«We condemn violence wherever it may come from», goes one of the most frequently used slogans of the past few years. But have those who use it considered the possibility of so-called «structural violence» on behalf of the Greek state towards its citizens?
It is true that the term structural violence is difficult to quantify. Yet this does not mean that one could not apply criteria in order to determine whether or not it is present within a certain state structure or not. The term structural violence was coined by Johan Galtung to describe «[...] the social structures – economic, political, legal, religious and cultural – that stop individuals, groups or societies from realizing their full potential[...]».
This definition has been used among other by physician and anthropologist Paul Farmer, to describe those structures in health care which, not taking account of social factors affecting care, adversely affect the spread of diseases. Farmer bases his argumentation in part on the Declaration of Economic and Social Rights, thus highlighting the legal obligations of states to uproot violent structures. Let us not look at a few examples of recent policies in the Greek National Health System, in order to determine whether health care service users in Greece are victims of structural violence.
Example #1: The reintroduction of the regulation first introduced by Andreas Loverdos in early 2012 regarding infectious disease control (for a brief discussion of the topic, see here: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61546-9/fulltext). Even those who do not know anything about the basic principles of social medicine will concede that this particular policy is aimed at stigmatising marginalised groups. In addition, the regulation goes against medical ethics, in that it denies the right of the patient to confidentiality and to service provision regardless of gender, ethnicity, political belief, occupation, etc. A quick comparison between the effects of this policy and the definition of structural violence provided above shows that the reintroduction of this particular regulation creates a social structure which, instead of providing care to the most vulnerable groups, instead creates what it supposedly aims to prevent, namely an «unsanitary bomb» International condemnation, including by official public health authorities of the European Union negates the Health Minister’s recent comments, according to which «[...] international institutions have no authority to determine the constitutionality of decision making in Greece [...]»[...}» when in fact member states do have an obligation to comply with EU guidelines.
Denying service provision based on the ability to pay should not be a factor affecting the decisions of the physician, who is currently asked to serve a violent structure which denies service users the right to «realize their full potential»
Example #2: The downgrading of hospitals and specialist treatment centres to Health Centres, which was made known at the time of writing, further restricts access to services, and once again stigmatises the vulnerable, since a hospital for infectious diseases and the Institute for Research on Thoracic Diseases and Hygiene and Work Safety are among the six hospitals which will be downgraded. The rise in infectious disease incidence during the Greek crisis, including the reemergence of malaria and tuberculosis is well documented. What remains unclear is the strategy to tackle the spread of these diseases, which is unheard of for a developed country. Therefore the downgrading of specialist centers for these diseases under these circumstances is absurd at the very least. If we also take into account the high numbers of uninsured, who avoid or postpone visits of health care facilities due to cost, then it becomes clear that this is a case of violent exclusion of part of the population from the Health system, especially since there is overlap between those classed as vulnerable and those suffering from infectious diseases such as HIV, malaria and tuberculosis.
Example #3: Perhaps the most striking, yet little discussed, challenge for the welfare state of Greece today is the exclusion of the uninsured from health care services. Unfortunately this may be due to a selective interpretation of what the term insurance means. Insurance should not be an individual relationship between each insured person and the insurance body, but the distribution of aggregated insurance contributions in such a way so that access to health care services is guaranteed for everyone and everywhere. With this in mind, and ignoring arbitrary numbers set by the troika, according to which health care spending must comprise 6% of GDP when in fact the EU average is 9%, it should be theoretically possible to define at least a «basic package» of services for the uninsured, among which are many unemployed who until recently regularly paid social insurance contributions. Denying service provision based on the ability to pay should not be a factor affecting the decisions of the physician, who is currently asked to serve a violent structure which denies service users the right to «realize their full potential».
Certainly, violent attacks against unpopular ministers do not achieve any goal except to legitimize the propagation of violent policies, since violence does not offer alternatives. Therefore the solution for structural violence is not violence against individuals; it is the exercise of pressure towards the creation of a National Health System worthy of its name.