Chapter 1

On Suffering and Structural Violence

Social and Economic Rights in the Global Era

 

Growth of GNP or of industrial incomes can, of course, be very important as means to expanding the freedoms enjoyed by the members of the society. But freedoms depend also on other determinants, such as social and economic arrangements (for example, facilities for education and health care) as well as political and civil rights (for example, the liberty to participate in public discussion and scrutiny).

Amartya Sen, Development as Freedom

 

Where do people earn the Per Capita Income? More than one poor starving soul would like to know.
In our countries, numbers live better than people. How many people prosper in times of prosperity? How many people find their lives developed by development?

Eduardo Galeano, "Those Little Numbers and People"

 

 

Everyone knows that suffering, violence, and misery exist. How to define them? Given that each person's pain has for him or her a degree of reality that the pain of others can surely never approach, is widespread agreement on the subject possible? And yet people do agree, as often as not, on what constitutes extreme suffering: premature and painful illnesses, say, as well as torture and rape. More insidious assaults on dignity, such as institutionalized racism and gender inequality, are also acknowledged by most to cause great and unjust injury.

So suffering is a fact. Now a number of corollary questions come to the fore. Whenever we talk about medicine or policy, a "hierarchy of suffering" begins to take shape, for it is impossible to relieve every case at once. Can we identify the worst assaults? Those most at risk of great suffering? Among persons whose suffering is not fatal, is it possible to identify those most at risk of sustaining permanent and disabling damage? Are certain "event" assaults, such as torture or rape, more likely to lead to later sequelae than is sustained and insidious suffering, such as the pain born of deep poverty or racism? Are certain forms of insidious discrimination demonstrably more noxious than others?

Anthropologists and others who take these as research questions study both individual experience and the larger social matrix in which it is embedded in order to see how various social processes and events come to be translated into personal distress and disease. By what mechanisms, precisely, do social forces ranging from poverty to racism become embodied as individual experience?¹ This has been the focus of most of my own research in Haiti, where political and economic forces have structured risk for AIDS, tuberculosis, and, indeed, most other infectious and parasitic diseases. Social forces at work there have also structured risk for most forms of extreme suffering, from hunger to torture and rape.

Working in contemporary Haiti, where in recent decades political violence has been added to the worst poverty in the hemisphere, one learns a great deal about suffering. In fact, the country has long constituted a sort of living laboratory for the study of affliction, no matter how it is defined.² "Life for the Haitian peasant of today," observed the anthropologist Jean Weise some thirty years ago, "is abject misery and a rank familiarity with death."³ The biggest problem, of course, is unimaginable poverty, as a long succession of dictatorial governments has been more engaged in pillaging than in protecting the rights of workers, even on paper. As Eduardo Galeano noted in 1973, at the height of the Duvalier dictatorship, "The wages Haiti requires by law belong in the department of science fiction: actual wages on coffee plantations vary from $.07 to $.15 a day."⁴

In some senses, the situation has worsened since. When in 1991 international health and population experts devised a "human suffering index" by examining several measures of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by "extreme human suffering."⁵ Only one of them, Haiti, was located in the Western hemisphere. In only three countries on earth was suffering judged to be more extreme than that endured in Haiti; each of these three countries was in the midst of an internationally recognized civil war.

Suffering is certainly a recurrent and expected condition in Haiti's Central Plateau, where everyday life has felt, often enough, like war. "You get up in the morning," observed one young widow with four children, "and it's the fight for food and wood and water." If initially struck by the austere beauty of the region's steep mountains and clement weather, long-term visitors come to see the Central Plateau in much the same manner as its inhabitants do: a chalky and arid land hostile to the best efforts of the peasant farmers who live here. Landlessness is widespread and so, consequently, is hunger. All the standard measures reveal how tenuous is the peasantry's hold on survival. Life expectancy at birth is less than fifty years, in large part because as many as two of every ten infants die before their first birthday.⁶ Tuberculosis and AIDS are the leading causes of death among adults; among children, diarrheal disease, measles, and tetanus ravage the undernourished.⁷

But the experience of suffering, it's often noted, is not effectively conveyed by statistics or graphs. In fact, the suffering of the world's poor intrudes only rarely into the consciousness of the affluent, even when our affluence may be shown to have direct relation to their suffering. This is true even when spectacular human rights violations are at issue, and it is even more true when the topic at hand is the everyday violation of social and economic rights.⁸ Because the "texture" of dire affliction is better felt in the gritty details of biography, I introduce the stories of Acéphie Joseph and Chouchou Louis.⁹ Since any example begs the question of its relevance, I will argue at the outset that the stories of Acéphie and Chouchou are anything but "anecdotal." In the eyes of the epidemiologist as well as the political analyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet similar fates. What these victims, past and present, share are not personal or psychological attributes. They do not share culture or language or a certain race. What they share, rather, is the experience of occupying the bottom rung of the social ladder in inegalitarian societies.

 

Acéphie's Story

For the wound of the daughter of my people is my heart wounded,
I mourn, and dismay has taken hold of me.
Is there no balm in Gilead? Is there no physician there?
Why then has the health of the daughter of my people not been restored?
O that my head were waters, and my eyes a fountain of tears, that
I might weep day and night for the slain of the daughter of my people! Jeremiah 8:22-9:1

 

Kay, a community of fewer than three thousand people, stretches along an unpaved road that cuts north and east into Haiti's Central Plateau. Striking out from Port-au-Prince, the capital, it can take several hours to reach Kay, especially if one travels during the rainy season, when the chief thoroughfare through central Haiti turns into a muddy, snaking path. But even in the dry season, the journey gives one an impression of isolation, insularity. The impression is misleading, as the village owes its existence to a project conceived in the Haitian capital and drafted in Washington, D.C.: Kay is a settlement of refugees, substantially composed of peasant farmers displaced more than forty years ago by the construction of Haiti's largest dam.¹⁰

Before 1956, the village of Kay was situated in a fertile valley, and through it ran the Rivière Artibonite, Haiti's largest river. For generations, thousands of families had farmed the broad and gently sloping banks of the river, selling rice, bananas, millet, corn, and sugarcane in regional markets. Harvests were, by all reports, bountiful; life there is now recalled as idyllic. When the valley was flooded, the majority of the local population was forced up into the stony hills on either side of the new reservoir. By all the standard measures, the "water refugees" became exceedingly poor; the older people often blame their poverty on the massive buttress dam a few miles away, bitterly noting that it brought them neither electricity nor water.

In 1983, when I began working in the Central Plateau, AIDS was already afflicting an ever-increasing number of city dwellers but was unknown in areas as rural as Kay. Acéphie Joseph was one of the first villagers to die of the new syndrome. But her illness, which ended in 1991, was merely the latest in a string of tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the region's sick.

The litany begins, usually, down in the valley, now hidden under the still surface of the lake. Both Acéphie's parents came from families who had made a decent living by farming fertile tracts of land—their "ancestors' gardens"—and selling much of their produce. Her father tilled the soil, and his wife, a tall and wearily elegant woman not nearly as old as she looks, was a "Madame Sarah," a market woman. "If it weren't for the dam," he once assured me, "we'd be just fine now. Acéphie, too." The Josephs' home was drowned, along with most of their belongings, their crops, and the graves of their ancestors.

Refugees from the rising water, the Josephs built a miserable lean-to on a knoll of high land jutting into the new reservoir. They remained poised on their knoll for some years; Acéphie and her twin brother were born there. I asked what had induced them to move higher up the hill, to build a house on the hard stone embankment of a dusty road. "Our hut was too near the water," replied their father. "I was afraid one of the children would fall into the lake and drown. Their mother had to be away selling; I was trying to make a garden in this terrible soil. There was no one to keep an eye on them."

Acéphie attended primary school in a banana-thatched and open shelter in which children and young adults received the rudiments of literacy in Kay. "She was the nicest of the Joseph sisters," recalled one of her classmates. "And she was as pretty as she was nice." Acéphie's beauty—she was tall and fine-featured, with enormous dark eyes—and her vulnerability may have sealed her fate as early as 1984. Though still in primary school then, she was already nineteen years old; it was time for her to help generate income for her family, which was sinking deeper and deeper into poverty. Acéphie began to help her mother by carrying produce to a local market on Friday mornings. On foot or with a donkey, it takes over an hour and a half to reach the market, and the road leads right through Péligre, site of the dam and a military barracks. The soldiers liked to watch the parade of women on Friday mornings. Sometimes they taxed them, literally, with haphazardly imposed fines; sometimes they levied a toll of flirtatious banter.

Such flirtation is seldom rejected, at least openly. In rural Haiti, entrenched poverty made the soldiers—the region's only salaried men—ever so much more attractive. Hunger was a near-daily occurrence for the Joseph family; the times were as bad as those right after the flooding of the valley. And so when Acéphie's good looks caught the eye of Captain Jacques Honorat, a native of Belladère formerly stationed in Port-au-Prince, she returned his gaze.

Acéphie knew, as did everyone in the area, that Honorat had a wife and children. He was known, in fact, to have more than one regular partner. But Acéphie was taken in by his persistence, and when he went to speak to her parents, a long-term liaison was, from the outset, a serious possibility:

What would you have me do? I could tell that the old people were uncomfortable, worried; but they didn't say no. They didn't tell me to stay away from him. I wish they had, but how could they have known? . . . I knew it was a bad idea then, but I just didn't know why. I never dreamed he would give me a bad illness, never! I looked around and saw how poor we all were, how the old people were finished . . . What would you have me do? It was a way out, that's how I saw it.

Acéphie and Honorat were sexual partners only briefly—for less than a month, according to Acéphie. Shortly thereafter, Honorat fell ill with unexplained fevers and kept to the company of his wife in Péligre. As Acéphie was looking for a moun prensipal—a "main man"—she tried to forget about the soldier. Still, it was shocking to hear, a few months after they parted, that he was dead.

Acéphie was at a crucial juncture in her life. Returning to school was out of the question. After some casting about, she went to Mirebalais, the nearest town, and began a course in what she euphemistically termed a "cooking school." The school—really just an ambitious woman's courtyard—prepared poor girls like Acéphie for their inevitable turn as servants in the city. Indeed, becoming a maid was fast developing into one of the rare growth industries in Haiti, and, as much as Acéphie's proud mother hated to think of her daughter reduced to servitude, she could offer no viable alternative.

And so Acéphie, twenty-two years old, went off to Port-au-Prince, where she found a job as a housekeeper for a middle-class Haitian woman who worked for the U.S. embassy. Acéphie's looks and manners kept her out of the backyard, the traditional milieu of Haitian servants. She was designated as the maid who, in addition to cleaning, answered the door and the phone. Although Acéphie was not paid well—she received thirty dollars each month—she recalled the gnawing hunger in her home village and managed to save a bit of money for her parents and siblings.

Still looking for a moun prensipal, Acéphie began seeing Blanco Nerette, a young man with origins similar to her own: Blanco's parents were also "water refugees," and Acéphie had known him when they were both attending the parochial school in Kay. Blanco had done well for himself, by Kay standards: he chauffeured a small bus between the Central Plateau and the capital. In a setting in which the unemployment rate was greater than 60 percent, he could command considerable respect, and he turned his attentions to Acéphie. They planned to marry, she later recalled, and started pooling their resources.

Acéphie remained at the "embassy woman's" house for more than three years, staying until she discovered that she was pregnant. As soon as she told Blanco, she could see him becoming skittish. Nor was her employer pleased: it is considered unsightly to have a pregnant servant. And so Acéphie returned to Kay, where she had a difficult pregnancy. Blanco came to see her once or twice. They had a disagreement, and then she heard nothing more from him. Following the birth of her daughter, Acéphie was sapped by repeated infections. A regular visitor to our clinic, she was soon diagnosed with AIDS.

Within months of her daughter's birth, Acéphie's life was consumed with managing her own drenching night sweats and debilitating diarrhea while attempting to care for the child. "We both need diapers now," she remarked bitterly, toward the end of her life. As political violence hampered her doctors' ability to open the clinic, Acéphie was faced each day not only with diarrhea but also with a persistent lassitude. As she became more and more gaunt, some villagers suggested that Acéphie was the victim of sorcery. Others recalled her liaison with the soldier and her work as a servant in the city, by then widely considered to be risk factors for AIDS. Acéphie herself knew that she had AIDS, although she was more apt to refer to herself as suffering from a disorder brought on by her work as a servant: "All that ironing, and then opening a refrigerator." She died far from refrigerators or other amenities as her family and caregivers stood by helplessly.

But this is not simply the story of Acéphie and her daughter, also infected with the virus. There is also Jacques Honorat's first wife, who each year grows thinner. After Honorat's death, she found herself desperate, with no means of feeding her five hungry children, two of whom were also ill. Her subsequent union was again with a soldier. Honorat had at least two other partners, both of them poor peasant women, in the Central Plateau. One is HIV-positive and has two sickly children. And there is Blanco, still a handsome young man, apparently in good health, plying the roads from Mirebalais to Port-au-Prince. Who knows if he carries the virus? As a chauffeur, he has plenty of girlfriends.

Nor is this simply the story of those infected with HIV. The pain of Acéphie's mother and twin brother was manifestly intense. But few understood her father's anguish. Shortly after Acéphie's death, he hanged himself with a length of rope.

 

Chouchou's Story

I never found the order
I searched for
but always a sinister
and well-planned disorder
that increases in the hands
of those who hold power
while the others
who clamor for
a more kindly world
a world with less hunger
and more hopefulness
die of torture
in the prisons.
Don't come any closer
there's a stench of carrion
surrounding me. Claribel Alegría, "From the Bridge"

 

Chouchou Louis grew up not far from Kay, in another small village in the steep and infertile highlands of Haiti's Central Plateau. He attended primary school for a couple of years but was forced to drop out when his mother died. Then, in his early teens, Chouchou joined his father and an older sister in tending their hillside garden. In short, there was nothing remarkable about Chouchou's childhood. It was brief and harsh, like most in rural Haiti.

Throughout the 1980s, church activities formed Chouchou's sole distraction. These were hard years for the Haitian poor, beaten down by a family dictatorship well into its third decade. The Duvaliers, father and son, ruled through violence, largely directed at people whose conditions of existence were similar to those of Chouchou Louis. Although many tried to flee, often by boat, U.S. policy maintained that Haitian asylum-seekers were "economic refugees." As part of a 1981 agreement between the administrations of Ronald Reagan and Jean-Claude Duvalier (known as "Baby Doc"), refugees seized by the U.S. Coast Guard on the high seas were summarily returned to Haiti. During the first ten years of the accord, approximately twenty-three thousand Haitians applied for political asylum in the United States. Eight applications were approved.¹¹

A growing Haitian pro-democracy movement led to the flight of Duvalier in February 1986. Chouchou Louis, who must have been about twenty years old when "Baby Doc" fell, shortly thereafter acquired a small radio. "All he did," recalled his wife, years later, "was work the land, listen to the radio, and go to church." On the radio, Chouchou heard about the people who took over after Duvalier fled. Like many in rural Haiti, Chouchou was distressed to hear that power had been handed to the military, led by hardened duvaliéristes. It was this army that the U.S. government termed "Haiti's best bet for democracy." (Hardly a disinterested judgment: the United States had created the modern Haitian army in 1916.) In the eighteen months following Duvalier's departure, more than $200 million in U.S. aid passed through the hands of the junta.¹²

In early 1989, Chouchou moved in with Chantal Brisé, who was pregnant. They were living together when Father Jean-Bertrand Aristide—by then considered the leader of the pro-democracy movement—declared his candidacy for the presidency in the internationally monitored elections of 1990. In December of that year, almost 70 percent of the voters chose Father Aristide from a field of almost a dozen presidential candidates. No run-off election was required—Aristide won this plurality in the first round.

Like most rural Haitians, Chouchou and Chantal welcomed Aristide's election with great joy. For the first time, the poor—Haiti's overwhelming majority, formerly silent—felt they had someone representing their interests in the presidential palace. This is why the subsequent military coup d'état of September 1991 stirred great anger in the countryside, where most Haitians live. Anger was soon followed by sadness, then fear, as the country's repressive machinery, which had been held at bay during the seven months of Aristide's tenure, was speedily reactivated under the patronage of the army.

One day during the month after the coup, Chouchou was sitting in a truck en route to the town of Hinche. Chouchou offered for the consideration of his fellow passengers what Haitians call a pwen, a pointed remark intended to say something other than what it literally means. As they bounced along, he began complaining about the condition of the roads, observing that, "if things were as they should be, these roads would have been repaired already." One eyewitness later told me that at no point in the commentary was Aristide's name invoked. But his fellow passengers recognized Chouchou's observations as veiled language deploring the coup. Unfortunately for Chouchou, one of the passengers was an out-of-uniform soldier. At the next checkpoint, the soldier had him seized and dragged from the truck. There, a group of soldiers and their lackeys—their attachés, to use the epithet then in favor—immediately began beating Chouchou, in front of the other passengers; they continued to beat him as they brought him to the military barracks in Hinche. A scar on his right temple was a souvenir of his stay in Hinche, which lasted several days.

Perhaps the worst after-effect of such episodes of brutality was that, in general, they marked the beginning of persecution, not the end. In rural Haiti, any scrape with the law (that is, the military) led to a certain blacklisting. For men like Chouchou, staying out of jail involved keeping the local attachés happy, and he did this by avoiding his home village. But Chouchou lived in fear of a second arrest, his wife later told me, and his fears proved to be well-founded.

On January 22, 1992, Chouchou was visiting his sister when he was arrested by two attachés. No reason was given for the arrest, and Chouchou's sister regarded as ominous the seizure of the young man's watch and radio. He was roughly marched to the nearest military checkpoint, where he was tortured by soldiers and the attachés. One area resident later told us that the prisoner's screams made her children weep with terror.

On January 25, Chouchou was dumped in a ditch to die. The army scarcely took the trouble to circulate the canard that he had stolen some bananas. (The Haitian press, by then thoroughly muzzled, did not even broadcast this false version of events; fatal beatings in the countryside did not count as news.) Relatives carried Chouchou back to Chantal and their daughter under the cover of night. By early on the morning of January 26, when I arrived, Chouchou was scarcely recognizable. His face, and especially his left temple, was deformed, swollen, and lacerated; his right temple was also scarred. His mouth was a coagulated pool of dark blood. Lower down, his neck was peculiarly swollen, his throat collared with bruises left by a gun butt. His chest and sides were badly bruised, and he had several fractured ribs. His genitals had been mutilated.

That was his front side; presumably, the brunt of the beatings had come from behind. Chouchou's back and thighs were striped with deep lash marks. His buttocks were macerated, the skin flayed down to the exposed gluteal muscles. Already some of these stigmata appeared to be infected.

Chouchou coughed up more than a liter of blood in his agonal moments. Although I am not a forensic pathologist, my guess is that the proximate cause of his death was pulmonary hemorrhage. Given his respiratory difficulties and the amount of blood he coughed up, it is likely that the beatings caused him to bleed, slowly at first, then catastrophically, into his lungs. His head injuries had not robbed him of his faculties, although it might have been better for him had they done so. It took Chouchou three days to die.

 

Explaining Versus Making Sense of Suffering

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes. The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?

Bertolt Brecht, "A Worker's Speech to a Doctor"

 

Are these stories of suffering emblematic of something other than two tragic and premature deaths? If so, how representative is either of these experiences? Little about Acéphie's story is unique; I have told it in some detail because it brings into relief many of the forces restricting not only her options but those of most Haitian women. Such, in any case, is my opinion after caring for hundreds of poor women with AIDS. Their stories move with a deadly monotony: young women—or teenage girls—fled to Port-au-Prince in an attempt to escape from the harshest poverty; once in the city, each worked as a domestic; none managed to find the financial security that had proven so elusive in the countryside. The women I interviewed were straightforward about the nonvoluntary aspect of their sexual activity: in their opinions, poverty had forced them into unfavorable unions.¹³ Under such conditions, one wonders what to make of the notion of "consensual sex."

What about the murder of Chouchou Louis? International human rights groups estimate that more than three thousand Haitians were killed in the year after the September 1991 coup that overthrew Haiti's first democratically elected government. Almost all were civilians who, like Chouchou, fell into the hands of the military or paramilitary forces. The vast majority of victims were poor peasants, like Chouchou, or urban slum dwellers. But note that the figures just cited are conservative estimates; I can testify that no journalist or human rights observer ever came to count the body of Chouchou Louis.¹⁴

Thus the agony of Acéphie and Chouchou was, in a sense, "modal" suffering. In Haiti, AIDS and political violence are two leading causes of death among young adults. These afflictions are not the result of accident or a force majeure; they are the consequence, direct or indirect, of human agency. When the Artibonite Valley was flooded, depriving families like the Josephs of their land, a human decision was behind it; when the Haitian army was endowed with money and unfettered power, human decisions were behind that, too. In fact, some of the same decision makers may have been involved in both cases.

If bureaucrats and soldiers seemed to have unconstrained sway over the lives of the rural poor, the agency of Acéphie and Chouchou was, correspondingly, curbed at every turn. These grim biographies suggest that the social and economic forces that have helped to shape the AIDS epidemic are, in every sense, the same forces that led to Chouchou's death and to the larger repression in which it was eclipsed. What's more, both of these individuals were "at risk" of such a fate long before they met the soldiers who altered their destinies. They were both, from the outset, victims of structural violence. The term is apt because such suffering is "structured" by historically given (and often economically driven) processes and forces that conspire—whether through routine, ritual, or, as is more commonly the case, the hard surfaces of life—to constrain agency.¹⁵ For many, including most of my patients and informants, choices both large and small are limited by racism, sexism, political violence, and grinding poverty.

While certain kinds of suffering are readily observable—and the subject of countless films, novels, and poems—structural violence all too often defeats those who would describe it. There are at least three reasons. First, the "exoticization" of suffering as lurid as that endured by Acéphie and Chouchou distances it. The suffering of individuals whose lives and struggles recall our own tends to move us; the suffering of those who are "remote," whether because of geography or culture, is often less affecting.

Second, the sheer weight of the suffering makes it all the more difficult to render: "Knowledge of suffering cannot be conveyed in pure facts and figures, reportings that objectify the suffering of countless persons. The horror of suffering is not only its immensity but the faces of the anonymous victims who have little voice, let alone rights, in history."¹⁶

Third, the dynamics and distribution of suffering are still poorly understood. Physicians, when fortunate, can alleviate the suffering of the sick. But explaining its distribution requires many minds and resources. Case studies of individuals reveal suffering, they tell us what happens to one or many people; but to explain suffering, one must embed individual biography in the larger matrix of culture, history, and political economy.

In short, it is one thing to make sense of extreme suffering—a universal activity, surely—and quite another to explain it. Life experiences such as those of Acéphie and Chouchou, and of other Haitians living in poverty who shared similar social conditions, must be embedded in ethnography if their representativeness is to be understood. These local understandings must be embedded, in turn, in the historical system of which Haiti is a part.¹⁷ The weakness of such analyses is, of course, their great distance from personal experience. But the social and economic forces that dictate life choices in Haiti's Central Plateau affect many millions of individuals, and it is in the context of these global forces that the suffering of individuals acquires its own appropriate context.

Similar insights are central to liberation theology, which preoccupies itself with the suffering of the poor. In The Praxis of Suffering, Rebecca Chopp notes, "In a variety of forms, liberation theology speaks with those who, through their suffering, call into question the meaning and truth of human history."¹⁸ Unlike most previous theologies, unlike much modern philosophy, liberation theology attempts to use social analysis both to explain and to deplore human suffering. Its key texts draw our attention not merely to the suffering of the wretched of the earth but also to the forces that promote that suffering. The theologian Leonardo Boff, commenting on one of these texts, observes that it "moves immediately to the structural analysis of these forces and denounces the systems, structures, and mechanisms that 'create a situation where the rich get richer at the expense of the poor, who get even poorer.'{hrs}"¹⁹

Put simply, few liberation theologians reflect on suffering without attempting to understand the mechanisms that produce it. Theirs is a theology that underlines connections. Robert McAfee Brown has these connections, and also the poor, in mind when, paraphrasing the Uruguayan Jesuit Juan Luis Segundo, he observes that "the world that is satisfying to us is the same world that is utterly devastating to them."²⁰

 

Making Sense of Structural Violence

Events of massive, public suffering defy quantitative analysis. How can one really understand statistics citing the death of six million Jews or graphs of third-world starvation? Do numbers really reveal the agony, the interruption, the questions that these victims put to the meaning and nature of our individual lives and life as a whole?

Rebecca Chopp, The Praxis of Suffering

My apologies to chance for calling it necessity.
My apologies to necessity if I'm mistaken, after all.
Please, don't be angry, happiness, that I take you as my due.
May my dead be patient with the way my memories fade.
My apologies to time for all the world I overlook each second.

Wislawa Szymborska, "Under One Small Star"

 

How might we discern the nature of structural violence and explore its contribution to human suffering? Can we devise an analytic model, one with explanatory and predictive power, for understanding suffering in a global context? This task, though daunting, is both urgent and feasible if we are to protect and promote human rights.

Our cursory examination of AIDS and political violence in Haiti suggests that analysis must, first, be geographically broad. The world as we know it is becoming increasingly interconnected. A corollary of this fact is that extreme suffering—especially when on a grand scale, as in genocide—is seldom divorced from the actions of the powerful.²¹ The analysis must also be historically deep: not merely deep enough to remind us of events and decisions such as those that deprived Acéphie's parents of their land and founded the Haitian military, but deep enough to recall that modern-day Haitians are the descendants of a people kidnapped from Africa in order to provide our forebears with sugar, coffee, and cotton.²²

Social factors including gender, ethnicity ("race"), and socioeconomic status may each play a role in rendering individuals and groups vulnerable to extreme human suffering. But in most settings these factors by themselves have limited explanatory power. Rather, simultaneous consideration of various social "axes" is imperative in efforts to discern a political economy of brutality. Furthermore, such social factors are differentially weighted in different settings and in different times, as even brief consideration of their contributions to extreme suffering suggests. In an essay entitled "Mortality as an Indicator of Economic Success and Failure," Amartya Sen reminds us of the need to move beyond "the cold and often inarticulate statistics of low incomes" to look at the various ways in which agency—what he terms the "capabilities of each person"—is constrained:

There is, of course, plenty of [poverty] in the world in which we live. But more awful is the fact that so many people—including children from disadvantaged backgrounds—are forced to lead miserable and precarious lives and to die prematurely. That predicament relates in general to low incomes, but not just to that. It also reflects inadequate public health provisions and nutritional support, deficiency of social security arrangements, and the absence of social responsibility and of caring governance.²³

To understand the relationship between structural violence and human rights, it is necessary to avoid reductionistic analyses. Sen is understandably concerned to avoid economic reductionism, an occupational hazard in his field. But numerous other analytic traps can also hinder the quest for a sound analytic purchase on the dynamics of human suffering.

 

The Axis of Gender

Acéphie Joseph and Chouchou Louis shared a similar social status, and each died after contact with the Haitian military. Gender helps to explain why Acéphie died of AIDS and Chouchou from torture. Gender inequality helps to explain why the suffering of Acéphie is much more commonplace than that of Chouchou. Throughout the world, women are confronted with sexism, an ideology that situates them as inferior to men. In 1974, when a group of feminist anthropologists surveyed the status of women living in disparate settings, they could agree that, in every society studied, men dominated political, legal, and economic institutions to varying degrees; in no culture was the status of women genuinely equal, much less superior, to that of men.²⁴ This power differential has meant that women's rights are violated in innumerable ways. Although male victims are clearly preponderant in studies of torture, females almost exclusively endure the much more common crimes of domestic violence and rape. In the United States alone, the number of such aggressions is staggering. Taking into account sexual assaults by both intimates and strangers, "one in four women has been the victim of a completed rape and one in four women has been physically battered, according to the results of recent community-based studies."²⁵ In many societies, crimes of domestic violence and rape are not even discussed and are thus invisible.

In most settings, however, gender alone does not define risk for such assaults on dignity. It is poor women who are least well defended against these assaults.²⁶ This is true not only of domestic violence and rape but also of AIDS and its distribution, as anthropologist Martha Ward points out: "The collection of statistics by ethnicity rather than by socio-economic status obscures the fact that the majority of women with AIDS in the United States are poor. Women are at risk for HIV not because they are African-American or speak Spanish; women are at risk because poverty is the primary and determining condition of their lives."²⁷

Similarly, only women can experience maternal mortality, a cause of anguish around the world. More than half a million women die each year in childbirth, but not all women face a high risk of this fate. In fact, according to analyses of 1995 statistics, 99.8 percent of these deaths occurred in developing countries.²⁸ Recent reported maternal mortality rates for Haiti vary, depending on the source, with numbers ranging from 523 deaths per 100,000 live births to the much higher rates of 1,100 and even as high as 1,400 deaths per 100,000 live births. Needless to say, these deaths are almost entirely registered among the poor.²⁹ Gender bias, as Sen notes, "is a general problem that applies even in Europe and North America in a variety of fields (such as division of family chores, the provision of support for higher training, and so on), but in poorer countries, the disadvantage of women may even apply to the basic fields of health care, nutritional support, and elementary education."³⁰

 

The Axis of "Race" or Ethnicity

The idea of "race," which most anthropologists and demographers consider to be a biologically insignificant term, has enormous social currency. Racial classifications have been used to deprive many groups of basic rights and therefore have an important place in considerations of human inequality and suffering. The history of Rwanda and Burundi shows that once-minor ethnic categories—Hutu and Tutsi share language and culture and kinship systems—were lent weight and social meaning by colonial administrators who divided and conquered, deepening social inequalities and then fueling nascent ethnic rivalry. In South Africa, one of the clearest examples of the long-term effects of racism, epidemiologists report that the infant mortality rate among blacks may be as much as ten times higher than that of whites. For black people in South Africa, the proximate cause of increased rates of morbidity and mortality is lack of access to resources: "Poverty remains the primary cause of the prevalence of many diseases and widespread hunger and malnutrition among black South Africans."³¹ The dismantling of the apartheid regime has not yet brought the dismantling of the structures of oppression and inequality in South Africa, and persistent social inequality is no doubt the primary reason that HIV has spread so rapidly in sub-Saharan Africa's wealthiest nation.³²

Significant mortality differentials between blacks and whites are also registered in the United States, which shares with South Africa the distinction of being one of the two industrialized countries failing to record mortality data by socioeconomic status. In 1988 in the United States, life expectancy at birth was 75.5 years for whites, 69.5 years for blacks. In the following decade, although U.S. life expectancies increased across the board, the gap between whites and blacks widened by another 0.6 years.³³ While these racial differentials in mortality have provoked a certain amount of discussion, public health expert Vicente Navarro recently pointed to the "deafening silence" on the topic of class differentials in mortality in the United States, where "race is used as a substitute for class." But in 1986, on "one of the few occasions that the U.S. government collected information on mortality rates (for heart and cerebrovascular disease) by class, the results showed that, by whatever indicators of class one might choose (level of education, income, or occupation), mortality rates are related to social class."³⁴

Indeed, where the major causes of death (heart disease and cerebrovascular disease) are concerned, class standing is a clearer indicator than racial classification. "The growing mortality differentials between whites and blacks," Navarro concludes, "cannot be understood by looking only at race; they are part and parcel of larger mortality differentials—class differentials."³⁵ The sociologist William Julius Wilson makes a similar point in his landmark study The Declining Significance of Race, where he argues that "trained and educated blacks, like trained and educated whites, will continue to enjoy the advantages and privileges of their class status."³⁶ Although new studies, discussed in Chapters 5 and 6, show that race differentials persist even among the privileged, it is important to insist that it is the African American poor—and an analysis of the mechanisms of their impoverishment—who are being left out. At the same time, U.S. national aggregate income data that do not consider differential mortality by race and place miss completely the fact that African American men in Harlem have shorter life expectancies than Bangladeshi men.³⁷ Again, as Sen remarks, race-based differences in life expectancy have policy implications, and these in turn are related to social and economic rights:

If the relative deprivation of blacks transcends income differentials so robustly, the remedying of this inequality has to involve policy matters that go well beyond just creating income opportunities for the black population. It is necessary to address such matters as public health services, educational facilities, hazards of urban life, and other social and economic parameters that influence survival chances. The picture of mortality differentials presents an entry into the problem of racial inequality in the United States that would be wholly missed if our economic analysis were to be confined only to traditional economic variables.³⁸

 

Other Axes of Oppression

Any distinguishing characteristic, whether social or biological, can serve as a pretext for discrimination and thus as a cause of suffering. Refugee or immigrant status is one that readily comes to mind, when thinking of the poor and the powerless. Sexual preference is another obvious example; homosexuality is stigmatized to varying degrees in many settings. "Gay bashing," like other forms of violent criminal victimization, is sure to have long-term effects. But crimes against gay men and women are again felt largely among the poor.

Questions about the relationship between homophobia and mortality patterns have come to the fore during the AIDS pandemic. In regard to HIV disease, homophobia may be said to lead to adverse outcomes if it "drives underground" people who would otherwise stand to benefit from preventive campaigns. But gay communities, at least middle-class ones in affluent nations, have been singularly effective in organizing a response to AIDS, and those most closely integrated into these communities are among the most informed consumers of AIDS-related messages in the world.³⁹

Homophobia may be said to hasten the development of AIDS if it denies services to those already infected with HIV. But this phenomenon has not been widely observed in the United States, where an "AIDS deficit"—fewer cases than predicted—has been noted among gay men, though not in other groups disproportionately afflicted with HIV disease in the early years of the epidemic: injection drug users, inner-city people of color, and persons originally from poor countries in sub-Saharan Africa or the Caribbean.⁴⁰ Those engaged in sex work have not benefited from the AIDS deficit. However, males involved in prostitution are almost universally poor, and it may be their poverty, rather than their sexual preference, that puts them at risk of HIV infection. Many men involved in homosexual prostitution, particularly minority adolescents, do not necessarily identify themselves as gay.

None of this is to deny the ill effects of homophobia, even in a country as wealthy as the United States. The point is rather to call for more fine-grained, more systemic analyses of power and privilege in discussions about who is likely to have their rights violated and in what ways. We did not need the AIDS pandemic to teach us this. In Maurice, E.M. Forster explores English class politics as much as he does the affective experience of Maurice, an upper-middle-class man who falls in love with Clive, an aristocrat with the expected political ambitions. Maurice's liberation, it would seem, comes from his relationship with Alec, a servant on Clive's family estate. In a postscript to the book, Forster deplores the persecution of gays in England, noting that "police prosecutions will continue and Clive on the bench will continue to sentence Alec on the dock. Maurice may get off."⁴¹

 

The Conflation of Structural Violence and Cultural Difference

Awareness of cultural differences has long complicated discussion of human suffering. Some anthropologists have argued that what outside observers construe as obvious assaults on dignity may in fact be longstanding cultural institutions highly valued by a society. Often-cited examples range from female circumcision in the Sudan to headhunting in the Philippines. Such discussions invariably appeal to the concept of cultural relativism, which has a long and checkered history in anthropology. Is every culture a law unto itself and answerable to nothing other than itself? In recent decades, confidence in reflexive cultural relativism faltered as anthropologists turned their attention to "complex societies" characterized by extremely inegalitarian social structures. Many found themselves unwilling to condone social inequity merely because it was buttressed by cultural beliefs, no matter how ancient or picturesque. Citizens of the former colonies also questioned cultural relativism as part of a broader critique of anthropology: for them, it appeared to be a mechanism for rationalizing and perpetuating inequalities between First and Third Worlds.⁴²

But this question has not yet eroded a tendency, evident in many of the social sciences but perhaps particularly in anthropology, to confuse structural violence with cultural difference. Far too many ethnographies have conflated poverty and inequality, the end results of a long process of impoverishment, with "otherness." Quite often, such myopia does not come down to motives but rather, as Talal Asad has suggested, to our "mode of perceiving and objectifying alien societies."⁴³ Part of the problem may be the ways in which the term "culture" is used. "The idea of culture," explains Roy Wagner approvingly in a book on the subject, "places the researcher in a position of equality with his subjects: each 'belongs to a culture.'{hrs}"⁴⁴ The tragedy, of course, is that this equality, however comforting to the researcher, is entirely illusory. Anthropology has usually "studied down" steep gradients of power.

Such illusions suggest an important means of sustaining other misreadings—most notably, the conflation of poverty and cultural difference—for they suggest that the anthropologist and "his" subject, being from different cultures, are of different worlds and of different times.⁴⁵ These sorts of misreadings, innocent enough when kept among scholars, are finding a more insidious utility within elite culture as it becomes increasingly transnational. Concepts of cultural relativism, and even arguments to reinstate the dignity of different cultures and "races," have been easily adopted and turned to profit by some of the very agencies that perpetuate extreme suffering.⁴⁶ The abuse of the concept of cultural specificity is particularly insidious in discussions of suffering in general and of human rights abuses specifically: cultural difference, verging on a cultural determinism, is one of several forms of essentialism used to explain away assaults on dignity and suffering. Practices including torture are said to be "part of their culture" or "in their nature"—"their" designating either the victims, or the perpetrators, or both, as may be expedient.⁴⁷

Such analytic vices are rarely questioned, even though systemic studies of extreme suffering suggest that the concept of culture should enjoy only an exceedingly limited role in explaining the distribution of misery. The role of cultural boundary lines in enabling, perpetuating, justifying, and interpreting suffering is subordinate to (though well integrated with) the national and international mechanisms that create and deepen inequalities. "Culture" does not explain suffering; it may at worst furnish an alibi.⁴⁸

 

Structural Violence and Extreme Suffering

At night I listen to their phantoms
shouting in my ear
shaking me out of lethargy
issuing me commands
I think of their tattered lives
of their feverish hands
reaching out to seize ours.
It's not that they're begging
they're demanding
they've earned the right to order us
to break up our sleep
to come awake
to shake off once and for all
this lassitude.

Claribel Alegría, "Nocturnal Visits"

Clearly, no single axis can fully define increased risk for extreme human suffering. Efforts to attribute explanatory efficacy to one variable lead to immodest claims of causality, for wealth and power have often protected individual women, gays, and ethnic minorities from the suffering and adverse outcomes associated with assaults on dignity. Similarly, poverty can often efface the "protective" effects of status based on gender, race, or sexual orientation. Leonardo Boff and Clodovis Boff, liberation theologians writing from Brazil, insist on the primacy of the economic:

We have to observe that the socioeconomically oppressed (the poor) do not simply exist alongside other oppressed groups, such as blacks, indigenous peoples, women—to take the three major categories in the Third World. No, the "class-oppressed"—the socioeconomically poor—are the infrastructural expression of the process of oppression. The other groups represent "superstructural" expressions of oppression and because of this are deeply conditioned by the infrastructural. It is one thing to be a black taxi-driver, quite another to be a black football idol; it is one thing to be a woman working as a domestic servant, quite another to be the first lady of the land; it is one thing to be an Amerindian thrown off your land, quite another to be an Amerindian owning your own farm.⁴⁹

This is not to deny that sexism or racism has serious negative consequences, even in the wealthy countries of North America and Europe. The point is simply to call for more honest discussions of who is likely to suffer and in what ways.

The capacity to suffer is, clearly, a part of being human. But not all suffering is equivalent, in spite of pernicious and often self-serving identity politics that suggest otherwise. Physicians practice triage and referral daily. What suffering needs to be taken care of first and with what resources? It is possible to speak of extreme human suffering, and an inordinate share of this sort of pain is currently endured by those living in poverty. Take, for example, illness and premature death, the leading cause of extreme suffering in many places in the world. In a striking departure from previous, staid reports, the World Health Organization now acknowledges that poverty is the world's greatest killer: "Poverty wields its destructive influence at every stage of human life, from the moment of conception to the grave. It conspires with the most deadly and painful diseases to bring a wretched existence to all those who suffer from it."⁵⁰

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. Why might this be so? One answer is that the poor are not only more likely to suffer; they are also less likely to have their suffering noticed, as Chilean theologian Pablo Richard, noting the fall of the Berlin Wall, has warned: "We are aware that another gigantic wall is being constructed in the Third World, to hide the reality of the poor majorities. A wall between the rich and poor is being built, so that poverty does not annoy the powerful and the poor are obliged to die in the silence of history."⁵¹

The task at hand, if this silence is to be broken, is to identify the forces conspiring to promote suffering, with the understanding that these are differentially weighted in different settings. If we do this, we stand a chance of discerning the causes of extreme suffering and also the forces that put some at risk for human rights abuses, while others are shielded from risk. No honest assessment of the current state of human rights can omit an analysis of structural violence, as the following chapters attempt to show.

 

 

NOTES

¹ The embodiment paradigm, for which we are to some extent indebted to Merleau-Ponty (e.g., 1945), has been used widely in medical anthropology. For a helpful review, see Csordas 1990 and 1994.

² Sidney Mintz reminds us of the non-newness of many of the global phenomena under study today. More specifically, the history of Haiti and much of the Caribbean presages current critiques concerning transnationalism:

Why, then, has the vocabulary of those events become so handy for today's transnationalists? Is one entitled to wonder whether this means that the world has now become a macrocosm of what the Caribbean region was, in the 16th century? If so, should we not ask what took the world so long to catch up—especially since what is happening now is supposed to be qualitatively so different from the recent past? Or is it rather that the Caribbean experience was merely one chapter of a book being written, before the name of the book—world capitalism—became known to its authors? (Mintz 1997, p. 120).

³ Weise 1971, p. 38.

⁴ Galeano 1973, p. 112. It's worth noting that those with miserable jobs are nonetheless considered fortunate in a country where unemployment is estimated, by the omniscient Central Intelligence Agency, at 70 percent (U.S. Central Intelligence Agency 2001). It's no wonder that the CIA is interested in the matter: Haiti was, until quite recently, one of the world's leading assemblers of U.S. goods. For more on the conditions of Haitian workers in U.S.-owned offshore assembly plants, see Kernaghan 1993. Of course, U.S. industries are not alone in exploiting cheap Haitian labor, as evidenced by a recent report on labor conditions on the orange plantations that lend Grand Marnier liqueur its distinctive tang; see Butler 2000.

⁵ In addition to standard indices of well-being and development, the "human suffering index" takes into account such factors such as access to clean drinking water, daily caloric intake, religious and political freedom, respect for civil rights, and degree of gender inequality. For information about the human suffering index and how it was derived, see the Web site at http://www.basics.org/programs/basics1/haiti.html.

⁶ Depending on the source, the demographic statistics vary. According to the World Health Organization's World Health Report 2000, life expectancy at birth is 52.8 years, while the mortality rate for children under five is 115.5 per 1,000 births (World Health Organization 2000c). The CIA, which should know, reports even grimmer statistics: life expectancy of 47.5 years for men and 49.2 years for women (U.S. Central Intelligence Agency 2001). Life expectancy is likely lower and mortality rates are likely higher in the Central Plateau than elsewhere in Haiti. See also United Nations Development Programme 2001.

⁷ For reviews of morbidity and mortality in Haiti, see the reports from the World Health Organization (WHO) and the United Nations Development Programme (UNDP) mentioned in note 6. The Pan American Health Organization (PAHO) regularly updates its data on Haiti (see Pan American Health Organization 2001). For a review of health trends in central Haiti, see Farmer and Bertrand 2000 as well as Farmer 1999b; the latter volume also presents pertinent information on HIV and tuberculosis in Haiti. Those seeking the latest available data on HIV should consult UNAIDS/World Health Organization 2000, with updated information on the Web. Underreporting, in large part a result of weak surveillance, is a major hindrance to those seeking to interpret official data and its echoes by the PAHO or the WHO. For example, the PAHO noted that Haiti reported 10,237 cases of tuberculosis in 1991, giving an estimated incidence of 154.7 per 100,000 population. In that same period (May 1990 to August 1992), Desormeaux and colleagues performed a house-to-house survey in Cité Soleil, an urban slum, and came up with a figure of 2,281 per 100,000 population. Among the HIV-infected, TB prevalence exceeded 5,770 per 100,000 population. See Pan American Health Organization 2001; Desormeaux, Johnson, Coberly, et al. 1996.

⁸ It's hard to think of a more compelling example than the 1981 massacre of all the inhabitants of El Mozote, El Salvador, by U.S.-trained and U.S.-funded troops. Leigh Binford lays out the challenges faced by those who would bring such events to broader attention:

From January 1983 through December 1989, "El Mozote" was cited in a mere fifteen articles published in major U.S. and Canadian newspapers. (During this same period the U.S. government provided the Salvadoran military with more than $500 million in direct military assistance.) . . . The coverage of El Mozote shows us that for the journalists, no less than for most people of the West, the daily lives of billions of people in the rest of the world do not exist outside the parameters of crisis or scandal: hurricanes, earthquakes, volcanic eruptions, droughts, crop failures, and civil wars (1996, p. 4).

⁹ The names of the Haitians cited here have been changed, as have the names of their home villages.

¹⁰ There is a large literature concerning the impact of dams on the lives of those displaced. In anthropology, a classic example would be the 1971 study by Elizabeth Colson. Alaka Wali (1989) charts the fate of those displaced by a hydroelectric dam in eastern Panama. Two different, more recent books on this subject provide poignant examples of the consequences of building big dams: Arundhati Roy's Cost of Living (1999) includes a passionate protest against the Sardar Samovar Dam in the Narmada Valley of India; Patrick McCully's Silenced Rivers: The Ecology and Politics of Large Dams (1996) details the specific effects of big dams on the health of the displaced (see esp. McCully's chapter "Dams and Disease," pp. 86-100). Michael Ignatieff outlines the links between human rights and dam projects in specific terms:

A human rights perspective on development, for example, would be critical of any macroeconomic strategy that purchased aggregate economic growth at the price of the rights of significant groups of individuals. A dam project that boosts electro-generation capacity at the price of flooding the lands of poor people without compensation and redress is an injustice, even if the aggregate economic benefit of such a measure is clear (2001, p. 167).

¹¹ Chapter 2 discusses this matter in greater detail. For a comprehensive and well-documented overview of the plight of Haitian refugees, see "Symposium: The Haitian Refugee Crisis: A Closer Look" 1993, a special issue of the Georgetown Immigration Law Journal. In an excellent overview of the roots of human rights violations in Haiti, an essay in that issue describes the Reagan-Duvalier pact (Executive Order 12,324 issued by Ronald Reagan on September 29, 1981) as follows:

The Interdiction Program worked with grim efficiency during the Duvalier era. From its inception in late 1981, thousands of Haitians have been stopped and forcibly repatriated to Haiti. In every case, the Coast Guard destroyed the Haitian vessel and the Coast Guard cutter returned crowded with Haitian asylum-seekers to Port-au-Prince. Despite well-documented evidence of gross and systematic human rights abuses during the Duvalier era and under the succeeding military governments, all but eight of the approximately 23,000 interdicted Haitians were returned to Haiti from October 1981 to September 1991 when President Aristide was overthrown in a military coup. Interviews conducted on the Coast Guard cutters were inherently flawed and help explain the blanket finding that all those interdicted were "economic refugees" (O'Neill 1993, p. 96).

O'Neill also provides a figure of 24,559 Haitian refugees applying for asylum during this period.

¹² For more on U.S. aid to the military "governments" of post-Duvalier Haiti, see Farmer 1994 and Ridgeway 1994. Hancock (1989) also discusses the impact of U.S. aid to the Duvalier regimes.

¹³ This topic is discussed, at greater length and in general terms, in Farmer, Connors, and Simmons 1996. Concerning the expanding epidemic of HIV in Haiti and its relationship to structural violence, see Farmer 1992a and 1999c. For more on the situation currently confronted by Haitian women, most of whom live in poverty, see the review by Neptune-Anglade (1986) and the testimonies collected by Racine (1999). More recently, Beverly Bell (2001) documents stories of Haitian women's struggles for survival as well as resistance against tyranny and terror.

¹⁴ For an overview of the human rights situation after the 1991 coup, see Americas Watch and the National Coalition for Haitian Refugees 1993 and O'Neill 1993. For a review of these and other reports, see Farmer 1994. Additional reports include Inter-American Commission on Human Rights 1994 and United Nations Human Rights Commission 1995 as well as the report on internal displacement issued in 1994 by Human Rights Watch/Americas, Jesuit Refugee Service/USA, and the National Coalition for Haitian Refugees.

Toward the end of the Cédras-led coup, which led to thousands of outright murders, the army and paramilitary began a campaign of politically motivated rape. One survey terms this campaign "arguably the greatest crime against womankind in the Caribbean since slavery" (Rey 1999, p. 74). See also Human Rights Watch/Americas and National Coalition for Haitian Refugees 1994. It was during these years that our clinic received its first rape victims (Farmer 1996a); one of my patients went on to testify about politically motivated rapes in a hearing on this topic held by the Organization of American States.

¹⁵ Some would argue that the relationship between individual agency and supraindividual structures forms the central problematic of contemporary social theory. I have tried, in this discussion, to avoid what Pierre Bourdieu has termed "the absurd opposition between individual and society," and here acknowledge the influence of Bourdieu, who has contributed enormously to the debate on structure and agency. For a concise statement of his (often revised) views on this subject, see Bourdieu 1990. That a supple and fundamentally nondeterministic model of agency would have such a deterministic—and pessimistic—"feel" is largely a reflection of my topic, suffering, and my "fieldwork site," which is Haiti. The relationship between agency and human rights is traced by Ignatieff, among others:

We know from historical experience that when human beings have defensible rights—when their agency as individuals is protected and enhanced—they are less likely to be abused and oppressed. On these grounds, we count the diffusion of human rights instruments as progress even if there remains an unconscionable gap between the instruments and the actual practices of states charged to comply with them (2001, p. 4).

¹⁶ Chopp 1986, p. 2.

¹⁷ I have made this argument at greater length elsewhere; see Farmer 1992a, chap. 22. The term "historical system" is used following Immanuel Wallerstein, who for many years has argued that even the most far-flung locales—Haiti's Central Plateau, for example—are part of the same social and economic nexus: "By the late nineteenth century, for the first time ever, there existed only one historical system on the globe. We are still in that situation today" (Wallerstein 1987, p. 318). See also his initial, magisterial formulation, The Modern World-System: Capitalist Agriculture and the Origins of the European World-Economy in the Sixteenth Century (1974).

¹⁸ Chopp 1986, p. 2. See also the works of Gustavo Gutiérrez (1973 and 1983, for example), who has written a great deal about the meaning of suffering in the twentieth century. (These books are cited more extensively in Chapter 5.) For anthropological studies of liberation theology in social context, see Burdick 1993 and Lancaster 1988.

¹⁹ Boff 1989, p. 20.

²⁰ Brown 1993, p. 44.

²¹ The connections between the fecklessness of the powerful and the fates of the fragile have been well traced. The political economy of genocide is explored in Simpson 1993; see also Aly, Chroust, and Pross 1994. On the transnational political economy of human rights abuses, see Chomsky and Herman 1979a and 1979c, a two-volume study. When Mike Davis explores "late Victorian holocausts," which led to some fifty million deaths, he concludes that "we are not dealing, in other words, with 'lands of famine' becalmed in stagnant backwaters of world history, but with the fate of tropical humanity at the precise moment (1870-1914) when its labor and products were being dynamically conscripted into a London-centered world economy. Millions died, not outside the 'modern world system,' but in the very process of being forcibly incorporated into its economic and political structures" (2001, p. 9).

²² For historical background on Haiti, see James 1980, Mintz 1974, and Trouillot 1990.

²³ Sen 1998, p. 2.

²⁴ Rosaldo and Lamphere 1974. For differing views, see Leacock 1981.

²⁵ Koss, Koss, and Woodruff 1991, p. 342. From November 1995 to May 1996, the National Institute of Justice and the Centers for Disease Control jointly conducted a national telephone survey that confirmed the high rates of assault against U.S. women (Tjaden and Thoennes 1998). See also Bachman and Saltzman 1995.

²⁶ It is important to note, however, that in many societies upper-class or upper-caste women are also subject to laws that virtually efface marital rape. The study by Koss, Koss, and Woodruff (1991) includes this crime with other forms of criminal victimization, but such information is collected only through community-based surveys.

²⁷ Ward 1993, p. 414.

²⁸ A recent joint report by WHO, UNICEF, and UNFPA on estimated maternal mortality for 1995 notes that of the 515,000 estimated maternal deaths worldwide, only 0.2 percent, or 1,200, occurred in industrialized countries. The lifetime risk of maternal death for women in such countries is calculated at 1:4,085, whereas for women in developing nations, the risk is much higher, at 1:61. In fact, for the subgroup of countries characterized as "least developed"—of which Haiti is one—the estimated risk of maternal death is, tragically, even higher, at 1:16 (World Health Organization, United Nations Children's Fund, United Nations Population Fund 2001, p. 48).

²⁹ The maternal mortality rate (MMR) of 523 deaths is for the year 2000 and is based on reports from the national health authority to PAHO; see Pan American Health Organization 2001. The much higher rate of 1,100 maternal deaths per 100,000 live births comes from the joint report published by WHO, UNICEF, and UNFPA; see World Health Organization, United Nations Children's Fund, United Nations Population Fund 2001 (p. 44). These numbers are likely to be even higher if one measures maternal mortality at the community level. The only community-based survey done in Haiti, conducted in 1985 around the town of Jacmel in southern Haiti, found that maternal mortality was 1,400 per 100,000 live births (Jean-Louis 1989). During that same period, "official" statistics reported much lower rates for Haiti, ranging from an MMR of 230 for the years 1980-87 (United Nations Development Programme 1990, p. 148) and an MMR of 340 for 1980-85 to a higher estimate in the years that followed, 1987-92, of 600 maternal deaths per 100,000 live births (World Bank 1994a, p. 148). For additional maternal mortality data from that period, see World Health Organization 1985.

³⁰ Sen 1998, p. 13. For an in-depth discussion of the population-based impact of gender bias in poor countries, see Sen's classic essay on "missing women" (Sen 1992b).

Sen summarizes the potential impact of public action in poor regions by examining Kerala state:

Kerala's experience suggests that "gender bias" against females can be radically changed by public action—involving both the government and the public itself—especially through female education, opportunities for women to have responsible jobs, women's legal rights on property, and by enlightened egalitarian politics. Correspondingly, the problem of "missing women" can also be largely solved through social policy and political radicalism. Women's movements can play a very important part in bringing about this type of change, and in making the political process in poor countries pay serious attention to the deep inequalities from which women suffer. It is also interesting to note, in this context, that the narrowly economic variables, such as GNP or GDP per head, on which so much of standard development economics concentrates, give a very misleading picture of economic and social progress (1998, p. 15).

³¹ Nightingale, Hannibal, Geiger, et al. 1990, p. 2098; emphasis added. For a more in-depth account, and a more complicated view of the mechanisms by which apartheid and the South African economy are related to disease causation, see Packard 1989.

³²  Although HIV is said to have recently "taken off" among South Africa's black population, it has been, from the beginning, an epidemic disproportionately affecting black people in that country. South African data indicate that in 1994, when seventeen white women were diagnosed with AIDS, almost fifteen hundred black women—nearly one hundred times as many—had the disease (Department of Health, South Africa 1995, p. 67).

Even after the dismantling of the apartheid system, HIV continues to disproportionately affect black South Africans (Lurie, Harrison, Wilkinson, et al. 1997). As Chapman and Rubenstein (1998) note in a report for the American Association for the Advancement of Science and Physicians for Human Rights, "the epidemiology of the HIV/AIDS epidemic . . . demonstrates the link between poverty, low status and vulnerability to infection" (p. 20). They report the "rigid segregation of health facilities; grossly disproportionate spending on the health of whites as compared to blacks, resulting in world-class medical care for whites while blacks were usually relegated to overcrowded and filthy facilities; public health policies that ignored diseases primarily affecting black people; and the denial of basic sanitation, clean water supply, and other components of public health to homelands and townships" (p. xix). Along with being denied medical services, many black South Africans were forced to relocate to townships and were later forced, by economic conditions, to live in squatter settlements on the outskirts of cities, creating a culture of migration and disrupted family ties (pp. 18-20). As Lurie and colleagues note, "migrant labour was a central tenet of apartheid, which sought to create a steady flow of cheap black labour to South Africa's mines, industries and farms. A myriad of laws prohibited black South Africans from settling permanently in 'whites only' areas, and as a result, migration patterns in South Africa tend to be circular, with men maintaining close links with their rural homesteads" (1997, p. 18).

This forced system of migration has had a distinct impact on the shaping of the AIDS epidemic. As Carol Kaufman explains, "the system of labor migration remains deeply entrenched, and women who have partners involved in labor circulation are especially vulnerable to unprotected sexual intercourse as well as STDs and HIV/AIDS transmission" (1998, p. 432). Quarraisha and Salim Abdool Karim cite a 1998 study conducted in rural South Africa which found that "women whose partners spent 10 or fewer nights per month at home had an HIV prevalence of 13.7% compared with 0% in women who spent more than 10 nights in a month with their partners" (1999, p. 139). See Lurie, Harrison, Wilkinson, et al. 1997 for further documentation of this link. Furthermore, data from 1994 reveal that poverty is rampant in South Africa, with close to two-thirds of black households surviving below the minimum subsistence level (Chapman and Rubenstein 1998, p. 20).

³³ The National Center for Health Statistics (1998) reported life expectancies at birth in 1996 as 76.8 years for whites and 70.2 years for blacks. Two years later, the same sources suggest a heartening trend: reported life expectancies increased to 77.3 for whites and 71.3 for blacks (National Center for Health Statistics 2000). But the discrepancy is still on the order of 9 to 10 percent of lifespan. For a detailed discussion of recent health status disparities and leading causes of death for African Americans, see Byrd and Clayton 2002, pp. 519-45.

³⁴ Navarro 1990, p. 1238.

³⁵ Ibid., p. 1240.

³⁶ Wilson 1980, p. 178.

³⁷ McCord and Freeman 1990.

³⁸ Sen 1998, p. 17.

³⁹ Although class differences between physicians and university students are not as significant as others examined here, it is notable that a study reported in the American Journal of Psychiatry (Klein, Sullivan, Wolcott, et al. 1987) observed that gay psychiatrists were much more likely than students to adopt effective risk reduction. Clearly, many factors—age, educational level, and so on—may be significant here. In the United States, we still lack economically informed studies of risky behavior among gay men; for gay men in France, one study (Pollak 1988) suggests that economic status is important in determining access to information and services.

⁴⁰ These data are reviewed in Farmer, Walton, and Furin 2000. See also Aalen, Farewell, De Angelis, et al. 1999.

⁴¹ Forster 1971, p. 255.

⁴² See the studies by Hatch (1983) and Gellner (1985). Of course, the discussion of violence and cultural difference is vastly more complicated than that presented here. One consideration is that anthropological confidence in cultural relativism failed not only as part of the shift to studying "complex societies" but also as a result of shifting demographics within anthropology itself. Following World War II, the entrance into U.S. professional anthropology of large numbers of veterans, some of working-class origins and with more radical political orientations, served to significantly undermine the extreme cultural relativist position. By the 1990s, it was no longer unusual to hear comments such as that made by Nancy Scheper-Hughes: "Anthropological relativism is no longer appropriate to the violent, vexed and contested political world in which we now live" (1994, p. 991). At the same time, however, argues William Roseberry, the "profoundly conservative reaction in politics and culture, marked politically by the Reagan victory in 1980," has had its echoes within anthropology: "What has fallen out of favor? In practice, it seems to be any work that is too ethnographic, too sociological, too structural, too political, too economic, or too processual" (1996, pp. 17, 21).

⁴³ Asad 1975, p. 17.

⁴⁴ Wagner 1975, p. 2.

⁴⁵ Johannes Fabian (1983) has argued that this "denial of coevalness" is much ingrained in our discipline. Not to be dismissed as an issue of style, such a denial contributes to the blindness of the anthropologist: "Either he submits to the condition of coevalness and produces ethnographic knowledge, or he deludes himself into temporal distance and misses the object of his search" (p. 32; emphasis added). See also Starn 1992.

⁴⁶ For a penetrating examination of the appropriation of identity politics by big business, see Kauffman 1993. Naomi Klein's more recent work (2000) is a sophisticated study of the same topic.

⁴⁷ Again, this chapter's discussion necessarily gives short shrift to the complexities of these debates. For a revealing example, see Amede Obiora's 1997 exploration of "polemics and intransigence in the campaign against female circumcision."

⁴⁸ One recent example of the conflation of structural violence and cultural difference is found in the long lists of reasons given by those who do not believe that AIDS treatment is possible in Africa. One U.S. Treasury Department official—who wisely declined to be identified—observed that "Africa lacked the basic medical and physical infrastructure that would make it possible to deploy effectively the complex cocktail of drugs to fight AIDS. He said Africans lacked a requisite 'concept of time,' implying that they would not benefit from drugs that must be administered on tight time schedules" (Kahn 2001, p. 10).

Officially sanctioned justifications and explanations for structural violence come most often, however, from the reading and writing classes—that is, us. Guatemalan poet Otto René Castillo, who was killed by the Guatemalan army on March 19, 1967, avers that the "Apolitical Intellectuals" of his country will one day be judged harshly by the poor:

"What did you do when the poor
suffered, when tenderness and life
were dangerously burning out in them?"

Apolitical intellectuals
of my sweet country,
you will have nothing to say.

A vulture of silence
will eat your guts.
Your own misery
will gnaw at your souls.
And you will be mute
in your shame.

⁴⁹ Boff and Boff 1987, p. 29.

⁵⁰ World Health Organization 1995, p. 5.

⁵¹ Richard is cited in Nelson-Pallmeyer 1992, p. 14.

Championing Health Care as a Human Right:
An Interview with Paul Farmer

"Pathologies of Power is an eloquent plea for a working definition of human rights that would not neglect the most basic rights of all: food, shelter, and health."
—Tracy Kidder, author of Mountains Beyond Mountains, a book about Paul Farmer

UC Press Executive Editor Naomi Schneider interviewed Paul Farmer, Professor of Medical Anthropology at Harvard Medical School and Founding Director of Partners in Health. The University of California Press recently published his book Pathologies of Power: Health, Human Rights, and the New War on the Poor. Farmer is the winner of a MacArthur Foundation "genius" award and the Margaret Mead Award for his contributions to public anthropology.

Tell us a little about your background. Did you grow up in an activist family?

Well, not an activist family in the "conventional" sense. My parents were in some senses working class (my mother, a farm girl, was a grocery-store cashier; my father went to teacher's college and was an on-again-off-again teacher) but in others were very unusual. I'm one of six kids, and the eight of us lived for over a decade in either a bus or a boat. The bus was a former tuberculosis-screening bus and sometimes I wonder . . . But as for activism, my parents did what they could, given the constraints, but were never involved in the causes I think of when I think of activists. They were more engaged in the quiet activism of the trailer parks: my dad, especially, was forever keeping an eye on the elderly, on the mentally challenged (the term back then was "retarded citizens"), or on just about anyone who needed a hand. My mother, of course, was keeping an eye on my dad, who needed a lot of tending, and on her six young kids. She had all of us by the time she was in her late twenties.

Why did you decide to become a medical anthropologist?

As strange as it seems now, I have to say I just loved the topic. I was in college and took a course in medical anthropology. I loved the readings, the suggested research (I volunteered in a big emergency room), the faculty, the broad view. By the time I was 21, I was dead sure I wanted to be a doctor and an anthropologist. Where that surety came from is now a mystery, but there's no doubt it was there.

What impact does your Catholicism have on your work?

Again, conventional Catholicism does not much appeal to me. Like tens of millions of U.S. citizens, I was "raised" Catholic, but for my agnostic father that meant fulfilling social obligations, including those to his family and that of my mother (both grandmas devout). It was as meaningless to me at 18 as it was to so many other young people. But then came liberation theology, which lent meaning to what I was reading in college (Central America was burning) and, later, to what I was to see and experience in Haiti. I would say that, intellectually, Catholicism had no more impact on me than did social theory. But emotionally and intellectually, liberation theology has been, well, a Godsend-- a resource for living and thinking and writing. It seeps into all of my books, but Pathologies of Power is the first one in which it's sort of front-and-center. Of course, I have no clue, yet, as to whether or not it "works" for the reader. I know it works in Haiti, but I don't have readers here . . .

Did winning the MacArthur spur your ability to raise money and achieve your goals?

Sure. That was 10 years ago, and I learned some lessons. One of them was that books can matter (AIDS and Accusation, my first book, seemed to figure prominently in the view of those who chose us, while prior to the MacArthur, writing seemed firmly put in its place by the illiteracy of those who came to our growing clinic). Another was that recognition of that sort-- the prize was called, I soon learned, "the genius award"-- meant deep ambivalence. After all, ours is fundamentally a group effort, and this was a prize for one person. But there's no question that the prize helped us to raise money and bring attention to our collective work.

Tell us a bit about how you decided to form Partners in Health with some of your colleagues at Harvard. What are its goals and accomplishments so far?

It was apparent from the early 80s that in order to do something lasting and significant in Haiti we would need a springboard in the States. A means of raising funds in order to remediate inequalities of access to health care. PIH was that springboard, and it was a dream of mine from the beginning. The goals are clear enough: go forth and remediate inequalities of access, with the term "access" serving to signal access to education, health care, clean water, whatever. Accomplishments so far? Well, we've worked with our friends in Haiti to establish nothing short of a modern medical center in one of the poorest parts of that country. It works! We've taken on the major health problems of the poorest-- tuberculosis, maternal mortality, AIDS, malaria-- in four countries. We've scored some victories in the sense that we've cured or treated thousands and changed the discourse about what is possible.

Tell us about your program in Haiti. Is it realistic to provide advanced AIDS treatments for the world's poor?

It's realistic because it's real. We've done it in one of the poorest places on the face of the earth for people who don't have access to the basics (food, water, education, housing) and we've done it while fighting for access to these basics. We've even argued that these basics should be rights. Basic birth rights, in our view.

At the same time, we know that it's not realistic. Not in terms of what is likely in a world riven by poverty and social inequalities.

Shuttling back and forth between what is possible and what is likely to occur is instructive and a lot of what shapes our sentiment.

In Pathologies of Power you critique market-based medicine. Why? And what do you propose as an alternative?

I critique market-based medicine not because I haven't seen its heights but because I've seen its depths. Anywhere you have extreme poverty and no national health insurance, no promise of health care regardless of social standing, that's where you see the sharp limitations of market-based health care. The poorest parts of the world are by and large the places in which one can best view the worst of medicine and not because doctors in these countries have different ideas about what constitutes modern medicine. It's the system and its limitations that are to blame.

An alternative? Well, I'm not a specialist in health economics. But there's a simple approach that is not simplistic, at least not in my view. Health care as a right. What sort of right would that be? The right to health care is usually classed as an "economic" or "social" right. And Pathologies of Power is a book about social and economic rights.

You have done groundbreaking work treating drug-resistant tuberculosis patients in Russian prisons, which you discuss in Pathologies of Power. Tell us about how you overcame obstacles from the World Bank and IMF in developing programs for these prisoners.

Well, it remains to be seen that we've "overcome" all the obstacles put in our way. But certainly progress has been made. Tuberculosis is a test case, because we've forced many to accept our basic point that tuberculosis care has to be seen as a right and as a public good. Even die-hard fans of the market acknowledge that TB care should be free. Why? Because it's an airborne disease and treatment equals prevention. Good treatment, that is. Bad treatment leads to drug-resistant TB and death and persistence of the epidemic. Even the bankers have been pushed to acknowledge that some things, including TB treatment, should be considered a public good. The reason, perhaps, that drug-resistant TB in prisons is significant in the international health arena is that it's expensive to treat. Like AIDS. Like malignancies or surgical problems. But it's airborne.

How is adequate medical care a basic human right?

The thing about rights is that in the end you can't prove what should be considered a right. Sure, there are some things we agree on widely (everyone deplores torture) but how long ago was it, in even the liberal democracies, that not everyone was allowed to vote? So I can't show you how, exactly, health care is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable. And I can also show you that people from all walks of life agree that someone who is sick deserves, in principle, compassion and care. In principle. Finally, I can show you all the things that go wrong, not just for the sick but for all of us, when health care is not construed as a basic human right. But in the end it's not really something you can prove.

You are now an academic superstar with a book about you written by Tracy Kidder about to be published by Random House. Is this exciting or a bit disconcerting? How will this celebrity have an impact on your work in Haiti and elsewhere?

Of course it's disconcerting. More so than exciting. I mentioned one of the reasons above: it's a group effort, so anything like this that focuses on me as an individual is disconcerting. There are other reasons to fear celebrity. It's not about us, it's about the patients, about the poor, the struggle.

The recent political turmoil in Haiti is ominous. What is happening in the country and how does this affect your programs?

It's true that political turmoil persists. There are two kinds of turmoil, as I argue in the book. There is the "classic" political turmoil, which has been a feature of living in Haiti for the past 15 years. There is also the turmoil born of poverty and inequality. Haiti has a good chance of defeating the first kind of turmoil, since it has gone, in the 20 years I've been there, from a dictatorship to a democracy. This is necessarily a long and painful process. It affects our programs. Just last month, members of our medical staff were held hostage by former soldiers; our ambulance was stolen and we never recovered it. But things are moving forward.

What are your goals for the next five years?

To scale up our efforts in Haiti, Peru, and Russia. To train a new generation of doctors and scholars and community health workers to take up this idea of health care as a right. I have a couple of ideas about things I'd like to write and these will get done over the next five years. Basically, I guess, more of the same.

To learn more about Partners in Health, visit www.pih.org