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“Structural Violence” and the $ocial Determinants of Health

March 19, 2011

The title of this post refers to the single most important lesson I have learned since coming to Ecuador.* Anyone who has read “Mountains Beyond Mountains” is likely familiar with the first term; it is Dr. Farmer’s (and by fanboy extension, my) chosen way to conceptualize the damage caused by poverty and social injustice. I’ll start with the definition Farmer himself uses in his essay on “Structural Violence and Clinical Medicine”:

In the influential view of sociologist Johan Galtung, structural violence is “the avoidable impairment of fundamental human needs,” embedded in longstanding “ubiquitous social structures, normalized by stable institutions and regular experience.” Because they seem so ordinary in our ways of understanding the world, such violent structures are almost invisible. Disparate access to resources, political power, education, and health care as well as unequal legal standing are just a few examples. Such arrangements do violence to society’s losers; the arrangements are structural because they are embedded in the economic organization of our social world (emphasis mine).1

I find the following statistic from the World Health Organization helpful in understanding how health inequality can be viewed as violence: “A girl born in Sweden will live 43 years longer than a girl born in Sierra Leone.”2 Imagining the huge loss of life implied by this statistic, it’s hard to see how such early deaths could be seen as anything but violence. But, as Farmer points out above, it’s invisible violence, because it’s become such a normal part of our experience and way of understanding the world.

What are the mechanisms of this violence? They are the “large-scale social forces—racism, gender inequality, poverty, political violence, and war, and sometimes the very policies that address them—[that] often determine who falls ill and who has access to care.”1 Simply put, they are the social determinants of health. Their reality is seen most readily through statistics. Johns Hopkins University professor Vicente Navarro, concluding that “the evidence that health and quality of life are socially determined is undeniable and overwhelming,” writes:

“In Glasgow, an unskilled, working-class person will have a lifespan 28 years shorter than a businessman in the top income bracket in Scotland”2… In East Baltimore… a black unemployed youth has a lifespan 32 years shorter than a white corporate lawyer. Actually, as I have documented elsewhere, a young African American is 1.8 times more likely than a young white American to die from a cardiovascular condition. Race mortality differentials are large in the United States, but class mortality differentials are even larger. In the same study, I showed that a blue-collar worker is 2.8 times more likely than a businessman to die from a cardiovascular condition.3

University of Michigan professor George Kaplan summarizes his article on poverty’s effects on health in the United States by stating:

[There are] many ways in which the health of the poor is put at risk on a daily basis and from generation to generation. The result is a kind of crazy quilt of risk, weaving together lack of access to quality education, medical care and other health-enhancing resources, low wages, embattled physical and social environments, and work that produces poor health. At the same time, a vicious cycle of disadvantage leading to poor health that in turn leads to further disadvantage and further poor health plays out over the life course and across generations.4

All this may seem fairly obvious. Of course poor people tend to have worse health than rich people; we’re not exactly breaking new ground here. So why even say it in the first place, and come up with terms like “structural violence” and “social determinants of health”? There are two reasons, one for each term used.

First, the term structural violence is galvanizing. If dying of poverty becomes normalized, seen as an inevitable consequence of “the way the world works,” we tend to lose both our sense of agency as well as our moral responsibility to do something about it. If, however, we learn to view inequality as violence, then it logically follows that if we benefit from the power and privilege at the top of the social order without doing anything to change it, we are guilty, however indirectly, of perpetrating and perpetuating that violence.** And my hope is that if enough of us develop guilty enough consciences, someday something might change.

The second reason is to put the focus back on the social determinants of health, to give them a name. When we think of “health,” too often our thoughts are limited to germs and doctor-patient visits, without asking ourselves why some people are always sick and why others never make it to the doctor’s office in the first place. If we accept the mandate of a physician as being “to heal the sick and to promote health (not just the absence of illness),” then we must broaden our focus in medicine to include poverty in addition to pills.


*Granted, I had already heard of “structural violence” before coming here, but the idea of social determinants of health was new to me (probably because I decided for some reason to major in the physical sciences). And being in Ecuador has given me the chance to see for myself exactly what Farmer is talking about.

**A related idea in the feminist movement is that just by exercising male privilege, one perpetuates gender inequality.


1. Farmer, Paul, et al. “Structural Violence and Clinical Medicine.” Farmer, Paul. Partner to the Poor: A Paul Farmer Reader. 2010. 377-8. (The original version of the article can be found online here.)

2. World Health Organization. “Commission on Social Determinants of Health- Final Report.” Geneva, 2008.

3. Navarro, Vicente. “What We Mean By Social Determinants of Health.” International Journal of Health Services (2009): 423-441.

4. Kaplan, George A. “The Poor Pay More- Poverty’s High Cost to Health.” 2009.


6 Comments leave one →
  1. Nick permalink
    March 20, 2011 11:21 AM

    So basically, you’re trying to solve a problem that many people don’t even acknowledge as a problem, or believe to be unsolvable. That sounds lovely 🙂

  2. David Englund permalink
    March 20, 2011 1:17 PM

    Scaling mountains in Ecuador, battling social injustice.

    Mountains Beyond Mountains.

    Hello Paul “David Droullard” Farmer.

  3. March 21, 2011 8:38 AM

    I wouldn’t go so far as to put it that way. I’d like to believe that people these days are pretty aware of the devastation caused by global poverty. And since, for example, everybody knows that the poorest continent is the one hardest-hit by HIV/AIDS, I don’t think the social determinants of health are too far off our radar either.

    However, knowledge of this reality still doesn’t seem to awaken our moral energy in the way that other causes of death (e.g. terrorism and war) do, even though they are both forms of violence, and both are the result of power struggles. And hell, even terrorism and war are almost always themselves the products of structural inequalities, but those are never examined in our “good guys vs. bad guys” mentality.

    So as a problem, global poverty certainly isn’t invisible. But it’s not very commonly viewed as a form of violence, and rarer still do we implicate ourselves in the perpetration of that violence.

  4. March 21, 2011 3:30 PM

    Dave, I didn’t even realize that you had recently written a piece on the social determinants of health. Now, I understand your violence metaphor a little better. Conceptualizing inequality as violence can be a quite forceful catalyst for moral urgency. On that note, it would be worth the time to examine what we mean by ‘inequality’ and what goals we can realistically expect to achieve in our pursuit to mitigate inequality. For me, this conjures up memories from our classes in Quito last semester where we were summoned on several occasions—que hablemos de equidad en lugar de igualdad. There will most certainly always be inequalities between and among human beings. The ultimate question seems to be: How much inequality is acceptable and under what circumstances?

    I feel you on the bit about global poverty being invisible. Domestic poverty is also invisible much of the time. I worked in Detroit last summer at a health center and I was asked by a mentor if I had noticed the depth of a certain highway in relation to the surrounding neighborhoods. She then proceeded to inform me of the theory that the highway was built lower so that people commuting from the suburbs to work in the city wouldn’t have to see the urban realities on either side as much. Although this little story is anecdotal and not completely verified, it can sort of represent a type of symbolic violence that attempts to conceal the salience of social injustice.

    I enjoyed the read!


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