- Poverty, Structural Violence, and Racism in a World Out of Balance
Nairobi's slums leave lasting impressions on the visitor. Of the roughly 4 million people living in and around Kenya's capital city, nearly half live in conditions of extreme poverty, with many in slums (Fryda 2000). Within the Dandora Slum, located in the northeast section of the city, one finds the Nairobi City Dump, a place an appallingly large number of people call home. I have seen many shocking things while working as a physician in rural and urban settings in East Africa. However, I vividly recall one of the most surreal being that of people sitting in trash, picking through it for food, and having casual conversation while standing in piles of acrid smelling garbage in Dandora. Barefoot young children played soccer just yards away from the fly-infested, rotting carcasses of several large dogs. According to those who live and work there, roughly a quarter of the slum population is HIV positive.1
Of the many patients I saw in Kenya, one remains forever fixed in my mind due to her innocent yet proud manner amid impossible circumstance. She sought our help in a clinic bordering the Kariobangi Slum for her progressive weakness, weight loss, and fevers. Like everyone else trapped by the circumstances of life in Kariobangi, she was foremost a survivor. Being young and female limited her choices, so she did the only thing that she and many other young girls in the slums of Nairobi did to survive—she became a commercial sex worker. She either entertained johns or she starved; not much of a choice, really. Try to picture your mother or sister or daughter faced with the same choice. This young girl learned the oldest profession from [End Page 115] lying under her now-deceased mother's bed. In the one-room shacks and huts that cover the slum landscape, the children either stay under the bed or go outside while the mother earns a living. Her mother got thirty shillings a night, the equivalent of less than one U.S. dollar—and AIDS—as compensation. This young woman joined the sad chorus of 15 million AIDS orphans worldwide, and was now following in her mother's footsteps on the worn paths of Kariobangi—yet another AIDS orphan harshly sentenced for the crime of being born into poverty.
I interviewed her through a nun serving as interpreter, and examined her. She had beautiful features yet clearly bore the emaciated countenance of AIDS. During the examination, she carefully avoided my eyes. I did not judge her, knowing that she had no other options. Still, she exuded shame and embarrassment, common feelings in those stigmatized by their illness. She knew the reason why she had been losing weight and having recurrent fevers. Her eyes revealed a street-born wisdom far beyond her years. Outside she was tough, inside a terrified little girl whose future was clear. As she walked away in silence, I felt the all too familiar feeling that one has in places like Kariobangi—that of my heart breaking. She was ten years old.
How, we might ask, can it be that this young girl had no better survival option than becoming a prostitute—a profession that carries with it in places like Kariobangi the virtual certainty of acquiring AIDS? How, we might also ask, can poverty and disease devastate entire populations while the "developed" world mostly watches in silence or diverts aid dollars into the pockets of those who will serve their interests? More relevant for us here, what role does this young girl's race and nationality play regarding her health and life prospects? Finally, in a world abounding in the knowledge, technology and resources to change these inequalities forever, why haven't we?
To answer these questions, we must first start by looking at our world with eyes fully open; it is a very imbalanced place. Enormous disparities in health and health care—with deep ties to race, ethnicity, and gender—still very much define our global order.
The World As It Is: Structural Violence
A cursory look at our...