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BMJ No 7123 Volume 315 Editorial Saturday 20/27 December Christmas 1997 issue
Social suffering: relevance for doctorsHealthcare professionals need to broaden their understanding of health and sufferingThe term social suffering describes collective and individual human suffering associated with life conditions shaped by powerful social forces.(1) Unlike physical suffering or mental illness, it is largely unrecorded. New measures such as disability adjusted life years, designed to document the global distribution of morbidity in economic and individualistic terms, only barely represent a much more complex concept of suffering as a social experience and neglect most of what is at stake for people globally.(2) Yet more than ever social suffering requires scholarly attention to facilitate cross cultural discourse and peaceful development in an increasingly interdependent world.(1-3)Social suffering has evolved from the state of ignorance, vulnerability to nature, and terror associated with naked tyrannical power in the dark ages to the diverse suffering associated with wealth creating progress since the Enlightenment.(2) In 16th century Europe enclosure of common land dispossessed the poor. A century later the industrial revolution generated abysmal working conditions in European factories. Pervasive forces in the 20th century continue to inflict suffering worldwide. Since the Enlightenment demands for respecting human dignity have progressively ameliorated indignities suffered under oppressive rulers, industrialists, and slave owners. The Universal Declaration of Human Rights and international law were expected further to reduce human suffering in the 20th century. But unprecedented population growth, ethnic and gender conflict, and global economic trends have rendered millions vulnerable to the ravages of exploitation, poverty, disease, genocidal slaughter, torture, and sexual abuse. Social suffering is now constructed on a greater scale than in the past through economic, military, and cultural forces which have become accepted as inevitable aspects of modern life.(2-5) A recent volume of writings expands our understanding of social suffering at the personal level and in the context of moral and political communities.(1) Anthropologists describe how the media manipulate images portraying and trivialising terrible human suffering of distant peoples to propagate local political rhetoric. Media arousal of public emotions shapes perceptions of human problems and policy development for commercial or political purposes in highly industrialised nations.(1) Atrocities that the media choose to ignore - for example, the starvation and death of over 30 million Chinese in the 1960s - are even more terrifying. Gender suffering is illustrated by the pain and suffering inflicted on the minds and bodies of thousands of Indian women subjected to violent sexual abuse as their country emerged from colonialism.(1) Political power manifests itself in the suffering of millions in China during a transformation driven by imperialism and Maoism.(1) Modern medical advances have altered patterns of life and death through new definitions of death to facilitate organ transplantation and through the consequences of life support systems, chemotherapy, transplantation, and immunosuppression.(6) The impact of medical progress on life and death is different in other cultures, for example, in Japan, even though it is a modern and secular society.(1) Intense suffering is intimately linked to violence built into the structure of society, as in Haiti.(1) Rwanda's tragedy is also being revealed in its full horror by those who have worked with victims of a genocidal war which decimated populations previously living peacefully together and permanently traumatised children by exposing them to the most brutal scenes and destroying their trust in adults (P Mugambo, unpublished data). Like the horrors of Bosnia,(7) these atrocities have yet to impinge fully on the hearts and minds of privileged peoples. Our modern world is indeed frightening.(1)( 5) Graubard reminds us of how people in privileged countries are only fleetingly aware of the horrifying conditions of life for billions of others and react only intermittently to media portrayal of horrors, without any sustained attempts to understand or act on the ethnic, racial, religious, or political causes of such profound misery.(1) When such indifference is seen in Africa, a continent withering under a debt generating process resembling the slave trade,(8) we must ask what this tells us about our state of humanity. Moreover, we must ask what can be done, at a time in history when the nuclear stockpile, ecological degradation, population growth, the arms trade, large numbers of refugees, cultural conflict, the recrudescence of old and emergence of new infectious diseases, and widening economic disparities threaten rich and poor alike.(9) At the end of a glorious, but also devastatingly cruel century, we have the opportunity to understand better our world view and to empathise with others.(3)(10) Our collective futures - increasingly linked - are at stake.(11) The overlapping challenges for anthropologists, philosophers, physicians, social and natural scientists, and scholars in the humanities call for empathy and multidisciplinary collaboration in new kinds of research across diverse societies to enhance our understanding of, and ability to diminish, social suffering.(1) The exposure of social suffering during the apartheid era in South Africa, through the testimonies at the Truth and Reconciliation Commission, reveals the importance of public acknowledgment in dealing with human suffering. Doctors may ask what relevance these considerations have to their daily practice of medicine. The answer lies in recognising that while modern medicine has done much to advance the health and prolong the lives of individuals, improving the health of populations will require profound social, economic, political, and cultural changes.(2)(12,13) Healthcare professionals are challenged to broaden their understanding of health, disease, and suffering and of their role in society. At the end of an epic century (scarred by suffering of horrendous magnitude when doctors were coopted as agents of the state's infliction of suffering and racial practice(14)), healthcare professionals are challenged to broaden their understanding of health, disease, suffering, and of their role in society. Healthcare systems need the influence of social science research to extend their gaze towards the social construction of disease and suffering and to develop an approach to population health that could complement and enhance the care of individuals. Solomon R Benatar
Professor of medicine
References
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2 Desjarlais R, Eisenberg L, Good B, Kleinman A, eds.
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3 Kothari R, Falk R, Kaldor M. Towards a liberating
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7 Rieff D. Slaughterhouse: Bosnia and the failure of the
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8 Pettifor A. Debt, the most potent form of slavery: a
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9 Benatar S R. War, or peace and development: South Africa's
message for global peace and security. Medicine, Conflict and
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10 Smart N. World views: cross cultural explorations of
human beliefs. 2nd ed. Englewood Cliffs, NJ: Prentice Hall,
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11 Teeple G. Globalisation and the decline of social
reform. Toronto: Garamond Press, 1995.
12 Murray C J L, Lopez A D, eds. The global burden of
disease. Cambridge, MA: Harvard University Press, 1996.
13 Benatar S R. Millennial challenges for modernity and medicine.
J Roy Coll Phys Lond (in press).
14 Barondess J A. Medicine against society: lessons from the Third
Reich. JAMA 1996;276:1657-61.
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