The pain in our shoulder comes you say, from the damp; and this is also the reason for the stain on the wall of our flat. So tell us: Where does the damp come from?

Bertholt Brecht

Note by HealthWrights Staff

When we ask deeply and persistently enough about the fundamental sources of unnecessary human suffering, we will always eventually arrive at a description of certain socio/economic conditions that build the comfort of one group of people upon the suffering of another. These conditions are neither natural nor inevitable. They are deliberately created by human beings. Farmer aptly refers to the suffering inflicted by these socio/economic conditions as “structural violence.”

That’s where the damp comes from.


On suffering and structural violence:

A view from below

by Paul Farmer

American Academy of Arts and Sciences

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.

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.”l 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 Acephie Joseph and Chouchou Louis.2 The stories of Aciphie and Chouchou are anything but “anecdotal.” For the epidemiologist as well as the political analyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet similar fates. What these victims, past and present, share are not personal or psychological attributes–they do not share culture, language, or race. Rather, what they share is the experience of occupying the bottom rung of the social ladder in inegalitarian societies.3

Acephie Joseph’s and Chouchou Louis’s stories illustrate some of the mechanisms through which large-scale social forces crystallize into the sharp, hard surfaces of individual suffering. Such suffering is structured by historically given (and often economically driven) processes and forces that conspire–whether through routine, ritual, or, as is more commonly the case, these hard surfaces–to constrain agency.4 For many, including most of my patients and informants, life choices are structured by racism, sexism, political violence, and grinding poverty.


For the wound of the daughter of my people is my heart wounded, I mourn, and dismay has taken hold of me. s there no balm in Gilead? Is there no physician there? Why then has the health of the daughter of my people not been restored? O that my head were waters, and my eyes a fountain of tears, that I might weep day and night for the slain of the daughter of my people! –Jeremiah 8:22-9.1


Kay, a community of fewer than fifteen hundred people, stretches along an unpaved road that cuts north and east into Haiti’s Central Plateau. Striking out from Port-au-Prince, the capital, it can take several hours to reach Kay. The journey gives one an impression of isolation, insularity. The impression is misleading, as the village owes its existence to a project conceived in the Haitian capital and drafted in Washington, D.C.: Kay is a settlement of refugees, substantially composed of peasant farmers displaced more 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, thousands of families had farmed the broad and gently sloping banks of the river, selling rice, bananas, millet, corn, and sugarcane in regional markets. Harvests were, by all reports, bountiful; life there is now recalled as idyllic. When the valley was flooded with the building of the dam, the majority of the local population was forced up into the stony hills on either side of the new reservoir. By all the standard measures, the “water refugees” became exceedingly poor; the older people often blame their poverty on the massive buttress dam a few miles away, and bitterly note that it brought them neither electricity nor water.

In 1983, when I began working in the Central Plateau, AIDS, although already afflicting an increasing number of city dwellers, was unknown in most areas as rural as Kay. Aciphie Joseph was one of the first villagers to die of the new syndrome. But her illness, which ended in 1991, was merely the latest in a string of tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the region’s sick.

The litany begins, usually, down in the valley hidden under the still surface of the lake. Aciphie’s parents came from families making a decent living by farming fertile tracts of land–their “ancestors’ gardens”–and selling much of their produce. M. Joseph tilled the soil, and his wife, a tall and wearily elegant woman not nearly as old as she looked, was a “Madame Sarah,” a market woman. “If it weren’t for the dam,’ M. Joseph assured me, “we’d be just fine now. Acephie, too.” The Josephs’ home was drowned along with most of their belongings, their crops, and the graves of their ancestors.

Refugees from the rising water, the Josephs built a miserable lean-to on a knoll of high land jutting into the new reservoir. They remained poised on their knoll for some years; AcCphie and her twin brother were born there. I asked them what induced them to move up to Kay, to build a house on the hard stone embankment of a dusty road. “Our hut was too near the water,” replied M. Joseph. “I was afraid one of the children would fall into the lake and drown. Their mother had to be away selling; I was trying to make a garden in this terrible soil. There was no one to keep an eye on them.”

Actphie attended primary school–a banana-thatched and open shelter in which children and young adults received the rudiments of literacy–in Kay. “She was the nicest of the Joseph sisters,” recalled one of her classmates. “And she was as pretty as she was nice.” Acephie’s beauty and her vulnerability may have sealed her fate as early as 1984. Though still in primary school, she was already nineteen years old; it was time for her to help generate income for her family, which was sinking deeper and deeper into poverty. AcCphie began to help her mother by carrying produce to a local market on Friday mornings. On foot or with a donkey it takes over an hour and a half to reach the market, and the road leads right through Peligre, the site of the dam and, until recently, a military barracks. The soldiers liked to watch the parade of women on Friday mornings. Sometimes they taxed them with haphazardly imposed fines; sometimes they taxed them with flirtatious banter.

Such flirtation is seldom unwelcome, at least to all appearances. In rural Haiti, entrenched poverty made the soldiers–the region’s only salaried men–ever so much more attractive. Hunger was again a near-daily occurrence for the Joseph family; the times were as bad as those right after the flooding of the valley. And so when Actphie’s good looks caught the eye of Captain Jacques Honorat, a native of Belladere formerly stationed in Port-au-Prince, she returned his gaze.

Acephie knew, as did everyone in the area, that Honorat had a wife and children. He was known, in fact, to have more than one regular partner. But AcCphie was taken in by his persistence, and when he went to speak to her parents, a long-term liaison was, from the outset, seriously considered:

What would you have me do? I could tell that the old people were uncomfortable, worried; but they didn’t say no. They didn’t tell me to stay away from him. I wish they had, but how could they have known?. . .I knew it was a bad idea then, but I just didn’t know why. I never dreamed he would give me a bad illness, never! I looked around and saw how poor we all were, how the old people were finished....What would you have me do? It was a way out, that’s how I saw it.

Acephie and Honorat were sexual partners only briefly–for less than a month, according to Acephie. Shortly thereafter, Honorat fell ill with unexplained fevers and kept to the company of his wife in Peligre. As Aciphie was looking for a moun prensipal–a “main man”–she tried to forget about the soldier. Still, it was shocking to hear, a few months after they parted, that he was dead.

Acephie was at a crucial juncture in her life. Returning to school was out of the question. After some casting about, she went to Mirebalais, the nearest town, and began a course in what she euphemistically termed “cooking school.” The school–really just an ambitious woman’s courtyard–prepared poor girls like Acephie for their inevitable turn as servants in the city. Indeed, domestic service was one of the rare growth industries in Haiti, and as much as Acephie’s proud mother hated to think of her daughter reduced to servitude, she could offer no viable alternative.

And so Acephie, at age twenty-two, went off to Port-au-Prince, where she found a job as a housekeeper for a middle-class Haitian woman working for the US embassy. Acephie’s looks and manners kept her out of the backyard, the traditional milieu of Haitian servants: she was designated as the maid who, in addition to cleaning, answered the door and the telephone. Although Acephie was not paid well–she received $30 each month–she tried to save a bit of money for her parents and siblings, recalling the hunger gnawing at her home village.

Still looking for a moun prensipal, Acephie began seeing Blanco Nerette, a young man with origins identical to her own: Blanco’s parents were also “water refugees” and Acephie had known him when they were both attending the parochial school in Kay. Blanco had done well for himself, by Kay standards: he chauffeured a small bus between the Central Plateau and the capital. In a setting characterized by an unemployment rate of greater than 60 percent, his job commanded considerable respect. He easily won the attention of Acephie. They planned to marry, and started pooling their resources.

Acephie had worked as a maid for over three years when she discovered that she was pregnant. When she told Blanco, he became skittish. Nor was her employer pleased: it is considered unsightly to have a pregnant servant. So Acephie returned to Kay, where she had a difficult pregnancy. Blanco came to see her once or twice; they had a disagreement, and then she heard nothing from him. Following the birth of her daughter, Acephie was sapped by repeated infections. She was shortly thereafter diagnosed with AIDS.

Soon Actphie’s life was consumed with managing drenching night sweats and debilitating diarrhea, while attempting to care for her first child. “We both need diapers now,” she remarked bitterly towards the end of her life, faced each day not only with diarrhea, but also with a persistent lassitude. As she became more . and more gaunt, some villagers suggested that Acephie was the victim of sorcery. Others recalled her liaison with the soldier and her work as a servant in the city, both locally considered risk factors for AIDS. Acephie herself knew that she had AIDS, although she was more apt to refer to herself as suffering from a disorder brought on by her work as a servant: “All that ironing, and then opening a refrigerator.”

But this is not simply the story of Acephie and her daughter. There is Jacques Honorat’s first wife, who each year grows thinner. After Honorat’s death, she found herself desperate, with no means of feeding her five hungry children, two of whom were also ill. Her subsequent union was again with a soldier. Honorat had at least two other partners, both of them poor peasant women, in the Central Plateau. One is HIV positive and has two sickly children. Blanco is still a handsome young man, apparently in good health and plying the roads from Mirebalais to Port-au-Prince. Who knows if he carries the virus? As an attractive man with a paying job, he has plenty of girlfriends.

Nor is this simply the story of those infected with the virus. The pain of Mme. Joseph and Acephie’s twin brother was manifestly intense, but few understood the anguish of her father. Shortly after Actphie’s death, M. Joseph hanged himself.


“History shudders, pierced by events of massive public suffering. Memory is haunted, stalked by the ghosts of history’s victims, capriciously severed from life in genocides, holocausts, and extermi nation camps. The cries of the hungry, the shrieks of political prisoners, and the silent voices of the oppressed echo slowly, painfully through daily existence. “ –Rebecca Chopp The Praxis of Suffering

Chouchou Louis grew up not far from Kay in another small village in the steep and infertile highlands of Haiti’s Central Plateau. He attended primary school for a couple of years but was obliged to drop out when his mother died. Then in his early teens, Chouchou joined his father and an older sister in tending their hillside gardens. In short, there was nothing remarkable about Chouchou’s childhood; it was brief and harsh, like most in rural Haiti.

Throughout the 1980s, church activities formed Chouchou’s sole distraction. These were hard years for the Haitian poor, beaten down by a family dictatorship well into its third decade. The Duvaliers, father and son, ruled through violence, largely directed at people whose conditions of existence were similar to that of Chouchou Louis. Although many of them tried to flee, often by boat, US policy maintained that Haitian asylum-seekers were “economic refugees.” As part of a 1981 agreement between the administrations of Ronald Reagan and Jean-Claude Duvalier, refugees seized on the high seas were summarily returned to Haiti. During the first ten years of the accord, 24,559 Haitians applied for political asylum in the United States; eight applications were approved.

A growing Haitian pro-democracy movement led, in February 1986, to the flight of Duvalier. Chouchou Louis must have been about twenty years old when “Baby Doc” fell, and he shortly thereafter acquired a small radio. “All he did,” recalled his wife years later, “was work the land, listen to the radio, and go to church.” \It was on the radio that Chouchou heard about the people who took over after Duvalier fled. Like many in rural Haiti, Chouchou was distressed to hear that power had been handed to the military, led by hardened duvalieristes. It was this army that the US government, which in 1916 had created the modern Haitian army, termed “Haiti’s best bet for democracy.” In the eighteen months following Duvalier’s departure, over $200 million in US aid passed through the hands of the junta.

In early 1989, Chouchou moved in with Chantal Brisi, who was pregnant. They were living together when Father Jean-Bertrand Aristide–by then considered the leader of the pro-democracy movement–declared his candidacy for the presidency in the internationally monitored elections of 1990. In December of that year almost 70 percent of the voters chose Father Aristide from a field of ten presidential candidates.

Like most rural Haitians, Chouchou and Chantal welcomed Aristide’s election with great joy. For the first time, the poorHaiti’s overwhelming majority, formerly silent–felt they had someone representing their interests in the presidential palace. These are the reasons why the military coup d’etat of September 1991 stirred great anger in the countryside, where the majority of Haitians live. Anger was soon followed by sadness, then fear, as the country’s repressive machinery, dismantled during the seven months of Aristide’s tenure, was hastily reassembled under the patronage of the army.

In the month after the coup, Chouchou was sitting in a truck en route to the town of Hinche. Chouchou offered for the consideration of his fellow passengers what Haitians call a pwen, a pointed remark intended to say something other than what it literally means. As they bounced along, he began complaining about the conditions of the roads, observing that, “if things were as they should be, these roads would have been repaired already.” One eyewitness later told me that at no point in the commentary was Aristide’s name invoked. But Chouchou’s complaints were recognized by his fellow passengers as veiled language deploring the coup. Unfortunately for Chouchou, one of the passengers was an out-of-uniform soldier. At the next checkpoint, the soldier had him seized and dragged from the truck. There, a group of soldiers and their lackeys–their attaches, to use the epithet then in favorimmediately began beating Chouchou, in front of the other passengers; they continued to beat him as they brought him to the military barracks in Hinche. A scar on his right temple was a souvenir of his stay in Hinche, which lasted several days.

Perhaps the worst aftereffect of such episodes of brutality was that, in general, they marked the beginning of persecution, not the end. In rural Haiti, during this time, any scrape with the law (i.e., the military) led to blacklisting. For men like Chouchou, staying out of jail involved keeping the local attaches happy, and he did this by avoiding his home village. But Chouchou lived in fear of a second arrest, his wife later told me, and his fears proved to be well-founded.

On January 22, 1992, Chouchou was visiting his sister when he was arrested by two attaches. No reason was given for the arrest, and Chouchou’s sister regarded as ominous the seizure of the young man’s watch and radio. He was roughly marched to the nearest military checkpoint, where he was tortured by soldiers and the attaches. One area resident later told us that the prisoner’s screams made her children weep with terror.

On January 25, Chouchou was dumped in a ditch to die. The army scarcely took the trouble to circulate the canard that he had stolen some bananas. (The Haitian press, by then thoroughly muzzled, did not even broadcast this false version of events.) Relatives carried Chouchou back to Chantal and their daughter under the cover of night. By early on the morning of January 26, when I arrived, Chouchou was scarcely recognizable. 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 peculiarly swollen, his throat collared with bruises, the traces of a gun butt. His chest and sides were badly bruised, and he had several fractured ribs. His genitals had been mutilated.

That was his front side; presumably, the brunt of the beatings came from behind. Chouchou’s back and thighs were striped with deep lash marks. His buttocks were macerated, the skin flayed down to the exposed gluteal muscles. Some of these stigmata appeared to be infected.

Chouchou coughed up more than a liter of blood in his agonal moments. Given his respiratory difficulties and the amount of blood he coughed up, it is likely that the beatings caused him to bleed, slowly at first, then catastrophically, into his lungs. His head injuries had not robbed him of his faculties, although it might have been better for him had they done so. It took Chouchou three days to die.


The pain in our shoulder comes you say, from the damp; and this is also the reason for the stain on the wall of our flat. So tell us: Where does the damp come from? Bertholt Brecht

Are these stories of suffering emblematic of something other than two tragic and premature deaths? If so, how representative is each of these experiences? Little about Acephie’s story is unique; I have told it in detail because it brings into relief many of the forces constraining not only her options, but those of most Haitian women. Such, in any case, is my opinion after caring for dozens of poor women with AIDS. There is a deadly monotony in their stories: young women–or teenaged girls–who were driven to Port-au-Prince by the lure of an escape from the harshest poverty; once in the city, each worked as a domestic; none managed to find financial security. The women interviewed were straightforward about the nonvoluntary aspect of their sexual activity: in their opinions, they had been driven into unfavorable unions by poverty.S Indeed, such testimony should call into question facile notions of “consensual sex.”

What about the murder of Chouchou Louis? International human rights groups estimate that more than three thousand Haitians were killed in the year after the September 1991 coup that overthrew Haiti’s first democratically elected government. Nearly all of those killed were civilians who, like Chouchou, fell into the hands of military or paramilitary forces. The vast majority of victims were poor peasants, like Chouchou, or urban slum dwellers. (The figures cited here are conservative estimates; I am quite sure that no journalist or observer ever came to count the body of Chouchou Louis.6)

Thus, the agony of Acephie and Chouchou was, in a sense, “modal” suffering. In Haiti, AIDS and political violence are two leading causes of death among young adults. These afflictions were not the result of accident or of force majeure; they were the consequence, direct or indirect, of human agency. When the Artibonite Valley was flooded, depriving families like the Josephs of their land, a human decision was behind it; when the Haitian army was endowed with money and unfettered power, human decisions were behind that, too. In fact, some of the same decisionmakers may have been involved in both cases.

If bureaucrats and soldiers seemed to have unconstrained sway over the lives of the rural poor, the agency of Acephie and Chouchou was, correspondingly, curbed at every turn. These grim biographies suggest that the social and economic forces that have helped to shape the AIDS epidemic are, in every sense, the same forces that led to Chouchou’s death and to the larger repression in which it was eclipsed. What is more, both were “at risk” of such a fate long before they met the soldiers who altered their destinies. They were both, from the outset, victims of structural violence.

While certain kinds of suffering are readily observable–and the subject of countless films, novels, and poems–structural violence all too often defeats those who would describe it. There are at least three reasons why this is so. First, there is the “exoticization” of suffering as lurid as that endured by AcCphie and Chouchou. The suffering of individuals whose lives and struggles recall our own tends to move us; the suffering of those who are distanced, whether by geography, gender, “race,” or culture, is sometimes less affecting.

Second, there is the sheer weight of the suffering, which makes it all the more difficult to render: “Knowledge of suffering cannot be conveyed in pure facts and figures, reportings that objectify the suffering of countless persons. The horror of suffering is not only its immensity but the faces of the anonymous victims who have little voice, let alone rights, in history.”7

Third, the dynamics and distribution of suffering are still poorly understood. Physicians, when fortunate, can alleviate the suffering of the sick. But explaining its distribution requires more minds, more resources. Case studies of individuals reveal suffering, they tell us what happens to one or many people; but to explain suffering, one must embed individual biography in the larger matrix of culture, history, and political economy.

In short, it is one thing to make sense of extreme suffering-a universal activity, surely–and quite another to explain it. Life experiences such as those of Acephie and Chouchou–who as Haitians living in poverty shared similar social conditions–must be embedded in ethnography if their representativeness is to be understood. These local understandings are to be embedded, in turn, in the larger-scale historical system of which the fieldwork site is a part.8 The social and economic forces that dictate life choices in Haiti’s Central Plateau affect many millions of individuals, and it is in the context of these global forces that the suffering of individuals receives its appropriate context of interpretation.

Similar insights are central to liberation theology, which takes the suffering of the poor as its central problematic. In The Praxis of Suffering, Rebecca Chopp notes that, “In a variety of forms, liberation theology speaks with those who, through their suffering, call into question the meaning and truth of human history.”9 Unlike most previous theologies, and unlike much modern philosophy, liberation theology has attempted to use social analysis to both explain and deplore human suffering. Its key texts bring into relief not merely the suffering of the wretched of the earth, but also the forces that promote that suffering. The theologian Leonardo Boff, in commenting on one of these texts, notes that it “moves immediately to the structural analysis of these forces and denounces the systems, structures, and mechanisms that `create a situation where the rich get richer at the expense of the poor, who get even poorer.”lO

In short, few liberation theologians engage in reflection on suffering without attempting to understand its mechanisms. Theirs is a theology that underlines connections. Robert McAfee Brown has these connections and also the poor in mind when, paraphrasing the Uruguayan Jesuit Juan Luis Segundo, he observes that “the world that is satisfying to us is the same world that is utterly devastating to them.”11


Haitian woman beside burning tires

“Events of massive, 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 really reveal the agony, the interruption, the questions that these victims put to the meaning and nature of our individual lives and life as a whole” –Rebecca Chopp The Praxis of Suffering

How might we discern the nature of structural violence and explore its contribution to human suffering? Can we devise an analytic model, one with explanatory and predictive power, for understanding suffering in a global context? Some would argue that this task, though daunting, is both urgent and feasible. Our cursory examination of AIDS and political violence in Haiti suggests that analysis must, first, be geographically broad. As noted, the world as we know it is becoming increasingly interconnected. A corollary of this belief is that extreme suffering–especially when on a grand scale, as in genocide–is seldom divorced from the actions of the powerful.’ The analysis must also be historically deep–not merely deep enough to remind us of events and decisions such as those which deprived Acephie of her land and founded the Haitian military, but deep enough to remember that modernday Haitians are the descendants of a people kidnapped from Africa in order to provide us with sugar, coffee, and cotton and to enrich a few in a mercantilist economy.

Factors including gender, ethnicity (”race”), and socioeconomic status may each be shown to play a role in rendering individuals and groups vulnerable to extreme human suffering. But in most settings these factors have limited explanatory power. Simultaneous consideration of various social “axes” is imperative in efforts to discern a political economy of brutality. Furthermore, such social factors are differentially weighted in different settings and at different times, as even brief consideration of their contributions to extreme suffering suggests.

The Axis of Gender

Acephie Joseph and Chouchou Louis shared, as noted, a similar social status, and each died after contact with the Haitian military. But gender helps to explain why Acephie died of AIDS whereas Chouchou died from torture. Gender inequality also helps to explain why the suffering of Acephie is much more commonplace than that of Chouchou. Throughout the world, women are confronted with sexism, an ideology that designates them as inferior to men. When, in 1974, a group of feminist anthropologists surveyed the status of women living in several disparate settings, they found that, in every society studied, men dominated political, legal, and economic institutions to varying degrees; in no culture was the status of women genuinely coordinate, much less superior, to that of men.13 This power differential has meant that women’s rights may be violated in innumerable ways. Although male victims are clearly preponderant in studies of torture, the much more common crimes of domestic violence and rape are almost exclusively endured by females. In the United States, the number of such aggressions is staggering. When sexual assaults by both intimates and strangers are considered, “one in four women has been the victim of a completed rape and one in four women has been physically battered, according to the results of recent communitybased studies.”14

In most settings, however, gender alone does not define risk for such assaults on dignity. It is poor women who bear the brunt of these assaults (15) This is true not only of domestic violence and rape, but also of AIDS and its distribution, as anthropologist Martha Ward points out:

The collection of statistics by ethnicity rather than by socio-economic status obscures the fact that the majority of women with AIDS in the United States are poor. Women are at risk for HIV not because they are African-American or speak Spanish; women are at risk because poverty is the primary and determining condition of their lives. (16)

Similarly, only women can experience maternal mortality, a cause of anguish around the world. More than half a million women die each year in childbirth, but not all women are at increased risk of adverse outcomes in pregnancy. In 1985, the World Health Organization estimated that maternal mortality is, on average, approximately 150 times higher in developing countries than in developed nations. In Haiti, where maternal mortality is as high as fourteen hundred deaths per one hundred thousand live births–almost five hundred times higher than in the wealthy countries–these deaths are almost all registered among the poor.l7

The Axis of “Race” or Ethnicity

The idea of race, which is considered to be a biologically insignificant term, has enormous social currency. Racial classifications have been used to deprive certain groups of basic rights, and therefore have an important place in considerations of human suffering. In South Africa, for years a living laboratory for the study of the long-term effects of racism, epidemiologists report that the infant mortality rate among blacks may be as much as ten times higher than among whites. For South African blacks, the proximate cause of increased rates of morbidity and mortality is lack of access to resources: “Poverty remains the primary cause of the prevalence of many diseases and widespread hunger and malnutrition among black South Africans.”18 And social inequality is seen in the uneven distribution of poverty.

Significant mortality differentials between blacks and whites are also registered in the United States, which shares with South Africa the distinction of being the only two industrialized countries failing to record mortality data by socioeconomic status. In the United States, in 1988, life expectancy at birth was 75.5 years for whites and 69.5 years for blacks. Accordingly, there has been a certain amount of discussion about race differentials in mortality, but public health expert Vicente Navarro recently complained about the “deafening silence” on the topic of class differentials in mortality in the United States, where “race is used as a substitute for class.” But in 1986, on “one of the few occasions that the US government collected information on mortality rates (for heart and cerebrovascular disease) by class, the results showed that, by whatever indicators of class one might choose (level of education, income, or occupation), mortality rates are related to social class.”19 Indeed, for the major causes of death (heart disease and cerebrovascular disease), class differentials were significantly larger than race differentials. “The growing mortality differentials between whites and blacks,” Navarro concludes, “cannot be understood by looking only at race; they are part and parcel of larger mortality differentials–class differentials.”20 The sociologist William Julius Wilson made a similar point in his landmark study, The Declining Significance of Race. He argues that “trained and educated blacks, like trained and educated whites, will continue to enjoy the advantages and privileges of their class status.”zl It is the black poor–and an analysis of the mechanisms of their impoverishment–that are being left out.

The Conflation of Structural Violence and Cultural Difference Awareness of cultural differences has long complicated discussions of human suffering. Some anthropologists have argued that what seem to outside observers to be obvious assaults on dignity may in fact be long-standing cultural institutions highly valued by a society. Often-cited examples range from female circumcision in the Sudan to head-hunting in the Philippines. Such discussions are invariably linked to the concept of cultural relativism, which has a long and checkered history in anthropology. Is every culture a law unto itself and a law unto nothing other than itself? In recent decades, confidence in reflex cultural relativism faltered as anthropologists turned their attention to “complex societies” characterized by extremely inegalitarian social structures. Many found themselves unwilling to condone social inequity merely because it was buttressed by cultural beliefs, no matter how ancient. Cultural relativism was also questioned as a part of a broader critique of anthropology by citizens of the former colonies.22

But this rethinking has not yet eroded a tendency, registered in many of the social sciences but perhaps particularly in anthropology, to confuse structural violence with cultural difference. Many are the ethnographies in which poverty and inequality, the end results of a long process of impoverishment, are conflated with “otherness.” Very often, such myopia is not really a question of motives, but rather, as Talal Asad has suggested, our “mode of perceiving and objectifying alien societies.”23 Part of the problem may be the ways in which the term “culture” is used. “The idea of culture,” explains one authority approvingly in a book on the subject, “places the researcher in a position of equality with his subjects: each `belongs to a culture.”24 The tragedy, of course, is that this equality, however comforting to the researcher, is entirely illusory. Anthropology has usually “studied down” steep gradients of power.

Such illusions suggest an important means by which other misreadings–most notably the conflation of poverty and cultural difference–are sustained. They suggest that the anthropologist and “his” subject, being from different cultures, are of different worlds and of different times.25 These sorts of misreadings, innocent enough within academia, are finding a more insidious utility within elite culture, which is becoming increasingly transnational. Concepts of cultural relativism, and even arguments to reinstate the dignity of different cultures and “races,” have been easily assimilated by some of the very agencies that perpetuate extreme suffering.26 Abuses of cultural concepts are particularly insidious in discussions of suffering in general and of human rights abuses more specifically: cultural difference is one of several forms of essentialism used to explain away assaults on dignity and suffering in general. Practices, including torture, are said to be “in their culture” or “in their nature”–“their” designating either the victims or the perpetrators, or both, as may be expedient.

Such analytic abuses are rarely questioned, even though systemic studies of extreme suffering would suggest that the concept of culture should have an increasingly limited role in explaining the distribution of misery. The interpretation of–and justifications for–suffering is usually patterned along cultural lines, but this, I would argue, is another question.


At night I listen to their phantoms shouting in my ear shaking me out of lethargy issuing me commands I think of their tattered lives of their feverish hands reaching out to seize ours. It’s not that they’re begging they’re demanding they’ve earned the right to order us to break up our sleep to come awake to shake off once and for all this lassitude.

–Claribel Alegria “Visitas Nocturnas”

Any distinguishing characteristic, whether social or biological, can serve as pretext for discrimination, and thus as a cause of suffering. In discussing each of the above factors, however, it is clear that no single axis can fully define increased risk for extreme human suffering. Efforts to attribute explanatory efficacy to one variable lead to immodest claims of causality, for wealth and power have often protected individual women, gays, and ethnic minorities from the suffering and adverse outcomes associated with assaults on dignity. Similarly, poverty can often efface the “protective” effects of status based on gender, race, or sexual orientation. Leonardo Boff and Clodovis Boff, writing from Brazil, insist on the primacy of the economic:

We have to observe that the socioeconomically oppressed (the poor) do not simply exist alongside other oppressed groups, such as blacks, indigenous peoples, women – to take the three major categories in the Third World. No, the “class-oppressed” – the socioeconomically poor – are the infrastructural expression of the process of oppression. The other groups represent “superstructural” expressions of oppression and because of this are deeply conditioned by the infrastructural. It is one thing to be a black taxi-driver, quite another to be a black football idol; it is one thing to be a woman working as a domestic servant, quite another to be the first lady of the land; it is one thing to be an Amerindian thrown off your land, quite another to be an Amerindian owning your own farm.27

None of this is to deny the ill effects of sexism or racism, even in the wealthy countries of North America and Europe. The point is merely to call for more fine-grained and systemic analyses of power and privilege in discussions of who is likely to suffer and in what ways.

The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise. One of the unfortunate sequelae of identity politics has been the obscuring of structural violence, which metes out injuries of vastly different severity. Careful assessment of severity is important, at least to physicians, who must practice triage and referral daily. What suffering needs to be taken care of first and with what resources? It is possible to speak of extreme human suffering, and an inordinate share of this sort of pain is currently endured by those living in poverty. Take, for example, illness and premature death, in many places in the world the leading cause of extreme suffering. In a striking departure from previous, staid reports, the World Health Organization now acknowledges that poverty is the world’s greatest killer: “Poverty wields its destructive influence at every stage of human life, from the moment of conception to the grave. It conspires with the most deadly and painful diseases to bring a wretched existence to all those who suffer from it.” (28)

As the twentieth century draws to a close, the world’s poor are the chief victims of structural violence–a violence which has thus far defied the analysis of many seeking to understand the nature and distribution of extreme suffering. Why might this be so? One answer is that the poor are not only more likely to suffer, they are also more likely to have their suffering silenced. As Chilean theologian Pablo Richard, noting the fall of the Berlin Wall, has warned, “We are aware that another gigantic wall is being constructed in the Third World, to hide the reality of the poor majorities. A wall between the rich and poor is being built, so that poverty does not annoy the powerful and the poor are obliged to die in the silence of history.”29

The task at hand, if this silence is to be broken, is to identify the forces conspiring to promote suffering, with the understanding that these will be differentially weighted in different settings. In so doing, we stand a chance to discern the forces motrices of extreme suffering. A sound analytic purchase on the dynamics and distribution of such affliction is, perhaps, a prerequisite to preventing or, at least, assuaging it. Then, at last, there may be hope of finding a balm in Gilead.30

ACKNOWLEDGMENTS I have the usual debts to faithful readers such as Haun Saussy and Jim Yong Kim, but wish also to acknowledge the constructive criticisms of this issue’s editors and of Didi Bertrand, Ophelia Dahl, Johanna Daily, Jonathan Mann, Joe Rhatigan, Joyce Bendremer, and Vinh Kim Nguyen.