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Structural violence and clinical medicine.

Farmer PE, Nizeye B, Stulac S, Keshavjee S - PLoS Med. (2006)

View Article: PubMed Central - PubMed

Affiliation: Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America. paul_farmer@hms.harvard.edu

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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... 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 and in studies of what were once termed “social diseases” such as venereal disease and tuberculosis (TB)... Using the concept of structural violence, we intend to begin, or revive, discussions about social forces beyond the control of our patients... From the outset of acute HIV infection to the endgame of recurrent opportunistic infections, disease course is determined by, to cite but a few obvious factors: (1) whether or not postexposure prophylaxis is available; (2) whether or not the steady decline in immune function is hastened by concurrent illness or malnutrition; (3) whether or not multiple HIV infections occur; (4) whether or not TB is prevalent in the surrounding environment; (5) whether or not prophylaxis for opportunistic infections is reliably available ; and (6) whether or not antiretroviral therapy (ART) is offered to all those needing it... Throughout the usually decade-long process of HIV progression, detrimental social structures and constructs—structural violence—have a profound influence on effective diagnosis, staging, and treatment of the disease and its associated pathologies... Although the variability of outcomes has been especially obvious in the era of effective therapy, it was so even before ART became widely available... In Baltimore in the early 1990s, Moore et al. showed that race was associated with the timely receipt of therapeutics: among patients infected with HIV, blacks were significantly less likely than whites to have received ART or Pneumocystis pneumonia prophylaxis when they were first referred to an HIV clinic, regardless of disease stage at the time of presentation... In an attempt to address these ethnic disparities in care, researchers and clinicians in Baltimore reported how racism and poverty—forms of structural violence, though they did not use these specific terms—were embodied as excess mortality among African Americans without insurance... We have used a similar model in urban Peru, and in Boston, Massachusetts... Rwanda presents unique challenges, but many barriers to care are quite similar to those seen in Haiti and other settings where social upheaval, poverty, and gender inequality decrease the effectiveness of distal services and of prevention efforts... In the first six months of operation, we screened for HIV infection more than 31,000 persons in the two districts in which we work... Without exception, pregnant women found to be infected with HIV expressed interest in ART to prevent MTCT, and all requested assistance not only with procuring infant formula, but also with the means to boil water and to store the formula safely (Figure 1)... When linked to more structural interventions, such ostensibly specific campaigns can help to trigger a “virtuous social cycle” that promises to shift the burden of pathology away from children and young adults—a major victory in the struggle to lessen structural violence... By insisting that our services be delivered equitably, even physicians who work on the distal interventions characteristic of clinical medicine have much to contribute to reducing the toll of structural violence.

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Components of the Package for Prevention of Mother-to-Child Transmission of HIV Provided by Partners In Health/Inshuti Mu Buzima in RwandaPhoto: Ophelia Dahl, Partners In Health
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pmed-0030449-g001: Components of the Package for Prevention of Mother-to-Child Transmission of HIV Provided by Partners In Health/Inshuti Mu Buzima in RwandaPhoto: Ophelia Dahl, Partners In Health

Mentions: Although our pilot project in Rwanda is only a year old, its feasibility is almost certain. In the first six months of operation, we screened for HIV infection more than 31,000 persons in the two districts in which we work. Without exception, pregnant women found to be infected with HIV expressed interest in ART to prevent MTCT, and all requested assistance not only with procuring infant formula, but also with the means to boil water and to store the formula safely (Figure 1).


Structural violence and clinical medicine.

Farmer PE, Nizeye B, Stulac S, Keshavjee S - PLoS Med. (2006)

Components of the Package for Prevention of Mother-to-Child Transmission of HIV Provided by Partners In Health/Inshuti Mu Buzima in RwandaPhoto: Ophelia Dahl, Partners In Health
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC1621099&req=5

pmed-0030449-g001: Components of the Package for Prevention of Mother-to-Child Transmission of HIV Provided by Partners In Health/Inshuti Mu Buzima in RwandaPhoto: Ophelia Dahl, Partners In Health
Mentions: Although our pilot project in Rwanda is only a year old, its feasibility is almost certain. In the first six months of operation, we screened for HIV infection more than 31,000 persons in the two districts in which we work. Without exception, pregnant women found to be infected with HIV expressed interest in ART to prevent MTCT, and all requested assistance not only with procuring infant formula, but also with the means to boil water and to store the formula safely (Figure 1).

View Article: PubMed Central - PubMed

Affiliation: Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America. paul_farmer@hms.harvard.edu

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

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... 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 and in studies of what were once termed “social diseases” such as venereal disease and tuberculosis (TB)... Using the concept of structural violence, we intend to begin, or revive, discussions about social forces beyond the control of our patients... From the outset of acute HIV infection to the endgame of recurrent opportunistic infections, disease course is determined by, to cite but a few obvious factors: (1) whether or not postexposure prophylaxis is available; (2) whether or not the steady decline in immune function is hastened by concurrent illness or malnutrition; (3) whether or not multiple HIV infections occur; (4) whether or not TB is prevalent in the surrounding environment; (5) whether or not prophylaxis for opportunistic infections is reliably available ; and (6) whether or not antiretroviral therapy (ART) is offered to all those needing it... Throughout the usually decade-long process of HIV progression, detrimental social structures and constructs—structural violence—have a profound influence on effective diagnosis, staging, and treatment of the disease and its associated pathologies... Although the variability of outcomes has been especially obvious in the era of effective therapy, it was so even before ART became widely available... In Baltimore in the early 1990s, Moore et al. showed that race was associated with the timely receipt of therapeutics: among patients infected with HIV, blacks were significantly less likely than whites to have received ART or Pneumocystis pneumonia prophylaxis when they were first referred to an HIV clinic, regardless of disease stage at the time of presentation... In an attempt to address these ethnic disparities in care, researchers and clinicians in Baltimore reported how racism and poverty—forms of structural violence, though they did not use these specific terms—were embodied as excess mortality among African Americans without insurance... We have used a similar model in urban Peru, and in Boston, Massachusetts... Rwanda presents unique challenges, but many barriers to care are quite similar to those seen in Haiti and other settings where social upheaval, poverty, and gender inequality decrease the effectiveness of distal services and of prevention efforts... In the first six months of operation, we screened for HIV infection more than 31,000 persons in the two districts in which we work... Without exception, pregnant women found to be infected with HIV expressed interest in ART to prevent MTCT, and all requested assistance not only with procuring infant formula, but also with the means to boil water and to store the formula safely (Figure 1)... When linked to more structural interventions, such ostensibly specific campaigns can help to trigger a “virtuous social cycle” that promises to shift the burden of pathology away from children and young adults—a major victory in the struggle to lessen structural violence... By insisting that our services be delivered equitably, even physicians who work on the distal interventions characteristic of clinical medicine have much to contribute to reducing the toll of structural violence.

Show MeSH
Related in: MedlinePlus