Sunday, June 07, 2009

Bioethics of Poverty or "Structural Violence"

The greatest bioethics issue of today is the existence of economic and social barriers to health and adequate medical care. In the United States, with the lack of universal healthcare, these barriers are growing with the poverty rate that has the increased by 20 percent between 2000 and 2004 according to a National Health Survey conducted by the U.S. Centers for Disease Control and Prevention. (2) According to the same survey, more 40 million people of all ages in the United States went without health insurance in 2005.

Poverty and lack of insurance are structural barriers that deprive people of their health and, eventually, their life. Uninsured children in the United States are at a greater risk of experiencing health problems such as obesity, heart disease and asthma that continue to affect them later in life says Steven Woolf, a professor at the Virginia Commonwealth University. (3)

Dr. Paul Farmer, a physician and human rights activist in Haiti, calls these structural barriers of poverty “structural violence.” He defines structural violence as “Large-scale national and international structures that place limits on the ability of individuals to act in ways that protect their health.”(4) An example of structural violence is malnutrition. An estimated 842 million people in the world are hungry or are food insecure.(5)

According to the Universal Declaration of Human Rights, being healthy and having access to adequate medical care is not just an ideal for Americans. It is an entitlement for everyone worldwide, rich or poor.(5) Farmer believes this to be true and has devoted his life to treating the poor and fighting the economic and social barriers to health that continue hurt and kill them. These barriers are behind the current epidemics of treatable diseases such as Tuberculosis, AIDS, malaria as well as chronic illnesses such as diabetes in all countries among the impoverished according to Farmer.

Farmer condemns social scientists and medical ethicists who ignore this problem of poverty in developing countries. “Surely it is an ethical problem, for example, that in the coming year an estimated six million people will die of tuberculosis, malaria, and AIDS—three treatable diseases that reap their grim harvest almost exclusively among populations without access to modern medical care.”

Farmer goes on to say that these same social scientists who, in the course of their field research and analysis have observed the day to day suffering caused by poverty but have neglected to document it, or explore it, in their ethnographies, are not only unethical but are in fact may be committing “a human rights abuse.” (7) Farmer asserts that social scientists are complicit in the maintenance structural violence by the powerful elite if they do not document it when they see it. The struggle for social and economic rights is as much a social and political issue as it is a public health issue according to Farmer. (8)

But what can doctors and public health officials to counteract structural violence? As Farmer said himself, these human rights abuses are caused by “large-scale national and international structures”. Here are some recommendations from his book Pathologies of Power: Health, Human Rights, and the New War on the Poor for physicians and public health officials:

1. Make health and healing the symbolic core of the agenda. Farmer cites the example of the Physicians for Human Rights and their partner organizations, which have argued that access to care should be construed as a basic right.(9)

2. Make the provision of health services central to the agenda. Farmer recommends that health workers listen to their patients and partner with local community-based health organizations to figure out the best ways to bring care to those in poverty. Collaborations with people local to a community are necessary to address the increasing inequalities here in the United States as well as in developing countries according to Farmer. However, he cautions that “States, not ‘Western” human rights groups, are best placed to protect the basic social and economic rights of populations living in poverty...State failure cannot be rectified by human rights activism on the part of NGOs.” (10)

3. Establish new research agendas that emphasize analyzing political and economic causes of inadequate health care. Farmer recommends “ serious scholarly work” that studies the health effects of war, political-economic disruption and the pathogenic effects of social inequalities, including racism, gender inequality, and the growing gap between rich and poor.”(11) He cautions that the research must not further imperil or victimize the poor and marginalized populations. He quotes R. Neugebauer, “ Public health research on violence and victimization among these groups must vigilantly guard against contributing to emotional and social harm.” (12)

4. Assume a broader educational mandate for health workers to educate the public about inadequate health care due to structural violence. Education is central to the task of combating social and economic barriers to health and medical care Farmer says. However, instead of teaching a select group of students with an expressed interest in health and human rights, there should be a broader educational mandate to teach all students about human rights issues in academia. Health workers and social scientists who are committed to easing the suffering of those victimized by structural violence should make a greater effort to publicize their observations in the popular media so people in affluent societies can better make the connection between health and human rights. (13)

5. Achieve independence from powerful governments and bureaucracies. Farmer says it best: “We need to be untrammeled by obligations to powerful states and international bureaucracies. A central irony of human rights law is that it consists largely of appeals to the perpetrators.”(14)

6. Secure more resources for health and human rights. As more social and political rights have been attained in some countries, economic and social rights have suffered from structural adjustments such as privatization, deregulation and entrepreneurial programs that favor those of means and further disadvantage the poor. (15)

Structural violence is responsible for millions of deaths each year. Each year about 16 million children worldwide die from preventable and treatable causes. Sixty percent of these deaths are from hunger and malnutrition.(1) We may not be able to eradicate structural violence globally. However, to lesson structural violence even a tiny bit, would save at least one life. To a family, that one life is of vital importance.


(1) Bread for the World, retrieved on May 2, 2008 from
(2) Rice, Sabriya. “Poverty and poor health are intertwined, experts say.” Septermber 4, 2006, retrieved on May 2, 2008 at
(3) Ibid.
(4) Farmer, Paul. “Social Scientists and the New Tuberculosis.” Ed. Elizabeth D. Whitiaker. Health and Healing in Comparative Perspective. New Jersey: Pearson Prentice Hall, 2006. 372-384.
(5) Rice, Sabriya. “Poverty and poor health are intertwined, experts say.” Septermber 4, 2006, retrieved on May 2, 2008 at
(6) Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Los Angeles: University of California Press, 2005. XXV-23.
(7) Ibid.
(8) Ibid.
(9) Farmer. 2005. 238
(10) Farmer. 2005. 239-240
(11) Famer. 2005. 241
(12) Neugebauer, R. “Research on Violence in Developing Countries: Benefits and Perils.” American Journal of Public Health 89 (10): 1473-74
(13) Farmer. 2005. 242
(14) Farmer. 2005. 243
(15) Farmer. 2005. 243

Monday, June 01, 2009

Scientific explanations of helping others through altruistic behavior and why we started KIRF

I like helping people. I discovered this after I finished the Hawaiian Ironman World Championships and tore my Achilles tendon while training to qualify for next year's race. During this time in my life, each day was designated as either a training day, a rest day or "lost day" when I couldn't train due to work. Basically, it was a life that was mostly about me: my triathlon training, my sales goals at Diamondback Bicycles,  and my social life at work and in the triathlon community.

When the micro-tears on my right Achilles tendon threatened to turn into a rip straight through the tendon that would require surgery and months of re-hab, I had to finally stop running and cycling. No more training rides or runs with my triathlon friends. I dropped out of Ironman Canada. I then put my energy into finally becoming a good swimmer. I swam Masters five days a week instead of the usual three days a week in between bike days and run days.  That lasted for about a month when I blew out my right shoulder. Then I had to stop swimming, too.

I cut my hair short and we got a dog. At least I could walk the dog. Six months into re-had, I got pregnant with our first child, a healthy, hungry and blue-eyed bald-headed little boy. As a new mom I discovered the joy and reward of giving myself to helping another person. It wasn't about me anymore and honestly, I did miss working out and doing long trail runs with my friends. But when I did, I missed my beautiful little boy more.

Two and half years later our daughter was born. By then, I was in full-mommy-mode and basically never saw our old triathlon friends much at all. The tires on my Baby Jogger wore out before my road bike tires. Months turned into years between triathlons. Over time, I realized that I needed more than a daily workout or a race PR to feel alive and accomplished. I would rather spend hours with my kids than sitting on a bike seat far from home on a 50-mile training ride--all the while feeling guilty and rushed. For the next decade I stopped doing long-distance triathlons. I just my annual sprint triathlon in Carpinteria or marathon race. They were much easier to train for. I only had to workout once a day!  One by one, our old triathlon friends were replaced by new parent friends that we met through our kids.

As the kids got older, they needed me less and things just got plain easier all around. In June 2005 I stopped working full-time and started volunteering at the kids' school and for a local land conservancy. I needed to exercise my altruistic care-taking muscles that I developed being a parent.

In 2005, husband and I started a non-profit organization to help survivors* of natural disasters the week after we returned from living through the Andaman Sea tsunami disaster with our kids during a family vacation in Thailand in December 2004. My husband gave our foundation a big name that reflected his big plans for it: Kirwin International Relief Foundation, or "KIRF" for short. But, it's really just the us two volunteering our time, writing grant proposals and infusing it with any cash we have left over from paying the bills. I like to think of KIRF as our way of doing something really rewarding with our lives and to leave behind a legacy, a
"we made a difference" in addition to our children. Our non-profit foundation is also a way we can exercise our altruistic muscles since neither of us in a classical "helping profession" like medicine, counseling or teaching.  I design and build web sites and he's a trial attorney and certified mediator.

Through our foundation, we fund sustainable and culturally appropriate projects that help people regain their economic self-sufficiency. For example, we purchase supplies that people tell us that they need after a disaster. We don't just give them left-over stuff from well-meaning companies who also benefit with a tax right off on un-sellable stuff. The need I discovered for cultural competency when doing field work, of building rapport with the locals and the many inefficiencies and mistakes made by larger non-profits inspired me to pursue a masters degree in cultural anthropology at California State University Northridge (CSUN) last year.

Much of our sustainable development work and educational scholarship programs we fund were inspired initially by my mother-in-law Diane Kirwin. She started an educational non-profit for lowest caste and street children in the northern state of Bihar in India. Her non-profit is now an Indian Charitable Trust called KIRF India. She has been helping street children, usually Dalit caste kids, get an academic education, medical care and nutritious food in Bihar, India since 2003.

Since January 2005, our non-profit KIRF has helped out in seven countries: Thailand, India, Burma, Cambodia, Peru, Mexico, Tanzania and the United States. Most of our projects cost a few thousand dollars. In countries like Thailand, the exchange rate amplifies our buying power exponentially. For example, $10,000 in funds to purchase supplies in Thailand in January 2005 was like having $70,000 here in the United States. With about that much, we funded the rebuilding of a co-operative fish farm, and purchased dry goods, food supplies, school supplies and two fishing boats for three coastal villages that got destroyed by the tsunami flooding in Thailand as part of our tsunami relief work.

I've been asked more times than I can remember, "Why did you come to help us?" or "Why did you start your foundation?" I've had really nice people tell me, "Oh, you are going to heaven."  And, I've had others, mostly Thais, insist that we help others to gain merit (for good karma).

Why do we volunteer to help others? I do not have a single or simple answer. When pushed for an answer I would often tell them that it's our way of giving back since our lives were spared during the tsunami disaster in 2004. But the real answer is that it just feels normal. It is also an extremely rewarding --if intense--experience. And, it can even be a lot of fun–albeit exhausting fun. The typical disaster relief day begins with a run from my host's home or a hotel at 6am in the morning, then goes from about 8 am in the morning until 9 or 10pm at night. It ends usually around midnight after I make my last journal entry and finish my notes and accounting from the day.  The 15-hour work days of disaster relief include meeting and engaging with other humanitarians, figuring out how to get what where, a lot of driving (and sometimes getting lost) on bad or non-existent roads and meeting with the people who are at their limit. Also, fundraising before and after a natural disaster relief trip is always an un-fun challenge.

But, the truth is, it seems like the right thing to do. I hesitate to give that answer because I don't want to imply that everyone has an obligation to help others by volunteering as a humanitarian. That's judgmental, self-centric and as ludicrous as saying everyone has an obligation to have children, or everyone should strive be a doctor, engineer or lawyer. And, that's not how I feel anyway.

So, in my Evolutionary Anthropology course last semester I was delighted to be assigned a book that explained altruism from an evolutionary perspective: Unto Others: the Evolution and Psychology of Unselfish Behavior by Elliot Sober and David S. Wilson.

From an evolutionary standpoint, altruism can be explained as an adaptation that helps to promote survival. But, to promote the survival of whom? Certainly not the individual altruist according to this definition: “a person unselfishly concerned for or devoted to the welfare of others (Dictionary 2009).” This is true in our case at least, in that our "KIRF work" has cost us personally in time, money, and, even, this is difficult to say, but precious time away from our family and loved ones.

An altruistic act is one that gives others a reproductive advantage while putting the altruist at a reproductive disadvantage (Campbell 2/18/09). Yep, that's us. By why do we do this?

According to scientists such as W. G. Hamilton, and many of the scientific community until the recently, altruism was best explained as an extension of individual selection and called “kin selection” (Moore 2001:58). Kin selection is an evolutionary adaptation to promote one’s genetic code by sacrificing oneself in order to help one’s kin (Sober 1998:58). Known as the “father of modern kin selection theory,” Hamilton was one of the first to promote kin selection as more in line with the new individual and genetically based evolutionary model called the Neo-Darwinian or Modern Synthesis Theory of Evolution (Moore 2001:166). The Modern Synthesis Theory combined Darwin’s theory of evolution through natural selection with heritability of traits and genetic research in the Twenties and Thirties. Richard Dawkins elaborated on kin selection and called it the “selfish gene theory” that claimed that we are “controlled by our genes whose only interest is to replicate themselves (Moore 2001:87).” However, kin selection, based on the modern syntheses’ gene-centric and individualistic theory of inheritance, does not explain the evolutionary adaptive altruistic behavior of non-genetically related (non-kin) individuals.

Group selection is the better theory in predicting altruistic behavior in humans and non-human primates according to Elliot Sober and David S. Wilson in Unto Others: the Evolution and Psychology of Unselfish Behavior. Group selection is “when an allele (or gene) increases in frequency if it bestows an advantage to the group, regardless of its impact on the individual (Campbell 2/25/09).” In other words, Charles Darwin had it right when he explained that a group of altruists would be reproductively more successful than a group of non-altruists. He didn’t specify that they had to be kin (Sober 1998:5). A population increases faster with more altruists according to John Maynard Smith with his Haystack model in 1964 (Sober 1998:68).

On the psychology side of research, studies done by Daniel Batson have shown that the key to altruism is not self-interest (genetic or otherwise) but is empathy. His research has shown that most people have an innate willingness to help a stranger when they feel empathetic about them (Richardson 2005:217).

And, back to the biologists, altruistic behavior is not limited to humans. Biologists have documented several examples of group selection with the presence of altruists increasing group fitness in non-humans. For example, the brain worm (or liver fluke) relies on the altruistic and suicidal behavior of several individuals in a population to promote its survival as a group (Sober 1998: 27). An experiment with guppies shows that even non-human creatures such as fish choose to associate with altruists. In the experiment, it showed that even guppies preferred the company of altruists of their own species who risked sacrificing themselves through dangerous predator inspection behavior. (Sober: 1998:140).” With that in mind, and the greater ability of humans to detect altruistic behavior through cultural transmissions and communication, (compared to guppies), helping others seems normal and biologically natural.

So, according to science, altruism is an evolutionary adaptive behavior that increases the fitness of groups in both humans and non-humans and it's trigger is empathy.

That seems to make sense to me. I can't tell you how many times, after helping a brave family by giving them some mundane items that I bought for them for their temporary shelter, after an earthquake or hurricane leveled their family home and turned their lives upside down, that I've had to fight back tears at their courage. And, I feel unworthy of their gratitude for the little that we could give. If there's one thing that I know for sure (to paraphrase her Oprah Winfrey), is that doing disaster relief is living with lot's of empathy. Too much at times It would be actually, easier to do my job helping others if I had less of it, from an emotional perspective. Just a few months ago, during Inauguration Week in Washington, DC, we helped out a transitional living facility (a fancy name for homeless shelter for little kids and their mothers) by purchasing and delivering play and educational supplies for the Homeless Children's Playtime Project (HCPP). After playing with the shelter's young residents one night, how I badly I wanted to do more for these kids who are being cheated out of so much in life. That part of being altruistic and feeling empathy is not easy at all. Yes, I cried.

But, it feels natural and so good to make a difference, too– even if its a little. At least, I know I did something. And, those that I helped know that I believe that they are worth helping. That in itself is a gift. It's a good feeling to have someone else go out of their way to help you.

Now, even science recognizes the worth of helping others. Science calls it "altruism" or "group selection"– an evolutionary adaptation that improves a specie's fitness.

I find that re-assuring and cool.

Thank you for reading this. For more information about how we help go to our main website or learn about our most recent projects on our Facebook page

Thank you,

:)Angela R. Kirwin (edited 6/12/13)

Note: A more thorough scientific exploration of group selection theory and the fitness advantages  and cultural evolution of religious groups is by David Sloan Wilson. It is called Darwin's Cathedral: Evolution, Religion and the Nature of Society


Campbell, Christine
2009 Human Behavior: Evolutionary Perspective, Unpublished lectures for Anthropology 423, Spring, California State University, Northridge, CA
2009 “Altruist”,, retrieved on May 14, 2009, from

Moore, David S.
2001 The Dependent Gene, New York, NY: Henry Holt and Company

Richardson, Peter J. and Robert Boyd
2005 Not By Genes Alone: How Culture Transformed Human Evolution, Chicago, IL: University of Chicago Press.

Sober, Elliot and David Sloan Wilson
1998 Unto Others: The Evolution and Psychology of Unselfish Behavior, Cambridge, MA: Harvard University Press.

*I hate the term "victims" because it doesn't recognize their often heroic efforts to prevail under truly horrific physical and emotional traumas; it's undignified.