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On Suffering and Structural Violence: A View from Below Paul Farmer

Race/Ethnicity: Multidisciplinary Global Contexts, Volume 3, Number 1, Autumn 2009, pp. 11-28 (Article)

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On Suffering and Structural Violence: A View from Below Paul Farmer

veryone knows that suffering exists. The question is how to define it. Given that each person’s pain has a degreeof reality forhimorher that thepainof others

cansurelyneverapproach, iswidespreadagreementonthesub- ject possible? Almost all of us would agree that premature and painful illness, torture, and rape constitute extreme suffering. Mostwouldalsoagree that insidiousassaultsondignity, suchas institutionalized racismandsexism, also causegreat andunjust injury. Givenourconsensusonsomeof themoreconspicuous forms

of suffering, a number of corollary questions come to the fore. Can we identify those most at risk of great suffering? Among those whose suffering is not mortal, is it possible to identify those most likely to sustain permanent and disabling damage? Arecertain“event”assaults, suchas tortureor rape,more likely to lead to late sequelae than are sustained and insidious suffer- ing, such as the pain born of deep poverty or of racism? Under this latter rubric, arecertain formsofdiscriminationdemonstra- blymorenoxious thanothers? Anthropologistswho take these as researchquestions study

both individualexperienceandthe larger socialmatrix inwhich it is embedded in order to see how various large-scale social forces come to be translated into personal distress and disease. By what mechanisms do social forces ranging from poverty to racismbecome embodiedas individualexperience?Thishasbeen the focus of most of my own research in Haiti, where political andeconomic forceshavestructuredrisk forAIDS, tuberculosis, and, indeed,mostother infectiousandparasiticdiseases. Social forces atwork therehavealso structured risk formost formsof extremesuffering, fromhunger to tortureandrape.

©2009TheOhioStateUniversity/Office ofMinorityAffairs/TheKirwan Institute


From Daedalus, 125:1 (Winter, 1996), pp. 251-283. @1996 by the Ameri- can Academy of Arts and Sciences. Reprinted with the permission of thepublisher,MITPress Journals.

Working in contemporaryHaiti,where in recent yearspolit- ical violence has been added to the worst poverty in the hemi- sphere,one learnsagreatdealabout suffering. In fact, thecoun- tryhas longconstituteda sort of living laboratory for the study of affliction, no matter how it is defined. “Life for the Haitian peasant of today,” observed anthropologist Jean Weise some twenty-five years ago, “is abject misery and a rank familiarity with death.”1 The situation has since worsened. When in 1991 international health and population experts devised a “human suffering index” by examining measures of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by “extreme human suffering.” Only one of them, Haiti, was located in the Western hemi- sphere. In only three countries in the world was suffering judged to be more extreme than that endured in Haiti; each of these three countries is currently in themidst of an internation- ally recognizedcivilwar. Suffering is certainly a recurrent and expected condition in

Haiti’s Central Plateau, where everyday life has felt like war. “You get up in the morning,” observed one young widow with four children, “and it’s thefight for foodandwoodandwater.” If initially struck by the austere beauty of the region’s steep mountainsandclementweather, long-termvisitors come to see theCentralPlateau inmuch thesamemanneras its inhabitants: a chalky and arid land hostile to the best efforts of the peasant farmerswho livehere.Landlessness iswidespreadandso, con- sequently, ishunger.All the standardmeasures revealhowten- uous the peasantry’s hold on survival is. Life expectancy at birth is less than fifty years, in large part because as many as twoof every ten infantsdie before theirfirst birthday.Tubercu- losis is the leading cause of death among adults; among chil- dren,diarrhealdisease,measles, and tetanus ravage theunder- nourished. But the experience of suffering, it is often noted, is not effec-

tively conveyedbystatisticsorgraphs.The“texture”ofdireaf- fliction isperhapsbest felt in thegrittydetailsofbiography,and so I introduce the stories of Acéphie Joseph and Chouchou Louis.2 The stories of Acéphie and Chouchou are anything but “anecdotal.”For theepidemiologist aswell as thepolitical ana- lyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet simi- lar fates. What these victims, past and present, share are not personalorpsychological attributes—theydonot shareculture, language, or race. Rather, what they share is the experience of occupying the bottom rung of the social ladder in inegalitarian societies.3

Acéphie Joseph’s and Chouchou Louis’s stories illustrate someof themechanisms throughwhich large-scale social forces crystallize into the sharp, hard surfaces of individual suffering. Suchsuffering is structuredbyhistoricallygiven (andofteneco- nomically driven) processes and forces that conspire—whether through routine, ritual, or, as is more commonly the case, these

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hard surfaces—to constrain agency.4 For many, including most of my patients and informants, life choices are structured by racism, sexism,political violence, andgrindingpoverty.

Acéphie‘s Story For the wound of the daughter of my people is my heart wounded, I mourn, and dismay has taken hold of me. Is there no balm in Gilead? Is there no physician there? Why then has the health of the daughter of my people not been restored? O that my head were waters, and my eyes a fountain of tears, that I might weep day and night for the slain of the daughter of my people!

—Jeremiah 8:22-9.1

Kay, a community of fewer than fifteen hundred people, stretches along an unpaved road that cuts north and east into Haiti‘s Central Plateau. Striking out from Port-au-Prince, the capital, it can takeseveralhours to reachKay.The journeygives one an impression of isolation, insularity. The impression is misleading, as the village owes its existence to a project con- ceived in the Haitian capital and drafted in Washington, D.C.: Kay isa settlementof refugees, substantially composedofpeas- ant farmers displaced more than thirty years ago by Haiti’s largestdam. Before1956, thevillageofKaywassituated ina fertilevalley,

andthrough it ran theRiviereArtibonite.Forgenerations, thou- sands of families had farmed the broad and gently sloping banksof the river, selling rice, bananas,millet, corn, andsugar- cane in regional markets. Harvests were, by all reports, bounti- ful; life there is now recalled as idyllic. When the valley was flooded with the building of the dam, the majority of the local population was forced up into the stony hills on either side of the new reservoir. By all the standard measures, the “water refugees” became exceedingly poor; the older people often blame their poverty on the massive buttress dam a few miles away, and bitterly note that it brought them neither electricity norwater. In1983,when Ibeganworking in theCentralPlateau,AIDS,

although already afflicting an increasing number of city dwell- ers,wasunknowninmostareasas rural asKay.Acéphie Joseph was one of the first villagers to die of the new syndrome. But her illness,whichendedin1991,wasmerely the latest inastring of tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the re- gion’s sick. The litany begins, usually, down in the valley hidden under

the still surface of the lake. Acéphie’s parents came from fami- liesmakingadecent livingbyfarmingfertile tractsof land—their “ancestors’gardens”—andsellingmuchof theirproduce.M. Jos- eph tilled the soil, andhiswife, a tall andwearilyelegantwom- an not nearly as old as she looked, was a “Madame Sarah,” a

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market woman. “If it weren’t for the dam,” M. Joseph assured me, “we’d be just fine now. Acéphie, too.” The Josephs’ home was drowned along with most of their belongings, their crops, and thegravesof their ancestors. Refugees fromthe risingwater, the Josephsbuilt amiserable

lean-to on a knoll of high land jutting into the new reservoir. They remained poised on their knoll for some years; Acéphie and her twin brother were born there. I asked them what in- duced them to move up to Kay, to build a house on the hard stone embankment of a dusty road. “Our hut was too near the water,” replied M. Joseph. “I was afraid one of the children would fall into the lake and drown. Their mother had to be away selling; I was trying to make a garden in this terrible soil. Therewasnoone tokeepaneyeon them.” Acéphie attended primary school—a banana-thatched and

open shelter in which children and young adults received the rudiments of literacy—in Kay. “She was the nicest of the Joseph sisters,” recalled one of her classmates. “And she was as pretty as she was nice.” Acéphie’s beauty and her vulnera- bilitymayhave sealedher fate as early as 1984. Thoughstill in primary school, she was already nineteen years old; it was time for her to help generate income for her family, which was sinkingdeeperanddeeper intopoverty.Acéphiebegan tohelp her mother by carrying produce to a local market on Friday mornings. On foot or with a donkey it takes over an hour and a half to reach the market, and the road leads right through Peligre, the site of the dam and, until recently, a military bar- racks.The soldiers liked towatch theparadeofwomenonFri- day mornings. Sometimes they taxed them with haphazardly imposed fines; sometimes they taxed them with flirtatious banter. Such flirtation is seldom unwelcome, at least to all appear-

ances. In rural Haiti, entrenched poverty made the soldiers— the region’s only salaried men—ever so much more attractive. Hunger was again a near-daily occurrence for the Joseph fam- ily; the timeswereasbadas those right after thefloodingof the valley. And so when Acéphie‘s good looks caught the eye of Captain Jacques Honorat, a native of Belladere formerly sta- tioned inPort-au-Prince, she returnedhisgaze. Acéphieknew,asdideveryone in thearea, thatHonorathad

a wife and children. He was known, in fact, to have more than one regular partner. But Acéphie was taken in by his persis- tence, andwhenhewent to speak toherparents, a long-termli- aisonwas, fromtheoutset, seriously considered:

What would you have me do? I could tell that the old people wereuncomfortable,worried;but theydidn’t sayno.Theydidn’t tell me to stay away from him. I wish they had, but how could they have known? ... I knew it was a bad idea then, but I just didn’t know why. I never dreamed he would give me a bad ill- ness, never! I looked around and saw how poor we all were, how the old people were finished ... What would you have me do? Itwasawayout, that’showI sawit.

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AcéphieandHonoratwere sexualpartnersonlybriefly—for less thanamonth,accordingtoAcéphie.Shortly thereafter,Hon- orat fell illwithunexplained fevers andkept to the companyof his wife in Peligre. As Acéphie was looking for a moun prensi- pal—a“mainman”—she tried to forgetabout thesoldier. Still, it was shocking to hear, a few months after they parted, that he wasdead. Acéphie was at a crucial juncture in her life. Returning to

school was out of the question. After some casting about, she went to Mirebalais, the nearest town, and began a course in what she euphemistically termed “cooking school.” The school —really just an ambitious woman’s courtyard—prepared poor girls likeAcéphie for their inevitable turnas servants in thecity. Indeed, domestic service was one of the rare growth industries inHaiti, andasmuchasAcéphie’sproudmotherhated to think of her daughter reduced to servitude, she could offer no viable alternative. And so Acéphie, at age twenty-two, went off to Port-au-

Prince, where she found a job as a housekeeper for a middle- class Haitian woman working for the U.S. embassy. Acéphie’s looksandmannerskeptheroutof thebackyard, the traditional milieu of Haitian servants: she was designated as the maid who, in addition to cleaning, answered the door and the tel- ephone. Although Acéphie was not paid well—she received $30 each month—she tried to save a bit of money for her par- ents and siblings, recalling the hunger gnawing at her home village. Still looking foramounprensipal,AcéphiebeganseeingBlan-

coNerette, ayoungmanwithorigins identical toherown:Blan- co’sparentswerealso“water refugees”andAcéphiehadknown himwhentheywerebothattending theparochial school inKay. Blanco had done well for himself, by Kay standards: he chauf- feureda small busbetween theCentral Plateauand the capital. In a setting characterized by an unemployment rate of greater than 60 percent, his job commanded considerable respect. He easily won the attention of Acéphie. They planned to marry, andstartedpooling their resources. Acéphie had worked as a maid for over three years when

shediscovered that shewaspregnant.Whenshe toldBlanco,he becameskittish.Norwasheremployerpleased: it is considered unsightly to have a pregnant servant. So Acéphie returned to Kay, where she had a difficult pregnancy. Blanco came to see heronceor twice; theyhadadisagreement, and then sheheard nothing fromhim.Following thebirthofherdaughter,Acéphie was sapped by repeated infections. She was shortly thereafter diagnosedwithAIDS. Soon Acéphie’s life was consumed with managing drench-

ing night sweats and debilitating diarrhea, while attempting to care for her first child. “We both need diapers now,” she re- marked bitterly towards the end of her life, faced each day not only with diarrhea, but also with a persistent lassitude. As she became more and more gaunt, some villagers suggested that

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Acéphie was the victim of sorcery. Others recalled her liaison with the soldier and her work as a servant in the city, both lo- cally considered risk factors for AIDS. Acéphie herself knew that shehadAIDS,althoughshewasmoreapt to refer toherself as suffering from a disorder brought on by her work as a ser- vant: “All that ironing, and thenopeninga refrigerator.” But this isnot simply the storyofAcéphieandherdaughter.

There is JacquesHonorat’sfirstwife,whoeachyeargrows thin- ner.AfterHonorat’sdeath, she foundherselfdesperate,withno means of feeding her five hungry children, two of whom were also ill. Her subsequent union was again with a soldier. Hono- rat had at least two other partners, both of them poor peasant women, in theCentralPlateau.One isHIVpositiveandhas two sickly children. Blanco is still a handsome young man, appar- ently in good health and plying the roads from Mirebalais to Portau-Prince. Who knows if he carries the virus? As an attrac- tivemanwithapaying job,hehasplentyofgirlfriends. Nor is this simply the story of those infected with the virus.

ThepainofMme. JosephandAcéphie‘s twinbrotherwasman- ifestly intense, but few understood the anguish of her father. ShortlyafterAcéphie‘sdeath,M. Josephhangedhimself.

Chouchou‘sStory “History shudders, pierced by events of massive public suffering. Memory is haunted, stalked by the ghosts of history’s victims, capriciously severed from life in genocides, holocausts, and exter- mination camps. The cries of the hungry, the shrieks of political prisoners, and the silent voices of the oppressed echo slowly, painfully through daily existence.”

—Rebecca Chopp,ThePraxisof Suffering

Chouchou Louis grew up not far from Kay in another small village in the steep and infertile highlands of Haiti’s Central Plateau. He attended primary school for a couple of years but was obliged to drop out when his mother died. Then in his early teens, Chouchou joined his father and an older sister in tending their hillside gardens. In short, there was nothing re- markable about Chouchou’s childhood; it was brief and harsh, likemost in ruralHaiti. Throughout the 1980s, church activities formed Chouchou’s

sole distraction. These were hard years for the Haitian poor, beatendownbya familydictatorshipwell into its thirddecade. The Duvaliers, father and son, ruled through violence, largely directedatpeoplewhoseconditionsofexistenceweresimilar to that of Chouchou Louis. Although many of them tried to flee, oftenbyboat,U.S.policymaintained thatHaitianasylum-seek- ers were “economic refugees.” As part of a 1981 agreement be- tween the administrations of Ronald Reagan and Jean-Claude Duvalier, refugees seized on the high seas were summarily re- turned to Haiti. During the first ten years of the accord, 24,559 Haitians applied forpolitical asylumin theUnitedStates; eight applicationswereapproved.

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AgrowingHaitianpro-democracymovement led, inFebru- ary 1986, to the flight of Duvalier. Chouchou Louis must have been about twenty years old when “Baby Doc” fell, and he shortly thereafter acquired a small radio. “All he did,” recalled hiswifeyears later, “waswork the land, listen to the radio, and go to church.” It was on the radio that Chouchou heard about thepeoplewhotookoverafterDuvalierfled.Likemany inrural Haiti, Chouchou was distressed to hear that power had been handed to themilitary, ledbyhardened duvaliéristes. Itwas this army that the U.S. government, which in 1916 had created the modernHaitianarmy, termed“Haiti’s best bet fordemocracy.” In the eighteen months following Duvalier’s departure, over $200million inU.S. aidpassed through thehandsof the junta. In early 1989, Chouchou moved in with Chantal Brise, who

was pregnant. They were living together when Father Jean- Bertrand Aristide—by then considered the leader of the pro- democracy movement—declared his candidacy for the presi- dency in the internationally monitored elections of 1990. In Decemberof that year almost 70percentof thevoters choseFa- therAristide fromafieldof tenpresidential candidates. Like most rural Haitians, Chouchou and Chantal welcomed

Aristide’s election with great joy. For the first time, the poor— Haiti’s overwhelming majority, formerly silent—felt they had someone representing their interests in the presidential palace. These are the reasons why the military coup d’etat of Septem- ber 1991 stirred great anger in the countryside, where the ma- jority of Haitians live. Anger was soon followed by sadness, then fear, as the country’s repressive machinery, dismantled during the seven months of Aristide’s tenure, was hastily re- assembledunder thepatronageof thearmy. In themonthafter thecoup,Chouchouwassitting ina truck

en route to the town of Hinche. Chouchou offered for the con- sideration of his fellow passengers what Haitians call a pwen, a pointed remark intended to say something other than what it literally means. As they bounced along, he began complaining about the conditions of the roads, observing that, “if things were as they should be, these roads would have been repaired already.” One eyewitness later told me that at no point in the commentary was Aristide’s name invoked. But Chouchou’s complaints were recognized by his fellow passengers as veiled languagedeploring thecoup.Unfortunately forChouchou,one of the passengers was an out-of-uniform soldier. At the next checkpoint, the soldier had him seized and dragged from the truck. There, a group of soldiers and their lackeys—their at- tachés, to use the epithet then in favor—immediately began beatingChouchou, in frontof theotherpassengers; theycontin- ued to beat him as they brought him to the militarybarracks in Hinche.Ascar onhis right templewasa souvenir of his stay in Hinche,which lasted severaldays. Perhaps the worst after-effect of such episodes of brutality

was that, ingeneral, theymarked thebeginningofpersecution, not theend. In ruralHaiti,during this time, anyscrapewith the

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law (i.e., the military) led to blacklisting. For men like Chou- chou, staying out of jail involved keeping the local attachés happy, andhedid thisbyavoidinghishomevillage.ButChou- chou lived in fear of a second arrest, his wife later told me, and his fearsproved tobewell-founded. On January 22, 1992, Chouchou was visiting his sister when

he was arrested by two attachés. No reason was given for the arrest, and Chouchou’s sister regarded as ominous the seizure of the young man’s watch and radio. He was roughly marched to the nearest military checkpoint, where he was tortured by soldiersandtheattachés.Onearea resident later toldus that the prisoner’s screamsmadeher childrenweepwith terror. OnJanuary25,Chouchouwasdumped inaditch todie.The

army scarcely took the trouble to circulate the canard that he had stolen some bananas. (The Haitian press, by then thor- oughly muzzled, did not even broadcast this false version of events.) Relatives carried Chouchou back to Chantal and their daughter under the cover of night. By early on the morning of January 26, when I arrived, Chouchou was scarcely recogniz- able. His face, and especially his left temple, was misshapen, swollen, and lacerated; his right temple was also scarred. His mouth was a pool of dark, coagulated blood. His neck was pe- culiarly swollen, his throat collaredwithbruises, the tracesof a gun butt. His chest and sides were badly bruised, and he had several fractured ribs.Hisgenitalshadbeenmutilated. That was his front side; presumably, the brunt of the beat-

ings came from behind. Chouchou’s back and thighs were stripedwithdeep lashmarks.Hisbuttocksweremacerated, the skinflayeddownto theexposedglutealmuscles. Someof these stigmataappeared tobe infected. Chouchou coughed up more than a liter of blood in his ago-

nalmoments.Givenhis respiratorydifficulties and theamount ofbloodhecoughedup, it is likely that thebeatingscausedhim tobleed, slowlyatfirst, thencatastrophically, intohis lungs.His head injuries had not robbed him of his faculties, although it mighthavebeenbetter forhimhad theydone so. It tookChou- chou threedays todie.

ExplainingVersusMakingSenseof Suffering The pain in our shoulder comes You say, from the damp; and this is also the reason For the stain on the wall of our flat. So tell us: Where does the damp come from?

—Bertholt Brecht

Are these storiesof sufferingemblematicof somethingother than twotragicandprematuredeaths? If so,howrepresentative is each of these experiences? Little about Acéphie’s story is unique; Ihave told it indetail because it brings into reliefmany of the forces constraining not only her options, but those of mostHaitianwomen.Such, inanycase, ismyopinionafter car-

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ing for dozens of poor women with AIDS. There is a deadly monotony in their stories: young women—or teenaged girls— who were driven to Port-au-Prince by the lure of an escape fromtheharshestpoverty;once in thecity, eachworkedasado- mestic; nonemanaged tofindfinancial security.Thewomen in- terviewedwere straightforwardabout thenonvoluntaryaspect of their sexual activity: in their opinions, they had been driven into unfavorable unions by poverty.5 Indeed, such testimony shouldcall intoquestion facilenotionsof “consensual sex.” What about the murder of Chouchou Louis? International

human rights groups estimate that more than three thousand Haitians were killed in the year after the September 1991 coup that overthrewHaiti’s first democratically elected government. Nearlyallof thosekilledwerecivilianswho, likeChouchou, fell into the hands of military or paramilitary forces. The vast ma- jority of victims were poor peasants, like Chouchou, or urban slum dwellers. (The figures cited here are conservative esti- mates; I am quite sure that no journalist or observer ever came to count thebodyofChouchouLouis.)6

Thus, the agony of Acéphie and Chouchou was, in a sense, “modal” suffering. InHaiti,AIDSandpoliticalviolenceare two leading causes of death among young adults. These afflictions werenot the resultofaccidentorof forcemajeure; theywere the consequence,director indirect, ofhumanagency.When theAr- tibonite Valley was flooded, depriving families like the Josephs of their land,ahumandecisionwasbehind it;when theHaitian army was endowed withmoney and unfettered power, human decisions were behind that, too. In fact, some of the same deci- sion-makersmayhavebeen involved inbothcases. If bureaucrats and soldiers seemed to have unconstrained

swayover the livesof the ruralpoor, theagencyofAcéphieand Chouchou was, correspondingly, curbed at every turn. These grim biographies suggest that the social and economic forces that have helped to shape the AIDS epidemic are, in every sense, the same forces that led to Chouchou’s death and to the larger repression in which it was eclipsed. What is more, both were “at risk” of such a fate long before they met the soldiers who altered their destinies. They were both, from the outset, victimsof structuralviolence. While certainkindsof sufferingare readilyobservable—and

thesubjectof countlessfilms,novels, andpoems—structuralvi- olence all too often defeats those who would describe it. There areat least three reasonswhythis is so.First, there is the“exoti- cization” of suffering as lurid as that endured by Acéphie and Chouchou. The suffering of individuals whose lives and strug- gles recall ourowntends tomoveus; thesufferingof thosewho aredistanced,whetherbygeography,gender, “race,”orculture, is sometimes less affecting. Second, there is the sheer weight of the suffering, which

makes it all the more difficult to render: “Knowledge of suffer- ing cannot be conveyed in pure facts and figures, reportings that objectify the suffering of countless persons. The horror of

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suffering is not only its immensity but the faces of the anony- mousvictimswhohave littlevoice, let alone rights, inhistory.”7

Third, the dynamics and distribution of suffering are still poorly understood. Physicians, when fortunate, can alleviate the sufferingof the sick.But explaining itsdistribution requires moreminds,more resources.Case studiesof individuals reveal suffering, they telluswhathappens tooneormanypeople; but to explain suffering, one must embed individual biography in the largermatrixof culture, history, andpolitical economy. In short, it is one thing tomake senseof extremesuffering—

auniversal activity, surely—andquiteanother toexplain it.Life experiences such as those of Acéphie and Chouchou—who as Haitians living in poverty shared similar social conditions— mustbeembedded inethnography if their representativeness is to be understood. These local understandings are to be embed- ded, in turn, in the larger-scale historical system of which the fieldworksite is apart.8 Thesocial andeconomic forces thatdic- tate life choices in Haiti’s Central Plateau affect many millions of individuals, and it is in the context of theseglobal forces that the suffering of individuals receives its appropriate context of interpretation. Similar insights are central to liberation theology, which

takes the suffering of the poor as its central problematic. In The Praxis of Suffering, Rebecca Chopp notes that, “In a variety of forms, liberation theologyspeakswith thosewho, throughtheir suffering, call into question the meaning and truth of human history.”9 Unlike most previous theologies, and unlike much modern philosophy, liberation theology has attempted to use social analysis tobothexplainanddeplorehumansuffering. Its key texts bring into relief not merely the suffering of the wretchedof the earth, but also the forces thatpromote that suf- fering.The theologianLeonardoBoff, in commentingononeof these texts, notes that it “moves immediately to the structural analysis of these forces and denounces the systems, structures, and mechanisms that ‘create a situation where the rich get richer at theexpenseof thepoor,whoget …