1 gennaio 2011

Illness narrative and social suffering


In this study I will try to delineate the transition matured in Medical Anthropology from the dimension of “the illness narrative”, a representation of a subjective experience of illness, to the explicitation of the social meaning of illness’ experience, of political and economic dynamics conditioning and limiting access to cares.
In this path, I will focus on ethnographic theories and practices of the main protagonists of Harvard School of Social Medicine: Arthur Kleinman and Paul Farmer, Harvard Department of Social Medicine; then I will dwell upon Allan Young, teacher of Anthropology in Mcgill University of Montreal and Michel Taussig, teacher of Anthropology of Columbia University.
Till the Seventies, Cultural Anthropology, had analysed knowledge and practices of medical systems of cultures far from ours, without discussing the Western medical system. Biomedicine, or the Western Medicine, as a new object of study and observation, and Medical Anthropology as independent disciplinary specialization, came out only when ethnographic observation was reoriented on complex societies. The main protagonists of this reconfiguration of the relation between Anthropology and Medicine are Harvard Medical School’s anthropologists, including Arthur Kleinman, psychiatrist and anthropologist, director of the Department of Anthropology of Harvard, and Byron J. Good, teacher of Medical Anthropology and assistant manager of the department itself.
The argument from which they start out is a cultural and historical dimension of knowledge, of Biomedical Science’s categories, esclusively focused on biological and organic dimensions of illness. The first objects of critical analysis are “the disease”, a functional or organic pathology described by doctors, and “the illness narrative”, a narration of a disease experience of a social actor in a specific historical, cultural, social and family context.
The most recent criticisms to Harvard School of Social Medicine have defined its theoretical limits. The first is to have operated a distinction between a symbolic effectiveness on our body – a prerogative attributed to non-western cultures – and a clinical one – quantifiable and noticeable – of medical knowledge about illness. A distinction of this kind doesn’t focus on, discussing it, the dichotomy between mind and body typical of western cultures.
The second limit of this approach is a marginal role attributed to economical, social – and of power – dynamics, to structural violence and to their effects on a collective and individual experience of disease and health.
The social Medicine of Harvard, in fact, is a cultural approach, at least in its initial phase, focused on the forms of a subjective narration of illness and on the ways of narration of Biomedical science rather than social and political determinants inscribing pain in our body and limiting chances of access to cure.
A redefinition of disease as an embodiment of social experience has been object of discussion only in the end of the Eighties. The innovative concepts introduced in Naturali Science by new critical anthropology have founded a new epistemology of body and healt; I mention, amongst others, the concept-terms of embodiment and mindful body (Thomas Csordas and Nancy Scheper Hughes), and that of structural violence analyzed by Paul Farmer, and, in the end, that of reification of our body by Michel Taussig and of sickness by Allan Young that has tested the social dimentions of a pathology and the social role of a patient. But, let’s follow the research and theoretical pathway of the anthropologists of Harvard and their last research and speculative landing.

Medical systems, explicative models and the “illness narrative”

Arthur Kleinman, teacher of Medical Anthropology of Harvard Medical School, and Byron J. Good, teacher of Medical Anthropology in the Department of Harvard Medical School, have focused on the analysis and the interpretation of the narrative dimension of an illness experience, illness narratives, and the doctor and patient’s explicative models, and, in the end, the concept of semantic net. The illness narrative renders explicit the whole of meanings and emotions expressed by a subject that structure a subjective and an intersubjective level of experience, produces and reproduces the cultural values of a social context that give shape to a symptom and to its social, individual, expressive and affective elements.
Kleinman’s theoretical model, a key to the reading of the ways of working out of illness in local specific worlds, shows us a direction of research: a transcultural comparison between different medical systems and different cultural categories of our body, health and disease to open a dialogue between Social Sciences and Health ones.
For Kleinman also the answers to requirements of health in every culture are socially organized in symbolic systems that structure the ways of taking care of patients, diagnostic and therapeutical paths and the authorized ways of representation of disease.
Three are the relevant social contexts in every medical system: family, where it’s taken every decision about a cure, popular context, made up by non-professionals specialists, and the professional one, formed by different medical traditions, included the western itself.
These arenas of cure are realities that differ among them and often register, also in their inside, different positions amid agents of care. It’s interesting to understand how cultures model clinic realities, professional identities, different conceptions of illness between a doctor and a patient, interpretative distorsions in relational and communicational contexts.
Therefore, Kleinman tries to give an answer to the interpretative problems arising in a dyadic relation doctor/patient where family is the third person present. He creates two models that allow an anthropologist to observe and analyze communication: doctor’s explicative model (ME) that explains illness, and patient’s explicative model made up by the whole of terms, knowledge and itineraries activated by subjects, and by possibilities of causes of illness elaborated in familiy and social context of belonging. They are cognitive models that structure themselves “in itinere”, along the ways of action of a patient, and where experiences and emotions – that orientate choices and pathways of research of care – come into play.
Doctor’s explicative models, instead, (ME of a Doctor) are organized beginning with knowledges acquired during the professional formation and the medical practice. It’s a knowledge that operates a sharper and sharper split between an “illness”, a subjective expression of pain made by a patient, and a “disease”, a physio-pathological condition elaborated in the texts of Biomedicine. The interlacement of these two different explicative models gives shape and matter to a communicative relation between a doctor and a patient, a relation where expressive languages and different points of view fight and confront each other.
Biomedical science has created a cultural idiom that links pathology with symptom and a results’ evaluation to a therapeutical course: it’s an example of scientific reductionism that, thanks to its technical and analytic instruments reads a body as a biological thing and that cures a “disease”, a pathology rather than a patient in his/her wholeness. It’s a model unable to explain the “no compliance” (way) of a patient.
An unsuccesfull answer of a patient to a therapeutical treatment (no compliance) and to healt promotional programs has, instead, a plausible answer in the interpretative conflicts created by the two different constructions of an illness on scene of cure: the explicative model of a doctor and the patient’s one. Then, the goal is, or it should be, to structure communicative contexts that make possible a progressive conquer of margins of shared knowledge.
The Mes and the analysis of cognitive transactions from a doctor to a patient offer a new paradigm for clinical practice,for modalities of cure, and for a not distorted communication in the relation between them, at the same time, they propitiate a new theoretic model for an anthropologist to compare medical systems and to test cultural dynamics that influence an illness experience and the medical categories of pathology.
If the asymmetrical relation between medical knowledge and profane one, but also and especially, the biomedical reductionism and the reification of illness and of our body, are the first cause of patient’s non-observant behaviour, then knowledge and illness narrative’s evaluation, of a subjective experience of illness, have to be an integrating part of medical knowledge, of a therapeutical routine and of a process of recovery.
The aim is to give keys to the reading of illness, as it’s elaborated and carried out by social actors, to promote the development of an effciacious communicative competence of a doctor in the contexts of cure and patient’s aware agreement to a medical treatment.

The ethnography of the experience of pain

In the Eigthties Kleinmann shifts his attention from medical systems’ comparative project and from explicative models to the ethnography of the experience of pain. First of all, Kleinmann criticizes both socio-anthropological theories that explain an illness as a consequence of inequalities, of oppressive social and productive relations, and Biomedical science, the western medical system, that, only after reducing an illness experience to nosological categories and taxonomies, elaborates efficacious disease’s representations. Both in the former and in the latter case, Kleinmann affirms, human condition’s distinctive peculiarities get lost. Now I’ll try to explicate Kleinmann’s theoretical way.
For Kleinmann, the symptoms of disease have a symbolic and cognitive dimension. And it’s beginning with this concept that ethnologist’s interpretative categories have to be near to the experience of the subjects. Anthropologist’s task is to focus on what is concrete and pertinent in daily life’s processes: his goal is to mature a more conscious reflection on the totally human specificity of an experience of pain and a more precise comprehension of psyco-physiological processes that are an integrating part of it.
The ethnography of subjective and intersubjective experience of illness is an analysis of cognitive transactions taking place in daily life’s worlds, in the interaction between cultural elements, social structures and cognitive, biological and psyco-physiological processes. Cognitive transactions fill the space between a physiological process, a disease, and its expression in a subject’s narration, an illness narrative full of social and individual meanings.
The experience of disease, of loss and deprivation emerging in subject’s narrations – Kleinmann used to say – is an unavoidable, transcultural and panhuman condition that generates forms of resistance, anguish, anger and fear. But the conditions of human experience of pain are universal and unavoidable disasters that are different in various societies thanks to processes of local cultural elaboration.
Therefore, it’s strategic to add to classical sociological categories – role, background, status, – a reading of what is involved for subjects in peculiar conditions in the ways of life of cultural and local worlds. For Kleinmann, indigenous categories offer to an anthropologist a matter to spot a disease as a universal and panhuman factor, noticeable in every human condition that binds experience and deprives a subject of every possible horizont and project of life.
The expression of disease and of its symptoms has both psyco-physiological and cultural and cognitive preconditions and, therefore, the conditions of pain in human beings, in universal and local dimensions (culturally determined), can come out from ethnographical reports.
Kleinmann contests the trend in Social Science to interpret different local expressions of pain esclusively in socio-economic terms. Agony is a universal aspect of experience as chronic diseases, wars and epidemics that, in the light of a careful comparative analysis, reveal themselves as a transversal condition to all cultures. Kleinmann contests both nosological categories of biomedical tradition – a scientific reductionism that doesn’t take into account a subjective experience of disease – and sociological ones that explain agony and illness as a devastating effect of systems of government on our bodys. For Harvard School’s anthropologist, illness and death are not the effect of strong powers, on the contrary they evoke an unavoidable human experience, devoid of every political connotation.
Yet, Kleinmann continues, we’re living in the flow of a symbolic and cultural experience, therefore, the expression of pain is a symbolically mediate psycophysiology. It’s the result of psycosomatic processes transmitting and receiving cultural codes. Psycosomatic processes have their own independence thanks to a psyco-physiological foundation of experience, they are a human acting’s universal bond that shows itself in local moral worlds according to specific modalities: there’s no world without sadness or threat, agony and trouble, oppression, pain or deprivation: only their manifestations are different because they’re shaped by culture and various individual answers to unavoidable misfortunes.
Pain and subjective and intersubjective meanings of disease can’t help emerging from patients’ narrations, from the stories they tell and that give order and meaning to events, symptoms and pain. The main point of the observation of an anthropologist is “illness” rather than “disease”.
Illness that breaks into daily life’s worlds, gives the starting-signal to narration and to the textual plot that recomposes the experience in a sequence of meanings and in an interlacement of individual and collective symbols. Then, the ability of subject to get a culturally shared inventory and the ways activated by subjects in the quest of cure and in the research of a meaning to attribute to illness, come out in ethnographies focused on an experience of illness.
The different itineraries of suffering subjects and the plurality of therapeutic ways are expressions both of the differences between western and non-western medical systems and of particular cultural worlds, of different chances of patients to access to medical-scientific information, of various practices of cure and self-cure.

A new season of Kleinmann’s theory: structural violence and social pain

In the Nineties, the third phase of his theoretic reflection, Kleinmann revises some of his considerations about the social eziopathogenesis of ilness and moves towards a redefinition of his theory: he connects a bodily and psyco-physiological dimension of an experience of suffering not only with local cultural worlds but also and, above all, to economic and political dynamics that leave on our bodies illness and poverty’s scars.
Kleinmann’s last notes, “Writing at the margins”, on the one hand confirms his attention to “the illness narrative”, on the other hand introduces the concepts of structural violence and social pain, that become part of his theories as a new exploration-source of mechanisms of oppression inscribed in our bodies, of economic and political dynamics (feeding social uneasiness), of the connection between a subjective experience of pain and social and productive relations.
Structural violence and its devastating effects, the renewed criticism to biomedicine and bioethics’ representations, to international projects of intervention in the field of health are the objects of reflection of this season of his theory. The categories mind/body and health/illness build the “disease” as a biological process altered by pathologies, delegitimate patient’s experience of suffering, medicalize social uneasiness, obesity, alcoholism, drug addictions and gender violence, but they neglect economical causes, social uneasiness and political violence.
Second point of analysis is Bioethics that doesn’t read and removes the obvious pluralism of ethical principles in the plurality of local visions, that presumes the existence of a universal ethics. Yet, also ethical relativism is a key to the reading no less misleading than universal bioethicals. According to an intercultural perspective, of a dialogue amid cultures, it’s the negotiation between different human condition’s theorizations that makes possible to progressively conquer margins of common and shared knowledge about our body, disease and health.
Other point of reflection are public health programs activated by international agencies for The developing Countries, experts’ debate about scientific objectivity, their standards of selection that determine the receivers of resources and medical actions’ priorities.
Therefore, Kleinmann proceeds with an analysis of western paradigm of modernization, of hidden political and economical interests (never totally shown by platforms of intervention), of particularistic dynamics that activate or freeze the authorization procedures of programs. Unilinear progress’s paradigm, of neopositivist kind, doesn’t give the opportunity to local worlds’ cultural specificity and to their difference to express themselves, it’s built on western economical categories and, as a matter of fact, it reflects the interests of states, academies, istitutions and non governative agencies (Ngo) but doesnt’ give exhaustive answers to priorities: heavy medical and epidemiological conditions, poverty, strong powers’effects on local worlds.
In the last part of the essay “Writing at the margins”, Kleinmann focuses on social pain’s roots and spots them in dynamics of power, in poverty conditions of local worlds shifted to the margins of modernity by disergarded promises of progress and wellbeing coming from economic globalization. Kleinmann suggests not to separate the analysis of socio-economical politics from health policies, to consider the collective tragedy of political violence’s victims and the inappropriate medicalization of torture’s victims that transform political refugees into patients and that, to the extent that they’re framed in nosological categories, are able to get benefits and resources of programs of medical intervention and assistance.
A doctor’s diagnosis defines the answer to a trauma of a political violence’s victim – a nosological definition of the effects of a traumatic event created by psychologists and psychiatrists rivaling each other for the bills of a limited number of patients – but doesn’t give a definition and an appropriate answer to a collective tragedy: torture and political dissidence’s repression.

Structural violence and social suffering

After this short exposition of Kleinman’s theory, we need to focus on theoretical pathways turning around the figures of our body, health and illness and that have forced and diverted research towards a greater rooting of the critical reflection on the limits of illness narratives and explicative models. In the first season of Kleinman’s theory is completely absent a research of social and political causes that shape and distribute disease and death according to different conditions of work, ethnic belonging and gender. There’s no careful consideration about social, political and economical causes of morbidity and mortality that limit both the possibility to access to cures and subjects’ capacity of resistance to structural violence of a social order rewriting the geography of bodies and their destiny. The key-concepts of anthropologists that, more than Kleinman, have worked on devastating effects of strong powers on local worlds are: structural violence, social pain and sickness, that make possible to analyze social conditions determining a pathology and the social role of a patient.
Analysis needs a focusing on medical categories of disease, of eziophysiopathologies legitimated by science that have social relapses when they don’t let emerge the first causes of mobidity and mortality: occupational diseases, absence of control on security sistems in workplaces, marginality, poverty, political and gender violence.
Medical Anthropology rethinks illness as an embodiment of social pain, as an effect of structural violence on our body, of the action of strong powers in the theatres of market and of neoliberal policies. Therefore In this second part of my study, I will speak about the centrality of the theory of some anthropologists that have considered a social and political dimension of an illness experience: Allan Young, teacher of Anthropology at McGill University in Montreal, and the concept-term of sickness, theoretical way of analysis of the social and political dimension of illness; Michel Taussig, teacher of Anthropology at Columbia University that analyzes from a marxian point of view the process of reification of a patient’s body.
I will end it with a wide exposition of Paul Farmer’s pathway, anthropologist and doctor of Harvard Department of Social Medicine that has made of ethnographic research on the field both a human and a scientific experience and of Medical Anthropology an interpretative science politically positioned.

The sickness by Allan Young

Allan Young has criticized the model of semantic net and patient’s explicative models created as rational models of explanation that spot causal links amid events, completely symmetrical to doctors’ explicative models but, in any case, below the level of plausibility and scientific quality of medical knowledge. His aim is to analyze and to render explicit the limits of explicative models and of ethnographies of experience focused on illness narratives.
The last landing of Kleinman’s work had been the consolidation of an efficacious relational and communicative dimension between a doctor and a patient and the remotion of the causes hindering an aware agreement to therapeutic treatment. A limit of Kleinman’s theoretical and research pathway is the unsuccesfull focusing of social causes that shape and distribute in a different way an illness experience and the word’s power, of its expressiveness in dyadic relations between a doctor and a patient.
In Mes’ model there’s no clear definition of economic – and of power – logics, of sickness meant as a process of socialization that induces a subject to incarnate the social role of patient; a process that builds around disease’s signs relevant social meanings interlaced between a politico-economic dimension and a sociocultural one. Sickness as lead-concept allows to render explicit Biopolitics’logics – biocontrol of bodies – on social tissue that favour or limit the access to medical services, to doctors that have the power to define a pathology and, at the same time, to keep secret the social eziopathogenesis of pathology itself.
The lead-concept of sicknes, also and above all, allows to spot istitutional, political and social dynamics that activate or don’t activate care pathways, limiting the access to medical services according to class, race, status and gender discriminants. Medical practices, for Young, are only ideological practices keeping secret desease’s social nature, power relations and forms of social pain and that limit subjects’ capacity to make things happen in their pathways to find recovery.
Young moves towards an alternative definition of medical effectiveness and productivity in practices of cure. He focuses his reflection on persons in their wholeness, as social and symbolic bodies. Clinical effectiveness of medical systems has always shown its limits: disparity of access to a correct medical-scientific information, scientific reductionism of a human being in his/her totality to his/her material evidence, our body, and a desocialized vision of a patient that reduces to natural facts disease’s non medical but social and economical determinants.
The alternative, for Young, is in an integration between several theoretical points of views: between the theories of illness narrative, disease, explicative models and sickness: a theoretical model where the key-concepts can productively dialogue among them to build new standards in order to measure not only medical productivity in terms of clinical effectiveness and economical efficiency of health plans but also and above all in a wider dimension of health as primary, common and inalienable goods to protect.

The process of reification of patient’s body

Michel Taussig’s theoretical and research pathway of has its heart in the essay “Working classes’ conscience and reification”by György Lukács, in the concept of reification of a patient’s body. Objective, natural, – and took for granted – entities, signs and symptoms of a pathology – object of observation of Medical Science and, more generally, of Natural Science – are, in Taussig’s perspective, expressions of natural relations. The objectivity of observed data and ideological mystification have to be analyzed and deconstructed by theoretical tools – of analysis and of criticism – of sociology of knowledge.
Marxs in his criticism to Capitalism had spotted the mystification of ideology in goods’ form. Lukács goes on in the same direction of analysis defined by Karl Marx: the system and the modalities of production of goods and of consumer products – where a relation between human subjects assumes the semblances of a trade in goods -, reificate social relations and a subject’s experience itself.
The phancy of platinized goods keeps secret and removes what is subjected to economic transactions and to trade in goods: a social relation. Goods assume a completely independent dimension in respect of social and productive relations where a subject is constrained to. In the same way, Taussig explains, Biomedical Science’s entities are built on the objectivity of a biological fact that seems to assume autonomy in respect of the iniquity of social and productive relations incorporated in symptoms. Science of things, of biological and physical entities is a mystification of that whole of social connections inscribed in our body and illness.
Western Philosophy and Biomedical Science’s object of observation is a completely disembodied subject or a body in a room where surgical departments are practiced. Medical Science explains biological processes but doesn’t delineate the social determinants of illness that are the first cause of morbidity, mortality and exposure to risk factors: poverty, unemployment, devolvement to market of public and inalienable goods: health. Eziopathology – Taussige says – has to be redifined as a group of social, physical, economical and political factors that show itself with symptoms and signs .
“A disease is a social connection and its therapy has to be addressed to this synthesis of social, moral and physical relations” (Michel Taussig, 2006: 78)
Yet cultural hegemony and our body’s reification are never total because, human being’s ability to make things happen, offering resistance to its reducibility to a thing, always comes out from the multiplicity of expressive languages of a collective and individual body. In a dyadic relation between a doctor and a patient, in cure’s contexts, in Biomedical Science’s official reports, our body becomes a writing-support of medical categories. The Clinical construction of reality operates a separation between physiopathology and pathology of social connections.
Taussig’s analysis of productions and knowledge of Biomedical science allows to re-read disease’s signs and symptoms as social facts: he critically observes one of the many techniques of medical marketing, the modalities of elaboration of Services Charters that make possible for a firm producing goods and medical services to intercept its client/patient.
In health markets, in a medical system of a privatistic-insurance kind, as that in use in the United States, patients obtain medical therapies and health benefits in the form of goods: citizens’ rights become customer’s rights when in contractual modalities between a patient-purchaser and a supplier of medical goods and services, health is transformed into a bargaining. Health service’s right to choice and consumption is an attractive alternative to costitutional right to health.
In consumer’s modality of behaviour and in its effects, we can spot a further and essential difference between consumer goods market and health goods. In his/her wanderings through the stalls of a supermarket a consumer chooses among more goods and learns to select the appropiate product. On the contrary, in health markets if the result of a selection of medical services and activities is unpropitious, it’s often irreversible.
In the relation between a customer and a provider of medical services, Taussig continues, istitutional responsabilities don’t count for much on public health because the chance of weakest members of population to access to health goods in medical markets is determined by price fluctuations.
The clinical context becomes an health market and a person bargaines as a presumed free agent with those who provide medical services as to assure them a right to take possession of the power of use-value that becomes incarnate into a recovery process.
Taussig’s criticisms to health and patient’s reification discuss both Kleinman’s explicative models focused only on the difference between disease (a biomedical definition of an illness as an objective fact) and an illness experience incorporated and narrated by a subject; and also a social system that keeps secret the most important causes of mortality and morbidity: a business management of health and an audit of economical efficiency rather than medical effectiveness.

Paul Farmer and the structural violence in Haiti

Paul Farmer, an American doctor and anthropologist, develops his research on the field in Haiti, according to a redefinition of the connection between health and globalization of markets. As a doctor he analyzes the effects of social iniquity and of the different distribution on a pain experience, of social uneasiness and illness, the forms they assume in Biomedical Science’s narrations and the “disease”. For Farmer, social pain is not an unavoidable universal condition , – as it was described by Kleinman in the first phase of his reflection –; it’s rather a devastating effect of a structural violence operated by social and political powers on bodies – a kind of violence used by glocalized orders of capitals and by iniquitous health policies of the First World Countries. In fact, in biographies of Farmer’s patiens, haitians, struck by Hiv and tubercolosis, we can read the individual and collective history of victims of political persecution, poverty and inequality in the access to care resources.
The individuation of the differences – in terms of race, ethnic group and sexual orientation – is more and more often used to elude in conversational contexts of politics and science every comparison with devastating consequences of civil and social rights’s violation in order to hide strong powers’ structural violence.
For Paul Farmer, to talk about structural violence means to highlight the rooting of pain in bodies and of direct and indirect effects of globalization on poverty induced by political and economical powers leading international markets. Farmer’s analysis is an explicit criticism to cultural and essentialist anthropology that had limited its area of research to cultural differences – as peculiar and distinctive essences of a people or a nation – completely neglecting the effects of violence operated by political and economical orders, social roots of poverty and disease, of infection and death. Disease has been explained as an undesired but unavoidable effect of randomly and geographically distributed misfortunes, as results of Third World Countries’ customs and local cultures, rather than in terms of different distribution of power between countries, ethnic groups and social clusters.
According to this point of view, a new militant anthropology takes root and it’s more and more involved as a party in political dynamics that is analyzing. Anthropologist’s presence at the margins of the world and his/her report when he/she returns home, is an action not deprived of political meanings. And it can impress a new deal to international movements of protection of weaker members of society.
Anthropological research renews its reading tools of social and historical reality and spots the pathogenic role of human action, the roots of suffering and uneasiness, in mechanisms of oppression inscribed in the social organization and in the symbolic representations of reality, in individual and collective conditions of existence. It’s time to pass from a medical anthropology as analysis of clinic realities in different worlds to an anthropology that turns around the themes of social equity and human rights, of political responsibility and care, of transformative action, watchful to social and political consequences of its interpretations. It’s a new anthropology that adds to its traditional tools of cultural criticism new modalities of social and political criticism.
Paul Farmer, anthropologist and doctor, works in this direction. His report is an ethnography of victims of inequality, poverty, poltical and gender violence, of racial and ethnical discriminations, of languages of oppression but, also and above all, it’s a criticism to our interpretative schemes that define a sort of culturalist eziopathogenesis of Hiv and tubercolosis in The Third World Countries and, in this case, Haiti.
Paul Farmer underlines the urgency to consider the relation between politico-economical dimension and the structural violence of social orders, between embodiment of illness and embodiment of social inequalities, explicit and not explicit violence. Inequality, violation of human rights, torture and rape, discriminations on ethnical, gender, race and status base are the first cause of exposure to a risk of starvation, Hiv, tubercolosis, leprosy and smallpox infection.
Farmer that has made on the field his activity of doctor in Haiti, reconstructs in his historical and ethnographical reports the familiarity with death of haitian farmers in an alternation of dictatorships, colonialist and neocolonialist regimes that have violated the most simple civil and human rights.
Today, undernourishment, dysentery, measles and tetanus are the first cause of mortality and morbidity in the first year of life. In the biographies of victims of structural violence that crosses axes of gender, race, etnicity and sexual orientation, we can read all the power of actions of social oppression acting on individual and collective stories, on the incorporated experience of illness and pain.
Poverty and exposure to the risk of Hiv infection rather than personal, individual and psychological conditions of existence or racial and cultural differences are what unites the history of Haiti and haitians’ biographies. But an anthropologist’s glance that notices today an impoverishment of fields and crops, starvation and disease in the interstices of haitian society, the lack of health structures able to answer to requirements of cares and medications, could forget to read in the history of slavery, of new and old imperialisms, the remote and less remote cause of misfortune of haitians today.
René Préval, the first president democratically elected in Hait after a long story of poverty and slavery, of dictatorships and military regimes, had to reckon with the devastation of economic and social tissue, torn by misery, criminality and national debt. The systematic cancellation of historical memory in media reports on Haiti has often allowed to attribute to cultural and local processes estreme poverty and an absolute absence of basic health services.
Farmer spots a correlation between the removal of historical memory of slavery and the removal of social and historical determinants of morbidity and mortality and proposes to make them re-emerge from oblivion, to disclose strategies put forward to elude political and economic matters pressing on a collective dimension of social uneasiness. Therefore, he goes over again the sequence of historical events that have influenced haitians’ destiny from The Seventeenth Century till this ethnographical present.
Capital’s accumulation, luxury, the waste of french well-off classes of the Eighteenth century, were the result – in economic and of power and ascendancy terms – of the exploitation of Haiti’s resouces: black african slaves, trade of sugar, rhum, tobacco and food stuffs. In 1803 Haiti became independent from France, but only after a bloody war that ruined and distructed haitian economic and social tissue: the embargo agreed by France, The United States and its european allies, further destabilized an ecomony in ruins.
Besides, France asked Haiti an allowance of 150 thousand million franks, a form of refund for the forfeit of valuable goods, black slaves, that opened an incurable national debt and a series of unbearable financial obligations for an economy already tried by colonialization, systematic exploitation of its resources and poverty. Thereafter, the United States, became an unavoidable and evident presence both as a partner and as a military power: a permanent state of siege.
This presence that, from 1915 till 1990, was a real occupation made possible to the United States to be a contributing factor on political and social history of Haiti and to support dictatorships and military governments, exclusive beneficiaries of the american prodigality and of health programs of intervention of the humanitarian missions in Haiti.
Haitian health infrastructures that Farmer could observe in that moment, were collapsed. Once again, after the contested elections of May 21, 2000, the resources of programs of intervention and reconstruction of haitian network of health services had been frozen with a new embargo approved by The United States, The European Union and internazional organizations. Therefore, the freezing of aids was once again a control strategy launched by Washington, the second embargo after the revolution of 1804.
The selective cancellation of memory, of the structural violence of the various military governments in charge, allows today to ignore the most important causes of morbidity in Haiti: structural violence bites in not new ways and its effects are systematic: because more than an half of population has no access to basic health services and mortality rates are among the highest in the world. Anthropology has often dwelled upon the analysis of profane medical knowledge and popular beliefs rather than upon the hegemony of strong powers that determine modalities of allocation of health resources. But today – Farmer explains – it’s not possible to comprehend haitian conditions of life without reading the history of old and new colonialisms. From haitian history, emerge an experience of extreme poverty in non egalitarian societies and a limitation of margins of resistance to processes led by international agencies, rather than psychological features or subjective dimensions,.
Haitian history’s heart is in the governemnt of a certain model of order and economic development: competition and disparities in terms of chances to access to resources, globalization of poverty, political violence, racism and sexism need to be analyzed and explained beginning with biographies’ recontextualization in the matrixes of history. They also need to be told by ethnographical reports including in the analysis of social contexts an analysis of structures of power that frame social suffering, death, torture and disease.
In the end, Farmer focuses on poverty conditions that crosses the differences of ethnicity, race, gender and socioeconomical status, interlaced, and simultaneously in action, with devastating effects. The differences of pathways of life based on gender explain on the one hand a greater exsposure of women to prostitution, rape, domestic violence and to risk of Hiv infection and, on the other hand, a wider danger for men as regards political persecution and torture. But gender, all by itself, doesn’t explain anything because the first causes of disease and death are absence of protecion of the most simple human rights, poverty and indigence.
In the same way, ethnical differences don’t explain a high mortality and morbidity rate. In epidemiological analyses in South Africa, ethnicity and skin color record among natives a high rate of infant mortality; ten times higher than caucasians’ one. But the disarticulation of data remaks that are rather poverty, disequality and lack of access to resources that clarify the greatest exposure to risk of native afrikaners. Black people die more than caucasians, because they’re poorer; there’s no connection bewteen high mortality rate and skin color.
In fact, mortality rates are in a inverselly proportional relation with all indicators of socioeconomic status (education, income, employment), so that, both black and white people, educated and in a medium-high range of income, can enjoy the same priviledges as regards access to health information and services in every geographical distribution. Another element of discrimination spotted by Farmer is sexual orientation but, once again, it’s poverty that determines disparities in the access to health resources: educated and rich homosexuals have been able to oppose, in their pathways of life, an efficacious resistance to homophobia and to assure themselves appropriate modalities of care; while poor ones are, in every geographical dimension, more exposed to risk of Hiv infection and prostitution.
The violation of human dignity is often explained as a sad but unavoidable destiny, inscribed in a Dna of difference of ethnicity, gender, race and sexual orientation or as an endogenous evil deep-rooted in cultural istitutions and in the local tradition rather than in history and social disproportion.
Farmer ends:
New medical and critical anthropology’s task is now to identify the forces conspiring to promote pain, with the understanding that they’re differently calibrated in different contexts. If we are able to do it we will have the chance to delineate the causes of extreme pain and also the powers that expose some of us to the risk of abuse of human rights, while others are protected.


I’ve tried to render explicit the passage from the centrality of subjective and intersubjective experience of illness to the centrality of relations, of connections of powers external to a dyadic dynamics between a doctor and a patient. On the one hand, I’ve focused on structural violence, construction of sickness, of patient’s social role, and, on the other hand, on biomedical categories of disease. In a socio-political dimension the centrality of hegemonic dialectics of istitutions and strong powers keeps secret non medical determinants of health, the structural violence of a social, political and economical order that rewrites bodies’ geography. A point of view able to trascend the limit of culturalist paradigm focused only on a symbolic dimension of a subjective experience of illness; it has to discuss not only biological reductionism – that observes a disease as a biological data and not a patient in his/her wholeness – but also to highlight the connection bewteen strong powers and the economic dynamics of health markets, between illness’s political and medical dimension. Therefore, social eziopathogenesis of diseases is to research in material and unhealthy working – and of existence – conditions; in poverty, unemployment and marginality.
Goal of the new and politically positioned anthropology is to focus on the relation between a scene of cure – where patients, doctors and manager of health organizations come into play -and istitutions that differently and dramatically distribute chances of access to health services. Politics and biomedical science’s languages naturalize the will, they transform the hegemony of strong powers and medical knowledge into ideology and ideology into a natural data, a disease, a took for granted and self-evident reality. Social and political dynamics of oppression are inscribed in the same modalities of care of a patient, in the ways and modalities of diagnosis that translate social pain into an objectyfing form of pathology. Medical anthropology in ethnographical reports of marginality and social exclusion has to be more and more involved as a party in social and political processes. It has to be able to redirect health policies, to promote an individual and collective ability to make things happen and a capability to negotiate margins of self-determination of existence.
It’s time to pass from a medical anthropology as a mere analysis of doctor and patient’s explicative models, of clinical realities in different cultures, to a militant anthropology, active on human, rights, political care and responsibility and on transformative action. It’s a new anthropology, watchful to social and political consequences of its interpretations, that adds to its traditional tools of cultural criticism other and new modalities of political care in the promotion of social equity and justice.