by Emily Frisch
Foundations of Structural Violence:
Structural violence is a theory used to explain the harm done to a person as a result of societal and institutional violence. Violence, fundamentally the opposite of peace, is detrimental to one’s autonomy when it prevents a person from meeting their basic needs. (2) In regards to health, structural violence refers to any institutional or societal barrier that interferes with a person receiving proper care or resources necessary to achieve good health. This includes, but is not limited to, discrepancies in receiving care based on race, gender, economic status, sexuality, age or class (2). In 1969, Johan Galtung, a Norwegian sociologist and founder of Peace and Conflict Studies, developed the theory of structural violence and explored its interplay with direct and cultural violence (3). Today, the theory of structural violence is most frequently used by Paul Farmer. Figure 1 represents the relationship between direct, cultural and structural violence, as adapted from Galtung’s Violence triangle (7).
According to Galtung, the unseen components of cultural and structural violence manifest in visible direct violence. Cultural violence stems from ones beliefs and attitudes that can be used to justify violence, for example, legitimize causing harm out of personal fear, hatred or dismissiveness (2). Structural violence occurs when groups of people are more/less likely to receive access to resources, services, opportunities, etc. based on race, gender, income, religion, age and other social determinants (6). In structural violence, there is no one person that commits harm. Rather, the violence is embedded within the society’s structural makeup, which leads to inequalities in power and opportunities for education, healthcare and employment (2). Together, the unseen determinants of cultural and structural violence contribute to direct violence, manifested through the detrimental physical actions committed by a particular person or group of people, such as assault, murder, torture and verbal abuse (6).
The theory of structural violence is useful for identifying the underlying factors that contribute to the inequitable access to quality health care rooted within a health system. By identifying various political, economic, social and cultural structures that prevent one from receiving care within a particular community, public health officials can pinpoint a specific area for intervention in order to reduce avoidable violence and promote autonomy. For example, Paul Farmer uses structural violence to explain how poverty, powerlessness and violence play a role in the worsening of TB and AIDS in Haiti, particularly for women (5). Structural violence is also used domestically to explain inequalities in health care. For example, in 2011, the infant mortality rate in the United States was 6.05 deaths/1,000 live births (4). When comparing the infant mortality rates by race in that same year, the infant mortality rate for white infants was 5.11 deaths/1,000 live births and 11.42 deaths/1,000 live births for black infants (4). Analyzing the evidence through the perspective of structural violence, there are clear shortcomings within the US health care system that result in inequitable care due to race, income and gender among other social determinants.
One limitation to the structural violence theory is that it does not take into account individual factors and decisions that contribute to harm. Though it serves as an excellent model for explaining inequalities in seeking accessible care, it fails to acknowledge harm as a consequence of personal choices. For example, a study conducted in Kenya interviewed female, heroin-addicted sex workers, aiming to identify the structural violence that led the women to these circumstances. However, the researchers discovered that these women were “not the passive victims of the circumstances in which they find themselves” (1). Instead, they found that these women could assert personal agency to improve their circumstances and were not simply victims of structural violence. This model does not take into consideration that humans are autonomous beings, and though they may be restricted by structural violence and societal factors, their free will to make decisions will either promote or reduce harm. This theory may cause individuals to neglect personal responsibility for their circumstances and displace all responsibility on society.
Public Health Utilization:
This model is best used when examining harm done on a large scale, for example, injustices that face entire populations. Though it is important to recognize its limitations, structural violence helps unveil the overarching factors embedded within a society that contribute to harm. This model is a helpful tool to be used by public health officials to pinpoint areas for intervention to overcome many social injustices, and ultimately, reduce avoidable harm.
(1) Beckerleg S, Hundt GL. Women heroin users: Exploring the limitations of the structural violence approach. International Journal of Drug Policy [Internet]. 2005 Jun [cited 2015 Mar 17];16(3):183–90. Available from: http://www.sciencedirect.com/science/article/pii/S0955395905000472
(2) Galtung J. Violence, Peace and Peace Research. Journal of Peace Research [Internet]. 1969;6(3):167–91. Available from: http://www.jstor.org/stable/422690
(3) Gattinger M. Johan Galtung [Internet]. Galtung-Institute for Peace Theory and Peace Practice. 2015. Available from: https://www.galtung-institut.de/en/home/johan-galtung/
(4)National Center for Statistics. National Vital Statistics Reports [Internet]. 2013 p. 1–52. Report No.: Volume 61, Number 6. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf
Farmer P. On Suffering and Structural Violence: A View from Below. Daedalus [Internet]. 1996 Jan 1 [cited 2015 Mar 17];125(1):261–83. Available from: http://www.jstor.org/stable/20027362
Understanding Violence Triangle and Structural Violence | KanglaOnline [Internet]. [cited 2015 Mar 17]. Available from: http://kanglaonline.com/2012/07/understanding-violence-triangle-and-structural-violence-by-rajkumar-bobichand/
Galtung J. Violence, Peace and Peace Research. Journal of Peace Research [Internet]. 1969;6(3):167–91. Available from: http://www.jstor.org/stable/422690