Mountains Beyond Mountains Study Guide
Mountains Beyond Mountains cover

STUDY NOTE

Explaining Difference: “Culture,” “Structural Violence,” and Medical Anthropology

By Professor Janelle S. Taylor, Anthropology, University of Washington
Email: jstaylor@u.washington.edu

What You Can Learn from Exploring This Topic

  • The lives of people in Haiti with whom Paul Farmer works are vastly different from the lives of most if not all UW freshmen reading Tracy Kidder’s book this year. How can we explain these stark differences? What do the concepts of “culture” and “structural violence” add to our understanding of these differences?
  • Why does it matter how we explain difference? In other words, how can our choice of the terms “culture” or “structural violence” carry real-world consequences?
  • What is medical anthropology and where can you learn more about it?

“Culture” versus “Structural Violence”

Rural Haiti, where Farmer lives and works much of the time, emerges in Kidder’s account as a place where life differs in many important respects from Seattle where you will be living as you study and discuss this book. Two passages from Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, provide glimpses into “culture” and “structural violence” as two very different ways of understanding and explaining what is distinctive about health and illness in rural Haiti.

A doctor who didn’t understand local culture would probably mistake many patients’ complaints for bizarre superstitions, or at best be utterly baffled – by the female complaint called move san, lèt gate, for instance. The condition was said to be brought on by seziman, that is, by a surprise or by someone’s frightening action. Move san, “bad blood,” could follow, and produce in turn lèt gate, a condition in which a nursing mother’s milk was spoiled or stopped flowing. None of this would be mysterious to a young ethnographer-doctor who, like Farmer, was willing to puzzle out the social meanings of the syndrome. (Mountains Beyond Mountains, 83)

In this passage, Kidder portrays Farmer as drawing on his knowledge of “local culture” to make sense of statements made by rural Haitians regarding illnesses that would otherwise be unfathomable to physicians trained in the very different “culture” of North American biomedicine (Taylor, 2003).

“Culture” is a term with a long history and many layers of meaning, in ordinary speech as well as in the specialized language of scholars. What all of these different meanings and uses of “culture” tend to share is a common emphasis on explaining what might seem like “bizarre,” “baffling” or “mysterious” aspects of what people think, say and do, by situating them in the context of a local way of life that has its own logic and integrity as a systematic whole.

“Culture” encourages us to look for coherence within local modes of thought and ways of life – and by the same token, to look for differences between distinct coherent systems. “Culture” also encourages an attitude of openness and curiosity in situations where moral outrage, dismissal or disgust might be the automatic reactions to unfamiliar ways of thinking and acting. It seems clear that such an interest in “culture” must have been at least part of what drew Farmer initially to Haiti.

Yet Kidder also recalls an exchange in which Farmer insisted upon a very different perspective:

I looked around. The airport, Charles de Gaulle, has an angular, steel-and-glass simplicity, which struck me just then as frighteningly complex, which made me feel projected into a future I didn’t understand. I thought of its duty-free shop, where one could buy first-class paté, confit d’oie, grand cru wines. “You started that letter on a hike in rural Haiti,” I mused aloud, thinking now of those arid highlands, of medieval peasant huts, donkey ambulances. “It seems like another world.”

Farmer looked up, smiling, and in a chirpy-sounding voice he said, “But that feeling has the disadvantage of being…” He paused a beat. “Wrong.”

“Well,” I retorted, “it depends on how you look at it.”

“No, it doesn’t,” he replied, in a very pleasant voice. “The polite thing to say would be, ‘You’re right. It’s a parallel universe. There really is no relation between the massive accumulation of wealth in one part of the world and abject misery in another.” He looked at me. He’d made me laugh. “You know I’m being funny about something serious,” he said. (Mountains Beyond Mountains, 218)

“Structural violence,” is a term that Farmer has developed in his own writings to explain differences between how people live in different parts of the world. He explains “the massive accumulation of wealth in one part of the world and abject misery in another” by showing how both exist in relation to each other, within the same political and economic system.

In using this term, Farmer draws upon the specialized lingo of the social sciences, where the word “structure” refers to a pattern of collective social action that has achieved a degree of permanence. A “structure” in this sense is not a material thing, but rather an observable regularity in human social activity, that has become so firmly entrenched (in habits, social relations, economic arrangements, institutional practices, law, policy, and so forth) as to have taken on thing-like qualities. Such “structures” also do have material manifestations, in the form of roads, buildings, power and sewer systems, and so forth.

“Structure” sounds like a neutral term – it sounds like something that is just there, unquestionable, part of the way the world is. By juxtaposing this with the word “violence,” however, Farmer’s concept of “structural violence” forces our attention to the forms of suffering and injustice that are deeply embedded in the ordinary, taken-for-granted patterns of the way the world is. From this follow some important and very challenging insights. First, the same “structures” that render life predictable, secure, comfortable and pleasant for some of us, also mar the lives of others through poverty, insecurity, ill-health and violence. Second, these structures are neither natural nor neutral, but are instead the outcome of long histories of political, economic, and social struggle. Third, being nothing more (and nothing less!) than patterns of collective social action, these structures can and should be changed.

“Structural violence” thus encourages us to look for differences within large-scale social structures – differences of power, wealth, privilege and health that are unjust and unacceptable. By the same token, “structural violence” encourages us to look for connections between what might be falsely perceived separate and distinct social worlds. “Structural violence” also encourages an attitude of moral outrage and critical engagement, in situations where the automatic response might be to passively accept systematic inequalities.

Thought Experiment #1: Make a mental list for yourself of what you see as the most important or interesting of these differences between rural Haiti as portrayed in Mountains Beyond Mountains, and Seattle as you have encountered it. First, imagine how you might explain these differences as aspects of Haitian “culture.” Then, imagine how you might explain them as evidence of “structural violence.” Which approach do you find more satisfying, and why?

 Why Does It Matter How We Explain Difference?

The ideas that people hold shape the actions that they take – and for this reason, they matter a great deal. So it’s not just academic to choose whether we use “culture” or “structural violence” to explain the differences between your lives and the lives of Haitians. Should we seek to understand Haitian “culture,” or should we inquire into forms of “structural violence” that both divide and connect lives lived in Seattle and Haiti?

The concept of “culture” explains things by showing how they make sense as part of a coherent way of life. From the beginnings of anthropology in the late nineteenth century, the idea of “culture” has helped people apply what Farmer might call an “H of G” (hermeneutic of generosity) to the unfamiliar. As such, “culture” has often provided a very valuable antidote to the tendency of people in power to dismiss less powerful others as “irrational,” “underdeveloped” or “primitive.” Today, claims to “culture” often provide a meaningful source of identity and pride to members of marginalized and minority groups. And although most anthropologists have now moved away from earlier understandings of “culture” (for reasons we shall touch upon below), the positive legacy of the “culture” concept lives on in the importance that anthropologists continue to give to local contexts of meaning.

“Culture” as a form of explanation does entail some problems, however. Farmer and others have argued that “culture” tends to ignore questions of power and history. One problem is that the notion of “culture” implicitly assumes that a given social world at a given moment is a coherent whole, and that whatever we find there does make sense. For this reason, “culture” does not equip us well to recognize, analyze and criticize the histories of oppression and injustice out of which present realities may have arisen, nor the dynamics of power and inequality in the present moment.

Indeed, more than just failing to help us perceive them, the concept of “culture” arguably plays an active role in rendering power, oppression and injustice invisible, and thus allowing them to persist. In his book Pathologies of Power, Farmer writes:

The abuse of the concept of cultural specificity is particularly insidious in discussions of suffering in general and of human rights abuses specifically: cultural difference, verging on a cultural determinism, is one of several forms of essentialism used to explain away assaults on dignity and suffering. Practices including torture are said to be “part of their culture”…. “Culture” does not explain suffering; it may at worst furnish an alibi. (Pathologies of Power, 48-49)

“Culture” can sometimes be used to try to justify what should properly be understood as abuses of power. Explanations that refer to “culture” can also fail to acknowledge the histories of colonialism, military conquest, economic exploitation, and political repression that lie behind the “differences” in question.

Thought Experiment #2: Make a mental list for yourself of things in U.S. society that you regard as examples of oppression and injustice. Now, for each item on your list, ask yourself: are there any individuals or groups within U.S. society who might justify this as an aspect of a their “culture”? Finally, consider: if someone in a position to speak out against this injustice or intervene to end it, were instead to justify this injustice as part of a coherent “culture,” what consequences might this have in real people’s lives?

While it certainly does not entail these same problems, “structural violence” as a framework does require its own rather different set of cautions. Accounts of “structural violence” may sometimes seem to reduce the poor and oppressed to little more than images of suffering (Butt, 2002). More generally, it is important that people concerned about “structural violence” also listen with thoughtful care to the voices and views of the people whose plight they decry, or else they may risk depicting them as unable to have insight into their situation and/or to take action on their own behalf.

Thought Experiment #3: Imagine that an individual or a small group of people works tirelessly and effectively to demand great changes on your behalf, while also writing articles that explain your problems and what you need. What circumstances or factors might be important in shaping how you regard these efforts and these writings?

How, then, shall we understand and explain difference? This is one of those important questions on which thoughtful people may deeply disagree. Farmer and other anthropologists continue to debate the relative merits and dangers of terms such as “culture” and “structural violence,” among others. You can learn more about these debates, and you too can enter them, to offer your own contributions.

What is Medical Anthropology and Where Can You Learn More About It?

Not only is Paul Farmer a public health physician and the driving force behind the Partners in Health and its sister organization Zanmi Lasante, he is also a very active and influential participant in the scholarly field of medical anthropology. The official website of the Society for Medical Anthropology (http://www.medanthro.net/) describes the field thus:

Medical Anthropology is a subfield of anthropology that draws upon social, cultural, biological, and linguistic anthropology to better understand those factors which influence health and well being (broadly defined), the experience and distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management, and the cultural importance and utilization of pluralistic medical systems. The discipline of medical anthropology draws upon many different theoretical approaches. It is as attentive to popular health culture as bioscientific epidemiology, and the social construction of knowledge and politics of science as scientific discovery and hypothesis testing. Medical anthropologists examine how the health of individuals, larger social formations, and the environment are affected by interrelationships between humans and other species; cultural norms and social institutions; micro and macro politics; and forces of globalization as each of these affects local worlds.

Medical anthropologists study such issues as:

  • Health ramifications of ecological “adaptation and maladaptation ”
  • Popular health culture and domestic health care practices
  • Local interpretations of bodily processes
  • Changing body projects and valued bodily attributes
  • Perceptions of risk, vulnerability and responsibility for illness and health care
  • Risk and protective dimensions of human behavior, cultural norms and social institutions
  • Preventative health and harm reduction practices
  • The experience of illness and the social relations of sickness
  • The range of factors driving health, nutrition and health care transitions
  • Ethnomedicine, pluralistic healing modalities, and healing processes
  • The social organization of clinical practices
  • The cultural and historical conditions shaping medical practices and policies
  • Medical practices in the context of modernity, colonial, and post-colonial social formations
  • The use and interpretation of pharmaceuticals and forms of biotechnology
  • The commercialization and commodification of health and medicine
  • Disease distribution and health disparity
  • Differential use and availability of government and private health care resources
  • The political economy of health care provision
  • The political ecology of infectious and vector borne diseases, chronic diseases and states of malnutrition, and violence
  • The possibilities for a critically engaged yet clinically relevant application of anthropology

The University of Washington offers many resources for students interested in learning more about medical anthropology. Here are some starting points for exploration:

Medical Anthropology page from the Department of Anthropology website:
https://depts.washington.edu/anthweb/programs/specialty.php

International Health Program website:
http://depts.washington.edu/ihprog/

Critical Medical Humanities website:
http://courses.washington.edu/cultmed/

Population Health Forum website:
http://depts.washington.edu/eqhlth/

Suggested Courses

HUM 201 Diagnosing Injustice: Ethics, Power and Global Health (5) Taylor & Goering
Surveys the problem of global health disparities and connections between power and health. Introduces conceptual tools from medical anthropology and medical ethics for critically analyzing health and illness in global, social and ethical perspectives. Topics include poverty and structural violence, war and terror, biotechnology and pharmaceuticals.

ANTH 374 Narrative, Literature, and Medical Anthropology (5) I& S Taylor
Introduces anthropological perspectives on the workings of narrative in illness, healing, and medicine. Considers writings in medical anthropology alongside other genres of writing about similar topics. Readings include memoirs and fiction as well as scholarly articles.

ANTH 375 Comparative Systems of Healing (3) I&S
Introduction to the anthropological study of healing. Examines four healing traditions and addresses their similarities and differences. Includes anthropological theories of healing and religion.

ANTH 474 Social Difference and Medical Knowledge (5) I&S Taylor
Explores relations between medical and social categories: how social differences become medicalized; how medical conditions become associated with stigmatized social groups; and how categories become sources of identity and bases for political action. Considers classifications (race, gender, sexuality, disability) and how each has shaped and/or been shaped by medical science/practice.

ANTH 475 Perspectives in Medical Anthropology (5) I&S
Introduction to medical anthropology. Explores the relationships among culture, society, and medicine. Examples from Western medicine as well as from other medical systems, incorporating both interpretive and critical approaches. Offered jointly with HSERV 475.

ANTH 476 Culture, Medicine, and the Body (5) I&S
Explores the relationship between the body and society, with emphasis on the role of medicine as a mediator between them. Case study material, primarily from contemporary bio-medicine, as well as critical, postmodern, and feminist approaches to the body introduced within a general comparative and anthropological framework.

ANTH 477 Medicine in America : Conflicts and Contradictions (3) I&S
Introduction to the pragmatic and theoretical dilemmas of current biomedical practice with emphasis on social and cultural context. Case studies in technological intervention, risk management, and other health-related issues used to explore connections among patients' experiences, medical practices, and the contemporary social context.

ANTH 478 Introduction to the Anthropology of Institutions (5) I& S Rhodes
Historical, theoretical, and ethnographic perspectives on the study of total institutions, with an emphasis on prisons and psychiatric facilities. Includes issues of subjection and subjectivity, institutional social dynamics, and social justice concerns.

ANTH 479 Advanced Topics in Medical Anthropology (3-5, max. 15) I&S Chapman, Rhodes, Taylor
Explores theoretical and ethnographic advanced topics in medical anthropology. Prerequisite: permission of instructor.

BIO A 465 Nutritional Anthropology (3) I&S/NW
Concerns interrelationships between biomedical, sociocultural, and ecological factors, and their influence on the ability of humans to respond to variability in nutritional resources. Topics covered include diet and human evolution, nutrition-related biobehavioral influences on human growth, development, and disease resistance. Prerequisite: BIO A 201. Offered: jointly with NUTR 465.

BIO A 483 Human Genetics, Disease, and Culture (5) NW
Considers relationships among genetic aspects of human disease, cultural behavior, and natural habitat for a wide variety of conditions. Also considers issues of biological versus environmental determinism, adaptive aspects of genetic disease, and the role of cultural selection. Prerequisite: BIO A 201.

Resources for further study

Students may wish to explore Paul Farmer’s own writings, many of which are listed in Kidder’s bibliography.

For an excellent, short, and accessible introduction to medical anthropology, please see:

Joralemon, Donald. (2006). Exploring Medical Anthropology, Second Edition. Boston: Allyn & Bacon.

Other works mentioned in this study note:

Butt, Leslie. (2002). The Suffering Stranger: Medical Anthropology and International Morality. Medical Anthropology 21(1): 1-24.

Farmer, Paul. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley : University of California Press.

Kidder, Tracy. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. New York: Random House.

Society for Medical Anthropology. “What is Medical Anthropology?” Retrieved 17 August 2006 from www.medanthro.net/definition.html.

Taylor, Janelle S. (2003). Confronting “Culture” in Medicine’s “Culture of No Culture.” Academic Medicine 78(3): 555-559.

Many thanks to Emily Lynch for helpful comments and suggestions on this study note.

To learn more about the UW Common Book program, visit the Common Book website at: http://www.uwcommonbook.org