The Rich-Poor Divide and the Matka of Structural Violence

I started off this newsletter in December 2020 talking about Kanti, who died of Guillain-Barre syndrome on my first emergency night-call in 2nd MBBS.

Kanti died because he was admitted to a public Municipal Hospital, which did not have a working ventilator for him.  Those in charge of funding the purchase and repair of ventilators in the Municipal corporation did not think that working ventilators were a priority. Knowingly or unknowingly, they had committed structural violence against Kanti, because he was poor and without means and forced to come to a Municipal Hospital because he couldn’t afford to go anywhere else, which eventually led to his death.

Structural violence is a term first used by John Galtung but popularized by Dr. Paul Farmer in his seminal work on the people of Haiti [1]. The concept is best understood after reading a transcript of his Sidney W Mintz lecture of 2001, but even Dr. Abhisake Kole’s article describing the travails of a poor patient named Ranjit who died because of his inability to navigate the healthcare system in India, explains this well. Galtung used the term broadly to describe “social structures characterized by poverty and steep grades of social inequality, including racism and gender inequality, exercised systemically and systematically, indirectly by those belonging to another social order.”

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A recent example of structural violence is the knee-jerk lockdown that was announced by a scared Government in March 2020, hoping to contain Covid-19, with just 4 hours of notice, in which the migrant workers were stuck with nowhere to go. This was a form of structural violence against the invisible who did not even figure in the calculations of the decision-makers and were just left to fend for themselves.

The Cowin app is another classic example of oblivious structural violence…those who created and propagated the app and the whole Cowin digital system forgot to take into account the large swathes of the population who would find it difficult or impossible to use. When the privileged don’t understand that there are enough people who don’t have a smartphone and even if they do, cannot navigate the various links needed to get an appointment for a vaccine shot…that is the classic definition of structural violence.

I was among the more fortunate ones, along with my entire medical staff, to get vaccinated in January, but even then it was my HR team that had to manage all the logistics for the ward-boys and the less educated staff, who on their own were unable to understand the system.

When the time came to get our household-help vaccinated recently, it was again a nightmare. One of them is uneducated and can’t read SMSes, the other does not own a smartphone…but because it was important to us that they be vaccinated, we had to solve this problem on their behalf. What happens to others like them who don’t have any help?

Ordinarily, no one would care. But with Covid-19, until everyone around us is vaccinated, none of us is really safe and that changes the equation. Thankfully, in the last few weeks, many decision-makers and those in power have realized this and are finally reaching out to the poorest of the poor and those without the means to navigate the Cowin app, to get them vaccinated.

The invisible usually don’t really matter…but now they do and if that means a preferential option for the poor, as Dr. Paul Farmer recently alluded to, then so be it.

The battle we won against smallpox took more than 200 years, from the time vaccination was recognized as a way to control the spread of this killer disease, to the final moments in the late 1970s when international co-operation allowed the vaccine to reach the poorest of the poor and the farthest corners of the globe.

The same realization is needed to ensure that no one is left behind with Covid-19. But it is not just Covid-19.  In 2019, 440000 people died of tuberculosis in India. We have 2.6 million (26.4 lakh) cases, the highest in the world. TB is the biggest infectious disease killer in the world and dengue and malaria still ravage large parts of this globe, especially the poorer countries and the poorer parts of both, the rich and the poor countries.

The rich countries have to work with the poor countries just as the privileged in the poor countries need to work with the less privileged and so on…We have to speed up vaccine research especially using mRNA and other similar technologies to tackle these infectious diseases that cause avoidable death and disability in our country and around the world. India was supposed to eradicate/control TB by 2025…perhaps with a fast-tracked vaccine, we may be able to get there by 2030.

So how does this matka affect you? Only when everyone around you is safe and healthy, can you also hope to live long and healthy. As long as the rich and the poor continue to live side by side, it is in everyone’s interest to be infection-free. Mosquitoes bearing malaria and dengue still reach the 50th floor of buildings in the toniest neighborhoods in India and infected household help can still pass on tuberculosis to the most privileged of children and adults anywhere. All of us therefore have to address the issue of structural violence, first by understanding the concept, then acknowledging its existence in our daily lives and then working to preferentially give better healthcare access to the poor and investing heavily in preventive healthcare at all levels, if we want to be atmasvasth and live long, healthy and be prosperous.

Footnotes

1. 1. Farmer P. An Anthropology of Structural Violence. Current Anthropology. 2004 Jun;45(3):305–25.