Mainstreaming an Understanding of Structural Violence
by Hannah Robbins on December 4, 2008
In his article “Structural Violence and Clinical Medicine,” Paul Farmer declares, “Medical professionals are not trained to make structural interventions.” However, it seems clear to those of us who ascribe to the concept of structural violence that this is an outlook on medical practice that cannot, and should not, be ignored. How then can we explain the fact that medical professionals, those whose job (and duty) it is to address health problems to the best of their ability, do not employ an understanding of structural violence? What can be done to conquer the discrepancy that exists between what we know needs to be done to improve the effectiveness of clinical medicine and the nonexistence of a professional position that can fill this void? Perhaps the issue surrounding the concept of structural violence is no longer a decision between a theoretical “yay” or “nay” to the commitment to follow this new, more comprehensive philosophy (which Farmer proves as effective in his description of Partners In Health projects in Baltimore, Haiti and Rwanda), yet how to incorporate this biosocial medical model into mainstream clinical medicine and how to act on this commitment.
In an attempt to answer this provocation, Farmer concludes that we must “link our efforts to those of others committed to initiating virtuous social cycles” and only then can we expect “a future in which medicine attains its noblest goals.” Though this is a valuable step in putting an understanding of structural violence into effective use, it seems there may be a way to go beyond merely linking medical efforts to social efforts, and instead fully incorporate one within the other. As Dr. Deborah Claire Stewart (from the UC Davis Medical Center) says, "As we look over the last two decades or so, what's really causing health problems in our society has changed, but we haven't actually changed the focus of our training." So, we must ask, why not?
Though the implementation of a biosocial curriculum within the field of medicine has by no means become the norm, we are certainly beginning to witness a major shift in clinical practice within many individuals and organizations. Yet can we expect this trend to catch on, and how far can we expect this changing perspective to take us? Will we one day be able to confidently say that medical professionals are trained to make structural interventions? Or if not trained to make structural interventions, are at least educated with a thorough understanding of the pervasiveness of social forces on clinical medicine?
But of course there are always the potential negatives to take into account. Is it possible that this inclusion of a biosocial philosophy within medicine will prove disastrous and promote the idea that medical professionals should stick to biology and chemistry and stray away from sociology and anthropology? If we ask the medical field to expand its horizons, what will be the realistic cost of this change? I don’t have the answers. But, as Farmer says, “Asking these questions needs to be the beginning of a conversation within medicine and public health, rather than the end of one.” Let’s not let our fear of uncertainty prevent us from continuing the conversation.
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