Violence Beneath Our Skin: An Anthropological Analysis of Our Endemic Violence and its Public Health
The most important place to begin when discussing the topic of violence is to understand how it is defined and what its implications are. The two types of violence that will be discussed are political violence and structural violence, and while there are other forms of violence, these two are the most predominant throughout the world. Although structural violence and political violence share similarities in that they are both political, the two will be separated in this analysis based on the fact that structural violence is a more indirect form of violence and political violence is much more direct in its format. Political violence is targeted physical violence and terror administered by official authorities and those opposing it, such as military repression, police torture, and armed resistance (Leatherman, Thomas 2009). The other form of violence is called structural violence. Farmer (2004) defines it as violence exerted systematically-that is, indirectly-by everyone who belongs to a certain social order. While there are several definitions for structural violence depending on which paradigm a researcher’s ideology is attuned to, Paul Farmer tends to look at structural violence from a perspective of political ecology. This perspective best suits an analysis of violence as a result of human agency; therefore the use of Farmers’ definition will be the most appropriate option. Political violence can often exacerbate or cause structural violence, thus these two types of violence are inextricable. Important to both definitions is to consider how both of these forms of violence stem from human agency, and because human behavior is subject to change then there is, indeed, a way to prevent violence. How this can and should be done will be discussed later.
Implications of Structural Violence
Structural violence is different from political violence in that it has no specific aim such as in war or direct oppression and discrimination. Rather, structural violence is a result of the effects of systems that allow for limitation of human ability to reach the potential of a holistic wellness. It is a process that makes cultural norms into caustic patterns of dehumanization. Unfortunately the trend in public health discourse has been to address individual risk factors alone, without attributing any blame to political institutions (Lane et. al 2004). The problem with this is that this way of thinking completely ignores institutional injustice, disadvantage, and discrimination which are where structural violence originates. This process can also be called “biomedical individualism” (Lane et. al 2004). An example of this can be taken from a case study conducted by Janice Harper (2004) on structural violence in Houston, Texas. The Houston ship channel, it is estimated, is the origin of seventy five percent of all of the toxins in the air in the entirety of the United States of America alone. Historically, Houston has been considered the energy capital of the United States, and the construction of its highways can be attributed, for the most part, to the oil boom of the 1970s. Public officials, believing that most people would have cars, didn’t put any effort forth in constructing a public transportation infrastructure, and because of the city’s layout, composed of several economic centers (originally for the use of decreasing traffic back ups), it is virtually impossible to travel effectively without a vehicle. Because of the energy industries in Houston, many environmental concerns were thought of as farfetched and that they opposed prosperity and capitalistic ideals, and so they were easily suppressed by the status quo even to the point of companies not allowing air standards to be published in the Houston Chronicle until the mid eighties. When the Texas Clean Air Act was passed in the 1960s, the environmental boards created in the city of Houston were composed of industry owners. Thus, the concern of air quality was made a private, not a public matter. One Hispanic woman, under the pseudonym of Isabella Gallegos, describes how her daughter suffers from agitated asthma due to the chemical factories that surround their neighborhood in southeast Houston: “To people in this area, it’s normal. It’s normal that they’re always throwing up from the smells, it’s normal that they have asthma, it’s normal that they have bronchitis, it’s normal that they have a rash. It’s normal.” When Isabella asks what she should do to help her daughter public health workers tell her that she should keep her house clear of dust and cockroaches in order to avoid higher risks for her daughter’s asthma, but, contrary to their claims, Harper (2004) describes Isabella’s house as “immaculate”. Analyzing this one particular case shows that the problem does not lie within the responsibility of the individual; it is the system of public power that has become caustic to the individual, and therefore it is an example of structural violence. This can be summed up in Isabella’s own words: “I’m so tired of filling my kids with chemicals to protect them from chemicals.” It is not the cockroaches and dust that are suffocating her daughter; it is the fault of the chemical factories, the plethora of diesel trucks, the concrete crushing facilities, and the blind application of public health policies that insist that it has nothing to do with these factors but has everything to do with Isabella. One of the most important things to consider from this example is that when studying a suffering population one must consider the history of the area. Structural violence is dependent on history and biology just as much as it is dependent upon politics and economics (Farmer 2004). Also, the erasure and replacement of history is the foremost tool used by those who perpetuate structural violence (Farmer 2004). If Houston’s history of an over-emphasis on pollution as a private matter as well as its construction of transportation and layout of the city were ignored in Harper’s case study then they would have failed to see how suffering and misery became legitimate as time moved forward. If this ignorance were allowed then the criticism of Houston’s public health practice could not be nearly as heavy handed as it is.
Because of its nature, structural violence can not only sharpen and increase the amount of chronic disease due to environmental factors; it can also lead to the proliferation and spread of infectious disease. In a case study on HIV transmission among homosexual men in Syracuse New York, spread of infection was found to be correlated with racial discrimination in incarceration, stigma, the inability to gain access to proper health care due to costly insurance, and disproportionate death rates among ethnic groups (Lane et. al 2004). In the case of disproportionate incarceration, 16% of the population is composed of African Americans, yet they endure 43% of arrests and 51% of the population in state prisons are African Americans. It has been shown that individuals, who are isolated, as in the case of prison, are more likely to choose partners from within their niche and are therefore more likely to spread infection among their social group (Lane et. al 2004). Social stigma and homophobia stemming from cultural and religious institutions is also a contributing factor in the spread of HIV. Men who practice homosexual behavior will also carry on heterosexual relationships in order to keep themselves on the “DL” (down low), thus giving females risk of infection as well, and because homosexual men are inclined to be secretive due to social stigma they will often not identify themselves as being gay. In many cases homosexual men will keep their relationships a secret because revealing their intentions would lead to ostracism and sometimes physical or verbal abuse by their society (Niang et. al 2003). This in turn leaves them at a disadvantage because the public health messages of safe sex and sexual health education will often not reach these men. To add to the disdain, the public health clinic in Syracuse did not have hours that were suitable for many working homosexual men. A similar example lies in the continent of Africa: Islamic societies in Africa will ostracize and condemn homosexuals, disallowing them from participating in religious and cultural activities (Niang et. al 2003). Niang quotes one religious leader: “Since the Muslim religion forbids homosexuality, we cannot accept homosexuals either in our homes or in our mosques.” African homosexuals will go so far as to not even reveal infection to doctors in certain areas of their body. They are willing to be examined in the genital region because infection in said region can be associated with heterosexual relationships. However, an infection revealed in the anal region would allow for inquiry into homosexual behavior (Niang et. al 2003). Lack of health education among homosexual men about sexually transmitted infections in Africa was shown when asked what they believed the cause of their symptoms were: “Most respondents mentioned such non-viral or bacterial causes as poor hygiene, irritation from intercourse without sufficient lubrication, spicy foods, long periods of abstinence, masturbation, too much sex, or other illnesses.” The former example yields more insight: because of the high death and disproportionate incarceration rate of African American men in Syracuse New York, there is a trend of low male to female sex ratio. This leaves women at a disadvantage because it decreases their ability to maintain monogamous relationships as well as decreases their bargaining power (Lane et al. 2004). Women will often find themselves having to perform more risky behavior in order to maintain relationships, behavior that they wouldn’t normally practice if there were more men within the population. Also, the advertisement and proliferation of douching products allows for further risk of infection because douching products have shown an increase in risk, not the opposite (Lane et. al 2004). It can be concluded from this evidence that, firstly, structural violence can stem from cultural causes such as false advertisement and stigma as well as governmental, and, secondly, that it affects not only the population it specifically oppresses.
Structural violence mostly affects populations that live in either relative or abject poverty more than anyone else. The most un-nerving recurrence in these case studies is not that they happen to all populations, but that it is a trend among lower class, poor, and non-white populations (Harper 2004). In light of this there seems to be no wonder why there is little access to health care for such individuals in an economy that has turned healthcare into a commodity. Paul Farmer (2005) explains that the systematic abuse of human rights can only be fully understood from the perspective of the poor and the marginalized. Thus, anthropology on the subject of structural violence from the perspective of the poor is immensely important in understanding the underlying causes of suffering. Lessons from this research must be incorporated in public health practice if proper indigenization of health programs is to be implemented. If the historical background and political and cultural context of suffering populations is ignored then public health programs will fail because of the continuation of unjust systems architecturally engineered for the oppression of populations. Farmer (2005) makes it clear that “civil rights cannot be defended if social and economic rights are not.”
Implications of Political Violence
In the field of public health, health is viewed as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (Leatherman, Thomas 2009).” Because the primary objective in an endeavor such as war is to literally maim, destroy and mutilate enemy soldiers and to cripple their resources it does not take an extensive analysis to come to the conclusion that political violence can affect the realm of public health immensely.
Political violence, because of what it produces, is, essentially, inextricable with structural violence. Direct violence and war against societies causes massive infrastructural damage, disables the proper allocation of needed resources, the proliferation and spread of infectious and chronic disease and illness, and the destruction of culture.
Because political violence causes such horror the first question ought to be: “What is the cause of such aggression within the human condition?” After all, if public health officials are committed to ending the source of the problem then this question needs to be asked. Cvjetanović (1998) gives the explanation that human aggression is derived from a mechanism of self defense that naturally occurs within every one of us. It is a mental process that takes our minds from a state of normality into a pathogenic state, and while this process depends on the individual’s inherent mentality it is also a matter of social context (Cvjetanović 1998). This mental process, according to Cvjetanović (1998), is a mixture between a natural defense mechanism and a process called “splitting”, or the classification of everyone and everything as either exclusively bad or good. Therefore, in essence, things like nationalism and authoritative coercing can provoke this process. For example: this explains why a disease such as AIDS is, more often than not, considered a disease of immigration (Seeman 1999). Suffering interacts with the mental process of splitting, causing a need to scapegoat or single out a group, turning them into the enemy. Because of the unfamiliarity of immigrants to new populations, they are perfect targets for blame. This process of “splitting”, it has been shown, is heightened with the presence of paranoid individuals within the population (Cvjetanović 1998), Thus xenophobia can move others to aggression towards an arbitrary enemy as well.
Henry (2006) explains that the attempt of war is to disestablish any processes that allow for individuals to see themselves as essentially human. When this occurs, it leaves populations more susceptible to violence due to the destruction of their own culture and self-worth. This allows for structural violence to persist long after violence is over. In Henry’s case study of the effects of violence in war-time Sierra Leone, even some of those who are sent to make peace can cause violence. During the civil war in Sierra Leone entire populations became displaced (Henry 2006). Between 50,000 and 75,000 were killed, and thousands more lost limbs from amputation and hacked off body parts at the hands of terror tactics used by the rebels. Many children were forced into being child soldiers and forced to commit horrifying acts against even their own family for fear of torture and death (Henry 2006). Child soldiers are also a concern of public health because of the psychological trauma they experience. In a study by Castelo-Bronco (1997), former child soldiers suffer from a loss of self confidence, regression, depression, introversion, poor memory capacity, flashbacks, gastric pains, an inability to accept social norms, phobias, and other symptoms of Post Traumatic Stress Disorder similar to adults who are involved in brutal militarism and war. Castelo-Bronco (1997) also explains that because these children were torn from their families at an early age, they were unable to go through a period of proper development in which they needed the love of their family, and as a result they were unable to accumulate a sense of self-esteem and needed adaptive behaviors. Women also face an immense amount of injustice as a result of political violence. The death toll of war is, more often than not, gender selective (Henry 2005) considering the fact that it is mostly men who do the fighting, and therefore it is more men that are killed in battle. Women in Sierra Leone are at a considerable disadvantage and become much more vulnerable during wartime because of the great amount of illiteracy, low education rates, and a lesser ability to accumulate financial income compared to men (Henry 2005). Henry tells of how this left many women to be subjected to massive amounts of sexual violence such as forced marriages, rape, torture and sexual slavery. Henry (2005) quotes one woman as saying: “Before the war, you had a husband, or a close man, and the two of you could work towards a bright future… But now, during this war, they’ve killed a lot of men. So a woman may be left with 2, 3, 4 children, but the rebels have killed your husband… So in all this, if she meets a man who wants to help her, will she sleep with him? Of course!” As seen from the earlier case study by Lane et. al (2004), a disproportionate sex ratio can make women lose their ability to bargain in their relationships. Women often times, in order not to lose their male companions, will agree to perform more risky behaviors that lead to higher rates of infectious disease. Because of women’s inability to reap income as well as men, many of them are forced into becoming sex workers, thus creating a “bridge” of infectious viral activity between peacekeeping troops and local young diamond miners. The disadvantage of women in this situation is also due in part to post-war relief programs that do not acknowledge needs or capabilities of women (Henry 2005). For example: Henry (2005) tells of how an uproar in 2002 erupted in the media because it was reported that male international relief workers were demanding sex from women in exchange for goods and food entitlements. Henry claims that “scarce supplies, vulnerability to exploitation, lack of economic opportunities, and lack of awareness or ability to access rights and recourse to protection could combine to necessitate that sex work remain a continued means of survival.” It is clear to see, due to the evidence, that the use of political violence has many more repercussions than simply the death of enemy soldiers. In no way does political violence harm societies than that of causing poverty. Because infrastructures are virtually shattered by political violence, poverty becomes an ever increasing health problem due to immense financial strain. Political violence is a catalyst for structural violence, which often lingers for decades or even centuries and can even lead to more political violence and aggression. In fact, debt and poverty has shown to be correlated with conflict and violence (Leatherman, Thomas 2009). Leatherman and Thomas (2009) state that the psychological trauma endured by soldiers is the most prevalent disorder in rural populations; this can lead to domestic violence and alcoholism, as well as “extremely aggressive” behavior from minors who had been forced into joining military movements. Leatherman and Thomas (2009) also explain that because of military spending there is misallocation of resources, allocating a lesser amount of needed funds to health care and education and more funds to military expenditure. Beside the obvious fact that health care receives less funding during wartime, this becomes a public health concern because, in order to escape the cycle of poverty, good health is an immensely important factor (Farmer 2004). Farmer (2005) tells of how many of the victims of political violence in Haiti had no choice but to live in poverty because their lives were curbed due to a post-war military structure. Farmer (2005) recalls one story of a girl named Acéphie, who died of AIDS after contracting it from a military officer. As observed by Henry (2005), women in post-war societies often have little choice but to resort to sexual activity in order to survive. The political coup that overthrew Haiti’s first democratically elected party led to the impoverishment of Acéphie’s village, which left her only with the option of sleeping with a military officer that gave her financial favor, thus resulting in her contraction of HIV.
By observing this body of evidence one can see how the mental process of aggression explained by Cvjetanović (1998) plays out in impoverished and abused populations. By recalling the mental process of aggression it can be seen that it is incurred by paranoia, nationalism, ethnocentrism, and the chaos that results from a destruction of infrastructure (Cvjetanović 1998) which are all results of political violence and the poverty incurred by enemy soldiers in some form or fashion. This, in turn, will cause “Splitting” because of the need to blame someone or something for the suffering of one’s culture, which will result in viewing those enemies who were involved in war as inherently evil. Thus this view is passed from generation to generation because it has become a part of cultural identity. Thus, we can conclude from Cvjetanović’s (1998) epidemiological perspective of violence, that violence only begets more violence. Because access and proliferation of health programs decreases during times of political violence, as observed earlier by Leatherman (2009), it is a concern of public health, but political violence should also be a public health concern because if it is not solved then poor health and well-being will perpetuate; thus, violence becomes a viscous cycle that pushes out proper health care practice.
Our Appropriate Response
Considering this body of evidence, if political violence is not already a concern of public health officials then it certainly ought to be. If public health programs do not focus on the proliferation of militarism, then there will be a continuous flow of structural violence that will never be solved. As one of Leatherman and Thomas’ (2009) observations made clear earlier, the goal of public health is to seek a holistic form of health that includes psychological, physical, and social well-being, therefore a goal of ending the proliferation of militarism should be of great importance. In fact, a proper stance of public health ought to be a campaign against and condemnation of any shape or form of rationalization of war or political violence. Henry (2005) explains that to rationalize and make sense of war actually comes dangerously close to making war into something that is reasonable: “Maybe this search for reason has allowed us to ‘explain war away’: concretizing in theory, set in fact, distanced to a comfortable vantage point.” Anthropologists and public health officials, when addressing the health disparities that war produces, then, ought to make it a priority to avoid the disappearance of the reality of war into the sea of academia by fighting against its rationality and sensibility in every possible way. Structural violence has a rich amount of literature surrounding its effects from Critical Medical Anthropologists. The trouble with Critical Medical Anthropology is not in its observation method or in how Critical Medical Anthropologists draw conclusions and theorize, it is the applications of these observations, conclusions and theories that is lacking. Most of the works of Critical Medical Anthropologists only reach as far as academia, and doesn’t reach the ears of policymakers (Singer, Castro 2004).
Gathered from the information presented here, there are several lessons we can learn. Number one is that if we are to solve the problem of violence then poverty must be eradicated, and public health policy must stem from a “preferential option for the poor”: the ideology that the poor are not merely just as deserving of healthcare as the affluent, but that the poor are more deserving of healthcare (Farmer 2005). Secondly, that there must be an emphasis on making Medical Anthropology a policy science, reaching the ears of policy makers in the realm of public health (Singer, Castro 2004). Third, there needs to be a change in “liberal” policy and ideology of developmentalism that places the burden of responsibility on those who suffer and denies the historical legitimization of poverty (Farmer 2005). In other words, there needs to be a shift from the emphasis of individual responsibility to an equal emphasis on structural responsibility (Lane et. al 2004). Fourth, public health programs must be modeled from the perspective of those whom it is meant to benefit (Henry 2005), otherwise public health programs will fail. Fifth, there should be an emphasis in policy making that focuses on limiting contributing factors in the mental process of aggression in order to avoid perpetual violence (Cvjetanović 1998).
Conclusion
Anthropology, as a significant science in studying health problems from an indigenous perspective, has a significant duty to affect public health policies. After all, suffering from violence is best understood from the perspective of the impoverished (Farmer 2005). However, because suffering due to violence is always due to the effects of human agency (Farmer 2005), Anthropology needs to contribute not in a legalistic or strictly political fashion but in ideology through an emphasis on cultural relativism and human rights. It is important to remember that Anthropology seeks to understand through the perspective of indigenous societies, and that playing into the strictly legal end of problem solving would not cater to this end because it stems from an outside perspective. The truth is that the flaws of human agency stems from a misallocation of power into only one segment of society. To place the hopes and dreams of equality and cultural relativism in the hands of law alone would be a disservice because doing so would lead policy to the conclusion that all of the problems of violence would be solved through a legal process. But politics and policy are merely a means to the end of equality, human rights and cultural relativism. The world will never run out of problems as long as it is in existence. Therefore the ideology that Critical Medical Anthropology and public health needs is that of a non-violent repudiation of authority, solving one problem and then anticipating the next. Critical Medical Anthropology must remain a practice of documenting “the complex workings of a vast machinery rooted in a political economy that only a romantic would term fragile (Farmer 2004).”
References:
Castelo-Branco, Viriato
1997 Child Soldiers: the Experience of the Mozambican Association for Public Health. Development in Practice. 7(4):494-496
Cvjetanović, B.
2000 Epidemiology of Violence and War. Coll. Anthropology. 24(1):11-25.
Farmer, Paul and Arachu Castro
2004 Pearls of the Antilles? Public Health in Haiti and Cuba. In Unhealthy Health Policy: A Critical Anthropological Examination. Arachu Castro and Merrill Singer, eds. Walnut Creek: Altamira Press, pp.3-28.
Farmer, Paul
2004 An Anthropology of Structural Violence. Current Anthropology. 45(3):305-325.
Farmer, Paul
2005 Introduction. In Pathologies of Power: Health, Human Rights, and the New War on the Poor. University of California Press.
Farmer, Paul
2005 Chapter 1 - On Suffering and Structural Violence. In Pathologies of Power: Health, Human Rights, and the New War on the Poor. University of California Press
Farmer, Paul
2005 Chapter 5 - Health, Healing, and Social Justice. In Pathologies of Power: Health, Human Rights, and the New War on the Poor. University of California Press.
Harper, Janice
2004 Breathless in Houston: A Political Ecology of Health Approach to Understanding Environmental Health Concerns. Medical Anthropology. 23:295-326
Henry, Doug
2005 The Legacy of the Tank: The Violence of Peace. Anthropological Quarterly. 78(2):443-456
Henry, Doug
2006 Violence and the Body: Somatic Expressions of Trauma and Vulnerability during War. Medical Anthropology Quarterly. 20(3):379-398.
Lane, Sandra, Robert Rubinstein, Robert Keefe, Noah Webster, Donald Cibula, Alan Rosenthal, Jesse Dowdell
2004 Structural Violence and Racial Disparity in HIV Transmission. Journal of Health Care for the Poor and Underserved. 15(3):319-335.
Leatherman, Tom and R. Brooke Thomas
2009 Structural Violence, Political Violence, and the Health Costs of Civil Conflict: A Case Study from Peru. In Anthropology and Public Health: Bridging Differences in Culture and Society Robert A. Inhorn and Marcia Inhorn, eds. Pp. 196-218.
Niang, Cheikh, Placide Tapsoba, Ellen Weiss, Moustapha Diagne, Youssoupha Niang, Amadou Mody Moreau, Dominique Gomis, Abdoulaye Sidbé Wade, Karim Seck, and Chris Castle
2003 ‘It’s Raining Stones’: Stigma, Violence and HIV Vulnerability Among Men Who Have Sex With Men in Dakar, Senegal. Culture, Health & Sexuality. 3(6):499-512.
Seeman, Don
1999 “One People, One Blood”: Public Health, Political Violence, and HIV in an Ethiopian-Israeli Setting. Culture, Medicine and Psychiatry 23:159-195.
Singer, Merrill and Arachu Castro
2004 Introduction: Anthropology and Health Policy: A Critical Perspective. In Unhealthy Health Policy: A Critical Anthropological Examination. Arachu Castro and Merrill Singer, eds. Walnut Creek: Altamira Press, pp. xi-xx
Implications of Structural Violence
Structural violence is different from political violence in that it has no specific aim such as in war or direct oppression and discrimination. Rather, structural violence is a result of the effects of systems that allow for limitation of human ability to reach the potential of a holistic wellness. It is a process that makes cultural norms into caustic patterns of dehumanization. Unfortunately the trend in public health discourse has been to address individual risk factors alone, without attributing any blame to political institutions (Lane et. al 2004). The problem with this is that this way of thinking completely ignores institutional injustice, disadvantage, and discrimination which are where structural violence originates. This process can also be called “biomedical individualism” (Lane et. al 2004). An example of this can be taken from a case study conducted by Janice Harper (2004) on structural violence in Houston, Texas. The Houston ship channel, it is estimated, is the origin of seventy five percent of all of the toxins in the air in the entirety of the United States of America alone. Historically, Houston has been considered the energy capital of the United States, and the construction of its highways can be attributed, for the most part, to the oil boom of the 1970s. Public officials, believing that most people would have cars, didn’t put any effort forth in constructing a public transportation infrastructure, and because of the city’s layout, composed of several economic centers (originally for the use of decreasing traffic back ups), it is virtually impossible to travel effectively without a vehicle. Because of the energy industries in Houston, many environmental concerns were thought of as farfetched and that they opposed prosperity and capitalistic ideals, and so they were easily suppressed by the status quo even to the point of companies not allowing air standards to be published in the Houston Chronicle until the mid eighties. When the Texas Clean Air Act was passed in the 1960s, the environmental boards created in the city of Houston were composed of industry owners. Thus, the concern of air quality was made a private, not a public matter. One Hispanic woman, under the pseudonym of Isabella Gallegos, describes how her daughter suffers from agitated asthma due to the chemical factories that surround their neighborhood in southeast Houston: “To people in this area, it’s normal. It’s normal that they’re always throwing up from the smells, it’s normal that they have asthma, it’s normal that they have bronchitis, it’s normal that they have a rash. It’s normal.” When Isabella asks what she should do to help her daughter public health workers tell her that she should keep her house clear of dust and cockroaches in order to avoid higher risks for her daughter’s asthma, but, contrary to their claims, Harper (2004) describes Isabella’s house as “immaculate”. Analyzing this one particular case shows that the problem does not lie within the responsibility of the individual; it is the system of public power that has become caustic to the individual, and therefore it is an example of structural violence. This can be summed up in Isabella’s own words: “I’m so tired of filling my kids with chemicals to protect them from chemicals.” It is not the cockroaches and dust that are suffocating her daughter; it is the fault of the chemical factories, the plethora of diesel trucks, the concrete crushing facilities, and the blind application of public health policies that insist that it has nothing to do with these factors but has everything to do with Isabella. One of the most important things to consider from this example is that when studying a suffering population one must consider the history of the area. Structural violence is dependent on history and biology just as much as it is dependent upon politics and economics (Farmer 2004). Also, the erasure and replacement of history is the foremost tool used by those who perpetuate structural violence (Farmer 2004). If Houston’s history of an over-emphasis on pollution as a private matter as well as its construction of transportation and layout of the city were ignored in Harper’s case study then they would have failed to see how suffering and misery became legitimate as time moved forward. If this ignorance were allowed then the criticism of Houston’s public health practice could not be nearly as heavy handed as it is.
Because of its nature, structural violence can not only sharpen and increase the amount of chronic disease due to environmental factors; it can also lead to the proliferation and spread of infectious disease. In a case study on HIV transmission among homosexual men in Syracuse New York, spread of infection was found to be correlated with racial discrimination in incarceration, stigma, the inability to gain access to proper health care due to costly insurance, and disproportionate death rates among ethnic groups (Lane et. al 2004). In the case of disproportionate incarceration, 16% of the population is composed of African Americans, yet they endure 43% of arrests and 51% of the population in state prisons are African Americans. It has been shown that individuals, who are isolated, as in the case of prison, are more likely to choose partners from within their niche and are therefore more likely to spread infection among their social group (Lane et. al 2004). Social stigma and homophobia stemming from cultural and religious institutions is also a contributing factor in the spread of HIV. Men who practice homosexual behavior will also carry on heterosexual relationships in order to keep themselves on the “DL” (down low), thus giving females risk of infection as well, and because homosexual men are inclined to be secretive due to social stigma they will often not identify themselves as being gay. In many cases homosexual men will keep their relationships a secret because revealing their intentions would lead to ostracism and sometimes physical or verbal abuse by their society (Niang et. al 2003). This in turn leaves them at a disadvantage because the public health messages of safe sex and sexual health education will often not reach these men. To add to the disdain, the public health clinic in Syracuse did not have hours that were suitable for many working homosexual men. A similar example lies in the continent of Africa: Islamic societies in Africa will ostracize and condemn homosexuals, disallowing them from participating in religious and cultural activities (Niang et. al 2003). Niang quotes one religious leader: “Since the Muslim religion forbids homosexuality, we cannot accept homosexuals either in our homes or in our mosques.” African homosexuals will go so far as to not even reveal infection to doctors in certain areas of their body. They are willing to be examined in the genital region because infection in said region can be associated with heterosexual relationships. However, an infection revealed in the anal region would allow for inquiry into homosexual behavior (Niang et. al 2003). Lack of health education among homosexual men about sexually transmitted infections in Africa was shown when asked what they believed the cause of their symptoms were: “Most respondents mentioned such non-viral or bacterial causes as poor hygiene, irritation from intercourse without sufficient lubrication, spicy foods, long periods of abstinence, masturbation, too much sex, or other illnesses.” The former example yields more insight: because of the high death and disproportionate incarceration rate of African American men in Syracuse New York, there is a trend of low male to female sex ratio. This leaves women at a disadvantage because it decreases their ability to maintain monogamous relationships as well as decreases their bargaining power (Lane et al. 2004). Women will often find themselves having to perform more risky behavior in order to maintain relationships, behavior that they wouldn’t normally practice if there were more men within the population. Also, the advertisement and proliferation of douching products allows for further risk of infection because douching products have shown an increase in risk, not the opposite (Lane et. al 2004). It can be concluded from this evidence that, firstly, structural violence can stem from cultural causes such as false advertisement and stigma as well as governmental, and, secondly, that it affects not only the population it specifically oppresses.
Structural violence mostly affects populations that live in either relative or abject poverty more than anyone else. The most un-nerving recurrence in these case studies is not that they happen to all populations, but that it is a trend among lower class, poor, and non-white populations (Harper 2004). In light of this there seems to be no wonder why there is little access to health care for such individuals in an economy that has turned healthcare into a commodity. Paul Farmer (2005) explains that the systematic abuse of human rights can only be fully understood from the perspective of the poor and the marginalized. Thus, anthropology on the subject of structural violence from the perspective of the poor is immensely important in understanding the underlying causes of suffering. Lessons from this research must be incorporated in public health practice if proper indigenization of health programs is to be implemented. If the historical background and political and cultural context of suffering populations is ignored then public health programs will fail because of the continuation of unjust systems architecturally engineered for the oppression of populations. Farmer (2005) makes it clear that “civil rights cannot be defended if social and economic rights are not.”
Implications of Political Violence
In the field of public health, health is viewed as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (Leatherman, Thomas 2009).” Because the primary objective in an endeavor such as war is to literally maim, destroy and mutilate enemy soldiers and to cripple their resources it does not take an extensive analysis to come to the conclusion that political violence can affect the realm of public health immensely.
Political violence, because of what it produces, is, essentially, inextricable with structural violence. Direct violence and war against societies causes massive infrastructural damage, disables the proper allocation of needed resources, the proliferation and spread of infectious and chronic disease and illness, and the destruction of culture.
Because political violence causes such horror the first question ought to be: “What is the cause of such aggression within the human condition?” After all, if public health officials are committed to ending the source of the problem then this question needs to be asked. Cvjetanović (1998) gives the explanation that human aggression is derived from a mechanism of self defense that naturally occurs within every one of us. It is a mental process that takes our minds from a state of normality into a pathogenic state, and while this process depends on the individual’s inherent mentality it is also a matter of social context (Cvjetanović 1998). This mental process, according to Cvjetanović (1998), is a mixture between a natural defense mechanism and a process called “splitting”, or the classification of everyone and everything as either exclusively bad or good. Therefore, in essence, things like nationalism and authoritative coercing can provoke this process. For example: this explains why a disease such as AIDS is, more often than not, considered a disease of immigration (Seeman 1999). Suffering interacts with the mental process of splitting, causing a need to scapegoat or single out a group, turning them into the enemy. Because of the unfamiliarity of immigrants to new populations, they are perfect targets for blame. This process of “splitting”, it has been shown, is heightened with the presence of paranoid individuals within the population (Cvjetanović 1998), Thus xenophobia can move others to aggression towards an arbitrary enemy as well.
Henry (2006) explains that the attempt of war is to disestablish any processes that allow for individuals to see themselves as essentially human. When this occurs, it leaves populations more susceptible to violence due to the destruction of their own culture and self-worth. This allows for structural violence to persist long after violence is over. In Henry’s case study of the effects of violence in war-time Sierra Leone, even some of those who are sent to make peace can cause violence. During the civil war in Sierra Leone entire populations became displaced (Henry 2006). Between 50,000 and 75,000 were killed, and thousands more lost limbs from amputation and hacked off body parts at the hands of terror tactics used by the rebels. Many children were forced into being child soldiers and forced to commit horrifying acts against even their own family for fear of torture and death (Henry 2006). Child soldiers are also a concern of public health because of the psychological trauma they experience. In a study by Castelo-Bronco (1997), former child soldiers suffer from a loss of self confidence, regression, depression, introversion, poor memory capacity, flashbacks, gastric pains, an inability to accept social norms, phobias, and other symptoms of Post Traumatic Stress Disorder similar to adults who are involved in brutal militarism and war. Castelo-Bronco (1997) also explains that because these children were torn from their families at an early age, they were unable to go through a period of proper development in which they needed the love of their family, and as a result they were unable to accumulate a sense of self-esteem and needed adaptive behaviors. Women also face an immense amount of injustice as a result of political violence. The death toll of war is, more often than not, gender selective (Henry 2005) considering the fact that it is mostly men who do the fighting, and therefore it is more men that are killed in battle. Women in Sierra Leone are at a considerable disadvantage and become much more vulnerable during wartime because of the great amount of illiteracy, low education rates, and a lesser ability to accumulate financial income compared to men (Henry 2005). Henry tells of how this left many women to be subjected to massive amounts of sexual violence such as forced marriages, rape, torture and sexual slavery. Henry (2005) quotes one woman as saying: “Before the war, you had a husband, or a close man, and the two of you could work towards a bright future… But now, during this war, they’ve killed a lot of men. So a woman may be left with 2, 3, 4 children, but the rebels have killed your husband… So in all this, if she meets a man who wants to help her, will she sleep with him? Of course!” As seen from the earlier case study by Lane et. al (2004), a disproportionate sex ratio can make women lose their ability to bargain in their relationships. Women often times, in order not to lose their male companions, will agree to perform more risky behaviors that lead to higher rates of infectious disease. Because of women’s inability to reap income as well as men, many of them are forced into becoming sex workers, thus creating a “bridge” of infectious viral activity between peacekeeping troops and local young diamond miners. The disadvantage of women in this situation is also due in part to post-war relief programs that do not acknowledge needs or capabilities of women (Henry 2005). For example: Henry (2005) tells of how an uproar in 2002 erupted in the media because it was reported that male international relief workers were demanding sex from women in exchange for goods and food entitlements. Henry claims that “scarce supplies, vulnerability to exploitation, lack of economic opportunities, and lack of awareness or ability to access rights and recourse to protection could combine to necessitate that sex work remain a continued means of survival.” It is clear to see, due to the evidence, that the use of political violence has many more repercussions than simply the death of enemy soldiers. In no way does political violence harm societies than that of causing poverty. Because infrastructures are virtually shattered by political violence, poverty becomes an ever increasing health problem due to immense financial strain. Political violence is a catalyst for structural violence, which often lingers for decades or even centuries and can even lead to more political violence and aggression. In fact, debt and poverty has shown to be correlated with conflict and violence (Leatherman, Thomas 2009). Leatherman and Thomas (2009) state that the psychological trauma endured by soldiers is the most prevalent disorder in rural populations; this can lead to domestic violence and alcoholism, as well as “extremely aggressive” behavior from minors who had been forced into joining military movements. Leatherman and Thomas (2009) also explain that because of military spending there is misallocation of resources, allocating a lesser amount of needed funds to health care and education and more funds to military expenditure. Beside the obvious fact that health care receives less funding during wartime, this becomes a public health concern because, in order to escape the cycle of poverty, good health is an immensely important factor (Farmer 2004). Farmer (2005) tells of how many of the victims of political violence in Haiti had no choice but to live in poverty because their lives were curbed due to a post-war military structure. Farmer (2005) recalls one story of a girl named Acéphie, who died of AIDS after contracting it from a military officer. As observed by Henry (2005), women in post-war societies often have little choice but to resort to sexual activity in order to survive. The political coup that overthrew Haiti’s first democratically elected party led to the impoverishment of Acéphie’s village, which left her only with the option of sleeping with a military officer that gave her financial favor, thus resulting in her contraction of HIV.
By observing this body of evidence one can see how the mental process of aggression explained by Cvjetanović (1998) plays out in impoverished and abused populations. By recalling the mental process of aggression it can be seen that it is incurred by paranoia, nationalism, ethnocentrism, and the chaos that results from a destruction of infrastructure (Cvjetanović 1998) which are all results of political violence and the poverty incurred by enemy soldiers in some form or fashion. This, in turn, will cause “Splitting” because of the need to blame someone or something for the suffering of one’s culture, which will result in viewing those enemies who were involved in war as inherently evil. Thus this view is passed from generation to generation because it has become a part of cultural identity. Thus, we can conclude from Cvjetanović’s (1998) epidemiological perspective of violence, that violence only begets more violence. Because access and proliferation of health programs decreases during times of political violence, as observed earlier by Leatherman (2009), it is a concern of public health, but political violence should also be a public health concern because if it is not solved then poor health and well-being will perpetuate; thus, violence becomes a viscous cycle that pushes out proper health care practice.
Our Appropriate Response
Considering this body of evidence, if political violence is not already a concern of public health officials then it certainly ought to be. If public health programs do not focus on the proliferation of militarism, then there will be a continuous flow of structural violence that will never be solved. As one of Leatherman and Thomas’ (2009) observations made clear earlier, the goal of public health is to seek a holistic form of health that includes psychological, physical, and social well-being, therefore a goal of ending the proliferation of militarism should be of great importance. In fact, a proper stance of public health ought to be a campaign against and condemnation of any shape or form of rationalization of war or political violence. Henry (2005) explains that to rationalize and make sense of war actually comes dangerously close to making war into something that is reasonable: “Maybe this search for reason has allowed us to ‘explain war away’: concretizing in theory, set in fact, distanced to a comfortable vantage point.” Anthropologists and public health officials, when addressing the health disparities that war produces, then, ought to make it a priority to avoid the disappearance of the reality of war into the sea of academia by fighting against its rationality and sensibility in every possible way. Structural violence has a rich amount of literature surrounding its effects from Critical Medical Anthropologists. The trouble with Critical Medical Anthropology is not in its observation method or in how Critical Medical Anthropologists draw conclusions and theorize, it is the applications of these observations, conclusions and theories that is lacking. Most of the works of Critical Medical Anthropologists only reach as far as academia, and doesn’t reach the ears of policymakers (Singer, Castro 2004).
Gathered from the information presented here, there are several lessons we can learn. Number one is that if we are to solve the problem of violence then poverty must be eradicated, and public health policy must stem from a “preferential option for the poor”: the ideology that the poor are not merely just as deserving of healthcare as the affluent, but that the poor are more deserving of healthcare (Farmer 2005). Secondly, that there must be an emphasis on making Medical Anthropology a policy science, reaching the ears of policy makers in the realm of public health (Singer, Castro 2004). Third, there needs to be a change in “liberal” policy and ideology of developmentalism that places the burden of responsibility on those who suffer and denies the historical legitimization of poverty (Farmer 2005). In other words, there needs to be a shift from the emphasis of individual responsibility to an equal emphasis on structural responsibility (Lane et. al 2004). Fourth, public health programs must be modeled from the perspective of those whom it is meant to benefit (Henry 2005), otherwise public health programs will fail. Fifth, there should be an emphasis in policy making that focuses on limiting contributing factors in the mental process of aggression in order to avoid perpetual violence (Cvjetanović 1998).
Conclusion
Anthropology, as a significant science in studying health problems from an indigenous perspective, has a significant duty to affect public health policies. After all, suffering from violence is best understood from the perspective of the impoverished (Farmer 2005). However, because suffering due to violence is always due to the effects of human agency (Farmer 2005), Anthropology needs to contribute not in a legalistic or strictly political fashion but in ideology through an emphasis on cultural relativism and human rights. It is important to remember that Anthropology seeks to understand through the perspective of indigenous societies, and that playing into the strictly legal end of problem solving would not cater to this end because it stems from an outside perspective. The truth is that the flaws of human agency stems from a misallocation of power into only one segment of society. To place the hopes and dreams of equality and cultural relativism in the hands of law alone would be a disservice because doing so would lead policy to the conclusion that all of the problems of violence would be solved through a legal process. But politics and policy are merely a means to the end of equality, human rights and cultural relativism. The world will never run out of problems as long as it is in existence. Therefore the ideology that Critical Medical Anthropology and public health needs is that of a non-violent repudiation of authority, solving one problem and then anticipating the next. Critical Medical Anthropology must remain a practice of documenting “the complex workings of a vast machinery rooted in a political economy that only a romantic would term fragile (Farmer 2004).”
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