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Given what you’ve learned in this course about globalization and the global consumer market – and the often unmarked cost in human misery and environmental destruction of our products and lifestyles – write a reflective essay on how your decisions as both citizen and consumer affect the lives of other people around the world. What are the hidden costs of your favorite products (clothing, electronics, food, cars, etc.)? How do these products contribute to ecological destruction (either in one locale or on a grand scale)? What, if anything, could you do to alleviate some of the suffering that the global consumer economy causes, to people and to the planet? Do you feel it’s your responsibility to make such changes to your habits and/or purchasing decisions – why or why not?Refer to at least three readings and one of the films/documentaries in your discussion. You do not have to provide formal citations or references (unless bringing in a source from outside the class readings and films), but DO refer to authors and films by name when discussing them. There is no minimum or maximum word count for this essay, but most students write 3-4 pages.3pages double spaced at 12 font use 3 sources from readings- added some sources in links and some downloads as long as instructions are followed itll be an A paperhttp://www.globalissues.org/article/62/child-laborhttps://www.thoughtco.com/mcdonaldization-of-socie…http://www.globalissues.org/article/239/sugar
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An Anthropology of Structural Violence
Author(s): Paul Farmer
Source: Current Anthropology , Vol. 45, No. 3 (June 2004), pp. 305-325
Published by: The University of Chicago Press on behalf of Wenner-Gren Foundation for
Anthropological Research
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C u r r e n t A n t h r o p o l o g y Volume 45, Number 3, June 2004
䉷 2004 by The Wenner-Gren Foundation for Anthropological Research. All rights reserved 0011-3204/2004/4503-0001$3.00
SIDNEY W. MINTZ LECTURE
FOR 2001
An Anthropology of
Structural Violence
1
by Paul Farmer
Any thorough understanding of the modern epidemics of AIDS
and tuberculosis in Haiti or elsewhere in the postcolonial world
requires a thorough knowledge of history and political economy.
This essay, based on over a decade of research in rural Haiti,
draws on the work of Sidney Mintz and others who have linked
the interpretive project of modern anthropology to a historical
understanding of the large-scale social and economic structures
in which affliction is embedded. The emergence and persistence
of these epidemics in Haiti, where they are the leading causes of
young-adult death, is rooted in the enduring effects of European
expansion in the New World and in the slavery and racism with
which it was associated. A syncretic and properly biosocial anthropology of these and other plagues moves us beyond noting,
for example, their strong association with poverty and social inequalities to an understanding of how such inequalities are embodied as differential risk for infection and, among those already
infected, for adverse outcomes including death. Since these two
diseases have different modes of transmission, different pathophysiologies, and different treatments, part of the interpretive
task is to link such an anthropology to epidemiology and to an
understanding of differential access to new diagnostic and therapeutic tools now available to the fortunate few.
p a u l f a r m e r is Presley Professor of Medical Anthropology in
the Department of Social Medicine of Harvard Medical School,
an attending physician in infectious diseases and chief of the Division of Social Medicine and Health Inequalities at Brigham and
Women’s Hospital in Boston, and medical director of the Clinique Bon Sauveur in rural Haiti (his mailing address: Partners in
Health, Harvard Medical School, 641 Huntington Ave., Boston,
MA 02115, U.S.A. [[email protected]]). In 1985 he
helped found Zanmi Lasante (Partners in Health), a multiservice
health complex that has pioneered the treatment of both multidrug-resistant tuberculosis and HIV in Haiti and played a key
role in Haiti’s becoming the first country in the world to receive
funds from the Global Fund to Fight AIDS, Tuberculosis, and
Malaria. Among his publications are Pathologies of Power
(Berkeley: University of California Press, 2003), Infections and
Inequalities (Berkeley: University of California Press, 1998), The
Uses of Haiti (Monroe, Me.: Common Courage Press, 1994), and
AIDS and Accusation (Berkeley: University of California Press,
1992). The present paper was accepted for publication 29 ix 03.
[Supplementary material appears in the electronic edition of this
issue on the journal’s web page (http://www.journals.uchicago.
edu/CA/home.html).]
1. This paper was delivered as the 2001 Sidney W. Mintz Lecture
in Anthropology on November 27, 2001, at Johns Hopkins University. My deepest appreciation goes to the Department of An-
The ethnographically visible, central Haiti, September
2000: Most hospitals in the region are empty. This is not
because of a local lack of treatable pathology; rather, patients have no money to pay for such care. One hospital—
situated in a squatter settlement just 8 kilometers from
a hydroelectric dam that decades ago flooded a fertile valley—is crowded. Medicines and laboratory studies are free.
Every bed is filled, and the courtyard in front of the clinic
is mobbed with patients waiting to be seen. Over a hundred have slept on the grounds the night before and are
struggling to smooth out wrinkles in hand-me-down
dresses or pants or shirts; hats are being adjusted, and some
are massaging painful cricks in the neck. The queue of
those waiting to have a new medical record created is long,
snaking toward the infectious-disease clinic I am hoping
to reach. First, however, it is better to scan the crowd for
those who should be seen immediately.
Less ethnographically visible is the fact that Haiti is
under democratic rule. For the first time in almost two
centuries, democratic elections are planned and could
result in a historic precedent: President René Préval,
elected some years earlier, could actually survive his
presidency to transfer power to another democratically
elected president. If Préval succeeds, he will be the first
president in Haitian history ever to serve out his mandate, not a day more, not a day less.
To local eyes, the prospect of this victory (which later
did indeed come to pass) is overwhelmed by the vivid
poverty seeping into the very seams of Haitian society.
For the rural poor, most of them peasants, this means
erosion and lower crop yields; it means hunger and sickness. And every morning the crowd in front of the clinic
seems to grow.
To foreign eyes, the Haitian story has become a confused skein of tragedies, most of them seen as local. Poverty, crime, accidents, disease, death—and more often
than not their causes—are also seen as problems locally
derived. The transnational tale of slavery and debt and
turmoil is lost in the vivid poverty, the understanding
of which seems to defeat the analyses of journalists and
even many anthropologists, focused as we are on the
ethnographically visible—what is there in front of us.
Making my way through this crowd has become a daily
chore and triage—seeking out the sickest—a ritual in the
years since I became medical director of the clinic. Now
the morning sun angles into the courtyard, but the patients are shaded by tall ficus trees, planted there years
before. The clinic and hospital were built into the hillside over the previous 15 years, but the dense foliage
gives the impression that the buildings have been there
for decades.
I see two patients on makeshift stretchers; both are
thropology for the honor of delivering this lecture; special thanks
go to Veena Das. For assistance in transforming a lecture into a
paper, I thank Alice Yang, Nicole Gastineau, Haun Saussy, and,
most of all, Barbara Rylko-Bauer, without whom this transformation would not have taken place. Finally, I am profoundly grateful
to Sidney Mintz, whose careful scholarship serves as inspiration to
all those who seek to understand the painful social processes that
came to constitute the world we inhabit.
305
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306 F c u r r e n t a n t h ro p o l o g y Volume 45, Number 3, June 2004
being examined by auxiliary nurses armed with stethoscopes and blood-pressure cuffs. Perhaps this morning it
will take less than an hour to cross the 600 or so yards
that separate me from another crowd of patients already
diagnosed with tuberculosis or AIDS. These are the patients I am hoping to see, but it is also my duty to see
to the larger crowd, which promises, on this warm
Wednesday morning, to overwhelm the small Haitian
medical staff.
A young woman takes my arm in a common enough
gesture in rural Haiti. “Look at this, doctor.” She lifts a
left breast mass. The tumor is not at all like the ones I
was taught to search for during my medical training in
Boston. This lesion started as an occult lump, perhaps,
but by this September day has almost completely replaced the normal breast. It is a “fungating mass,” in
medical jargon, and clear yellow fluid weeps down the
front of a light-blue dress. Flies are drawn to the diseased
tissue, and the woman waves them away mechanically.
On either side of her, a man and a woman help her with
this task, but they are not kin, simply other patients
waiting in the line.
“Good morning,” I say, although I know that she is
expecting me to say next to nothing and wants to be the
speaker. She lifts the tumor toward me and begins speaking rapidly.
“It’s hard and painful,” she says. “Touch it and see
how hard it is.” Instead, I lift my hand to her axilla and
find large, hard lymph nodes there—likely advanced and
metastatic cancer—and I interrupt her as politely as I
can. If only this were a neglected infection, I think. Not
impossible, only very unlikely. I need to know how long
this woman has been ill.
But the woman, whose name is Anite, will have none
of it. She is going to tell the story properly, and I will have
to listen. We are surrounded by hundreds, and at least 40
can hear every word of the exchange. I think to pull her
from the line, but she wants to talk in front of her fellow
sufferers. For years I have studied and written about these
peculiarly Haitian modes of declaiming about one’s travails, learning how such jeremiads are crafted for a host
of situations and audiences. There is so much to complain
about. Now I have time only to see patients as a physician
and precious little time for interviewing them. I miss this
part of my work, but although I want to hear Anite’s story,
I want even more to attend to her illness. And to do that
properly will require a surgeon, unless she has come with
a diagnosis made elsewhere. I look away from the tumor.
She carries, in addition to a hat and a small bundle of
oddments, a white vinyl purse. Please, I think, let there
be useful information in there. Surely she has seen other
doctors for a disease process that is, at a minimum,
months along?
I interrupt again to ask her where she has come from
and if she has sought care elsewhere. We do not have a
surgeon on staff just now. We have been promised, a
weary functionary at the Ministry of Health has told me,
that the Cuban government will soon be sending us a
surgeon and a pediatrician. But for this woman, Anite,
time has run out.
“I was about to tell you that, doctor.” She has let go
of my arm to lift the mass, but now she grips it again.
“I am from near Jérémie,” she says, referring to a small
city on the tip of Haiti’s southern peninsula—about as
far from our clinic as one could be and still be in Haiti.
To reach us, Anite must have passed through Port-auPrince, with its private clinics, surgeons, and
oncologists.
“I first noticed a lump in my breast after falling down.
I was carrying a basket of millet on my head. It was not
heavy, but it was large, and I had packed it poorly, perhaps. The path was steep, but it had not rained on that
day, so I don’t know why I fell. It makes you wonder,
though.” At least a dozen heads in line nod in assent,
and some of Anite’s fellow patients make noises encouraging her to continue.
“How long ago was that?” I ask again.
“I went to many clinics,” she says in front of dozens
of people she has met only that morning or perhaps the
night before. “I went to 14 clinics.” Again, many nod
assent. The woman to her left says “Adjè!” meaning
something along the lines of “You poor thing!” and lifts
a finger to her cheek. This crowd response seems to
please Anite, who continues her narrative with gathering
tempo. She still has not let me know how long she has
been ill.
“Fourteen clinics,” I respond. “What did they say was
wrong with you? Did you have an operation or a biopsy?”
The mass is now large and has completely destroyed the
normal architecture of her breast; it is impossible to tell
if she has had a procedure, as there is no skin left to scar.
“No,” replies Anite. “Many told me I needed an operation, but the specialist who could do this was in the
city, and it costs $700 to see him. In any case, I had
learned in a dream that it was not necessary to go to the
city.” (“The city” means Port-au-Prince, Haiti’s capital.)
More of the crowd turns to listen; the shape of the line
changes subtly, beginning to resemble more of a circle.
I think uncomfortably of the privacy of a U.S. examination room and of the fact that I have never seen there
a breast mass consume so much flesh without ever having been biopsied. But I have seen many in Haiti, and
almost all have proven malignant.
Anite continues her narrative. She repeats that on the
day of the fall, she discovered the mass. It was “small
and hard,” she says. “An abscess, I thought, for I was
breastfeeding and had an infection while breastfeeding
once before.” This is about as clinical as the story is to
get, for Anite returns to the real tale. She hurt her back
in the fall. How was she to care for her children and for
her mother, who was sick and lived with her? “They all
depend on me. There was no time.”
And so the mass grew slowly “and worked its way
under my arm.” I give up trying to establish chronology.
I know it had to be months or even years ago that she
first discovered this “small” mass. She had gone to clinic
after clinic, she says, “spending our very last little
money. No one told me what I had. I took many pills.”
“What kind of pills?” I ask.
Anite continues. “Pills. I don’t know what kind.” She
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f a r m e r An Anthropology of Structural Violence F 307
had given biomedicine its proper shot, she seems to say,
but it had failed her. Perhaps her illness had more mysterious origins? “Maybe someone sent this my way,” she
says. “But I’m a poor woman—why would someone wish
me ill?”
“Unlikely,” says an older man in line. “It’s God’s sickness.” Anite had assumed as much—“God’s sickness”
being shorthand for natural illness rather than illness
associated with sorcery—but had gone to a local temple,
a houmfor, to make sure. “The reason I went was because
I’d had a dream. The mass was growing, and there were
three other small masses growing under my arm. I had
a dream in which a voice told me to stop taking medicines and to travel far away for treatment of this illness.”
She had gone to a voodoo priest for help in interpreting
this dream. Each of the lumps had significance, said the
priest. They represented “the three mysteries,” and to
be cured she would have to travel to a clinic where doctors “worked with both hands” (this term suggesting that
they would have to understand both natural and supernatural illness).
The story would have been absurd if it were not so
painful. I know, and once knew more, about some of the
cultural referents; I am familiar with the style of illness
narrative dictating some of the contours of her story and
the responses of those in line. But Anite has, I am almost
sure, metastatic breast cancer. What she needs is surgery
and chemotherapy if she is lucky (to my knowledge,
there is no radiation therapy in Haiti at this time). She
does not need, I think, to tell her story publicly for at
least the fifteenth time.
Anite seems to gather strength from the now-rapt
crowd, all with their own stories to tell the harried doctors and nurses once they get into the clinic. The semicircle continues to grow. Some of the patients are straining, I can tell, for a chance to tell their own stories, but
no one interrupts Anite. “In order to cure this illness,
he told me, I would have to travel far north and east.”
It has taken Anite over a week to reach our clinic. A
diagnosis of metastatic breast cancer is later confirmed.
I am privileged to be presenting this lecture in honor of
someone whose work I very much admire. I will be talking about Haiti and about tuberculosis and AIDS. I’m
not sure I would know how not to talk about these diseases, which each day claim almost 15,000 lives worldwide, most of them adults in their prime. I hope less to
take on grand theory than to ask how the concept of
structural violence might come to figure in work in anthropology and other disciplines seeking to understand
modern social life. Standing on the shoulders of those
who have studied slavery, racism, and other forms of
institutionalized violence, a growing number of anthropologists now devote their attention to structural
violence.
Just as everyone seems to have his or her own definitions of “structure” and “violence,” so too does the term
“structural violence” cause epistemological jitters in our
ranks. It dates back at least to 1969, to Johan Galtung, as
well as the Latin American liberation theologians (see Farmer 2003b, Gilligan 1997, Galtung 1969). The latter used
the term broadly to describe “sinful” social structures
characterized by poverty and steep grades of social inequality, including racism and gender inequality. Structural
violence is violence exerted systematically—that is, indirectly—by everyone who belongs to a certain social order: hence the discomfort these ideas provoke in a moral
economy still geared to pinning praise or blame on individual actors. In short, the concept of structural violence
is intended to inform the study of the social machinery
of oppression. Oppression is a result of many conditions,
not the least of which reside in consciousness. We will
therefore need to examine, as well, the roles played by the
erasure of historical memory and other forms of desocialization as enabling conditions of structures that are
both “sinful” and ostensibly “nobody’s fault.”
The degree to which people can fight back against such
infernal machinery—or its symbolic props—has been the
subject of much discussion in anthropology. We have
written about “the weapons of the weak,” to use James
Scott’s term (1976, 1985, 1990), and many texts have
celebrated various forms of “resistance” to the dominant
social order and its supports, symbolic and material. Romanticism aside, the impact of extreme poverty and social marginalization is profound in many of the settings
in which anthropologists work. These settings include
not only the growing slums and shrinking villages of the
Third World (or whatever it is called these days) but also,
often, the cities of the United States. In some of these
places, there really are social spaces of spirited resistance.
Often, however, the impact of such resistance is less
than we make it out to be, especially when we contemplate the most desperate struggles and attempt in any serious way to keep a body count. One way of putting it is
that the degree to which agency is constrained is correlated inversely, if not always neatly, with the ability to
resist marginalization and other forms of oppression. We
already have good ethnographic accounts of, for example,
how young working-class “lads” in England resist, or do
not resist, “learning to labor” (Willis 1981). We have solid
accounts of how women in industrialized countries—Japan and the United States—contest the meanings and experience of menopause (see Lock 1993, Martin 1987). We
have in-depth reports on “social …
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