By Professor Matthew Sparke, Geography and International Studies, University of Washington
Email: sparke@u.washington.edu
Homepage: http://faculty.washington.edu/sparke/
Reading Note: Terms such as globalization that are shown in these notes in bold have longer definitions provided in UW’s online Mountains Beyond Mountains glossary.
Structural violence consists of economic, political and cultural dynamics that work systematically through social structures to create human suffering and constrain human agency. It is ‘structural’ in the sense that the suffering is not produced by direct one-on-one acts of violence such as spousal abuse, lynching or torture – although even these kinds of inter-personal violence are clearly tied to social structures (including patriarchy, white supremacy and militarism) that extend beyond the individuals involved. Structural violence is still less personal, intentional and direct “[s]ince the misery in question need not involve bullets, knives, or implements of torture” (Farmer, 2005: 8). It involves more mediated and multi-factor forms of oppression in which sexism, racism, homophobia and other forms of social pathology frequently come together with economic exploitation and deprivation. For Farmer it is therefore “a broad rubric that includes a host of offenses against human dignity … ranging from racism to gender inequality… [to] extreme and relative poverty” (Farmer, 2005: 8). He cautions against economic reductionism (i.e. explaining everything in terms of economic dynamics), but it is nevertheless clear that he thinks “the world’s poor are the chief victims of structural violence” (2005: 50). It is in turn his driving concern to explain poverty as a kind of generalized “coinfection” (Kidder, 2003: 198) creating the context for disease that accounts for why Farmer frequently talks about structural violence as if it operated like an unseen virus destroying a patient’s immune system. While the visible hands of abusive husbands, white supremacists and military interrogators all go on producing suffering, Farmer emphasizes that structural violence more generally involves invisible hands that produce global inequality through transnational political-economic processes. “Only through careful analysis of growing transnational inequalities,” he therefore underlines, “will we understand the complex social processes that structure risk” (2005: 18).
In Mountains Beyond Mountains we first come across the term structural violence on page 34. “One health worker recited a Haitian saying: ‘Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.’… The health workers’ theory amounted to a description of the kind of socioeconomic arrangement that [Farmer] called ‘structural violence.’” (Kidder, 2003: 34). On reading references like this to a “kind of socioeconomic arrangement,” some readers’ eyes probably glaze over. Despite the link to real suffering that Kidder underlines, a “kind of socioeconomic arrangement” is the kind of phrase that, taken on its own, tends to induce apathy. Against this, Farmer himself is always trying to remind privileged audiences that they are part of the arrangement and thus part of the problem. “[S]urely,” he asks, “there are direct and causal connections between a protected minority enjoying great ease and those billions who go without the bare necessities of food, shelter, potable water and medical services? (2005: 255).” But even amongst audiences who accept that there are these connections, there are many who respond by saying that this socioeconomic arrangement is impossible to re-arrange. ‘Wealthy governments and businesses will always exploit the world’s poor,’ they may say, ‘because this socioeconomic arrangement is based on the profit-making needs of economic elites and share-holders’. This sort of response also inspires apathy, but at the same time it further underlines the pertinence of structural violence as a term of description. The socioeconomic arrangement of contemporary capitalism is indeed structured to make profits on a systematic global basis. The processes of exploitation it unleashes on the ground and the inequalities it creates need therefore to be understood as ‘structural’ rather than as deliberate plans to make poor people suffer. But for the same reason, conceiving of the violence as being structured by a socioeconomic arrangement ought to inspire the idea that rearrangement is possible. Something that is socially and economically organized one way can be reorganized in another more just and humane way. Certainly this is Farmer’s hope. By saying that “we profit from a social and economic order that promises a body count” (2005: 255), he wants to mobilize reordering. And in this he follows Johan Galtung (1964) in arguing that structural violence is every bit as much an abuse of human rights as something direct like killing unarmed civilians. We should not just accept the sickness of the poor as something that will always be with us. Instead, Farmer insists, their sickness is a human rights abuse, a result of structural violence in which “historically given (and often economically driven) processes and forces conspire to constrain individual agency” (Farmer, 1999: 79).
What then are the “historically given (and often economically driven) processes” that produce structural violence? As the Nobel prize-winning economist Amartya Sen explains in his foreword to Pathologies of Power, Farmer’s own investigations into structural violence proceed on a case by case basis. Treating it a little like a disease that works behind the scenes to increase vulnerability, he proceeds as any doctor might by collecting case histories and comparing symptoms. One such case that we learn of early in Mountains Beyond Mountains is that of the water refugees created by the building of the Péligre Dam in Haiti in the mid-1950s. As Kidder explains, “Farmer had taken great pains to assert the interconnectedness of the rich and poor parts of the world, and the dam was his favorite case study” (2003: 37). For the same reason, it is also a good example to consider here as a way of illustrating how academic literatures relating to globalization can help expand on Farmer’s account of structural violence. The broad features of this account are already clear in Kidder’s 
summary: the loan from the U.S. Export-Import Bank, the planning by the U.S. Army Corps of Engineers, and the building work by the Brown and Root corporation of Texas; the use of the electricity from the dam to supply downstream agribusiness, foreign-owned assembly plants and homes of the elite in Port-au-Prince; and the unintended but devastating consequences on the displaced communities who, being dispossessed of their means of subsistence, were forced either into exploitative and dangerous work in the city, or onto hill-sides above Lac Péligre where erosion made farming next to impossible and famine and malnutrition a constant threat to life. From the perspective of academic work on globalization, all three of these aspects of the structural violence visited on the water refugees – the role of American institutions, the advancement of the interests of economic elites, and the dispossession of the poor – can be understood in terms of neoliberalism.
For scholars of globalization, neoliberalism is a name for today’s dominant model of market-based and business-friendly government (for some great introductions see George, 1999; and Harvey, 2005). Sometimes referred to as ‘market fundamentalism’ or ‘laissez-faire’, the model dictates an approach to government based on the idea that capitalist social relations work best when they are liberalized from regulation and organized on the basis of so-called free-market forces (for an insider look at how this idea was developed in the work of the Chicago School and Mont Pélerin Society see the online materials assembled by the PBS, 2005; UW students should note that the related PBS film is used in SIS 201). The result of putting this idea into governmental practice has been the emergence of a suite of neoliberal policies that are now familiar right around the world: policies of free trade, privatization, tax-cuts, business deregulation, financial deregulation, cutbacks in government services, a commitment to low inflation and price stability, the rollback of welfare, and a more general emphasis on competition, individualism and entrepreneurial behavior as the essence of social life (for studies of how these policy emphases create a system of global governance see Gill, 2003, and Tabb, 2004; and for the argument that this creates structural violence in wealthy countries as well as poor ones, see Brennan, 2003, Duggan, 2003, and Giroux, 2004). That these sorts of free market policies are called ‘neoliberal’ is often confusing for American audiences because we normally associate liberalism with a concern for the welfare of the poor and the marginalized. It needs to be explained therefore that the ‘neo’ does mark something discrete and new historically: namely, the revival of classical 19th century free market liberalism after and in opposition to the social-welfare liberalism of the midtwentieth century (this is something that I explain in GEOG/SIS 123 in terms of the transition from Fordism to Post-Fordism). The ways in which neoliberal policy-makers advocate the ‘rolling back’ of the state (except in policing, penal and military areas) and the ways in which they celebrate the invisible hand of the market as the best mechanism for producing a just distribution of resources needs thus to be understood as a kind of systemic backlash against the welfare-statism that was established in the wake of the Great Depression (for an excellent investigation into the backlash against welfare in the U.S. see Peck, 2001). However, while the backlash and return to 19th century ideas explains the ‘neo’ in neoliberal, it does not explain its pertinence to a place such as Haiti and a case such as the Péligre dam. To understand this we have to take account of studies that have examined how neoliberal policies have been forced on the developing world as a form of neocolonialism – a new kind of colonialism that has tended to operate more through the machinations of the market than the interventions of armies and colonial administrators (see Petras, 2004; Roy, 2004; Sirisena, M. 2001; and for a great graphic account El Fisgón, 2004). Such studies reveal that in two key respects the neocolonial frontier of the developing world was the cutting edge of neoliberalism: it was here that neoliberal reforms were introduced most early and radically, and it was here too that the processes of neoliberalization were most brutal and violent. In understanding these processes the three main components of the water refugees case – the role of American institutions, the advancement of the interests of economic elites, and the dispossession of the poor – are key.
In terms of American institutions it should be noted that another name for neoliberalism amongst its advocates and critics alike is the ‘Washington Consensus’ (see Williamson, 1993 for the pro-side, and Klein, 2000 for the no-side). The original reason for this name related to the consensus amongst economists in Washington, D.C., about the virtues of neoliberal policies, but over time the Washington Consensus has also come to refer to the huge influence held by three D.C.-based economic institutions – the International Monetary Fund (IMF), the World Bank and the U.S. Treasury – in forcing developing countries to remake policy on the basis of neoliberal norms (see Hart, 2001; Peet et al, 2003; and Sparke, 2006a). Partly because of the global power of the U.S. itself, and partly because of how the IMF and World Bank took up the role of managing the debt crises of poor countries in the 1980’s, these institutions were able to impose neoliberal policy by demanding so-called structural adjustment in return for debt restructuring (see Agnew, 2005; Corbridge 2002; and Lawson, 2006 as well as the courses taught by Professor Lawson at UW: GEOG 230, GEOG 330 and GEOG 430). Countries that could not pay their debts were thereby told that they had to follow structural adjustment plans (SAPs) and transform their economies along free market lines if they wanted IMF or World Bank support on debt rescheduling or new loans (see Fort et al, 2004, chapter 4). Even countries that did not seek support were generally obliged to go along with the Consensus thanks to the rising influence of economic ‘experts’ trained in the U.S. (see Dezalay and Garth, 2002; and for a more literary take on the influence of World Bank expertise, see Kumar, 2003). And in yet other countries where U.S.-backed dictators held control, neoliberal norms were introduced especially early and aggressively through military force (see Valdés, 1995 on the case of Pinochet’s Chile). Indeed, as Farmer notes in his own critique of neoliberalism: “The proponents of harsh market ideologies have never been afraid to put money – and sometimes bullets – behind their minimal and ever-shrinking conception of rights and freedoms” (Farmer, 2005: 10). That Farmer would say this also reflects his own Haitian experience because while Chile is the most famous example of such coercive neoliberalization, Haiti is another illustration too (see Trouillot, 1990). The country is a miserably ironic example in this regard because the coercive neoliberalization of the 1950’s, 60’s, 70’s and 80’s led to debts that have subsequently made it very hard for Haiti’s recent democratically elected leaders – Jean-Bertrand Aristide and René Préval – to govern.
In brief, the ties between American influence and Haiti’s forced neoliberalization go back to the dictatorships of the U.S.-backed Duvaliers – whose combined regimes lasted from 1957 to 1986 (see Trouillot, 1990). Not only did their regimes borrow from U.S. banks to fund projects such as the export processing factories and agribusiness powered by hydroelectricity from the Péligre Dam. They also borrowed money simply to enrich themselves and persecute citizens who protested. Such debt is generally referred to as odious debt because the borrowed money was spent on persecuting the people who ended up having to pay it back. The Haiti Support Group based in London estimates that of Haiti’s $1.134 billion in foreign debts, 40% is odious debt dating from the Duvaliers and the remaining 60% is debt that has been used to fund more recent structural adjustment initiatives (Haiti Support Group, 2006). The Support Group has led calls for the cancellation of at least the 40% of Haiti’s debt that is technically odious. 
But these calls have fallen on deaf ears amongst economists at the World Bank. Instead, arguing that the country’s government was not proceeding adequately with neoliberal reforms, they declared that “the Bank should approach any re-engagement in Haiti with extreme caution” (World Bank, 2002). More recently despite the global debt cancellation plans announced in 2005 for so-called Highly Indebted Poor Countries (HIPCs) – plans announced with great fanfare at Gleneagles, Scotland by the G8 club of rich countries (see Oxfam, 2005) – Haiti continues to be treated as ineligible for debt relief by the IMF, World Bank and U.S.. Supposedly this is because of its ongoing political crisis situation. But, as Paul Farmer has himself explained in his own account of the situation, Haiti’s debt mountain was one of the reasons the democratically elected government of Aristide was so easily undermined after his return to power in 2000 (Farmer, 2004a). Anti-Aristide interests in the US were able to freeze aid and new lo ans by saying that, amongst other things, Haiti had to pay back arrears on old loans first – a classic example of market-mediated neocolonial control (see also Chossudovsky, 2004). Consequently, notes Farmer, “in July 2003, Haiti sent more than 90 per cent of all its foreign reserves to Washington to pay off these arrears.” Then, having been undermined financially, on February 28th 2004, Aristide was forced from power altogether and taken to a French military base in the Central African Republic (Farmer, 2004a). Farmer argues that this force d removal related in part to Aristide’s attempts to calculate the former colonisers’ debts to Haiti – debts which, as we shall see in the next section, go back to Haiti’s history as the largest Caribbean plantation economy of the 18th century and its rebirth as a free but deeply resented republic after the historic slave revolution of the 1790s. For the moment, let us turn from Haiti’s especially egregious and ongoing experience of forced neo-liberalization to the questions critics are asking about the impact of neoliberalism more generally.
Clearly neoliberal policies have been implemented in different ways in different places with varying degrees of domestic support and opposition. However, right around the world there have been two consistent results: 
namely, the increasing enrichment of economic elites and the simultaneous dispossession of the poor. The geographer David Harvey calls these parallel processes ‘accumulation by dispossession’ (Harvey 2003 and 2005), and many medical scholars have sought to point to the twin dynamics with titles such as Sickness and Wealth (Fort et al, 2004) and Dying for Growth (Kim, 2000). But whatever name we give to the parallel processes of class advancement and class impoverishment, they have become strikingly obvious results in a wide range of settings (results revealed statistically by increasing in-country inequality: see the University of Texas Inequality Project http://utip.gov.utexas.edu/about.html). In recent years there has been considerable debate over whether inequality between countries internationally has fallen due to the very rapid economic growth in India and most especially China (Wade, 2004; and Sutcliffe, 2004, plus see the clear summary of this debate and other great materials at http://ucatlas.ucsc.edu/). Notwithstanding one’s view on this debate, it is clear that wherever there has been rapid growth it has also come with rising in-country inequality, and in many developed countries as well as in China and India, these patterns of in-country inequality are closely correlated with reduced average life expectancy (see the many materials gather together by the UW public health program here as well as the much-discussed results of a recent US/UK health comparison Banks et al, 2006). The U.S. federal government itself recognized this problem in 2003 when its Institute of Medicine reported that “more egalitarian societies (i.e. those with a less steep differential between the richest and the poorest) have better average health.” (Institute of Medicine, 2003: 59). For these reasons it is very important to keep in mind the distinction between international and national level measures of inequality (a point also made in a recent World Bank report, Revallion, 2004).
From the downstream benefits and the upstream costs of the Péligre dam in Haiti, to the Ecuadoran activities of a self-confessed ‘economic hit man’ (Perkins, 2004), to the power politics of the Narmada project in India (Roy, 2001), dam projects have provided some particularly clear examples of the enrichment of the few and intertwined immiseration of the many (UW students should also note that Professor Sanjeev Khagram who teaches SIS 313 has written an especially compelling book about this himself [Khagram, 2004]). More generally, there are a whole variety of other spaces in which scholars have tracked the resulting consolidation of a new and increasingly deep class divide (see the very useful presentations of UNDP data here.) Whether these spaces be nation-states (Harvey, 2005), global-cities (Sassen, 2001), border regions (Sparke, 2006b), or businesses themselves (Sklair, 2001), they have all been witness to the privileging of a transnationally mobile business class.
The processes that have consolidated the power of the today’s global economic elite have simultaneously multiplied the ways in which working people, the poor and the economically peripheral have been dispossessed, including being dispossessed of life expectancy itself (see Sapolsky, 2005 on what he calls the “sickness of poverty”; and for a statistical examination of the correlation between high infant mortality – an especially tragic kind of health dispossession – and economic peripherality see Moore et al, 2006). From the abandonment of universal welfare, education and healthcare commitments, to the sell-offs of public assets (such as water and electrical utilities), to the privatization of public spaces and lands, to attacks on unions and the wholesale commercialization of democratic politics, these forms of dispossession have been many. And yet from the Zapatista uprising in Chiapas to the anti-WTO protests in Seattle to World Social Forum attempts to find alternatives to neoliberalism, they have led to a global dissensus on the Washington Consensus, a dissensus 
that has led in turn to new calls for a repossession of the commons (see Featherstone, 2004; Fisher and Ponniah, 2003; Klein, 2002; Sparke et al, 2005). This dissensus is often denigrated by promoters of neoliberalism as economically irrational and unrealistic (e.g. Bhagwati, 2004), but, in the wake of the Asian economic melt-down of 1997-98, the discontent with neoliberal policy and the insecurities it creates has even been voiced by insiders, including both a former World Bank economist (Stieglitz, 2002) and one of the world’s most successful financial traders (Soros, 2002). To be sure, most representatives of the global economic elite continue to invoke the language of economic efficacy. They argue thus that (in a formula made famous by the Conservative British Prime-minister Margaret Thatcher) There Is No Alternative – TINA – to neoliberal reform (e.g. Wolf, 2004). And as ‘TINA-touts’ they talk repeatedly about the need for economic rationality and realism, all the while they downplay the ties between their supposedly rational neoliberal policies and real suffering. But for critics the causal ties connecting the policies of structural adjustment with structural violence are clear. For the same reason, much resistance against structural violence is articulated in terms of anti-neoliberalism (this is especially the case in Latin America, but for a useful discussion of anti-neoliberal resistance in Africa and the US see Katz, 2004). Farmer himself outlines both the problem and the resulting resistance very clearly: “As a physician who has worked for much of my adult life among the poor of Haiti and the United States, I know that the laws of supply and demand will rarely serve the interests of my patients. And so they and others in their position – globally, this would be hundreds of millions – have fought to construe as a basic human right access to health care, education, and other social services. Indeed many would argue that most of Latin America’s conflicts have been fought over neoliberalism, far too many human rights abuses are committed in the name of protecting and promoting some variant of market ideology” (Farmer, 2005: 5-6).
As well as representing an ongoing controversy at the heart of public debates over globalization, another reason for taking note of the competing discourses over neoliberalism is that it helps provide a context for understanding Farmer’s critical comments about ‘cost efficacy’ in Mountains Beyond Mountains. Behind this criticism are two key concerns. First, there is the concern noted in various places through Mountains Beyond Mountains with the profiteering of pharmaceutical companies making millions from drugs that ought to be free for the world’s poor (see also Fort et al, 2004). And, second, there is Farmer’s outrage at the neoliberal 
premise that care should be delivered only on a least cost, economic efficiency basis. “So we’ll give him a couple of hundred dollars of Ensure, and I’ll take great pleasure in violating the principle of cost-efficacy” (Kidder, 2003: 25), he says in an aside reported near the start of the text. Likewise, later on we hear about how he and Jim Kim seek to contest the talk of cost effectiveness altogether. “It often meant, ‘Be realistic.’ But it was usually uttered, Kim and Farmer felt, without any recognition of how, in a given place, resources had come to be limited…. Strictly speaking, all resources everywhere were limited, Farmer would say in speeches. Then he’d add, ‘But they’re less limited now than ever before in human history’. That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them” (Kidder, 2003: 175). Besides leading the Partners in Health team to label international heath professionals TBMIs (‘transnational bureaucrats managing inequality’), this critique also clearly has a basis in Farmer’s wider concerns with the violence of neoliberal economic jargon itself: including its tendency to ignore suffering and squelch protests against dispossession by presenting reform as simply technical and neutral. “[B]ullets are increasingly unnecessary,” he says, “when defenders of social and economic rights are silenced by technocrats who regard themselves as neutral” (Farmer, 2005: 10).
Against the technocrats of the Washington Consensus and other TBMIs, Farmer’s reply is at once sarcastic, angry and persuasive. “Aren’t we ‘starry eyed’,” he exclaims, repeating the rhetoric of the realists, “if we complain too much about the ‘new consensus’ preaching ‘trade rather than aid’? Isn’t Manno mostly 
a victim of the ‘inefficiencies’ and ‘archaisms’ of a ‘Third World’ economy in need of thorough-going ‘reform’?” (2005: 253). Of course, anyone who has read Mountains Beyond Mountains knows that Farmer’s own answers to such questions are a loud ‘No’ and ‘No’. And yet by using sarcasm, Farmer seeks to prompt his readers to do more than answer questions. He also challenges us to rethink our own tendency to shut ourselves off from suffering in the world by turning to “action films and other entertainments, sport-utility vehicles, high irony, identity politics that erase the world’s poor, or struggles for personal advancement in this or that institution” (2005: 255). Amongst these criticisms, the one about ‘identity politics’ connects up to others that have been made in recent years about the cooptation of anti-racist struggles by a kind of corporate and formulaic multiculturalism (see Mitchell, 1993 and 2004; Zizek, 1997). While perhaps this is more common in privileged contexts like the shopping malls where we see the Benneton-styled commodification of cultural diversity, Farmer’s own criticism seems also to have been shaped by seeing non-commercial examples of the same instrumentalism in Haiti. Most notably, in Pathologies of Power, he introduces the example of General Raoul Cédras, who having overthrown Aristide in the deadly 1991 military coup declared that: “The foreign powers who dominate Haiti have for more than a century refused to acknowledge the integrity of Haitian culture and our right as the world’s independent black nation to steer our own ship of state” (Farmer, 2005: 14). For Farmer and for many other critics of the violent coup, this appeal to Haitian culture and black independence was cooptation in the extreme. But to understand why, one has to have at least a basic understanding of Haiti’s post-colonial history. This topic is covered in my essay, What Postcolonial Theory Tells Us about Haitian History and Struggle.
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Useful Websites
The London based Haiti Support Group has some excellent updates on social and economic life and struggle in the country, including a useful set of explanations of some of the social justice campaigns it is running: http://www.haitisupport.gn.apc.org/ab_who_index.html
The World Bank website on Haiti is the place to look for official explanations on why Haiti continues to be refused real debt relief: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LACEXT/HAITIEXTN/0,,menuPK:338184~pagePK:141159~piPK:141110~theSitePK:338165,00.html.
Gapminder has some excellent graphic interfaces with which to view UNDP charts of inequality and development data: http://www.gapminder.org/
Our own UW Population Health Forum also has some great materials, including a series of ‘Health Olympics’ charts that show how various countries compare in terms of average life expectancy and other key measures of public health (the US only came 29 th in 2003 behind Costa Rica, Chile and Ireland and only just ahead of Cuba): http://depts.washington.edu/eqhlth/pages/issues.html#healthO
The University of Texas Inequality Project measures and explains pay inequality and patterns of industrial change at the global level, the national level for Russia, China, and India, and at the regional level for Europe: http://utip.gov.utexas.edu/default.htm.