The poor health status among Aboriginal and Torres Strait Islander people (hereafter referred to as Indigenous Australians) is well researched (1, 2), with chronic diseases such as cardiovascular disease (CVD) being the greatest contributor to their health burden (3–5). Rates of CVD are significantly higher among Indigenous Australians compared to non-Indigenous Australians, with coronary heart disease 2–3.1 times higher and rates of stroke 1.5–2.3 times higher (3). Additionally, risk factors for CVD such as diabetes, hypertension and obesity occur at a higher rate among Indigenous Australians compared to non-Indigenous Australians (3, 4). However, the rising burden of CVD among Indigenous Australians is also greatly influenced by structural forces, such as the social, economic, and political systems within society (3, 4). By using Paul Farmer’s conceptualisation of structural violence, this essay explores how structural forces create the conditions that invite and sustain CVD in Indigenous Australian communities.
This essay will first define structural violence and explore how Paul Farmer’s conceptualisation of this theory has offered valuable insights to the field of public health. The essay then discusses how the concept of structural violence can advance our understanding of the structural forces that contribute to the rising rates of CVD among Indigenous Australians. From this, the essay analyses the importance of implementing public health interventions at a structural level to achieve positive health outcomes among Indigenous Australians. Lastly, this essay explores a limitation of structural violence, which is the conceptual ambiguity it poses. Based off these claims, this essay argues that the structural violence experienced by Indigenous Australians have been a contributing factor to the high burden of CVD and that it is these structural forces that must be addressed for better health outcomes to occur.
What is Structural Violence?
Norwegian sociologist Johan Galtung introduced the concept of structural violence in his seminal essay, “Violence, Peace, and Peace Research”, published in 1969 (6–10). Galtung argued that structural violence was a form of systemic violence that drew its power from political, social, economic or cultural institutions (6–10). He claimed that these institutions constantly failed to meet the basic needs of marginalized groups and that since these institutions are ingrained in society, the violence they exert are difficult to identify and address (6–10). However, it was Paul Farmer, a physician and medical anthropologist, who offered a nuanced insight into the structural forces that fostered the development of diseases such as HIV and tuberculosis (7–11). In his book, Pathologies of Power, published in 2003 (12), Farmer illustrates that structural violence refers to a range of offenses against humanity, such as poverty, gender inequality, racism and discrimination (8, 11). Farmer applies Galtung’s theory of structural violence to ethnographic research on marginalised communities in Haiti and Peru to delineate how social, economic and political forces have contributed to the risk of developing diseases (7–11).
Structural Violence and Public Health
Paul Farmer’s conceptualisation of structural violence can enhance our understanding of how structural forces shape the context in which CVD develops among Indigenous Australians. Paul Farmer’s work on structural violence relies on an analysis that is ‘‘geographically broad” and “historically deep” (11, 13). He argues that in order to understand how diseases develop in marginalised settings it is pertinent to deeply engage with the history of the country and identify how that history manifests into the structures that govern society (11). The structural forces impacting the health of Indigenous Australians and contributing to the high rates of CVD are deeply embedded in a history of colonization (2, 14–16). Cultural genocide, systemic racism and policies of segregation and assimilation were different forms of structural violence exerted upon Indigenous Australians during colonisation (2, 14, 16). The intergenerational trauma caused by these horrific acts permeates the lives of current Indigenous Australians and has contributed to their low levels of education, high unemployment rate and experiences of poverty (2, 15–17). These historically contingent acts of structural violence consequently restrict the opportunities individuals have in improving their health (2, 15–17). For instance, Indigenous Australians with low levels of income have limited access to specialist healthcare (4) and are at increased risk of engaging in behaviours that can lead to the development of CVD, such as the consumption of unhealthy foods (3). Moreover, Farmer claims that the atrocities occurring against marginalised groups are closely related to the actions of those in power (11), such as health care providers (2). It has been well documented that healthcare services are often culturally insensitive towards Indigenous Australians, with many Individuals experiencing racism (4, 15). This consequently alienates patients and prevents them from seeking further treatment for conditions such as CVD (4, 15). Additionally, 22% of Indigenous Australians live in rural and remote regions (2, 3), where access to specialist cardiology services and acute care is limited (4). By applying Paul Farmer’s conceptual framework, it becomes apparent how historically contingent acts of structural violence (2) have given rise to the high rates of CVD experienced among Indigenous Australians. Therefore, to address the rising rates of CVD it is pertinent that interventions be implemented at a structural level for better health outcomes to occur (18).
Paul Farmer’s theoretical insights have reinforced the importance of implementing public health interventions at a structural level to address the health inequities caused by structural violence. Structural interventions promote health by changing the structural forces that contribute to the development of illness (18). Farmer claims that for structural interventions to be effective, medical and public health experts should work alongside stakeholders such as the Government to implement ‘proximal’ interventions (8, 19). These include structural level initiatives that prevent illness through measures such as education and policy change (8). Structural approaches to preventing CVD among Indigenous Australians include subsidizing healthy foods so that they’re more affordable and taxing unhealthy energy dense foods (18). These fiscal policy measures alter the food consumption of individuals by nudging them towards healthier options and has shown great success in other countries (18). In his work, Farmer also voices his concern on how medical practitioners are inadequately trained to recognize how structural violence interferes with a patients adherence and access to medicine (8). He contends that medical and public health practitioners need to address health inequities by “resocializing” disease (8), whereby the biomedical model of health takes into consideration the social forces that exist beyond the control of the patient (8, 19). Therefore, structural interventions implemented in healthcare settings should incorporate Indigenous culture into service delivery as a way of addressing the cultural barriers existing in healthcare (20, 21). Empirical evidence indicates that nurse educators who hold cultural competency sessions on Aboriginal culture for students, healthcare professionals and in hospitals are able to break down stereotypes and reduce racial disparities in healthcare (20). Healthcare providers with culturally sensitive communication skills would be able to build trust with Indigenous Australians (21), thereby increasing the likelihood that patients adhere to their advice and seek early treatment for CVD (4, 20). Farmer claims that structural interventions that aim to increase the agency of marginalised people achieve better health outcomes (8). Therefore, structural initiatives such as fiscal policy and cultural competency sessions in healthcare can address the rising rates of CVD by empowering Indigenous Australians rather than forcing them to change their behaviour (18, 20).
Although the theory of structural violence has advanced our understanding of the structural forces perpetuating health inequality, a fundamental drawback is that it becomes an ambiguous term for describing different forms of oppression. Since structural violence exists in different forms, critics argue that the concept is a ‘black box’ (13) and has been oversimplified (11, 13, 22–24). The implications of this is that it becomes difficult to identify the specific structural forces (13) influencing the high rates of CVD in Indigenous Australians. As a result, many scholars contend that the theory requires further unpacking to become a well-defined conceptual tool (11, 13, 22). Additionally, since structural violence encompasses different forms of inequality it becomes difficult to measure (11). Since there is no metric for structural violence, epidemiologists and quantitative researchers are hesitant to incorporate the theory in their work (11). Without having a metric to measure it becomes difficult to identify if structural level interventions are effective (18) in reducing the rates of CVD. Despite these limitations, Farmer acknowledges that addressing structural violence and the barriers it poses should never be the sole focus (8). Instead, Farmer advocates that the social sciences and biomedicine should be complementary when improving public health (8).
Paul Farmer’s work on structural violence can enhance our understanding of the structural forces contributing to the development of CVD among Indigenous Australians and the importance of implementing structural-level interventions to address these rising rates.
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