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The Oxford Handbook of the Social Science of Poverty
David Brady (ed.), Linda M. Burton (ed.) https://doi.org/10.1093/oxfordhb/9780199914050.001.0001
Published: 2016       Online ISBN: 9780190459604       Print ISBN: 9780199914050
CHAPTER
3 Structural Violence, Poverty, and Social Suffering £
Barbara Rylko-Bauer, Paul Farmer
https://doi.Org/10.1093/oxfordhb/9780199914050.013.4   Pages 47-74 Published: 05 April 2017
Abstract
This article examines the interrelationships among structural violence, poverty and social suffering. It begins with a vignette from Haiti, the poorest country in the Western Hemisphere, that puts a face on structural violence. It then traces the historical roots and characteristic features of the concept of structural violence and goes on to discuss its relationship to other types of violence. It also considers how the notion of structural violence has been applied across various disciplines to enhance our understanding of social problems linked to profound poverty and social suffering. Furthermore, it describes the utility and relevance of structural violence to social analysis before concluding with an overview of how anthropology can be used in refining the concept of structural violence.
Keywords: structural violence, poverty, social suffering, Haiti, social problems, social analysis, anthropology
Subject: Economic Sociology, Sociology Series: Oxford Handbooks Collection: Oxford Handbooks Online
structural violence is the violence of injustice and inequity—"embedded in ubiquitous social structures [and] normalized by stable institutions and regular experience" (Winter and Leighton 2001:99). By structures we mean social relations and arrangements—economic, political, legal, religious, or cultural— that shape how individuals and groups interact within a social system. These include broad-scale cultural and political-economic structures such as caste, patriarchy, slavery, apartheid, colonialism, and neoliberalism, as well as poverty and discrimination by race, ethnicity, gender, sexual orientation, and migrant/refugee status. These structures are violent because they result in avoidable deaths, illness, and injury; and they reproduce violence by marginalizing people and communities, constraining their capabilities and agency, assaulting their dignity, and sustaining inequalities.
While these outcomes are "experienced individually, structural violence targets classes of people and subjects them to common forms of lived oppression. Hence, the experience of structural violence and the pain it produces has been called 'social suffering' " (Singer and Erickson 20llb:l). Like structural violence,
this concept defies neat categorization, since it "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" (Kleinman, Das, and Lockl997:ix). Social suffering captures the lived experience of distress and injustice, while exposing the "often close linkage of personal problems with societal problems," thereby challenging the problematic tendency in the social, health, and policy sciences to focus mainly on the individual and ignore broader determinants (Kleinman et al. I997:ix).
Structural violence focuses attention on the social machinery of exploitation and oppression—"the ways in which epic poverty and inequality, with their deep histories, become embodied and experienced as violence" p. 48    (Farmer 2010:293). We have yet to U find a better phrase to convey these harmful and often fatal processes. We begin with a vignette from the poorest country in the Western Hemisphere that vividly illustrates such processes and puts a face on structural violence. We then discuss the historical roots and characteristic features of this concept, explore its relationship to other types of violence, and survey how it has been applied across various disciplines to enhance our understanding of social problems linked to profound poverty and social suffering. We conclude with an overall assessment of the utility and relevance of structural violence to social analysis.
The Face of Structural Violence
Mirebalais is a busy market town in the middle of Haiti's Central Plateau. It appears on maps from the colonial era, when French slaveholders extracted great bounty from their most productive colony until a slave revolt that began in 1791 brought at least this form of exploitation to a bloody end. Through the first century of Haiti's independence, Mirebalais was a small agricultural hub where peasant farmers—the descendants of the victorious rebel slaves—gathered on Saturdays to buy and sell their wares.
In the 1920s, the Central Plateau was the site of skirmishes between the United States' Marine Corps, who were then occupying Haiti, and the armed resistance that ensued. The remainder of the twentieth century was not particularly kind to Mirebalais either. While its population grew, the town enjoyed very little in the way of modern infrastructure development. A few paved roads crossed the town square, and a single bridge spanned the Latem River. This relative modernity may have accounted for the decision in 2004. to site the regional hub of the UN's peacekeeping mission there.
In 2008, four hurricanes hit Haiti in less than two months. During the third of these, a tributary of the Latem rose in fury through the peacekeepers' camp, manned largely by Nepali troops, sweeping white containers emblazoned with the UN logo first into the river and then against the bridge, which collapsed. The bridge over the Latem has never been repaired; only a cement ford connects the Central Plateau to Haiti's western coast.
The hurricanes, powerful though their impact was, did not change life in Haiti as radically as the 2010 earthquake that killed over a quarter-million people and displaced over three million more, including 500,000 to the Central Plateau. One consequence was the nation's first recorded cholera epidemic. The lack of clean water in Haiti had been earlier identified as a predisposing risk factor for epidemic illness, including cholera (Varma et al. 2008). With few sources of water for drinking and cleaning other than the local rivers, the stage was set for the introduction of waterborne pathogens and their rapid spread throughout the country. Among the most vulnerable were those living with both poverty and mental illness (Ivers and Walton 2012).
From the age of 12, Pierre (a pseudonym) and his family knew that something was wrong. Pierre "heard things," and his auditory hallucinations evolved into frank paranoia and grossly disorganized thought. He p. 49    left his family and took to wandering U the streets of Mirebalais, often naked, sometimes taunted by local
children and passersby, but mostly left alone as mounfou (crazy person). He regularly bathed and drank directly from the Latem River, living a fragile, often miserable existence on the city's streets.
On October 12, 2010, Pierre, now in his 30s, suffered a violent onset of profuse watery diarrhea. He returned home but quickly died before his family could seek medical attention. They contacted a funeral home in Mirebalais, where Pierre was bathed, dressed, and laid out for a classic Haitian wake. When two of the helpers who had prepared Pierre's body for burial fell ill with similar explosive diarrhea, suspicions of communicable disease were raised. By October 20, less than two weeks after Pierre's attack of sickness, there were scores of cases of profuse diarrhea in Mirebalais and in the villages connected to it by the Latem and its tributaries. The epidemic raced west along Haiti's largest river, reaching the coastal cities of Gonai'ves and Saint-Marc. By October 22, the Haitian authorities, working with international authorities, announced that for the first time in recorded history, cholera had reached Haiti—likely brought there by Nepali UN forces and introduced into the river system through faulty sanitary practices at the UN base camp at Mirebalais.
In reporting on this first case, Ivers and Walton (2012:37-38) conclude: "This patient's case illustrates the relationship between an infectious disease epidemic, mental health, and globalization. It highlights the fact that to provide and maintain health in circumstances of destitute poverty where many factors are at play... attempts to address individual pieces of health without consideration of the whole are as the Haitian proverb goes, 'like washing your hands and drying them in the dirt.' "
Understanding Structural Violence
Historical Roots
The term "structural violence" was introduced in a 1969 essay by Norwegian sociologist Johan Galtung, the main founder of peace and conflict studies and of the Journal of Peace Research. He defined peace as the absence of not only direct physical violence—ranging from interpersonal to collective violence—but also indirect structural violence, caused by forces such as poverty, marginalization, and exploitation.1 According to Weigert (1999:4.32), the notion of peace as more than the absence of war originates with Quincy Wright (194.2:1305), who in A Study of War wrote that "the positive aspect of peace—justice—cannot be separated from the negative aspect—elimination of violence." Galtung (1969:183) further conceptualized "positive peace" as the "absence of structural violence" and explicitly linked structural violence to unequal power, especially "the power to decide over the distribution of resources," which results in "unequal life chances" (1969:171). He claimed that structural violence led to more death and suffering than physical violence, an p. 50    observation later u confirmed by Kohler and Alcock (1976), who estimated that the fatal consequences of structural violence globally for 1965 were about 130 times greater than for direct violence (Gilligan 1999).
Galtung illustrated the idea of structural violence as avoidable harm by noting that deaths from tuberculosis in the eighteenth century were unavoidable, "but if [a person] dies from it today, despite all the medical resources in the world, then violence is present," and he similarly argued that "differential social impact" from earthquakes is preventable (Galtung 1969:168,186). Since then, others have linked the structural violence of poverty and environmental destruction to the increased risks and consequences of "so-called natural disasters, where conscious policies have made populations vulnerable and unprepared for predictable harms triggered by dramatic weather events" (Demenchonok and Peterson 2009:53; Kagawa 2005).
The tragic aftermath of the 2010 Haitian earthquake, for example, included immediate fatalities and injuries as well as subsequent deaths and disease that were due to largely avoidable circumstances—lack of clean
water, inadequate shelter, insufficient food, and poor access to medical care. It brutally exposed the pervasive, deeply rooted, and multifaceted structural violence that has plagued Haiti for decades (Farmer 2011a). The earthquake was, to use a term from clinical medicine, an "acute-on-chronic" event—direct violence on layers of structural violence. "It was devastating because a history of adverse social conditions and extreme ecological fragility primed Port-au-Prince for massive loss of life and destruction when the ground began shaking on January 12" (Farmer 20llb:3).
Johan Galtung expanded on structural violence in later writings, suggesting ways of measuring its impact (Galtung and H0ivikl97l), examining "social science as structural violence" (1975:264.), and exploring how all types of violence are legitimized (1990). There were even attempts to compute an "index of structural violence" (H0ivikl977) that focused on differential outcomes, such as life expectancy, death rates, or loss of life years.
Other scholars and advocates of social justice have explored the relationship of violence and injustice. Martin Luther King Jr. (1966) referred to "the violence of poverty" (see also Lee 1996; Gilligan 1997), and others have written about the violence of racism (Geiger 1997) and of hunger in the midst of plenty (Brown 1989). Newton Garver characterized violence as the violation of fundamental human rights, illustrated through examples from inner city ghetto life. His category of covert institutional violence that "operates when people are deprived of choices in a systematic way by the very manner in which transactions normally take place" is similar to Galtung's structural violence (Garver 1973:265). The feminist movement also played a role "in opening up the definitions of violence to include a range of behaviours including... physical, emotional and psychological abuse" (Morgan and Bjorkert 2006:4.4.2).
Around the same time, Latin American liberation theologians, such as Gustavo Gutierrez (1973,1983) and Dom Helder Camara (1971) were applying tools of social analysis to understand violence in that part of the world. Social structures such as profound poverty and racism, in conjunction with pervasive political p. 51    oppression, were U causing great suffering. Brazilian philosopher Paulo Freire (2004:118) wrote in 1977 that violence "refers not only to direct, physical violence, but also to ... violence and hunger, violence and the economic interests of superpowers, violence and religion, violence and politics, violence and racism, violence and sexism, violence and social classes" — in other words, structural violence.
Structural Violence: A View from Below
For the last three decades, considerable effort has been devoted to critically examining and analyzing the epidemiology, political economy, and sociocultural nature of two deadly but treatable infectious diseases of global proportions: AIDS and tuberculosis—both the "centuries-old" TB and the "new" TB in its multidrug-resistant forms (see Farmer 1992,1997a, 1999, 2003, 2010). The aim of this work was to use theory and knowledge to advance praxis—to improve prevention and treatment for those most at risk of acquiring these diseases and dying from them. AIDS and TB serve as perfect laboratories for the study of structural violence (Farmer 1997b; Farmer et al. 2006), and are best understood as biosocial phenomena shaped by history, geography, and political economy, as well as the biological and social context of individuals and their communities (Farmer 2004). Both diseases disproportionately target populations living in great poverty. And such poverty is closely linked with gender inequality, racism, lack of access to the basic necessities of life, and lack of access to resources that maintain well-being, such as healthcare, education, jobs, and security (Farmer 2003; Mukherjee 2007).
All diseases that affect primarily the poor are, by definition, neglected diseases, and cholera offers an object lesson. One hundred fifty years after John Snow took the handle off the Broad Street pump, more than a century after his suspicions of bacterial origin were confirmed, 60 years after antibiotic therapy was
discovered, and 30 years after a safe and effective oral vaccine was developed, cholera remains—among the world's poorest—a leading infectious killer.
The cholera epidemic in Haiti, an island nation of 10 million, is the world's largest in recent history. In its first year, cholera claimed some 6,500 lives and caused half a million cases (Farmer and Ivers 2012). These official numbers are undoubtedly low because there is little reporting capacity in rural areas, where the disease struck first and hardest.
If we know so much about cholera and its pathophysiology, epidemiology, treatment, and prevention, how did it become the leading infectious killer of young adults in Haiti during the international humanitarian response to the January 2010 earthquake? The short answer is that expectations are lowered for diseases that disproportionately afflict poor people. Investment in long-term public-sector water and sanitation p. 52    systems, the bulwark against cholera and other waterborne diseases, have stalled or failed to keep U up
with demand. Safe, effective, and affordable oral vaccines exist, and yet remain largely unavailable in Haiti, and the same is true for timely diagnosis and care. We have the knowledge and tools for prevention and treatment; what we lack is an equity plan linked to a delivery system (Farmer and Ivers 2012).
The Haitian epidemic also demonstrates why structural violence is so often hard to describe. It is distant. In our postmodern world of global connections and instant images, "being a spectator of calamities taking place in another country is a quintessential modern experience" (Sontag 2003:18). Nevertheless, while the suffering of individuals whose lives and struggles recall our own tends to move us, the anonymous suffering of those more remote, geographically, culturally, or socially is often less affecting (Farmer 2006a).
It is largely invisible. Physical violence shows, whereas "structural violence is silent... [and] may be seen as about as natural as the air around us" (Galtung 1969:173). Many structural inequities are long-standing; they seem a natural part of the social order. But as anthropologist Nancy Scheper-Hughes reminds us (1996:889), "invisible" does not mean "secreted away and hidden from view, but quite the reverse.... [T]he things that are hardest to perceive are often those which are right before our eyes and therefore simply taken for granted." Haiti's extreme poverty and underdevelopment has certainly been visible for decades (Farmer 1997a; 2006b). Another factor is the preoccupation of politicians and the media with dramatic forms of violence. "Injustice—in either deed or word—is never linked to violence but rather interpreted in an economic, symbolic, or psychologist register.... [P]hysical violence ... is never related to that other violence—of exclusion, discrimination, and humiliation" (Fassin 2009:117).
It is massive. The sheer weight and enormity of suffering is not easily or effectively conveyed by statistics or graphs. Economist Amartya Sen (1998:2) has argued for moving beyond "cold and often inarticulate statistics of low incomes" to look in detail at the various ways in which agency— "the capabilities of each person"—is constrained. In other words, we need individual case studies that are embedded in the larger matrix of culture, history, and political economy.
While no single axis of inequality—gender, race, ethnicity, immigrant status, sexual orientation, class—can fully define extreme human suffering, we argue for the primacy of poverty, which is often linked with other structures of inequity. "Today, the world's poor are the chief victims of structural violence—a violence that has thus far defied the analysis of many who seek to understand the nature and distribution of extreme suffering" (Farmer 2003:50).
Typologies and Intersections of Violence
In an effort to address violence as a global public health problem, the World Health Organization (WHO), developed a typology (Krug et al. 2002) that focuses on a U "minimalist" notion of violence as direct and physical force, with no mention of structural violence despite recognizing poverty as an important risk factor in all kinds of violence (Bufacchi 2007:23; Perry 2009:377). As this example illustrates, typologies of violence, while useful (Rutherford et al. 2007), can lead to narrow conceptualizations of social issues. In addition, within real-life contexts, such categories are fluid and not so easily delineated. For example, in their discussion of how interpersonal physical violence becomes a routine part of everyday urban life for vulnerable and marginalized groups, Singer and Erickson (20lla) identify the subsets of "street violence" and "private violence," subcategories that often overlap or merge.
Rape, especially gang rape, can be a form of street violence but most often (certainly in the United States) occurs out of public view. In both instances it is often linked to structural factors, such as poverty and gender inequality, and to sociocultural meanings ascribed to women and their bodies. Rape can also be political violence when used systematically as a weapon of aggression or war (Stark and Wessells 2012), and its consequences often lead to increased structural violence. The global distribution of the AIDS epidemic, for example, is determined to a large degree by structural violence and "rape is a major factor driving the AIDS epidemic" (Mukherjee 2007:117). In such circumstances, rape encompasses several kinds of violence, with roots well established in "peacetime meanings of sexuality" (Olujic I998b:33). Similarly, in the context of refugee and IDP (internally displaced persons) camps, rape may have all of these connotations and be a manifestation of structural violence, since it goes largely unreported and is often dismissed by humanitarian organizations and their staff as an "unfortunate" part of the refugee context (Whiteford 2009).
This complex relationship between direct and structural violence was noted over 150 years ago by German physician and anthropologist Rudoph Virchow, who wrote that "war, plague and famine condition each other" (cited in Rather 1985:115). There is ample evidence that war and political violence have grave impacts on the health and well-being of individuals, communities, and nations—beyond the immediacy of conflict-induced injury and death (Geneva Declaration Secretariat 2008; Levy and Sidel 2008; Pedersen 2002; Taipale et al. 2002).
Anthropologists, in particular, have shown that war and conflict not only affect infrastructures supporting local health care, education, markets, and farming activities, but also disrupt families and community support systems, damage the environment, interrupt means of livelihood, and displace populations (Leatherman and Thomas 2008; Rylko-Bauer and Singer 2010; Rylko-Bauer, Whiteford, and Farmer 2009; Singer and Hodge 2010). These impacts are often mediated by preexisting forms of structural violence which, in the aftermath of conflict, contribute to even greater levels of poverty, political marginalization, and racism (Fassin 2009; Miller and Rasmussen 2010; Nordstrom 2004; Panter-Brick20l0; Quesada 2009). Moreover, these consequences often have a long half-life (Becker, Beyene, and Ken 2000; Das 2007; Johnston 2007, 2011; Johnston and Barker 2008). Women are especially victimized by multiple forms of violence, which often interact and are shaped by both gendered dimensions of conflict and preexisting gender discrimination (Annan and Brier 2010). And children are U particularly vulnerable, but the "costs [they] pay for the actions of war and its devastating aftermath... are often neglected" (Quesada 1998:64.-65; see also Kent 2006; McEvoy-Levy 2001; Nordstrom 2009; Olujic 1998a).
Structural violence, in turn, contributes in complex ways to the preconditions for explosive direct violence (Bonnefoy, Burgat, and Menoret 2011; Rylko-Bauer and Singer 2010; Rylko-Bauer et al. 2009; Singer and Hodge 2010). Armed conflict is more likely in low to middle-income countries with slower economic growth, greater gaps in income and resource distribution, and high rates of poverty, hunger, and poor
health (Krug et al. 2002; Pinstrup-Andersen and Shimokawa 2008; Stewart 2002). Structural violence has even been examined as a form of genocide (Ahmed 2007; Lewy 2007). Rwanda is a compelling example. Decades of colonial and imperialist exploitation, coupled with the construction of ethnic difference, laid the groundwork for the explosive violence of 1994. (Farmer 2009). Western development aid ignored structural inequities and human rights violations, thus contributing to already existing poverty, unequal distribution of land and resources, social exclusion, and class divisions—so that by "the 1990s, the interaction between structural violence and racism created the conditions for genocidal manipulation by the elites" (Uvin 1999:54)-
Several models have been proposed for exploring how both direct and indirect violence serve as precursors to collective physical violence (De Jong 2010). One example is the notion of a continuum of violence (Scheper-Hughes 1996, 2007; Scheper-Hughes and Bourgois 2004), based on the recognition that social tolerance of "everyday" structural violence, and the humiliation that accompanies it, sets the stage for normalization of more overt and visible forms, from police brutality and state-directed political violence to massacres and genocides (Scheper-Hughes 1996; Uvin 1999).
This is particularly applicable to Latin America where there has been a shift from the brutal political violence of the latter twentieth century to the more recent growth in criminal and interpersonal violence (Briceňo-León and Zubillaga 2002; Sanchez 2006). These rates correlate with lower levels of development and higher income inequality within the region (Bliss 2010; United Nations Office on Drugs and Crime 20ll). While conventional analyses link these trends to drug trafficking, gang membership, readily available firearms, and a weak criminal justice system (World Bank 20ll), a number of anthropologists see a deeper link with the past (Bourgois 2001; Heggenhougen 2009; Manz 2009; Metz, Mariano, and Garcia 2010), a "continuum of violence spanning the civil war years to the present... [the] outcome of a history of structural violence, gender norms, and political repression" as well as racism directed against indigenous populations (Bourgois 2009:36).
Layered upon this legacy of political violence is the more recent "structural violence [of] rampant economic inequality, social exclusion, and persistent poverty arising from the imposition of neoliberal economic policies," namely structural adjustment programs linked to development aid and unfair international trade agreements (Sanchez 2006:179; Quesada 2009). Similar processes in other parts of the Global South have exacerbated the poverty, dislocation, and lack of jobs in the U formal economy that serve "as a trigger" for growing rates of "reactive" social and criminal violence (Winton 2004:166-67).
Understanding Invisible Violence
Structural violence is only one among several forms of less visible violence that are interconnected in complex ways. Anthropologist Philippe Bourgois (2009) has proposed a conceptual framework for critically examining how the invisible processes of structural, as well as symbolic, and normalized violence are linked across time and space to various kinds of direct violence. A central element in all three concepts is the normalization of unequal power relations.
Symbolic violence is associated with sociologist Pierre Bourdieu (2000) and refers to sociocultural mechanisms and relations of unequal power and domination that exist within interpersonal relationships and in other spheres of life. It is embedded in ordinary daily life, manifested through language, symbolism, and actions that are perceived by both perpetrator and victim as normal or deserved, a legitimate and inevitable part of the natural social order. "Symbolic violence is... so powerful precisely because it is unrecognizable for what it is." Its power "rests precisely in its lack of visibility—in the fact that for those exposed to it the doubts and the fear engendered by it cause them to question themselves" (Morgan and
Bjorkert 2006:4.4.8). A classic example is that of intimate partner violence, where women blame themselves and are blamed by others for the violence perpetrated against them.
Symbolic violence harms both psychologically and emotionally and is often used to justify everyday interpersonal and structural violence, as Simic and Rhodes (2009) demonstrate in their study of street sex workers in Serbia. Similarly, in his research of Puerto Rican crack dealers in New York's East Harlem, Bourgois (2003) shows how structural and symbolic violence interact and set conditions for the everyday interpersonal conflicts "that the socially vulnerable inflict mainly onto themselves (via substance abuse), onto their kin and friends (through domestic violence and adolescent gang rape), and onto their neighbors and community" (Bourgois 200l:ll).
The normalized violence that Bourgois (2001, 2009) refers to is an adaptation of the concept of everyday violence initially developed by Scheper-Hughes (1992) to highlight the extreme poverty and high infant and child mortality that characterized life in Brazilian shantytowns. She later applied this concept to life circumstances affecting other socially marginalized people, such as Brazilian and South African street youth or the elderly in U.S. nursing homes (Scheper-Hughes 1996, 2007).
The concept of normalized violence recognizes the indifference in broader society and identifies mechanisms by which violence becomes an inevitable part of daily life for its victims. For example, in his life history of a street drug addict named Tony, Merrill Singer (2006:72) observes that "the threat of violence-emotional and physical—daily preparation for violence on the street, and enduring the agony of violence-p. 56    inflicted U pain were all commonplace to [Tony] as an integral part of the world of street drug use and
sales. He had come to accept violence as he had bad weather, harsh but unavoidable." Some scholars have called for more detailed and nuanced analysis. For example, in examining the "routinization of political violence as a social violence of the everyday" in communist China, Kleinman (2000:235) concludes that we should pay closer attention to the "multiplicity of violences of everyday life" across classes of people and social contexts, each with "different histories, sustained by different social dynamics," and varied "outcomets] in trauma and suffering."
Applying Structural Violence in Social Analysis
Recent social science reviews call for multidisciplinary perspectives on violence (Bufacchi 2009; Krause 2009; Panter-Brick 2010) that counter the tendency to compartmentalize, with "few links among different ... approaches" (Mcllwaine 1999:455). We decided to examine the potential of structural violence as a unifying cross-disciplinary concept by surveying the literature in social science, social medicine, and public health from the last 15 years (1997-2012). We focused on published articles and limited the search to structural violence per se. The articles covered a broad range of topics, varied methodologies, and often appeared in cross-disciplinary journals, which made it difficult at times to assign articles to one particular discipline. We begin with general remarks on how this concept has been used and then provide a more disciplinary-focused assessment.
Structural violence has definitely become part of the social science and public health lexicon. It seems to be used most often by scholars who take a critical materialist or political economy approach to social problems and issues. The majority reference Galtung's classic 1969 essay, and others refer to Farmer and his colleague's elaboration of this concept.
The nature of structures of violence and the harms they inflict are context specific, which may explain the variability we found in how authors define structural violence. Many definitions are quite general: "violence inherent in the social order" (Eckermann 1998:304); "institutionalized injustice" (Nevins 2009:915); or "political and economic inequality" (Shannon et al. 2008:914). More detailed definitions tend to stress
specific elements, such as exclusion, unequal distribution of resources, avoidable harm, or historically rooted, large-scale forces: "the systematic exclusion of a group from the resources needed to develop their full human potential" (Mukherjee et al. 2011:593); "processes historically rooted in... institutions that differentially enrich or deprive individuals of resources based on the individual's membership in a specific group" (Kohrt and Worthman 2009:239); and "social arrangements that systematically bring subordinated and disadvantaged groups into harm's way and put them at risk for various forms of suffering" (Benson 2008:590).
p. 57   Authors refer to structural violence variously as a lens, frame, rubric, model, theory, or perspective, but in most cases, it seems to primarily serve as a conceptual framework that broadens levels of analysis. Many note its utility in countering traditional explanatory models that narrowly focus on individual-level proximate causes relating to biology, behavior, attitudes, and cultural values of vulnerable persons or groups (e.g., Banerjee et al. 2012; Chakrapani et al. 2007; Huffman et al. 2012; Parker 2012; Sinha 1999; Towle and Lende 2008) or that assume agency, choice, and individual control over behavior and circumstance (Adimora et al. 2009; Mukherjee 2007; Shannon et al. 2008).4
A structural violence framework shifts attention to "what puts people at risk of risks" (Link and Phelan 1995:80); it moves "beyond identifying health disparities to a clear understanding of the inequalities that shape inequalities" and the power relations that structure and sustain them (Leatherman and Goodman 2011:33); and it gets at cumulative root causes (Peha 20ll) by addressing historical forces and social, economic, and political processes that shape risk and local reality. This has important implications for the kinds of measures chosen to restore social stability, security, and peace in the aftermath of violence (Sanchez 2006).
Critiques of the concept urge greater attention to how structural violence is understood locally, by examining emotions, perceptions, and meanings within studies of how those affected by poverty, exclusion, and discrimination respond against or adapt to these assaults (Biehl and Moran-Thomas 2009; Bourgois and Scheper-Hughes 2004.). This includes assessing how poverty, racism, and exclusion create contexts of shame, stigma, humiliation, loss of respect, and violation of self-integrity, which in turn affect health, well-being, and interpersonal relations, and sometimes lead to self-destructive behavior, extralegal activities, and physical—even collective—violence (Benson 2008; Bourgois 2003; Bufacchi 2007; Gilligan 1997; Metz et al. 2010; Uvin 1999).
Many of the articles we looked at can be classified as reviews or analytic essays, but there were also a number of largely qualitative empirical studies, They focus on varied sets of structural factors, depending on the topic being analyzed, but only a few attempt to operationalize and measure dimensions of structural violence (James et al. 2003; Kohrt and Worthman 2009). Variables chosen as proxies for structural violence are often not readily applicable to other research problems or contexts. For example, one study identified childhood malnutrition and diarrhea as the dependent variable and operationalized structural violence along dimensions such as development and gender inequality, measured by country and individual-level indices (Burroway 20ll). Another multilevel study identified the closing of supermarkets in poor urban neighborhoods of Syracuse, New York, as an outcome of the structural violence of poverty and racism. The resulting poor access to food variety was associated with statistically significant increased risk for intrauterine growth restriction, a premature condition linked to low birth weight and other subsequent health problems (Lane et al. 2008). The most detailed example of operationalization is the National Index of Violence and Harm, developed to measure trends in the United States by explicitly quantifying both direct p. 58   violence and the harm "done through negligence" or "the structuring of society U overall" (Brumbaugh-Smith et al. 2008:352). The Societal subindex is divided into two domains: institutional and structural. Variables of structural harm include social negligence in addressing "basic human needs" relating to food, housing, health care, and education; infant mortality and life expectancy, as general indicators of quality of life; hate crimes, as reflections of prejudice; employment discrimination; poverty disparity, examined along
lines of class, race, gender, and age; and gang membership, as a measure of disenfranchisement (Brumbaugh-Smith et al. 2008:355-57).
Some studies explicitly examine the interaction of a select group of such factors by incorporating multiple levels of analysis (Annan and Brier 2010; Shannon et al. 2008), modeling how structural violence relates to other kinds of violence (James et al. 2003), or developing a heuristic framework that includes facets of structural violence along with other factors that operate at different ecological levels—in one case, to understand the social epidemiology of HIV/AIDS (Poundstone, Strathdee, and Celentano 2004). Other studies diagram how structural violence within family, community, legal, and health care systems leads to interpersonal violence, discrimination, stigmatization, and increased HIV vulnerability (Chakrapani et al. 2007); model the interactions of factors—within employment, legal, and health care contexts—that increase vulnerability to tuberculosis and reduce treatment access for poor Uzbek labor migrants in Kazakhstan (Huffman et al. 2012); and identify ecological pathways for how macrolevel risk factors interact to increase HIV vulnerability for women of color (Lane et al. 2004b).
Structural violence clearly covers a long list of structures and harms. This has been a point of critique by some (Nichter 2008:14.8-4.9) who argue that it conflates different kinds of violence (Wacquant 2004) or labels all inequality as violent (Boulding 1977), critiques that both Galtung (1987) and Farmer (2004) have responded to. We believe that this flexibility is a positive feature of structural violence, making it applicable to a wide range of problems and issues which can be characterized as unjust, historically and socially determined, insidious, widespread, and causing avoidable social suffering.
Use of Structural Violence across Disciplines
The largest number of sources was distributed across political science and peace studies, public health and social medicine, and anthropology, but our survey starts with philosophy. Vittorio Bufacchi (2007, 2009) broadly defines violence as violation of a person's physical and psychological integrity and proposes a theory of violence that incorporates social justice without requiring a separate concept. While acknowledging that structural violence focuses needed attention on victims and the harm and humiliation they suffer from forces such as poverty and oppression, he critiques it for overlapping with the notion of p. 59    social injustice. Others concerned with the ethics of peace U have looked at the relationship between the globalization of violence and the structural violence of globalization (Demenchonok and Peterson 2009).
Critical geographers, in turn, have used the concept as an analytic tool to examine the geographies of disease (Hunter 2007); the shift in postsocialist Poland from intentional structural violence of the state, as in expulsions of minorities, to the indirect structural violence of the market (Fleming 2012); the geopolitics of militarization, disease, and humanitarianism (Loyd 2009); the relationship of increased violence and crime to unequal development in the aftermath of political repression in different parts of the world (Mcllwaine 1999; Winton 2004); and negative impacts of postcolonial imperialism that have stymied justice and reparations for wrongs perpetuated during Indonesia's invasion and occupation of East Timor (Nevins 2009). These studies affirm that geography matters in the global distribution of injustice.
Articles with sociological analyses focus largely on issues of gender inequality and sexuality in relation to poverty and health. Several studies demonstrate the links between gendered structural violence and intimate partner violence (Morgan and Bjorkert 2006); disenfranchising economic policies that force poor women into sex work (Hudgins 2005); exploitative working conditions that result in poor quality of elder care and increased risk of physical violence against female caretakers (Banerjee et al. 2012); and the feminization of poverty due to neoliberal policies in sub-Saharan Africa (Ezeonu and Koku 2008). Others focus attention on the less studied topic of children as victims of structural violence, millions of whom are condemned to die from easily preventable and treatable diseases (Kent 2006). For example, structural
factors relating to economic development and women's status, such as maternal education, control over reproduction, and political participation, were found to predict variation in childhood malnutrition and diarrhea across a sample of developing countries (Burroway 20ll). Clearly, addressing gendered structural violence and improving the status of women are critical to continued progress in children's well-being and broader global health and development (Mukherjee 20ll).
Galtung's influence is especially evident in peace psychology, which is concerned with "theories and practices aimed at the prevention and mitigation of direct and structural violence," and focuses on the devastating impact of social forces and structures such as moral exclusion, patriarchy, militarism, globalization, and human rights violations (Christie, Wagner, and Winter 2001:7). Social psychology has also been increasingly concerned with the causes and psychological antecedents of both direct and structural violence, especially regarding racism and discrimination against ethnic minorities (Vollhardt and Bilali 2008), and this is reflected in articles on gender, poverty, and violence (James et al. 2003); the consequences of historical racism and assimilation policy for Aboriginal Australian children (Bretherton and Mellor 2006); and the importance of historically determined poverty in understanding domestic violence within African American communities (Conwill 2007). Psychiatrist James Gilligan (1997:192), who incorporates structural violence into his key work on the root causes of violence, argues for shifting attention "from a clinical or psychological U perspective, which looks at one individual at a time, to the epidemiological perspective of public health and preventive medicine."
Examples from peace and conflict studies or political science include critiques or expansions of Galtung's notion of structural violence (Barnett 2008; Parsons 2007); how structural inequalities shape peace-building efforts (McEvoy-Levy 2001); attempts to conceptualize and measure different facets of institutional and structural violence (Brumbaugh-Smith et al. 2008); explorations of how violent activism in the Persian Gulf region (Bonnefoy et al. 20ll) or interpersonal violence in Latin America (Sanchez 2006) are shaped by historically rooted contexts of structural and everyday violence; assessment of the role of gendered inequality in predicting intrastate conflict (Caprioli 2005); and analyses of historic and contemporary global economic policies, such as transatlantic slavery, colonization and imperialism, artificial famines, and neoliberalism (Ahmed 2007; Prontzos 2004). Many of these studies crossover into development economics since they deal with the harmful consequences of global economic policies (Briceho-Leon and Zubillaga 2002; Uvin 1999).
The frequency of articles from public health, social epidemiology, and social medicine reflects, in part, the influence of those who have helped redefine notions of epidemiological risk by shifting attention from individual to sociocultural, political-economic, and environmental factors that constrain or shape behavior (Janes and Corbett 2011:139; Krieger 1994, 2005; Marmot and Wilkinson 2005). Many studies are cross-disciplinary and often focus on how poverty, racism, and gender inequity become embodied or expressed as disease and illness, in contrast with the "predominant public health approach to ... health disparities" that targets health promotion and has "each person take responsibility for his/her own health" (Lane et al. 2008:4.17). A fair number examine how structural violence shapes increased risk for HIV infection or decreased access to prevention and treatment among vulnerable and disadvantaged populations, such as poor women, male and female sex workers, and ethnic minorities (Adimora, Schoenbach, and Floris-Moore 2009; Cameron 2011; Chakrapani et al. 2007; Lane et al. 2004b; Renwick2002; Shannon et al. 2008; Simic and Rhodes 2009).
Several qualitative empirical studies link these broader social and structural contexts to individual experiences, perceptions of self, or cultural norms and prejudices that determine the reality of those at risk or living with HIV/AIDS. For example, Towle and Lende (2008) demonstrate how cultural constraints on women's decision-making and roles in childbearing, childrearing, and health-care seeking intersect with poverty and women's disenfranchisement to negatively impact effective prevention of mother-to-child HIV
transmission. They support the assertions that "structural violence... is the shadow in which the AIDS virus lurks" (Mukherjee 2007:116) and that AIDS is "a symptom of 'structural violence' " (Hunter 2007:691).
Others look more specifically at how stigma and prejudice based on HIV/AIDS status and other health conditions, or sexual orientation, or immigrant/migrant laborer status, lead to discrimination and structural barriers to care, resulting in poor outcomes for health and well-being (Abadia-Barrero and Castro 2006; U Chakrapani et al. 2007; Huffman et al. 2012; Larchanche 2012; Parker 2012). For example, stigmatization, coupled with poverty, homelessness, and disproportionate incarceration, adversely influence the presentation, management, and outcome of mental illness and limit the role and voice of the mentally ill in civic and social life (Kelly 2005), which translates into "a lack of emphasis on mental health issues on social and political agendas" and inadequate services for the mentally ill (Kelly 2006:2121). Gender inequality, poverty, and marginalization also play a role in explaining women's experiences and risk for depression and anxiety in parts of India and Nepal (Kohrt and Worthman 2009; Rao, Horton, and Raguram 2012).
Expanding Structural Violence: Anthropology's Perspective
Structural violence was introduced to anthropology primarily through the work of Farmer (2003, 2004) and colleagues (Farmer, Connors, and Simmons 1996), whose understanding of the concept includes the importance of global connections, historical processes, and social context in shaping local realities; the embodiment of these inequalities as disease and social suffering; the interaction of biology with culture and political economy; and the limits of resistance and agency. Other anthropologists have expanded on this in creative ways (many have been cited throughout this chapter), some of whom have focused their ethnographic attention specifically on those forces that constrain agency and create suffering (Vine 2009). For example, one case study of environmental degradation and labor safety in Ciudad Juarez, Mexico, incorporated the previously mentioned elements of structural violence in a multifactorial analysis of health risks associated with a foreign-owned chemical plant and their consequences to well-being for nearby residents and workers (Morales et al. 2012). Another example is Akhil Gupta's (2012) multilayered ethnography of bureaucracy and poverty in India, which highlights key mechanisms of structural violence enacted by the state: corruption, the use of written records in a context where the poor are largely illiterate, and the expansion of bureaucratization. These result in the normalization of high poverty rates and avoidable deaths, despite large state investment in less-than-successful programs aimed at improving the lives of the poor.
Biological anthropologists, who take a critical biocultural approach, have found the concept useful in understanding how history and political economy help explain "the causes of malnutrition, disease, and other biological outcomes of social processes," such as poverty and racism (Leatherman and Goodman 2011:4.0) and in analyzing the origins and impact of conflicts (Leatherman and Thomas 2008; Martin 2008). Critical archaeologists have used a structural violence framework to address academic inequities (Bernbeck 2008); expand analyses of the slave trade and African diaspora U (Eiselt 2009:139); and examine the misuse of archaeology in revising national histories, reinforcing nationalism and state control, and appropriating land and cultural heritage within the Israeli-Palestinian context (Hole 2010; Starzmann 2010).
The widest application of structural violence has been in medical anthropology, especially among proponents of critical medical anthropology, some of whom have used this framework in much of their research (e.g., Lane and Rubinstein 2008; Lane et al. 2004a, 2004b, 2008; Leatherman and Thomas 2008; Leatherman 2011; Singer 2009a). Linda Whiteford, for example, highlights how particular groups are systematically excluded from basic resources—the poor from health care access in the Dominican Republic,
volcano-relocated families from access to their lands and livelihoods, indigenous peoples in highland Ecuador from clean water and sewage disposal, and refugee women from reproductive health care-resulting in increased disease, illness, and social suffering (Whiteford 2000, 2005, 2009; Whiteford and Tobin 2004.). Others have integrated structural violence with an environmental justice perspective (Johnston 2011; Morales et al. 2012; Peha 20ll) or with critiques of unhealthy public policies, shaped by racism and political-economic interests, that increase vulnerability to harm, prevent access to care, deny human rights, and sustain poverty and other inequalities (Benson 2008; Castro and Singer 2004; Holmes 2013; Quesada, Hart, and Bourgois 2011; Rylko-Bauer and Farmer 2002).
Medical anthropologists have called for refining structural violence "as a theoretical frame, a method of inquiry, and a moral/ethical imperative" by paying attention to "the complexity and the contradictions of the lives of the poor" (Green 2004.319-20); by documenting how structural violence "operates in real lives" (Bourgois and Scheper-Hughes 2004:318) and how it is expressed "physically and psychically in everyday social suffering" (Walter, Bourgois, and Loinaz 2004:1167); by analyzing how past and present oppression and discrimination are inscribed in public policy and discourse, and on bodies and biographies (Fassin 2007, 2009); and by fleshing out the subjective aspects—emotions, meanings, perceptions—of social suffering and exploring the interconnections of structure and agency (Biehl and Moran-Thomas 2009), as well as examining how structural forces are mediated by cultural understandings.
Building upon Leatherman's (2005) notion of a "space of vulnerability," Quesada and colleagues have proposed extending "the economic, material, and political insights of structural violence to encompass... cultural and idiosyncratic sources of physical and psychodynamic distress" through the concept of structural vulnerability (Quesada et al. 2011:341), which they apply to their analysis of the living and working conditions of Latino immigrants in the United States. (Cartwright 2011; Holmes 20ll). Others have noted the cumulative nature of structural vulnerabilities (Huffman et al. 2012; Ribera and Hausmann-Muela 20ll).
Finally, syndemics offers another means of refining the concept of structural violence. Developed initially by Merrill Singer (1996) to describe the complex interaction between substance abuse, violence, and AIDS among inner city poor, syndemics is "the concentration and deleterious interaction of two or more diseases p. 63    or other health conditions in a population, especially as a consequence of U social inequality and the unjust exercise of power" (Singer 2009b:xv). It underscores the synergistic "adverse health effects arising from connections among epidemic disease clustering, disease interaction, and health and social disparities" (Singer 2009b:l8), and has been applied to a wide variety of cases (Cartwright 2011; Ribera and Hausmann-Muela 2011; Singer 2009a; Singer et al. 20ll). Using this perspective, Singer (2009b:l40-53) notes that the impact of structural violence on health and well-being can be direct via factors such as poverty and racism that often have a cumulative effect, or it can be mediated through mechanisms such as stress, environmental conditions, diet, and self-destructive strategies for coping with the social suffering that structural violence inflicts.
Conclusion: The Relevance and Utility of Structural Violence
As the chapters in this Handbook demonstrate, poverty is a complex phenomenon linked to other forms of social, political, and economic inequities and often rooted in long-standing, historically determined social structures. The analytic framework of structural violence focuses attention on mechanisms that support poverty and other forms of inequity, highlights the interdependence of these structural factors and their relationship to other forms of violence, and identifies the ways by which they cause unequal distribution of harm.
We have described how structural violence redefines the notion of risk by expanding the analytic gaze from individual characteristics or interpersonal relations to a nested series of broader social contexts and
structural forces. Many authors argue that the understandings gained from such an approach, grounded in the real-life experiences of vulnerable populations, can lead to more effective local interventions, better social policy, and social change that addresses the roots of poverty, inequality, and social suffering (e.g., Abadia-Barrero and Castro 2006; Adimora et al. 2009; Towle and Lende 2008; Whiteford and Whiteford 2005).
Structural violence is a morally weighted term, not only because "structures of violence" clearly carry a negative social valence, but also because it is firmly linked to the notion of social and economic human rights (Lykes 2001). The "violence" part of the concept lends "the needed sense of both brutality and intent" (Mukherjee et al. 2011:593) and focuses attention on "the premature and untimely deaths of people. Violence here is not so much the violation of the everyday but the reduction to bare life" (Gupta 2012:21). The emphasis on avoidable harm is at the heart of structural violence and raises issues of social responsibility, redefines global ethics, and challenges the prevailing social change paradigm that is guided by utilitarian economics, where basic human needs like food, clean water, housing, and health—all too often denied to the poor—are viewed dispassionately as variables in global economic development.
p. 64    Finally, structural violence challenges the notion of a purely descriptive and objective social science. It
demands that we look at the world through the eyes of those least able to change it and that our research be linked in some way to advocacy and action. The end result will be a more engaged social science with a better chance of making a difference in alleviating poverty and addressing other pressing social issues of our time.
Notes
1. Galtung (1969:170,171) used "personal" instead of "physical" to emphasize that such direct violence involved some actor, be it an individual, a group, an army, or the state, in contrast to structural violence, "where there is no such actor... the violence is built into the [social] structure."
2. Four search engines were used: Google Scholar, JSTOR, PubMed, and Web of Science. Commentaries, book reviews, and gray literature were not included. We were greatly assisted in this task by Gretchen Williams Pierce (n.d.).
3. One study (James et al. 2003) draws its understanding of structural violence from Bulhan's (1985) work on Frantz Fanon and several cite Amartya Sen's (1999) theory of "development as freedom" and notion of "capabilities and needs."
4. See the following for discussions of this point within epidemiology (Heggenhougen 2005; Link and Phelan 1995), public health and medicine (Farmer 2010; Farmer et al. 2006; Quesada et al. 2011), environmental health (Peha 2011), and psychology (Christie et al. 2001).
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