Structural Violence and Clinical Medicine

Because of contact with patients, physicians readily appreciate that large-scale social forces—racism, gender inequality, poverty, political violence and war, and sometimes the very policies that address them—often determine who falls ill and who has access to care. For practitioners of public health, the social determinants of disease are even harder to disregard. Unfortunately, this awareness is seldom translated into formal frameworks that link social analysis to everyday clinical practice. One reason for this gap is that the holy grail of modern medicine remains the search for the molecular basis of disease. While the practical yield of such circumscribed inquiry has been enormous, exclusive focus on molecular-level phenomena has contributed to the increasing “desocialization” of scientific inquiry: a tendency to ask only biological questions about what are in fact biosocial phenomena [1]. Biosocial understandings of medical phenomena are urgently needed. All those involved in public health sense this, especially when they serve populations living in poverty. Social analysis, however rudimentary, occurs at the bedside, in the clinic, in field sites, and in the margins of the biomedical literature. It is to be found, for example, in any significant survey of adherence to therapy for chronic diseases [2,3] and in studies of what were once termed “social diseases” such as venereal disease and tuberculosis (TB) [4–8]. The emerging phenomenon of acquired resistance to antibiotics—including antibacterial, antiviral, and antiparasitic agents—is perforce a biosocial process, one which began less than a century ago as novel treatments were introduced [9]. Social analysis is heard in discussions about illnesses for which significant environmental components are believed to exist, such as asthma and lead poisoning [10–15]. Can we speak of the “natural history” of any of these diseases without addressing social forces, including racism, pollution, poor housing, and poverty, that shape their course in both individuals and populations? Does our clinical practice acknowledge what we already know—namely, that social and environmental forces will limit the effectiveness of our treatments? Asking these questions needs to be the beginning of a conversation within medicine and public health, rather than the end of one.

CitationFarmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3(10):e449.

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