Before these articles by Paul Farmer, I didn’t know how
structural violence impacted social determinants of health. I understood what
structural violence meant in terms of racism and inequity, but I had never
linked it to how it influence diagnosing, staging and treatment of disease and
its associated pathologies. When those in power create systems that disenfranchise
one group of people, this structure affects all aspects of the people disenfranchised.
For my Master’s thesis I worked with an HIV positive
population in the inner city of Baltimore. The participants were poor, most
living on the streets without access to medical care or food. Many indicated that they came to donate blood
just for the money and free food.
Although we could only take blood once, most came back and brought their
friends just to talk so that they could get free cookies and juice. I dealt
with young adults who left home because of their sexual identity and after being
on the streets and hungry dulled the pain with drugs, leaving them open to
HIV/AIDS. The poor were not poor by choice but a structural problem that needed
structural interventions.
Paul Farmer writes that structural violence is a social
determinant of disease and it impacts disease distribution because it puts
individuals and populations in harm’s way. Social suffering, "results from
what political, economic, and institutional power does to people and,
reciprocally, from how these forms of power themselves influence responses to
social problems." Institutions and their agents can perpetrate violence in
the name of health and welfare. Social forces - including economics, politics,
social institutions, social relationships, and culture - can cause pain and
suffering in individuals.
Without insurance the poor in Baltimore did not have access
to proper medical care and saw disease as just another thing, another string of
bad luck that was inflicted upon them. The
only time that the poor could receive medical care was if they went to an
emergency room for life threatening health issues, at which time they were
patched up and released. Most ended up dying in the streets from the same issue
that they went to the hospital to get help with. When structural violence is
overlooked, agency is often overestimated, constraint underestimated.
Structural violence helps deconstruct why for some suffering with disease and
disability, an illness such as AIDS is but one additional misfortune piled on
previous layer of hardship.
It really is crazy the amount of impact social determinants have on ones health. Where you live, and the conditions you live in, your education, community organizations and structure, family,social norms, and more all play such a big role. When living in an impoverished community and experiencing discrimination and racism, thinking about and taking care of your own health is the least of some people's priorities. What you said in class about AIDS is "just another thing added to a million other problems" is both shocking and realistic. First, because they have many other things to worry about. And second, because even if they know they have AIDS or another disease they are not always able to seek the care they need to be cured. They have limited hope and motivation to become healthy again. This is a big problem that needs to be addressed. Preventative measures must be put into place to keep these people healthy, and they also need to have access to quality healthcare and insurance.
ReplyDeleteThis is a sad but all too usual case for those living under conditions like you described. I appreciated how Farmer in “Rethinking Health and Human Rights” mentioned the comparison between how Michael Jordan’s income from being a brand sponsor was equal to that of 60,000 years-worth of work from an Indonesian footwear assembly worker. It really made me wonder what we are putting our value in today. Like really? Are we really putting unequal amounts of value into a basketball player than in an average hardworking individual? Concepts like this make me angry, but also power me to want to make a change. It seems that structural violence is very evident in this case. Perhaps once we (and be we I am not sure exactly who I mean, perhaps the government) start to reorganize where our values and priorities are, structural violence can start to deteriorate on itself.
ReplyDeleteSV is an elegant concept developed by Galtung in his peace studies and taken to scale by Farmer. But you will realize that the concept has been around since long and indeed this is a pivotal determinant of health. I think the first step as we are doing now as PH professionals is to know that it exists and exerts significant violence in lives of the under/ low resource communities, marginalized communities. As usual it affects the vulnerable the most.
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