Guest post by: Catia C. Confortini (Wellesley College), with Tiina Vaittinen (University of Tampere)
This week we post a two-part piece based on a paper presented by Dr. Catia Confortini in Dakar, Senegal during the annual CIHA Blog Conference in December 2017. Finding that there was little engagement between Peace Research (PR) and questions of global health and feminism, the author, together with Dr. Tiina Vaittinen (University of Tampere, Finland) concluded that bringing together feminist PR and global health scholarship has the capacity to enrich both scholarly traditions. This paper represents a brief summary of their working conceptual framework with evidence drawn from Dr. Confortini’s research thus far. A different version of the arguments presented here will be published as the introduction to a co-edited volume entitled Gender, Global Health, and Violence: Feminist Perspectives on Peace and Disease (Rowman & Littlefield 2019). Today’s post examines the notions of structural violence and slow violence, especially in the context of breast cancer advocacy in Nigeria. Stay tuned later this week for the second part of this piece which turns to the concept of epistemic violence before exploring the concept of “slow peace.”
Breast cancer is the most prevalent cancer for women in Nigeria as well as the deadliest. It has the highest incidence (almost 51 Age Standardized Rate (ASR)) and very high mortality (almost 26 ASR). Research suggests there has been a sharp increase in the past 10 years or so in the incidence of breast cancer. There are also important comparisons in incidence and mortality between the global North and South; the risk of dying from the disease (the WHO calculates it as “cumulative risk”) in Nigeria is double that of Norway, for example.
Global health organizations often refer to the rising burden of cancer in the global south, since cancer is predicted to surge from an estimated 14.1 million new cases in 2012 to 20 million in 2025. By 2020, 70 percent of breast cancer cases worldwide will occur in the developing world with disproportionately high rates of mortality. Not only are women dying in proportionately greater numbers, but due to a number of reasons, not least the unavailability and/or unaffordability of drugs, including anti-emetics, pain medication, and palliative drugs, patients are also physically suffering disproportionately compared to those in global north.
The most populous country in Africa as well as Africa’s biggest economy, Nigeria is also the site of local breast cancer activism that pre-dates the surge of global health and transnational advocacy organizations. At least three domestic advocacy/awareness organizations are over 20 years old; other local organizations have emerged more recently. These organizations have some lessons for our understanding of the intersections between global health and peace research.
Peace Research is an academic field primarily concerned with the elimination or reduction of violence in the world. Violence in Peace Research is understood as having multiple forms. Global Health rarely speaks in terms of violence, but we see instead how such a focus could be of use to this field, particularly when employing feminist lenses. A feminist focus on violence allows us to direct our attention to embodiment and the enactment of harm, putting the emphasis squarely on the victims of violence. But a feminist approach to violence also rejects the gendered simplistic opposition between victim and agent, where one who is a victim is also passive and without agency of her own. A feminist peace research approach recognizes that victims of violence also have the capacity and inventiveness, the resilience, and creativity to live through and despite violence, responding to violence even in contexts where their agency is restricted. It also looks to uncover the resources, cultural or otherwise, for such creativity and resilience. In both critical feminism and peace research, understanding the power of critical methodologies is especially important if our goal is to get closer to more just and more equitable societal relations.
This post is based on insights from field work in Nigeria in October/November 2016 and May 2017, as well as in Ethiopia (for a conference on cancer in Africa), Geneva (WHO and UICC) and Paris for the World Cancer Congress. I also conducted interviews or participant observation with global health officers, oncologists, breast cancer advocates, activists and some patients.
My argument hinges on the articulation of the linkages between three forms of violence (structural, slow and epistemic). In what follows, I explicate these different forms of violence, and drawing from the practices of breast cancer advocates in Nigeria, I bring feminist insights on embodiment into each, in order to understand aspects of social and political realities that are not obvious until we think of bodies. I want to clarify also I do not understand these different forms of violence as separate and discrete “levels of analysis.” They are injustices that are deeply entangled in the actual embodied empirical realities of life and its governance. I use them as heuristic devices, whose lines of separation are not clean, but which help us probe more deeply and, through a feminist method centered on the body, identify strategies to address them.
Structural Violence
When it comes to breast cancer in Nigeria as well as the global south more in general, structural violence is the most obvious form of violence, and it is also, if perhaps implicitly, talked about by the global health literature. The absences of adequate breast cancer care in Nigeria must be understood in the context of post-colonial history, neoliberal economic policies dictated by global financial institutions, and a global health governance system that is subjected to both biomedical and neoliberal demands of governance emphasizing cost-effectiveness, and liberal individual self-care. But the inadequacy of health infrastructure and human resources, however, is not what causes the ‘breast cancer epidemic’ in Nigeria (or elsewhere). Oncologists and breast cancer organizations in Nigeria respond to the immediate needs they face every day with the resources they have, “improvising medicine” and care, as anthropologist Julie Livingston put it referring to cancer care in Malawi. But one must not forget that the cancer crisis in Low- and Middle-Income Countries is partially a result of externally imposed Structural Adjustment Programs since the mid-1980s, which disrupted health systems as well as a burgeoning pharmaceutical industry. It is also the result of post-colonial development models that favor rapid industrialization with little to no environmental regulation. All of these can be seen as sources of structural violence, which contribute to poor outcomes for breast cancer patients and also limit the options for women living with breast cancer.
Nigerian breast cancer patients’ bodies matter to individual carers, but the system is structured not to care about them in ways that make sense for them. In other words, where global/local economic structures enable the wellbeing of some bodies and populations at the cost of others’ suffering, we see structural violence. So, what can an attention to bodies help here?
Breast cancer advocacy organizations in Nigeria are of course painfully aware of structural violence, whether or not they call it such. They are, however, concerned about what it does to women’s bodies. So, for example, some breast cancer organizations spend a considerable amount of their time and resources to provide prostheses, mastectomy bras, wigs, lingerie, even in one case a cold cap for chemo. They also provide “navigation services,” clinic accompaniment, bereavement services, as well as financial assistance to those in need. In other words, they attend to the bodily and emotional needs of the women they work with, in addition to addressing the financial hardships that result from unaffordability of care.
Some of the younger advocates make extensive use of social media for these efforts (Twitter Project Pink Blue). The vast majority of NGOs do a lot of “awareness raising” and “outreach.” Their advocacy efforts include “walks,” “bike-a-thons,” “marches,” etc., which they market as “awareness raising” efforts about breast cancer. But what do they mean in this context? One of my informants says that what they are doing amounts to “trivializing breast cancer.” In other words, they are trying to dispel the fear of cancer and portraying it as a disease one can live through (they do use the battle/war metaphor too, but that’s for another blog post), despite the lack of resources. Further, their “awareness raising” has a lot to do with exposing the inadequacies and failures of the state and health system, not directly and confrontationally or in abstract, but by raising the profile of breast cancer in Nigerian society and politics, through making the bodies of women who live with breast cancer visible. Breast cancer advocates simultaneously dramatize breast cancer for their public and global health audiences, while trivializing it for women who might be at risk of contracting the disease. These insights about embodiment point to the need to understand breast cancer in Nigeria not only as structural but also as slow violence.
Slow Violence
The articulation of the concept of slow violence (which emerges actually from environmental concerns) helps us understand how violence impacts bodies. In his book Slow Violence and the Environmentalism of the Poor Rob Nixon defines slow violence as “a violence that occurs gradually and out of sight, a violence of delayed destruction that is dispersed across time and space, an attritional violence that is typically not viewed as violence at all.” Slow violence, he says, is “neither spectacular nor instantaneous, but rather incremental and accretive.” It takes time to hurt, maim or kill. Slow violence challenges us to go beyond an understanding of violence as a drama and as a spectacle. In this regard the cancer “crisis” in Nigeria (as in much of the global south) is to be seen and analyzed as slow violence, that is “somatized into cellular dramas of mutation that—particularly in the bodies of the poor—and remain largely unobserved, undiagnosed, and untreated.”
Going back to Nigeria, the increasing numbers and staggering mortality rates of Nigerians (mostly women) from breast cancer can be seen as a form of slow violence: Only in the last decade and a half or so, for example, have global health organizations started to pay attention to NCDs, including cancer, in the global south. In fact, this on-surge of cancer has been contrary to earlier predictions, what was termed “the epidemiological transition”: people in “under-developed countries,” the theory went, die mostly of infectious diseases, and as they “develop” we will see a transition to NCDs, because people will adopt western life styles, live longer, thus develop diabetes, cancer, etc., and start dying less of infectious diseases.
In Nigeria, one of my interviewees (Dr. Okoye) complained that her organization’s numerous efforts to get WHO’s attention have yielded no results. To-date WHO has no breast cancer program in Nigeria. As a whole, at the World Health Organization’s Department of Non-Communicable Diseases, Disability, Violence and Injury Prevention, only two people are in charge of cancer. Neither has the Bill and Melinda Gates Foundation, who has an otherwise impressive presence in the country, but whose focus is on infectious diseases and, more recently, on cervical cancer. Another one of my interviewees, a US global health consultant who used to work for the Gates Foundation, told me that the only way she was able to get even cervical cancer on the Foundation’s agenda was through the connection with their vaccination program. In fact, cervical cancer seems to get the majority of the external funding so far. There is very little funding coming from outside organizations for breast cancer, or even cancer in general (other than cervical), with the exception of the Union for International Cancer Control and only a few others.
Slow violence also forces us to “foreground questions of time, movement, and change, however gradual.” One explanation that global health organizations give for the deadliness of breast cancer in Nigeria is “late stage presentation.” In other words, women die in such great numbers because they get to their doctors too late. The key to better survival rates is early detection, which offers greater options for treatment. But a focus on early detection does not explain why women get the disease (that would be the job of primary prevention), nor does it help decrease the suffering of women with advanced stage breast cancer. Their bodies are in effect invisible, as is the slow violence of breast cancer.
Recent feminist and critical literature on breast cancer in the global north warns us to be skeptical about the “myth” of early detection, as there are types of breast cancer that are deadly even when detected early. Feminist investigation again points to bodies: because of the conspicuous absence of research on breast cancer in African women and women of African descent in the global north, we don’t quite understand why breast cancer incidence in these women is rising so rapidly. Breast cancer advocates in Nigeria, on their part, call for clinical trials to be undertaken in Nigeria, as a way to both increase our understanding of the disease and its causes and a way to partially address the dearth of resources and treatment options for women at all stages of the disease.
Featured image source: Catia Confortini powerpoint presentation slide 4, Dec 2017.
About the Authors
Dr. Catia Confortini
Dr. Catia C. Confortini is Associate Professor and Co-Director of the Peace & Justice Studies Program at Wellesley College in Massachusetts (USA). She is the author of Intelligent Compassion: Feminist Critical Methodology in the Women’s International League for Peace and Freedom (OUP, 2012); co-editor (with Tiina Vaittinen) of Gender Global Health and Violence: Feminist Perspectives on Peace and Disease (Rowman & Littlefield 2019); and co-editor (with Tarja Väyrynen, Élise Féron, Peace Meadie, and Swati Parashar) of The Handbook of Feminist Peace Research (Routledge 2020). Her current interests lie at the intersection of feminist peace research and global health. This research was made possible by a postdoctoral fellowship by the American Association of University Women.
Dr. Tina Vaittinen
Dr. Tiina Vaittinen is a postdoctoral researcher in Peace Research Institute TAPRI at the University of Tampere. Her research seeks to integrate Feminist Peace Research with Global Health as well as Social Policy. Thematically, she works in the intersections of the (bio)politics of migration, old age care, and different forms of violence and peace. Her most recent interests include various tabooed questions to do with global health and faeces, such as incontinence care and faecal microbiota transplantation. Her book The Global Biopolitical Economy of Needs: Migration, Care, Ageing Bodies is due to come out with Rowman and Littlefield in 2019.