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On
and
Suffering
Violence:
Structural
A View
from
Below
Paul Farmer
is
veryone knows that suffering exists. The question
how to define it.Given that each person's pain has a
J?mmmi degree of reality for him or her that the pain of others
can surely never approach,
iswidespread
agreement on the sub
us
would
Almost
all
of
agree that premature and
ject possible?
painful illness, torture, and rape constitute extreme suffering.
I
Most would
institutionalized
injury.
Given
our consensus
on some of themore
forms
conspicuous
a
come to the fore.
of suffering,
number of corollary questions
Can we identify those most at risk of great suffering? Among
is it possible
to identify
those whose
suffering is not mortal,
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 suffer
as the
or of racism? Under
ing, such
pain born of deep poverty
this latter rubric, are certain forms of discrimination demonstra
more noxious
than others?
bly
who take these as research questions
Anthropologists
study
both individual experience and the larger social matrix inwhich
in order to see how various
it is embedded
social
large-scale
forces come to be translated into personal distress and disease.
do social forces ranging from poverty to
By what mechanisms
racism become embodied as individual experience? This has been
the focus of most of my own research inHaiti, where political
and economic
autumn
2009
11
PAUL
Working
ical violence
one
sphere,
has
try
long
FARMER
it is defined.
anthropologist
a rank
familiarity
twenty-five years ago, "is abject misery and
in 1991
When
with death."1 The situation has since worsened.
a "human
international health and population
devised
experts
measures
of human welfare
suffering index" by examining
to political
freedom, 27 of 141
ranging from life expectancy
"extreme
human
countries were
characterized
by
suffering."
one of them, Haiti, was
in
the
Western
hemi
located
Only
was
countries
in
In
the
world
three
suffering
sphere.
only
more extreme than that endured
inHaiti; each of
judged to be
these three countries is currently in themidst of an internation
ally recognized
civil war.
a recurrent and
in
expected condition
Suffering is certainly
life has felt like war.
Haiti's Central Plateau, where everyday
observed one young widow with
"You get up in themorning,"
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 to see
mountains
and clement weather,
long-term visitors
manner
as
its inhabitants:
inmuch the same
the Central Plateau
a chalky and arid land hostile to the best efforts of the peasant
iswidespread
and so, con
farmers who live here. Landlessness
measures
reveal
the
All
standard
how ten
is
sequently,
hunger.
at
uous the peasantry's
is. Life expectancy
hold on survival
as
as
in
birth is less than fiftyyears,
many
large part because
two of every ten infants die before their first birthday. Tubercu
losis is the leading cause of death among adults; among chil
and tetanus ravage the under
dren, diarrheal disease, measles,
nourished.
But the experience of suffering, it is often noted, is not effec
or
tively conveyed by statistics
graphs. The "texture" of dire af
or
societies.3
stories illustrate
Louis's
Ac?phie
Joseph's and Chouchou
some of themechanisms
which
through
large-scale social forces
of
individual suffering.
hard
surfaces
the
into
sharp,
crystallize
Such suffering is structured by historically given (and often eco
and forces that conspire?whether
nomically driven) processes
as
ismore commonly the case, these
through routine, ritual, or,
RACE/ETHNICITY
VOL.
3 /NO.
12
on
suffering
and
structural
violence:
a view
from
below
hard
Ac?phie's
Story
For thewound
8:22-9.1
a
of fewer than fifteen hundred
Kay,
community
people,
an
road that cuts north and east into
stretches along
unpaved
Central Plateau.
the
Haiti's
Striking out from Port-au-Prince,
can take several hours to reach
it
The
journey gives
Kay
capital,
one an
is
impression of isolation, insularity. The impression
a
as the
owes its existence
con
to
project
misleading,
village
ceived in the Haitian
D.C.:
capital and drafted inWashington,
of peas
Kay is a settlement of refugees, substantially composed
more
ant farmers displaced
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 Riviere Artibonite. For generations,
thou
nor
water.
In 1983, when
2009
13
PAUL
FARMER
market woman.
"If itweren't
for the dam," M. Joseph assured
be just fine now. Ac?phie,
too." The Josephs' home
drowned
with
most
of
their
their crops,
along
belongings,
and the graves of their ancestors.
from the rising water, the Josephs built a miserable
Refugees
lean-to on a knoll of high land jutting into the new reservoir.
on their knoll for some years;
They remained poised
Ac?phie
and her twin brother were born there. I asked them what
in
duced
them to move up to Kay, to build a house on the hard
"we'd
me,
was
stone embankment
replied M.
fall into the lake and drown. Their mother had to be
away selling; Iwas trying tomake a garden in this terrible soil.
There was no one to keep an eye on them."
water,"
would
banter.
in Port-au-Prince,
never!
I looked
around
and
saw
how
poor
we
all were,
you have me
VOL.
3 /NO.
14
on
suffering
structural
and
violence:
a view
from
below
was
dead.
was
ents and
siblings,
recalling
the hunger
gnawing
at her home
village.
Still looking for a moun prensipal, Ac?phie began seeing Blan
co Nerette, a young man with
own: Blan
origins identical to her
co's parents were also "water refugees" and Ac?phie had known
him when they were both attending the parochial school inKay.
Blanco had done well for himself, by Kay standards: he chauf
feured a small bus between the Central Plateau and the capital.
an
In a setting characterized
rate of greater
by
unemployment
than 60 percent, his job commanded
considerable
respect. He
the attention of Ac?phie.
to marry,
easily won
They planned
Soon Ac?phie's
lifewas consumed with managing
drench
sweats
and debilitating diarrhea, while attempting to
ing night
care for her first child. "We both need
diapers now," she re
marked bitterly towards the end of her life, faced each
day not
a
with
but
also
with
lassitude.
As she
diarrhea,
only
persistent
became more and more gaunt, some villagers
that
suggested
AUTUMN
2OO9
15
PAUL
FARMER
was
the victim of sorcery. Others recalled her liaison
Ac?phie
with the soldier and her work as a servant in the city, both lo
risk factors for AIDS. Ac?phie
herself knew
cally considered
was
more apt to refer to herself
that she had AIDS, although she
a disorder
on
a ser
as
from
by her work as
suffering
brought
vant: "All that ironing, and then opening a refrigerator."
and her daughter.
But this is not simply the story of Ac?phie
in the Central
One isHIV
is still a handsome
Plateau.
positive
two
and has
death, M.
Joseph hanged
himself.
Chouchou's
Story
"History shudders, pierced by events ofmassive public suffering.
Memory is haunted, stalked by theghosts of history's victims,
capriciously severed from life ingenocides, holocausts, and exter
mination camps. The cries of thehungry, the shrieks of political
prisoners, and the silent voices of "the oppressed echo slowly,
painfully through daily existence.
?Rebecca
Chopp, The Praxis of Suffering
in rural Haiti.
Haitians
asylum
in the United
RACE/ETHNICITY
VOL.
States; eight
3 /NO.
l6
ON
AND
SUFFERING
STRUCTURAL
A VIEW
VIOLENCE:
FROM
BELOW
movement
A growing Haitian pro-democracy
led, in Febru
to
must have
Louis
of
the
Duvalier.
Chouchou
ary 1986,
flight
Doc"
been about twenty years old when
fell, and he
"Baby
a small radio. "All he did," recalled
thereafter
shortly
acquired
his wife years later, "was work the land, listen to the radio, and
heard about
go to church." Itwas on the radio that Chouchou
the people who
Haiti,
handed
Chouchou
distressed
to hear
election with
Haiti's
overwhelming
someone representing
These
sideration
pointed
call a pwen, a
other than what
it
what Haitians
remark
something
literally means. As they bounced
along, he began complaining
of the roads, observing
about the conditions
that, "if things
were as
have been repaired
they should be, these roads would
me
One
at no point in the
later
that
told
eyewitness
already."
commentary
was
Aristide's
name
invoked.
But Chouchou's
were
as veiled
complaints
recognized by his fellow passengers
one
the
for
Chouchou,
coup. Unfortunately
language deploring
was an out-of-uniform
of the passengers
soldier. At the next
which
the worst
autumn
2009
17
PAUL
FARMER
led to blacklisting.
For men
like Chou
(i.e., the military)
out
of
involved
the
local
attach?s
chou, staying
jail
keeping
he
did
this
and
his
home
But
Chou
happy,
by avoiding
village.
chou lived in fear of a second arrest, his wife later told me, and
law
was
in a ditch to die. The
January 25, Chouchou
dumped
to
took
the
trouble
circulate
the canard that he
army scarcely
some
had stolen
bananas.
(The Haitian
press, by then thor
even broadcast
not
did
this false version of
muzzled,
oughly
to
Relatives
carried
Chouchou
back
Chantai
and their
events.)
on the
cover of
the
of
under
daughter
night. By early
morning
On
was
I arrived, Chouchou
January 26, when
scarcely recogniz
able. 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 pe
his
throat
collared
with
swollen,
bruises, the traces of a
culiarly
were
His
chest
and
butt.
sides
gun
badly bruised, and he had
several
That was
ings came
striped with deep
skin flayed down
the
lash marks. His buttocks were macerated,
to the exposed gluteal muscles.
Some of these
to be infected.
stigmata appeared
Chouchou
coughed up more than a liter of blood in his ago
nal moments. Given his respiratory difficulties and the amount
of blood he coughed up, it is likely that the beatings caused him
three days
to die.
Sense of Suffering
Explaining Versus Making
The pain in our shoulder comes
You say,from the damp; and this is also the reason
For the stain on thewall of ourflat.
So tell us:
?Bertholt
Brecht
VOL.
3 /NO.
l8
ON
SUFFERING
AND
STRUCTURAL
VIOLENCE:
A VIEW
FROM
BELOW
There is a deadly
ing for dozens of poor women with AIDS.
in their stories: young women?or
monotony
teenaged girls?
an escape
who were driven to Port-au-Prince
by the lure of
as a do
from the harshest poverty; once in the city, each worked
none
women
to
in
find
The
financial
mestic;
security.
managed
terviewed were
aspect
straightforward about the nonvoluntary
of their sexual activity: in their opinions,
they had been driven
into unfavorable
unions by poverty.5 Indeed, such testimony
What
of military or paramilitary
forces. The vast ma
were
or urban
of
victims
like
Chouchou,
poor peasants,
jority
are
slum dwellers.
here
cited
conservative
esti
(The figures
or
am
sure
no
I
ever
came
that
observer
mates;
quite
journalist
into the hands
to have unconstrained
and soldiers seemed
over
lives
of
the
the
rural
the
and
sway
agency of Ac?phie
poor,
at
Chouchou
curbed
turn.
These
was, correspondingly,
every
forces
grim biographies
suggest that the social and economic
to shape
that have helped
the AIDS
in
are,
every
epidemic
death and to the
sense, the same forces that led to Chouchou's
itwas eclipsed. What
ismore, both
larger repression inwhich
were "at risk" of such a fate
met
before
the soldiers
long
they
who altered their destinies. They were both, from the outset,
victims of structural violence.
certain kinds of suffering are readily observable?and
While
the subject of countless films, novels, and poems?structural
vi
olence all too often defeats those who would
it. There
describe
are at least three reasons
so. First, there is the "exoti
why this is
cization" of suffering as lurid as that endured
and
by Ac?phie
The suffering of individuals whose
lives and strug
our
own
move
to
recall
tends
us; the suffering of those who
gles
are distanced, whether
by geography, gender, "race," or culture,
is sometimes
less affecting.
Chouchou.
2009
19
PAUL
FARMER
suffering is not only its immensity but the faces of the anony
mous victims who have little voice, let alone
rights, in history."7
and distribution
of suffering are still
Third, the dynamics
in ethnography
is
if their representativeness
are to be embed
These local understandings
the
ded, in turn, in the larger-scale historical
system of which
a
forces that dic
fieldwork site is part.8 The social and economic
must be embedded
to be understood.
are
central to liberation
theology, which
In The
takes the suffering of the poor as its central problematic.
notes that, "In a variety of
Praxis of Suffering, Rebecca Chopp
forms, liberation theology speaks with those who, through their
the meaning
and truth of human
suffering, call into question
most
and unlike much
previous
theologies,
history."9 Unlike
to use
liberation theology has attempted
modern
philosophy,
social analysis to both explain and deplore human suffering. Its
the suffering of the
key texts bring into relief not merely
of the earth, but also the forces that promote that suf
wretched
Boff, in commenting on one of
fering. The theologian Leonardo
to the structural
notes
that it "moves
these texts,
immediately
the systems, structures,
analysis of these forces and denounces
the rich get
that 'create a situation where
and mechanisms
richer at the expense of the poor, who get even poorer.'"10
in reflection on
In short, few liberation theologians
engage
to
its
mechanisms.
understand
without
attempting
suffering
connections. Robert McAfee
Theirs is a theology that underlines
the poor inmind when,
the Uruguayan
Jesuit Juan Luis Segundo, he ob
paraphrasing
serves that "the world
that is satisfying to us is the same world
Brown
has
these connections
and also
to them."11
of Suffering
Models
"Events ofmassive, 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 re
that these
ally reveal the agony, the interruption, the questions
our
nature
lives and
individual
to
the
and
victims put
of
meaning
as a whole?"
life
?Rebecca
Chopp, The Praxis of Suffering
Multiaxial
RACE/ETHNICITY
VOL.
/NO.
20
on
suffering
and
a view
violence:
structural
from
BELOW
that this task, though daunting, is both urgent and feasible. Our
of AIDS and political violence inHaiti sug
cursory examination
broad. As
that
must,
first, be geographically
gests
analysis
we
as
it
is
the
world
know
noted,
becoming
increasingly inter
connected. A corollary of this belief is that extreme suffering?
on a
as in genocide?is
seldom di
grand scale,
especially when
vorced from the actions of the powerful.12 The analysis must also
us of
be historically deep?not
merely deep enough to remind
events and decisions
such as those which deprived Ac?phie
of
her land and founded the Haitian military, but deep enough to
are the descendants
remember that modern
of a
day Haitians
from Africa in order to provide us with sugar,
people kidnapped
coffee, and cotton and to enrich a few in a mercantilist economy.
Factors
But
in most
power.
settings
Simultaneous
these
factors have
consideration
limited
of various
explanatory
social "axes" is
military.
whereas
ismuch
ity also helps to explain why the suffering of Ac?phie
more
that
than
of
the
Chouchou.
commonplace
Throughout
are confronted with sexism, an
that
world, women
ideology
them as inferior tomen. When,
in 1974, a group of
designates
feminist anthropologists
living in
in
that,
every society
disparate
settings,
institu
studied, men dominated
political, legal, and economic
tions to varying degrees;
in no culture was the status ofwomen
several
surveyed
they found
2009
21
PAUL
FARMER
can
Similarly, only women
experience maternal mortality, a
cause of
around
the
world.
More
than half a million
anguish
women die each year in childbirth, but not all women
are at in
outcomes
creased risk of adverse
in pregnancy.
In 1985, the
World
Health Organization
estimated
that maternal mortality
150 times higher in developing
is, on average, approximately
countries than in developed
nations.
In Haiti, where maternal
as
as
is
fourteen
hundred
deaths per one hun
mortality
high
dred thousand
live births?almost
times higher
five hundred
than in thewealthy countries?these
tered among the poor.17
deaths
VOL.
3 /NO.
22
ON
SUFFERING
AND
STRUCTURAL
VIOLENCE:
A VIEW
FROM
BELOW
class differ
disease),
(heart disease and cerebrovascular
race differentials.
than
entials were
"The
larger
significantly
between
whites
differentials
and
blacks,"
growing mortality
death
"cannot be understood
concludes,
by looking only at
are
race; they
part and parcel of larger mortality differentials
class differentials."20 The sociologist William
JuliusWilson made
a similar
in
his
landmark
The
study,
point
Declining Significance
Navarro
of their impoverishment?that
are
cussions
gued
on
in fact be long-standing
cultural institutions
dignity may
a
valued
Often-cited
range from fe
by
highly
society.
examples
to
male circumcision
in the Sudan
in the Philip
head-hunting
are
pines. Such discussions
invariably linked to the concept of
cultural relativism, which has a long and checkered history in
Is every culture a law unto itself and a law unto
anthropology.
other
than
itself? In recent decades,
confidence in reflex
nothing
cultural relativism faltered as anthropologists
turned their at
to
tention
societies" characterized
"complex
by extremely ine
found themselves unwilling
galitarian social structures. Many
to condone social inequity merely because
itwas buttressed by
cultural beliefs, no matter how ancient. Cultural relativism was
as a part of a broader
also questioned
critique of anthropology
citizens
the
of
former
colonies.22
by
But this rethinking has not yet eroded a tendency, registered
inmany of the social sciences but perhaps
in an
particularly
to
confuse
structural
violence
with
cultural
differ
thropology,
ence. Many
are the
in which poverty and in
ethnographies
a
end
the
of
results
equality,
long process of impoverishment,
are conflated with "otherness."
is not
Very often, such myopia
a
as
of
but
Talal
has
Asad
motives,
rather,
really
question
sug
our "mode of
and objectifying alien soci
gested,
perceiving
eties."23 Part of the problem may be theways
inwhich
the term
is used.
ture.'"24 The
comforting
has usually
autumn
2009
PAUL
Such
illusions
misreadings?most
tural difference?are
FARMER
suggest
cultural
Structural Violence
I thinkof theirtatteredlives
feverishhands
of their
ours.
reaching out to seize
It's not that they're begging
they're demanding
us to break up our sleep
they've earned the right to order
come
to
awake
to shake offonce and for all this lassitude.
?Claribel
Alegr?a
"Visitas Nocturnas"
RACE/ETHNICITY
on
gender,
VOL.
race, or
3 /NO.
24
ON
SUFFERING
sexual
AND
VIOLENCE:
STRUCTURAL
A VIEW
FROM
BELOW
orientation.
from Brazil,
the
poor?are
socioeconomically
infrastructural
expres
thing
to be
a woman
working
as
a domestic
servant,
None
owning
your
of this is to deny
countries
in the wealthy
point ismerely
own
farm.27
to call formore
fine-grained
in discussions
physicians,
ment
has
lenced. As Chilean
theologian Pablo Richard, noting the fall of
the Berlin Wall, has warned,
"We are aware that another gigan
ticwall is being constructed in the Third World, to hide the real
the rich and poor is
ity of the poor majorities. A wall between
so
not
that
does
and
annoy the powerful
poverty
being built,
the poor are obliged to die in the silence of history"29
autumn
2009
25
PAUL
FARMER
distribution
Acknowledgments
I have
the usual
and
Saussy
constructive
Bertrand,
Rhatigan,
debts
to faithful readers
such
as Haun
the
Jim Yong Kim, but wish also to acknowledge
criticisms of this issue's
editors and of Didi
Dahl,
Johanna Daily,
Jonathan Mann,
Ophelia
and
Vinh
Kim
Joyce Bendremer,
Nguyen.
Joe
Endnotes
1. JeanWeise, "The Interaction ofWestern and Indigenous Medi
cine inHaiti in Regard to Tuberculosis/' Ph.D. Dissertation, Depart
ment of Anthropology, University of North Carolina at
Chapel Hill,
1971.
2. The names of theHaitians cited here have been changed, as have
the names of their home villages.
contributed
enormously
to the debate
on
structure
and
For
agency.
RACE/ETHNICITY
VOL.
3 /NO.
20
SUFFERING
ON
AND
STRUCTURAL
VIOLENCE:
A VIEW
FROM
BELOW
stein, who
for many
cales?Haiti's
years
Central
has
Plateau,
that
argued
for
example?are
even
the most
part
lo
far-flung
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 Anal
ysis," in Social Theory Today, ed. Anthony Giddens and Jonathan Turner
(Stanford, Calif.: Stanford University Press, 1985), 318. See also Im
manuel Wallerstein, TheModern World-System: Capitalist Agriculture and
theOrigins of theEuropean World-Economy in theSixteenth Century (San
Diego, Calif.: Academic Press, 1974). The weakness of these analyses is,
of course,
their extreme
divorce
from personal
experience.
It is
important
to note,
however,
that upper
class/caste
women
in-depth
AUTUMN
2OO9
account,
and
a more
complicated
view
of
the mecha
27
PAUL
FARMER
nisms by which apartheid and the South African economy are related
to disease causation, see Randall Packard, White Plague, Black Labor: Tu
berculosis and thePolitical Economy ofHealth and Disease in South Africa
(Berkeley, Calif.: University of California Press, 1989).
19. "Vicente
"Race
Navarro,
or Class
versus
Race
and
Class:
Mortal
Editors'
note:
Paul
Farmer's
paper
was
not
one
of
the papers
RACE
/ETHNICITY
VOL.
3 /NO.
so
28