Fátima’s son, José, was severely malnourished.

At two years of age, he was so small

that Fátima wasn’t able to buy him shoes. For months Dr. Felipe, CREN’s paediatrician,
tried relentlessly to fight off José’s recurrent infections with antibiotics and anthelmintics,
without any success. One day, Dr. Felipe decided to visit the family home. Here he
identified the main cause of José’s non-stop infections: the neighbours’ open-air
sewage passed in front of Fátima’s house. This was barefoot José’s playground.
Assuming that the family were too poor to find a permanent solution, Dr. Felipe
suggested to lay planks of wood on top of the most contaminated areas in order to
decrease José’s exposure to infections. Fátima “woke” up to the doctor’s suggestion
and actively searched for resources, something that she had never done before. She
decided to restructure her whole shack (barraco) and also bought a new sofa. The
following month she went to tell Dr. Felipe: “Now my shack is beautiful.”

What is extreme poverty, a condition that affects Fátima and at least another 1 billion
people in the world (World Bank, 2011)?

Our experience at CREN (Centre of Nutritional Recovery and Education) has shown
that being poor means to be exposed to a range of adverse conditions that go against,
limit, or put obstacles to the fulfillment of the person, to their “coming-to-be” themselves.
People in poverty suffer from pain. It attacks a person not only materially but also
morally, eating away at one’s dignity and driving one into total despair.

According to the World Bank (2000), pains caused by poverty include:

 physical pain that comes with too little food and long hours of work;
 emotional pain stemming from the daily humiliations of dependency and lack of
power;
 moral pain from being forced to make choices such as whether to pay to save the
life of an ill family member or use the money to feed their children.

Thus, while poverty is material in its origins, it has psychological effects such as distress
at being unable to feed one’s children, insecurity from not knowing when the next meal
will come, and shame at having to go without. All these situations have strong symbolic
value. People in poverty are also more likely to develop non-specific psychopathological
manifestations and become mentally ill.

Frequently parents tell CREN’s staff that they deal with food insecurity by going hungry
so that they won’t have to see their children starve. Poverty brings a humiliation for the
parent who is unable to feed their children. In this sense, material poverty reinforces a
sense of personal limitations and inhibits the fulfillment of the person. Living in this
situation is to live inhumanly, deprived of something more than food or money. The
vicious cycle of this existential malnutrition is rendered inevitable by the effects of lost
confidence in the ability to earn a living or to fulfill an ideal.

In addition to this, the place to where one belongs is also the place that provides one an
identity. In the ’70s, mass migration from the north to the south of Brazil caused a boom
in the number of urban slums. Millions left their homelands for the urban cities in search
for better conditions, education and work, places in which they had no historical,
cultural, or social roots.

Over time, people in these conditions understand that they are not human beings like
others, that they are not as valued. The person becomes fatalistic and powerless,
believing that if happiness exists, it is not meant for him or her. Poverty provokes a sort
of amnesia: the person forgets who he or she is and merely accepts their dehumanizing
conditions. This double composition of poverty explains why paternalistic interventions,
focused only on improving material conditions, fail.

As such, our treatment at CREN attempts to make a friendship, a companionship, in

which an equality of needs (both those of the patient and the professional) is
acknowledged and made visible. For the wound of poverty to be treated, it is not
enough to undo the material disadvantage, which has been inflicted; it is also necessary
to reach out to the wounded person and welcome him back into the human family.
“Exclusion,” then, is not primarily an economic phenomenon, but an existential one.