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Abstract
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Every day and in every country around the world people are harmed, and robbed of their life chances, by social structures and institutions. Their lives are cut short or limited by ill health. The Norwegian sociologist Johan Galtung, who died earlier this year aged 93, introduced the term "structural violence" to describe this phenomenon in his 1969 article "Violence, Peace, and Peace Research."12 Spending his early teens under Nazi occupation, and disgusted by war, Galtung discovered that while endless effort had been devoted to the study of armed conflict, there was no equivalent that aimed to understand the creation and maintenance of peace.
In founding the discipline of peace studies, he set out two concepts: negative peace, defined as the absence of direct violence (the application of physical force), and positive peace, the presence of social justice, where social structures and institutions no longer cause harm to individuals. A third, related phenomenon is cultural violence.3 This is not itself harmful, like direct and structural violence, but rather represents aspects of culture (ideological, scientific, historic, religious etc) which make these forms of violence acceptable or even desirable. Concepts like an underclass, the undeserving poor, or racial supremacy serve to make structural as well as direct violence more acceptable. They underpin what Patricia Hill Collins describes as the "lethal intersections" of race, class, gender and sexuality.4
When considering health and questions of who does or does not become unwell, and how people with health conditions live their lives, structural violence is a useful and direct concept. It brings the fact that individuals are being harmed squarely into focus. Both acute medical events and long term health conditions are not merely things that people have, they frequently represent what has been done to them. An important note is that the concept of structural violence relates to outcomes that are possible. Not every adverse event is incorporated--death is inevitable, but substantial inequalities in life expectancy across social class and ethnic groups are not.
Health inequalities are particularly relevant in respiratory disease. A typical person with chronic obstructive pulmonary disease (COPD) will be born with already impaired lung function due to pre-conception and in utero exposures and stress linked to poverty. A childhood in poor housing, with poor nutrition and passive smoke exposure from relatives, as well as restricted access to healthcare, further primes the lungs to be vulnerable.5 Family and peer smoking makes them more likely to take up smoking themselves, and at work they are not protected from occupational exposure to dust fumes and chemicals. Symptoms of cough, sputum, and breathlessness are normalised as they age, diagnostic tests like spirometry are not performed, and when the diagnosis of COPD is finally made, basic aspects of care are omitted.6 The low status of the condition means poor care is normalised. Little resource is allocated to research, so there is only slow progress in treatment. Austerity policies that limit social care make it harder than it needs to be for people with the condition to cope. ...
Language: en |