Physical violence and its manifestations are frequently found in the medical consultation: the battered wife, the abused child, or the aftermath of a drunken altercation that needs to be sutured back together again. Just as common, though less visible to the eye, are anthropological and sociological concepts of violence. If not sought out, they are missed, and can have a dramatic impact on the health and wellbeing of our patients.
STRUCTURAL VIOLENCE
‘Structural violence is the violence of injustice and inequity.’1 The term was first used by the sociologist Johan Galtung, who defined it as the:
‘… difference between the potential and the actual, between what could have been and what is … Thus, if a person died from tuberculosis in the eighteenth century it would be hard to conceive of this as violence since it might have been quite unavoidable, but if he dies from it today, despite all the medical resources in the world, then violence is present.’2
The physician anthropologist Paul Famer has popularised the concept of structural violence further and draws heavily from his work in Haiti. For Farmer:
‘… the concept of structural violence is intended to inform the study of the social machinery of oppression. Oppression is a result of many conditions, not the least of which reside in consciousness.’3
In the aftermath of the Haitian earthquake, there were immediate fatalities from the physical effects of the natural disaster; unfortunately, there were also many subsequent deaths due to what should have been avoidable circumstances — a lack of food and clean water, limited access to adequate shelter, and poor medical care.
For Farmer, the earthquake in Haiti is an example of acute-on-chronic violence, ‘… direct violence on layers of structural violence’.1
Closer to home, we can see the Grenfell Tower tragedy as a similar example of this acute-on-chronic picture, a marginalised community subjected to multiple layers of structural violence made worse by a devastating act of physical violence via the fire.
SYMBOLIC VIOLENCE
The sociologist Pierre Bourdieu formulated the idea of symbolic violence, which he defined as ‘… violence which is exercised upon a social agent with his or her complicity’.4
Bourdieu first conceptualised his notion in the study of gift giving among the Kabyle people of Algeria. These gifts created bonds of obligation, which resulted in the domination of those who were unable to reciprocate; this system was able to continue only due to the complicity of all parties, along with the misrecognition that domination was taking place.5 Symbolic violence is thus when the social agent internalises blame. Blaming a patient for their poverty or being racist towards a patient is not in itself an act of symbolic violence;6 it is only when the patients begin to blame themselves for their poverty, for example, believing ‘it’s because I do not work hard enough’, or when racist ideologies lead to further self-degradation by the already victimised.
EVERYDAY VIOLENCE
The anthropologist Nancy Scheper-Hughes is credited with coining the term everyday violence in her ethnography set in the favelas of Brazil. Here she found: ‘… normalization and institutionalized social indifference to staggering infant and child mortality’.7 This was a place where:
‘Local political leaders, Catholic priests and nuns, coffin makers, and even the shantytown mothers themselves casually dispatched a multitude of hungry “angel-babies” to the afterlife each year saying: “Well, they themselves wanted to die”. (The babies were described as having no “taste”, no “knack” and no “talent” for life).’7
Everyday violence is thus the ‘… production of social indifference to outrageous suffering through institutional processes and discourses’.6 Often, as physicians, we can be guilty of perpetuating everyday violence through medicalising social and political problems. As Scheper-Hughes argues:
‘Medicalisation mystifies. It isolates the experience of misery and it domesticates people’s anger. There is power and domination to be extracted from the defining of a population as “sick” or “nervous”. To acknowledge hunger (which is not a disease but a social illness) would be tantamount to political suicide.’8
CONCLUSION
GPs are the ethnographers of the medical profession. Embedded in communities over long periods of time, we are in a unique position to see the fault lines, and bear witness to both the physical and sociological violence that is present. We are ideally placed to advocate on behalf of victims of this violence, or, at the very least, make sure we are not perpetuating it.
- © British Journal of General Practice 2018