Poverty and health - what they have to do with other?

“Structural violence” – a brilliant fresh term to the phenomenon I have understood earlier but never really thought about its consequences through before. Farmer et al (2006) introduced this term to me and enlightened how structural violence is connected to both public health and clinical medicine. Structural violence is not a new discovery, not even a new concept, though it has been developed already in 1960s by Johan Galtung and liberation theologians. They described structural violence as social structures, including every field of our life – that eliminate individuals, groups and societies from reaching their full potential. (Galtung et al. 1969). These structures are acting as supporting things in our everyday life but actually they work as a social machinery of oppression to some of us – who usually are not the richest and self-supporting ones. Poverty is one manifestation of structural violence. I have always known that poverty causes diseases through unfavorable living conditions and makes it more difficult to treat diseases especially because of the high costs of modern medicines. But I have never before really thought about how deep and wide-ranging the effects really are. The article by Farmer et al (2006) enlightened the phenomenon really clearly: if we want to affect the structural violence and poverty, we really have to go to the grassroots. We have to bring the health services close to the patients or at least facilitate the patients to come to the treatment (paying for transportation costs, for example), we need to answer to the social and economical need of them, we need to educate people in their own level and courage to achieve their own links and support nets (accompagneteurs, for example). In a word: we have to make sure that nothing within the medical system or the surrounding community stops poor people from getting the standard of care. That is struggling against structural violence about.
The other fascinating concept I want to introduce here and which is highly connected to structural violence is “social disease”. Good example of social diseases is AIDS. AIDS is considered as a social disease – it is just highly varying why clinicians and people in health care think it is a social disease. As Farmer (2006) describes, many doctors thinks AIDS is a social disease due to the behaviors and lifestyle that influence the disease or the risk of it. But could it be that the social background of this disease and its consequences is also wider? It has been found that when a person gets HIV the course and outcome of that disease varies a lot according to the social factors, such as poverty. Actually in many cases the social factors have such a great effect that the course and prognosis of the disease has got only a little do with the universal pathophysiology of that disease (Farmer et al 2006). If we could change the direction of those social factors, we may be able to affect the disease itself. A huge possibility!
Well, what stops us, why do we not utilize the effects of social factors? At first, we people in medical area and health care are not used to the idea that we could affect this kind of things. Also, even though we would, there could be some external moderators. As Farmer (2006) also demonstrated, the greatest opposition against struggling with structural violence is does not come from the patients – not the rich or the poor ones – but from the structure itself. For example, if we want to prevent mothers from contaminating their babies with HIV, we need to educate them with proper manners. Nevertheless, in Rwanda, where the local intervention took place, these local and global health policy makers were the most difficult to get co-operate and get rid of the old, harm-causing manners (Farmer et al. 2006).
Poverty has got so strong roots concerning health. Poverty causes hunger, hunger makes people sick, sickness steals their working ability, they become unemployed, they do not get education, and these factors fortifies poverty. A vicious circle that is hard to cut down. Everything is about inequality. In Finland we may not even see the real meaning of structural violence, for we have such a functional health care system which is not based on the insurances as in many other countries. Nevertheless, we can also see the inequality here and notice that health problems are gathered to the people in the lower socio-economic status – even though we cannot really talk about poverty here. Social diseases have social root. And social diseases should also have social treatments, I think.

References:
Farmer PE, Nizeye BN, Stulac S, Keshavjee S. Structural Violence and Clinical Medicine. PLoS Medicine 2006;3(10):0001-0005.
Galtung J. Violence, peace and peace research. J Peace Res. 1969;6:167-191.