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On Suffering and Structural Violence: a View from Below Author(S): Paul Farmer Source: Race/Ethnicity: Multidisciplinary Global Contexts, Vol On Suffering and Structural Violence: A View from Below Author(s): Paul Farmer Source: Race/Ethnicity: Multidisciplinary Global Contexts, Vol. 3, No. 1, Race and the Global Politics of Health Inequity (Autumn, 2009), pp. 11-28 Published by: Stable URL: http://www.jstor.org/stable/25595022 . Accessed: 10/04/2014 03:16 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. http://www.jstor.org This content downloaded from 133.30.212.149 on Thu, 10 Apr 2014 03:16:53 AM All use subject to JSTOR Terms and Conditions On Suffering and Structural Violence: A View from Below Paul Farmer j veryone knows that suffering exists. The question is a I how to define it.Given that each person's pain has or J?mmmi degree of reality for him her that the pain of others never on can surely approach, iswidespread agreement the sub us ject possible? Almost all of would agree that premature and painful illness, torture, and rape constitute extreme suffering. on as Most would also agree that insidious assaults dignity, such institutionalized racism and sexism, also cause great and unjust injury. our consensus on some more Given of the conspicuous forms a of suffering, 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? as or more Are certain "event" assaults, such torture rape, likely are to lead to late sequelae than sustained and insidious suffer as or ing, such the pain born of deep poverty of racism? Under this latter rubric, are certain forms of discrimination demonstra more bly noxious than others? as Anthropologists who take these research questions study both individual experience and the larger social matrix inwhich see it is embedded in order to 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 as racism become embodied individual experience? This has been most own the focus of of my research inHaiti, where political and economic forces have structured risk forAIDS, tuberculosis, and, indeed, most other infectious and parasitic diseases. Social forces at work there have also structured risk formost forms of extreme suffering, from hunger to torture and rape. From Daedalus, 125:1 (Winter, 1996), pp. 251-283. @1996 by theAmeri can Academy of Arts and Sciences. Reprinted with the permission of the publisher, MIT Press Journals. ? 2009 The Ohio State Office autumn 2009 11 University / ofMinority Affairs/The Kirwan Institute This content downloaded from 133.30.212.149 on Thu, 10 Apr 2014 03:16:53 AM All use subject to JSTOR Terms and Conditions PAUL FARMER Working in contemporary Haiti, where in recent years polit ical violence has been added to the worst poverty in the hemi one a coun sphere, learns great deal about suffering. In fact, the a sort tryhas long constituted of living laboratory for the study of affliction, no matter how it is defined. "Life for the Haitian some peasant of today/' observed anthropologist Jean Weise a twenty-five years ago, "is abject misery and rank familiarity with death."1 The situation has since worsened. When in 1991 a international health and population experts devised "human measures suffering index" by examining of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by "extreme human suffering." one was Only of them, Haiti, located in the Western hemi was sphere. In only three countries in the world suffering more judged to be extreme than that endured inHaiti; each of an these three countries is currently in the midst of internation war. ally recognized civil a Suffering is certainly recurrent and expected condition in war. Haiti's Central Plateau, where everyday life has felt like one "You get up in the morning," observed 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 come mountains and clement weather, long-term visitors to see the Central Plateau inmuch the same manner as its inhabitants: a chalky and arid land hostile to the best efforts of the peasant farmers who live here. Landlessness iswidespread and so, con measures sequently, is hunger. All the standard reveal how ten on uous the peasantry's hold survival is. Life expectancy at as as birth is less than fiftyyears, in large part because many two of every ten infants die before their first birthday. Tubercu cause losis is the leading of death among adults; among chil dren, diarrheal disease, measles, and tetanus ravage the under nourished. is not But the experience of suffering, it is often noted, effec or tively conveyed by statistics graphs. The "texture" of dire af fliction is perhaps best felt in the gritty details of biography, and so I introduce the stories of Ac?phie Joseph and Chouchou are Louis.2 The stories of Ac?phie and Chouchou anything but as as ana "anecdotal." For the epidemiologist well the political in fashion. of lyst, they suffered and died exemplary Millions circumstances can tomeet simi people living in similar expect lar fates. What these victims, past and present, share are not or do not share personal psychological attributes?they culture, or race. share is the of language, Rather, what they experience in occupying the bottom rung of the social ladder inegalitarian societies.3 stories Ac?phie Joseph's and Chouchou Louis's illustrate some of themechanisms through which large-scale social forces of individual crystallize into the sharp, hard surfaces suffering. often eco Such suffering is structured by historically given (and nomically driven) processes and forces that conspire?whether as more the through routine, ritual, or, is commonly case, these RACE/ETHNICITY VOL. 3 /NO. I 12 This content downloaded from 133.30.212.149 on Thu, 10 Apr 2014 03:16:53 AM All use subject to JSTOR Terms and Conditions on suffering and structural violence: a view from below hard surfaces?to constrain agency4 For many, including most are of my patients and informants, life choices structured by racism, sexism, political violence, and grinding poverty. Ac?phie's Story For thewound of the daughter ofmy people ismy heart wounded, me. I mourn, and dismay has taken hold of Is there no balm inGilead? Is thereno physician there? Why thenhas thehealth of thedaughter of my peoplenot been restored? a 0 thatmy head were waters, and my eyes fountain of tears, that 1might weep day and nightfor theslain of thedaughter of my people! ?Jeremiah 8:22-9.1 a Kay, community of fewer than fifteen hundred people, east stretches along an unpaved road that cuts north and into Haiti's Central Plateau. Striking out from Port-au-Prince, the can capital, it take several hours to reach Kay The journey gives one an impression of isolation, insularity. The impression is as owes a con misleading, the village its existence to project ceived in the Haitian capital and drafted inWashington, D.C.: a Kay is settlement of refugees, substantially composed of peas more ant farmers displaced than thirty years ago by Haiti's largest dam. was a Before 1956, the village of Kay situated in fertile valley, ran and through it the Riviere Artibonite. For generations, thou sands of families had farmed the broad and gently sloping banks of the river, selling rice, bananas, millet, corn, and sugar cane in regional markets. Harvests were, by all reports, bounti now as was ful; life there is recalled idyllic. When the valley flooded with the building of the dam, the majority of the local was on population forced up into the stony hills either side of new the reservoir. By all the standard measures, the "water refugees" became exceedingly poor; the older people often blame their poverty on the massive buttress dam a few miles note away, and bitterly that it brought them neither electricity nor water. In 1983, when I began working in the Central Plateau, AIDS, an although already afflicting increasing number of city dwell was areas as as ers, unknown inmost rural Kay. Ac?phie Joseph was one new of the first villagers to die of the syndrome. But was a her illness, which ended in 1991, merely the latest in string of tragedies that she and her parents readily linked together in a now long lamentation, by familiar to those who tend the re gion's sick. The litany begins, usually, down in the valley hidden under came the still surface of the lake. Ac?phie's parents from fami a liesmaking decent living by farming fertile tracts of land?their "ancestors' gardens"?and selling much of their produce. M. Jos a eph tilled the soil, and his wife, tall and wearily elegant wom an as not nearly as old she looked, was a "Madame Sarah," a autumn 2009 13 This content downloaded from 133.30.212.149 on Thu, 10 Apr 2014 03:16:53 AM All use subject to JSTOR Terms and Conditions PAUL FARMER market woman. "If itweren't for the dam," M.
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