Read the Brondo article #6.1: “An Anthropology of Structural Violence” and answer the reflection questions.

1. Reflecting on the article “An Anthropology of Structural Violence”

1. After finishing the module and all of the reading, explain in your own words your understanding of the concept of “violence,” and how violence relates to culture.
2. After reading Paul Farmer’s article, explain your understanding of the concept of structural violence. According to this article, how does structural violence play into health issues in Haiti?
3. Read again carefully the last two paragraphs of this article. What justifications were given by the U.S. officials in the Department of the Treasury and the U.S. Agency for International Development (USAID) to NOT invest U.S. resources in AIDS therapy for Africa? Why is Farmer so troubled by these justifications?

5.1 An Anthropology of Structural ViolencePAUL FARMERStructural violence refers to the systematic ways in which the political and economic organization of our social world harms or otherwise disadvantages individuals and populations. These forces are often not ethnographically visible, but, Farmer argues, they are essential to understanding that which is apparent to the ethnographer’s eye. Drawing on his experience as an anthropologist-physician, Farmer illustrates the profound violence Haiti’s history of slavery and debt has inflicted on the bodies of the world’s vulnerable, resulting in tuberculosis and AIDS epidemics on a grand scale. These leading causes of young adult death in Haiti, Farmer argues, are outcomes of European expansion in the New World, and the slavery and racism that accompanied it. In addition to its place as a seminal piece illustrating structural violence, this ethnographically rich piece is also a key example of medical anthropology. Through it, students are introduced to an illness narrative, which is an explanatory model for what is happening to a patient’s body that covers the psychological and social experiences that a patient encounters. Illness is distinct from disease, which refers to the physiological conditions that doctors tend to focus on. Through Farmer’s narration of Anite, a patient he encountered with a large, fungating breast mass and her search for explanation and cure, one can see the tensions that arise at the interface of traditional and biomedical health systems.QuestionsWhat is important about Anite’s illness narrative? What does it reveal about Haitian ideas about biomedicine and about the social nature of illness? How does her narration—its content and the context of her telling it—differ from Western biomedical interactions between doctors and patients and the settings in which they interact?What is the relationship between debt, trade, and HIV and tuberculosis?Discuss the importance of situating what is ethnographically visible within that which is not visible. Apply the concept of structural violence in this response, using examples from the reading.The ethnographically visible, central Haiti, September 2000: Most hospitals in the region are empty. This is not because of a local lack of treatable pathology; rather, patients have no money to pay for such care. One hospital—situated in a squatter settlement just 8 kilometers from a hydroelectric dam that decades ago flooded a fertile valley—is crowded…. Every bed is filled, and the courtyard in front of the clinic is mobbed with patients waiting to be seen. Over a hundred have slept on the grounds the night before and are struggling to smooth out wrinkles in hand-me-down dresses or pants or shirts; hats are being adjusted, and some are massaging painful cricks in the neck. The queue of those waiting to have a new medical record created is long, snaking toward the infectious disease clinic I am hoping to reach. First, however, it is better to scan the crowd for those who should be seen immediately.Less ethnographically visible is the fact that Haiti is under democratic rule. For the first time in almost two centuries, democratic elections are planned and could result in a historic precedent: President Ren Prval, elected some years earlier, could actually survive his presidency to transfer power to another democratically elected president. If Prval succeeds, he will be the first president in Haitian history ever to serve out his mandate, not a day more, not a day less. To local eyes, the prospect of this victory (which later did indeed come to pass) is overwhelmed by the vivid poverty seeping into the very seams of Haitian society. For the rural poor, most of them peasants, this means erosion and lower crop yields; it means hunger and sickness. And every morning the crowd in front of the clinic seems to grow.To foreign eyes, the Haitian story has become a confused skein of tragedies, most of them seen as local. Poverty, crime, accidents, disease, death—and more often than not their causes—are also seen as problems locally derived. The transnational tale of slavery and debt and turmoil is lost in the vivid poverty, the understanding of which seems to defeat the analyses of journalists and even many anthropologists, focused as we are on the ethnographically visible—what is there in front of us.Making my way through this crowd has become a daily chore and triage—seeking out the sickest—a ritual in the years since I became medical director of the clinic….I see two patients on makeshift stretchers; both are being examined by auxiliary nurses armed with stethoscopes and blood-pressure cuffs. Perhaps this morning it will take less than an hour to cross the 600 or so yards that separate me from another crowd of patients already diagnosed with tuberculosis or AIDS….A young woman takes my arm in a common enough gesture in rural Haiti. “Look at this, doctor.” She lifts a left breast mass. The tumor is not at all like the ones I was taught to search for during my medical training in Boston. This lesion started as an occult lump, perhaps, but by this September day has almost completely replaced the normal breast. It is a “fungating mass,” in medical jargon, and clear yellow fluid weeps down the front of a light blue dress. Flies are drawn to the diseased tissue, and the woman waves them away mechanically. On either side of her, a man and a woman help her with this task, but they are not kin, simply other patients waiting in the line.“Good morning,” I say, although I know that she is expecting me to say next to nothing and wants to be the speaker. She lifts the tumor toward me and begins speaking rapidly. “It’s hard and painful,” she says. “Touch it and see how hard it is.” Instead, I lift my hand to her axilla and find large, hard lymph nodes there—likely advanced and metastatic cancer—and I interrupt her as politely as I can. If only this were a neglected infection, I think. Not impossible, only very unlikely. I need to know how long this woman has been ill.But the woman, whose name is Anite, will have none of it. She is going to tell the story properly, and I will have to listen. We are surrounded by hundreds, and at least 40 can hear every word of the exchange. I think to pull her from the line, but she wants to talk in front of her fellow sufferers…. There is so much to complain about. Now I have time only to see patients as a physician and precious little time for interviewing them. I miss this part of my work, but although I want to hear Anite’s story, I want even more to attend to her illness. And to do that properly will require a surgeon, unless she has come with a diagnosis made elsewhere. I look away from the tumor. She carries, in addition to a hat and a small bundle of oddments, a white vinyl purse. Please, I think, let there be useful information in there. Surely she has seen other doctors for a disease process that is, at a minimum, months along?I interrupt again to ask her where she has come from and if she has sought care elsewhere. We do not have a surgeon on staff just now. We have been promised, a weary functionary at the Ministry of Health has told me, that the Cuban government will soon be sending us a surgeon and a pediatrician. But for this woman, Anite, time has run out.“I was about to tell you that, doctor.” She has let go of my arm to lift the mass, but now she grips it again. “I am from near Jrmie,” she says, referring to a small city on the tip of Haiti’s southern peninsula—about as far from our clinic as one could be and still be in Haiti. To reach us, Anite must have passed through Port au Prince, with its private clinics, surgeons, and oncologists.“I first noticed a lump in my breast after falling down. I was carrying a basket of millet on my head. It was not heavy, but it was large, and I had packed it poorly, perhaps. The path was steep, but it had not rained on that day, so I don’t know why I fell. It makes you wonder, though.” At least a dozen heads in line nod in assent, and some of Anite’s fellow patients make noises encouraging her to continue.“How long ago was that?” I ask again.“I went to many clinics,” she says in front of dozens of people she has met only that morning or perhaps the night before. “I went to 14 clinics.” Again, many nod assent. The woman to her left says “Adj!” meaning something along the lines of “You poor thing!” and lifts a finger to her cheek. This crowd response seems to please Anite, who continues her narrative with gathering tempo. She still has not let me know how long she has been ill.“Fourteen clinics,” I respond. “What did they say was wrong with you? Did you have an operation or a biopsy?” The mass is now large and has completely destroyed the normal architecture of her breast; it is impossible to tell if she has had a procedure, as there is no skin left to scar.“No,” replies Anite. “Many told me I needed an operation, but the specialist who could do this was in the city, and it costs $700 to see him. In any case, I had learned in a dream that it was not necessary to go to the city.”