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MEDICAL ANTHROPOLOGY, 30(4): 339–362
Copyright # 2011 Taylor & Francis Group, LLC
ISSN: 0145-9740 print=1545-5882 online
DOI: 10.1080/01459740.2011.576725
INTRODUCTION
Structural Vulnerability and Health:
Latino Migrant Laborers in the
United States
James Quesada, Laurie Kain Hart, and Philippe Bourgois
Latino immigrants in the United States constitute a paradigmatic case of a population group subject to structural violence. Their subordinated location in the global economy and their culturally depreciated status in the United States are exacerbated by legal persecution. Medical Anthropology, Volume 30, Numbers 4 and 5, include a series of ethnographic analyses of the processes that render undocumented Latino immigrants structurally vulnerable to ill health. We hope to extend the social science concept of ‘‘structural vulnerability’’
JAMES QUESADA is Associate Professor of Anthropology in the Department of Anthropology, San Francisco State University, San Francisco, California, USA. His critical medical anthropology research on political violence and transnational migration ranges from Nicaragua to California. He is currently engaged in an NIH=NIAAA research project on Latino day laborers in the San Francisco Bay Area.
LAURIE KAIN HART is the Edmund and Margiana Stinnes Professor of Global Studies and Professor of Anthropology in the Department of Anthropology at Haverford College, Haverford, Pennsylvania, USA. Her research focuses on ethnicity, border conflict, and territorial segregation in the Mediterranean, the Balkans, and the US inner city. She is the author of Time, Religion, and Social Experience in Rural Greece as well as of numerous articles on the long-term effects of civil war and ethnic displacement.
PHILIPPE BOURGOIS is the Richard Perry University Professor of Anthropology and Family and Community Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. He is the author of In Search of Respect: Selling Crack in El Barrio and Righteous Dopefiend, as well as over 150 articles on drugs, violence, labor migration, ethnic conflict, homelessness, and urban poverty (http://philippebourgois.net). Correspondence may be directed to James Quesada, Department of Anthropology, San Francisco State University, 1600 Holloway Ave., San Francisco, CA 94132, USA. E-mail: [email protected]
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to make it a useful concept for health care. Defined as a positionality that imposes physical=emotional suffering on specific population groups and individuals in patterned ways, structural vulnerability is a product of class-based economic exploitation and cultural, gender/sexual, and racialized discrimination, as well as complementary processes of depreciated subjectivity formation. A goodenough medicalized recognition of the condition of structural vulnerability offers a tool for developing practical therapeutic resources. It also facilitates political alternatives to the punitive neoliberal policies and discourses of individual unworthiness that have become increasingly dominant in the United States since the 1980s.
Key Words: citizenship; Hispanic health outcomes; immigrants; social inequality; social medicine; structural violence
The embattled passage of health care legislation in the United States in 2010, founded on a rhetoric of ‘‘health care for all,’’ expressly barred undocumented immigrants from accessing coverage, officially reaffirming their exclusion from public services and basic legal rights. At the same time, increased enforcement of immigration laws has exacerbated personal insecurity, labor market discrimination, and residential segregation (Gradstein and Schiff 2006; Canales 2007). Most importantly from a health perspective, this kind of systemic social marginalization inflicts pain (Eisenberger, Liberman, and Williams 2003).
Explicit political exclusion is one of the more visible manifestations of what has been called structural violence in social science analysis. Latino migrant laborers are a population especially vulnerable to structural violence because their economic location in the lowest rungs of the US labor market is conjoined with overt xenophobia, ethnic discrimination, and scapegoating. Simultaneously perceived as unfair competitors in a limited-good economy (Foster 1965; Quesada 1999) and freeloaders on the shrinking welfare safety net (Cockcroft 1986; Go´mez-Quin˜ones 1994; Gutie´rrez 1995; Mahler 1995; Coutin 2000; De Genova 2004), they are subjected to a conjugation of economic exploitation and cultural insult (Bourgois 1988). The term structural violence is generally attributed to the sociologist Johan Galtung (1969). Arguing for a social-democratic commitment to universal human rights, in the face of US Cold War blindness to the political effects of third-world poverty and the legacy of colonial inequity, Galtung defined structural violence as ‘‘the indirect violence built into repressive social orders creating enormous differences between potential and actual human self-realization’’ (Galtung 1975:173). He specifically differentiated structural violence from institutional violence, emphasizing the former’s ‘‘more abstract nature . . . that can [not] be traced down to a particular institution’’ (Galtung 1975:173, 175).
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The theorization of structural violence also has radical roots in anticolonial resistance movements (Fanon 1963) and in Catholic liberation theology’s advocacy for a ‘‘preferential option for the poor’’ (Camara 1971; Martin-Baro, Aron, and Corne 1994). In medical anthropology the term has been used to highlight disparities and to identify socially structured patterns of distress and disease across population groups, from mental health, occupational health, and interpersonal=domestic violence, to infant mortality, substance abuse, and infectious diseases (Galtung 1969; Martin-Baro et al.; Scheper-Hughes 1996; Kleinman 2000; Parker, Easton, and Klein 2000; Bourgois 2001; Pedersen 2002; Farmer 2004; Walter, Bourgois, and Loinaz 2004; Heggenhougen 2005). The infectious disease physician and anthropologist Paul Farmer (2003) has made structural violence the centerpiece of his argument that access to health care is a fundamental human right. Many analyses of structural violence have included cultural factors such as gender inequality and racism. Nevertheless, in practice the concept has been used primarily to invoke materialist forces calling attention to class oppression and economic injustice. The semantic tension in the phrase effectively conveys the urgency of its analytical point and mobilizes political, ethical, and practical engagement: it rhetorically juxtaposes the morally evocative and physically concrete word ‘‘violence with the abstract and ostensibly neutral word ‘‘structure.’’ However, the term’s political and humanitarian valence—especially in its Latin American manifestation as liberation theology in solidarity with armed revolutionary struggles—alienates some critics. Other scholars object to the purposefully provocative broadening of the concept of violence into a political-economic abstraction. The more neutral and inclusive term ‘‘vulnerability’’ may be useful, consequently, to extend the economic, material, and political insights of structural violence to encompass more explicitly (and to project to a wider audience) not only political-economic but also cultural and idiosyncratic sources of physical and psychodynamic distress. These include (1) social hierarchies buttressed by symbolic taxonomies of worthiness (Bourdieu 2000); (2) historically distinctive discourses of normativity and ethics (Foucault 1984); and (3) the intersection of individual medical pathology and biography with social exclusion (Biehl 2005). In our conceptualization, structural vulnerability is a positionality. The vulnerability of an individual is produced by his or her location in a hierarchical social order and its diverse networks of power relationships and effects (Leatherman 2005; Watts and Bohle 1993). Individuals are structurally vulnerable when they are subject to structural violence in its broadest conceptualization. This includes the interface of their personal attributes—such as appearance, affect, and cognitive status—with cultural values and institutional structures.
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Economically exploited and politically subordinated individuals and collectivities often internalize their externally generated depreciated status in a complex and poorly understood process of embodiment that shapes their behaviors, practices, and self-conceptions—their ‘‘habitus’’ (Bourdieu 2000) or their ‘‘subjectivities’’ (Foucault 1978, 1995; see Butler 1997:86; Biehl, Good, and Kleinman 2007; Pine 2008:12–14, 17; Bourgois and Schonberg 2009:18–19). This embodiment of subordinated status produces a form of symbolic violence whereby the everyday violence of imposed scarcity and insecurity is understood as natural and deserved (Bourdieu 2000; for ethnographic accounts of the negative effects of symbolic violence on health, see Bourgois, Prince, and Moss 2004; Pine; Auyero and Swistun 2009). Ill health under these conditions, as Nguyen and Peschard argued (2003), can be conceptualized as the outcome of forms of violence sustained by politicaleconomic and cultural rationales, and can be managed through historically specific modes of governmentality in a social milieu and political context of marked indifference to the afflicted.
Structural vulnerability implies a critique of the concept of agency because it requires an analysis of the forces that constrain decision making, frame choices, and limit life options (for a rejection of the agency-structure polarity through the concept of habitus and ‘‘practice,’’ see Bourdieu and Wacquant 1992; Calhoun, LiPuma, and Postone 1993; see also Bourgois and Hart 2010). It identifies ‘‘spaces that configure a specific set of conditions in which people live, and set constraints on how these conditions are perceived, how goals are prioritized, what sorts of actions and responses might seem appropriate, and which ones are possible’’ (Leatherman 2005:53). When translated into health care practice, the concept of structural vulnerability can become a productive tool for contextualizing diagnosis and informing critical praxis (Singer 1995; Delor and Hubert 2000). Demystifying agency and removing the moral judgment inherent to a theoretical concept that implies that individuals understand and control the consequences of their everyday actions can contribute to rectifying the misdiagnosis, blame, and maltreatment that accompany the experience of poverty and cultural subordination. This is especially important in a society like the United States, which individualizes responsibility for survival and relies on an ideology of free market forces to distribute goods, services, and health to the disenfranchised.
THE CRITIQUE OF RISK IN PUBLIC HEALTH AND MEDICINE
Conventional public health interventions primarily target individuals by promoting behavior change through imparting knowledge, skills, motivation, and=or ‘‘empowerment’’ based on a cognitive model of rational
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choice theory in medical decision-making. There is a growing recognition in the field of public health and medicine, however, of the ways social inequality imposes ‘‘risk’’ on subordinated population groups. This involves an awareness that a larger ‘‘risk environment’’ precedes individual decision-making (Rhodes 2002), but, significantly, there is not yet a logically consistent conceptual vocabulary or analytical approach to the definition of the risk environment in public health and medicine. Critical public health approaches propose a broad range of overlapping terms for grappling with the effects of social inequality, including, among others: ‘‘social epidemiology’’ (Poundstone, Strathdee, and Celentano 2004; Diez Roux 2007; Galea, Hall, and Kaplan 2009), the ‘‘eco-social’’ or ‘‘socio-environmental perspective’’ (Brown and Inhorn 1990; Krieger 1994, 2001; Richard, Potvin, and Mansi 1998; Burris et al. 2004), ‘‘eco-epidemiology’’ (Susser 1996), and the ‘‘the risk environment framework’’ (Rhodes and Simic 2005; Rhodes 2009; also see review by Strathdee et al. 2010). They call for a focus on ‘‘fundamental social causes’’ (Link and Phelan 1996, 2002), ‘‘social determinants of health inequality’’ (Strathdee et al. 1997; Kawachi and Kennedy 1999; Marmot 2005; Marmot and Wilkinson 2006), ‘‘income inequality’’ (Kawachi and Kennedy), ‘‘political and economic determinants’’ (Singer 2001; Navarro and Muntaner 2004), ‘‘conjugated oppression’’ and ‘‘hierarchies of embodied suffering’’ (Holmes 2007), ‘‘zones of abandonment’’ (Biehl 2005), ‘‘higher order causal level structural factors’’ (Miller and Neaigus 2001), and ‘‘discrimination’’ and ‘‘racial disparities in health outcomes’’ (Marmot, ...