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  • On Suffering and Structural ViolenceA View from Below
  • Paul Farmer

Everyone knows that suffering exists. The question is how to define it. Given that each person's pain has a degree of reality for him or her that the pain of others can surely never approach, is widespread agreement on the subject possible? Almost all of us would agree that premature and painful illness, torture, and rape constitute extreme suffering. Most would also agree that insidious assaults on dignity, such as institutionalized racism and sexism, also cause great and unjust injury.

Given our consensus on some of the more conspicuous forms of suffering, a 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? Are certain "event" assaults, such as torture or rape, more likely to lead to late sequelae than are sustained and insidious suffering, such as the pain born of deep poverty or of racism? Under this latter rubric, are certain forms of discrimination demonstrably more noxious than others?

Anthropologists who take these as research questions study both individual experience and the larger social matrix in which it is embedded in order to see 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 racism become embodied as individual experience? This has been the focus of most of my own research in Haiti, where political and economic forces have structured risk for AIDS, tuberculosis, and, indeed, most other infectious and parasitic diseases. Social forces at work there have also structured risk for most forms of extreme suffering, from hunger to torture and rape. [End Page 11]

Working in contemporary Haiti, where in recent years political violence has been added to the worst poverty in the hemisphere, one learns a great deal about suffering. In fact, the country has long constituted a sort of living laboratory for the study of affliction, no matter how it is defined. "Life for the Haitian peasant of today," observed anthropologist Jean Weise some twenty-five years ago, "is abject misery and a rank familiarity with death."1 The situation has since worsened. When in 1991 international health and population experts devised a "human suffering index" by examining measures of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by "extreme human suffering." Only one of them, Haiti, was located in the Western hemisphere. In only three countries in the world was suffering judged to be more extreme than that endured in Haiti; each of these three countries is currently in the midst of an internationally recognized civil war.

Suffering is certainly a recurrent and expected condition in Haiti's Central Plateau, where everyday life has felt like war. "You get up in the morning," observed one 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 mountains and clement weather, long-term visitors come to see the Central Plateau in much the same manner as its inhabitants: a chalky and arid land hostile to the best efforts of the peasant farmers who live here. Landlessness is widespread and so, consequently, is hunger. All the standard measures reveal how tenuous the peasantry's hold on survival is. Life expectancy at birth is less than fifty years, in large part because as many as two of every ten infants die before their first birthday. Tuberculosis is the leading cause of death among adults; among children, diarrheal disease, measles, and tetanus ravage the undernourished.

But the experience of suffering, it is often noted, is not effectively conveyed by statistics or graphs. The "texture" of dire affliction is perhaps best felt in the gritty details of biography, and so I introduce the stories of Acéphie Joseph and Chouchou Louis.2 The stories of Acéphie and Chouchou are anything but "anecdotal." For the epidemiologist as well as the political analyst, they suffered and died in exemplary fashion...


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