Violence, health and human rights

Challenges for medical anthropology

Annemiek Richters

Abstract

This survey article addresses the question what medical anthropology can contribute to the study of, and interventions in, the field of violence conceptualised as a health and a human rights issue. Medical anthropology is positioned on the crossroads of recent developments in public health and anthropology. Throughout the article a number of issues are raised for a medical anthropology agenda. Particular attention is paid to issues in the areas of social suffering, justice, memory, and torture. In addition, a number of crosscutting methodological issues are presented. They include the public role of anthropologists, anthropological fieldwork in dangerous situations, speaking and silencing about the unspeakable, and theory development. The article is meant as an incentive to contributions for a symposium to be held in the Netherlands and planned for December 2004.

Introduction

“The twentieth century will be remembered as a century marked by violence. It bur-dens us with the legacy of mass destruction, of violence inflicted on a scale never seen and never possible before in human history. But this legacy – the result of new technol-ogy in the service of ideologies of hate – is not the only one we carry, nor that we must face up to. Less visible, but even more widespread, is the legacy of day-to-day, individ-ual suffering. It is the pain of children who are abused by people who should protect them, women injured or humiliated by violent partners, elderly persons maltreated by their caregivers, youths who are bullied by other youths, and people of all ages who inflict violence on themselves. This suffering – and there are many more examples I could give – is a legacy that reproduces itself, as new generations learn from the vio-lence of generations past, as victims learn from victimizers, and as the social condi-tions that nurture violence are allowed to continue. No country, no city, no community is immune. But neither are we powerless against it” (Mandela 2002). With these words Mandela starts his Foreword to the first World report on violence and health of the World Health Organization (Krug 2002).

In 1996, the Forty-Ninth World Health Assembly, adopted Resolution WHA49.25, declaring violence a major and growing public health problem across the world. The World report on violence and health is an important part of WHO’s response to thatResolution. It is aimed mainly at researchers and practitioners. In this article I address the question what medical anthropologists, as researchers and practitioners, have to of-fer in the fight against violence, in terms of, for instance, contributing to awareness raising about the problem of violence, the prevention of its occurrence, the mitigation of suffering as its consequence, and theory development. The article is meant as an in-centive to contributions for a symposium on the subject to be held later this year.

Violence is a multifaceted phenomenon. I will approach it in particular as a health and a human rights issue. Medical anthropology as an interdisciplinary field will be po-sitioned on the crossroads of recent developments in public health and anthropology. There has been a growing attention in anthropological research during the last few dec-ades for all sorts of violence pervading the modern world. Meanwhile health profes-sionals have started to pay increasing attention to the human rights aspects of their work, thereby in particular trying to bridge legal and public health approaches. Both developments have raised a number of challenges for medical anthropology, a disci-pline trying to bridge the worlds of anthropology and medicine and thus working in the borderland between both disciplines and their respective fields of study and interven-tions (Diasio 2003).

To begin with I will describe recent developments in public health, which focus on ‘violence and health’ and ‘health and human rights’, and in the ‘anthropology of vio-lence’ and ‘anthropology of human rights’ and the challenges these developments raise for medical anthropology. I will then illustrate what these challenges are by presenting a few of the themes in the area of violence, health and human rights that are or should be on the agenda of medical anthropology. The subject I will introduce is wide. I there-fore have to be selective in the literature I refer to and the themes I present. The same applies to my presentation of specific problems encountered during fieldwork, the pub-lic role of medical anthropology in the field described, and the theoretical issues that have come up in that field.

Public health, violence and human rights

Violence is a broad concept, lending itself to various definitions and theories, signifi-cations, categorizations and linking up of different types of violence. The WHO defines violence as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (WHO 1996). This definition covers aspects of vio-lence – intentionality, power, categories of violence, and impacts of violence – which in similar phrasings are part of a variety of definitions of violence in circulation. Within the different categories of violence, violence is regularly classified according to its nature as physical violence, sexual violence, psychological violence and violence involving deprivation or neglect (cf. e.g. Hof & Richters 1999).

A number of other distinctions are being made, such as the one between direct and indirect violence. The latter includes for Navarro (1974) the ‘hidden’ and silent vio-lence, the violence resulting from the inequitable structure of apartheid (of ‘other-ness’). He stated at the time metaphorically that in Latin America the equivalent of 20 nuclear bombs explode every year without making a single sound. The health of, for in-stance, Guatemalans is not only infected as a result of this structural violence, however, but has also been deeply affected by direct violence (large scale torture and murder) and a pervasive atmosphere of fear. Such issues are fundamental to public health (Heggenhougen 1995).

The concern of public health is to prevent health problems and to extend better care and safety to entire populations, without ignoring the care for individuals. The preven-tion of violence and its health consequences, according to the public health approach, begins with a description of the magnitude and impact of the problem. The roots of vio-lence are regularly examined by means of an ecological model, approaching violence as the result of a complex interplay of risk factors at individual, relationship, commu-nity and societal level (Krug 2002: 12-15). The information collected is supposed to lay the foundation for appropriate responses. Increasingly, the language and principles of human rights are used to advocate the necessary interventions in situations of vio-lence. The various forms of violence at issue in particular situations are then presented as abuses of people’s human rights that need to be redressed.

Since the early 1990s the belated prominence of a linkage between health and hu-man rights has strongly influenced the character of public health. One of the advocates of this influence was the physician Jonathan Mann, who was tragically killed in the crash of Swissair Flight 111 in 1998. In 1994 he launched the Journal Health and Hu-man Rights, published by the François-Xavier Bagnoud Center for Health and Human Rights. This Center was founded in 1993 at the Harvard School of Public Health to pro-mote and catalyze the health and human rights movement; to influence policies and practices in health and human rights; and to expand the knowledge about linkages be-tween health and human rights in specific contexts such as HIV/AIDS, children’s rights and health, and women’s health and rights. “The central idea of the health and human rights movement is that health and human rights act in synergy. Promoting and protecting health requires explicit and concrete efforts to promote and project human rights and dignity, and greater fulfillment of human rights necessitates sound attention to health and to its societal determinants” (Mann et al. 1999: 5).

Mann and with him many others (e.g. Farmer 2003) have presented HIV/AIDS as illustrative of a more general phenomenon in which individual and population vulner-ability to disease, disability, and premature death is linked to the status of respect for human rights and dignity. The evolving HIV/AIDS pandemic has shown a consistent pattern through which discrimination, marginalization, stigmatization, and, more gen-erally, a lack of respect for the human rights and dignity of individuals and groups heighten their vulnerability to becoming exposed to HIV.

Connections between health and human rights are these days made by a number of organisations, such as Amnesty International, the International Society for Health and Human Rights, Physicians for Social Responsibility, Physicians for Human Rights, Healthnet International, Médicins Sans Frontières and Médicins du Monde, to name a few. The sociologist Fox did exploratory research on the last two organizations (1995). Both have played a generative role in linking medical humanitarianism and human rights action, thereby operating within the larger framework of a sans frontièrisme movement. One of their fundamental principles of action is to heal the human body as well as the body politic by bearing public witness to the violations of human right and dignity that they encounter in the field. In their philosophical outlook, however, Fox observes, both organizations seem to attach greater weight to a ‘global’ than a ‘multi-cultural’ perspective. She refers with approval to Václav Havel who in an address de-livered in 1994 stated that the problem of how to be ‘global and at the same time clearly multicultural’ is the supreme political, moral, and spiritual challenge of our era. This challenge is not taken up, in Fox’s observation, by MSF and MDM. Their universalist-ic value systems, with their emphasis on a transcendent conception of human worth, have contributed to their reluctance to attach undue importance to particularistic social and cultural factors. Similarly, Robben and Nordstrom (1995: 7) refer to the question that has plagued Amnesty International since its inception: How can anyone determine what are human rights and wrongs, and how can these be universalized, when in fact we have not even determined what such fundamentals as self, identity, existence, soci-ety, and culture are?

Fox, Robben and Nordstrom point to a problem of wider significance. According the WHO World report on violence and health, the public health approach to any prob-lem is interdisciplinary and science-based. “It draws upon knowledge from many dis-ciplines, including medicine, epidemiology, sociology, psychology, criminology, edu-cation and economics” (Krug et al. 2002: 3). By the way this sentence is phrased, cultural and medical anthropology is not excluded, but it is not explicitly included either. The same applies to what I consider to be standard works in the field of health and human rights: The reader Health and human rights edited by Mann et al. (1999) and the handbook The medical profession and human rights compiled by the British Medical Association (2001). The first explores in a collection of essays the fundamen-tal connections between public health and human rights and the responsibilities of health professionals for promoting and protecting human rights. The latter addresses in the concrete medical doctors and discusses the dilemmas and challenges they face in confrontation with assaults on human dignity. Examples are given from all over the world. The issues discussed include the work of prison doctors and forensic doctors, medical care for asylum seekers, the rehabilitation of torture victims, various forms of violence against women and children, trade in organs, and the medical involvement in armed conflicts and weapons research. In discussing these issues, doctors are exposed to the possibilities of expanding their professional roles to include those of advocate and agent for social justice.

Given the fact that many past public health efforts are seen to have failed because of not having taken sufficient note of socio-cultural factors, the anthropological perspective appears imperative for improving public health (cf. e.g. De Jong 2002, 2004). A main component of what it can add to the required collaborative approach for the ‘new’ public health, is a more valid understanding of the issues at stake (cf. e.g. Trostle & Sommerfeld 1996). The four characteristics of anthropological methods which can complement epidemiological research methods as listed by Heggenhougen and Pedersen (1997) are: emphasizing quality and validity, looking for questions as well as answers, gaining an insider’s perspective, and being open to expect the unexpected. For the phys-ician and anthropologist Farmer, whose focus is particularly structural violence and the abuses it inevitably breeds, anthropology’s contribution to the field of health and human rights with respect to content should be the exploration of ‘macrologics of power’ with-out sacrificing ethnographic depth (Farmer 2003). However, as I will show below there are many other ways to look at the content of what anthropology has to offer in studies of violence. It depends in part on the kind of violence that is at stake.

The antropology of violence and of human rights

While some anthropologists argue that armed conflict, genocide, ethnocide and vari-ous other forms of violence have always been a favourite topic in ethnography, others lament that the discipline, until quite recently, has been mute on the subject. In a now classic essay, Starn (1991) deplores the failure of his fellow Andeanists to consider the terrible suffering all around them, even though a guerrilla war was soon to wrack Peru. Part of the explanation rests according to Starn with the state of anthropological theory in the 1960s and 1970s. Much of the thinking in these years sorted in the general camp of either cultural ecology or symbolic anthropology. This alignment carried into stud-ies of the Andes. The analysis of mobilization and protest did not have a real place on either side.

Almost a decade later, Linda Green in her book on how Mayan widows are building and constantly rebuilding their lives within and against situations of totalizing and ines-capable violence (1999), still complains of ‘anthropology’s diverted gaze’. According to her, despite an alarming rise in the most blatant forms of transgressions, repression, and state terrorism, the topic has not captured the anthropological imagination until re-cently. In particular not the imagination on how terror and violence operate on the level of lived experience (pp. 57-58). Zur, who also studied Mayan war widows in Guate-mala, similarly makes a plea for more studies of violence elucidating the lived realities of people who lived through war, thereby enhancing knowledge of its effects. Given the fact that one third of the world’s countries are presently engaged in war and two thirds regularly practice human rights abuses in order to control their populations, it is evident that social scientists, no matter what their field of study, will in all likelihood confront some instance of socio-political violence in the field (Zur 1998, Epilogue).

According to Robben and Suárez-Orozco (2000: 26) ethnographic attention has al-ways been directed more at the constitutive than the destructive dimensions of human societies. Aijmer and Abbink (2000: xiv), on the other hand, state that a large corpus of ethnography focusing on ‘tribal warfare’, ethnic conflict and personal violence, etc. has already been available since at least the 1940s. What has been lacking is an accom-panying explicit theorizing of violence in anthropology. What has also been lacking, I should add, is a full account of all forms of violence. Counts (1992) notes that at least prior to 1985 little ethnography and discussion of family violence against women ap-peared in anthropological literature. One of the reasons which has been suggested to account for this neglect is fear that research on the subject might encourage women to protest traditional gender roles in marriage – including men’s right to beat their wives – and that as a consequence the institution of marriage itself could be destabilized so that family life would suffer. Aversion to any such destabilization is widespread. As one High Court Judge in Uganda, a man, once phrased it, “it is better for one person to suf-fer rather than risk a complete breakdown in family life”. Thus, perhaps, spouse abuse, a potential threat to the social order, has been hushed up and glossed over at both the in-dividual and societal level. One of the reasons why anthropologists contributed to this denial could have been their fear for being considered a threat to the society in question and for being expelled from it. Since about a decade the tide has turned and all sorts of gender violence, both as a violation of human rights and a priority public health issue, has become a growing area of anthropological research (cf. e.g. Richters 1994; Manderson & Bennett 2003).

Scheper-Hughes and Bourgois (2004), both anthropologists who have extensively addressed violence in their work (cf. e.g. Scheper-Hughes 1992, Bourgois 1995), com-piled a comprehensive anthology on violence in war and peace drawing on a range of sources, coming from the social sciences, moral and political philosophy, psychiatry, literature, and journalism. All their selections, however, are infused with “an ethno-graphic, anthropological sensibility in which scientific observations is combined with moral and political witnessing” (p. 5). Anthropology itself is, according to both, a late arrival in the field. The anthology is supposed to represent an opening gambit in an at-tempt to establish an ‘anthropologically informed’ field of multidisciplinary violence studies. The gift of the ethnographer is, as they phrase it, “some combination of thick description, eye-witnessing, and radical juxta-position based on cross-cultural insight” (p. 26).

In their anthology, Scheper-Hughes and Bourgois strive, above all, to ‘trouble’ the usually made distinctions between public and private, visible and invisible, legitimate and illegitimate forms of violence in times that can best be described as neither war nor peacetime in so many parts of the world (p. 4). They also stress that violence and geno-cide is a continuum. Violence, in their view, cannot be readily objectified, quantified and neatly defined. This all may be necessary for, for instance, epidemiological, policy and legal reasons, but in reality violence defies easy categorization. “Rather than suigeneris, violence is the eyes of the beholder” (p. 2). The danger of many scientific ap-proaches to violence lies in making definitions of violence appear too polished and fin-ished – for reality will never be. Robben and Nordstrom (1995) are of a similar opinion, stating that many ‘definitions’ of violence are powerful fictions and negotiated half-truths.

While the emic perspective of anthropology is very much promoted by Sche-per-Hughes and Bourgois (2004), they also defend that in the end anthropologists have the moral obligation to give their own political views and contribute to ‘human liberati-on’. The propositions underlying the ‘militant anthropology’, which was already defended earlier by Scheper-Hughes (1995) are contested within anthropology. Simi-lar to the various positions taken in the ethical debates with regards to the neutrality of humanitarian public health interventions in situations of (post)conflict (Richters 2004), anthropologists have different views on the moral position to be taken with regards to their work in and on these situations (cf. e.g. Aijmer & Abbink 2000; Kovats-Bernat 2002; Cushman 2004). Kovats-Bernat (2002), for instance, defends that anthropology can contribute to social reform without being ‘militant’.

The question of which political-ethical political position to take becomes especi-ally prominent when violence is conceptualized as an abuse of human rights. At pre-sent, discussions of the cross-cultural applicability of human rights still revolve around the universalism/relativism debates and the importance of culture (Wilson 1997a; Cowan et al. 2001). Human rights can be seen as one of the most globalised political values of our times. Particularly, anthropologists have positioned themselves in critical opposition to universal values and transnational processes such as ‘human rights’. On the other hand, it can also be defended that anthropologists should make greater use of the human rights framework in their theoretical, action- or policy-oriented analyses of social transformations (Messer 1993: 225).

Wilson (1997a) proposes an ‘existential ethnography of rights’. While most human rights reports “strip events free of actors’ consciousness and socio-cultural contexts”, Wilson argues that “it is part of anthropologists’ brief to restore the richness of subjec-tivities, and chart the complex fields of social relations, contradictory values and the emotional accompaniment to macro-structures that human rights account often exclude” (p. 15). That existing forms of human rights reporting may fail to capture the multiplicity of narratives on political violence, and therefore engage in a process of decontextualization, is illustrated by, for instance, the reports made by the Immigration and Naturalisation Service of the Dutch Ministry of Justice (the IND) of asylum see-kers’ stories of persecution (Bel Khodja 2003; Oomen 2004). It is precisely the contex-tualization of people’s narratives about experienced violence and human rights abuses and their suffering as a consequence of it, that belongs to the field of medical anthro-pology. This contextualisation is not only needed in order to compensate for the indivi-dualised, a-cultural, deracinated and therefore universalistic nature of most human rights accounts (Wilson 1997b: 157) but also of most medical accounts of human suf-fering as a consequence of human rights abuses. I will illustrate this point with a short discussion of a selection of themes from the medical anthropological literature. My focus will be on issues of health (particularly public health) and healing in the context of organized violence and its aftermath.

Organized violence can be defined as the inflicting of significant and avoidable pain and suffering on others by an organized group according to a declared or implied strategy and/or system of ideas and attitudes. It comprises the use of any behaviour un-acceptable by general human standards. It includes among other things ‘torture, cruel, inhuman or degrading treatment or punishment’ as mentioned in article 5 of the United Nations Universal Declarations of Human Rights (1948). This ‘working definition’ presupposes the existence of ‘general human standards’. As I already discussed, the question is whether a certain form of violence in a particular society may be considered ‘normal’ or acceptable because of prevailing cultural values and norms, whereas in other societies the same behaviour is clearly a gross violation of human rights.

Themes and approaches in medical anthropology

Social suffering and healing

A key element of modern organized violence is the creation of states of terror to pene-trate the entire fabric of grassroots social relations, as well as subjective mental life, as a means of social control. The valued institutions and a way of life of a whole population are under attack. This can mean that a whole community or society is left traumatized. In that case the individualistic focus of many of the Western trauma programmes that are in the process of being globalized around the world risks neglecting the core issue: the role of the social and cultural world. Both are invariably targeted and yet still em-bodying the capacity of survivor populations to manage their suffering, adapt and re-cover on a collective basis. Recently a number of ethnographic studies have confirmed the importance of social and cultural processes in understanding the effects of organized violence in the form of massive or collective trauma and ways of dealing with them (cf. e.g. Summerfield 1997; Zur 1998; Green 1999; Robben & Suarez 2000; Kleinman et al. 1997; Das et al. 2000; Das et al. 2001; Put & Eisenbruch 2004).

Kleinman, Das and colleagues have introduced the term social suffering in a series of three volumes, which examine anthropological questions about the relation of vio-lence to states, local communities and individuals (Kleinman et al. 1997, Das et al. 2000, Das et al. 2001). Included under the category of social suffering are conditions that are usually divided among separate fields and that are for research and intervention purposes splintered into measurable attributes. The conditions, however, involve health, welfare, legal, political, moral, cultural and religious issues, which form a do-main that should be approached as a whole. At least if one wants to understand peo-ple’s suffering due to organized violence, study their own attempts to remake their every day life, and contribute in one way or the other to social recovery and healing. Let me instead of listing all the issues at stake in the study of social suffering and heal-ing, give a summary of one ethnographic study, which addresses at least a number of them; the study by Green on Mayan women in Guatemala (1999).

Guatemala suffered from a 36 year lasting civil war; a war, which, like so many re-cent wars, was directed at the destruction of social structures and important cultural symbols. In 1996 a peace treaty was made. There is, however, still a high degree of im-punity that pervades daily life with fear. Chronic fear has spread throughout the whole individual and social body. On individual level it regularly comes to the surface in dreams and chronic illnesses. Many Mayan women have lost their husband during the war. Their bodies since speak poignantly of trauma and sadness, of loneliness and des-olation, of poverty and doubt. While history and memories in the past were reposited in ancestral lands, the recent war history and social memories of the Mayan women of death and loss of loved ones are sedimented in their bodies. Their memorias de sangre (blood memories) run through their veins literally and figuratively. The widows still, after the official peace accord, live in a chronic state of emotional, physical, spiritual and social pain. Pain that is difficult to categorize as a clinical psychiatric or somatic syndrome. Such categorization would do injustice to what the women experience. Through their bodies the women speak of social suffering due to the war in a climate of fear that suppresses other forms of speaking. While silencing is a powerful mechanism of control enforced through fear, it can also operate as a survival strategy. The experi-ence of violence has not only caused suffering and cultural alienation, but also new possibilities to deal with both and to rebuild changing ways of lives.

The fact that almost all women suffer from similar complaints results in a new com-munity feeling. The complaints include headaches, gastritis, stomach ulcers, weak-ness, diarrhoea, irritability, insomnia, weak blood, and folk illness such as nervios (nerves), susto (fright) en pena (pain, grief, sorrow). The chronic pains have become a mechanism of social commentary and political consciousness. Instead of completely demolishing the women, the illnesses have a reduction of experienced powerlessness as a result. The women search together for herbs in the mountains, even though their headaches will not disappear until justice has been done. The widows do more than re-vitalize Mayan traditions. They develop new social networks, extending beyond trad-itional family ties, which give them support. This happens through weaving activities. The weaving of cloth has always served to transmit traditions and values from the past to the next generation. Now, women reconstruct through the weaving process a feeling of identity and community life. Through their weaving they also find temporary emo-tional relief. This all happens despite recent development projects, which bring about cultural alienation through their disintegrating effect on daily routines, family struc-tures and indigenous identity. One also finds a new way of developing social ties and social support networks through alignment with new fundamentalist religious move-ments (cf. Tankink 2000 & Pfeiffer 2002 for a description of similar developments in respectively Uganda and Mozambique). That means that the progressive Catholic church in Guatemala, which has always fought for social justice, has had to surrender territory to a Christian fundamentalism that could be seen as a very conservative move-ment, in which one has to surrender to authority and in which collective identity and social actions for justice are undermined. The Pentecostal churches, however, do give space for the collective expressions of suffering through catharsis. The widows find in these churches a certain degree of mutual trust, cooperation, community feeling, dig-nity, and a feeling of justice. In addition, they can integrate parts of their traditional cosmology into a new cosmology. Thus, they make syncretistically use of various sources available for remaking their world.

The question Green does not raise, but which is very topical in international hu-manitarian governmental and non-governmental organizations that want to contribute to healing and peacemaking in so-called post-conflict countries like Guatemala, is if and how Western human rights and trauma rights programmes can relate to indigenous strategies for peacemaking and healing (cf. e.g. Foxen 2000; Manz 2002).

Justice and healing

The restoration of a sense of justice and the coming to terms with the events of the past appear to be central elements of healing from the wounds of organized violence. Peo-ple’s post-traumatic symptoms after war are not just a private and individual problem, but also an indictment of the social context that produced all sorts of injustices (Richters 2001a). The language of human rights is increasingly used as a vehicle to reinstate justice and thereby contribute to healing. In countries around the world, including Guatemala, truth commissions have been established to confront the massive human rights abuses suffered in those countries. These commissions link together complex ideas about suffering, justice, human rights, history, witnessing, accountabil-ity, forgiveness, reconciliation, and healing. A rhetoric about healing has accompanied many commissions’ work, with the powerful claim that truth heals the individual and social body (Amadiume & An-Na’im 2000; Hayner 2001; Wilson 2001; Hastrup 2003; Ross 2003). South Africa provides a powerful example of the use of biomedical and psychological metaphors in describing the work of the Truth and Reconciliation Com-mission (TRC). But, as critiques argue, the very idea that individuals and nations can heal and ultimately recover from violence falls prey to inappropriate and impoverished medical and psychological metaphors. This history of human violence teaches us that there are few happy endings (Scheper-Hughes & Bourgois 2004: 27). Another fre-quently made criticism of the work of the Commission is that talk of reconciliation and of restorative justice has side-tracked the legitimate demand for redistributive justice (Wilson 2001).

Meanwhile a basic forceful critique of the rise of human rights as the main univer-sal standard against which to judge violence and suffering has been formulated. Hastrup (2003), for instance, argues that rights-based conceptions of justice distort our understanding of suffering and pare down social and moral narratives. Legal language instrumentalizes, cutting out the symbolic and expressive dimensions of violence. In-stead of giving voice to people, victims of violence are often silenced by truth commis-sions. In her study of the South African truth commission, Ross (2003) demonstrates the paucity of mechanisms the commission had available to give voice to suffering and receive acknowledgment for it. Another language of social suffering than the legal one, she argues, would be needed to permit the expression of the full range of experiences, admit the integrity of silence, recognise the fragmented and unfinished nature of social recovery; a language that does not presume closure (p. 165).

Hastrup (2003) further raises the question whether the particular claim to justice of human truth commission contributes to the remaking of the world, or whether the rights-based thinking implied actually distorts the nature of social and individual suf-fering by translating ‘thick’ moral (and political) problems into ‘thin’ legal representa-tions. This translation happens also in, for instance, legal reports of asylum seekers claims for asylum. The destruction of language in this kind of reporting may be closely related to the destruction of the selfhood of the asylum seeker.

While public discursive spaces in the form of truth commissions and war crimes tri-bunals for healing have been created in many countries, governments in other countries have shifted hurt out of the public domain. In post-war Nigeria the underlying premise was that healing of post-war trauma can be done socially, and that the practice of such healing takes place at the level of the community (Last 2000). Also in the Mozambican case the deafening silence of the state has rendered intersubjective healing through public dialogues about a painful past state exceedingly difficult (Hayner 2001, West 2003). In Mozambique traditional healers contribute to healing the wounds of the past. In healing ceremonies, it is the spirit who decides how justice and reparation can be achieved in order to restore the health of the patient and her family (Honwana 1998; Igreja 2003). Similarly in Sri Lanka, justice in the secular and legal sense has not yet been achieved. Instead the possessions and ghost stories have given people an oppor-tunity to express their hatred as well as expectations of justice and revenge in a socially and ritually accepted fashion. Lacking a secular system of law, the justice of the deity is invoked (Perera 2001).

In Rwanda one has adopted a middle course. The government came to the conclu-sion that the regular judicial system could not answer the justice problems Rwanda was facing and came with a proposal of a unique Rwandan alternative: the Gacaca tribu-nals. They stand for a new system of participatory justice: a kind of reinvented trad-itional ways of community based conflict resolution, in which society at large would participate. The future will tell whether this hoped-for instrument of alternative justice will reach the goals set, and whether it will contribute in any way to healing the wounds of the past.

Hastrup (2003) observes that ethnographies of cruelty show that violence is rarely represented in terms of violations of rights. This may change in the near future. It could be that one does not find that representation in ethnographies. Working for a violence against women project in Tajikistan, however, I learned that for the many abused women in this country it can be a relief to learn that something like ‘human rights’ ex-ists and that the human rights framework can be used to fight against gender violence (Richters 2001b, 2002a). It is not unlikely that women’s voicing on these issues may be represented in future ethnographies. In line with Ross’s observations with regards to testimonies for the TRC in South Africa (2003), Foxen in an article on Mayan narrative of remembrance and forgetting in Guatemala (2000: 378) writes that the silences, ambivalences, syncretistic discourses and contradictions of Mayan narrative style and traumatic memory are not indulged in courtrooms. She points to the cacophony of voices in the process of recovering a collective memory of the violence for the purpose of healing and re-entering history after decades of fear and silence. There is still a cleavage between ambivalent, shifting memory processes and the more coherent his-tories necessitated by urgent political processes. At this point Foxen makes use of the human rights framework in her theoretical, action- or policy-oriented analysis of a par-ticular social transformation, as promoted by Messer (1993) (see above).

Memory and healing

Violence is not only experienced in bodies but also in memories. In her ethnography on violent memories among Mayan K’iche’ war widows in Guatemala, Zur (1998) interprets the entire history of la violencia in that country as a war against memory. The military state attempted in various ways to deny people access to truth. Forced to ‘for-get’ the episodes of violence the Mayan women witnessed and experienced and to repress pain caused by their losses, the women’s pain re-emerged as physical pain. Like the Mayan widows in Green’s study (see above), the K’iche’ widows have em-bodied the painful experiences they have been unable to articulate as a result of being silenced and of the non-narratability of atrocious experiences. Knowing what not to know has become a major coping response to terror. The past is produced through pri-vate memory and, as such, can be distinguished from the dominant memory which is produced through ‘public representations of history’.

Zur’s case study raises a problem that has a wide significance (cf. e.g. Tankink 2004). How does remembrance take place in post-conflict societies when forgetting seems an act of salvation, when silence is still experienced to be the best survival strat-egy? How is the past retrieved when powerful social institutions, individual actors and the fallibility of memory itself all conspire to redefine what took place? The K’iche’ women eventually succeeded in surpassing the silence enforced by the state and did re-tell and rework their memories in an attempt to resolve them. Constructing narratives collectively is for them a means of coming to terms with the events of the past and inte-grating them into their lives in a way which makes sense in the present. Zur (1998: 171) describes this process as a creative and a healing one, a process that makes the un-known known and less frightening. Memory, however, is tangled in trauma, and unrav-elling the tangle can itself be traumatic. This raises a central question in ‘trauma ther-apy’ on an individual as well as social level: when, how and to what extent should the past be sealed or re-opened in order to be able to work towards a better future. And how do memory constructions on the level of an individual, a group and the state relate to each other? (cf. e.g. Antze & Lambek 1996; Van Dongen 2004a).

Various authors in the book by Das et al. (2001) on ‘remaking the world’ address the relation between collective memories and individual memories, highlighting the disjunction between public culture, official memories, and the ‘sensory’ memory of in-dividuals. Two themes stand out in their work, that of contesting the history of official inattention to individual and social suffering and that of using the sensory memory of individuals to challenge the official memory created through the official record. The is-sue raised in various critical writings on the work on truth commissions, however, is precisely that memory construction through the official record takes place that does not permit the expression of a range of sensory memories, particularly not those of women as Krog (2001) and Ross (2003) demonstrate for South Africa. But not only the stories of women as victim’s did not become part of the collective memory. Older people did suffer from the system of apartheid and some of them were actively involved in the struggle. But many of them do not belong to one of the two groups – perpetrators and victims – that were so clearly distinguished in the work of the TRC. They were ‘by-standers’ and as such neglected in the national fabric of commemoration during the TRC sessions (Van Dongen 2004b).

Collective memory influences, positively or negatively, attempts to healing ruined memories and procure social justice in post-conflict situations. This raises the question of how therapeutic interventions relate to collective memorizing. How, for instance, can therapeutic interventions initiate changes in shared psychological states of trauma-tized persons in a way that the hegemonic collective memory that keeps the cycle of violence going is challenged? Narratives, including those constructed in therapies, can keep the memory of former conflicts alive in stories, either by glorifying one’s own group’s achievements and benefits or by the perceived injustice, losses or suffering in-curred by one’s own group. This type of social memory can be easily capitalised upon by state elites and elaborated into a hegemonic ideology of violence. Volkan (2000) suggests that there is a special role for mental health workers in breaking the cycle of the traumatized and traumatizing society. NGOs that deal with traumatized societies need to recognize the shared psychological problems and maladaptive societal changes that may lead to future conflict because of transgenerational transmission. Children of parents traumatized by ethnic or other large-group conflicts may see it as their task to keep the ‘memory’ of the parents’ trauma alive, and to take revenge on their behalf. Therapeutic interventions and ‘psychopolitical dialogues’ are needed to break that cycle of revenge. This kind of preventive public health work is by necessity long-term work. The question is also when to make a start with it. Setting up a ‘trauma pro-gramme’ in besieged Sarajevo in 1994 for MSF I tried to pay attention to the preven-tion of further trauma in the training of counsellors. It did not work. Most trainees, being involved in day to day survival and never having learned to reflect critically on one’s own history, were not ready for it (yet). Only now, ten years later, I am told by some of them, is the time ripe for this kind of work.

The anthropologist Kidron (2003) gives in an ethnographic case study of the cul-tural construction of trauma descendant identity a critical analysis of this construction. In a support group of descendants of Holocaust survivors participants narratively re-emplot their life stories as having been personally constituted by the distant past. The discursive practices of the support group are ultimately carriers of memory to both sus-tain and revitalize historical grand narratives and the cultural scenarios they embed. Kidron argues that the potential of illness constructs as a collective mnemonic tool must be further explored. Future research may also explore group memory work as ex-panding its cultural horizon from tales of individual distress to tales of collective catas-trophes and collective identities in the making. Considering the globalization of West-ern trauma therapies based on the post-traumatic stress disorder (PTSD) psychiatric concept to conflict-ridden areas around the world, the questions raised by Kildron are pertinent. For her the conjunction of the person-centered psychological illness con-struct with a collective commemorative agenda raises perhaps the most interesting questions. The final concrete question that resulted from her ethnographic study is whether culture-specific concepts and healing practices from around the world have merged with imported PTSD therapies to allow for recovery and closure, or whether global trends in memoropolitics have brought about an evolution of the concepts of healing, witnessing and survivorship to produce eternally wounded survivors of distant pasts, and, I would add, an accompanying eternal lust for revenge. Another side of the coin is that the globalizing Western posttraumatic stress disorder (PTSD) approach to memory also can contribute to selective forgetting, the forgetting of social suffering, collective responsibility and guilt (Van Dongen 2002). The role of the various kinds of trauma healing (the ‘working through of trauma’) that take place around the world in the politics of remembering and forgetting is one of the issues that could be further ex-plored in medical anthropological research.

Torture, suffering, healing and refugee medicine

Another under-researched area is the socially embedded forms of narrative and moral recognition of various kinds of suffering vis-à-vis the universalistic human rights ap-proach of suffering. Let me illustrate what is at issue by focusing on torture. Torture as an exercise of power `unmakes’ an individual’s world. Only through verbally express-ing the inexpressibility of the pain caused by torture can the world be `made’ again (Scarry 1985; Gibson 2003). According to Article 5 of the Universal Declaration of Human Rights torture is a violation of human rights. The article states that “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punish-ment”. Asad (1999) is skeptical, intellectually, not morally, about univeralist dis-courses that have been generated around this phrase. The universal rules enshrined in the Declaration cover a wide range of qualitatively different kinds of behaviour. The phrase ‘torture or cruel, inhuman, or degrading treatment’ serves today as a cross-cultural criterion for making moral and legal judgements about pain and suffering, while it serves much of its operative sense historically and culturally. In the West we have not only a rather uniform idea about torture but also about the long-term negative effects on the psyche of the tortured individual (Summerfield 1997).

In line with Asad’s argument, more anthropologist nowadays conceptualize in crit-ical opposition to the disengaged self of human rights, a more socially embedded and dialogical understanding of the self in their ethnographic studies on human rights (Wil-son & Mitchell 2003). The idea is that ethnographic inquiries are necessary to clarify our transcultural judgements on torture and inform human rights and (public) health care interventions. Torture as a form of organized violence can be deeply symbolic, embodying a cultural patterning (cf. e.g. Zarkov 2001). It can also be differently expe-rienced subjectively, in part determined by the socio-cultural context in which it takes place. Not only can the same act of torture, such as rape, have different functions and meanings depending on the type of conflict and the cultures of the warring parties (Richters 1998), but there also seem to be culturally favoured forms of torture in differ-ent societies. Not all methods are used everywhere. Countries differ in whether one uses, for instance, falanga (the beating of the soles of the feet), electric shock, or torture by machetes. The latter happened in Rwanda. Taylor (2002) explains that patterns of many of the horrible acts during the Rwandan genocide must be at least partially ex-plained in terms of local understandings of blockage and flow. Rwandan conceptions of the body are frequently structured in terms of a root metaphor or (orderly) flow and (disorderly) blockage. Health and well-being depend upon properly bodily flow. In a variety of other domains blockage signified the antithesis of order, an obstruction that had to be removed to ensure personal and communal well-being. Hutu perpetrators dis-played a tendency to carry out their brutal deeds in terms of this cultural idiom. These deeds included to mark Tutsis as blocked beings, by, for instance, severing Achilles tendons, genital mutilation and breast oblations, impalement from anus or vagina to mouth, and compelling Tutsis to rape and forced incest. Rwandan refugees who sur-vived somaticized their ordeal by expressing these various modes of obstruction that made sense to them in terms of Rwandan cultural experience. This and other studies about embodiment and subjectivity regarding torture illustrate the utility of medical anthropological inquiries for addressing larger political debates about human rights (cf. also e.g. Adams 1998, and other contributions to Green 1998).

Like so many aspect of organized violence, also torture is in many ways ‘gendered’. Since the war in the former Yugoslavia sexual torture of women as a war strategy – its gendered functions, meanings and consequences – has been extensively documented. Much less is known of the gender aspects of torture of men, particular of sexual torture. Peteet (1994) described how torture of Palestinian men during the intifada by Israeli’s with the intent of humiliating has been reversed by the men in question into one of honor, manhood, and moral superiority. Marks on the body, though certainly un-wanted, signalled a resistant, masculine subjectivity and agency. Once the occupying authorities understood this reversion, interrogation procedures started to contain a sex-ual practice designed to thwart the meaning and agency of physical violence as rites of passage into masculinity and manhood, violating the intimated realm of gendered self-hood. Out of shame, knowledge of this sexual torture may not have circulated so widely within the communities of the tortured men as other forms of torture. By silenc-ing the sexual part of the torture, men can still be seen by their communities as heroes who survived, while women who experienced sexual torture – despite efforts to hide the experience the community they belong to usually knows what happened – from whatever group are usually seen as victims, and commonly ostracized by their commu-nities in one way or the other. It remains to be seen what role will be assigned to the Iraqi men imprisoned by the Americans who were shown naked on television screens around the world in the spring of 2004, in case they will be allowed to return to their community. For these men, the exposure of their naked bodies is the ultimate humilia-tion, worse than torture.

That the meanings ascribed to experiences of sexual violence, on a collective and on an individual level, are reconstructed dynamically and refer both to symbolic ma-terials from the culture of origin and to the new conditions of existence experienced by refugees in exodus, is illustrated by Atlani and Rousseau (2000) in their study of female Vietnamese refugees with experiences of sexual violence. It is obvious from a medical anthropological perspective that the cultural construction and its dynamism should be taken into account in health interventions. What is important to recognize thereby is that refugeedom in a country with a distinctly different culture brings con-tact with different sets of meaning assigned to particular life events, such as torture. Kurdish men who at home experienced their maltreatment during interrogation in police stations, partly in terms of their capacity to endure and resist, can find their expe-riences reinterpreted in toto as torture in the country of exile, as an abuse of human rights that can have negative effects on their health (Summerfield 1997). An appropri-ation of this interpretation can help asylum seekers to get a refugee status, but whatdoes it mean for their earlier perception of themselves, their capacity to feel whole and effective? Within refugee medicine there should be space to consider these and similar questions.

By now there is ample evidence that actual concerns of survivors of human rights violations such as (sexual) torture, are much broader and inclusive than perceived from the perspective of a medical or psychiatric paradigm (cf. e.g. Cense 2003; Kagee 2004; Dekker 2004). The various types of chronic suffering asylum seekers and refugees ex-perience are mediated by political-moral-psychological processes of diasporic coping created by fundamental cultural transformations in their country of origin, in their own cohort, and in their host country. Particularly salient is the usual ‘indifference’ by the host culture and its bureaucracies toward the cultural other and his or her search for affirmation (Daniel 1999; Ong 2003). This raises a number of dilemma’s for health pro-fessionals, one of them being whether it is their duty to act as an advocate of human rights, or whether that is beyond the scope of their professional duties (Richters 2002b, 2002c). For (medical) anthropologists it raises the question if and how, based on (their) ethnographic work on suffering due to organized violence and asylum policies, to contribute to larger political debates about human rights (cf. e.g. Wikan 2002).

Methodological issues

As the body of research on the anthropology of violence and terror grows, so too grows the frequency with which anthropologists are thrust or are thrusting themselves into dangerous fields. In these fields customary approaches, methods, and ethics of anthropological fieldwork may be insufficient, irrelevant, inapplicable, imprudent or simply naïve. What are needed are updated field strategies. Based on fieldwork experiences of anthropologists who have conducted field research in dangerous circumstances (cf. e.g. Nordstrom & Robben 1995), Kovats-Bernat (2002) outlines a pragmatic strategy for dealing with threats to the safety, security, and well-being of anthropologists and informants who work amid the menace of violence.

A methodological problem of a different nature is the unbridgeable gap between the theoretical models at our disposal and the unfathomable depths of human suffering. Traumatic events are per definition incomprehensible because partial forgetting is a defining characteristic of trauma. And what is remembered may be silenced because it is unspeakable, to painful to tell, or culturally and/or politically silenced (cf. e.g. Sheriff 2000; Todeschini 2001; Ross 2001; West 2003). Anthropologists, however, may have ‘the privilege’ to break this silence. As one of West’s informants told him: “Only someone like you can get at this history – only someone from outside” (West 2003: 356). West gathered life stories of men who had been the victims of torture at the hands of the Portuguese during the Mozambican war for independence. Decades after their experience of violence, West as an outsider created the opportunity for them to finally ‘whisper’ about their ordeal to him as a foreigner. He openly writes about the feelings listening to the stories of his informants left him with, feelings of exhaustion, bewilderment, outrage, revulsion and confusion. Having chosen to conduct research in an area of Mozambique only marginally affected by the civil war, West was unex-pectedly drawn into the topic of violence and suffering. Like other anthropologists in similar situations, he hesitated to ask questions, fearing that he might be forcing these men to relive the violence once done to them. At the same time, however, he sensed that his failure to appropriately acknowledge the accounts these men shared might con-stitute another form of violence against them. Nevertheless, it took him some time to decide what to do with these narratives, whether retelling them yes or no, to whom and with what purpose. Here we are confronted again with the issue what the public role of the anthropology of violence can and should be. How can anthropologists contribute to overcoming various states of denial, whether by victims, perpetrators or bystanders (Cohen 2001). Denial can be found on the level of individuals, groups of people, or governments; governments who are responsible for atrocities or deny their responsibil-ity to intervene (cf. (Cohen 2001).

In contrast to West, Hatzfeld (2004), a war reporter for decades, deliberately held in-depth interviews with men involved in the war in Rwanda in 1994, not as victims but as perpetrators. The result gives us a fascinating but distressing insight into the psychology of the perpetrators, in the banality of evil or evil of banality, in the unimagin-able, and in the reasons behind it. Trying to understand what happened in Rwanda is a painful task, which, according to Sontag (2004), we should not avoid; not if we are adults with a conscience. How to address that conscience as a medical anthropologist?

Medical anthropological studies up to now have focused mainly on the victims of violence; on the suffering as a consequence of violence and the various ways to deal with the suffering. The strength of many of these studies – and this also applies to the study by Hatzfeld – is their phenomenological descriptions. One of their weaknesses is that they may reinforce a tendency to abdicate efforts to comparative explanation. The volumes by Aijmer and Abbink (2000) and Schmidt and Schröder (2001) are explicitly aimed at the theorizing of violence from historical and socio-cultural comparative per-spectives, focusing thereby in particular on respectively the historical conditions which tend to generate or stimulate violence and the experiences of violence as repre-sented differently by perpetrators, victims and observers. While most theories on the causes, meanings, and consequences of organized violence come from history, psychology, psychiatry, psychoanalysis, theology, comparative law, human rights and political science, recently (medical) anthropology, gender studies and public health can be added to this list. What is specific to anthropology and gender studies is that they try to develop an integrative perspective in their theorizing.

In the medical anthropological work discussed above a number of theoretical issues stand out. They include, I am not exhaustive, linkages between complex ideas about suffering, justice, human rights, history, witnessing, accountability, forgiveness, rec-onciliation and healing; culture and the universality of human rights; the meaning of socio-cultural healing and the re-creation of the ‘normal’; the relation between collec-tive memory, individual experience and healing; the creation of an alternative public space to counter the silence created by state-sanctioned narratives for the sake of healing; the recovery of voice after trauma and tragedy; the role of religion and justice in healing; the embodiment of violence; ethical issues and the (public) role of the anthropologist concerning social reform aimed at the promotion and protection of human rights. What (medical) anthropologists have to offer in particular to theory develop-ment is their empirical work done in various cultures and the cross-cultural perspective derived from it. The focus of medical anthropology on suffering in relation to all sorts of violence, however, is very recent, which means that only a few first steps have been made on the road to theory development concerning the multifaceted area of issues at stake. Precisely because the previous neglect in anthropological studies of attention for the suffering of victims of violence from their perspective, ‘experience’ as the most au-thentic form of knowledge was privileged in medical anthropological writings at first. Gradually, however, a move has been made to address issues of violence, health and human rights also from more objective, historical, institutional, structural and comparative perspectives. 

Concluding remarks

In this article I have sketched the contours of violence as a health and a human rights issue as a study area for medical anthropology. The subject itself has no clear boundar-ies. It is also difficult to determine which of the literature I have used in approaching the subject can be labelled as medical anthropology and which not. Because the subject area covers a wide range of phenomena, which can all be thematically approached from a multiplicity of angles I had to be very selective in what I presented. I started with a quote from Mandela, in which he mentions some of the forms of violence which are prevalent in today’s world. But there are many more. My primary focus has been organized violence. Within that context I did pay attention to only a few relevant gender differences, but hardly considered other kinds of differences, such as differences in race, class and age. I only briefly referred to the elderly (cf. also Ferreira & Van Dongen 2004), but did not discuss particular problems of children, such as child sol-diers, and adolescents (cf. e.g. Honwana & De Boeck 2004; Lindegaard & Henriksen 2004). What remained also underexposed are “the small wars and invisible genocides” (Scheper-Hughes 1996) daily enacted by ordinary citizens in the homes, workplaces and on the streets (cf. e.g. Wattie 2004). Furthermore, there are a number of commonal-ities in the experiences of rape survivors and combat veterans, battered women and political prisoners, the survivors of vast concentration camps created by tyrants who rule nations, and the survivors of small, hidden concentration camps created by tyrants who rule in their homes (Herman 1992) and parallels between the patterns of everyday domination and aggression during times of peace and war (Olujic 1998), which all ask for investigation. I have not addressed AIDS as ‘man-made holocaust’ or as ‘geno-cide’, nor the effects of the recent waves of international terrorism and feelings of in-security they provoke in the Western world. The list is long. The reader may have noticed that I also was selective in the kind of health problems I focused on. I had more attention for mental health problems, than for problems such as injuries due to land mines, and reproductive health problems due to sexual violence. In the symposium planned for December 2004 there is space to address all these issues and more.

The body of medical anthropological literature on violence, health and human rights is rapidly growing. I did refer in this article to the work I know that is done in this field by Dutch (medical) anthropologists, (medical) anthropologists from abroad who are somehow affiliated with institutes in the Netherlands, and public health specialists with an interest in anthropology. Most probably I have forgotten relevant contributions made to the field outlined in this article by Dutch and Belgian colleagues. This article is meant as an invitation to all of them to present their work in the symposium for discus-sion. I particularly welcome contributions to the necessary theory development in the field. Because ‘violence’ is also a relatively new topic for medical anthropologists in the Netherlands and Belgium, and the number of anthropologists focusing on it in their work seems relatively small, the theme of the symposium is on purpose not narrowed down to specific aspects of ‘violence’. Nevertheless I hope I have given some direction for the kind of contributions we would like to bring together. As a side effect, the sym-posium may give us a clearer idea what it is precisely that medical anthropology has to offer to the multidisciplinary field of ‘violence’ as an issue of health and of human rights.

Note

Annemiek Richters is professor of Culture, Health and Illness at the Leiden University Medical Center. E-mail: J.M.Richters@lumc.nl

I thank Marian Tankink for her comments on a draft of this article.

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