Structural Violence and Clinical Medicine

“Because of contact with patients, physicians readily appreciate that large-scale social forces—racism, gender inequality, poverty, political violence and war, and sometimes the very policies that address them—often determine who falls ill and who has access to care. “

“For practitioners of public health, the social determinants of disease are even harder to disregard. Unfortunately, this awareness is seldom translated into formal frameworks that link social analysis to everyday clinical practice. One reason for this gap is that the holy grail of modern medicine remains the search for the molecular basis of disease. While the practical yield of such circumscribed inquiry has been enormous, exclusive focus on molecular-level phenomena has contributed to the increasing “desocialization” of scientific inquiry: a tendency to ask only biological questions about what are in fact biosocial phenomena. Biosocial understandings of medical phenomena are urgently needed. All those involved in public health sense this, especially when they serve populations living in poverty…Social analysis is heard in discussions about illnesses for which significant environmental components are believed to exist, such as asthma and lead poisoning. Can we speak of the “natural history” of any of these diseases without addressing social forces, including racism, pollution, poor housing, and poverty, that shape their course in both individuals and populations?”

“The term “structural violence” is one way of describing social arrangements that put individuals and populations

in harm’s way. The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people. With few exceptions, clinicians are not trained to understand such social forces, nor are we trained to alter them. Yet it has long been clear that many medical and public health interventions will fail if we are unable to understand the social determinants of disease. The good news is that such biosocial understandings are far more “actionable” than is widely recognized. There is already a vast and growing array of diagnostic and therapeutic tools born of scientific research; it is possible to use these tools in a manner informed by an understanding of structural violence and its impact on disease distribution and on every step of the process leading from diagnosis to effective care. This means working at multiple levels, from “distal” interventions—performed late in the process, when patients are already sick—to “proximal” interventions— trying to prevent illness through efforts such as vaccination or improved water and housing quality…”

Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural violence and clinical medicine. PLoS Med 3(10): e449. DOI: 10.1371/journal.pmed.0030449