“As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research

Abstract

This article examines the concept of "structural violence." Originating in the work of Johan Galtung in 1969 and popularized by Paul Farmer, structural violence is increasingly invoked in health literature. It is a complex concept - rich in its explanatory potential but vague in its operational definition and arguably limited in its theoretical precision. Its potential lies in the focus it gives to the deep structural roots of health inequities; in contrast to the more passive term "social determinants of health," structural violence explicitly identifies social, economic, and political systems as the causes of the causes of poor health. It is also evocative in its framing of health inequities as an act of violence. Yet the formulation of structure used in this literature is largely atheoretical and, by extension, apolitical. Development of the concept hinges on clarifying the precise aspects of structure it points to (perhaps through using the concept in conjunction with larger theoretical frameworks) as well as improving operational definitions to enable its use in quantitative social epidemiology. We argue that the concept of structural violence can provide a useful lens for understanding health inequities, but its full potential is only realized when combined with larger theoretical frameworks.

Structural Violence and Health-Related Outcomes in Europe: A Descriptive Systematic Review

“…According to De Maio and Ansell, there is a challenge in conceptualizing SV, and specifically in spelling out the precise aspects of SV to be researched, which therefore poses difficulties for those interested in carrying out quantitative studies [ 4 ].…”

“…Although SV has drawn research attention in the fields of sociology and anthropology, it has only in recent years been brought into the research discourse of the health sciences and, specifically, the public health sciences. According to De Maio and Ansell [ 4 ], the potential of SV theory in studying health outcomes lies in its focus on deeper structural roots of health inequalities rather than in it being a passive approach centered on the social determinants of health (SDHs), i.e., a social epidemiological approach [ 4 ]. Traditionally, the social epidemiological approach identifies social characteristics that affect the pattern of disease and health distribution in a society in order to understand its mechanisms [ 5 , 6 , 7 ].…”

“…The term “structural determinants of health” refers to mechanisms that generate stratification and social class divisions in society and that simultaneously define an individual’s socioeconomic position in terms of “hierarchies of power, prestige and access to resources” [ 8 ]. De Maio and Ansell [ 4 ] argue that the terms “SV” and “structural determinants of health” call attention to the societal arrangements that exist upstream from the “behaviour and biology of individuals; they both extend the traditional social determinants of health model by prioritizing the causal force of structural forces” [ 4 ]. However, SV has a distinct etiology, as it describes health inequalities as an act of violence, arguably adding something that the “structural determinants of health” term lacks.…”

“…There still is an ongoing debate on what precise aspects should be measured to enable the use of SV theory in social epidemiology [ 4 ]. Research using the SV approach has increased over the past 30 years, especially in the Global South (low and middle-income countries) as compared with the Global North (mostly the US and Canada).…”

How Do We Explain the Social, Political, and Economic Determinants of Health? A Call for the Inclusion of Social Theories of Health Inequality Within U.S.-Based Public Health Pedagogy

“…The second is structural violence , which seeks to explain social structures, a core sociological concept, and the harmful role they can play in producing avoidable harm and suffering (Farmer, 2004; Farmer et al, 2006; Galtung & Höivik, 1971). De Maio and Ansell (2018) show that structural violence is increasingly being incorporated within health science literature to explain the harms produced by a wide range of social phenomena, such as gender inequality, poverty, and historical trauma. Third, the political economy of health provides a theoretical framework for explaining the relationship among political economic systems, class structure, political power, and the unequal distribution of morbidity and mortality (Doyal & Pennell, 1979; Minkler et al, 1994; Navarro, 1976a).…”