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On Suffering and Structural Violence: A View from Below Author(s): Paul Farmer Source: Daedalus, Vol. 125, No. 1, Social Suffering (Winter, 1996), pp. 261-283 Published by: The MIT Press on behalf of American Academy of Arts & Sciences Stable URL: http://www.jstor.org/stable/20027362 . Accessed: 01/08/2013 10:55

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Paul Farmer

On Suffering and Structural Violence: A View from Below

EVERYONE KNOWS THAT SUFFERING EXISTS. The question is how

to define it. Given that each person's pain has a degree of

reality for him or her that the pain of others can surely never approach, is widespread agreement on the subject possible? Almost all of us would agree that premature and painful illness,

torture, and rape constitute extreme suffering. Most would also

agree that insidious assaults on dignity, such as institutionalized

racism and sexism, also cause great and unjust injury. Given our consensus on some of the more conspicuous 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? Are certain

"event" assaults, such as torture or rape, more likely to lead to late

sequelae than are sustained and insidious suffering, such as the

pain born of deep poverty or of racism? Under this latter rubric, are certain forms of discrimination demonstrably more noxious

than others?

Anthropologists who take these as research questions study both individual experience and the larger social matrix in which it is embedded in order to see how various large-scale social forces come to be translated into personal distress and disease. By what

mechanisms do social forces ranging from poverty to racism be

Paul Farmer, an Assistant Professor in the Department of Social Medicine at Harvard Medical School, practices medicine at the Brigham and Women's Hospital in Boston and at the Clinique Bon Sauveur in rural Haiti.

261

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262 Paul Farmer

come embodied as individual experience? This has been the focus

of most of my own research in Haiti, where political and economic

forces have structured risk for AIDS, tuberculosis, and, indeed, most other infectious and parasitic diseases. Social forces at work

there have also structured risk for most forms of extreme suffer

ing, from hunger to torture and rape.

Working in contemporary Haiti, where in recent years political violence has been added to the worst poverty in the hemisphere, one learns a great deal about suffering. In fact, the country has

long constituted a sort of living laboratory for the study of afflic

tion, 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 expec

tancy to political freedom, 27 of 141 countries were characterized

by "extreme human suffering." Only one of them, Haiti, was

located in the Western hemisphere. 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 the midst of

an internationally recognized civil war.

Suffering is certainly a recurrent and expected condition in

Haiti's Central Plateau, where everyday life has felt like war. "You

get up in the morning," observed one young widow with four

children, "and it's the fight for food and wood and water." If

initially struck by the austere beauty of the region's steep moun

tains and clement weather, long-term visitors come to see the

Central Plateau in much the same manner as its inhabitants: a

chalky and arid land hostile to the best efforts of the peasant farmers who live here. Landlessness is widespread and so, conse

quently, is hunger. All the standard measures reveal how tenuous

the peasantry's hold on survival is. Life expectancy at birth is less

than fifty years, in large part because as many as two of every ten

infants die before their first birthday. Tuberculosis is the leading cause of death among adults; among children, diarrheal disease,

measles, and tetanus ravage the undernourished.

But the experience of suffering, it is often noted, is not effec

tively conveyed by statistics or graphs. The "texture" of dire

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On Suffering and Structural Violence 263

affliction is perhaps best felt in the gritty details of biography, and so I introduce the stories of Ac?phie Joseph and Chouchou Louis.2

The stories of Ac?phie and Chouchou are anything but "anec

dotal." For the epidemiologist as well as the political analyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet similar fates. What

these victims, past and present, share are not personal or psycho

logical attributes?they do not share culture, language, or race.

Rather, what they share is the experience of occupying the bottom

rung of the social ladder in inegalitarian societies.3

Ac?phie Joseph's and Chouchou Louis's stories illustrate some

of the mechanisms through which large-scale social forces crystal lize into the sharp, hard surfaces of individual suffering. Such

suffering is structured by historically given (and often economi

cally driven) processes and forces that conspire?whether through

routine, ritual, or, as is more commonly the case, these hard

surfaces?to constrain agency.4 For many, including most of my

patients and informants, life choices are structured by racism,

sexism, political violence, and grinding poverty.

ac?phie'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?

0 that my head were waters, and my eyes a fountain of tears, that 1 might weep day and night for the slain of the daughter of my

people!

?]eremiah 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 Cen

tral Plateau. Striking out from Port-au-Prince, the capital, it can

take several hours to reach Kay. The journey gives one an impres sion of isolation, insularity. The impression is misleading, as the

village owes its existence to a project conceived in the Haitian

capital and drafted in Washington, D.C.: Kay is a settlement of

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264 Paul Farmer

refugees, substantially composed of peasant farmers displaced more

than thirty years ago by Haiti's largest dam.

Before 1956, the village of Kay was situated in a fertile valley, and through it ran the Rivi?re Artibonite. For generations, thou

sands of families had farmed the broad and gently sloping banks of the river, selling rice, bananas, millet, corn, and sugarcane in

regional markets. Harvests were, by all reports, bountiful; life

there is now recalled as idyllic. When the valley was flooded 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 exceed

ingly 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 nor water.

In 1983, when I began working in the Central Plateau, AIDS, although already afflicting an increasing number of. city dwellers,

was unknown in most areas as rural as Kay. Ac?phie Joseph was

one of the first villagers to die of the new syndrome. But her

illness, which ended in 1991, was merely the latest in a string of

tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the region's sick.

The litany begins, usually, down in the valley hidden under the

still surface of the lake. Ac?phie's parents came from families

making a decent living by farming fertile tracts of land?their

"ancestors' gardens"?and selling much of their produce. M. Jo

seph tilled the soil, and his wife, a tall and wearily elegant woman

not nearly as old as she looked, was a "Madame Sarah," a market

woman. "If it weren't for the dam," M. Joseph assured me, "we'd

be just fine now. Ac?phie, too." The Josephs' home was drowned

along with most of their belongings, their crops, and the graves of

their ancestors.

Refugees from the rising water, the Josephs built a miserable

lean-to on a knoll of high land jutting into the new reservoir. They remained poised on their knoll for some years; Ac?phie and her twin brother were born there. I asked them what induced 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

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On Suffering and Structural Violence 265

make a garden in this terrible soil. There was no one to keep an

eye on them."

Ac?phie 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." Ac?phie's beauty and her vulnerability may have sealed her

fate as early as 1984. Though still in primary school, she was

already nineteen years old; it was time for her to help generate income for her family, which was sinking deeper and deeper into

poverty. Ac?phie began to help her mother by carrying produce to

a local market on Friday mornings. On foot or with a donkey it

takes over an hour and a half to reach the market, and the road

leads right through Peligre, the site of the dam and, until recently, a military barracks. The soldiers liked to watch the parade of

women on Friday mornings. Sometimes they taxed them with

haphazardly imposed fines; sometimes they taxed them with flirta

tious banter.

Such flirtation is seldom unwelcome, at least to all appearances. 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 family; the times were

as bad as those right after the flooding of the valley. And so when

Ac?phie's good looks caught the eye of Captain Jacques Honor?t, a native of Bellad?re formerly stationed in Port-au-Prince, she

returned his gaze.

Ac?phie knew, as did everyone in the area, that Honor?t had a

wife and children. He was known, in fact, to have more than one

regular partner. But Ac?phie was taken in by his persistence, and

when he went to speak to her parents, a long-term liaison was, from the outset, seriously considered:

What would you have me do? I could tell that the old people were

uncomfortable, worried; but they didn't say no. They didn't tell me

to stay away from him. I wish they had, but how could they have known?.. .1 knew it was a bad idea then, but I just didn't know why. I never dreamed he would give me a bad illness, never! I looked around and saw how poor we all were, how the old people were

finished-What would you have me do? It was a way out, that's

how I saw it.

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266 Paul Farmer

Ac?phie and Honor?t were sexual partners only briefly?for less

than a month, according to Ac?phie. Shortly thereafter, Honor?t

fell ill with unexplained fevers and kept to the company of his wife in Peligre. As Ac?phie was looking for a moun prensipal?a "main

man"?she tried to forget about the soldier. Still, it was shocking to hear, a few months after they parted, that he was dead.

Ac?phie 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 like Ac?phie for their inevitable turn as servants in the city. Indeed, domestic

service was one of the rare growth industries in Haiti, and as much

as Ac?phie's proud mother hated to think of her daughter reduced to servitude, she could offer no viable alternative.

And so Ac?phie, 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 US embassy. Ac?phie's looks and manners

kept her out of the backyard, the traditional milieu of Haitian

servants: she was designated as the maid who, in addition to

cleaning, answered the door and the telephone. Although Ac?phie was not paid well?she received $30 each month?she tried to

save a bit of money for her parents and siblings, recalling the

hunger gnawing at her home village. Still looking for a moun prensipal, Ac?phie began seeing Blanco

Nerette, a young man with origins identical to her own: Blanco's

parents were also "water refugees" and Ac?phie had known him

when they were both attending the parochial school in Kay. Blanco

had done well for himself, by Kay standards: he chauffeured a

small bus between the Central Plateau and the capital. In a setting characterized by an unemployment rate of greater than 60 percent, his job commanded considerable respect. He easily

won the atten

tion of Ac?phie. They planned to marry, and started pooling their

resources.

Ac?phie had worked as a maid for over three years when she

discovered that she was pregnant. When she told Blanco, he be

came skittish. Nor was her employer pleased: it is considered

unsightly to have a pregnant servant. So Ac?phie returned to Kay, where she had a difficult pregnancy. Blanco came to see her once

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On Suffering and Structural Violence 267

or twice; they had a disagreement, and then she heard nothing

from him. Following the birth of her daughter, Ac?phie was sapped

by repeated infections. She was shortly thereafter diagnosed with

AIDS. Soon Ac?phie's life was consumed with managing drenching

night sweats and debilitating diarrhea, while attempting to care

for her first child. "We both need diapers now," she remarked

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 Ac?phie was the

victim of sorcery. Others recalled her liaison with the soldier and

her work as a servant in the city, both locally considered risk

factors for AIDS. Ac?phie herself knew that she had AIDS, al

though she was more apt to refer to herself as suffering from a

disorder brought on by her work as a servant: "All that ironing,

and then opening a refrigerator." But this is not simply the story of Ac?phie and her daughter.

There is Jacques Honorat's first wife, who each year grows thin

ner. After Honorat's death, she found herself desperate, with no

means of feeding her five hungry children, two of whom were also

ill. Her subsequent union was again with a soldier. Honor?t had at

least two other partners, both of them poor peasant women, in the

Central Plateau. One is HIV positive and has two sickly children.

Blanco is still a handsome young man, apparently in good health

and plying the roads from Mirebalais to Port-au-Prince. Who

knows if he carries the virus? As an attractive man with a paying

job, he has plenty of girlfriends. Nor is this simply the story of those infected with the virus. The

pain of Mme. Joseph and Ac?phie's twin brother was manifestly

intense, but few understood the anguish of her father. Shortly after

Ac?phie's death, M. Joseph hanged himself.

CHOUCHOU'S STORY

"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 extermi

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268 Paul Farmer

nation camps. The cries of the hungry, the shrieks of political

prisoners, and the silent voices of the oppressed echo slowly, pain

fully through daily existence. "

?Rebecca Chopp The Praxis of 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 gar dens. In short, there was nothing remarkable about Chouchou's

childhood; it was brief and harsh, like most in rural Haiti.

Throughout the 1980s, church activities formed Chouchou's

sole distraction. These were hard years for the Haitian poor, beaten down by a family dictatorship well into its third decade.

The Duvaliers, father and son, ruled through violence, largely directed at people whose conditions of existence were similar to

that of Chouchou Louis. Although many of them tried to flee, often by boat, US policy maintained that Haitian asylum-seekers

were "economic refugees." As part of a 1981 agreement between

the administrations of Ronald Reagan and Jean-Claude Duvalier,

refugees seized on the high seas were summarily returned to Haiti.

During the first ten years of the accord, 24,559 Haitians applied for political asylum in the United States; eight applications

were

approved. A growing Haitian pro-democracy movement led, in February

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 his wife

years later, "was work the land, listen to the radio, and go to

church." It was on the radio that Chouchou heard about the

people who took over after Duvalier fled. Like many in rural

Haiti, Chouchou was distressed to hear that power had been

handed to the military, led by hardened duvali?ristes. It was this

army that the US government, which in 1916 had created the modern Haitian army, termed "Haiti's best bet for democracy." In

the eighteen months following Duvalier's departure, over $200

million in US aid passed through the hands of the junta.

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On Suffering and Structural Violence 269

In early 1989, Chouchou moved in with Chantai Bris?, who was

pregnant. They were living together when Father Jean-Bertrand

Aristide?by then considered the leader of the pro-democracy movement?declared his candidacy for the presidency in the inter

nationally monitored elections of 1990. In December of that year almost 70 percent of the voters chose Father Aristide from a field

of ten presidential candidates.

Like most rural Haitians, Chouchou and Chantai welcomed

Aristide's election with great joy. For the first time, the poor? Haiti's overwhelming majority, formerly silent?felt they had some

one representing their interests in the presidential palace. These

are the reasons why the military coup d'?tat of September 1991

stirred great anger in the countryside, where the majority of Hai

tians 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 reassembled under the patronage of the army.

In the month after the coup, Chouchou was sitting in a truck en

route to the town of Hinche. Chouchou offered for the consider

ation 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 recog nized by his fellow passengers as veiled language deploring the

coup. Unfortunately for Chouchou, one of the passengers was an

out-of-uniform soldier. At the next checkpoint, the soldier had him seized and dragged from the truck. There, a group of soldiers and their lackeys?their attach?s, to use the epithet then in favor?

immediately began beating Chouchou, in front of the other pas sengers; they continued to beat him as they brought him to the

military barracks in Hinche. A scar on his right temple was a

souvenir of his stay in Hinche, which lasted several days.

Perhaps the worst aftereffect of such episodes of brutality was

that, in general, they marked the beginning of persecution, not the end. In rural Haiti, during this time, any scrape with the law (i.e., the military) led to blacklisting. For men like Chouchou, staying

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270 Paul Farmer

out of jail involved keeping the local attach?s happy, and he did this by avoiding his home village. But Chouchou lived in fear of a second arrest, his wife later told me, and his fears proved to be

well-founded.

On January 22, 1992, Chouchou was visiting his sister when he

was arrested by two attach?s. No reason was given for the arrest, and Chouchou's sister regarded as ominous the seizure of the

young man's watch and radio. He was roughly marched to the

nearest military checkpoint, where he was tortured by soldiers and

the attach?s. One area resident later told us that the prisoner's screams made her children weep with terror.

On January 25, Chouchou was dumped in a ditch to die. The

army scarcely took the trouble to circulate the canard that he had

stolen some bananas. (The Haitian press, by then thoroughly

muzzled, did not even broadcast this false version of events.) Relatives carried Chouchou back to Chantai and their daughter under the cover of night. By early on the morning of January 26,

when I arrived, Chouchou was scarcely recognizable. His face, and

especially his left temple, was misshapen, swollen, and lacerated; his right temple was also scarred. His mouth was a pool of dark,

coagulated blood. His neck was peculiarly swollen, his throat

collared with bruises, the traces of a gun butt. His chest and sides

were badly bruised, and he had several fractured ribs. His genitals had been mutilated.

That was his front side; presumably, the brunt of the beatings came from behind. Chouchou's back and thighs were striped with

deep lash marks. His buttocks were macerated, the skin flayed down to the exposed gluteal muscles. Some of these stigmata

appeared to be infected.

Chouchou coughed up more than a liter of blood in his agonal moments. Given his respiratory difficulties and the amount of

blood he coughed up, it is likely that the beatings caused him to

bleed, slowly at first, then catastrophically, into his lungs. His

head injuries had not robbed him of his faculties, although it might have been better for him had they done so. It took Chouchou three

days to die.

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On Suffering and Structural Violence 271

EXPLAINING VERSUS MAKING SENSE OF 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 stories of suffering emblematic of something other than

two tragic and premature deaths? If so, how representative is each

of these experiences? Little about Ac?phie's story is unique; I have

told it in detail because it brings into relief many of the forces

constraining not only her options, but those of most Haitian

women. Such, in any case, is my opinion after caring 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 from the harshest poverty; once in the city, each worked as a domestic; none managed to find

financial security. The women interviewed were straightforward about the nonvoluntary aspect of their sexual activity: in their

opinions, they had been driven into unfavorable unions by pov

erty.5 Indeed, such testimony should call into question facile no

tions of "consensual sex."

What about the murder of Chouchou Louis? International hu

man rights groups estimate that more than three thousand Hai

tians were killed in the year after the September 1991 coup that

overthrew Haiti's first democratically elected government. Nearly all of those killed were civilians who, like Chouchou, fell into the hands of military or paramilitary forces. The vast majority of

victims were poor peasants, like Chouchou, or urban slum dwell

ers. (The figures cited here are conservative estimates; I am quite sure that no journalist or observer ever came to count the body of

Chouchou Louis.6)

Thus, the agony of Ac?phie and Chouchou was, in a sense, "modal" suffering. In Haiti, AIDS and political violence are two

leading causes of death among young adults. These afflictions

were not the result of accident or of force majeure; they were the

consequence, direct or indirect, of human agency. When the

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272 Paul Farmer

Artibonite Valley was flooded, depriving families like the Josephs of their land, a human decision was behind it; when the Haitian

army was endowed with money and unfettered power, human

decisions were behind that, too. In fact, some of the same

decisionmakers may have been involved in both cases.

If bureaucrats and soldiers seemed to have unconstrained sway over the lives of the rural poor, the agency of Ac?phie and Chouchou

was, correspondingly, curbed at every turn. These grim biogra

phies 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, victims of structural violence.

While certain kinds of suffering are readily observable?and the

subject of countless films, novels, and poems?structural violence

all too often defeats those who would describe it. There are at least

three reasons why this is so. First, there is the "exoticization" of

suffering as lurid as that endured by Ac?phie and Chouchou. The

suffering of individuals whose lives and struggles recall our own

tends to move us; the suffering of those who are distanced, whether

by geography, gender, "race," or culture, is sometimes less affect

ing.

Second, there is the sheer weight of the suffering, which makes

it all the more difficult to render: "Knowledge of suffering cannot

be conveyed in pure facts and figures, reportings that objectify the

suffering of countless persons. The horror of suffering is not only its immensity but the faces of the anonymous victims who have

little voice, let alone rights, in history."7

Third, the dynamics and distribution of suffering are still poorly understood. Physicians, when fortunate, can alleviate the suffering of the sick. But explaining its distribution requires more minds,

more resources. Case studies of individuals reveal suffering, they tell us what happens to one or many people; but to explain

suffering, one must embed individual biography in the larger ma

trix of culture, history, and political economy. In short, it is one thing to make sense of extreme suffering?a

universal activity, surely?and quite another to explain it. Life

experiences such as those of Ac?phie and Chouchou?who as

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On Suffering and Structural Violence 273

Haitians living in poverty shared similar social conditions?must

be embedded in ethnography if their representativeness is to be

understood. These local understandings are to be embedded, in

turn, in the larger-scale historical system of which the fieldwork

site is a part.8 The social and economic forces that dictate life

choices in Haiti's Central Plateau affect many millions of individu

als, and it is in the context of these global 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 theology speaks with those who, through their suffering, call into question the meaning and truth of human history."9

Unlike most previous theologies, and unlike much modern phi

losophy, liberation theology has attempted to use social analysis to

both explain and deplore human suffering. Its key texts bring into relief not merely the suffering of the wretched of the earth, but

also the forces that promote that suffering. The theologian Leonardo

Boff, in commenting on one of these texts, notes that it "moves

immediately to the structural analysis of these forces and de

nounces the systems, structures, and mechanisms that 'create a

situation where the rich get richer at the expense of the poor, who

get even

poorer.'"10

In short, few liberation theologians engage in reflection on suf

fering without attempting to understand its mechanisms. Theirs is

a theology that underlines connections. Robert McAfee Brown has

these connections and also the poor in mind when, paraphrasing the Uruguayan Jesuit Juan Luis Segundo, he observes that "the

world that is satisfying to us is the same world that is utterly

devastating to them."11

MULTIAXIAL MODELS OF 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 really reveal

the agony, the interruption, the questions that these victims put to

the meaning and nature of our individual lives and life as a whole?"

?Rebecca Chopp The Praxis of Suffering

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274 Paul Farmer

How might we discern the nature of structural violence and ex

plore its contribution to human suffering? Can we devise an ana

lytic model, one with explanatory and predictive power, for un

derstanding suffering in a global context? Some would argue that

this task, though daunting, is both urgent and feasible. Our cur

sory examination of AIDS and political violence in Haiti suggests that analysis must, first, be geographically broad. As noted, the

world as we know it is becoming increasingly interconnected. A

corollary of this belief is that extreme suffering?especially when

on a grand scale, as in genocide?is seldom divorced from the

actions of the powerful.12 The analysis must also be historically

deep?not merely deep enough to remind us of events and deci

sions such as those which deprived Ac?phie of her land and founded the Haitian military, but deep enough to remember that modern

day Haitians are the descendants of a people kidnapped from Africa in order to provide us with sugar, coffee, and cotton and to

enrich a few in a mercantilist economy. Factors including gender, ethnicity ("race"), and socioeconomic

status may each be shown to play a role in rendering individuals

and groups vulnerable to extreme human suffering. But in most

settings these factors have limited explanatory power. Simulta

neous consideration of various social "axes" is imperative in ef

forts to discern a political economy of brutality. Furthermore, such social factors are differentially weighted in different settings and at different times, as even brief consideration of their contri

butions to extreme suffering suggests.

The Axis of Gender

Ac?phie Joseph and Chouchou Louis shared, as noted, a similar

social status, and each died after contact with the Haitian military. But gender helps to explain why Ac?phie died of AIDS whereas Chouchou died from torture. Gender inequality also helps to

ex

plain why the suffering of Ac?phie is much more commonplace

than that of Chouchou. Throughout the world, women are con

fronted with sexism, an ideology that designates them as inferior

to men. When, in 1974, a group of feminist anthropologists sur

veyed the status of women living in several disparate settings, they found that, in every society studied, men dominated political,

legal, and economic institutions to varying degrees; in no culture

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On Suffering and Structural Violence 275

was the status of women genuinely coordinate, much less superior, to that of men.13 This power differential has meant that women's

rights may be violated in innumerable ways. Although male vic

tims are clearly preponderant in studies of torture, the much more

common crimes of domestic violence and rape are almost exclu

sively endured by females. In the United States, the number of such

aggressions is staggering. When sexual assaults by both intimates

and strangers are considered, "one in four women has been the

victim of a completed rape and one in four women has been

physically battered, according to the results of recent community based studies."14

In most settings, however, gender alone does not define 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 violence and

rape, but also of AIDS and its distribution, as anthropologist Martha Ward points out:

The collection of statistics by ethnicity rather than by socio-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 determining condition of their lives.16

Similarly, only women can experience maternal mortality, a cause

of anguish around the world. More than half a million women die

each year in childbirth, but not all women are at increased risk of

adverse outcomes in pregnancy. In 1985, the World Health Orga nization estimated that maternal mortality is, on average, approxi

mately 150 times higher in developing countries than in developed nations. In Haiti, where maternal mortality is as high as fourteen

hundred deaths per one hundred thousand live births?almost five

hundred times higher than in the wealthy countries?these deaths are almost all registered among the poor.17

The Axis of "Race" or Ethnicity The idea of race, which is considered to be a biologically insignifi cant term, has enormous social currency. Racial classifications

have been used to deprive certain groups of basic rights, and

therefore have an important place in considerations of human

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276 Paul Farmer

suffering. In South Africa, for years a living laboratory for the

study of the long-term effects of racism, epidemiologists report that the infant mortality rate among blacks may be as much as ten

times higher than among whites. For South African blacks, the

proximate cause of increased rates of morbidity and mortality is

lack of access to resources: "Poverty remains the primary cause of

the prevalence of many diseases and widespread hunger and mal

nutrition among black South Africans."18 And social inequality is

seen in the uneven distribution of poverty.

Significant mortality differentials between blacks and whites are

also registered in the United States, which shares with South Africa

the distinction of being the only two industrialized countries fail

ing to record mortality data by socioeconomic status. In the United

States, in 1988, life expectancy at birth was 75.5 years for whites

and 69.5 years for blacks. Accordingly, there has been a certain

amount of discussion about race differentials in mortality, but

public health expert Vicente Navarro recently complained about

the "deafening silence" on the topic of class differentials in mortal

ity in the United States, where "race is used as a substitute for

class." But in 1986, on "one of the few occasions that the US

government collected information on mortality rates (for heart

and cerebrovascular disease) by class, the results showed that, by whatever indicators of class one might choose (level of education,

income, or occupation), mortality rates are related to social class."19

Indeed, for the major causes of death (heart disease and cere

brovascular disease), class differentials were significantly larger than race differentials. "The growing mortality differentials be

tween whites and blacks," Navarro concludes, "cannot be under

stood by looking only at race; they are part and parcel of larger

mortality differentials?class differentials."20 The sociologist Wil

liam Julius Wilson made a similar point in his landmark study, The Declining Significance of Race. He argues that "trained and

educated blacks, like trained and educated whites, will continue to

enjoy the advantages and privileges of their class status."21 It is the

black poor?and an analysis of the mechanisms of their impover ishment?that are being left out.

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On Suffering and Structural Violence 277

The Conflation of Structural Violence and Cultural Difference Awareness of cultural differences has long complicated discussions

of human suffering. Some anthropologists have argued that what

seem to outside observers to be obvious assaults on dignity may in

fact be long-standing cultural institutions highly valued by a soci

ety. Often-cited examples range from female circumcision in the

Sudan to head-hunting in the Philippines. 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 nothing other than itself? In recent

decades, confidence in reflex cultural relativism faltered as anthro

pologists turned their attention to "complex societies" character

ized by extremely inegalitarian social structures. Many found them

selves unwilling to condone social inequity merely because it was

buttressed by cultural beliefs, no matter how ancient. Cultural

relativism was also questioned as a part of a broader critique of

anthropology by citizens of the former colonies.22

But this rethinking has not yet eroded a tendency, registered in

many of the social sciences but perhaps particularly in anthropol

ogy, to confuse structural violence with cultural difference. Many are the ethnographies in which poverty and inequality, 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 suggested, our "mode of

perceiving and objectifying alien societies."23 Part of the problem

may be the ways in which the term "culture" is used. "The idea of

culture," explains one authority approvingly in a book on the

subject, "places the researcher in a position of equality with his

subjects: each 'belongs to a culture.'"24 The tragedy, of course, is

that this equality, however comforting to the researcher, is entirely

illusory. Anthropology has usually "studied down" steep gradients of power.

Such illusions suggest an important means by which other

misreadings?most notably the conflation of poverty and cultural

difference?are sustained. They suggest that the anthropologist and "his" subject, being from different cultures, are of different

worlds and of different times.25 These sorts of misreadings, inno

cent enough within academia, are finding a more insidious utility

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278 Paul Farmer

within elite culture, which is becoming increasingly transnational.

Concepts of cultural relativism, and even arguments to reinstate

the dignity of different cultures and "races," have been easily assimilated by some of the very agencies that perpetuate extreme

suffering.26 Abuses of cultural concepts are particularly insidious

in discussions of suffering in general and of human rights abuses

more specifically: cultural difference is one of several forms of

essentialism used to explain away assaults on dignity and suffering in general. Practices, including torture, are said to be "in their

culture" or "in their nature"?"their" designating either the vic

tims or the perpetrators, or both, as may be expedient. Such analytic abuses are rarely questioned, even though sys

temic studies of extreme suffering would suggest that the concept of culture should have an increasingly limited role in explaining the distribution of misery. The interpretation of?and justifica tions for?suffering is usually patterned along cultural lines, but

this, I would argue, is another question.

STRUCTURAL VIOLENCE AND EXTREME SUFFERING

At night I listen to their phantoms

shouting in my ear

shaking me out of lethargy

issuing me commands

I think of their tattered lives

of their feverish hands

reaching out to seize ours.

It's not that they're begging

they're demanding

they've earned the right to order us

to break up our sleep to come awake

to shake off once and for all

this lassitude.

?Ciar ib el Alegr?a "Visitas Nocturnas"

Any distinguishing characteristic, whether social or biological, can

serve as pretext for discrimination, and thus as a cause of suffer

ing. In discussing each of the above factors, however, it is clear

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On Suffering and Structural Violence 279

that no single axis can fully define increased risk for extreme

human suffering. Efforts to attribute explanatory efficacy to one

variable lead to immodest claims of causality, for wealth and

power have often protected individual women, gays, and ethnic

minorities from the suffering and adverse outcomes associated

with assaults on dignity. Similarly, poverty can often efface the

"protective" effects of status based on gender, race, or sexual

orientation. Leonardo Boff and Clodovis Boff, writing from Bra

zil, insist on the primacy of the economic:

We have to observe that the socioeconomically oppressed (the poor) do not simply exist alongside other oppressed groups, such as blacks,

indigenous peoples, women?to take the three major categories in

the Third World. No, the "class-oppressed"?the socioeconomi

cally poor?are the infrastructural expression of the process of

oppression. The other groups represent "superstructural" expres sions of oppression and because of this are deeply conditioned by the infrastructural. It is one thing to be a black taxi-driver, quite another to be a black football idol; it is one thing to be a woman

working as a domestic servant, quite another to be the first lady of

the land; it is one thing to be an Amerindian thrown off your land,

quite another to be an Amerindian owning your own farm.27

None of this is to deny the ill effects of sexism or racism, even in

the wealthy countries of North America and Europe. The point is

merely to call for more fine-grained and systemic analyses of

power and privilege in discussions of who is likely to suffer and in

what ways. 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 unfortunate

sequelae of identity politics has been the obscuring of 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 resources? It is possible to

speak of extreme human suffering, and an inordinate share of this

sort of pain is currently endured by those living in poverty. Take, for example, illness and premature death, in many places in the

world the leading cause of extreme suffering. In a striking depar ture from previous, staid reports, the World Health Organization

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280 Paul Farmer

now acknowledges that poverty is the world's greatest killer: "Pov

erty wields its destructive influence at every stage of human life, from the moment of conception to the grave. It conspires with the

most deadly and painful diseases to bring a wretched existence to

all those who suffer from it."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? One answer is that the poor are not only more likely to suffer, they are

also more likely to have their suffering silenced. As Chilean theo

logian Pablo Richard, noting the fall of the Berlin Wall, has warned, "We are aware that another gigantic wall is being constructed in

the Third World, to hide the reality of the poor majorities. A wall between the rich and poor is being built, so that poverty does not

annoy the powerful and the poor are obliged to die in the silence

of history."29 The task at hand, if this silence is to be broken, is to identify the

forces conspiring to promote suffering, with the understanding that these will be differentially weighted in different settings. In so

doing, we stand a chance to discern the forces motrices of extreme

suffering. A sound analytic purchase on the dynamics and distri

bution of such affliction is, perhaps, a prerequisite to preventing or, at least, assuaging it. Then, at last, there may be hope of

finding a balm in Gilead.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, Joyce Bendremer, and Vinh Kim Nguyen.

ENDNOTES

\Jean Weise, "The Interaction of Western and Indigenous Medicine in Haiti in Re

gard to Tuberculosis," Ph.D. Dissertation, Department of Anthropology, Uni

versity of North Carolina at Chapel Hill, 1971.

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On Suffering and Structural Violence 281

2The names of the Haitians cited here have been changed, as have the names of

their home villages.

3For a recent review of the effects of inegalitarian social structures on the health of

wealthier populations, see Michael Marmot, "Social Differentials in Health Within and Between Populations," Dcedalus 123 (4) (Fall 1994): 197-216.

4Some would argue that the relationship between individual agency and

supraindividual structures forms the central problematic of contemporary social

theory. I have tried, in this essay, to avoid what Pierre Bourdieu has termed "the

absurd opposition between individual and society," and I acknowledge the in fluence of Bourdieu, who has contributed enormously to the debate

on structure

and agency. For a concise statement of his (often revised) views on this subject, see Pierre Bourdieu, In Other Words: Essays Towards a Reflexive Sociology (Cambridge: Polity, 1990). That a supple and fundamentally non-deterministic

model of agency would have such a deterministic?and pessimistic?"feel" is

largely a reflection of my topic, suffering, and my fieldwork site.

5Paul Farmer, "Culture, Poverty, and the Dynamics of HIV Transmission in Rural

Haiti," in Han ten Brummelhuis and Gilbert Herdt, eds., Culture and Sexual

Risk: Anthropological Perspectives on AIDS (New York: Gordon and Breach, 1995), 3-28.

6For an overview of the human rights situation during the recent coup, see Ameri

cas 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 Roots of Human Rights Violations in Haiti,"

Georgetown Immigration Law Journal 7 (1) (1993): 87-117. I have reviewed these and other reports in Paul Farmer, The Uses of Haiti (Monroe, Maine:

Common Courage, 1994).

7Rebecca Chopp, The Praxis of Suffering (Maryknoll, N.Y.: Orbis, 1986), 2.

8This argument is made at greater length in "AIDS and the Anthropology of Suffer

ing," in Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame

(Berkeley, Calif.: University of California Press, 1992). The term "historical sys tem" is used following Immanuel Wallerstein, who for many years has argued that even the most far-flung locales?Haiti's Central Plateau, for example?are

part of the same social and economic nexus: "by the late nineteenth century, for

the first time ever, there existed only one historical system on the globe. We are

still in that situation today." See Immanuel Wallerstein, "World-Systems Analy

sis," in Social Theory Today, ed. Anthony Giddens and Jonathan Turner

(Stanford, Calif.: Stanford University Press, 1985), 318. See also Immanuel

Wallerstein, The Modern World-System: Capitalist Agriculture and the Origins of the European World-Economy in the Sixteenth Century (San Diego, Calif.:

Academic Press, 1974). The weakness of these analyses is, of course, their ex

treme divorce from personal experience.

9Chopp, The Praxis of Suffering, 2. See also the works of Gustavo Guti?rrez, who has written a great deal about the meaning of suffering in the twentieth century: for example Gustavo Guti?rrez, A Theology of Liberation (Maryknoll, N.Y.:

Orbis, 1973) and Gustavo Guti?rrez, The Power of the Poor in History (Maryknoll, N.Y.: Orbis, 1983). For anthropological studies of liberation theol

ogy in social context, see the ethnographies by John Burdick, Looking for God

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282 Paul Farmer

in Brazil (Berkeley, Calif.: University of California Press, 1993) and Roger Lancaster, Thanks to God and the Revolution (New York: Columbia University Press, 1988).

10From the Puebla document, cited in Paul Farmer, "Medicine and Social Justice:

Insights from Liberation Theology," America 173 (2) (1995): 14. 11 Robert McAfee Brown, Liberation Theology: An Introductory Guide (Louisville,

Ky.: Westminster, 1993), 44.

12The 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 G?tz Aly, Peter Chroust, and Christian

Pross, Cleansing the Fatherland: Nazi Medicine and Racial Hygiene (Baltimore, Md.: Johns Hopkins University Press, 1994). As regards the transnational politi

cal economy of human rights abuses, see the two-volume study by Noam

Chomsky and Edward S. Herman, The Washington Connection and Third World Fascism and After the Cataclysm (Boston, Mass.: South End Press, 1979).

13Michelle Rosaldo and Louise Lamphere, eds., Women, Culture, and Society

(Stanford, Calif.: Stanford University Press, 1974).

14Mary Koss, Paul Koss, and Joy Woodruff, "Deleterious Effects of Criminal Vic

timization on Women's Health and Medical Utilization," Archives of Internal Medicine 151 (1991): 342.

15It is important to note, however, that upper class/caste women are in many soci

eties also subject to laws that virtually efface marital rape. The study by Koss,

Koss, and Woodruff includes this crime with other forms of criminal victimiza

tion, but it is only through community-based surveys that such information is

collected.

16Martha Ward, "A Different Disease: HIV/AIDS and Health Care for Women in

Poverty," Culture, Medicine and Psychiatry 17 (4) (1993): 414.

17World Health Organization, "Maternal Mortality: Helping Women Off the Road to Death," WHO Chronicle 40 (1985): 175-83.

18Elena Nightingale, Kari Hannibal, Jack Geiger, Lawrence Hartmann, 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 mechanisms by which apartheid and the South African

economy are related to disease causation, see Randall Packard, White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa (Berkeley, Calif.: University of California Press, 1989).

19Vicente Navarro, "Race or Class versus Race and Class: Mortality Differentials in

the United States," The Lancet 336 (1990): 1238.

20Ibid., 1240.

21 William Julius Wilson, The Declining Significance of Race: Blacks and Changing American Institutions, 2nd ed. (Chicago, 111.: University of Chicago Press, 1980), 178.

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On Suffering and Structural Violence 283

22See the studies by Elvin Hatch, Culture and Morality: The Relativity of Values in

Anthropology (New York: Columbia University Press, 1983), and by Ernest

Gellner, Relativism and the Social Sciences (Cambridge: Cambridge University Press, 1985).

23Talal Asad, ta.. Anthropology and the Colonial Encounter (London: Ithaca Press,

1975), 17.

24Roy Wagner, The Invention of Culture (Englewood Cliffs, N.J.: Prentice-Hall, 1975), 2.

25Johannes 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: "Either he submits to the condition of coevalness and produces ethnographic knowledge, or he deludes himself into

temporal distance and misses the object of his search." See Johannes Fabian, Time and the Other: How Anthropology Makes its Object (New York: Colum bia University Press, 1983). See also the compelling essay by Orin Starn, "Miss

ing the Revolution: Anthropologists and the War in Peru," in George Marcus,

ed., Rereading Cultural Anthropology (Durham, N.C.: Duke University Press, 1992), 152-80.

26For a penetrating examination of the appropriation of identity politics by big business, see the essay by L. A. Kauffman, "The Diversity Game," The Village Voice, 31 August 1993.

27Leonardo Boff and Clodovis Boff, Introducing Liberation Theology (Maryknoll, N.Y.: Orbis Books, 1987), 29.

28World Health Organization, Bridging the Gaps (Geneva: World Health Organi zation, 1995), 5.

29Cited by Jack Nelson-Pallmeyer, Brave New World Order: Must We Pledge Alle

giance? (Maryknoll, N.Y.: Orbis, 1992), 14.

30Editors' note: Paul Farmer's paper was not one of the papers presented at the

Bellagio Conference on "Social Suffering." It was solicited by the editors after

that meeting took place.

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