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On Suffering and Structural Violence:

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On Suffering and Structural Violence: A View from Below
Paul Farmer

Race/Ethnicity: Multidisciplinary Global Contexts, Volume 3, Number

1, Autumn 2009, pp. 11-28 (Article)

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DOI: 10.1353/rac.0.0025

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On Suffering and
Structural Violence:
A View from Below
Paul Farmer

E veryone 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 sub-
ject 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 suffer-
ing, such as the pain born of deep poverty or of racism? Under
this latter rubric, are certain forms of discrimination demonstra-
bly 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.

From Daedalus, 125:1 (Winter, 1996), pp. 251-283. @1996 by the Ameri-
can Academy of Arts and Sciences. Reprinted with the permission of
the publisher, MIT Press Journals.

autumn 2009 11 © 2009 The Ohio State University/Office

of Minority Affairs/The Kirwan Institute
 paul farmer

Working in contemporary Haiti, where in recent years polit-

ical violence has been added to the worst poverty in the hemi-
sphere, one learns a great deal about suffering. In fact, the coun-
try 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 hemi-
sphere. 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 internation-
ally 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, con-
sequently, is hunger. All the standard measures reveal how ten-
uous 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. Tubercu-
losis is the leading cause of death among adults; among chil-
dren, diarrheal disease, measles, and tetanus ravage the under-
nourished.
But the experience of suffering, it is often noted, is not effec-
tively conveyed by statistics or graphs. The “texture” of dire af-
fliction 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 ana-
lyst, they suffered and died in exemplary fashion. Millions of
people living in similar circumstances can expect to meet simi-
lar 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
Acéphie 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 eco-
nomically driven) processes and forces that conspire—whether
through routine, ritual, or, as is more commonly the case, these

race /ethnicity vol. 3 / no. 1 12

ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

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.

Acéphie‘s Story
For the wound of the daughter of my people is my heart wounded,
I mourn, and dismay has taken hold of me.
Is 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 con-
ceived in the Haitian capital and drafted in Washington, D.C.:
Kay is a settlement of refugees, substantially composed of peas-
ant 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, thou-
sands of families had farmed the broad and gently sloping
banks of the river, selling rice, bananas, millet, corn, and sugar-
cane in regional markets. Harvests were, by all reports, bounti-
ful; 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 dwell-
ers, was unknown in most areas as rural as Kay. Acéphie 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 re-
gion’s sick.
The litany begins, usually, down in the valley hidden under
the still surface of the lake. Acéphie’s parents came from fami-
lies making a decent living by farming fertile tracts of land—their
“ancestors’ gardens”—and selling much of their produce. M. Jos-
eph tilled the soil, and his wife, a tall and wearily elegant wom-
an not nearly as old as she looked, was a “Madame Sarah,” a

autumn 2009 13
 paul farmer

market woman. “If it weren’t for the dam,” M. Joseph assured

me, “we’d be just fine now. Acéphie, 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; Acéphie
and her twin brother were born there. I asked them what in-
duced 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.”
Acéphie 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.” Acéphie’s beauty and her vulnera-
bility 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. Acéphie 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 bar-
racks. The soldiers liked to watch the parade of women on Fri-
day 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 appear-
ances. 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 fam-
ily; the times were as bad as those right after the flooding of the
valley. And so when Acéphie‘s good looks caught the eye of
Captain Jacques Honorat, a native of Belladere formerly sta-
tioned in Port-au-Prince, she returned his gaze.
Acéphie 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 Acéphie was taken in by his persis-
tence, and when he went to speak to her parents, a long-term li-
aison 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 ill-
ness, 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.

race /ethnicity vol. 3 / no. 1 14

ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

Acéphie and Honorat were sexual partners only briefly—for

less than a month, according to Acéphie. Shortly thereafter, Hon-
orat fell ill with unexplained fevers and kept to the company of
his wife in Peligre. As Acéphie was looking for a moun prensi-
pal—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.
Acéphie 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 Acéphie 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 Acéphie’s proud mother hated to think
of her daughter reduced to servitude, she could offer no viable
alternative.
And so Acéphie, 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 U.S. embassy. Acéphie’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 tel-
ephone. Although Acéphie was not paid well—she received
$30 each month—she tried to save a bit of money for her par-
ents and siblings, recalling the hunger gnawing at her home
village.
Still looking for a moun prensipal, Acéphie began seeing Blan-
co Nerette, a young man with origins identical to her own: Blan-
co’s parents were also “water refugees” and Acéphie had known
him when they were both attending the parochial school in Kay.
Blanco had done well for himself, by Kay standards: he chauf-
feured 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 Acéphie. They planned to marry,
and started pooling their resources.
Acéphie 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 Acéphie 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, Acéphie
was sapped by repeated infections. She was shortly thereafter
diagnosed with AIDS.
Soon Acéphie’s life was consumed with managing drench-
ing night sweats and debilitating diarrhea, while attempting to
care for her first child. “We both need diapers now,” she re-
marked 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

autumn 2009 15
 paul farmer

Acéphie was the victim of sorcery. Others recalled her liaison

with the soldier and her work as a servant in the city, both lo-
cally considered risk factors for AIDS. Acéphie 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 ser-
vant: “All that ironing, and then opening a refrigerator.”
But this is not simply the story of Acéphie and her daughter.
There is Jacques Honorat’s first wife, who each year grows thin-
ner. 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. Hono-
rat 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, appar-
ently in good health and plying the roads from Mirebalais to
Portau-Prince. Who knows if he carries the virus? As an attrac-
tive 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 Acéphie‘s twin brother was man-
ifestly intense, but few understood the anguish of her father.
Shortly after Acéphie‘s death, M. Joseph hanged himself.

Chouchou‘s Story
“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 exter-
mination 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 re-
markable 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, U.S. policy maintained that Haitian asylum-seek-
ers were “economic refugees.” As part of a 1981 agreement be-
tween the administrations of Ronald Reagan and Jean-Claude
Duvalier, refugees seized on the high seas were summarily re-
turned 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.

race /ethnicity vol. 3 / no. 1 16

ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

A growing Haitian pro-democracy movement led, in Febru-

ary 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 duvaliéristes. It was this
army that the U.S. 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 U.S. aid passed through the hands of the junta.
In early 1989, Chouchou moved in with Chantal Brise, 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 presi-
dency in the internationally monitored elections of 1990. In
December of that year almost 70 percent of the voters chose Fa-
ther 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 poor—
Haiti’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 Septem-
ber 1991 stirred great anger in the countryside, where the ma-
jority 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 re-
assembled 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 con-
sideration 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 at-
tachés, to use the epithet then in favor—immediately began
beating Chouchou, in front of the other passengers; they contin-
ued 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 after-effect 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

autumn 2009 17
 paul farmer

law (i.e., the military) led to blacklisting. For men like Chou-
chou, staying out of jail involved keeping the local attachés
happy, and he did this by avoiding his home village. But Chou-
chou 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 attachés. 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 attachés. 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 thor-
oughly 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 recogniz-
able. 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 pe-
culiarly 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 beat-
ings 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 ago-
nal 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 Chou-
chou three days to die.

Explaining Versus Making Sense of Suffering

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 Acéphie’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 car-

race /ethnicity vol. 3 / no. 1 18

ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

ing 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 do-
mestic; none managed to find financial security. The women in-
terviewed were straightforward about the nonvoluntary aspect
of their sexual activity: in their opinions, they had been driven
into unfavorable unions by poverty.5 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 ma-
jority of victims were poor peasants, like Chouchou, or urban
slum dwellers. (The figures cited here are conservative esti-
mates; I am quite sure that no journalist or observer ever came
to count the body of Chouchou Louis.)6
Thus, the agony of Acéphie 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 Ar-
tibonite 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 deci-
sion-makers 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 Acéphie 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 vi-
olence all too often defeats those who would describe it. There
are at least three reasons why this is so. First, there is the “exoti-
cization” of suffering as lurid as that endured by Acéphie and
Chouchou. The suffering of individuals whose lives and strug-
gles 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 suffer-
ing cannot be conveyed in pure facts and figures, reportings
that objectify the suffering of countless persons. The horror of

autumn 2009 19
 paul farmer

suffering is not only its immensity but the faces of the anony-
mous 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 Acéphie 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 embed-
ded, in turn, in the larger-scale historical system of which the
fieldwork site is a part.8 The social and economic forces that dic-
tate 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 suf-
fering. 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.’”10
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 ob-
serves that “the world that is satisfying to us is the same world
that is utterly devastating to them.”11

Multiaxial Models of Suffering

“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 re-
ally 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

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ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

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 sug-
gests that analysis must, first, be geographically broad. As
noted, the world as we know it is becoming increasingly inter-
connected. A corollary of this belief is that extreme suffering—
especially when on a grand scale, as in genocide—is seldom di-
vorced from the actions of the powerful.12 The analysis must also
be historically deep—not merely deep enough to remind us of
events and decisions such as those which deprived Acéphie of
her land and founded the Haitian military, but deep enough to
remember that modern day 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 socioeco-
nomic status may each be shown to play a role in rendering in-
dividuals 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 considera-
tion of their contributions to extreme suffering suggests.

The Axis of Gender

Acéphie 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 Acéphie died
of AIDS whereas Chouchou died from torture. Gender inequal-
ity also helps to explain why the suffering of Acéphie 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 institu-
tions 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 vio-
lated 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 en-
dured by females. In the United States, the number of such ag-
gressions 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 commu-
nity-based studies.”14

autumn 2009 21
 paul farmer

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 vio-
lence and rape, but also of AIDS and its distribution, as anthro-
pologist Martha Ward points out:
The collection of statistics by ethnicity rather than by socio-eco-
nomic 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 deter-
mining 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 in-
creased 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 hun-
dred thousand live births—almost five hundred times higher
than in the wealthy countries—these deaths are almost all regis-
tered among the poor.17

The Axis of “Race”or Ethnicity

The idea of race, which is considered to be a biologically in-
significant term, has enormous social currency. Racial classifi-
cations 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 labora-
tory for the study of the long-term effects of racism, epidemiol-
ogists 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 mor-
bidity and mortality is lack of access to resources: “Poverty re-
mains 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 distri-
bution 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 coun-
tries 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 mor-
tality, but public health expert Vicente Navarro recently com-
plained about the “deafening silence” on the topic of class dif-
ferentials in mortality in the United States, where “race is used
as a substitute for class.” But in 1986, on “one of the few occa-
sions that the U.S. government collected information on mortal-

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ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

ity rates (for heart and cerebrovascular disease) by class, the re-
sults 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 differ-
entials 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.”21 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 dis-
cussions of human suffering. Some anthropologists have ar-
gued 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 fe-
male circumcision in the Sudan to head-hunting in the Philip-
pines. 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 at-
tention to “complex societies” characterized by extremely ine-
galitarian 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 an-
thropology, to confuse structural violence with cultural differ-
ence. Many are the ethnographies in which poverty and in-
equality, 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 sug-
gested, our “mode of perceiving and objectifying alien soci-
eties.”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 cul-
ture.’”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.

autumn 2009 23
 paul farmer

Such illusions suggest an important means by which other

misreadings—most notably the conflation of poverty and cul-
tural difference—are sustained. They suggest that the anthro-
pologist and “his” subject, being from different cultures, are of
different worlds and of different times.25 These sorts of misread-
ings, innocent enough within academia, are finding a more in-
sidious utility within elite culture, which is becoming increas-
ingly 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 agen-
cies that perpetuate extreme suffering.26 Abuses of cultural con-
cepts 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, in-
cluding torture, are said to be “in their culture” or “in their na-
ture”—“their” designating either the victims or the perpetra-
tors, or both, as may be expedient.
Such analytic abuses are rarely questioned, even though sys-
temic studies of extreme suffering would suggest that the con-
cept of culture should have an increasingly limited role in ex-
plaining 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.

Structural Violence and Extreme Suffering

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 biologi-

cal, 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 ex-
treme 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 as-
sociated with assaults on dignity. Similarly, poverty can often
efface the “protective” effects of status based on gender, race, or

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ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

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 expres-
sion of the process of oppression. The other groups represent
“superstructural” expressions of oppression and because of this
are deeply conditioned by the infra structural. 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 anal-
yses 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 un-
fortunate 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 re-
sources? 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 prema-
ture death, in many places in the world the leading cause of ex-
treme suffering. In a striking departure from previous, staid re-
ports, the World Health Organization now acknowledges that
poverty is the world’s greatest killer: “Poverty wields its de-
structive influence at every stage of human life, from the mo-
ment 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 si-
lenced. As Chilean theologian Pablo Richard, noting the fall of
the Berlin Wall, has warned, “We are aware that another gigan-
tic wall is being constructed in the Third World, to hide the real-
ity 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

autumn 2009 25
 paul farmer

The task at hand, if this silence is to be broken, is to identify

the forces conspiring to promote suffering, with the understand-
ing that these will be differentially weighted in different settings.
In so doing, we stand a chance to discern the forces motrices of ex-
treme suffering. A sound analytic purchase on the dynamics and
distribution of such affliction is, perhaps, a prerequisite to pre-
venting 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.

Endnotes
1. Jean Weise, “The Interaction of Western and Indigenous Medi-
cine in Haiti in Regard to Tuberculosis,” Ph.D. Dissertation, Depart-
ment of Anthropology, University of North Carolina at Chapel Hill,
1971.
2. The names of the Haitians cited here have been changed, as have
the names of their home villages.
3. For a recent review of the effects of inegalitarian social structures
on the health of wealthier populations, see Michael Marmot, “Social
Differentials in Health Within and Between Populations,” Daedalus 123
(4) (Fall 1994): 197-216.
4. Some would argue that the relationship between individual
agency and supraindividual structures forms the central problematic
of contemporary social theory. I have tried, in this essay, to avoid what
Pierre Bourdieu has termed “the absurd opposition between individ-
ual and society,” and I acknowledge the influence of Bourdieu, who
has contributed enormously to the debate on structure and agency. For
a concise statement of his (often revised) views on this subject, see
Pierre Bourdieu, In Other Words: Essays Towards a Reflexive Sociology
(Cambridge: Polity, 1990). That a supple and fundamentally non-de-
terministic model of agency would have such a deterministic—and
pessimistic—“feel” is largely a reflection of my topic, suffering, and
my fieldwork site.
5. Paul Farmer, “Culture, Poverty, and the Dynamics of HIV Trans-
mission in Rural Haiti,” in Han ten Brummelhuis and Gilbert Herdt,
eds., Culture and Sexual Risk: Anthropological Perspectives on AIDS (New
York: Gordon and Breach, 1995), 3-28.
6. For an overview of the human rights situation during the recent
coup, see Americas Watch and the National Coalition for Haitian
Refugees, Silencing a People: The Destruction of Civil Society in Haiti
(New York: Human Rights Watch,1993) and William O’Neill, “The
Roots of Human Rights Violations in Haiti,” Georgetown Immigration
Law Journal 7 (1) (1993): 87-117. I have reviewed these and other re-
ports in Paul Farmer, The Uses of Haiti (Monroe, Maine: Common
Courage, 1994).
7. Rebecca Chopp, The Praxis of Suffering (Maryknoll, N.Y.: Orbis,
1986), 2.

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ON SUFFERING AND STRUCTURAL VIOLENCE : A VIEW FROM BELOW

8. This argument is made at greater length in “AIDS and the An-

thropology of Suffering,” in Paul Farmer, AIDS and Accusation: Haiti and
the Geography of Blame (Berkeley, Calif.: University of California Press,
1992). The term “historical system” is used following Immanuel Waller-
stein, who for many years has argued that even the most far-flung lo-
cales—Haiti’s Central Plateau, for example—are part of the same social
and economic nexus: “by the late nineteenth century, for the first time
ever, there existed only one historical system on the globe. We are still in
that situation today.” See Immanuel Wallerstein, “World-Systems Anal-
ysis,” in Social Theory Today, ed. Anthony Giddens and Jonathan Turner
(Stanford, Calif.: Stanford University Press, 1985), 318. See also Im-
manuel Wallerstein, The Modern World-System: Capitalist Agriculture and
the Origins of the European World-Economy in the Sixteenth Century (San
Diego, Calif.: Academic Press, 1974). The weakness of these analyses is,
of course, their extreme divorce from personal experience.
9. Chopp, The Praxis of Suffering, 2. See also the works of Gustavo
Gutierrez, who has written a great deal about the meaning of suffering
in the twentieth century: for example Gustavo Gutierrez, A Theology of
Liberation (Maryknoll, N.Y.: Orbis, 1973) and Gustavo Gutierrez, The
Power of the Poor in History (Maryknoll, N.Y.: Orbis, 1983). For anthro-
pological studies of liberation theology in social context, see the ethno-
graphies by John Burdick, Looking for God in Brazil (Berkeley, Calif.:
University of California Press,1993) and Roger Lancaster, Thanks to
God and the Revolution (New York: Columbia University Press, 1988).
10. From the Puebla document, cited in Paul Farmer, “Medicine and
Social Justice: Insights from Liberation Theology,” America 173 (2)
(1995): 14.
11. Robert McAfee Brown, Liberation Theology: An Introductory Guide
(Louisville, Ky.: Westminster, 1993), 44.
12. The political economy of genocide is explored by Christopher
Simpson in The Splendid Blond Beast: Money, Law, and Genocide in the
Twentieth Century (New York: Grove Press, 1993). See also Gotz Aly,
Peter Chroust, and Christian Pross, Cleansing the Fatherland: Nazi
Medicine and Racial Hygiene (Baltimore, Md.: Johns Hopkins University
Press, 1994). As regards the transnational political economy of human
rights abuses, see the two-volume study by Noam Chomsky and Ed-
ward S. Herman, The Washington Connection and Third World Fascism
and After the Cataclysm (Boston, Mass.: South End Press, 1979).
13. Michelle Rosaldo and Louise Lamphere, eds., Women, Culture,
and Society (Stanford, Calif.: Stanford University Press, 1974).
14. Mary Koss, Paul Koss, and Joy Woodruff, “Deleterious Effects of
Criminal Victimization on Women’s Health and Medical Utilization,”
Archives of Internal Medicine 151 (1991): 342.
15. It is important to note, however, that upper class/caste women
are in many societies also subject to laws that virtually efface marital
rape. The study by Koss, Koss, and Woodruff includes this crime with
other forms of criminal victimization, but it is only through commu-
nity-based surveys that such information is collected.
16. Martha Ward, “A Different Disease: HIV/AIDS and Health Care
for Women in Poverty,” Culture, Medicine and Psychiatry 17 (4) (1993):
414.
17. World Health Organization, “Maternal Mortality: Helping Wom-
en Off the Road to Death,” WHO Chronicle 40 (1985): 175-83.
18. Elena Nightingale, Kari Hannibal, Jack Geiger, Lawrence Hart-
mann, Robert Lawrence, and Jeanne Spurlock, “Apartheid Medicine:
Health and Human Rights in South Africa,” Journal of the American
Medical Association 264 (16) (1990): 2098. The italics are mine. For a
more in-depth account, and a more complicated view of the mecha-

autumn 2009 27
 paul farmer

nisms by which apartheid and the South African economy are related
to disease causation, see Randall Packard, White Plague, Black Labor: Tu-
berculosis and the Political Economy of Health and Disease in South Africa
(Berkeley, Calif.: University of California Press, 1989).
19. “Vicente Navarro, “Race or Class versus Race and Class: Mortal-
ity Differentials in the United States,” The Lancet 336 (1990): 1238.
20. Ibid.,1240.
21. William Julius Wilson, The Declining Significance of Race: Blacks
and Changing American Institutions, 2nd ed. (Chicago, Ill.: University of
Chicago Press, 1980), 178.
22. See the studies by Elvin Hatch, Culture and Morality: The Relativ-
ity of Values in Anthropology (New York: Columbia University Press,
1983), and by Ernest Gellner, Relativism and the Social Sciences (Cam-
bridge: Cambridge University Press, 1985).
23. Talal Asad, ed., Anthropology and the Colonial Encounter (London:
Ithaca Press,1975), 17.
24. Roy Wagner, The Invention of Culture (Englewood Cliffs, N.J.:
Prentice-Hall,1975), 2.
25. Johannes Fabian has argued that this “denial of coevalness” is
much ingrained in our discipline. Not to be dismissed as an issue of
style, such a denial contributes to the blindness of the anthropologist:
“Either he submits to the condition of coevalness and produces ethno-
graphic knowledge, or he deludes himself into temporal distance and
misses the object of his search.” See Johannes Fabian, Time and the
Other: How Anthropology Makes its Object (New York: Columbia Uni-
versity Press, 1983). See also the compelling essay by Orin Starn,
“Missing the Revolution: Anthropologists and the War in Peru,” in
George Marcus, ed., Rereading Cultural Anthropology (Durham, N.C.:
Duke University Press, 1992), 152-80.
26. For a penetrating examination of the appropriation of identity
politics by big business, see the essay by L. A. Kauffman, “The Diver-
sity Game,” The Village Voice, 31 August 1993.
27. Leonardo Boff and Clodovis Boff, Introducing Liberation Theology
(Maryknoll, N.Y.: Orbis Books, 1987), 29.
28. World Health Organization, Bridging the Gaps (Geneva: World
Health Organization, 1995), 5.
29. Cited by Jack Nelson-Pallmeyer, Brave New World Order: Must
We Pledge Allegiance? (Maryknoll, N.Y.: Orbis, 1992), 14.
30. Editors’ note: Paul Farmer’s paper was not one of the papers
presented at the Bellagio Conference on “Social Suffering.” It was so-
licited by the editors after that meeting took place.

race /ethnicity vol. 3 / no. 1 28