Causes and cures VII: Structural violence

Structural violence, though mostly hidden, is a concept important enough in any study of violence to prompt a full article in this series. Given its scope, importance, and implications in terms of causing other forms of violence, we may even argue that it is a central concept. It refers to the avoidable limitations society places on groups of people that constrain them from achieving the quality of life that would have otherwise been possible. These limitations could be political, economic, religious, cultural, or legal in nature and usually originate in institutions that have authority over particular subjects. Because of its embedding within social structures, people tend to overlook them as ordinary difficulties that they encounter in the course of life. A sample scenario might be when people desperately need education, healthcare, political power, or legal assistance but are unable to access them easily. Unlike the more visible forms of violence where one person perpetrates physical harm on another, structural violence occurs through economically, politically, or culturally driven processes working together to limit subjects from achieving full quality of life (Gupta, 2012). For example, if someone died of tuberculosis, autoimmune deficiency syndrome (AIDS), or other preventable diseases in the present state where advanced medications are available, then that would be a form of structural violence (Ho, 2007). We consider it a form of violence because these deaths are now preventable and only occur because of the disparities in distribution of healthcare among the different strata or regions. The harm is structural because it is a product of the way we have organized our social world; it is violent because it causes injury and death.

In the first article of this Causes and Cures series (Lee, 2015), we discussed how the World Report on Violence and Health (Krug et al., 2002) has been instrumental in shaping global discourse on violence, beginning with a standard definition. It is remarkable in that it embeds in it a larger concept of violence that goes beyond physical force to include: “… power, threatened or actual, that either results in or has a high likelihood of resulting in … maldevelopment or deprivation” (p. 5). Structural violence directly illustrates a power system wherein social structures or institutions cause harm to people in a way that results in maldevelopment or deprivation. Because it is a product of human decisions and not natural occurrences, and because it is correctable and preventable through human agency, there is increasing advocacy that we call it violence (Winter and Leighton, 2001), rather than simply social injustice or oppression. A key aspect of structural violence is that it is often subtle, invisible, and accepted as a matter of course; even more difficult than detecting this type of violence is assigning culpability, for the actors are often impossible to identify. However, if we took into account the victim's (or observer's) and not just the perpetrator's perspective, structural violence has similar effects as behavioral violence, including death (Morgan et al., 2014). Structural violence, in fact, is by far the most lethal form of violence as well as the most potent cause of other forms of violence (Butchart and Engström, 2002). The excess rates of death and disability resulting from the social and economic structure of our society—that is, its division into rich and poor, powerful and weak, and superior and inferior—are measurable using life expectancy data, as we will see in the next section. Between 10 to 20 million per year (Høivik, 1977), these are about ten times the rates of those from suicide, homicide, and warfare combined. This is why failing to capture structural violence, therefore, is akin to letting loose big fish while retaining “small fry.”

From an ecological perspective, all violence originates from a continuum of bio-psycho-social-environmental causes, and no form is entirely individual or entirely without agency, and therefore structural violence is equally of collective responsibility as any other type of violence. Societal structures are what we choose while deciding as a society, as every society does, how to distribute or not to distribute, or how to share or not to share, the collective income and wealth that the society produces. For example, Indian economist Amartya Sen (1982) in part won the Nobel Prize for showing that the mass deaths occurring during famines were not the result of a shortage of food but rather a shortage of money on the part of the poor, who simply could not afford to purchase the food that was available in their countries. The millions of deaths occurring because of the AIDS epidemic in low-income nations, such as those of sub-Saharan Africa, are not the result of natural causes but of poverty: that is, the inability of individuals suffering from AIDS to afford to pay for the medicines that could save their lives and currently are saving millions of lives of similar victims in high-income countries. The effects of unequal control over the distribution of resources worsen if the persons low on income are also low on education, on health, and on power—as is frequently the case because these dimensions interlink in the social structure. In order to account for all these areas of harm, we need to adopt a larger definition of violence that does not confine itself to existing fields of inquiry but adapts inquiry to the need for understanding.