Haiti, structural violence, and responsibility.

I finished up Pathologies of Power today, over lunch. It’s a hard book to read. The language is dense, and the reader is expected to think for themselves. However, the stories are crisp and to the point. I excerpt below (totally without permission) the section of the “Afterward” that grabbed at my heart and inspired these thoughts. As Farmer himself says “This book isn’t harsh, the realities it describes are harsh.”

I’m not sure of the point, exactly, except to look hard and honestly at the realities of life for the less fortunate billions in the world … and then perhaps to judge and act for myself.

Tuesday, I hurt my left knee at the gym. Yesterday, I saw a doctor at a hospital, and this evening I’m getting an MRI. Perhaps in a few weeks I’ll have minor surgery. One thing that sticks with me is that that both me and the kid in this story (Manno) hurt our left legs. More than that: Where I am now, and where little Manno was when he hurt his leg, these are differences of birth. I can’t take credit for being born to educated parents in Virginia. I can’t take credit for my current comfort relative to his discomfort – and I certainly can’t blame little Manno for being unfortunate enough to be born and to live in Haiti.

The fact that I get an MRI and he gets an offer of amputation is not attributable to our life choices. There is no amount of hard work and perseverance that would have turned him into me, or me into him.

I am no better or worse than him – but I would hazard to say that I am considerably luckier. I am beginning to feel that leaving this level of difference in life experience to the luck of the draw is to fall considerably short of our human potential. Certainly, no existing law demands anything of me, and I’m not suggesting pure socialism, but perhaps raising the bar for the least fortunate billions would be a better use of our time than advancing the opulence of the most fortunate millions. I have no problem with social classes. Work hard, eat better, be more important. It’s all great so long as the result is not “early and preventable death for billions.”

Farmer points out that billions today live without benefit of the discoveries of Pasteur or Salk … while the focus of 1st world pharmaceuticals is on impotence and baldness. “End of life” care is an ethical issue in the first world when it occurs in the 80th year, but not when “end of life” happens at age 5 – from starvation or malnutrition – just a short airplane ride from Miami.

Farmer goes further: He calls this situation a “crime” against Manno. Not just the bullet … (and notice that we leave un-wept the woman who died in the street that day) … but the entire social situation that he must endure. A complex, violent, and subtle crime – with so many individual choices and players that there is no good word for it except perhaps Farmer’s “structural violence.” It is said that without a victim, there is no crime. Well here we have victims aplenty. Is there a cause? Certainly. Is this situation within human control? Without a doubt.

Most troubling: If the violence is in the structure, and I am at the lucky top of that structure, then are we, am I, perhaps guilty of at least a crime of neglect here? Certainly I didn’t pull that trigger – nor did I underpay the nurses in Port-au-Prince – nor did I, nor did I. Yet I cannot help but notice that I’ve voted in this great democracy of mine since I was 18 – since before Manno was born – and still the structures persist. I have the power in this great power disparity. Is this not mine to own? To fix?

I have consistently seen what little charity I do as something above and beyond. I take great and vocal pride in being able to not only fend for myself – but also to give a little bit back. Look how generous I am! But what if, perhaps, I am called to these things not out of some desire to do more than I have to – but because I am culpable of these structural crimes. Each one is small, but the mass of preventable suffering in the world is large.

Here’s the excerpt:

It’s now the fourth of March. I am back in the little hospital in rural Haiti, trying to help Manno, a young man I have known since childhood, hobble back to his bed. He is whimpering, his left leg frozen in a foot to hip cast. His story is sad, but I can’t really call it shocking; I’ve heard similar ones many times and had heard a good part of his while still in Moscow.

It all happened right here in the village, just yards from the clinic gate. A few days ago, a woman we both know was walking in the road not far from the clinic. It was shortly before dawn, and she was on her way to market. As she rounded a corner, she was struck and killed by a truck. The driver saw what he had done and panicked, fleeing the hue and cry raised by the villagers. Some of the passengers leapt from the truck, assuming that its brakes had failed.

The villagers gathered around the stricken woman. Her family began to wail inconsolably. The crowd decided to block the road with rocks and debris and to alert the officials at the closest town so that the driver could be apprehended. Another truck, coming from the opposite direction, stopped at the roadblock. The truck’s occupants demanded to be let through, and when the villagers refused to dismantle the roadblock, an angry passenger got out and started shooting. Manno took a bullet in his left leg, just above the ankle.

The assailant was later arrested, but Manno’s problems were just beginning. An X-ray taken in the clinic showed that both tibia and fibula were shattered. The bullet was still there, too. So Manno was taken to Port-au-Prince. In the general hospital – the national university’s teaching hospital – he was told that they could not operate unless he could come up with the necessary hardware (pins, plates, an external fixator). While still in Moscow, I’d been told by the Haitian priest with whom I work that “one of the doctors said the leg might have to be cut off.” An extreme course of action, from a medical point of view. Bit the reason for the assessment was really social: the doctors were pessimistic about Manno’s chances of acquiring the requisite hardware, which would cost him six thousand dollars. Furthermore, the nurses in Port-au-Prince were on strike – the priest was not sure why – and Manno would be more likely to receive care, or at least not endure neglect, if he returned to our small, impoverished village of Cange. I argued from moscow that he should not be transferred back to Cange, where there is no orthopedic surgeon. Instead, every effort should be made to secure the needed hardware.

Having made this suggestion, I headed back. For two days, I’ve been mostly on airplanes or driving a jeep. Now, as soon as I reach Cange, I come to see Manno, who, having seen not a single doctor or nurse for two days, returned home. Te foot looks fine, and there is certainly no reason to amputate it. What did they do down there in Port-au-Prince, I wonder? To answer this question, I obtain a second film. Looking at the still-dripping film, I curse in English, to no one in particular. I thought they’d have done something, anything. But there’s the damn bullet. There are the fractures, still out of line.

As I leave the ward, Manno is still whimpering, even though he’s settled comfortably back into bed. More out of fear, I suspect, than pain. The outcome, here in Haiti, of a comminuted fracture resulting from roadside violence could indeed be the loss of his foot. That would be a crime. But what kind of crime? Manno’s attacker is in jail; there’s now less impunity in Haiti than there was a few years earlier. But that doesn’t help Manno get his left leg fixed. The bullet is still there, still lodged in his flesh, the fractures unpinned. Haiti does not guarantee its citizenry access to orthopedic hardware, although most anything can be bought for the right price. The word “insurance” is unknown among the poor.

Is Manno’s injury just hard luck, a freak accident? Of course not. If it were, I would not have seen anything like it before. But how, exactly, does one explain that what is violated, in Manno’s case and in the case of all those denied decent medical care, are social and economic rights? Aren’t we “starry-eyed” if we complain too much about the “new consensus” preaching “trade rather than aid?” Isn’t Manno mostly a victim of the “inefficiencies” and “archaisms” of a “Third World” economy in need of thorough-going “reform?”

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