Prompt 1

On Suffering and Structural Violence: A View from Below Paul Farmer

Race/Ethnicity: Multidisciplinary Global Contexts, Volume 3, Number 1, Autumn 2009, pp. 11-28 (Article)

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On Suffering and Structural Violence: A View from Below Paul Farmer

veryone knows that suffering exists. The question is how to define it. Given that each person’s pain has a degreeof reality forhimorher that thepainof others

cansurelyneverapproach, iswidespreadagreementonthesub- ject possible? Almost all of us would agree that premature and painful illness, torture, and rape constitute extreme suffering. Mostwouldalsoagree that insidiousassaultsondignity, suchas institutionalized racismandsexism, also causegreat andunjust injury. Givenourconsensusonsomeof themoreconspicuous forms

of suffering, a number of corollary questions come to the fore. Can we identify those most at risk of great suffering? Among those whose suffering is not mortal, is it possible to identify those most likely to sustain permanent and disabling damage? Arecertain“event”assaults, suchas tortureor rape,more likely to lead to late sequelae than are sustained and insidious suffer- ing, such as the pain born of deep poverty or of racism? Under this latter rubric, arecertain formsofdiscriminationdemonstra- blymorenoxious thanothers? Anthropologistswho take these as researchquestions study

both individualexperienceandthe larger socialmatrix inwhich it is embedded in order to see how various large-scale social forces come to be translated into personal distress and disease. By what mechanisms do social forces ranging from poverty to racismbecome embodiedas individualexperience?Thishasbeen the focus of most of my own research in Haiti, where political andeconomic forceshavestructuredrisk forAIDS, tuberculosis, and, indeed,mostother infectiousandparasiticdiseases. Social forces atwork therehavealso structured risk formost formsof extremesuffering, fromhunger to tortureandrape.

©2009TheOhioStateUniversity/Office ofMinorityAffairs/TheKirwan Institute

E

From Daedalus, 125:1 (Winter, 1996), pp. 251-283. @1996 by the Ameri- can Academy of Arts and Sciences. Reprinted with the permission of thepublisher,MITPress Journals.

Working in contemporaryHaiti,where in recent yearspolit- ical violence has been added to the worst poverty in the hemi- sphere,one learnsagreatdealabout suffering. In fact, thecoun- tryhas longconstituteda sort of living laboratory for the study of affliction, no matter how it is defined. “Life for the Haitian peasant of today,” observed anthropologist Jean Weise some twenty-five years ago, “is abject misery and a rank familiarity with death.”1 The situation has since worsened. When in 1991 international health and population experts devised a “human suffering index” by examining measures of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by “extreme human suffering.” Only one of them, Haiti, was located in the Western hemi- sphere. In only three countries in the world was suffering judged to be more extreme than that endured in Haiti; each of these three countries is currently in themidst of an internation- ally recognizedcivilwar. Suffering is certainly a recurrent and expected condition in

Haiti’s Central Plateau, where everyday life has felt like war. “You get up in the morning,” observed one young widow with four children, “and it’s thefight for foodandwoodandwater.” If initially struck by the austere beauty of the region’s steep mountainsandclementweather, long-termvisitors come to see theCentralPlateau inmuch thesamemanneras its inhabitants: a chalky and arid land hostile to the best efforts of the peasant farmerswho livehere.Landlessness iswidespreadandso, con- sequently, ishunger.All the standardmeasures revealhowten- uous the peasantry’s hold on survival is. Life expectancy at birth is less than fifty years, in large part because as many as twoof every ten infantsdie before theirfirst birthday.Tubercu- losis is the leading cause of death among adults; among chil- dren,diarrhealdisease,measles, and tetanus ravage theunder- nourished. But the experience of suffering, it is often noted, is not effec-

tively conveyedbystatisticsorgraphs.The“texture”ofdireaf- fliction isperhapsbest felt in thegrittydetailsofbiography,and so I introduce the stories of Acéphie Joseph and Chouchou Louis.2 The stories of Acéphie and Chouchou are anything but “anecdotal.”For theepidemiologist aswell as thepolitical ana- lyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet simi- lar fates. What these victims, past and present, share are not personalorpsychological attributes—theydonot shareculture, language, or race. Rather, what they share is the experience of occupying the bottom rung of the social ladder in inegalitarian societies.3

Acéphie Joseph’s and Chouchou Louis’s stories illustrate someof themechanisms throughwhich large-scale social forces crystallize into the sharp, hard surfaces of individual suffering. Suchsuffering is structuredbyhistoricallygiven (andofteneco- nomically driven) processes and forces that conspire—whether through routine, ritual, or, as is more commonly the case, these

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hard surfaces—to constrain agency.4 For many, including most of my patients and informants, life choices are structured by racism, sexism,political violence, andgrindingpoverty.

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 fifteen hundred 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 takeseveralhours to reachKay.The journeygives one an impression of isolation, insularity. The impression is misleading, as the village owes its existence to a project con- ceived in the Haitian capital and drafted in Washington, D.C.: Kay isa settlementof refugees, substantially composedofpeas- ant farmers displaced more than thirty years ago by Haiti’s largestdam. Before1956, thevillageofKaywassituated ina fertilevalley,

andthrough it ran theRiviereArtibonite.Forgenerations, thou- sands of families had farmed the broad and gently sloping banksof the river, selling rice, bananas,millet, corn, andsugar- cane in regional markets. Harvests were, by all reports, bounti- ful; life there is now recalled as idyllic. When the valley was flooded with the building of the dam, 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, and bitterly note that it brought them neither electricity norwater. In1983,when Ibeganworking in theCentralPlateau,AIDS,

although already afflicting an increasing number of city dwell- ers,wasunknowninmostareasas rural asKay.Acéphie Joseph was one of the first villagers to die of the new syndrome. But her illness,whichendedin1991,wasmerely the latest inastring of tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the re- gion’s sick. The litany begins, usually, down in the valley hidden under

the still surface of the lake. Acéphie’s parents came from fami- liesmakingadecent livingbyfarmingfertile tractsof land—their “ancestors’gardens”—andsellingmuchof theirproduce.M. Jos- eph tilled the soil, andhiswife, a tall andwearilyelegantwom- an not nearly as old as she looked, was a “Madame Sarah,” a

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market woman. “If it weren’t for the dam,” M. Joseph assured me, “we’d be just fine now. Acéphie, too.” The Josephs’ home was drowned along with most of their belongings, their crops, and thegravesof their ancestors. Refugees fromthe risingwater, the Josephsbuilt amiserable

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 them what in- duced them to move up to Kay, to build a house on the hard stone embankment of a dusty road. “Our hut was too near the water,” replied M. Joseph. “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. Therewasnoone tokeepaneyeon them.” Acéphie attended primary school—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 and her vulnera- bilitymayhave sealedher fate as early as 1984. Thoughstill in primary school, she was already nineteen years old; it was time for her to help generate income for her family, which was sinkingdeeperanddeeper intopoverty.Acéphiebegan tohelp 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 Peligre, the site of the dam and, until recently, a military bar- racks.The soldiers liked towatch theparadeofwomenonFri- day mornings. Sometimes they taxed them with haphazardly imposed fines; sometimes they taxed them with flirtatious banter. Such flirtation is seldom unwelcome, at least to all appear-

ances. In rural Haiti, entrenched poverty made the soldiers— the region’s only salaried men—ever so much more attractive. Hunger was again a near-daily occurrence for the Joseph fam- ily; the timeswereasbadas those right after thefloodingof the valley. And so when Acéphie‘s good looks caught the eye of Captain Jacques Honorat, a native of Belladere formerly sta- tioned inPort-au-Prince, she returnedhisgaze. Acéphieknew,asdideveryone in thearea, thatHonorathad

a wife and children. He was known, in fact, to have more than one regular partner. But Acéphie was taken in by his persis- tence, andwhenhewent to speak toherparents, a long-termli- aisonwas, fromtheoutset, seriously considered:

What would you have me do? I could tell that the old people wereuncomfortable,worried;but theydidn’t sayno.Theydidn’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 ill- ness, never! I looked around and saw how poor we all were, how the old people were finished ... What would you have me do? Itwasawayout, that’showI sawit.

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AcéphieandHonoratwere sexualpartnersonlybriefly—for less thanamonth,accordingtoAcéphie.Shortly thereafter,Hon- orat fell illwithunexplained fevers andkept to the companyof his wife in Peligre. As Acéphie was looking for a moun prensi- pal—a“mainman”—she tried to forgetabout thesoldier. Still, it was shocking to hear, a few months after they parted, that he wasdead. 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 “cooking school.” The school —really just an ambitious woman’s courtyard—prepared poor girls likeAcéphie for their inevitable turnas servants in thecity. Indeed, domestic service was one of the rare growth industries inHaiti, andasmuchasAcéphie’sproudmotherhated to think of her daughter reduced to servitude, she could offer no viable alternative. And so Acéphie, at age twenty-two, went off to Port-au-

Prince, where she found a job as a housekeeper for a middle- class Haitian woman working for the U.S. embassy. Acéphie’s looksandmannerskeptheroutof thebackyard, the traditional milieu of Haitian servants: she was designated as the maid who, in addition to cleaning, answered the door and the tel- ephone. Although Acéphie was not paid well—she received $30 each month—she tried to save a bit of money for her par- ents and siblings, recalling the hunger gnawing at her home village. Still looking foramounprensipal,AcéphiebeganseeingBlan-

coNerette, ayoungmanwithorigins identical toherown:Blan- co’sparentswerealso“water refugees”andAcéphiehadknown himwhentheywerebothattending theparochial school inKay. Blanco had done well for himself, by Kay standards: he chauf- feureda small busbetween theCentral Plateauand the capital. In a setting characterized by an unemployment rate of greater than 60 percent, his job commanded considerable respect. He easily won the attention of Acéphie. They planned to marry, andstartedpooling their resources. Acéphie had worked as a maid for over three years when

shediscovered that shewaspregnant.Whenshe toldBlanco,he becameskittish.Norwasheremployerpleased: it is considered unsightly to have a pregnant servant. So Acéphie returned to Kay, where she had a difficult pregnancy. Blanco came to see heronceor twice; theyhadadisagreement, and then sheheard nothing fromhim.Following thebirthofherdaughter,Acéphie was sapped by repeated infections. She was shortly thereafter diagnosedwithAIDS. Soon Acéphie’s life was consumed with managing drench-

ing night sweats and debilitating diarrhea, while attempting to care for her first child. “We both need diapers now,” she re- marked bitterly towards the end of her life, faced each day not only with diarrhea, but also with a persistent lassitude. As she became more and more gaunt, some villagers suggested that

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Acéphie was the victim of sorcery. Others recalled her liaison with the soldier and her work as a servant in the city, both lo- cally considered risk factors for AIDS. Acéphie herself knew that shehadAIDS,althoughshewasmoreapt to refer toherself as suffering from a disorder brought on by her work as a ser- vant: “All that ironing, and thenopeninga refrigerator.” But this isnot simply the storyofAcéphieandherdaughter.

There is JacquesHonorat’sfirstwife,whoeachyeargrows thin- ner.AfterHonorat’sdeath, she foundherselfdesperate,withno means of feeding her five hungry children, two of whom were also ill. Her subsequent union was again with a soldier. Hono- rat had at least two other partners, both of them poor peasant women, in theCentralPlateau.One isHIVpositiveandhas two sickly children. Blanco is still a handsome young man, appar- ently in good health and plying the roads from Mirebalais to Portau-Prince. Who knows if he carries the virus? As an attrac- tivemanwithapaying job,hehasplentyofgirlfriends. Nor is this simply the story of those infected with the virus.

ThepainofMme. JosephandAcéphie‘s twinbrotherwasman- ifestly intense, but few understood the anguish of her father. ShortlyafterAcéphie‘sdeath,M. Josephhangedhimself.

Chouchou‘sStory “History shudders, pierced by events of massive public suffering. Memory is haunted, stalked by the ghosts of history’s victims, capriciously severed from life in genocides, holocausts, and exter- mination camps. The cries of the hungry, the shrieks of political prisoners, and the silent voices of the oppressed echo slowly, painfully through daily existence.”

—Rebecca Chopp,ThePraxisof Suffering

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 obliged to drop out when his mother died. Then in his early teens, Chouchou joined his father and an older sister in tending their hillside gardens. In short, there was nothing re- markable about Chouchou’s childhood; it was brief and harsh, likemost in ruralHaiti. Throughout the 1980s, church activities formed Chouchou’s

sole distraction. These were hard years for the Haitian poor, beatendownbya familydictatorshipwell into its thirddecade. The Duvaliers, father and son, ruled through violence, largely directedatpeoplewhoseconditionsofexistenceweresimilar to that of Chouchou Louis. Although many of them tried to flee, oftenbyboat,U.S.policymaintained thatHaitianasylum-seek- ers were “economic refugees.” As part of a 1981 agreement be- tween the administrations of Ronald Reagan and Jean-Claude Duvalier, refugees seized on the high seas were summarily re- turned to Haiti. During the first ten years of the accord, 24,559 Haitians applied forpolitical asylumin theUnitedStates; eight applicationswereapproved.

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AgrowingHaitianpro-democracymovement led, inFebru- ary 1986, to the flight of Duvalier. Chouchou Louis must have been about twenty years old when “Baby Doc” fell, and he shortly thereafter acquired a small radio. “All he did,” recalled hiswifeyears later, “waswork the land, listen to the radio, and go to church.” It was on the radio that Chouchou heard about thepeoplewhotookoverafterDuvalierfled.Likemany inrural Haiti, Chouchou was distressed to hear that power had been handed to themilitary, ledbyhardened duvaliéristes. Itwas this army that the U.S. government, which in 1916 had created the modernHaitianarmy, termed“Haiti’s best bet fordemocracy.” In the eighteen months following Duvalier’s departure, over $200million inU.S. aidpassed through thehandsof the junta. In early 1989, Chouchou moved in with Chantal Brise, 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 presi- dency in the internationally monitored elections of 1990. In Decemberof that year almost 70percentof thevoters choseFa- therAristide fromafieldof tenpresidential candidates. 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. These are the reasons why the military coup d’etat of Septem- ber 1991 stirred great anger in the countryside, where the ma- jority of Haitians live. Anger was soon followed by sadness, then fear, as the country’s repressive machinery, dismantled during the seven months of Aristide’s tenure, was hastily re- assembledunder thepatronageof thearmy. In themonthafter thecoup,Chouchouwassitting ina truck

en route to the town of Hinche. Chouchou offered for the con- sideration 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 conditions 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 Chouchou’s complaints were recognized by his fellow passengers as veiled languagedeploring thecoup.Unfortunately forChouchou,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 at- tachés, to use the epithet then in favor—immediately began beatingChouchou, in frontof theotherpassengers; theycontin- ued to beat him as they brought him to the militarybarracks in Hinche.Ascar onhis right templewasa souvenir of his stay in Hinche,which lasted severaldays. Perhaps the worst after-effect of such episodes of brutality

was that, ingeneral, theymarked thebeginningofpersecution, not theend. In ruralHaiti,during this time, anyscrapewith the

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law (i.e., the military) led to blacklisting. For men like Chou- chou, staying out of jail involved keeping the local attachés happy, andhedid thisbyavoidinghishomevillage.ButChou- chou lived in fear of a second arrest, his wife later told me, and his fearsproved tobewell-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 soldiersandtheattachés.Onearea resident later toldus that the prisoner’s screamsmadeher childrenweepwith terror. OnJanuary25,Chouchouwasdumped inaditch todie.The

army scarcely took the trouble to circulate the canard that he had stolen some bananas. (The Haitian press, by then thor- oughly muzzled, did not even broadcast this false version of events.) 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 recogniz- able. His face, and especially his left temple, was misshapen, swollen, and lacerated; his right temple was also scarred. His mouth was a pool of dark, coagulated blood. His neck was pe- culiarly swollen, his throat collaredwithbruises, the tracesof a gun butt. His chest and sides were badly bruised, and he had several fractured ribs.Hisgenitalshadbeenmutilated. That was his front side; presumably, the brunt of the beat-

ings came from behind. Chouchou’s back and thighs were stripedwithdeep lashmarks.Hisbuttocksweremacerated, the skinflayeddownto theexposedglutealmuscles. Someof these stigmataappeared tobe infected. Chouchou coughed up more than a liter of blood in his ago-

nalmoments.Givenhis respiratorydifficulties and theamount ofbloodhecoughedup, it is likely that thebeatingscausedhim tobleed, slowlyatfirst, thencatastrophically, intohis lungs.His head injuries had not robbed him of his faculties, although it mighthavebeenbetter forhimhad theydone so. It tookChou- chou threedays todie.

ExplainingVersusMakingSenseof Suffering 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?

—Bertholt Brecht

Are these storiesof sufferingemblematicof somethingother than twotragicandprematuredeaths? If so,howrepresentative is each of these experiences? Little about Acéphie’s story is unique; Ihave told it indetail because it brings into reliefmany of the forces constraining not only her options, but those of mostHaitianwomen.Such, inanycase, ismyopinionafter car-

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ing for dozens of poor women with AIDS. There is a deadly monotony in their stories: young women—or teenaged girls— who were driven to Port-au-Prince by the lure of an escape fromtheharshestpoverty;once in thecity, eachworkedasado- mestic; nonemanaged tofindfinancial security.Thewomen in- terviewedwere straightforwardabout thenonvoluntaryaspect of their sexual activity: in their opinions, they had been driven into unfavorable unions by poverty.5 Indeed, such testimony shouldcall intoquestion facilenotionsof “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 overthrewHaiti’s first democratically elected government. Nearlyallof thosekilledwerecivilianswho, likeChouchou, fell into the hands of military or paramilitary forces. The vast ma- jority of victims were poor peasants, like Chouchou, or urban slum dwellers. (The figures cited here are conservative esti- mates; I am quite sure that no journalist or observer ever came to count thebodyofChouchouLouis.)6

Thus, the agony of Acéphie and Chouchou was, in a sense, “modal” suffering. InHaiti,AIDSandpoliticalviolenceare two leading causes of death among young adults. These afflictions werenot the resultofaccidentorof forcemajeure; theywere the consequence,director indirect, ofhumanagency.When theAr- tibonite Valley was flooded, depriving families like the Josephs of their land,ahumandecisionwasbehind it;when theHaitian army was endowed withmoney and unfettered power, human decisions were behind that, too. In fact, some of the same deci- sion-makersmayhavebeen involved inbothcases. If bureaucrats and soldiers seemed to have unconstrained

swayover the livesof the ruralpoor, theagencyofAcéphieand 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 is more, both were “at risk” of such a fate long before they met the soldiers who altered their destinies. They were both, from the outset, victimsof structuralviolence. While certainkindsof sufferingare readilyobservable—and

thesubjectof countlessfilms,novels, andpoems—structuralvi- olence all too often defeats those who would describe it. There areat least three reasonswhythis is so.First, there is the“exoti- cization” of suffering as lurid as that endured by Acéphie and Chouchou. The suffering of individuals whose lives and strug- gles recall ourowntends tomoveus; thesufferingof thosewho aredistanced,whetherbygeography,gender, “race,”orculture, is sometimes less affecting. Second, there is the sheer weight of the suffering, which

makes it all the more difficult to render: “Knowledge of suffer- ing cannot be conveyed in pure facts and figures, reportings that objectify the suffering of countless persons. The horror of

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suffering is not only its immensity but the faces of the anony- mousvictimswhohave littlevoice, let alone rights, inhistory.”7

Third, the dynamics and distribution of suffering are still poorly understood. Physicians, when fortunate, can alleviate the sufferingof the sick.But explaining itsdistribution requires moreminds,more resources.Case studiesof individuals reveal suffering, they telluswhathappens tooneormanypeople; but to explain suffering, one must embed individual biography in the largermatrixof culture, history, andpolitical economy. In short, it is one thing tomake senseof extremesuffering—

auniversal activity, surely—andquiteanother toexplain it.Life experiences such as those of Acéphie and Chouchou—who as Haitians living in poverty shared similar social conditions— mustbeembedded inethnography if their representativeness is to be understood. These local understandings are to be embed- ded, in turn, in the larger-scale historical system of which the fieldworksite is apart.8 Thesocial andeconomic forces thatdic- tate life choices in Haiti’s Central Plateau affect many millions of individuals, and it is in the context of theseglobal forces that the suffering of individuals receives its appropriate context of interpretation. Similar insights are central to liberation theology, which

takes the suffering of the poor as its central problematic. In The Praxis of Suffering, Rebecca Chopp notes that, “In a variety of forms, liberation theologyspeakswith thosewho, throughtheir suffering, call into question the meaning and truth of human history.”9 Unlike most previous theologies, and unlike much modern philosophy, liberation theology has attempted to use social analysis tobothexplainanddeplorehumansuffering. Its key texts bring into relief not merely the suffering of the wretchedof the earth, but also the forces thatpromote that suf- fering.The theologianLeonardoBoff, in commentingononeof these texts, notes 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 theexpenseof thepoor,whoget evenpoorer.’”10

In short, few liberation theologians engage in reflection on suffering without attempting to understand its mechanisms. Theirs isa theology thatunderlinesconnections.RobertMcAfee Brown has these connections and also the poor in mind when, paraphrasing the Uruguayan Jesuit Juan Luis Segundo, he ob- serves that “the world that is satisfying to us is the same world that isutterlydevastating to them.”11

MultiaxialModelsof Suffering “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 re- ally 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,ThePraxisof Suffering

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How might we discern the nature of structural violence and explore its contribution to human suffering? Can we devise an analyticmodel, onewith explanatoryandpredictivepower, for understanding suffering inaglobal context? Somewouldargue that this task, thoughdaunting, is bothurgent and feasible.Our cursoryexaminationofAIDSandpoliticalviolence inHaiti sug- gests that analysis must, first, be geographically broad. As noted, the world as we know it is becoming increasingly inter- connected. Acorollary of this belief is that extreme suffering— especiallywhenonagrandscale, as ingenocide—is seldomdi- vorcedfromtheactionsof thepowerful.12 Theanalysismustalso be historically deep—not merely deep enough to remind us of events and decisions such as those which deprived Acéphie of her land and founded the Haitian military, but deep enough to remember that modern day Haitians are the descendants of a peoplekidnappedfromAfrica inorder toprovideuswithsugar, coffee, andcottonandtoenricha fewinamercantilist economy. Factors including gender, ethnicity (“race”), and socioeco-

nomic status may each be shown to play a role in rendering in- dividuals and groups vulnerable to extreme human suffering. But in most settings these factors have limited explanatory power. Simultaneous consideration of various social “axes” is imperative in efforts to discerna political economyof brutality. Furthermore, such social factors are differentially weighted in different settingsandatdifferent times, asevenbrief considera- tionof their contributions toextremesuffering suggests.

The Axis of Gender

Acéphie Joseph and Chouchou Louis shared, as noted, a similar social status, and each died after contact with the Haitianmilitary.Butgenderhelps toexplainwhyAcéphiedied ofAIDSwhereasChouchoudied fromtorture.Gender inequal- ity also 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 designates them as inferior to men. When, in 1974, a group of feminist anthropologists surveyedthestatusofwomenliving in several disparate settings, they found that, in every society studied, men dominated political, legal, and economic institu- tions tovaryingdegrees; innoculturewas the statusofwomen genuinely coordinate, much less superior, to that of men.13 This power differential has meant that women’s rights may be vio- lated in innumerable ways. Although male victims are clearly preponderant in studies of torture, the much more common crimesofdomesticviolenceandrapearealmost exclusivelyen- dured by females. In the United States, the number of such ag- gressions is staggering.Whensexual assaults byboth intimates andstrangers are considered, “one in fourwomenhasbeen the victim of a completed rape and one in four women has been physically battered, according to the results of recent commu- nity-basedstudies.”14

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Inmost settings, however, gender alonedoesnotdefine risk for such assaults on dignity. It is poor women who bear the brunt of these assaults.15 This is true not only of domestic vio- lence and rape, but alsoofAIDSand itsdistribution, as anthro- pologistMarthaWardpointsout:

Thecollectionof statisticsbyethnicity rather thanbysocio-eco- nomic 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 deter- miningconditionof their lives.16

Similarly, only women can experience maternal mortality, a cause of anguish around the world. More than half a million womendie eachyear in childbirth, butnot allwomenare at in- creased risk of adverse outcomes in pregnancy. In 1985, the World Health Organization estimated that maternal mortality is, on average, approximately 150 times higher in developing countries than in developed nations. In Haiti, where maternal mortality is as high as fourteen hundred deaths per one hun- dred thousand live births—almost five hundred times higher than in thewealthycountries—thesedeathsarealmostall regis- teredamong thepoor.17

The Axis of “Race”or Ethnicity

The ideaof race,which is considered tobeabiologically in- significant term, has enormous social currency. Racial classifi- cations have been used to deprive certain groups of basic rights, and thereforehavean importantplace in considerations of human suffering. In South Africa, for years a living labora- tory for the studyof the long-termeffectsof racism, epidemiol- ogists report that the infant mortality rate among blacks may be as much as ten times higher than among whites. For South African blacks, the proximate cause of increased rates of mor- bidity and mortality is lack of access to resources: “Poverty re- mains the primary cause of the prevalence of many diseases and widespread hunger and malnutrition among black South Africans.”18 And social inequality is seen in the uneven distri- butionofpoverty. Significantmortalitydifferentialsbetweenblacksandwhites

arealso registered in theUnitedStates,whichshareswithSouth Africa thedistinctionofbeing theonly two industrializedcoun- tries failing to recordmortalitydatabysocioeconomicstatus. In theUnitedStates, in1988, life expectancyatbirthwas75.5years forwhitesand69.5years forblacks.Accordingly, therehasbeen a certain amount of discussion about race differentials in mor- tality, but public health expert Vicente Navarro recently com- plained about the “deafening silence” on the topic of class dif- ferentials in mortality in the United States, where “race is used as a substitute for class.” But in 1986, on “one of the few occa- sions that theU.S.governmentcollected informationonmortal-

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ity rates (forheart andcerebrovasculardisease) by class, the re- sults showed that, by whatever indicators of class one might choose (level of education, income, or occupation), mortality ratesare related tosocial class.”19 Indeed, for themajor causesof death (heart disease and cerebrovascular disease), class differ- entials were significantly larger than race differentials. “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- classdifferentials.”20 ThesociologistWilliamJuliusWilsonmade a similar point in his landmark study, The Declining Significance ofRace.Heargues that“trainedandeducatedblacks, like trained andeducatedwhites,will continue toenjoy theadvantagesand privileges of their class status.”21 It is the black poor—and an analysis of the mechanisms of their impoverishment—that are being left out.

The Conflation of Structural Violence and Cultural Difference

Awareness of cultural differences has long complicated dis- cussions of human suffering. Some anthropologists have ar- guedthatwhat seemtooutsideobservers tobeobviousassaults on dignity may in fact be long-standing cultural institutions highlyvaluedbyasociety.Often-citedexamples range fromfe- male circumcision in the Sudan to head-hunting in the Philip- pines. Such discussions are invariably linked to the concept of cultural relativism, which has a long and checkered history in anthropology. Is every culture a law unto itself and a law unto nothingother than itself? In recentdecades, confidence in reflex cultural relativism faltered as anthropologists turned their at- tention to “complex societies” characterized by extremely ine- galitarian social structures. Many found themselves unwilling to condone social inequity merely because it was buttressed by cultural beliefs, nomatterhowancient.Cultural relativismwas also questioned as a part of a broader critique of anthropology bycitizensof the former colonies.22

But this rethinkinghasnotyet erodeda tendency, registered in many of the social sciences but perhaps particularly in an- thropology, to confuse structural violence with cultural differ- ence. Many are the ethnographies in which poverty and in- equality, the end results of a long process of impoverishment, are conflated with “otherness.” Very often, such myopia is not really a question of motives, but rather, as Talal Asad has sug- gested, our “mode of perceiving and objectifying alien soci- eties.”23 Part of theproblemmay be the ways inwhich the term “culture” is used. “The idea of culture,” explains one authority approvingly inabookon thesubject, “places the researcher ina position of equality with his subjects: each ‘belongs to a cul- ture.’”24 The tragedy, of course, is that this equality, however comforting to the researcher, is entirely illusory. Anthropology hasusually“studieddown”steepgradientsofpower.

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Such illusions suggest an important means by which other misreadings—most notably the conflation of poverty and cul- tural difference—are sustained. They suggest that the anthro- pologist and “his” subject, being from different cultures, are of differentworldsandofdifferent times.25 Thesesortsofmisread- ings, innocent enough within academia, are finding a more in- sidious utility within elite culture, which is becoming increas- ingly transnational. Concepts of cultural relativism, and even arguments to reinstate the dignity of different cultures and “races,”havebeeneasily assimilatedbysomeof theveryagen- cies thatperpetuate extremesuffering.26 Abusesof cultural con- cepts are particularly insidious in discussions of suffering in general and of human rights abuses more specifically: cultural difference isoneof several formsofessentialismusedtoexplain awayassaults ondignityandsuffering ingeneral. Practices, in- cluding torture, are said to be “in their culture” or “in their na- ture”—“their” designating either the victims or the perpetra- tors, orboth, asmaybeexpedient. Suchanalyticabusesare rarelyquestioned, even thoughsys-

temic studies of extreme suffering would suggest that the con- cept of culture should have an increasingly limited role in ex- plaining the distribution of misery. The interpretation of—and justifications for—suffering is usually patterned along cultural lines, but this, Iwouldargue, is anotherquestion.

StructuralViolenceandExtremeSuffering 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 Alegria “Visitas Nocturnas”

Any distinguishing characteristic, whether social or biologi- cal, can serve as pretext for discrimination, and thus as a cause of suffering. Indiscussingeachof theabove factors, however, it is clear thatno single axis can fullydefine increased risk for ex- tremehumansuffering.Efforts toattributeexplanatoryefficacy toonevariable lead to immodest claimsof causality, forwealth and power have often protected individual women, gays, and ethnic minorities from the suffering and adverse outcomes as- sociated with assaults on dignity. Similarly, poverty can often efface the“protective”effectsof statusbasedongender, race,or

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sexual orientation. Leonardo Boff and Clodovis Boff, writing fromBrazil, insist on theprimacyof theeconomic:

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 expres- sion of the process of oppression. The other groups represent “superstructural”expressionsofoppressionandbecauseof this are deeply conditioned by the infra structural. It is one thing to beablack taxi-driver,quiteanother tobeablack football idol; it is one thing to be a woman working as a domestic servant, quiteanother tobe the first ladyof the land; it isone thing tobe an Amerindian thrown off your land, quite another to be an Amerindianowningyourownfarm.27

Noneof this is todenythe ill effectsof sexismorracism,even in the wealthy countries of North America and Europe. The point is merely to call for more fine-grained and systemic anal- yses of power and privilege in discussions of who is likely to suffer and inwhatways. The capacity to suffer is, clearly, part of being human. But

not all suffering is equal, in spite of pernicious and often self- serving identity politics that suggest otherwise. One of the un- fortunate sequelaeof identitypoliticshasbeen theobscuringof structural violence, which metes out injuries of vastly different severity. Careful assessment of severity is important, at least to physicians, who must practice triage and referral daily. What suffering needs to be taken care of first and with what re- sources? It ispossible to speakofextremehumansuffering, and an inordinate share of this sort of pain is currently endured by those living in poverty. Take, for example, illness and prema- turedeath, inmanyplaces in theworld the leadingcauseof ex- tremesuffering. In a strikingdeparture fromprevious, staid re- ports, the World Health Organization now acknowledges that poverty is the world’s greatest killer: “Poverty wields its de- structive influence at every stage of human life, from the mo- ment of conception to the grave. It conspires with the most deadlyandpainfuldiseases tobringawretchedexistence toall thosewhosuffer fromit.”28

As the twentieth century draws to a close, the world’s poor are the chief victims of structural violence—a violence which has thus far defied the analysis of many seeking to understand the nature and distribution of extreme suffering. Why might this be so?Oneanswer is that thepoor arenot onlymore likely to suffer; they are also more likely to have their suffering si- lenced. As Chilean theologian Pablo Richard, noting the fall of theBerlinWall, haswarned, “Weare aware that anothergigan- ticwall isbeingconstructed in theThirdWorld, tohide the real- ity of the poor majorities. Awall between the rich and poor is being built, so that poverty does not annoy the powerful and thepoorareobliged todie in the silenceofhistory.”29

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The task at hand, if this silence is to be broken, is to identify the forcesconspiring topromotesuffering,with theunderstand- ing that thesewillbedifferentiallyweighted indifferent settings. Insodoing,westandachance todiscern the forcesmotricesofex- tremesuffering.Asoundanalyticpurchaseonthedynamicsand distribution of such affliction is, perhaps, a prerequisite to pre- ventingor, at least, assuaging it.Then,at last, theremaybehope offindingabalminGilead.30

Acknowledgments

I have the usual debts to faithful readers such as Haun Saussy and Jim Yong Kim, but wish also to acknowledge the constructive criticisms of this issue’s editors and of Didi Bertrand, Ophelia Dahl, Johanna Daily, Jonathan Mann, Joe Rhatigan, JoyceBendremer, andVinhKimNguyen.

Endnotes

1. Jean Weise, “The Interaction of Western and Indigenous Medi- cine in Haiti in Regard to Tuberculosis,” Ph.D. Dissertation, Depart- ment of Anthropology, University of North Carolina at Chapel Hill, 1971. 2.Thenamesof theHaitianscitedherehavebeenchanged,ashave

thenamesof theirhomevillages. 3.Fora recent reviewof theeffectsof inegalitariansocial structures

on the health of wealthier populations, see Michael Marmot, “Social Differentials inHealthWithinandBetweenPopulations,”Daedalus123 (4) (Fall 1994): 197-216. 4. Some would argue that the relationship between individual

agency and supraindividual structures forms the central problematic of contemporarysocial theory. Ihave tried, in this essay, toavoidwhat Pierre Bourdieu has termed “the absurd opposition between individ- ual and society,” and I acknowledge the influence of Bourdieu, who hascontributedenormously to thedebateonstructureandagency.For a concise statement of his (often revised) views on this subject, see Pierre Bourdieu, In Other Words: Essays Towards a Reflexive Sociology (Cambridge: Polity, 1990). That a supple and fundamentally non-de- terministic model of agency would have such a deterministic—and pessimistic—“feel” is largely a reflection of my topic, suffering, and myfieldworksite. 5.PaulFarmer, “Culture,Poverty, and theDynamicsofHIVTrans-

mission in Rural Haiti,” in Han ten Brummelhuis and Gilbert Herdt, eds.,Culture andSexualRisk:AnthropologicalPerspectives onAIDS (New York:GordonandBreach, 1995), 3-28. 6. For an overview of the human rights situation during the recent

coup, see Americas Watch and the National Coalition for Haitian Refugees, Silencing a People: The Destruction of Civil Society in Haiti (New York: Human Rights Watch,1993) and William O’Neill, “The RootsofHumanRightsViolations inHaiti,”GeorgetownImmigration Law Journal 7 (1) (1993): 87-117. I have reviewed these and other re- ports in Paul Farmer, The Uses of Haiti (Monroe, Maine: Common Courage, 1994). 7. Rebecca Chopp, The Praxis of Suffering (Maryknoll, N.Y.: Orbis,

1986), 2.

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8. This argument is made at greater length in “AIDS and the An- thropologyofSuffering,” inPaulFarmer,AIDSandAccusation:Haiti and the Geography of Blame (Berkeley, Calif.: University of California Press, 1992).The term“historical system”isusedfollowingImmanuelWaller- stein, who for many years has argued that even the most far-flung lo- cales—Haiti’sCentralPlateau, forexample—arepartof thesamesocial and economic nexus: “by the late nineteenth century, for the first time ever, thereexistedonlyonehistorical systemontheglobe.Wearestill in that situation today.”See ImmanuelWallerstein,“World-SystemsAnal- ysis,” inSocialTheoryToday, ed.AnthonyGiddensandJonathanTurner (Stanford, Calif.: Stanford University Press, 1985), 318. See also Im- manuelWallerstein,TheModernWorld-System:CapitalistAgriculture and the Origins of the European World-Economy in the Sixteenth Century (San Diego,Calif.:AcademicPress, 1974).Theweaknessof theseanalyses is, of course, their extremedivorce frompersonal experience. 9. Chopp, The Praxis of Suffering, 2. See also the works of Gustavo

Gutierrez,whohaswrittenagreatdealabout themeaningof suffering in the twentieth century: for exampleGustavoGutierrez,ATheology of Liberation (Maryknoll, N.Y.: Orbis, 1973) and Gustavo Gutierrez, The Power of the Poor in History (Maryknoll, N.Y.: Orbis, 1983). For anthro- pological studiesof liberation theology insocial context, see theethno- graphies by John Burdick, Looking for God in Brazil (Berkeley, Calif.: University of California Press,1993) and Roger Lancaster, Thanks to God and the Revolution (NewYork:ColumbiaUniversityPress, 1988). 10.FromthePuebladocument, cited inPaulFarmer, “Medicineand

Social Justice: Insights from Liberation Theology,” America 173 (2) (1995): 14. 11.RobertMcAfeeBrown, Liberation Theology: An Introductory Guide

(Louisville,Ky.:Westminster, 1993), 44. 12. The political economy of genocide is explored by Christopher

Simpson in The Splendid Blond Beast: Money, Law, and Genocide in the Twentieth Century (New York: Grove Press, 1993). See also Gotz Aly, Peter Chroust, and Christian Pross, Cleansing the Fatherland: Nazi Medicine andRacialHygiene (Baltimore,Md.: JohnsHopkinsUniversity Press, 1994).As regards the transnationalpolitical economyofhuman rights abuses, see the two-volume study by Noam Chomsky and Ed- ward S. Herman, The Washington Connection and Third World Fascism and After the Cataclysm (Boston,Mass.: SouthEndPress, 1979). 13. Michelle Rosaldo and Louise Lamphere, eds., Women, Culture,

and Society (Stanford,Calif.: StanfordUniversityPress, 1974). 14.MaryKoss,PaulKoss, and JoyWoodruff, “DeleteriousEffectsof

Criminal Victimization on Women’s Health and Medical Utilization,” Archives of Internal Medicine151 (1991): 342. 15. It is important to note, however, that upper class/caste women

are in many societies also subject to laws that virtually efface marital rape.The studybyKoss,Koss, andWoodruff includes this crimewith other forms of criminal victimization, but it is only through commu- nity-basedsurveys that such information is collected. 16.MarthaWard, “ADifferentDisease:HIV/AIDSandHealthCare

for Women in Poverty,” Culture, Medicine and Psychiatry 17 (4) (1993): 414. 17.WorldHealthOrganization, “MaternalMortality:HelpingWom-

enOff theRoad toDeath,”WHO Chronicle40 (1985): 175-83. 18. Elena Nightingale, Kari Hannibal, Jack Geiger, Lawrence Hart-

mann, Robert Lawrence, and Jeanne Spurlock, “Apartheid Medicine: Health and Human Rights in South Africa,” Journal of the American Medical Association 264 (16) (1990): 2098. The italics are mine. For a more in-depth account, and a more complicated view of the mecha-

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nisms by which apartheid and the South African economy are related todiseasecausation, seeRandallPackard,WhitePlague,BlackLabor:Tu- berculosis and the Political Economy of Health and Disease in South Africa (Berkeley,Calif.:UniversityofCaliforniaPress, 1989). 19. “VicenteNavarro, “RaceorClassversusRaceandClass:Mortal-

ityDifferentials in theUnitedStates,”The Lancet336 (1990): 1238. 20. Ibid.,1240. 21. William Julius Wilson, The Declining Significance of Race: Blacks

andChangingAmerican Institutions, 2nded. (Chicago, Ill.:Universityof ChicagoPress, 1980), 178. 22. See the studies by Elvin Hatch, Culture and Morality: The Relativ-

ity of Values in Anthropology (New York: Columbia University Press, 1983), and by Ernest Gellner, Relativism and the Social Sciences (Cam- bridge:CambridgeUniversityPress, 1985). 23. TalalAsad, ed., Anthropology and the Colonial Encounter (London:

IthacaPress,1975), 17. 24. Roy Wagner, The Invention of Culture (Englewood Cliffs, N.J.:

Prentice-Hall,1975), 2. 25. Johannes Fabian 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: “Eitherhesubmits to theconditionof coevalnessandproducesethno- graphic knowledge, or he deludes himself into temporaldistance and misses the object of his search.” See Johannes Fabian, Time and the Other: How Anthropology Makes its Object (New York: Columbia Uni- versity Press, 1983). See also the compelling essay by Orin Starn, “Missing the Revolution: Anthropologists and the War in Peru,” in George Marcus, ed., Rereading Cultural Anthropology (Durham, N.C.: DukeUniversityPress, 1992), 152-80. 26. For a penetrating examination of the appropriation of identity

politics by big business, see the essay by L. A. Kauffman, “The Diver- sityGame,”The Village Voice, 31August 1993. 27. Leonardo Boff and Clodovis Boff, Introducing Liberation Theology

(Maryknoll,N.Y.:OrbisBooks, 1987), 29. 28. World Health Organization, Bridging the Gaps (Geneva: World

HealthOrganization, 1995), 5. 29. Cited by Jack Nelson-Pallmeyer, Brave New World Order: Must

We Pledge Allegiance? (Maryknoll,N.Y.:Orbis, 1992), 14. 30. Editors’ note: Paul Farmer’s paper was not one of the papers

presented at the Bellagio Conference on “Social Suffering.” It was so- licitedby theeditors after thatmeeting tookplace.

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