Who Lives? Who Dies?

“It makes no great difference how a society distinguishes the marks of infamy that allow it to separate those who may live from those who can or must die; the human mind, endowed with limitless imagination, can redefine them in accordance with the latest notions of an ideal society. While in certain countries skin colour or the way a particular word is pronounced is enough to provoke a roadside execution, in contemporary Western societies such indicators have been displaced from the surface to the interior of the human body. Today, because of ‘biological deviance’ (hypocholesterolaemia) or ‘behavioural deviance’ (obesity), an individual may be refused treatment or medical insurance.”

-In the Shadow of 'Just Wars': Violence, Politics and Humanitarian Action

It’s interesting how the idea of what society should be changes the discriminatory factors attached to certain peoples. It changes like fashion—yesterday it was the minimal, two button blazer; today it’s the strong shouldered blazer heralding the shoulder pads of the early 90s. While discrimination by race in the US has reduced since the Jim Crow days, new forms of discrimination have bubbled under the surface of society, so ingrained that most don’t notice them on a daily basis. The genetic factors that deprive people of appropriate health insurance, the economically challenged neighborhood that denies residents access to fresh foods. These are forms of structural violence that go widely unnoticed in the United States—in Knoxville—except by those who live it.

Perhaps it’s because I spend too much time reading of people living far away that the implications of the above passage stopped me. As soon as the change from external to internal discrimination indicators was explicitly stated, it was blatantly obvious. I knew these problems existed; I’ve spent hours in conversation denouncing the injustices of the healthcare system and the health inequities due to socioeconomic status. But never had I directly linked them to the term structural violence* and put them on the same mind page as corrupt aid-hording governments I come across in my readings of the developing world.

Lately, my global health comrades at AMSA (American Medical Student Association) have been pushing the fact that global health includes the entire globe—yes, that includes the U.S. We are not above global health inequities, yet we like to talk as if we are in another class. We have “the best healthcare in the world”. (I’m still trying to figure out what statistics people are looking at when they declare this.) Yet Americans are plagued by government corruption (any lobbyists in the crowd?) that creates obstacles in obtaining healthcare. Complaints in some regions of sub-Saharan Africa are that there are no clinics, no doctors. We have the clinics and doctors, but that doesn’t mean they are accessible to the average uninsured person. A person without health insurance likely cannot afford medical treatment. They almost positively will not seek preventative care. If they have a known genetic disorder and try to purchase insurance? Forget it. No one will insure them if they have a preexisting condition.

In the States it’s no longer denial of opportunities because you’re black. But it might be because your grandfather had high cholesterol. The internalization of discriminatory factors has pushed injustices behind the curtains. You only notice them if you’re in the play. If you’re healthy and living in suburbia with 2.1 kids, you probably won’t notice the violence committed against your fellow citizens by the very government that is supposed to protect them. These internal markers are not as blatant as skin color, but the consequences of modern discrimination create inequities just the same.

*Structural violence is the violence that systems—political, economical, social, cultural, religious– commit against individuals.