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the social structures – economic, political, legal, religious and cultural – that stop individuals, groups and societies from achieving their full potential

How structural violence can be used to understand the health related vulnerabilities that migrants face.

Structural violence is a powerful concept for understanding health-related vulnerabilities that migrants face, which will be explored through three different angles. The relationship structural violence has with gender will be first explored to unpack the ways in which assumptions about gender and sexuality impact health using ethnographies by Constable (2015, 2017). This will be followed with a discussion of Kau-Gill (2020) and Ye’s (2021) work regarding the relationship structural violence also has with race, revealing how migrants are often the subjects of racialised treatments leading to structures that can dictate health vulnerabilities. The final angle takes on almost an inverse approach in exploring how health vulnerabilities may sometimes be desirable to the migrants themselves and how this is also a product of structural violence highlighted through Ticktin’s work (2006, 2011). 

 

Structural violence will be used as a term referring to the “social structures – economic, political, legal, religious and cultural – that stop individuals, groups and societies from achieving their full potential” (Farmer 2006 cited in Qureshi 2013: 210). Farmer’s definition drawn from Galtung (1969) parallels a point made by Sargeant and Larchante who identify the “underlying political, economic, and social structures that produce particular patterns of health and disease among transnational migrants” (2011: 345). This understanding of structural violence and its relationship to health will be brought to life with ethnographic examples that reveal the ways in which certain structures inherently make migrants more susceptible health vulnerabilities. It must also be noted that this kind of violence is structural because it is not inflicted by a single actor and the key role the state plays in its infliction must be highlighted. Qureshi uses Foucault to define the state not as a coherent entity but a “dispersed new political anatomy of modern ‘biopolitics’ or ‘governmentality’” (Foucault 1977, 1984 cited in Qureshi 2013: 211). Structural violence is consequentially also an ideological phenomenon that Scheper-Hughes argues has ‘normalised’ and ‘naturalised’ everyday violence into public consciousness (2004 cited in Qureshi 2013: 210). Gupta builds on this by demonstrating how a “normal state of affairs” is maintained in contexts where “violence towards poor and marginalised populations is taken for granted” (2012 cited in Qureshi 2013: 210). In the ethnographic examples discussed below, the state as well as cultural common-sense assumptions about migrants will be revealed as intrinsically linked to the structural conditions that produce health vulnerabilities for these groups. 

 

Constable (2015, 2017) has written two profound texts that both highlight the experience of foreign domestic helpers (FDH) from Indonesia and the Philippines in Hong Kong. Constable’s work exposes how the cultural and legal dimensions of structural violence make pregnancy a huge health risk for female domestic helpers. This then also brings to life the way gender intersects with the health implications of structural violence as the sexuality of women becomes a threat to their stability in Hong Kong. Ginsberg and Rapp’s concept, ‘stratified reproduction’ therefore becomes helpful in understanding “the power relations by which some categories of people are empowered to nurture and reproduce, while others are disempowered" (1995 cited in Sargeant, and Larchante 2011: 349). FDHs are disempowered to reproduce, and it is within the crux of the power relations that instigate this disempowerment where pregnancy becomes a health vulnerability for these women. FDHs come to Hong Kong as reproductive labourers working and often living in the home of their employers. On a cultural front, FDHs are marginalised through common-sense understandings and anxieties held by locals that they are a sexual threat to “Chinese women employers in particular, the Chinese family in general, and Hong Kong society at large” (Constable 2017: 539). Their sexuality is particularly threatening to the Chinese woman employer because it risks compromising her role both a mother and a wife. This is heightened in a context where 90% of guest workers are women between the ages of 25 and 35, three quarters of which are also single (Ibid). Strict disciplining measures are deployed by employers such as a curfew, the requirement of conservative clothing, no jewellery, hair must be short, that FDHs must adhere to. This drive to keep FDHs as gender/sexually neutral subjects reflect the anxieties held in dominant cultural discourse about them being a “symbol of a moral order turned inside out” (Ibid). Domestic helpers working in their employer’s home consequentially reveals extreme tensions as FDHs are forced to exist within a paradox of intimacy and distance (Killias 2013). Spending six days a week in the intimacy of someone else’s home is complicated by the consistent creation of distance through othering and disciplining practices of employers, reflecting how the micro politics of cohabitation can parallel transnational boundaries. 

 

These cultural structures that isolate FDHs run alongside marginalising legal structures – such as the fickleness of employment contracts – and act as roadblocks to cohesive integration. Seargeant and Larchanteargue that “the health of immigrants is directly correlated with their degree of social integration and productivity, and illness debilitates immigrant populations, exacerbating their marginalisation" (2011: 346), highlighting why FDHs lack of integration poses serious issues. Their integration highlighted first in the cultural structures that deem FDHs a sexual threat to society, are also reflected legally as FDHs often only stay in Hong Kong for around four years. This works by being employed initially on a two-year contract that usually is only renewed once. FDHs are made to be temporary and almost ‘disposable’ as “the regulations stated in the ‘foreign domestic helper’ employment contract ensure that they are excluded from the benefits of citizens" (Constable 2015: 137-138). FDHs ironically depend on insecure employment contracts that do not open any doors to becoming permanent residents and can also be terminated very easily as without them, their options become very precarious. Terminating contracts abruptly is not always legal and almost always attributed to FDH’s sexuality, either due to jealousy of the woman employer or because helpers become pregnant. "If a worker presents her employer with official certification of pregnancy, theoretically she is safe from arbitrary termination"(Ibid: 143), however many do not know this. This is itself a product of structural violence as their cultural isolation as well as the temporary nature of their employment contracts act as functions within the political anatomy of the state that remove FDHs from assuming their rights. FDH’s temporary status is therefore solidified both culturally and legally, as employers often take advantage of this state inflicted temporary status where, FDHs then accept termination as 'inevitable’ or ‘deserved'. 

 

Pregnancy therefore becomes a health vulnerability as it is not only an isolating experience for FDHs who are made peripheral in Hong Kong’s society, but also creates large potentials for precarity. As evidenced above, domestic helpers are not well integrated, which as Sargeant and Larchante have argued correlates with the health of migrants (Ibid). This correlation is evident in the health concerns surrounding domestic helper pregnancies as it ‘proves’ the stereotypes about the sexual promiscuity of FDHs and means that they will often receive little support from employers whom their life in Hong Kong depends. The options available to FDHs also pose serious health concerns as they are limited in a context where domestic helpers are unintegrated and barely protected by locals or the state. During pregnancy, domestic helpers only have three options, and because of their temporary migrant status all three options increase their already vulnerable status. Women can choose to put their child up for adoption; however, this is difficult as consular staff and locals often force a guilt complex onto FDHs who consider this. Constable highlights some comments made by consular staff: “do the right thing and take her home”, “you are the mother, how can you do this?”, “eventually your family will accept the child” (2015: 143). Many domestic helpers also do not consider adoption because employers will likely terminate their contracts, which as stated above technically violates laws aimed to protect FDHs however employers nevertheless continue obstructing these protections. Contract termination also means that the only way FDHs can stay long enough to give birth to even consider adoption is to file an asylum/torture claim, which only allows a few extra months, offers minimal social support, and denies access to work (Constable 2015). Single motherhood without work poses serious health challenges for women as it exposes them to poverty in having to raise a child as an asylum. 

 

The second option is to abort the child, which is also made very difficult in Hong Kong as three medical visits are required before women are allowed to undergo the procedure. As domestic helpers work six days this is not an accessible option and exposes women to illegal and sometimes life-threatening abortions. Women may also experience mental health vulnerabilities in undergoing an abortion, where it can be particularly traumatising for those going against their own religious beliefs. This implies a fundamental gap in the health options and natal care available to FDHs. Constable explains how many pregnancies were also unplanned due to either a lack of consent or a lack of sexual health knowledge to explain why many women would want an abortion. Women may also want abortions because even consenting relationships often did not “last beyond the temporary and spatial confines of Hong Kong, because of the non-resident status of the women and of the men" (Ibid: 142). The structural violence experienced both culturally and legally therefore make both adoption and abortion extremely inaccessible options and most domestic helpers end up having to return to their home country to raise their child. Once domestic helpers return home however, they are viewed as a ‘failed’ migrant by their family and community. Raising a child back home also risks precarity for FDHs due to an end of remittances and having another mouth to feed. The shame these women face could also become a source of anxiety as she no longer fulfils her role as a daughter committed to improving her family’s standard of living. The irony is that FDHs become forced to rely on their parents for health and economic support when they themselves were the ones sent to mitigate the precarity of their families in the first place. 

 

Like Hong Kong, Singapore similarly employs female domestic workers, however the island state additionally employs male migrants often from Bangladesh, Mainland China and India for construction and shipyard work (Ye 2021). Prior to the Covid-19 pandemic, migrant workers in Singapore were already a very marginalised group who generally had a lower quality of health and whose access to health services was made extremely difficult (Kaur-Gill 2020). However, during the pandemic health vulnerabilities were only heightened where migrant workers were most impacted by Covid-19 infections. In Singapore, migrant workers are both culturally and physically isolated as they have become a racialised group whose integration is viewed as unnecessary, foreshadowing how structural violence played a role in the ill health of migrants during Covid-19. As with Constable’s work, migrant workers in Singapore are viewed as disposable, replaceable workers who are deemed to be subjects that need disciplining. For Constable discipline was enacted out of fear of domestic helpers as a sexual threat however for Kaur-Gill migrants are instead disciplined for being a racialised, biosecurity threat to the nation. Ye argues that globally migrants are disproportionately marginalised and are people “who were already deeply challenged by structural inequalities of race, gender, and income… the virus [therefore] starkly exposes pre-COVID-19 inequalities" (2021, 15). This is affirmed in the structures that specifically isolate and discipline migrant workers firstly including othering and racialising discourse in the press, most of which is moderated and censored by the state. Kaur-Gill highlights how the Singaporean state believes that "journalism should be about shaping a core national identity and setting societal norms and agendas” (George 2012 cited in 2020: 5) that often become unquestioned common-sense ideas in Singaporean society. Racialised discourse about migrants is no exception where the media has created a “space for the discussion of xenophobic and racist discourses that contribute to the othering of workers" (Kaur-Gill 2020: 14). Migrant workers were racialised even before Covid-19 as culturally irrelevant however also during Covid-19 as a biosecurity threat, where pandemic biopolitics therefore “reinforced existing spatial difference while normalising new ones" (Ye 2021, 15). Spatial difference becomes apparent in the way Covid-19 infections were measured as the Singaporean government characterised the pandemic as one virus with ‘two separate infections’ where "migrant cases" were separate from "community cases" (Ibid). This not only rationalised but also further perpetuated the divides and structures that isolate migrant workers from being part of Singaporean society.

 

Spatial difference is also evidenced in migrant workers marginalised dormitory housing often located on the periphery of Singapore which became "a site where the spread of COVID-19 infections took place rapidly due to the poor conditions that enabled the surge in infections" (Kaur-Gill 2020: 11). At the beginning of the Covid-19 pandemic, press reports would advocate that dorms had to adhere to social distancing, however the confinements of the space where 12-20 men would normally share one room, bathrooms, kitchens, and communal spaces made this impossible (Ye 2020). Consequentially, the majority of Covid-19 infections in Singapore impacted these low-skilled migrant workers. Migrant workers’ legal status in Singapore also offered little protection against this surge in infections and exposed them to even greater precarity. Legally, migrant workers can only remain in Singapore if they are working however these contracts offer little security, social protection, and financial stability. The migrant worker permit system is usually 2 years and must be renewed by the employer, creating no opportunity to later obtain citizenship or ever enjoy the same rights as citizens (Ye 2020). Work permit renewals were also challenged during Covid-19 as workers were unable to work for extended periods of time, which meant contracts were sometimes not renewed and the anxious fear of deportation was ever-looming. The structural conditions therefore of racialised assumptions in the media, marginalised housing and temporary work permits fundamentally isolated migrants and made this group more susceptible to Covid-19 infections. 

 

It has been explored how certain cultural, political, and legal conditions perpetuate violence structurally onto migrants and lead to vulnerable health conditions. However, in some cases these vulnerable health conditions are desirable to migrants as they become a way to mitigate the legal dimension of their own precarity. Ticktin (2006, 2011) has written two pieces on humanitarianism in France and how ‘regimes of care’ have become determinants of which migrants are deserving of aid. Ticktin contextualises this by discussing how the ‘illness clause’ in France was turned into law in 1998 granting legal residency permits to undocumented migrants living there who have life-threatening diseases. These permits were however only granted if subjects were not able to receive adequate treatment in their own country, where after five years people could claim citizenship, “thus, continual renewal of illness permits may eventually lead undocumented immigrants to citizenship" (Ticktin 2011: 38). While this did establish a legal change, it more profoundly established a significant health change to the lives of migrants as their security in France became premised upon the ability to prove mental or physical traumas. Those who were best able to prove health vulnerabilities – including HIV, polio, TB, or assault – became the most deserving and consequentially more mobile despite their ill status. In the clinics, social workers and doctors would work together and determine deservingness by asking undocumented migrants, ‘are you sick?’, and if answered ‘yes’ would follow with, ‘how sick?’. These actors representing the state had every intention of helping, however because the state determinant of deservingness became rooted in the ability to prove ill health conditions, humanitarian regimes consequentially became more destructive than good. 

 

Regimes of care problematically worked to maintain “certain people as less than human" (Ticktin 2006: 35), where migrants became wholly identified as ‘suffering bodies’ through this ‘proving’ process of obtaining medical citizenship. Being identified in this way means that migrants will never experience full citizenship or be viewed as politically relevant by society or by the state as “they are forever marked and interpellated as sick, as already handicapped - they can never realise equality" (Ibid, 44). Goldade discusses therefore how even though migrants can and do use this idea of the ‘suffering body’ to strategically make claims on the state, “deploying the body as a political tool thus illustrate the constraints on medical citizenship" (2009 cited in Sargeant and Larchante 2011: 348). This highlights the fundamental role of the state in perpetuating ill health structurally and specifically onto migrants, who have made deservingness premised on ill health. Obtaining legality in France therefore becomes a double-edged sword for migrants as poor health ironically becomes synonymous with legal status that is saturated with equality. Marginalising structures consequentially establish and maintain health vulnerabilities for migrants where the desire to use ill health as a gateway into France clearly becomes a product of structural violence. This is because ill health being readily adopted by migrants was accentuated by the lack of structural conditions that allowed them to migrate in a healthier way. 

 

It has been highlighted through several key ethnographic examples the ways in which certain forms of structural violence make migrant groups more susceptible to health vulnerabilities. Constable’s work contextualised the way gender and the consequential cultural and legal structures established through fears over female sexuality transformed pregnancy into an intense health risk. Kaur-Gill and Ye’s work were then used to frame how racialised conceptions of migrant workers isolate them in Singapore whose peripheral, marginalised housing made them more at risk of being infected by Covid-19. Finally, Ticktin’s work revealed how in some cases poor health becomes desirable for migrants to obtain legal status, which is also a product of structural violence as it highlights fundamental gaps in access to healthy migration.

 

 

Works Cited

 

Constable, N. 2014. Migrant Motherhood, ‘Failed Migration’, and the Gendered Risks of Precarious Labour. TRaNS: Trans-Regional and -National Studies of Southeast Asia 3, 135-151.

 

Constable, N. 2017. Sexuality and discipline among Filipina domestic workers in Hong Kong. In Gender in Cross-Cultural Perspective C. Brettell & C. Sargent(ed) , 545-564. (7th edition). Routledge.

 

Kaur-Gill, S. 2020. The COVID-19 Pandemic and Outbreak Inequality: Mainstream Reporting of Singapore's Migrant Workers in the Margins. Frontiers in Communication 5, 1-18.

 

Killias, O. 2013. Intimate Encounters: the ambiguities of belonging in the transnational migration of Indonesian domestic worker to Malaysia. Citizenship Studies 18(8): 885-899.

 

Qureshi, A. 2013. Structural violence and the state: HIV and labour migration from Pakistan to the Persian Gulf. Anthropology & medicine, 20(3), 209-220.

 

Sargeant, C., & S. Larchante (2011). Transnational Migration and Global Health: The Production and Management of Risk, Illness, and Access to Care. Annual Review of Anthropology. 40: 345–361.

 

Ticktin, M., 2006. Where ethics and politics meet. American Ethnologist, 33(1), pp.33-49.

 

Ticktin, Miriam I. 2011. Casualties of Care : Immigration and the Politics of Humanitarianism in France. 1st arg. University of California Press.

 

Ye, J. 2021. Ordering Diversity: Co‐Producing the Pandemic and the Migrant in Singapore during COVID‐19. Antipode 53, 1-26.