On the other hand, the system is actually exploiting them, supporting the status quo, and creating more poverty. This is the cruelest face of the neoliberal reformism and it fosters structural violence
14 Amartya Sen writes that equity in health requires social arrangements that achieve fairness and justice. See Amartya Sen, "Why Health Equity?," in Public Health, Ethics, and Equity, Sudhinr Anand; Fabienne Peter; Amartya Sen, eds. (New York: Oxford University Press, 2004): 21.
15 Sen, "Why Health Equity?," 22.
16 Jon Sobrino, Jesus, o Libertador. 2nd ed. (Petrópolis: Vozes, 1996): 121.
17 Thomas Aquinas affirms that the supreme good is God who is the creator of all goods. The good of all things depends on God. David Hollenbach says: "The good of each person is linked with the good shared with others in the community, and the highest good common to the life of all is God's own self." See David Hollenbach, The Common Good and Christian Ethics (Cambridge, MA: Cambridge University Press, 2002): 4.
18 Gaudium et Spes, no. 26, in Catholic Social Thought: The Documentary Heritage, O'Brien, David J., Shannon,
Thomas A., eds. (Maryknoll, NY: Orbis, 2010).
19 Paul VI. Populorum Progressio, nos. 14-21, in O'Brien, David J., Shannon, Thomas A., eds. op. cit.
20 Hollenbach, The Common Good and Christian Ethics, 192.
21 John Paul II. Sollicitudo Rei Socialis, no. 38, in O'Brien, David J.; Shannon, Thomas A., eds. op. cit.
22 See Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church, (Washington, D.C.: Libreria Editrice Vaticana, 2004): no. 201.
23 Hollenbach, The Common Good and Christian Ethics, 198.
24 Lisa S. Cahill, Bioethics and the Common Good, (Milwaukee: Marquette University Press, 2004): 10.
25 See Paulo Freire, Education for Critical Consciousness, (New York: Continuum, 2005): 3-5.
26 Farmer, Pathologies of Power, 140.
27 Farmer, Pathologies of Power, 162, 165.
28 This is an experience of Brazilian Public Healthcare System that has given good results. See Associação Paulista de Medicina, SUS: O Que Você Precisa Saber Sobre o Sistema Único de Saúde, (São Paulo: Atheneu, 2010).
29 Lisa S. Cahill says: "Structures and networks are developing locally and globally through which the participation of the poor and of those in solidarity with them is becoming more effective." See Lisa S. Cahill, Bioethics and the Common Good, 77.
30 The experience of basic Christian communities (CEBs) in Brazil has permitted the development of a social ministry (Pastoral Sociais) that created Pastoral of Health. Pastoral of Health spread throughout the whole country in parishes and CEBs and has helped to empower people who have worked to build the Brazilian Public Health System that offers universal assistance. See Conferência Nacional dos Bispos do Brasil, Fraternidade e Saúde Pública: Que a Saúde se Difunda Sobre a Terra, (Brasília: Edições CNBB, 2011).
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