Structural Violence and Mental Illness
One of the greatest lessons we have drawn from our experiences in Haiti and the Dominican Republic is that mental health disparities occur within broader systems of structural violence. Mental health research and service provision in low- and middle-income countries cannot stop at clinical treatment; there must be a concomitant effort to dismantle the institutional and structural arrangements that lead to suffering in the first place. To address this topic, we will present work in the Dominican Republic, where we investigated the mental health of Haitian migrant workers (Keys et al. 2015). Experience of Haitian migrants in the Dominican Republic illustrate how social, political, and historical spheres come together to perpetuate subjugation and suffering, mental illness being just one example.
Structural violence refers to broadly operating social, economic, and political forces that structure risk for death and disease (Farmer 1996). As a theoretical construct, structural violence explores why certain groups suffer more disease or disadvantage than others. Suffering takes myriad forms: from ‘event-based’ assaults such as torture or rape to more engrained, institutionalized forms of suffering such as racism and poverty (Farmer 1996). Structural violence acknowledges that suffering is diverse and is disproportionately spread across the human population. In the face of such complexity, however, structural violence traces this disproportionate burden of suffering back to the unjust institutional processes that create and perpetuate it. Indeed, those institutional-level processes can range from the economic arrangements that benefit some people over others, to social and political forces that confer greater power and standing to some groups, even to ways in which disadvantage itself is explained or talked about: how do our socioeconomic privilege and historical trajectory influence how we understand and explain other people’s suffering?
Haitian migrants in the Dominican Republic, as well as Dominicans of Haitian descent, are familiar with disadvantage. To this day, the Dominican Republic, a country that originated from a Spanish colony, celebrates its independence from Haiti (won in 1844) rather than Spain (self-imposed annexation ended in 1865). This is a telling fact because it reveals how the Dominican Republic contrasts its national identity with that of Haiti’s, instead more readily embracing the identity of its Spanish founders. The distinction goes beyond nationality, however. Race and racism are deeply implicated in the two countries’ shared history as well and are embedded in the present-day experience of Haitian migrants.
When we consider how racism becomes institutionalized, the story of anti- haitianismo (anti-Haitianism) in the Dominican Republic provides a clear example. Dominican independence brought with it differentiation of one group from another: of one population defining itself in opposition to Haiti and all its negative tropes. This gave rise to attitudes among some Dominicans that Haitians are ‘more African’, have a different language, culture, and spirituality that is un-Christian and superstitious, and that they are determined to invade and conquer the entire island (Paulino 2006; Sagas 2000). In its most egregious form, anti-Haitianism was official State practice during the Trujillo dictatorship (1930-1961), culminating in the massacre of thousands of Haitians along the border region in 1937. The genocide has never been formally acknowledged as such by the Dominican government.
Anti-Haitian ideology differentiates Dominicans from Haitians on cultural and moral grounds and helps consolidate power over the Haitian and Haitian-descended minority in Dominican society. It is not only a discourse that moralizes against Haiti and Haitians but a political and economic structure that supports and justifies the exploitation of those minorities. The economic benefit of migrant workers from Haiti is well understood. In the early twentieth century, Haitian migrant workers were recruited en masse for work on sugar plantations, housed in batey communities, and employed as manual labor for a thriving economic sector in the country’s early history (Martinez 1999). Over time, Haitian migrant workers, seeking to escape poverty, political turmoil, and structural violence in their home country, have sought opportunities in other industries as well, including construction, rice and cacao agriculture, and tourism. Today, there are an estimated 500,000 to 1.5 million Haitians and Haitian descendants in the Dominican Republic, the vast majority undocumented, many of whom have lived in the country for two or more generations (Canales et al. 2009).
One of the most apparent ways in which anti-Haitianism operates as structural violence is through widespread denial of authorized documents to Haitian migrants and their descendants, the periodic stripping of citizenship and legal rights of Dominicans of Haitian descent, and round-ups and forced expulsions of Haitians or ‘Haitian-looking’ persons. The laws surrounding documentation of migrant workers in the Dominican Republic, and their interpretation and enforcement, appear deliberately obfuscated in order to create an underclass of exploitable workers.
In many of our conversations with Haitian migrants, they describe the profound insecurity that comes from not having documents, of having them arbitrarily confiscated, and the fear and uncertainty that accompanies such a life (Keys et al. 2015). For example, one Haitian street market vendor recounted how immigration authorities may demand proof of documentation, which is then sold to another Haitian migrant. In other accounts, research participants expressed their frustration at the impossibility of completing all required steps, and paying all necessary fees, to acquire documents legally. Lack of documents constrains upward mobility in the job market, leaving most in menial, low-paying jobs and engendering fear of apprehension should they leave their communities, even for medical care (Leventhal 2014). They are unable to organize or petition for their human rights easily, and as such live in communities that lack basic services such as water and sanitation and workplace or living standards (Simmons 2010). In short, a policy and practice of ‘non-documentation’ further pushes this population to the fringes of society. Keeping an entire population undocumented thus represents a form of institutionalized anti-Haitianism.
To examine how mental illness relates to these forms of structural violence, we need only examine the stories and explanations provided by Haitian migrants themselves. Imilyasyon is something felt by an individual, often one in a very low-paying, unskilled job. More than likely, this individual does not have authorized documents. Consequently, this individual lives in an isolated community with other migrants, probably without basic infrastructure or access to healthcare. Interactions with Dominicans may involve daily insults such as name-calling or overt discrimination in markets, the workplace, or healthcare settings. All of this occurs alongside fear of apprehension and expulsion by Dominican authorities. Furthermore, in the face of such difficulty, this individual may feel a sense of failure to meet expectations of family back in Haiti, who are perhaps relying on this individual for remittances. In short, life is precarious.
Structural violence sits at the intersection of economic and social forces that simultaneously disparage and exploit the Haitian minority; it is the racist, nationalistic discourse that blames Haitian migrants and their descendants for their problems. Our research findings point to ways in which Dominican society arranges itself to create disadvantage among Haitians and their descendants. One obvious impact of that arrangement is the effect on mental health, including increased depression and anxiety symptoms, feelings of worthlessness and humiliation, uncertainty, and the perception that such hardships in life are unavoidable (Keys et al. 2015). Structural violence not only ‘structures’ the conditions in which many migrants live but also shapes how an individual perceives those conditions, to the point that suffering itself is assumed to be inevitable.