In the fall of 2011, a Catholic priest named Fr. Gustavo Gutierrez and an American physician named Dr. Paul Farmer engaged in a public discussion about global health at the University of Notre Dame. In particular, they discussed the practice of accompaniment, an international health care delivery model which seeks to provide long-term healthcare and social support from the level of individual communities. While both the Catholic Church and the WHO claim to have a preferential option for the planet’s poorest inhabitants, they have often disagreed vehemently about how such an option should be provided. In recent years, the Catholic Church and WHO’s opposing stances on international health issues have been thrown into sharp relief by their disagreement on use of condoms as a means for enhancing sexual health and inhibiting the spread of HIV/AIDS [1]. This article will examine the deep roots that accompaniment has in both Catholic social thought and modern trends in secular global health, and will consider whether this common ground indicates that the Church and secular global health institutions are on somewhat convergent ideological tracks in the arena of global health.

Historical Context

When internationally organized healthcare efforts began with the WHO in the mid-20th century, the dominant model for delivering aid looked something like this: European or American health professionals would focus on a specific healthcare need in an impoverished country, raise funds for supplies, assemble a brigade of volunteer doctors and nurses from the aiding country, and travel to the country in need. Once the team arrived, they would hire local translators to accompany them to the primary cities and villages of the country where they would set up ad hoc clinics, distribute their supplies, and preform basic medical operations for the populace (i.e. remove decaying teeth, set broken bones, preform cataract surgery, etc.). Once their supplies were consumed, the international volunteers would return to their home countries and begin the process again. This model has undoubtedly been effective for many international healthcare operations, especially in the WHO’s focused campaign to eradicate smallpox from 1967-1980 [2].

However, over the last sixty years, it has become apparent that this model for international healthcare, which I will from now on refer to as expatriate aid, leaves much to be desired. If one understands poverty as a chronic disease, then expatriate aid can be compared to a medical treatment which only addresses the symptoms, and not underlying causes of, the disease. The root cause of poor health in developing countries is usually tied to chronic economic shortcomings and political turmoil which result in insufficient healthcare infrastructure and a shortage of food and clean drinking water. As a result, easily preventable diseases like malnutrition, intestinal worms, and diarrhea continue to plague countries which have received large amounts of expatriate aid. Also, misappropriated funds from expatriate sources can sometimes be used to fuel civil wars and solidify the power of oppressive regimes. One can only imagine the frustration of well-meaning expatriate volunteer organizations which poured resources into developing nations for years, only to see their efforts counteracted by a severe famine or a brutal dictator’s rule [3, 4]. In short, expatriate aid seems to be ineffective in the long term development of a country’s health infrastructure.


According to Catholic and secular global health organizations like Catholic Relief Services (CRS) and Partners in Health (PIH), the impoverished sick need to be accompanied on their long-term road to recovery and their maintenance of health; merely being delivered neatly packaged expatriate aid periodically is insufficient. There are strong parallels between this Catholic understanding of accompaniment and modern trends in the secular global health movement. Dr. Farmer, PIH’s founder, understands this accompaniment strategy as, “medical, social, and economic support provided by paid community health workers – the key to delivering quality health care in poor communities [5].” However, Dr. Farmer explained in a recent pre-commencement address to Harvard’s Kennedy School of Business that his use of the term accompaniment is in fact borrowed from the theological work of Fr. Gutierrez [6]. Indeed, accompaniment’s Latin etymology, ad + cum + panis, literally means “breaking bread together,” an action which is an important part of the Liturgy of the Eucharist in the Catholic Mass.

Within Catholicism, accompaniment is understood as an important offshoot of the virtue of solidarity. Pope John Paul II described solidarity in the social encyclical Sollicitudo Rei Socialis as a firm commit of oneself to the common good, which is nothing less than the good of each and every individual [7]. From the Catholic Church’s perspective, the driving force behind such a commitment is the recognition of a Catholic’s intrinsic responsibility for the well-being of all mankind. From the side of secular global health, Dr. Farmer has echoed John Paul II’s same gist of solidarity by explaining that accompaniment entails sticking with a task until it is deemed completed, not by the accompagnateur, but by the person being accompanied. This understanding of accompaniment conveys the same strong sense of personal responsibility for the well-being of the person being accompanied as Pope John Paul II describes in Sollicitudo Rei Socialis.

Unlike the expatriate aid model, the model of accompaniment does not draw its human resources from university-educated foreign volunteers, but rather draws on the human resources local to the community being served. These human resources are community health workers: lay members of the community who receive healthcare training from accompanying institutions like PIH or CRS. In recent years, a severe health worker shortage has been recognized in 57 countries, 36 of which are in sub-Saharan Africa. The WHO recognized the necessity of accompaniment in these crisis countries and responded by creating the Global Health Workforce Alliance (GHWA) in 2006 [8]. According to the WHO, the GHWA “will strive to address the worldwide shortage of nurses, doctors, midwives and other health workers…[and] mobilize key stakeholders engaged in global health to help countries improve the way they plan for, educate and employ health workers [9].” The GHWA’s focus on solving problems at the community level is in concert with the Church’s teaching on subsidiarity, which maintains that communal problems should be solved at an organizational level as proximate as is deemed possible.

Social Sin

This promotion of the practice of accompaniment through initiatives like the GHWA will undoubtedly highlight an enduring roadblock on the road out of poverty, which is also accompaniment’s natural enemy: structural sin. The genesis of “structural sin” from the perspective of Latin American Catholics like Fr. Gutierrez can be traced back to the 1968 Medellin Conference of the Latin American Bishops [10]. In the conference’s final document, structural sin was defined as “the lack of solidarity which, on the individual and social levels, leads to the committing of serious sins, evident in the unjust structures which characterize the Latin American situation [11].” Structural sin is difficult to talk about authoritatively from a doctrinal Catholic perspective though, as the topic is still theologically controversial.

However, structural sin’s close cousin, social sin, has been widely recognized as doctrinally sound by the Vatican. Therefore, for the purposes of this analysis, social sin will be portrayed as accompaniment’s natural antagonist. Pope John Paul II saw social sin as a destructive force which perpetuates evil through the same currents of human life which solidarity uses to perpetuate peace. That is to say, in the same way that one’s pursuit of the common good acts to raise up society by virtue of human solidarity, the lowering of one’s soul through personal sin drags down with itself the church and, in some way, the whole world by virtue of that same solidarity [12]. Therefore, when the Catholic Church speaks of social sin it means the accumulated effect upon society brought about by sins committed by individuals. Every personal sin has a social dimension, though some sins are more socially caustic than others. If one were to consult a list of these more socially caustic sins, one would undoubtedly recognize certain actions and behaviors which the modern secular global health movement would also decry as evil: disregard for the plight of the poor, participation in unjust economic systems, neglect of the elderly and enfeebled, corporate greed, usury, and the trafficking of drugs, weapons, and human beings. Indeed, if one only considers the listed actions which the Catholic Church and institutions like PIH would likely agree agree are intrinsically evil, it seems as though their common understanding of social sin binds the two together even more strongly.

However, the Catholic Church’s understanding of social sin expands from these mutually agreed upon evils to cover an array of actions, intentions, and operations which the modern global health movement sees not as evils, but as critically important facets of modern global health. Almost all of these facets concern reproductive medicine, including access to safe, reliable contraception, abortion on demand, and voluntary sterilization. The modern secular global health community believes that providing access to these reproductive resources is a key feature of effective accompaniment, while the Catholic Church sees them as particularly grave social sins. Much of the Church’s teaching on contraception stems from Pope Paul VI’s encyclical Humana Vitae, which excludes “every action which, either in anticipation of the conjugal act, or in its accomplishment, or in the development of its natural consequences, proposes, whether as an end or as a means, to render procreation impossible [13].” From the perspective of the Catholic Church, the use of contraception is a sin with an expressly social aspect because the choice to close off a sexual union from the possibility of children can result in an under populated, arguably sterile and unnatural society which sees pregnancy and child bearing as a tiresome inconvenience to be avoided.

Critics of the Catholic Church’s stance on contraception have historically argued that the birth of a child who cannot be adequately cared for is not for the greater good of society. The premise of this criticism is twofold: first, that a child born to a poor family will not be adequately cared for, and second, that it would be better for a child to not be born at all, rather than face the challenge of being born into a family with minimal material resources where the chance for a short, miserable existence is high. From a secular global health perspective, taking this chance makes no sense: why add another mouth to feed to the family of an already over taxed mother? Why not give her the choice to control the size of her family, so she can have a chance at adequately providing for the amount children she chooses to have? From this perspective, the oppressive mandates of the Church are the real structures of sin to be campaigned against.

The Catholic Church’s responses to these criticisms come from many different angles. One common argument is that it is never lawful, even for the gravest reasons, to do evil that good may come of it [14]. Thus, the evil act of using contraception cannot be justified by the good desire to foster healthy families. Another response is that sexual unions which employ contraception have an element of the sin of lust at their core, with the desire for the pleasure of sex outstripping a couple’s desire to responsibly attend to the best interests of their family over the long term. Instead of using contraception, the Catholic Church teaches that couples with serious reasons to space out births should practice natural family planning, which has a 95-99.6% rate of success when practiced correctly [15].


As sweeping accompaniment measures like the Global Health Workforce Alliance take effect in the coming years, health workers for pro-contraception organizations like PIH and anti-contraception institutions like CRS may come to identify each other as the agents of social sin in their communities. It would be a mistake to downplay the importance of family dynamics, the roles of men and women, the purpose of sex, and other basic human realities touched by differing stances on reproductive medicine as merely secondary to other issues involved in international healthcare. The answer to this question is intimately tied up with the purpose of life itself, a topic on which both sides have strong opinions. While the Catholic Church and secular global health efforts may, in the case of accompaniment, agree on how to work for the good of humanity, they most assuredly do not agree on what constitutes the good of humanity.

The appearance of unity between the Catholic Church and secular global health movements over the issue of accompaniment can be misleading. Although both institutions value accompaniment as an effective means for seeking the good of developing nations, their differing understandings of social sin set them at odds with each other. While accompaniment will bring their representatives closer together physically in the form of community health workers operating in the same villages and cities, it is unlikely that it will bring them together ideologically. This analysis is not meant as a pessimistic critique of the future of these ideologically entrenched institutions. It is the author’s hope that the practice of accompaniment will lead to compromises wherever possible, and that the impoverished of this planet will benefit from a clear understanding of the ideological differences between these accompanying institutions.