versión On-line ISSN 2078-5135
versión impresa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.98 no.7 Cape Town jul. 2008
Division of Infectious Diseases and HIV Medicine Department of Medicine Groote Schuur Hospital Cape Town
The measure of a civilization/society is how it treats its weakest members.
Javier Perez de Cuellar
If we judge South African society by this measure, the brutal beatings, burnings and displacements of our emigrant communities over the past few weeks must suggest that we are still a sick society. Responsibility for the wave of xenophobia sweeping across South Africa has been laid at the feet of various factors and actors: criminal groups, our present and past governments for lack of service delivery, and institutions responsible for law and order.
While there is certainly considerable truth in many of these perspectives, it is important that our response as health professionals to all epidemics (be they of violence or plague) should be determined by appraising all the aetiological evidence available from both upstream (root causes) and downstream factors. A useful starting point in elucidating the causes of this xenophobic pandemic is to map out the pattern of the violence. This could be broadly characterised as South Africans in poor communities attacking persons they defined as foreigners in a wave of violence that rapidly engulfed every province in the land. This pattern suggests that individual level factors (such as Ebrahim Rasool's contention that it was merely the acts of criminals) were less important than social forces (acting at a population level) that had turned poor communities across the country into a dry tinderbox waiting for a spark. What might constitute these social forces? The first thing to recognise is that these violent attacks on foreigners erupted not out of the (tranquil) blue, but rather from a baseline rate of violent crime that is one of the highest in the world (Human Development Report 2007/2008,1 Table 27). What then determines such high violent crime rates?
The rapidly growing field of Social Epidemiology has examined the evidence and has now produced a vast and convincing array of evidence as to the key role that economic inequality plays in determining population levels of violent crime. There are now over 50 papers2 and one meta-analysis3 that have demonstrated elevated rates of violence in countries with bigger income inequalities. The relationship is strong both when comparing different countries and small areas within countries. The relationship remains robust after controlling for poverty, average income, education levels, degree of urbanisation and economic growth rate.4 One study found a tenfold difference in homicide rates related to different rates of inequality in different regions of North America. In this study inequality accounted for half of all homicides.5 In fact many criminologists have accepted that inequality is the most well-established relation between homicide and any environmental factor.6
How do we explain this relationship, and in particular the fact that the evidence shows such a strong relationship between violence and inequality but little if any relationship between violence and poverty? Richard Wilkinson, who has pioneered much of the research in this field, explains it as follows. Greater income inequality leads to increased social distance between income groups and less of a sense of common identity.2 Large differences in material wealth are read as status differences and differences in people's intrinsic merits. More unequal societies are also associated with an increased acquisitiveness for status-conferring objects. When this occurs in societies where one's sense of self-worth is significantly determined by one's material wealth, then those at the bottom of the social hierarchy, who are largely excluded from the means of earning a living, end up with a poor self-image and high levels of frustration. Males in these circumstances are especially prone to lash out at the slightest provocation. Of note, this excess violence is not determined by poverty per se, as communities where most of the population is poor but there are few (or no) wealthy persons (to compare oneself to) are characterised by low levels of violence.
This increased violence in unequal societies is not directed predominantly against the rich, but generally disproportionately affects the poor. Sociologists have explained this in terms of 'displaced aggression', whereby increased inequality and dominance relations lead to increased discrimination against any more vulnerable group - be they emigrants, women, or minorities. This master-kicks-the-servant-servant-kicks-the-dog phenomenon explains why people (and other socially hierarchical primates7) who have had their sense of selfhood most devalued by low social status try to reassert it by enforcing their superiority over any individual or group weaker than they are.2 It is not surprising that racist attacks are more common in times of high unemployment and economic hardship - such as the recent food and travel cost increases in South Africa.8
There is good evidence linking increased inequality to reduced levels of trust,9 reduced social capital, and increased levels of hostility as well as higher homicide rates. Places with high homicide rates are also places with more hostility, lower levels of trust and less involvement in community life. People living in unequal areas are also more likely to hold racist, sexist, elitist and hyper-nationalist (and hence probably xenophobic) views.2
This co-variation of levels of trust, violence, social capital and inequality leads Wilkinson2 to suggest that we should 'rather than regarding homicide as a bizarre form of behaviour, unrelated to others ... see it as the extreme end of a continuum of relationships which run all the way from the most kindly, supportive and trusting to the most hostile and violent. The implication is that the whole balance of relationships is different in different societies, so that the quality of social relations right across a society is shifted either toward the gentler, more affiliative end of the spectrum or (in more unequal societies) toward the more antisocial and violent end' (p. 54).
Different societies then, can have vast differences in the quality of their social relations, and these differences translate into large differences in homicide rates, racism and overall health.10 Since these social relations are built on material foundations (how unequal our societies are) we can make a good case that we, as health professionals, should be advocating for more redistributive social policies.
Devastating events such as those that have displaced and killed so many residents of South Africa over the past few weeks call attention to an unhealthy society. It is incumbent on us, as health workers, to analyse at all levels what the causal factors are, and use the window of opportunity provided to address them. In our case one of the most important conclusions seems to be one of the hardest to digest. We live in one of the most violent societies in the world,1 and yet very few of us are prepared to accept what is one of the most important causes of this - our society is one of the most unequal in the world (Fig. 1) and this inequality has increased since 1994.11 The outburst of xenophobic attacks should serve as a jolt to rekindle in us the egalitarian spirit of the pioneers of social medicine such as Sidney Kark and Steve Biko, and their intellectual forbears such as Jean-Jacques Rousseau who in 1755 wrote: 'Are you unaware that vast numbers of your fellow men suffer or perish from need of the things that you have to excess, and that you required the explicit and unanimous consent of the whole human race for you to appropriate from the common subsistence anything besides that required for your own?'12
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12. Rousseau JJ. Quoted in: Farmer P. Infections and Inequalities: The Modern Plagues. Berkley University of California Press, 1999. [ Links ]