Medical Humanitarianism: Ethnographies of Practice 9780812291698

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Medical Humanitarianism

PENNSYLVANIA STUDIES IN HUMAN RIGHTS Bert B. Lockwood, Jr., Series Editor

Medical Humanitarianism Ethnographies of Practice

Edited by

Sharon Abramowitz and Catherine Panter-Brick Foreword by

Peter Piot

U N I V E R S I T Y O F P E N N S Y LVA N I A P R E S S PHIL ADELPHIA

Copyright 䉷 2015 University of Pennsylvania Press All rights reserved. Except for brief quotations used for purposes of review or scholarly citation, none of this book may be reproduced in any form by any means without written permission from the publisher. Published by University of Pennsylvania Press Philadelphia, Pennsylvania 19104-4112 www.upenn.edu/pennpress Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Medical humanitarianism : ethnographies of practice / edited by Sharon Abramowitz and Catherine Panter-Brick. pages cm. — (Pennsylvania studies in human rights) Includes bibliographical references and index. ISBN 978-0-8122-4732-9 (alk. paper) 1. Medical assistance—Case studies. 2. Humanitarian assistance—Case studies. 3. Medical anthropology—Case studies. 4. Disaster medicine—Case studies. I. Abramowitz, Sharon Alane, editor, author. II. Panter-Brick, Catherine, 1959– editor, author. III. Series: Pennsylvania studies in human rights. RA390.A2M43 2015 362.17—dc23 2015006400

Contents

Foreword ix Peter Piot

Bringing Life into Relief: Comparative Ethnographies of Humanitarian Practice 1 Sharon Abramowitz and Catherine Panter-Brick

PART I. INTIMATE INTERVENTIONS: HEALTH WORKER EXPERIENCES IN HUMANITARIAN CONTEXTS

Chapter 1. Dignity Under Extreme Duress: The Moral and Emotional Landscape of Local Humanitarian Workers in the Afghan-Pakistan Border Areas 23 Patricia Omidian and Catherine Panter-Brick

Chapter 2. Compassion and Care at the Limits of Privilege: Haitian Doctors amid the Influx of Foreign Humanitarian Volunteers 41 Laura Wagner

Chapter 3. Trust and Caregiving During a UNICEF-Funded Relief Operation in the Somali Region of Ethiopia 58 Lauren Carruth

vi Contents

PART II. THE ARCHITECTURE OF HUMANITARIAN KNOWLEDGE, ETHICS, AND IMPERATIVES

Chapter 4. Evidence and Narratives: Recounting Lethal Violence in Darfur, Sudan 77 Alex de Waal

Chapter 5. Life Beyond the Bubbles: Cognitive Dissonance and Humanitarian Impunity in Northern Uganda 96 Tim Allen

Chapter 6. Staging a ‘‘Medical Coup’’? Me´decins Sans Frontie`res and the 2005 Food Crisis in Niger 119 Jean-Herve´ Je´ze´quel

PART III. STRONG STATES, WEAK STATES, AND CONTESTED HEALTH SOVEREIGNTIES

Chapter 7. What Happens When MSF Leaves? Humanitarian Departure and Medical Sovereignty in Postconflict Liberia 137 Sharon Abramowitz

Chapter 8. Humanitarianism and ‘‘Mobile Sovereignty’’ in Strong State Settings: Reflections on Medical Humanitarianism in Aceh, Indonesia 155 Byron J. Good, Jesse Hession Grayman, and Mary-Jo DelVecchio Good

Chapter 9. The British Military Medical Services and Contested Humanitarianism 176 Stuart Gordon

PART IV. THE AFTERLIVES OF INTERVENTION

Chapter 10. Anthropology and Medical Humanitarianism in the Age of Global Health Education 193 Peter Locke

Contents vii

Chapter 11. The Creation of Emergency and Afterlife of Intervention: Reflections on Guinea Worm Eradication in Ghana 209 Amy Moran-Thomas

Chapter 12. Medical NGOs in Strong States: Working the Margins of the Israeli Medical Bureaucracy 226 Ilil Benjamin

Conclusion. A Measured Good 242 Peter Redfield

List of Contributors Index

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Foreword Peter Piot

Having spent four decades of my professional life addressing health care issues and pursuing social change, I welcome this timely and thoughtful volume that engages scholars and practitioners working at the intersection of medical science, anthropology, and emergency humanitarianism. The field of humanitarian health, as it takes a higher priority on the global agenda, needs such sensitive and expert study of the intersection of humanitarian medicine and global health interventions. As a practitioner and scientist in Belgium, in what was then Zaire, and subsequently through the United Nations on a global scale, I have learned the hard way about the extreme complexity involved in tackling the challenges of infectious diseases and epidemics, as well as the holistic nature of human health and well-being. This personal and professional journey has also compelled me to become a practitioner of the art of politics at all levels: from the micropolitics of the village or the laboratory to the international politics of energizing the United Nations system to respond to an entirely novel threat, such as the AIDS pandemic or the West African Ebola crisis. The politics of human health has obliged me to study and practice the methods of social anthropology, becoming a reflective observer as well as a participant. Questioning the cultural and scientific premises of our approaches to humanitarian assistance and being prepared to see the problem from others’ points of view are necessary to tackle the biggest international public health and humanitarian challenges of our time. Medical humanitarianism is an especially vital area of comparative and analytical research. As this field of scholarship grows, we are seeing important quantitative and qualitative research, alongside the development of

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codes of practice. Going forward, the skills of the epidemiologist, ethnographer, and ethicist are equally necessary. The chapters in this volume address many of the challenges I have encountered and struggled with during my career, and I am delighted that these issues are obtaining the scholarly attention that they warrant. They deal with people of diverse backgrounds, local and international institutions, social and political struggles, and encounters with political power, bureaucracy, and prejudice. They showcase the concerns of today’s anthropologists and other social scientists, analyzing the encounter between different societies and institutions with their challenges of mutual comprehension and the effective application of science. Each chapter offers a compelling human story and addresses tough questions about medical humanitarianism without getting mired in critique or jargon. Some of the toughest issues facing physicians and humanitarian practitioners are addressed in this volume. For example, the decision by humanitarian organizations to withdraw from a project has rarely been scrutinized. It is an area that has largely been shielded from attention by closed-door institutional decision making. The dilemmas and dangers faced by the local staff of humanitarian agencies—most starkly seen recently in the killings of local polio health workers in Pakistan—are another area that is given much-needed attention in this volume. Other chapters grapple with relations between foreign experts and their local counterparts, the application of technology and expertise to complicated local problems, and ensuring that humanitarian principles do not become dogmas. Contributions bring new methods to bear on familiar problems and familiar methods on new issues, such as applying the methods of infectious disease epidemiology to delve into shifting patterns of lethal violence in complex internal conflicts. In brief, medical humanitarianism has emerged as a significant global agenda, and this book, with its particular attention to detailed ethnography, represents a truly important contribution to the field. I am especially fascinated by the trope of ‘‘comparative humanitarian ethnographies’’ advanced by the editors, Sharon Abramowitz and Catherine Panter-Brick. In light of the recent Ebola crisis, which unfolded as this book went to press, this book becomes even more prescient of the lessons that can be learned by examining well-grounded ethnographies in comparative perspective for a more critical and compassionate understanding of humanitarian assistance.

Bringing Life into Relief: Comparative Ethnographies of Humanitarian Practice Sharon Abramowitz and Catherine Panter-Brick

Medical Humanitarianism: Ethnographies of Practice offers twelve ethnographic case studies focused on the tensions inherent in the practice of medical humanitarianism. We define medical humanitarianism as the field of biomedical, public health, and epidemiological initiatives undertaken to save lives and alleviate suffering in conditions of crises born of conflict, neglect, or disaster. This volume aims to expand the scope of ethnographic research on humanitarian assistance and provide relevant insights into medical humanitarian practice. Its intended readers are those who appreciate the power of ethnography and are curious about the intersection of medical humanitarianism, global health, international development, peacebuilding, and human rights advocacy. Ethnography in conflict and disaster settings has already established medical humanitarianism as a distinct field of practice and cultural inquiry (reviews by Abramowitz, Martern and Panter-Brick 2014, and Good, DelVecchio Good, Abramowitz, Kleinman, and Panter-Brick, 2014). This initiative follows the significant intellectual and moral efforts to redefine and reimagine the field of global health (Biehl and Petryna 2013, Farmer, Kim, Kleinman, and Basilico 2013, Panter-Brick, Eggerman, and Tomlinson 2014) as well as the practice of politics and international development (Duffield 2007, Li 2007, Farmer 2012). With their long-term commitments to local populations, ethnographers are well situated to articulate the space of points of view articulated by Pierre Bourdieu: ‘‘[Cases] must be brought together as they are in reality, not to relativize them in an infinite number

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of cross-cutting images, but, quite to the contrary, through simple juxtaposition, to bring out everything that results when different or antagonistic visions of the world confront each other—that is, in certain cases, the tragic consequences of making incompatible points of view confront each other, where no concession or compromise is possible because each one of them is equally founded in social reason’’ (Bourdieu 1999: 3). By prioritizing ethnographic juxtaposition and thematic continuity, we hope that this work might offer a template for a next generation of ethnographies of practice—to make visible the range of humanitarian assistance and the logic of institutional actors across sites of emergency. To advance this comparative endeavor, we asked our contributors to offer memorable short ethnographies of medical humanitarianism that would foreground their own experiences, provide deep context for humanitarian crises, and invite empirical and theoretical reflection. They brought us accounts of medical humanitarian engagement from sub-Saharan Africa, Asia, the Middle East, and the Caribbean that showcase medical humanitarianism as a diverse arena, deeply embedded in local contexts. Our contributors narrate how medical humanitarian encounters can become a fulcrum of moral and ethical experiences as well as give rise to proxy battles over state sovereignty, humanitarian autonomy, and the right to intervene. They address the complications involved in offering, implementing, or withdrawing aid and examine issues of social justice and biomedical authority through place-based interrogations of systems of humanitarian delivery. They map unique configurations of medical humanitarian engagement to reveal the distribution of suffering and healing and the tensions between ethical and political engagement. Ethnographies of humanitarianism often seek to integrate local and transnational levels of analysis (Harrell-Bond 1986, Terry 2002, Magone, Neuman, and Weissman 2012, de Waal 1994, 1997), medical and institutional complexities (Fox 2014, Orbinski 2008, Redfield 2013), and global discursive realities (Fassin and Rechtman 2009, Duffield 2001, 2007). However, it can be an enormous challenge for ethnographers to ‘‘go deep’’ in order to capture the inner workings of subjectivity and agency, while remaining mobile enough to track the circumlocutions of power from donors to the clinic, from the clinic to national headquarters, and from headquarters to central offices in Paris, Geneva, or New York. Some researchers become especially attentive to the local facets of social, moral, and emotional experience in the face of great suffering or danger (Kleinman

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2006, Eggerman and Panter-Brick 2010), while others are drawn to undertake forensic investigations of humanitarian aid (Abramowitz 2014, Strathern 2000, Bornstein 2012). Some track the movements of cash and regulations (Bornstein 2012), the allocation of health resources (Benton 2012), the use of novel forensic technologies (Wagner 2008), or the movements of bureaucracies and humanitarian authority (Feldman 2008). A growing line of inquiry examines the discourses that span humanitarian and ‘‘metropolitan’’ sites from the wealthy centers of global power where interventions are selected, planned, and funded to the poorer peripheries where interventions occur (Calhoun 2010, Fassin 2011, Weizman 2012) and the role that humanitarian assistance often plays as ‘‘the lesser evil’’ (Keen 2014). In this way, qualitative scholars are emerging as ‘‘historians of the present’’ to document individual experiences, institutional memory, and the cultural values that shape humanitarian practice from site to site.

Comparative Humanitarian Ethnographies Such ethnographic accounts can inspire new avenues for research, ones that better link ethnographic insights to the practical concerns of humanitarian assistance by conveying a grounded, or emic, representation of humanitarian space. In this spirit, we advance both critical and compassionate ethnographies that offer robust insights into the nature and structure of humanitarian practice, while insisting on a deep commitment to the human values, social relationships, and political structures conducive to health. We see the need for an explicitly comparative approach to medical humanitarian practice that expands the scope of intellectual inquiry but retains a very humane purpose. Through the telling of a story, ethnographies powerfully elicit both social critique and human compassion, while through the comparative juxtaposition of ethnographic cases, one learns more of the forest than one does of singular trees. We believe that comparative humanitarian ethnographies bring medical humanitarian life into sharper relief, inspiring innovation, accountability, and relevance in the field. Building upon a long history of engagement between humanitarian practice and social science research, we also hope that this collection will seed ongoing conversations for pedagogy and help shape teaching and training agendas in humanitarian practice and in the social sciences. Such agendas are vigorously debated in the field of humanitarianism, with issues

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ranging from the importance of local views to engagement with the military (Barnett and Weiss 2011). Moving beyond the current critical dialectic between humanitarian practitioners and academic researchers, we ask how ethnography can engage with humanitarianism work without becoming mired in struggles over practical relevance and moral legitimacy. Indeed, many social scientists have offered reflective insights that go beyond the confines of adapting research protocols to local cultures and have instead played an integral role in program evaluation or decision making in policy (Ventevogel et al. 2012, Tol et al. 2011).

The Contested Space of Medical Humanitarianism Since the nineteenth century, when humanitarian aid emerged as an important moral force in the modern era (Hochschild 2011), medical humanitarian interventions have been present at battlefields to provide care, triage, and comfort to the dying (Irwin 2013, Moorehead 1998, Bass 2008, Haskell 1985) and have delivered material goods like bandages and prostheses to the survivors of war and disaster. Throughout the twentieth century, and especially after the end of the Cold War, medical humanitarianism grew in scale and complexity, moving far beyond its early goal of direct physical and spiritual support to the creation of clinics, hospitals, and camps where refugees can seek services ranging from surgery to mental health counseling and HIV/AIDS treatment. Today medical humanitarianism holds a prominent presence in international development, global health, human rights advocacy, and international peacekeeping and diplomacy. Funding for medical humanitarian institutions has come from political and charitable platforms that have included individual benefactors, schools, and places of worship, as well as corporate fund-raising partners, states, national militaries, and international nongovernmental organizations (NGOs) that support policy or coordinate humanitarian assistance such as the World Health Organization, the World Bank, the Inter-Agency Standing Committee (IASC), and the UN’s Office for the Coordination of Humanitarian Affairs (UNOCHA). Fame has tracked closely with the fortunes expended on medical humanitarian assistance: dozens of humanitarian organizations have earned recognition for their provision of healthcare in emergency conditions. Most prominently, Me´decins Sans Frontie`res was awarded the Nobel Peace Prize

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in 1999; this was widely recognized as an international gesture calling attention to the ability of humanitarian organizations to link global health with conflict resolution and peacebuilding (Arya 2007). Culturally, medical humanitarianism has gained visibility on television (e.g., NBC’s ER and ABC’s Off the Map) and in feature films (e.g., Welcome to Sarajevo [1997]; Beyond Borders [2003]; An Imperfect Offering [2008]). But understanding humanitarianism solely through its global reputation would render observers blind to its internal operations, debates, trends, and countertrends, as well as to how power, culture, knowledge, and authority work through local sites and centralized bureaucracies. In this section, we identify several issues in humanitarian practice that would benefit from ethnographic examination. While there are significant overlaps between humanitarianism, global health, and development discourses, the healthcare work that takes place in humanitarian contexts continues to be defined by its exceptionality (Agamben 2005). The discourse of medical emergencies demarcates the space, time frames, governance paradigms, and systems of accountability of humanitarian aid. Although ‘‘exceptions’’ are present in nearly all examples of medical humanitarian practice, it is the contextually specific details that give form and variation to real-life instances of medical care in disasters and humanitarian crises. Concerns about regional security, trending perceptions of humanitarian neutrality, or institutional ability to negotiate access to healthcare and affordable life-saving medications, all have the ability to shape the particular content and relations that take place in the clinic, in the health education project, or in the management of local epidemics. Global humanitarian culture shapes medical humanitarian practice at the local level just as surely as the presence of conflict, the arrival of medical supplies, or the availability of experienced doctors does. Ethnographic accounts have the ability to make visible the interdependence of an expatriate or national doctor holding a stethoscope to the chest of an elderly refugee woman and the global cultural, financial, and political flows that make that intimate interaction possible. The borderlands between humanitarian medicine and global health are often stitched together through the personal careers of global health and humanitarian practitioners. The classic archetype of humanitarian healthcare involves local health workers supervised by international expatriate staff, but the composition of both expatriate and local workforces is rapidly changing (Shevchenko and Fox 2008, Ager and Iacovou 2014). The binary

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categories of ‘‘expat’’ and ‘‘local’’ encompass people who seek lifelong careers in global health and humanitarian medicine, as well as volunteer medical professionals, students, and short-term consultants. The category of ‘‘expat’’ includes medical professionals from wealthy and developed nations, regional experts from low- and middle-income countries, and students with relatively little medical experience. ‘‘Local’’ humanitarians, for their part, might include part-time volunteers, full-time government staff charged with distributing health, education, and social services, or private businesses and institutional contractors tasked with providing construction, security, or infrastructure development. As medical humanitarian personnel move from field site to field site, they carry with them the sum of their knowledge, experiences, and training. Through rumors and storytelling, they share their experiences, as well as their beliefs, their biases, and their priorities, with colleagues and employees. This results in the emergence of noticeable regional medical humanitarian subcultures with orally transmitted histories and memories that fuse humanitarian cultures with the structure and practice of local humanitarian healthcare delivery. As informal humanitarian interaction, movement, and communication accelerate, humanitarian policies and technologies are shifting toward the formalization of humanitarian practice. In the last few decades, humanitarian organizations have matured from their earlier and much-celebrated flyby-night heroics. They have grown more bureaucratic and professionalized. They are continually developing frameworks to standardize humanitarian practice and management, and they are rapidly investing resources in all aspects of institution-building. This has substantial implications for technology, policy, and knowledge across mobile global governance networks (Grayman 2014). Handbooks, textbooks, and training materials on humanitarian management, logistics, supply chains, and materiel (Kova´cs and Spens 2007, Van Wassenhove 2005) are no longer concealed in gray literatures and are easily accessible in print and on the Internet. There has been widespread demand for instruction in humanitarian policy, law, information systems, logistics, media relations, security, and communications, facilitating transitions from humanitarian aid to development praxis. Through initiatives like the Financial Tracking Service at UNOCHA, increasing requirements for monitoring and evaluation, and growing investments in postcrisis stabilization and transitions, humanitarian agencies are using information in new ways to increase transparency and accountability, while remaining ambivalent about the creation of strong oversight mechanisms.

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Professional knowledge is highly valued in the upper levels of NGO management and in the most central functions of medical humanitarian organizations. Alongside medical doctors, one finds logisticians, financial managers, and policy directors setting short-term intervention goals and defining long-term institutional strategies. The professionalization of the humanitarian sector has become a substantial stand-alone industry, and nowhere more so than in the medical humanitarian domain. In universities and medical schools, new service-learning, graduate, and certificate programs are being created every year to meet the demands of a rising tide of medical students seeking novel professional experiences in global health that are consistent with a liberal ethic of ‘‘giving back,’’ ‘‘doing good,’’ or ‘‘making a contribution.’’ Although the service-learning aspect is often vaunted by universities, ethnographic research has demonstrated that in practice, service learning is of uncertain value. It can generate ethics of internationalization, charitable giving, and volunteerism in new healthcare professionals, but it can also lead to the weakening of local health sectors, significant medical malpractice, questionable medical ethics, and generally low or inappropriate standards of care, which stunt the humanitarian impulse. This is increasingly being documented through ethnographic investigation: in sub-Saharan Africa, for example, thousands of volunteers have been helping sustain an overstretched workforce (Laleman et al. 2007), while research in Guatemala suggests that medical volunteerism, even when overseen by major research and academic institutions, can be more focused on ‘‘doing something’’ for the sake of student experience than on providing competent medical care (Berry 2014). These social experiments with medicine, however, are happening on the bodies of the poor and vulnerable. Some ethnographic observers of medical humanitarianism have criticized humanitarian assistance activities for the same reasons that they have criticized international development projects: they often have substantial unintended consequences, weak international oversight, and little local input, and they have the ability to wield a tremendous amount of political and financial power in changeable and resource-scarce contexts. Fairly or not, humanitarian assistance has been criticized for fostering dependency and failing to address the political and economic conditions that are the root causes of human suffering (de Waal 1997, Barnett and Weiss 2011, Rieff 2003, Maren 2009, Moyo 2009, Polman 2010). Numerous case studies have emerged to track humanitarian missteps and failures (Terry 2002). In particular, scholarly work has highlighted the problematic aspects of

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‘‘humanitarian reason’’ and ‘‘moral untouchability’’ that impede critical analysis (Fassin 2011) and humanitarian policy innovations such as ‘‘the right to intervene’’ and ‘‘the responsibility to protect’’ that enable a flexible interpretation of sovereignty in disaster and crisis scenarios (Weiss 2004, Allen and Styan 2000, Pandolfi 2003). It has also challenged humanitarian intimacy with military paradigms (Duffield 2001, Von Boemcken 2007), neocolonial tendencies (Atlani-Duault and Dozon 2011, Bricmont 2007), and medical humanitarian agencies’ uncomfortable relationship with international development praxis (de Sardan 2011). But critique requires care. While the scholarly critiques of humanitarian reason (Fassin 2011, Feldman and Ticktin 2010), of humanitarian responses to complex emergencies (Harrell-Bond 1986, de Waal 1994, Allen and Schomerus 2008), and of global health (Singer and Hodge 2010, Fassin 2012) are wholly necessary, from the standpoint of humanitarian practice, there is a sense that critical scholarship fails to convey the real-time exigencies of humanitarian experience and the range of internal debates taking place within humanitarian networks. As one study documented, there are ‘‘frustrations that research projects were being optimally geared not towards informing programs but towards informing academic debates without relevance for practice’’ (Tol et al. 2012: 33). This complaint has merit: many researchers are concerned with trying to understand and represent the multifaceted nature of humanitarian assistance, and ethnography is not necessarily at its best when put to ‘‘use’’ as the technical handmaiden of humanitarian projects. Sometimes ethnographic research can seem to have little understanding of the contingent conditions that surround humanitarian projects and to overstate the ability of humanitarian organizations to forecast future developments and foresee unintended consequences. For humanitarians, accepting critique might mean inviting paralysis— which is simply not a viable option in the face of massive threats to human life and security. Humanitarian practitioners often maintain that the purpose of humanitarian action is to address immediate needs, while initiatives to resolve crises or rebuild after disasters must be taken at the political level. They seek tactical recommendations from critical observers that will help them meet those goals while respecting the fundamental structures and limits of humanitarian action. By contrast, many anthropologists maintain that in order to address population needs in humanitarian crises, institutions must first address the structural and political causes of such crises (see

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Abramowitz, Marten, and Panter-Brick 2014). How does this debate work in specific locations, such as Sierra Leone, Syria, or Sri Lanka? Herein lies a framework for an important debate about the purpose, possibilities, limitations, and claims presented through humanitarian assistance. In different conditions of disaster and emergency, medical humanitarian action is confronted with differential distributions of access, resources, labor, risk, and global public support for intervention and assistance. Ethnography offers a way to thread the needle on this problem by tracking these trends within and between contexts, empirically linking them to global flows and local experiences, and presenting the ethnographic case as the vehicle for analysis and evaluation. Contrasting evidence provides insights into unseen continuities, and striking divergences between mandates often point the way toward consistent but opaque processes of decision making and prioritization. What explains the fact that mental health and psychosocial support are deemed a priority for some conflict-affected populations but hardly funded for others? Ethnographic study offers a path to explanations that move us beyond mea culpa and identify the root processes that determine specific outcomes. The competing ethical, medical, material, and financial needs and priorities that characterize medical humanitarianism have direct consequences for the bodies and lives of beneficiary populations. The medical imperative to ‘‘first, do no harm’’ can conflict with the conditions of medical care in uncertain or chaotic situations, and the ethical principles of neutrality, impartiality, and independence are often severely tested at the site of healthcare delivery (Terry 2002, Magone, Neuman, and Weissman 2012). In order to address these challenges, medical humanitarian organizations have joined together to establish guidelines for the practices of their professional and volunteer membership. In the last decade alone, humanitarian action has been increasingly informed by emerging standards for practice, institutional reforms, and monitoring and evaluation efforts. Such efforts include the development of voluntary standards and ethical frameworks, such as The Sphere Project (2011), endorsed by many humanitarian agencies, and the Code of Conduct (1994), developed by the International Committee of the Red Cross (ICRC), now integral to a common curriculum for humanitarian practitioners. More than just a disparate network of actors, the humanitarian system of interagency cooperation now establishes funding priorities, negotiates international agreements, and advocates for humanitarian political agendas in addition to regulating ‘‘on-the-ground’’

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humanitarian activities, prioritizing the distribution of healthcare, and maintaining relationships with state governments and local populations. Often the humanitarian system functions with a quiet heroism and accomplishes tremendous feats with limited resources. NGOs and multilateral institutions are growing in their capacities for critical self-reflection, self-regulation, and self-determination in order to resolve the endemic issues that have compromised medical humanitarian assistance in the past. Some of the energy behind these reforms comes from medical humanitarian workers’ own expectations of what is possible, tolerable, or the morally right thing to do, while some of it derives from past experiences of failure. However, the global movement to transform, professionalize, and improve humanitarian practice suggests that previously unrecognized mechanisms for innovating institutional memory, culture, and ethics are being developed and communicated across global ‘‘intervention-scapes’’ (borrowing from Appadurai 1996). How do these processes work? What are the intellectual, cultural, ethical, and material forces in play in specific negotiations over self-regulation, selfgovernance, and interagency cooperation and reform? Tracing the cultural infrastructure that sustains humanitarian institutions across shifting landscapes, personnel, and historical moments requires a comprehensive, evidence-driven examination of how these particular practices are globalized, translated, and localized across time and space. This, we argue, is the next direction for ethnographic research of medical humanitarianism, and it can serve as the foundation for a grounded, meaningful, and constructive dialogue between social science and humanitarian practice.

Ethnographies of Practice Our volume is divided into four parts. In Part I, ‘‘Intimate Interventions: Health Worker Experiences in Humanitarian Contexts,’’ the contributors narrate medical humanitarian encounters at the site of the most elemental efforts to engage with complex health events and moral quagmires. We offer three specific examples of the intimate nature of physical and psychosocial care in contexts of extreme vulnerability. In their analyses of the cultural, moral, and emotional worlds of local humanitarians, Patricia Omidian and Catherine Panter-Brick (Chapter 1) describe the dramatic dangers experienced by Pakistani healthcare workers at risk of summary

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execution or kidnapping for their perceived collusion with Western powers, in the border areas with Afghanistan currently in the grips of a military insurgency. The emotional toll of healthcare work in camps for internally displaced people challenges us to recognize how local humanitarians embrace suffering—as well as search for dignity in the face of considerable economic, political, and moral pressure. In this case, government-run humanitarian agencies search for culturally relevant ways to respond to the dire safety and psychosocial needs of their employees. The fact that they have so little space and time to adequately address safety and health issues at the forefront of humanitarian life also raises pressing and unresolved issues regarding how institutions respond to the danger, vulnerability, or burnout of humanitarian workers rooted in the area. Laura Wagner (Chapter 2) narrates Haitian doctors’ experiences of frustration, envy, and structural inequality in the presence of medical humanitarian practice after the 2010 earthquake that decimated Haiti. As betterresourced medical humanitarian NGOs delivered both healthcare and moral censure in a context of deep societal rupture, there were emotionally fraught engagements between Haitian and expatriate doctors. Wagner compels us to confront how the emotional architecture of humanitarian ‘‘gifts’’ operates in resource-scarce contexts. She also asks us to think about the fraught relationships between medical humanitarian practice and local medical systems. Lauren Carruth’s depiction of medical humanitarianism in a Somali region on the Ethiopian border (Chapter 3) shows how healthcare delivery encounters can become a site for peacebuilding. Our challenge here is to consider how medical humanitarian encounters can become sites for enacting intimate trust and for producing healing political subjectivities. All three essays are concerned, in different ways, with the subjective and affective worlds of medical humanitarian encounters, providing concrete examples of how ethnography illuminates the dynamics of humanitarian engagement and the materiality of medical humanitarian assistance. In Part II, ‘‘The Architecture of Humanitarian Knowledge, Ethics, and Imperatives,’’ we present three case studies of the contested sources of moral authority in a humanitarian emergency, which has been problematized elsewhere by Craig Calhoun (e.g., Calhoun 2010) as a dominant discourse in humanitarian intervention. Each of these stories challenges naı¨ve assumptions about humanitarian expert knowledge, asking us to reconsider who has the authority to declare emergencies and on what grounds, and

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to rethink the presumed neutrality of medical humanitarian appeals for assistance. Alex de Waal (Chapter 4) provides a critical, grounded epidemiology of lethal violence in the Darfur conflict, and challenges us to reconsider the ‘‘motivated truths’’ that shape expert knowledge pertaining to the representation of certain kinds of emergency. Here de Waal shows how the fierce Darfur conflict that began in 2003 came to be labeled as genocide, just as the empirical data on mortality and microlevel descriptions of violence had begun to support more nuanced readings of this conflict. In turn, Tim Allen (Chapter 5) demonstrates how medical humanitarians, when managing decisions about the distribution of emergency aid, live inside ‘‘bubbles’’ of knowledge, bubbles akin to hastily wired-up circuits of humanitarian knowledge about the evidence ‘‘out there.’’ These bubbles solidify certain kinds of humanitarian ‘‘truths’’—about the power of a traditional healing ritual, about the relative threat of HIV/AIDS, and about a generation of disappeared children—while occluding a much bigger and visible truth: the fact that humanitarian institutions accidentally colluded in the establishment and justification of a vast network of concentration camps for Ugandan citizens. Jean-Herve´ Je´ze´quel (Chapter 6) draws upon his own experiences working with Me´decins Sans Frontie`res (MSF) during the 2005 food crisis in Niger to discuss how a single NGO became involved in reshaping the definition of the food crisis emergency and effectively engaged in a ‘‘medical coup’’ by promoting emergency biomedical care and sidelining long-term livelihood development. The articulation of humanitarian assistance as a biomedical intervention capitalized on the distribution of Plumpy’Nut, a highly successful treatment for severe protein and energy malnutrition, targeted at starving children, and managed to supersede Niger’s own sovereignty over food security surveillance and strategies for development. In Part III, ‘‘Strong States, Weak States, and Contested Health Sovereignties,’’ the conflict between humanitarian and state sovereignty comes to the fore. Sharon Abramowitz (Chapter 7) narrates the experience of the withdrawal of MSF-France and MSF-Belgium from Liberia in 2006, during a postconflict recovery that began in 2003, after a thirteen-year-long civil war. She offers several possible interpretations of the meaning of humanitarian sovereignty—custodial sovereignty, mobile sovereignty, and empirical sovereignty—through the test of the right of medical humanitarian NGOs to summarily withdraw aid. By examining how humanitarian institutions withdraw from crisis contexts, Abramowitz considers how medical

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humanitarian institutions independently negotiate debates over state responsibility, economic influence, and epidemiological outcomes in accordance with institutional missions, global funding streams, and current development ideals. She also considers how humanitarian aid withdrawal challenges conventional thinking about the meaning of state sovereignty, health sovereignty, and the ‘‘responsibility to protect.’’ In their study of post-tsunami humanitarian intervention in Banda Aceh, Indonesia, Byron Good, Jesse Grayman, and Mary Jo DelVecchio Good (Chapter 8) show that the central presuppositions of humanitarian practice have already presumed the presence of ‘‘weak states’’ or ‘‘statelessness’’ in the architecture of aid. As a result, when confronted with the reality of a strong state like Indonesia, humanitarian institutions must deal with the reality of strong state institutions in a moment of disaster transition. The chapter shows, however, that in reality, humanitarian organizations critiqued as forms of ‘‘mobile sovereignty’’ are most often far from sovereign and are enormously dependent upon local actors and structures to carry out their work, whether in strong or weak state settings, and that their work is mediated via very complex local forms of power, social organization, and culture, all of which change over time as emergencies evolve. Stuart Gordon (Chapter 9) demonstrates the conflicted character of negotiations over health sovereignty in his portrayal of military officers and doctors working for the British Army Medical Services in Iraq and Afghanistan. Gordon scrutinizes the multifarious roles of medical officers in the military, who as medical doctors profess to save lives but who take lives as soldiers in their allegiance to a military body. Although military and civilian medical humanitarians shared ethical precepts, medical practices, and community relationship ideals, military medicine was regarded as a threat to civilian medical NGOs, as a competitor for humanitarian space, and as de facto violators of the humanitarian ethic of neutrality. Part IV, ‘‘The Afterlives of Intervention,’’ offers three case studies that examine the pragmatic challenges of undertaking ethical ‘‘missions’’ in medical humanitarian practice. Peter Locke’s account (Chapter 10) of his involvement with a small U.S./Sierra Leonean medical NGO shows that in recent years, medical humanitarianism has become a powerful focal point for medical students, public health students, epidemiologists, doctors, international development workers, and humanitarian experts. One ambiguous consequence of this activity is the emergence of dubious or ‘‘flexible’’ medical research ethics among highly vulnerable populations.

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Unlike Locke’s study of a small humanitarian start-up, Amy MoranThomas’s essay (Chapter 11) analyzes a vast campaign—the Carter Center’s Guinea Worm Eradication Program—that covered many countries simultaneously. Moran-Thomas elegantly traces the history, practice, and ‘‘afterlife’’ of the eradication program in Ghana and demonstrates how the Carter Center was able to transform a concern about life-threatening water sanitation issues (especially waterborne parasites) into a characterization of the prevalence of the nonlethal guinea-worm as a ‘‘state of emergency.’’ Deftly tracking the Carter Center’s campaign from Ghana to war-torn Sudan, Moran-Thomas demonstrates how the satellite nature of the campaign succeeded in targeting a waterborne disease without providing clean water, a basic necessity of life. In doing so, she questions the prominence of magic bullets in global health interventions, the cultural history of war metaphors and military technologies in health campaigns, and the ways these complex repertories have intersected with ongoing political violence and contested meanings of humanitarian emergency. From her vantage point as an anthropologist-volunteer for a human rights–oriented medical humanitarian NGO in Israel, Ilil Benjamin (Chapter 12) considers the tension between long-term human rights advocacy and emergency healthcare for illegal migrants. Benjamin’s chapter presents a moving account of how the organization’s volunteers struggle to reconcile their clinic’s limited medical potential with the human rights ambitions of the organization’s membership. Her essay suggests that in countries in which healthcare constitutes a form of citizenship entitlement, human rights agendas can create an undertow against the imperative to provide medical care. It also underscores how access to care becomes a political issue for citizenship reform in the Israeli State. Finally, in the conclusion, Peter Redfield offers further reflection on our ‘‘ethnographic challenge’’ to gain a deeper understanding of humanitarian practice through the juxtaposition of specific case studies and the questions they generate. Noting that ‘‘medicine, then, might be good to think with when considering humanitarianism,’’ Redfield brings into focus how, in each of the narratives presented in this book, the frameworks of social sciences analyses on care, suffering, and medical knowledge interact with humanitarian exceptionalism to create new ways of being, knowing, and interacting in humanitarian contexts. He presses the reader to recognize, as the diversity of cases manifests, that the medicine in humanitarianism constitutes a highly politicized yet pluralistic space of action that benefits from measured observation and reflection.

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Conclusion The chapters in this book are challenging: through intense, close-up studies of the interactions that transpire between medicine, global health, and humanitarianism, they uncover corruption, flawed prioritization, and structural conflicts but also human resourcefulness and dignity in the face of adversity. In seeking to engage two principal audiences—humanitarian practitioners and social science researchers—we chose case studies that demonstrate the value of rigorous and immersive observation of humanitarian praxis as it intersects with biomedical, public health, and epidemiological interventions. We offer concrete narratives that ‘‘track’’ the human and social architecture of humanitarian practice in order to shift the ethnographic research agenda to ‘‘where the action is’’ in cultural inquiry. We hope that this collection will inspire ethnographers to seek fluency in the local languages of humanitarian practice—not just foreign languages per se but rather the bureaucratic, technical, medical, and financial languages of medical humanitarianism. The ethnographic comparison of cases in juxtaposition brings attention to how power and privilege shape the production of knowledge, structure the practice of medicine, and mediate the performance of human compassion. In advancing comparative ethnographies, we seek innovations to render humanitarian practice more accountable to outside observation while asking ethnography to be more relevant to the concerns of humanitarian relief. References Abramowitz, Sharon. (2014) Searching for Normal in the Wake of the Liberian War. Philadelphia, PA: University of Pennsylvania Press. Abramowitz, S., Meredith Marten, and Catherine Panter-Brick. (2014) ‘‘Medical Humanitarianism: Anthropologists Speak Out on Policy and Practice.’’ Medical Anthropology Quarterly 29 (1): 1–23. doi: 10.1111/maq.12139. Agamben, Giorgio. (2005) State of Exception. Trans. Kevin Attell. Chicago: Chicago University Press. Ager, A. and M. Iacovou. (2014) ‘‘The Co-construction of Medical Humanitarianism: Analysis of Personal, Organizationally Condoned Narratives from an Agency Website.’’ Social Science & Medicine 120: 430–438. Allen, T. and M. Schomerus. (2008) Complex Emergencies and Humanitarian Responses. London: University of London Press. Allen, Tim and David Styan. (2000) ‘‘A Right to Interfere? Bernard Kouchner and the New Humanitarianism.’’ Journal of International Development 12 (6): 825–842. Appadurai, Arjun. (1996) Modernity al Large: Cultural Dimensions of Globalization. Minneapolis, MN: University of Minnesota Press.

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Arya, Neil. (2007) Peace Through Health? Oxford: Routledge. Atlani-Duault, Lae¨titia and Jean-Pierre Dozon. (2011) ‘‘Colonisation, de´veloppement, aide humanitaire: Pour une anthropologie de l’aide internationale.’’ Ethnologie franc¸aise 41 (3): 393–403. Bakhtin, Mikhail Mikhaı˘lovich and Michael Holquist. (1981) The Dialogic Imagination: Four Essays. Vol. 1. Austin: University of Texas Press. Bans, J., producer. (1992) Off the Map. American Broadcasting Company. Barnett, Michael and Thomas G. Weiss, eds. (2011) Humanitarianism Contested: Where Angels Fear to Tread. Global Institutions Series. New York: Routledge. Bass, Gary J. (2008) Freedom’s Battle: The Origins of Humanitarian Intervention. New York: Vintage. Benton, Adia. (2012) ‘‘Exceptional Suffering? Enumeration and Vernacular Accounting in the HIV-Positive Experience.’’ Medical Anthropology 31 (4): 310–328. Bergman, C., ed. (2003) Another Day in Paradise: Front Line Stories from International Aid Workers. London: Earthscan Publications. Berry, Nicole S. (2014) ‘‘Did We Do Good? NGOs, Conflicts of Interest and the Evaluation of Short-Term Medical Missions in Solola´, Guatemala.’’ Social Science & Medicine 120: 344–51. Biehl, Joa˜o and Adriana Petryna, eds. (2013) When People Come First: Critical Studies in Global Health. Princeton, NJ: Princeton University Press. Bornstein, Erica. (2012) Disquieting Gifts: Humanitarianism in New Delhi. Stanford, CA: Stanford University Press. Bornstein, Erica and Peter Redfield, eds. (2011) Forces of Compassion: Humanitarianism Between Ethics and Politics. Santa Fe, NM: School for Advanced Research Press. Bourdieu, Pierre, ed. (1999) The Weight of the World: Social Suffering in Contemporary Society. Stanford, CA: Stanford University Press. Bricmont, Jean. (2007) Humanitarian Imperialism: Using Human Rights to Sell War. New Delhi: Aakar Books. Broadbent, G., producer, and M. Winterbottom, director. (1997) Welcome to Sarajevo. Miramax Films. Calhoun, Craig. (2010) ‘‘The Idea of Emergency: Humanitarian Action and Global (Dis)order.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 29–58. New York: Zone Books. Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief. (1994) ICRC/ International Federation. Publication Ref. 1067. de Sardan, Jean-Pierre Olivier. (2011) ‘‘Aide humanitaire ou aide au de´veloppement? La ‘famine’ de 2005 au Niger.’’ Ethnologie franc¸aise 41 (3): 415–429. de Waal, Alexander. (1994) ‘‘Humanitarianism Unbound? Ethical Dilemmas of Multimandate Relief Operations in Political Emergencies.’’ Discussion Paper No. 5. African Rights, November 1994.

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———. (1997) Famine Crimes: Politics & the Disaster Relief Industry in Africa. Bloomington: Indiana University Press. Duffield, Mark. (2001) Global Governance and the New Wars: The Merging of Development and Security. London: Zed Books. ———. (2007) Development, Security and Unending War: Governing the World of Peoples. Cambridge, UK: Polity. Eggerman, Mark and Catherine Panter-Brick. (2010) ‘‘Suffering, Hope, and Entrapment: Resilience and Cultural Values in Afghanistan.’’ Social Science & Medicine 71: 71–83. Farmer, Paul. (2012) Haiti After the Earthquake. New York: PublicAffairs. Fassin, Didier. (2011) Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press. ———. (2012) ‘‘That Obscure Object of Global Health.’’ In Medical Anthropology at the Intersections: Histories, Activisms, and Futures, edited by Marcia C. Inhorn and Emily A. Wentzell, 95–115. Durham, NC: Duke University Press. Fassin, Didier and Mariella Pandolfi. (2010) Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions. New York: Zone Books. Fassin, Didier and Richard Rechtman. (2009) The Empire of Trauma. Translated by Rachel Gomme. Princeton, NJ: Princeton University Press. Feldman, Ilana. (2008) Governing Gaza: Bureaucracy, Authority, and the Work of Rule, 1917–1967. Durham, NC: Duke University Press. Feldman, Ilana and Miriam Ticktin, eds. (2010) In the Name of Humanity: The Government of Threat and Care. Durham, NC: Duke University Press. Fox, Rene´e C. (2014) Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Me´decins Sans Frontie`res. Baltimore: Johns Hopkins University Press. Good, Byron J., Mary-Jo DelVecchio Good, Sharon Abramowitz, Arthur Kleinman, and Catherine Panter-Brick. (2014) ‘‘Medical Humanitarianism: Research Insights in a Changing Field of Practice.’’ Social Science & Medicine 120: 311–316. Grayman, Jesse Hession. (2014) ‘‘Rapid Response: Email, Immediacy, and Medical Humanitarianism in Aceh, Indonesia.’’ Social Science & Medicine 120: 334–43. Harrell-Bond, Barbara. (1986) Imposing Aid: Emergency Assistance to Refugees. New York: Oxford University Press. Haskell, Thomas L. (1985) ‘‘Capitalism and the Origins of the Humanitarian Sensibility, Part 1.’’ American Historical Review 90 (2): 339–361. Hochschild, Adam. (2011) King Leopold’s Ghost. London: Pan Macmillan. Irwin, Julia F. (2013) Making the World Safe: The American Red Cross and a Nation’s Humanitarian Awakening. New York: Oxford University Press. Keen, David. (2014) ‘‘ ‘The Camp’ and ‘the Lesser Evil’: Humanitarianism in Sri Lanka.’’ Conflict, Security & Development 14 (1): 1–31. Kleinman, Arthur. (2006) What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. Oxford: Oxford University Press. ———. (2010) ‘‘Four Social Theories for Global Health.’’ The Lancet 375: 1518–1519.

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Kova´cs, Gyo¨ngyi, and Karen M. Spens. (2007) ‘‘Humanitarian Logistics in Disaster Relief Operations.’’ International Journal of Physical Distribution & Logistics Management 37 (2): 99–114. Laleman, Geert, Guy Kegels, Bruno Marchal, Dirk Van der Roost, Isa Bogaert, and Wim Van Damme. (2007) ‘‘The Contribution of International Health Volunteers to the Health Workforce in Sub-Saharan Africa.’’ Human Resources for Health 5 (1): 19. Leaning, Jennifer, Susan M. Briggs, and Lincoln C. Chen, eds. (1999) Humanitarian Crises: The Medical and Public Health Response. Cambridge, MA: Harvard University Press. Li, Tania Murray. (2007) The Will to Improve: Governmentality, Development, and the Practice of Politics. Durham, NC: Duke University Press. Magone, C., M. Neuman, and Fabrice Weissman. (2012) Humanitarian Negotiations Revealed: The MSF Experience. New York: Columbia University Press. Marcus, George. (2010) ‘‘Experts, Reporters, Witnesses: The Making of Anthropologists in States of Emergency.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi. New York: Zone Books. Maren, Michael. (2009) The Road to Hell. New York: Simon and Schuster. Mauss, Marcel. (1990) The Gift: The Form and Reason for Exchange in Archaic Societies. Translated by W. D. Halls. New York: W. W. Norton. Moorehead, Caroline. (1998) Dunant’s Dream: War, Switzerland and the History of the Red Cross. London: HarperCollins. Moyo, Dambisa. (2009) Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. New York: Macmillan. Orbinski, James. (2008) An Imperfect Offering: Dispatches from the Medical Frontline. London: Rider. Pandolfi, Mariella. (2003) ‘‘Contract of Mutual (In)difference: Governance and the Humanitarian Apparatus in Contemporary Albania and Kosovo.’’ Indiana Journal of Global Legal Studies 10 (1): 369–381. Panter-Brick Catherine, Mark Eggerman, and Mark Tomlinson. (2014) ‘‘How Might Global Health Master Deadly Sins and Strive for Greater Virtues?’’ Global Health Action 7: 23411. Polman, Linda. (2010) The Crisis Caravan: What’s Wrong with Humanitarian Aid? New York: Metropolitan Books. Redfield, Peter. (2013) Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Rieff, David. (2003) A Bed for the Night: Humanitarianism in Crisis. New York: Simon and Schuster. Shevchenko, Olga and Rene´e C. Fox. (2008) ‘‘ ‘Nationals’ and ‘Expatriates’: Challenges of Fulfilling ‘Sans Frontie`res’ (‘Without Borders’) Ideals in International Humanitarian Action.’’ Health & Human Rights: An International Journal 10 (1): 109–122.

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Singer, Merrill and G. Hodge, eds. (2010) The War Machine and Global Health: A Critical Medical Anthropological Examination of the Human Costs of Armed Conflict and the International Violence Industry. Plymouth: AltaMira Press. The Sphere Project. (2011) Humanitarian Charter and Minimum Standards in Humanitarian Response. Dunsmore, UK: Practical Action Publishing. Strathern, Marilyn. (2000) Audit Cultures: Anthropological Studies in Accountability, Ethics, and the Academy. New York: Routledge. Szamet, D., producer and M. Campbell, director. (2003) Beyond Borders. Paramount Pictures. Terry, Fiona. (2002) Condemned to Repeat? The Paradox of Humanitarian Action. Ithaca, NY: Cornell University Press. Ticktin, Miriam I. (2011) Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press. Tol, W. A., V. Patel, M. Tomlinson, F. Baingana, A. Galappatti, C. Panter-Brick, D. Silove, E. Sondorp, M. G. Wessells, and M. van Ommeren. (2011) ‘‘Research Priorities for Mental Health and Psychosocial Support in Humanitarian Settings.’’ PLoS Medicine 8 (9): pp. 1–5, e1001096. Tol, W. A., V. Patel, M. Tomlinson, F. Baingana, A. Galappatti, D. Silove, E. Sondorp, M. van Ommeren, M. G. Wessells, and C. Panter-Brick. (2012) ‘‘Relevance or Excellence? Setting Research Priorities for Mental Health and Psychosocial Support in Humanitarian Settings.’’ Harvard Review of Psychiatry 20: 25–36. Van Wassenhove, Luk N. (2005) ‘‘Humanitarian Aid Logistics: Supply Chain Management in High Gear.’’ Journal of the Operational Research Society 57 (5): 475–489. Ventevogel, P., W. van de Put, H. Faiz, B. van Mierlo, M. Siddiqi, and I. H. Komproe. (2012) ‘‘Improving Access to Mental Health Care and Psychosocial Support Within a Fragile Context: A Case Study from Afghanistan.’’ PLoS Medicine 9 (5): e1001225. Von Boemcken, Marc. (2007) ‘‘Liaisons Dangereuses: The Cooperation Between Private Security Companies and Humanitarian Aid Agencies.’’ In Private Military and Security Companies, 259–272. Wiesbaden, Germany: Springer VS. Wagner, Sarah E. (2008) To Know Where He Lies: DNA Technology and the Search for Srebrenica’s Missing. Berkeley: University of California Press. Weiss, Thomas G. (2004) ‘‘The Sunset of Humanitarian Intervention? The Responsibility to Protect in a Unipolar Era.’’ Security Dialogue 35 (2): 135–153. Weizman, Eyal. (2012) The Least of All Possible Evils: Humanitarian Violence from Arendt to Gaza. New York: Verso Books.

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PA R T I

Intimate Interventions: Health Worker Experiences in Humanitarian Contexts

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Chapter 1

Dignity Under Extreme Duress: The Moral and Emotional Landscape of Local Humanitarian Workers in the Afghan-Pakistan Border Areas Patricia Omidian and Catherine Panter-Brick

Targeted Killings: The Landscape of Humanitarian Aid The threat of kidnapping, beheading, and bloodletting is now part of the landscape of humanitarian aid in the border areas of Afghanistan and Pakistan. Let us begin with one concrete example. In January 2013, one of the headlines of the Pakistan edition of the International Tribune read: ‘‘Swabi Bloodletting: In Grisly Attack, Gunmen Kill Seven Aid Workers’’ (Express Tribune 2013). Two attackers, riding a motorcycle, intercepted the van transporting staff from a nongovernmental organization (NGO) (Support With Working Solutions) working in Khyber Pakhtunkhwa province. They pulled a five-year-old child away from his mother before spraying the vehicle with bullets, killing one man and six women, all local Pakistani workers delivering healthcare and education in the region. In speaking to the press, the NGO director described the crux of the tragedy, from a local perspective, in these terms: ‘‘The innocent girls worked to support their families.’’ This example situates humanitarian practice in the context of militant violence and states of emergency, articulates the dangers and dire tension that local humanitarian aid workers confront because of their profession, and

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highlights their predicament in having assumed humanitarian work to guarantee their families’ livelihood. Targeted killings of local aid workers, such as the January 2013 attack, have profound consequences on both NGO and government employees who develop and manage the delivery of health and other services. For example, the killings of nine polio fieldworkers, shot dead in a string of attacks in Karachi and border towns in December 2012, prompted the government of Pakistan to suspend the polio eradication campaign in many areas of the country and forced the World Health Organization (WHO) and UNICEF to withdraw their technical and monitoring personnel; despite all political efforts and increased resources, the eradication campaign could not be implemented in areas where polio was most prevalent. Targeted killings also have critical health and social consequences for the local staff who work as technicians, health workers, teachers, translators, or drivers for government and humanitarian agencies. Until recently, we have known more about the frontline stories of expatriate aid workers (Bergman 2003, Orbinski 2008, Redfield 2012, Ager and Iacovou 2014) than the circumstances of local aid workers, in terms of the risks they undertake to provide for their families and the dilemmas they face with heightened insecurity. Unlike their expatriate counterparts, local aid workers, often employed by small NGOs, have few safety nets and travel with little or no protection (Omidian 2001, 2011). They are called upon to provide services within their own communities, often eliciting local jealousy and resentment. They may be internally displaced persons (IDPs) themselves. As we illustrate in this chapter, even those employed by government agencies are placed at risk; in the humanitarian business, no one is now exempt from death threats. One recent appraisal of the systematic harassment of health workers described the situation in northern districts of Pakistan as follows: ‘‘The Taliban had launched a systematic campaign of abuse and harassment of the primary healthcare programme and its core workforce. . . . They used a combination of fatwas (religious decrees), threats, and physical assaults’’ (Ud Din, Mumtaz, and Ataullahjan 2012). These fatwas had serious implications for women community health workers, who ‘‘deliver services to the doorstep since societal norms restrict women’s ability to attend healthcare facilities.’’ Accordingly, one fatwa declared that the presence of women in public spaces was a form of public indecency and that a Muslim man’s duty was to kidnap female health workers when they paid home visits and marry them forcibly, even if they were already married; one Taliban chief stated it

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was acceptable to kill them. A second fatwa declared that it was morally illegal for Muslim women to work for wages. Daily radio programs were used to discredit female health workers, fueling encouragement to harass them (Ud Din, Mumtaz, and Ataullahjan 2012). It should be noted that many of the antigovernment actors are often labeled as Taliban, even though they represent varied groups in the region, including the Taliban, jihadists, and drug lords, regardless of their background or affiliation. Such militant groups target Pakistani state and military representatives in this region and, by extension, local health workers, given that in Pakistan much of the humanitarian aid is delivered through the operation of local government. Thus community health and humanitarian aid workers have to operate within a context of systematic harassment and routine threats of violence, facing the same dangers as government employees such as police or security personnel.

A History of War and Insurgency The area of Pakistan that borders Afghanistan, inclusive of Khyber Pakhtunkhwa (KP, formerly called the Northwest Frontier Province of Pakistan), the Federally Administered Tribal Areas (FATA), and Baluchistan, is especially dangerous and violent. This region has been undergoing a rapid transformation, as border areas shudder under the weight of war and violence—drone attacks by the United States, fighting between the Pakistani army and the Pakistani faction of the Taliban, and killings by local war or drug lords. More than thirty local aid workers were killed or kidnapped in these areas in 2012 alone. These were men and women employed by agencies of the provincial government, delivering health and education services in the conflict zones or in the IDP camps established within FATA and KP. The targeted killing of government employees involved in the delivery of humanitarian aid or reconstruction efforts has roots in the recent history of Pakistan-Afghanistan relations. Pakistan had hosted one of the single largest refugee populations in the world: Afghans fled their country during the war against the Soviet-backed regime (1979–1989), with another surge of refugees during the period of civil war when the Taliban gained control of most of Afghanistan. At that time, Pakistan also supported the Taliban and other insurgent groups. With the attacks on the World Trade Towers

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in 2001, the United States led a coalition of international forces to launch new military operations. The Taliban forces reverted to an insurgency campaign, now in its second decade. This war has brought into stark relief the weaknesses of Pakistani military support, given its tolerance for radical groups—often no more than drug or gun runners operating under a guise of Islamic rhetoric, connected to groups that Pakistan supported to fight against the Indian army along its joint border in Kashmir. Government and insurgent groups are engaged in a long, drawn-out battle over the strategic control of these regions. Unfortunately for Pakistan, the support of militants along its two borders has brought about major instability in a country traditionally tolerant of diversity. Pakistan is now a deeply divided nation struggling to contain and curtail radical militants within its own borders, even as it tries to maintain pressure on Afghanistan. The methods used by Taliban and other insurgents in Afghanistan, including selective assassination of government workers, military personnel, and civilians, are now common in Pakistan. Many of the insurgent groups take action against high-profile health campaigns to keep up pressure on the Pakistani government. In the midst of all this upheaval and complex politics, humanitarian work comes under duress, as targeted harm is inflicted on those who deliver healthcare and other forms of aid.

Reflections on Humanitarianism in Action In this chapter, we reflect upon the narratives of local humanitarian aid workers and the concerns of organizations delivering humanitarian aid locally. Our material is primarily drawn from group discussions and faceto-face interviews held during training workshops in Islamabad, funded by UN Women at the request of the government of Pakistan’s FATA Secretariat, specifically its Women Empowerment Wing in the Social Sector, a department within the provincial government that administers social welfare, health, and humanitarian assistance in tribal areas. We provide reflections on medical humanitarianism in action, at both personal and institutional levels, through the lens of the personal narratives of local humanitarians and through the lens of institutional training practices and policy concerns.

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First we highlight the dilemmas faced by local humanitarians, individuals who put themselves and/or their families at great personal risk because of their involvement with local and international humanitarian organizations. We provide ethnographic context to understand their situation, convey their psychological distress, and articulate the many different reasons for pursuing this type of work in the face of such grave danger. This gives voice to ‘‘what really matters’’ when living a moral life amid uncertainty or danger (Kleinman 2006). It helps us reflect on what dimensions of emotional and social experience will make everyday life possible under the threat of targeted killings. We touch upon expressions of suffering, precariousness, and extreme duress, as well as the cultural straitjacket on public displays of emotion. We also reveal expressions of resilience and human dignity, articulated by the significance of a moral calling. As described in the narratives of ordinary men and women in neighboring Afghanistan, a strong sense of resilience to adversity is anchored in cultural values of faith, honor, moral code, service, perseverance, and family unity (Eggerman and Panter-Brick 2010). Such values promote a sense of coherence about life: namely, a sense that one’s life is worth something, a sense of responsibility to one’s family and community, and a sense of moral and social respectability. In this cultural context, resilience means more than an individual’s ability to cope with adversity: it means holding onto a narrative of life that coalesces together psychosocial well-being with collective notions of social justice, social worth, and social responsibility (Panter-Brick 2014). Second, we reflect on the value of training workshops, capturing the complexities of life inside humanitarian spaces. Such workshops, using a person-centered psychology approach known as Focusing (Gendlin 1982), served two institutional purposes. It provided psychosocial training to humanitarian staff working for local government or NGO agencies to alleviate distress, fear, and burnout. It also served to develop materials for humanitarian staff and beneficiaries, such as a training manual to be published in two local Pakhtu dialects for use during future workshops in IDP camps within FATA and KP areas. In our case study, twenty-two participants (twelve women, ten men) were invited by the FATA Secretariat from a range of border areas (Malakand, Bajour, Mohmand, Khyber, Orakzai, and Waziristan), all of which experienced poor health services and very low literacy rates. They came to the workshop for a period of four weeks, both

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to cope with their work-related stress and to articulate what might be useful in the creation of a manual designed to assist the agencies’ beneficiaries.

Living a Life Under Extreme Duress During the workshop, the extreme psychological distress experienced by participants soon became evident. Each person had a tale of extreme danger to tell: direct threats received or instances where colleagues had been killed, kidnapped, or threatened. One young woman working in a social welfare capacity within FATA whispered that her brother-in-law had recently been kidnapped. Her whole family was waiting to hear from the kidnappers regarding the ransom demand, hoping that he had been kidnapped for money and not by the Taliban, who would more likely kill him because he worked for the Pakistani government. The family also worried about this woman’s own safety, given the nature of her employment and her movements along roads within tribal areas. Another aid worker recounted that his cousin had been killed on his way home from his office in Peshawar. His killers were never identified; while the police in Peshawar blamed the victim, saying it must have been the result of an enmity between rival family members, no one in the family could believe this. A third government worker gave this account: ‘‘I have been threatened several times by religious extremists and I regularly receive threatening calls from unknown numbers. Our project staff was attacked several times as they went about their work. In 2011, one of our colleagues was killed in the FATA area, and another was abducted—he is still in captivity, after two years.’’ Most participants stated that they took some type of tranquilizer to help them sleep at night, to control their stress, and to help hide their fear; though they were only in their twenties and thirties, they experienced headaches, generalized body pain, sleep disturbances and nightmares, stomach problems, and high blood pressure. Most expressed their gratitude: although they were under a great deal of stress, they had homes and families to return to at the end of each day. Many found their work to be not only dangerous but also frustrating and distressing. In IDP camps, for example, conditions were grim, in that tents did not suffice to protect people from scorching hot summers or freezing winters, and the humanitarian services provided were extremely limited.

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Why did humanitarian aid workers continue to work in this field, facing serious threats of kidnapping or assassination? One woman, trained in public administration and public health in emergency settings, had taken up her position out of a desire to serve her community; she continued her work because to stop would mean abandoning people in dire need. She felt a personal responsibility to give ‘‘service’’ to her community and country— her duty as a citizen and as a Muslim. Another program officer, who ‘‘thought of quitting’’ in the wake of repeated threats, expressed both relative powerlessness given his ‘‘very limited choices’’ for livelihood in Peshawar and a dignified stance to fulfilling a moral duty: ‘‘I believe in what I am doing, so I think I will stick to what I am doing.’’

Three Personal Narratives We focus on three narratives to give ethnographic substance to the concerns, fears, and motives of humanitarian workers and to the moral calling that permeates everyday life with necessary dignity. Our interlocutors gave verbal informed consent to reproduce their stories; we changed their names and omit mention of their employing agency to protect anonymity. Our first narrative illustrates the concerns of humanitarian workers who delivered aid to IDP camps catering to Pakistani communities in the wake of armed conflict. Barialai worked in Jalozai Camp, one of the largest IDP camps near Peshawar. This site had originally been designated for Afghan refugees; in the 1980s, it was a very large ‘‘village-like’’ settlement, with adobe brick homes, shops, and clinics. To hasten the repatriation of these refugees to Afghanistan, the settlement was dismantled by the Pakistani government—and bulldozed to the ground, just before war broke out in Swat/Malakand in 2007–2009. The site was newly designated to house IDPs from within Pakistan but strictly limited to tents rather than permanent dwellings. The camp now hosts approximately 12,500 families from FATA areas. As recounted by Barialai: A few years ago all the [Afghan] refugees were finally expelled from the camp. UNHCR [the UN High Commissioner for Refugees] and other UN agencies were told by the Pakistan government to make sure there was nothing left of the camps; so the Afghans took their roofing poles and some even took their building stones. Clinics were

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dismantled and all the equipment taken away. The tube wells were removed and the whole area was bulldozed. The government gave the land back to the villagers who had originally owned it. But within six months after the final destruction of the last of the houses, the war in FATA and the north started and IDPs began to arrive in large numbers from Malakand. The [Pakistani] government had to scramble. They got the land back from the villages on a lease and allowed the IDPs to start settling on it. But there were new rules. No one was allowed to build a wall, enclosure, or building. Only tents were allowed. The government wants to make sure there are no permanent structures. Where the Afghan refugees had been able to make their camps into villages and replace their tents with permanent and weatherproof structures, the Pakistani IDPs are forced to survive the extreme heat of summer and the freezing winter temperatures in tents. Barialai noted that people are suspicious of him because he is from the area but works for an international organization. He is resentful of the fact that Afghan refugees, who used to live in this camp, had a better standard of living compared to the conditions his own people are now forced to live in. He is ashamed of and frustrated by the government’s policies toward Pakistani IDPs but at the same time thanks Allah that his own family does not have to struggle in that way. He has received threatening phone calls and has attended the funerals of friends (fellow humanitarian aid workers) who were murdered. Threats hang heavy over him, but this is the only job he knows that can provide for his family, allowing his children to attend private schools and have a comfortable life. He draws on a sense of moral capital, which gives meaning to his life and provides consolation: working with people who are suffering helps sustain him through pain and fear, and seeing the dire conditions that exist in the tribal areas and IDP camps makes him feel that he has no right to complain. Rather, he expresses gratitude for his situation. The emotional downside comes with the cultural prohibition on expressing fear or even admitting to being afraid. Barialai can only privately share what he feels: in his words, he has a hard external shell that is the only thing that the public can see. The day he witnessed a bomb blast in Peshawar, he acted strong and brave, telling people to have courage and focus on the upside (no one was killed or injured and only property was

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lost): ‘‘We, my colleagues and I, had to evacuate people from the area, in case there were other bombs that might go off. I had to pretend to be something I am not. All the while I was shaking inside, feeling fear that I could never share. All I want is to go into a safe place where I can be what I am really like. I am a human being, not a Rambo. But if I show people my soft side, that is a worry.’’ Our second narrative highlights the fears and plight of local humanitarian workers during a kidnapping. Taimor was kidnapped and held prisoner for many months until his family could buy his freedom with over a million Pakistani rupees. He and several colleagues were taken hostage by a group claiming to be Taliban in an attack near his office; he works for a humanitarian aid organization on the outskirts of Peshawar. They were blindfolded and transported in the back of a truck for several hundred kilometers to the south, into FATA. Their captors often stopped for breaks; they bought the captives some juice to drink and asked if they wanted to eat but treated them roughly and pushed them around in such a way that the captives did not know if they would survive the ordeal. Once in FATA, the captors drove up to a house owned by a local thug, entered the building, and killed the inhabitants before transferring their hostages inside. Other captives joined the hostages over the course of their imprisonment. Taimor stated: ‘‘There were twenty-five personnel from law enforcement agencies with me while I was being detained by the Taliban. Two of them were severely wounded. I forgot my own suffering and [gave] them medical help by putting on bandages and when required changing them. . . . This boosted the morale for all of us.’’ Taimor believed he could be killed, either by Taliban militants or by U.S. drones targeting the area. To this day, he shakes and breaks out in a sweat when he hears the sounds of jets or helicopters overhead. Our third narrative illustrates the repercussions of such an ordeal on everyday family life. At the time of his kidnapping, Taimor was engaged to his cousin, Romeena, a university student. She called this period the most difficult time in her life; not only did she suffer, but it proved to be one more struggle to overcome in order to finally get married. She waited and waited for news—whether Taimor was still alive, where he might be, and how they might secure his release—and felt too weak to continue her studies: ‘‘It was a sudden shock for me and I spent those months in desperation, all the time praying, not going to classes at the university. And when Taimor was freed, I thanked Allah for His kindness. I feel I am honored with bravery and that I handled the situation with patience. Now I am

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happy to recover from that tragedy.’’ While Taimor was held captive, her family rallied around her: ‘‘My friends supported me and my neighbors visited my house daily. They organized a khatam [reading of the Holy Quran] for me, and they gave me strength and the power to stand. With the help of my community members I got such good support every day and they held me and helped me in my stress.’’ But this is not a ‘‘happily ever after’’ story. There are lingering consequences for Romeena and her family. She confided that Taimor has really changed since the kidnapping. These days, the family is terrified when he becomes violent and loses his temper. Romeena tries to have patience, but right now she has to deal with a violent husband. Within Pakhtun culture, she has few resources to help her cope with violence in the home. She searches for ways to help her husband curb his violent outbursts, which she says are the aftermath of trauma. Taimor himself does not feel right about his new level of violence. Both Taimor and Romeena work for humanitarian organizations. When asked why, they say they want to succor others who desperately need help. And when pressed, they admit that the pay is very good and they would not make as much money in other jobs. Taimor now has a different position in the provincial government, getting lower pay but better benefits, which include housing and a car. Because conflict between the government and local Taliban continues, he remains a potential target. Yet he sees himself as blessed: ‘‘After I got freed, I got back all that I had lost by the Grace of Allah, and now I am very happy. Our son and daughter go to good schools in Peshawar.’’ The ability to choose the school their children can attend is one reason why this couple remains in the humanitarian arena. They gain decision-making power, as well as prestige, through ‘‘noble’’ work.

Humanitarian Training We now turn to reflect on the training workshops, born of institutional concerns to address fear, restore well-being, and strengthen resilience in the face of mounting insecurity and danger. Our case exemplar was co-facilitated by Omidian, a U.S. medical anthropologist resident in

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Afghanistan and Pakistan from 1997 to 2012, and a Pakistani humanitarian worker, who had attended training workshops following the Kashmir earthquake of 2005 and had specifically requested that the FATA Secretariat sponsor similar initiatives in Khyber Pakhtunkhwa. The workshop was designed to provide an opportunity for a number of humanitarian workers to take a break, learn participatory training techniques, and work on personal issues. The workshop built upon an ongoing program developed specifically for Afghans (www.focusing.org/afghan.htm), implemented in Kabul nine years earlier (Omidian and Papadapoulus 2003, Omidian and Lawrence 2007, Omidian 2012). It was evaluated in situ for its efficacy in emotional healing and cultural relevance (Frohbo¨se 2010). Its modular and participative format allows workers to identify and develop culturally grounded and gender-sensitive approaches to address salient psychosocial issues, discuss resilience and the culture of emotions from local perspectives, and practice the mindfulness techniques of Focusing. The workshop provides opportunities for participants to identify positive exceptions to the norm of experiencing suffering and fear in everyday life through identifying people who manage to do well and adopt coping behaviors that are locally valued. This process of identifying ‘‘exception through exemplars’’ is akin to drawing power through the recognition of positive deviance (Pascale, Sternin, and Sternin, 2010). The process of centering on the positive aspects of human experience connects well with cultural values, Islamic practices, and local Sufi traditions. Focusing techniques have been developed over a decade of work in Afghanistan: more than seventeen thousand Afghans participated in school-based and community-based training programs between 2002 and 2011. In its implementation with humanitarian staff, the adoption of participative techniques ran counter to the prevalent educational culture, a system that values social hierarchy and rote learning of absolute truth. Participants expected to be instructed on rights and wrongs. They were glad to actively engage in small group discussions and other endeavors but would be silent during large group discussions, falling in line with a cultural tradition that emphasizes received answers rather than asking critical questions and reflexive thinking. Participants had known they would draw concrete benefits from the workshop: here was the time and place for a four-week respite from the dangers and fears encountered in the frontlines of everyday

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humanitarian work. But little by little, they also found themselves engaged with its content: the program resonated with their own needs, and the emphasis on mindfulness was consonant with their traditions. As the following examples illustrate, the workshop provided a space for learning to negotiate troublesome emotions while articulating the significance of their moral calling.

Emotions and Resilience In the workshop, participants discussed various ways of understanding emotions and resilience in the context of delivering humanitarian aid in the wake of armed conflict. In groups of four to six people, they discussed the range of emotions arising from this work. What became clear was that men were restricted with respect to emotional expression: they were not allowed to show fear, grief, love, or doubt, as this would bring shame on the man and his family. Only three emotions were available to men for public display: anger, jealousy, and hate. Furthermore, displaying anger was contingent on social status. When angry, a man cannot take action against someone of higher status but will use aggression against someone who has little power over him. And when afraid, a man is not able to admit fear and must instead react with anger or hate. One man categorically stated: ‘‘a man who is afraid would act violently, even shoot a gun at someone, then escape.’’ Because many men experienced trouble sleeping at night, which often led to extreme tiredness, outbursts of anger and aggression were common outcomes. Relative to men, women were less constrained in public displays of emotion, especially love, fear, and sadness. Once married, however, they had to be very careful, as they lived with in-laws in extended family settings. The straitjacket of emotional expression after marriage is captured by a local saying: ‘‘when a co-wife’s son dies, a woman would weep on the outside, but laugh in her heart.’’ Humanitarian aid workers constantly negotiated a changing landscape of emotions for themselves, their clients, and their own family members. The burden of fear, in a culture that disdains the weakness of men, led men to internalize psychosocial stressors in ways that are toxic to well-being and to manifest explosive anger in unpredictable, violent outbursts. The burden of frustration and anger also weighed on women, who had few outlets to show such emotions.

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As a counterpoint to this discourse on emotions, participants drew upon a discussion of resilience through the identification of specific exemplars in their locality. They identified types of resilience that encompassed personal, family, community, religious, and economic dimensions. Most participants felt that they could draw from a well of inner strength, which allowed them to continue to work. They stated that maintaining a firm belief in Allah and a sharp awareness of one’s duties and responsibilities were some of the most important building blocks to nurture a capacity for resilience. In addition, remaining a loyal citizen of Pakistan and loyal to the government was articulated as an important notion of duty and service to the country, over and above duty and service to one’s family.

Focusing Through Culture, Islam, and Sufism We detail two examples of Focusing practices implemented in this workshop to illustrate how they served to foster psychological strength and build social connections. The first practice is designed to help a person find a safe, quiet, inner place in a visualization exercise that is meditative and healing. A facilitator quietly gives instructions to help participants relax and turn their awareness inward to ‘‘a safe place inside.’’ This aligns with the Sufi notion that the inner world is greater than the outer world and that one comes close to Allah, the divine, when one turns inward. Participants are invited to think of a place that is calm and relaxing (a garden or a place in the mountains near a river) and imagine themselves sitting in that space as they breathe deeply. They are then asked to remember something in their lives for which they are grateful and to pay attention to how their body feels as they recall this. This first step of Focusing thus aims to elicit feelings of calm and peace that can be anchored to a specific place, recalled with gratitude. The next step is designed to help people distance themselves emotionally from specific problems, and envisage their resolution, through the analogy of handling each troubling issue as if it were ‘‘a guest in my life.’’ For Pakhtuns, guests are highly valued: welcome or unwanted, guests must be treated with respect, kindness, and courtesy. In Pakhtun society, most houses have a separate space (called a hujra) such that guests (meelma) can be made comfortable without disturbing the inner sanctum and privacy of women in the home. The same imagery is used in the workshop: emotional issues are

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likened to the ‘‘inner guests’’ of the mind and deliberately managed in a specific social space. Participants were asked to close their eyes and imagine themselves in their safe place, then move forward to a hujra where specific problems could be met in the same way that guests should be greeted, after which they would return to their sanctum for renewed peace and calm. One participant declared, ‘‘I have too many things that worry me and I cannot stay in the safe place’’ but found in the ‘‘guesthouse technique’’ a concrete way of making his worries less troublesome. The second Focusing exercise involved a weighing scale and a handful of dried beans. One participant would enumerate all the problems he or she could think of, placing a bean for each problem on one side of the scale, then think of all the good things he or she could be thankful for, placing a bean for each one of those onto the other side of the scale. Other participants in the group would prompt the person with ideas of blessings for which one might be thankful. One woman could not find anything to be thankful for: she struggled with harassment at work and a mother afflicted by mental illness at home. In her case, the Focusing activity simply gave her the opportunity to safely express her emotions and frustrations within the group, prompting her to say that she now felt some ‘‘ease,’’ in contrast to what she had been feeling during the previous months. Other participants reached the conclusion that the ‘‘good’’ in their lives far outweighed the ‘‘bad.’’ Against all odds, the balance sheet of life tended to the positive. One man was delighted by this realization: ‘‘We spend so much time complaining about what we don’t have and forget to thank Allah for everything he has given us. It is always more.’’ Many participants felt inspired to write local sayings, poetry, and Quranic verses on sheets of paper and then pin them on the walls. One handwritten hadith (a saying of the Prophet) thus hung on the wall: ‘‘Indeed amazing are the affairs of a believer! They are all for his benefit. If he is granted ease of living he is thankful; and this is best for him. And if he is afflicted with a hardship, he perseveres; and this is best for him.’’

Conclusion Humanitarian aid work in this region is very difficult, even in quieter times, because of the remoteness of this area and the conservative social norms of its population. With increasing threats to both local and international

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aid workers, and the deaths of so many in the Afghan-Pakistan border areas, it has become a profession of high stress and great danger. Workers, who are often seen as colluding with the Pakistani government and U.S. policy in the region, face targeted attacks and the uncertainty of being at the wrong place at the wrong time; they are also vulnerable to bombings by insurgents, drone attacks, and military forces. In spite of such dangers, local people continue to work for agencies that channel humanitarian aid: they cite a moral calling, a religious duty, a family responsibility, and a social obligation of service to one’s community or country as primary reasons to extend help to fellow countrymen and women. For some, this type of work is the only option available to support their families economically; even so, their profession is described as a calling that carries high moral capital. Human dignity is the key to resilience, as previous ethnographic work in this region has shown: the six cultural values of faith, perseverance, service, family unity, moral code, and honor constitute the bedrock of resilience in the face of extreme duress, misery, and violence (Eggerman and Panter-Brick 2010). Put simply, human dignity is manifested by perseverance and a notion of honorable service to one’s family and community; it is both a sense of self-worth and social respectability. In Pakistan, as in Afghanistan, we encounter specific forms of cultural and economic entrapments: people are squeezed tight between the cultural dictates that govern their behavior in public spaces and the economic dictates that compel them to provide for their family. Ordinary people hold onto their faith, work to secure a livelihood, and express gratitude for their situation in order to retain personal and social dignity amid a landscape of competing cultural and economic obligations. There is, nonetheless, a shrinking configuration of opportunities for the expression of human dignity, given persistent violent conflict, chaotic governance, economic instability, and widening social inequalities (Panter-Brick and Eggerman 2012). While ‘‘dignity’’ and ‘‘service’’ provide meaning and coherence to life, this does not mean that ordinary people doing extraordinary work do not experience fear, despair, or resignation. And while resilience is key to weathering the stresses inherent in humanitarian work, and the expression of human dignity key to why local humanitarians feel able to face danger, it does not mean that dignity is easy to come by. Extreme duress, longstanding suffering, and dignified resilience are facts of life in the Afghan-Pakistan border areas marred by poverty and violence.

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There is no ethical or logistical quick fix to such a difficult situation. The officials responsible for local governance struggle with the huge challenge of delivering social welfare, humanitarian aid, and immunization campaigns in these conflict-ridden areas. The FATA Secretariat took steps to address the enormous toll exerted on the physical, social, and emotional well-being of its humanitarian staff, seeking to develop culturally meaningful training sessions for men and women in their employment. They were driven, in part, by the desire to emulate global humanitarian practice, namely workshops held in the wake of disasters to address mental health and psychosocial well-being and the development of manuals as concrete ‘‘deliverables’’ to help with humanitarian activity. This desire was, however, tempered with a tangible concern to steer away from Western-style psychotherapy in favor of culturally grounded techniques to strengthen well-being. Focusing techniques—similar to mindfulness techniques—explicitly drew upon locally meaningful practices: turning inward rather than outward, expressing gratitude and fortitude to Allah, embedding resilience in family and community service, and addressing toxic issues as one might greet unwanted guests. These techniques worked well in the context of a training workshop, where emphasis on spiritual practices to counteract fear or despair could be carried over into everyday life or practiced with a support group. Indeed, upon their return from the workshop, three participants developed a plan to introduce Focusing training sessions for women in the Jalozai IDP camp. In Afghanistan, where the program was originally developed, similar workshops continue to be organized in formal and semiformal ways, being endorsed by at least two NGOs more than a decade after they were first locally developed. The Focusing workshops have undoubtedly helped many men and women cope with extreme adversity with a greater measure of social and emotional composure, but from an institutional rather than a personal standpoint, they constitute only small steps to meeting the needs of humanitarian workers for tangible professional support. Our ethnography highlights the importance of understanding in greater depth not only the fears and dangers of humanitarian work but also the culture of emotions, the wells of resilience, the moral and socioeconomic dimensions of human dignity, and the opportunities for institutions to take small but important steps toward managing the burden of violence in humanitarian settings. We have focused attention on the extreme duress of everyday life: danger and pain stem from prominent threats of abduction

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and targeted killings but also from the concerted efforts to uphold Pakhtun dictates of honor and service to family and community while navigating the cultural straitjacket of emotional expression. Highlighting humanitarian work as a moral calling is a way for local humanitarians to ascribe moral value and meaning to their experiences of extreme uncertainty, stress, and danger. But to infuse life with human dignity is a constant struggle: tragedy, misery, and relative powerlessness are part and parcel of the humanitarian encounter in refugee camps and conflict zones, and institutional responses are limited or patchy. Holding onto a sense of dignity is, in essence, an exercise of mindfulness: it is an ongoing effort to create spaces for calm and composed social behavior and, in the midst of fear and pain, to valorize faith, hope, and gratitude. References Ager, A. and M. Iacovou. (2014) ‘‘The Co-construction of Medical Humanitarianism: Analysis of Personal, Organizationally Condoned Narratives from an Agency Website.’’ Social Science & Medicine 120: 430–438. Bergman, C., ed. (2003) Another Day in Paradise: Front Line Stories from International Aid Workers. London: Earthscan Publications. Eggerman, M. and C. Panter-Brick. (2010) ‘‘Suffering, Hope, and Entrapment: Resilience and Cultural Values in Afghanistan.’’ Social Science & Medicine 71 (1): 71–83. Express Tribune. (2013) ‘‘Swabi Bloodletting: In Grisly Attack, Gunmen Kill Seven Aid Workers.’’ January 2. Frohbo¨se, A. (2010) ‘‘Focusing in Afghanistan: An Exploratory Study of a CopingStrategy for Traumatized Communities.’’ Master’s thesis, Carl von Ossietzky University of Oldenburg. Gendlin, E. (1982) Focusing. 2nd ed. New York: Bantam Books. Kleinman, A. (2006) What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. Oxford: Oxford University Press. Omidian, P. A. (2001) ‘‘Afghan Aid Workers and Psychosocial Well-Being.’’ The Lancet, November 3. ———. (2011) When Bamboo Bloom: An Anthropologist in Taliban’s Afghanistan. Long Grove, IL: Waveland Press. ———. (2012) ‘‘Developing Culturally Relevant Psychosocial Training for Afghan Teachers.’’ Intervention 10 (3): 237–248. Omidian, P. A. and N. J. Lawrence. (2007) ‘‘A Community-Based Approach to Focusing: The Islam and Focusing Project of Afghanistan.’’ The Folio: A Journal for Focusing and Experiential Therapy 20 (1): 152–164. Omidian, P. A. and N. Papadopoulos. (2003) ‘‘Addressing Afghan Children’s Psychosocial Needs in the Classroom: A Case Study of a Training for Trainers.’’ IRC

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Female Education Program, Peshawar, Pakistan. http://healingclassrooms.org/ downloads/Addressing_Afg_Childrens_Psychosocial_Needs.pdf. Accessed December 4, 2014. Orbinski, J. (2008) An Imperfect Offering: Humanitarian Action for the Twenty-First Century. New York: Walker & Co. Panter-Brick, C. (2014). ‘‘Health, Risk, and Resilience: Interdisciplinary Concepts and Applications.’’ Annual Review of Anthropology 43: 431–448. Panter-Brick, C. and M. Eggerman. (2012) ‘‘Understanding Culture, Resilience, and Mental Health: The Production of Hope.’’ In The Social Ecology of Resilience: A Handbook of Theory and Practice, edited by M. Ungar, 369–386. New York: Springer. Pascale, R., J. Sternin, and M. Sternin. (2010) The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems. Boston: Harvard Business Review Press. Redfield, P. (2012) ‘‘The Unbearable Lightness of Expats: Double Bind of Humanitarian Mobility.’’ Cultural Anthropology 27: 358–382. Ud Din, I., Z. Mumtaz, and A. Ataullahjan. (2012) ‘‘How the Taliban Undermined Community Healthcare in Swat, Pakistan.’’ British Medical Journal 344: e2093.

Chapter 2

Compassion and Care at the Limits of Privilege: Haitian Doctors amid the Influx of Foreign Humanitarian Volunteers Laura Wagner

In the first days, the NGOs came from all over, like bulldozers. And they gave free care for surgery, for deliveries of pregnant women, for consultations, without ever going to the locals and asking, ‘‘Can we do some of this together?’’ —Dr. Theard, quoted in Dallas Morning News, June 2010

´ xantus, February 2011 The Death of Guerda E By the end, Guerda E´xantus1 had become unrecognizable. She was stickthin, and her skin clung to the sharp angles of her skull, while her belly swelled tautly, as though she were nine months pregnant. She hadn’t eaten or defecated in more than a month. Her family, migrants from the Haitian countryside now living in a poor neighborhood in Port-au-Prince, tried to care for her, but they knew little about medicine and lacked the social connections and economic resources needed to navigate the healthcare system. They had taken her to numerous hospitals in Port-au-Prince, from the General Hospital to a series of private hospitals, but they claimed to have gotten no diagnosis and no help. As a relatively wealthy foreigner accustomed to dealing with doctors as peers, I possessed the social and cultural capital to help them contact the

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right people and navigate the medical system (Abel 2007, Shim 2010). I made some phone calls and was eventually put in touch with a Haitian specialist. He could come to see Guerda in her home. That was good, as Guerda was too ill to stand and transporting her would have been difficult. And I thought it better, ethically and politically, to support Haitian healthcare providers rather than to turn immediately to a foreign nongovernmental organization (NGO). When the doctor showed up, however, we didn’t realize who he was because he didn’t introduce himself, not even responding when I called out to him as he approached Guerda’s doorstep through the uneven alleyway, ‘‘Are you Dr. Auguste?’’ During his examination of Guerda, he did not ask for her name or her family members’ names or ask her how she was feeling. He stood over Guerda where she lay on her low cot and, lifting her nightdress, felt her swollen belly briefly. Then he sat on the single plastic chair in the small living room and proceeded to address all his questions to me. ‘‘Are there any X-rays?’’ he asked. From a manila envelope the family produced X-rays, which confirmed his suspicions: she had a large mass. ‘‘A mass?’’ asked Guerda’s son. ‘‘We never heard anything about a mass.’’ No one had ever told them that it was cancer, or a tumor. Dr. Auguste told me that the options were either to do nothing or to perform a colostomy to relieve the obstruction—implying, though never stating explicitly, that the colostomy would only make her more comfortable and could not save her life. At the same time, he peppered me with personal questions. Guerda’s family said little. ‘‘Why are you talking to me?’’ I asked him. ‘‘Talk to her and her family.’’ ‘‘You’re the one who called me,’’ he told me. ‘‘You’re the one I owe the information to.’’ To Dr. Auguste, I had assumed the classic role of patron and benefactor, with Guerda and her family taking on subsidiary roles as my clients, whereas I had imagined myself to be simply a facilitator. ‘‘Why do you think I called you?’’ I asked sharply. ‘‘Because I’m the one who has the means and the access to do that and who isn’t afraid to talk to a doctor.’’ In presenting a colostomy as the only course of action, Dr. Auguste never said aloud what everyone in the room knew to be true: that the operation would be prohibitively expensive for the family. He left without resolving anything. I followed him after he went outside. ‘‘How much do I owe you?’’ I asked. ‘‘A hundred,’’ he replied.

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‘‘A hundred Haitian?’’ I asked. ‘‘No, American.’’ I was taken aback. I knew that a normal consultation with a private practitioner in Haiti was about 1,000 gourdes—a little more than US$20. I didn’t have US$100 on me. So I gave him 2,000 Haitian gourdes, and I told him I’d get him the rest of the money by the end of the week. The next evening, Guerda’s daughter called. ‘‘That thieving doctor just sent his nurse chasing after us,’’ she reported. ‘‘She was demanding the rest of the money.’’ Dr. Auguste knew, of course, that Guerda’s family didn’t have the money he was demanding. The daughter laughed. ‘‘Oh, don’t pay any attention to him. Don’t give him the money. He’s a thief. He’s just doing this because you’re American and he thinks you have money.’’ The next day, I called an American NGO that provides free medical transport, and they brought Guerda to a hospital run by a second American NGO known as Project Medishare. Guerda arrived on makeshift gurney in the back of a pickup truck, attended by a young American EMT, a young American nurse, and Guerda’s daughter, who held an umbrella over her mother’s face to shield her from the sun. While Guerda’s illness was not related to the earthquake—in fact, the events I’ve described all took place more than a year after the quake—the free medical services of which her family availed themselves were in place because of the disaster. The NGO that provided transport to Guerda came to Haiti in the aftermath of the quake, and Medishare, which had previously concentrated its efforts in rural Haiti, expanded its operations in Port-au-Prince because of the earthquake. The Medishare volunteers were mostly teams from U.S. teaching hospitals, consisting of young residents and nurses and a handful of more senior physicians. They were energetic and excited to help. They started with an ultrasound, which revealed a huge mass that had obstructed Guerda’s bowel. ‘‘Probably ovarian cancer,’’ they said. When Guerda’s family realized that it was going to be a long day, they started chatting and telling jokes and buying sodas outside. Meanwhile the American EMT, an angry expression on his face, paced back and forth, seemingly tense and impatient and impelled by emergency. After the doctors drained six liters of greenish-yellow fluid into a plastic basin, Guerda’s belly grew smaller and softer and the mass became visible from the outside, its outline dominating the whole lower-right side of her

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abdomen. Her daughter felt it gingerly. ‘‘Feel how hard it is,’’ she said softly, almost reverently. The mass, which they hadn’t believed in, suddenly became real. Draining the liquid made Guerda more comfortable, but only slightly. She lay with her eyes closed, or asked to be held, leaning her back against one of her children’s chests. What she really wanted, she kept telling us weakly when we asked if she was feeling any better, was to relieve herself, and we couldn’t make that happen. Still, her family seemed satisfied. ‘‘People should always go see blan [foreigners] if they can,’’ Guerda’s daughter said. ‘‘Haitian doctors don’t care about people.’’ Although the attitude of the American medical personnel differed from that of the Haitian Dr. Auguste, their basic conclusion was the same: either do nothing or perform a colostomy, but in the end, there would be no cure. Guerda’s husband and daughter opposed the colostomy, even though at Medishare, unlike in a Haitian hospital, it would have been free. Some members of the extended family, however, felt strongly that the operation should be performed, and the fact that Guerda’s immediate family ‘‘let her die’’ later became a serious point of contention among her relatives. It was undisputed, though, that the colostomy—even assuming she survived the operation, weak and starved as she was—would, at best, have relieved her discomfort and given her only a few more weeks. Staring at me from the other side of Guerda’s bed, the American EMT sent me a text message in all caps: ‘‘THIS IS RIDICULOUS AND STUPID. THE FAMILY IS JUST GOING TO LET HER DIE BECAUSE IT’S NOT CONVENIENT FOR THEM?’’ He wanted me to plead with the family to do what he thought was the right thing for a woman who was undoubtedly going to die soon, regardless of any intervention. (The nurse who had come with him emailed me later to apologize for his rudeness: ‘‘It can definitely be tough for healthcare providers to see something that can be fixed/helped and not have that done. Especially for EMTs whose sole job is keeping people alive.’’) The other medical volunteers were more understanding. ‘‘I realize this outcome is suboptimal,’’ a young surgical resident said. ‘‘Suboptimal,’’ I repeated her euphemism. ‘‘That’s a good word.’’ She smiled back, in a way that conveyed that none of this was really funny. ‘‘I’ve been using it a lot here.’’ Guerda E´xantus died at home, six days later—after all those interventions, a death that no intervention could have prevented or even, perhaps, forestalled.

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The story of Guerda E´xantus’s final illness and death contains within it particular stereotypes and interactions. There is Guerda herself, dying and powerless, and her family, poorly informed and resigned. There is Dr. Auguste, the stereotype of the uncaring, financially motivated, callous Haitian doctor; if the story has a villain, it would be he. There are the international medical volunteers, motivated by compassion, who believe in and promote heroic and invasive interventions. And there is the engaged anthropologistcum-humanitarian, whose desire to ‘‘do good’’ brings frustration. Historically and archetypically, medical doctors in Haiti are revered and respected, even feared. They can be highly hierarchical and bureaucratic, are often rude or unkind to patients, and tend not to connect macro social processes (like power and poverty) with interactions within the clinic (Maternowska 2006). Nurses, similarly, are often brusque and hierarchical, even verbally abusive to patients. The biomedical system is grounded on relations of ‘‘deference’’ and ‘‘authority’’ (Brodwin 1996). Patients are expected to be deferential and to refrain from challenging or questioning the doctor, while the doctors themselves can be abrupt and rush patients through an appointment, often resulting in huge gaps in communication and understanding. Minn (2011), however, offers a more nuanced view of Haitian providers, describing how Haitian doctors are constrained socially, professionally, and financially, in particular by the presence of the humanitarian apparatus. In a place where people die of tuberculosis, malaria, cholera, or are crushed under poorly constructed buildings, Guerda’s death is not, for once, what Paul Farmer has called a ‘‘stupid death’’ (2003), that is, one that was easily preventable but for a lack of basic resources or basic justice. Cancer, particularly ovarian cancer, can be insidious and deadly even under the most privileged of circumstances (not to discount how poverty, chronic stress, and environmental factors might have contributed to Guerda’s disease). Dr. Auguste’s apparent ‘‘villainy,’’ then, lay not in his inability or unwillingness to save Guerda’s life but rather in his attitude, his lack of care. The apparent ‘‘heroics’’ of the foreign medical volunteers—whom the family ‘‘liked’’ more—lay in their willingness to help and to care, even in a hopeless situation, and in their ability to render the disease palpable and visible (and therefore believable). But the divisions between ‘‘hero’’ and ‘‘villain’’ become blurred when we place people’s actions in their broader social and economic context. Most Haitian doctors, who depend on their profession for their livelihood, charge for their services, whereas most foreign doctors, who are paid by NGOs or who are in Haiti in a short-term humanitarian capacity, do not.

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This is the key difference between crisis response doctors, who participate only temporarily, and doctors living in crisis, who must endure it every day. This chapter discusses the experiences and perceptions of Haitian doctors in general, and during the post-earthquake influx of expatriate medical volunteers in particular, with a focus on how they frame their moral commitments amid the financial obstacles they face. Understanding these engagements and threats complicates the stereotype of the uncaring, profitdriven Haitian doctor.

Background The January 12, 2010, earthquake that devastated Port-au-Prince and the areas around it created an immense medical humanitarian emergency, in response to which Haiti experienced a sudden, massive influx of foreign volunteer medical professionals providing free care. The Haitian medical system, already incapable of caring for the country’s population even under ordinary circumstances, was overwhelmed by patient need and by its own severe losses. Parts of the General Hospital in downtown Port-au-Prince collapsed. A multilevel obstetric hospital collapsed completely, killing many of its staff and patients, including pregnant women and new mothers with their infants. Existing medical humanitarian projects were also crippled: Me´decins Sans Frontie`res’ trauma center collapsed, killing seven patients and two staff members. Hundreds of thousands of people were in desperate need: the provision of free care was necessary and seemingly morally unambiguous. The international community—from large donors to private citizens— responded to the Haiti earthquake with an abundance of money and sentiment. In March 2010, various foreign governments, the World Bank, the Inter-American Development Bank, the European Community, the International Monetary Fund, and other donors—of which the United States was the largest—pledged $5.5 billion for Haitian relief and recovery at the International Donors’ Conference. Between 2010 and 2012, multilateral and bilateral donors pledged $9.28 billion to Haiti, though only $5.68 billion have been disbursed (Ramachandran and Walz 2012).2 The January 22 Hope for Haiti telethon was the most watched telethon in history, and it raised $58 million, a record amount in private donations for relief NGOs (McAlister 2012); overall, private donations reached an unprecedented $3.1 billion. Individual Americans alone gave $774 million in the first five weeks after the quake.

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Yet despite the sudden outpouring of cash and goodwill, the situation on the ground during the initial days following the quake—when the country was still in shock and humanitarian routines had not yet been established—was turmoil. It was not lawless chaos and looting, as some media would lead viewers to believe; in fact, acts of nobility, perseverance, and kindness by ordinary Haitian people were common. But the initial aid response was highly disorganized. Untold numbers of volunteers from all over the world, speaking an assortment of languages—some possessing relevant professional qualifications and some not—descended upon Haiti into a postdisaster situation that did not yet have the framework to receive them. It was, in the words of several Haitian doctors, a ‘‘Tower of Babel.’’ Motivated by a desire to help and facilitated by the proximity of Haiti to the United States and the inability of the weak Haitian government to regulate the activities of foreign organizations, they came. Many of these foreign medical volunteers had never worked outside a well-appointed Western hospital before and were ill equipped (in terms of materials and experience) to work in a postdisaster setting (Costello 2012). As I will show, an unintended consequence of the influx of foreign medical volunteers was to challenge not just the financial livelihoods of Haitian providers but also their moral commitment and professional expertise. At the same time, many private Haitian hospitals gave free care to earthquake victims—not just short-term emergency treatment but also followup for amputees and other seriously injured people requiring long-term care. This was financially crippling for many of these hospitals, which even before the quake were far from solvent. The best-known example was the Centre Hospitalier du Sacre-Coeur, a Haitian-run hospital in Port-auPrince. In March 2010—not even three months after the earthquake— having exhausted its operational funds in the provision of free care, it declared bankruptcy and was permanently shuttered.

Before and After the Quake While the situation of medical professionals in Haiti parallels in ways that of medical professionals in other poor countries with weak infrastructures (Wendland 2012), one circumstance sets Haiti apart: the post-earthquake emergency aid came on top of a preexisting widespread aid apparatus. Haiti is famously known as the ‘‘republic of NGOs’’ (Klarreich and Polman

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2012), in which nongovernmental organizations have supplanted the role of the state (Farmer 1994, Buss and Gardner 2008, Schuller 2012). Since at least the 1990s Haiti has been cited as having the highest per capita concentration of NGOs anywhere in the world. Though that assertion is difficult to verify, there is no doubt that Haiti possesses one of the world’s densest concentrations of NGOs. Among these are a host of medical NGOs, which vary widely in size, organization, and mission, offering free or discounted care, by differing combinations of national and foreign staff. Even before the quake, Haitian physicians’ and other providers’ professional choices and livelihoods were shaped by the humanitarian apparatus (Minn 2011). Brusqueness, authoritarianism, and preoccupation with money are not inherent features of ‘‘Haitian medical culture’’ and training—Haitian providers are not inherently inhumane or uncaring. Their behavior is best explained by the pressures to which they are subject: financial stress, lack of resources, constant undermining by foreigners who know little about the Haitian context, and the never-ending state of crisis. Money, of course, is central to this story: the corrupting influence of money, the desire for money, the need for money. Foreign medical volunteers in Haiti need not and do not work for money; Haitian doctors do. The most obvious impact of the sudden appearance of foreign volunteers providing free care was the additional financial burden it placed on already strained Haitian hospitals and doctors. And the ability of foreign volunteers to practice without financial constraints has in turn bred resentment in some Haitian doctors. Dr. Gise`le Rouzier, a surgeon in private practice, explained: Every bit of this is money. Medishare doesn’t have this problem. For example, if I have a patient who comes here, I’m in trouble. I want to do the surgery even if it’s free. But I need general anesthesia at the hospital, and not many hospitals can do it. . . . The anesthesia people are asking US$200 an hour. I’m not talking about OR [the operating room], I’m not talking about anything. So the person who has the possibility of doing free care doesn’t care about how much that care is going to cost. . . . When you walk into Medishare, everything is free, so the doctor doesn’t even have to care, he doesn’t have to worry. It’s another way of seeing things. But I have another way of seeing things, because I’m alone, I’m a private practitioner. So as soon as I start any kind of treatment, it has a consequence, which is money.

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Of her two sisters, who are both physicians who live and practice in North America but who returned to Haiti temporarily as volunteers after the earthquake, Dr. Rouzier says, ‘‘When they come, they’re always telling me all the things I should do better. That’s another thing you take all the time. They don’t know how much you put out of your energy trying to survive.’’ Dr. Rouzier articulates, with unusual candor and vulnerability, many of the most important social, emotional, and financial challenges faced by Haitian doctors post- (as well as pre-) earthquake.

The Sacrifice of Staying Two trends have shaped the lives and careers of Haitian medical professionals in the twentieth century: increased availability of employment by international health institutions and campaigns and the emigration of healthcare workers to other countries, commonly known as ‘‘brain drain’’ (Minn 2011). In 2010, the World Bank estimated that tertiary-educated Haitians were emigrating at a rate of 83.6 percent in 2000; for physicians, the annual emigration rate was more than 35 percent (Bhargava, Docquier, and Moullan 2011). This is not a new development; the flight of oppressed Haitian intellectuals en masse dates back to the early days of the Duvalier dictatorships. As renowned Haitian novelist—and physician—Jacques Ste´phen Alexis wrote in a 1960 letter to Franc¸ois Duvalier denouncing his regime: In some civilized countries in which it would please me to live, I believe I can say that I would be welcomed with open arms—that’s a secret to no one. But my dead ones sleep in this land, and this earth is red with the blood of generations of men who bear my name; I am descended twice, directly, from men who founded this country, so I too have decided to live and perhaps to die here. In my class of twenty-two doctors, nineteen are living in foreign lands. Myself, I remain, despite the offers that have been given to me. In many countries far nicer than this one, in many countries where I would be more esteemed and honored than I am in Haiti, it would be a bridge of gold, if I consented to live there. Nevertheless, here I remain.3 (Alexis 1960 [2013]) Although Alexis chose to remain in Haiti, many Haitian doctors have found irresistible the idea of practicing medicine in a place where they can receive

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higher pay, enjoy superior resources and greater respect, and be able to live and raise their families without the insecurity, stress, and sadness that living in Haiti means for everyone, not only doctors. Dr. Rouzier is an exception; of her two doctor sisters living abroad, she says, ‘‘They can’t take it.’’ For her, like Alexis, the decision to stay was a conscious moral decision, an act of idealism: ‘‘And many of us [doctors] that are in Haiti, it was a choice. It was not that we couldn’t [leave]. It was a choice.’’ But it is a fraught choice—one that leaves the provider constantly reminded of the money, social status, and medical resources she has forgone. When doctors are scrambling to make a living and practice their profession under such unfavorable and poorly funded conditions, compassion toward patients may become a lower priority for both the ‘‘good doctors’’—like Dr. Rouzier—and the seemingly ‘‘bad doctors’’—like Dr. Auguste.

Victims and Saviors, in the Tower of Babel Throughout the emergency response to the 2010 earthquake, interactions between Haitian practitioners and foreign medical volunteers were fraught with misunderstanding, lack of coordination, and uncomfortable power dynamics. Dr. Rouzier described, with some humor, an encounter with an American orthopedic surgeon who, she believed, arrogantly flouted the hospital’s rules. I am a surgeon, so I am allowing myself to say that: there is nothing cockier than a surgeon, and even cockier, an orthopedic surgeon. So when they arrive, in a situation like that, and they’re thinking they’re God, in a situation where the nurse in the United States would be handing them scalpels and gowning them, etcetera, and they have the same expectations, and when it doesn’t happen they become very aggressive. Now, the orthopedic surgeon would come, and he needed space. And they move everything, and not caring about the equipment, which is very important for us because it’s very expensive for us. . . . And I found it even worse in the American surgeons than any other surgeons. Because, at a point, I felt like I was going to become very aggressive if I had stayed working around the OR. One of them, in January shortly after the earthquake, a new team

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arrived and I’m trying to explain to them how we function, and this orthopedic surgeon interrupted me saying, ‘‘Where’s my case? Where’s my case? Where’s my case? I need to start surgery.’’ It was upon arrival. That guy, I just walked him to another foreigner who had been there a while, and I walked out [so that I wouldn’t] punch him. Unlike the foreign medical volunteers, individual Haitian doctors and the entire Haitian medical system had suffered losses from the earthquake. Some healthcare workers had been injured or killed; some had lost their homes or their practices; nearly all had lost family or friends; and all had been emotionally affected by the experience. Of her six colleagues at their clinic in downtown Port-au-Prince, Dr. Rouzier was the only one who did not lose her home or have a close family member who was dead, missing, or trapped under the rubble. For the first forty-eight hours, there was no help. Everyone . . . was overwhelmed. . . . Dr. Calixte, his wife is also an MD and she was at a seminar. He was at home. . . . Every single house in the neighborhood fell, except his house. And he was also alone with his kids, no news of his wife. Do you think someone like that would go to a hospital? There were enough in that neighborhood to take care of. Dr. Jean, he was waiting for his wife to walk out of her office. He was in his car and he saw the building fall. . . . She appeared out of the dust. And then . . . they found out his wife’s mother was under [the rubble]. They had to dig for her and then buried her. And then he went to Doctors Without Borders, and . . . Doctors Without Borders had collapsed, a doctor and a nurse had died. Yet within forty-eight hours they were giving care, in shipping containers. Dr. Louis, her brother was under [the rubble] . . . and for three days, she’s a doctor, her, and the whole family, not only were they digging for people, they were giving care to all those people who were coming. And she had a sister who is very skinny, she was even going through the holes, to hand water to people, and even pray when people died. But when they found her brother’s body, after four days, he was dead, okay, and took care of that, she went to Doctors Without Borders to give care. She didn’t just go home and cry. And Dr. Boucard, her house was down, she had an old mother, she was

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staying in the streets. The first time I saw her she just burst out crying, because all of a sudden she had nothing and was living in the street in front of her house. . . . Dr. Lambert, I was with her when it happened, and the next day when I saw her . . . I thought she’d come to give help, she told me no, her sister was under [the rubble] by Montana, and her sister was a heart patient, so she came to get insulin to be able to give her insulin as she was dragged out. . . . Actually, I was maybe the only one that had no broken home, and I went to the hospital that same day. But many foreign medical volunteers forgot that Haitian doctors were not only healthcare providers but also victims. Having come to Haiti with a sense of selflessness and compassion, foreign volunteers often criticized Haitian health professionals for not giving the same kind of care that they themselves provided. An incident that occurred one night in February 2010 poignantly illustrates the difference between Haitian caregivers who had experienced the quake and foreign volunteers who had not. It was a month after the earthquake, and the hospital where Dr. Rouzier was volunteering was filled with different teams of foreign medical volunteers. At around 1 a.m., a significant aftershock hit Port-au-Prince. Many of the Haitian medical staff— doctors, nurses, and auxiliary staff—fled the building. Their flight drew great opprobrium from the foreign medical volunteers, who thought that the Haitian staff were not dedicated to their work. Dr. Rouzier, who was in the operating room at the time, fought the urge to run. ‘‘I wanted to run, but I didn’t,’’ she said. What the foreign volunteers did not sufficiently appreciate was that for those who had survived the January earthquake, an aftershock triggers an overpowering urge to flee and get out from under a concrete ceiling, overriding other feelings. Not only did many of the Haitian medical staff flee, many of the patients—those who were ambulatory or who had family members who could carry them—fled into the courtyard as well and spent the night sleeping outside. But the foreign volunteers, who had not been there on January 12, did not have the same instinct or the same history of trauma. To them, the flight of the Haitian medical staff looked like negligence. They had ‘‘abandoned’’ their patients. According to Dr. Rouzier, the aftershock also laid bare the low professional esteem in which the foreign volunteers held Haitian practitioners

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and the tendency of the foreigners to circumvent rules set by the Haitian hospital staff: ‘‘We [the Haitian staff] had organized the patients as priorities, by putting stickers on their foreheads, and there was an aftershock, so all the patients had run out. And there was this American orthopedic surgeon who wanted to do surgery, so he was driving this nurse crazy about ‘where’s the next case?’ And the nurse—and I’m looking around to find a priority 1—as soon as I find a priority 1 I walk into the OR, and I saw them going in with a priority 3.’’ ‘‘They didn’t know the triage system at all?’’ I asked hopefully. ‘‘They knew!’’ she snapped. ‘‘They just wanted a case, so they’re taking a 3 because they need a case in! And all the patients are out. That day I could have screamed. And the nurse kind of backed away and took on the priority 3 patient, now very upset, because that other patient is suffering, but is not a priority.’’

Desensitization and Affect At times I, too, witnessed what struck me as callousness and lack of compassion on the part of many Haitian healthcare providers. Dr. Auguste’s perfunctory physical examination of Guerda E´xantus and his unwillingness to communicate humanely with her family is but one example. I saw nurses yelling at and berating tuberculosis patients, seemingly unsympathetic to the social problems and poverty that made them ‘‘noncompliant,’’ even accusing them of willfully infecting others. I heard of OB/GYNs giving women in labor extra Pitocin to hurry along the delivery and sometimes scolding women for not giving birth quickly enough. As a former healthcare worker, I frequently felt angry and horrified. A Haitian physician who is now in his mid-sixties who had grown disillusioned early in his training and has not formally practiced medicine in decades gave his opinion about the processes that numb a healthcare provider to the plight of patients. At first, his observations were condemnatory: When I worked at the General Hospital [in the 1960s], I saw that the majority of Haitian doctors have a way of behaving where they don’t care about the patients. The patients are just something that’s there so that the doctors can learn the profession they’re going to practice. So I never felt that there was any humanity on the part of

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my colleagues. You understand? Except two or three of them, who really had generosity in what they were doing. But many among them, they just treated the patients like guinea pigs. They don’t go into medicine as an act of generosity. They go into medicine because it’s a way to advance socially. That’s what it is for them. There’s only one single thing that interests the doctor, and that’s to become a doctor and make money. Yet later in our conversation, this doctor grew more reflective and perhaps more forgiving of his former colleagues: ‘‘When you are powerless to change something, even if you have a good heart, even if you are generous, in order not to feel bad all the time—because you have to protect yourself, too—it’s a normal reaction, you put a curtain in front of yourself, so you don’t see the suffering.’’ When I asked Dr. Rouzier about desensitization, she responded with a story that touched not only on tenderness and compassion but also on helplessness, the desire to leave Haiti, and the resentment of foreigners who arrive equipped with resources and unsapped energy. She began: ‘‘That’s a prayer I made when I was in med school every day. ‘I’m not being desensitized.’ And it is one of the reasons that [doctors] leave.’’ ‘‘Leave Haiti?’’ ‘‘Yes. It’s not only because they’re looking for a better life. It’s because they’re tired of having to live with all those problems. Because things that you can take care of—it’s easy. But most things are beyond you.’’ Her voice grew quiet then, and she recounted the story of a four-yearold boy who had been abandoned in a Catholic clinic in the shantytown of Cite´ Soleil with an oozing cancer covering his skin: ‘‘I took off the tumor, cleaned his hair, cleaned his whole body, but he had so many tumors that there was nothing we could do. So for a while we regularly put him under general anesthesia, and I took care of the tumors around the other eye, to try to save some vision, just try to keep him clean.’’ Dr. Rouzier swallowed, then continued. ‘‘The nurse or one of the nuns found out he could sing. And he had this beautiful voice, and they kept on teaching him singing, and they would take him to this orphanage to sing. . . . But he knew he was going to die. Finally I couldn’t see him anymore. I got too attached. The pediatrician told me he decided that when he died he was going to be an angel to protect the priests.’’ The elements of the story—the wise and

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knowing child who could sing beautifully—took on religious, even mythic weight. The doctor began to cry. ‘‘Sorry.’’ ‘‘So it’s very hard. . . . So.’’ She wiped her eyes. ‘‘To be able to survive one has to tell oneself that I’m doing a lot of good things. And, um, it becomes very offending when people come out with their new technology, their new equipment that were donated to them, and become very aggressive telling you that you’re not doing anything. Because through the years, we’re there day by day.’’ The majority of foreign volunteers come for a relatively short period of time and can plunge themselves experientially into the crisis and suffering. Blessed with the ‘‘unbearable lightness of expats’’ (Redfield 2012), they are free to leave Haiti when they wish or when economic constraints require. In contrast, Haitian providers—those who elect to divest themselves of that ‘‘lightness’’—experience the crisis and suffering every day. It is difficult to remain perpetually idealistic and compassionate. They may attempt to provide care and maintain a sense of compassion at the limits of financial and social privilege—but not all succeed. It is a sacrifice for Haitian doctors to remain in their homeland. Those who do may find themselves transformed from doctor-as-nationalist-hero to doctor-as-unfeeling-villain for having stayed in Haiti and responding to the economic and social pressures that staying entails.

Conclusion: No System for Heroes? In a land like Haiti, with so much suffering, injustice, and poverty and in the aftermath of a disaster like the earthquake, which left hundreds of thousands dead, injured, grieving, homeless, displaced, or emotionally and psychologically scarred, the plight of Haitian doctors is not the most moving. But it is an important factor in any long-term development of a qualified and functional medical system: if Haiti remains a country where medical professionals cannot make a living, where they are made to compete with foreigners who provide free care and challenge their expertise and commitment, it will be impossible for Haiti to train and keep qualified Haitian doctors. Physicians and other intellectuals—even those who possess a true desire to help the suffering—have been fleeing Haiti for decades, further enfeebling an already weak and inadequate healthcare system. Good intentions and humanitarian aspirations—on the part of Haitian providers and

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foreign volunteers alike—are not enough. A sustainable medical system that will ultimately benefit Haitian patients must respect the professionalism of Haitian providers, recognize their moral engagements, and provide financial and professional incentives for them to stay in Haiti and, by so doing, contribute to a more humane medical practice that is based on healing rather than desperation. Haitian physicians may choose to leave Haiti and practice abroad (and perhaps return as volunteers, as Dr. Rouzier’s sisters did, after the earthquake). They may find work with international NGOs, which may provide both remuneration and moral satisfaction. But if a Haitian provider joins the aid apparatus permanently, beyond the moment of crisis—if in order to be a ‘‘good doctor’’ she must be subsumed into the larger aid economy—is she still a nationalist hero? There must be a place for Haitian physicians to practice, beyond the shifting, transient, and externally directed world of humanitarian aid, if Haiti is ever to have a functioning and sustainable healthcare system. Notes 1. Guerda E´xantus is a pseudonym, as are the other names herein. 2. While the lack of transparency and accountability by foreign NGOs and other nonstate actors in post-quake Haiti is well-documented, a few alarming statistics illustrate the overall long-term failure of the post-quake aid response. Less than 1 percent of U.S. aid went to the Haitian government. Few of the contracts awarded by the United States Agency for International Development (USAID) went to Haitian companies, while $76 million of those contracts (39.4 percent of the total) went to Washington, D.C.-based firms (the so-called Beltway Bandits). A mere 0.004 percent of aid money went to Haitian NGOs (Ramachandran and Walz 2012, Katz 2013). 3. Translation from the French by the author.

References Abel, Thomas. (2007) ‘‘Cultural Capital and Social Inequality in Health.’’ Journal of Epidemiology & Community Health 62 (7). doi:10.1136/jech.2007.066159. Alexis, Jacques Ste´phen. (1960 [2013]) ‘‘Lettre de Jacques Ste´phen Alexis a` Franc¸ois Duvalier.’’ Parole en Archipel. http://parolenarchipel.com/2013/02/07/lettre-de -jacques-stephen-alexis-a-francois-duvalier-2/. Accessed March 3, 2014. Bhargava, Alok, Fre´de´ric Docquier, and Yasser Moullan. (2011) ‘‘Modeling the Effects of Physician Emigration on Human Development.’’ Economics & Human Biology 2: 172–183. Brodwin, Paul. (1996) Medicine and Morality in Haiti: The Contest for Healing Power. Cambridge: Cambridge University Press.

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Buss, Terry and Adam Gardner. (2008) Haiti in the Balance: Why Foreign Aid Has Failed and What We Can Do About It. Washington, DC: Brookings Institute. Costello, Amy. (2012) ‘‘Haiti Medical Volunteers: Learning from Mistakes.’’ The World, October 11. http://www.theworld.org/2012/10/haiti-medical-volunteers/. Accessed March 3, 2014. Farmer, Paul. (1994) The Uses of Haiti. Monroe, ME: Common Courage Press. ———. (2003) Pathologies of Power: Human Rights and the New War on the Poor. Berkeley: University of California Press. Farwell, Scott. (2010) ‘‘Haiti’s Private Medical Sector Collapsing as Charities Rush to Provide Free Health Care.’’ Dallas Morning News, June 20. Katz, Jonathan M. (2013) The Big Truck That Went By: How the World Came to Save Haiti and Left Behind a Disaster. New York: Palgrave Macmillan. Klarreich, Kathie and Linda Polman. (2012) ‘‘The NGO Republic of Haiti.’’ The Nation, November 19. http://www.thenation.com/article/170929/ngo-republic -haiti. Accessed March 3, 2014. Maternowska, M. Catherine. (2006) Reproducing Inequities: Poverty and the Politics of Population in Haiti. New Brunswick, NJ: Rutgers University Press. McAlister, Elizabeth. (2012) ‘‘Soundscapes of Disaster and Humanitarianism: Survival Singing, Relief Telethons, and the Haiti Earthquake.’’ Small Axe 39: 22–38. Minn, Pierre H. (2011) ‘‘ ‘Where They Need Me’: The Moral Economy of International Medical Aid in Haiti.’’ Ph.D. diss., McGill University. Ramachandran, Vijaya and Julie Walz. (2012) ‘‘Haiti: Where Has All the Money Gone?’’ CGD Policy Paper 004. Washington, DC: Center for Global Development. http://www.cgdev.org/sites/default/files/ 1426185_file_Ramachandran_Walz_haiti_FINAL_0.pdf. Accessed March 3, 2014. Redfield, Peter. (2012) Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Schuller, Mark. (2012) Killing with Kindness: Haiti, International Aid, and NGOs. New Brunswick, NJ: Rutgers University Press. Shim, Janet. (2010) ‘‘A Theoretical Approach to Understanding Health Care Interactions and the Dynamics of Unequal Treatment.’’ Journal of Health and Social Behavior 51 (1): 1–15. UN Office of the Special Envoy for Haiti. (2011) ‘‘Has Aid Changed? Channelling Assistance to Haiti Before and After the Earthquake.’’ http://www.lessonsfromhaiti.org/download/Report_Center/has_aid_changed_en.pdf. Accessed March 3, 2014. Wendland, Claire. (2012) ‘‘Animating Biomedicine’s Moral Order: The Crisis of Practice in Malawian Medical Training.’’ Current Anthropology 53 (6): 755–788. World Bank. (2011) Haiti: Migration and Remittances Factbook. http://siteresources .worldbank.org/INTPROSPECTS/Resources/334934-1199807908806/Haiti.pdf. Accessed March 3, 2014.

Chapter 3

Trust and Caregiving During a UNICEFFunded Relief Operation in the Somali Region of Ethiopia Lauren Carruth

By two o’clock in the afternoon, Abdul and Hussein,1 two Somali nurses who made up one of UNICEF’s Mobile Health & Nutrition Teams in northeastern Ethiopia, were exhausted and hungry. But the crowd continued to swell inside the small cement clinic. Hollered jokes between teenagers, ululations of proud grandmothers, screams of impatient infants, and gregarious banter between men filled the small space with a steady clamor. In the midst of the growing chaos, an older Somali woman named Ubay made her way inside, leaned her hip against the side of the intake table, and after pronouncing that she felt dizzy and sick, brusquely posed a series of questions to Abdul: ‘‘Are you the doctor [dhaktarka]?’’ ‘‘What is your clan [reer]?’’ ‘‘Your subclan [jilib]?’’ ‘‘Your mother’s family?’’ ‘‘Where did you come from?’’ And so on. Abdul answered each of her questions patiently, one by one, despite the swirl of activity building around them, gently nodding and wrapping the blood pressure band around her arm, feeling for her pulse, and

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checking the line of women pressing at her back—women all leaning forward now, warily listening to the dialogue between patient and provider. Abdul, like Hussein, was from the Ogaden clan—the largest Somali clan in Ethiopia—and he had grown up farther south, in towns nearer the borders of Kenya and Somalia. Quietly smiling, near the end of his final answer, Ubay said, ‘‘We are Issa [Ciise]—we are dark [madoobe] here.’’ At the conclusion of this thorough exposition of Abdul’s and her own social positions, control of the conversation turned again. Abdul asked how long she had felt dizzy. National staffs of relief agencies, around the world, regularly care for persons from rival groups during medical humanitarian responses. Grievances, fears, and hardened dispositions regularly accompany healthcare providers and patients as they face one another in makeshift clinical spaces. Such is the case in northeastern Ethiopia: displaced Somalis from the Issa clan increasingly receive healthcare not from expatriate aid workers but from Somali clinicians affiliated with the rival Ogaden clan. To examine the significance and potentials of such encounters, this chapter provides an ethnographic portrait of Abdul and Hussein’s mobile team as they responded to a localized epidemic of dysentery and a spike in rates of severe acute malnutrition among children in the small village of Elahelay.2 As sick and apprehensive patients sought care from Abdul and Hussein, they divulged private and potentially embarrassing symptoms, experiences of suffering and disparity, ignorance of biomedicine, fears of not qualifying for aid, and even fears of spirit possession. Abdul and Hussein made the best of these encounters through explicit recognition of popular health cultures, customary caregiving practices, and local determinations of need. In so doing, they were able to rupture existing social dispositions pitting Issas against Ogadeni Somalis and forge new relations of trust that extended past the walls of the clinic and the timelines of the relief operation. I did not find observable shifts in identity politics or political persuasions as a result of these medical humanitarian interventions. Rather, in this chapter I document subtle shifts in the ways people related to one another across clan and ethnic boundaries. During the mobile team interactions, historically salient—and often reified—rivalries between Issas and Ogadenis were subsumed by individuals’ greater concerns for medical care as well as support for a more unified Somali contingent within Ethiopia. Political subjectivities transformed, for one, through meaningful clinical encounters during humanitarian response. Abdul and Hussein were charismatic individuals and competent providers, to be sure. But their strategic,

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compassionate efforts to forge familiar, kinship-based, and uniquely Somali relations of care helped forge new and enduring relations of trust and care between Somalis from different clans. In this chapter, I first describe the UNICEF-funded Mobile Health & Nutrition Team and the history and context of medical humanitarian interventions in eastern Ethiopia. Then I outline two relevant and interrelated antagonistic relationships: historic rivalries between the minority Issa and dominant Ogaden Somali clans, and between dominant ethnic Habasha3 Ethiopians and ethnic Somalis as a growing and unified constituency within Ethiopia. Throughout the chapter, I provide ethnographic vignettes of significant clinical interactions between the mobile team and local patients. Abdul and Hussein’s efforts may, as such, serve as models for how medical responses can help redress local antagonistic relationships that underpin so many humanitarian emergencies around the world.

Medical Humanitarianism and ‘‘Mobile Teams’’ in Ethiopia Abdul and Hussein ran the mobile team in Elahelay from October 2008 until March 2009. Elahelay is a village of approximately four hundred persons in the northeastern corner of the Somali Region of Ethiopia, close to borders with Somaliland and Djibouti. Elahelay sits within a larger district in the Somali Region called Aysha. Most residents of Elahelay were, at some point, either designated a refugee or internally displaced as a result of a combination of drought, livestock loss, and political conflict. Several residents had fled from multiple wars, natural disasters, and personal calamities during their lifetimes and at different times lived in Ethiopia, Somalia, Somaliland, and Djibouti. More generally, pastoralist livelihoods in the Horn of Africa have been ravaged by recurrent rainfall shortages, currency and price fluctuations, and international livestock trade restrictions. Many families camped in remote pasturelands around Aysha lost livestock and cash holdings during successive droughts in 1999–2001, 2003, and 2010–2011. Somalis’ expectations of medicine and clinical care in Ethiopia have been shaped by a long history of episodic forms of medical humanitarian aid there. Between fifteen thousand and thirty thousand refugees and internally displaced persons from Somalia, Somaliland, and the surrounding

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Somali Region of Ethiopia settled in a refugee camp nearby in Aysha district from the mid-1980s until 2005. In 1985, the nongovernmental organization (NGO) Me´decins Sans Frontie`res opened a clinical facility to service the burgeoning camp. After 1989, the clinic was operated and funded primarily by the United Nations High Commissioner for Refugees (UNHCR) with assistance from other international NGOs and later operated by the Ethiopian federal governmental refugee agency (ARRA). Through the years, this facility provided free medicine and medical care to local residents, refugee and not. But with the resettlement of most displaced persons in 2005, the facility closed, leaving the remaining population without easy access to clinical care. Remnants of additional past medical relief operations and shuttered clinical facilities dotted the landscape: a small clinic in the county seat of Aysha was opened in the 1930s and closed in the early 1980s by the Italian government. A two-room clinic a few kilometers farther west was opened in 1998 by Me´decins Sans Frontie`res and then closed five years later. In 2002 a small clinic was erected in Elahelay by another (now forgotten) German humanitarian relief NGO. Around the same time two clinics were constructed and supplied with basic medications and medical equipment by the Hararge Catholic Secretariat in cooperation with Catholic Relief Services, but less than one year later both were closed. And a one-room concrete shelter was built on the northeastern edge of Aysha district with funding from a World Bank infrastructure development project nearby but was neither staffed nor supplied. Today this shed stores bags of donated grain. In the last fifteen years, medical humanitarian aid has been increasingly funneled through regional governmental institutions and staffs as one part of the Ethiopian government’s efforts to decentralize and organize rural healthcare delivery systems and the distribution of aid commodities (FDREMH 2011). Consequently, many of these abandoned clinical spaces have reopened at least once to house ephemeral public health initiatives, headquarter vaccination campaigns, or store food aid. From July 2007 until August 2009, both long and short rainy seasons in the northern Somali Region of Ethiopia were delayed, and rainfall totals were significantly lower than normal (IRIN 2009). Compounding the drought conditions, multiple epidemics of diarrheal disease and measles occurred in various communities in Aysha district (woreda), and rates of severe acute malnutrition among children peaked. To respond, UNICEF funded the deployment of Abdul and Hussein’s Mobile Health & Nutrition Team to Elahelay and other nearby villages (UNICEF 2009). Places qualified

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for mobile team visits based on rates of acute malnutrition or incidence of diarrheal disease in children less than five years old; as expected, the mobile team visited vastly underserved and impoverished locales. Abdul and Hussein’s unit was tasked with providing basic screenings, hospital referrals, vaccinations, a few essential medications, BP-5 supplementary biscuits, and Plumpy’Nut therapeutic food to a limited number of beneficiary groups: sick or malnourished infants, young children, and their pregnant and lactating mothers. Mobile teams, as such, were the vanguard of efforts to provide highquality healthcare by trained Somali professionals and to transform provisional funding for humanitarian emergencies into sustainable improvements in the health system (UNICEF 2009). Abdul and Hussein accomplished even more than that. Faced with an overwhelming mission and even several heated social confrontations, they garnered high esteem from local populations. The mobile team did constant translational work between oftentimes incommensurate and vexing illness presentations and labels, all the while explaining the many limitations of their mission. Hassan, a young father and community leader in Aysha, offered this review, one month after the mobile team departed: ‘‘The mobile team provided pills [kiniini], mostly, to the people here. People loved the mobile team. And [people here] believed in [aamina] that medicine [dawo], during the six months they were serving us. The people, all of them, they focused on the mobile team, they liked them personally, they took the services from them and they believed that their medicine was high-quality medicine. The people even said that these pills were not sent by [the government of] Ethiopia, they were surely sent by Allah!’’ Even in the face of limited material donations and a limited time frame for response, Abdul and Hussein were not austere or apathetic. Quite the opposite: by the end of their second week living in the northern Somali Region, they had subsidized and shared evening khat with village elders, community leaders, and mullahs. Beyond filling in the necessary patient logs and vaccination cards, they had begun remembering their patients’ names, kinship relations, and medical and personal histories. Rather than strictly adhering to UNICEF’s targeted beneficiary groups, the mobile team siphoned therapeutic and supplementary food aid to two families who cared for severely disabled family members, and they distributed analgesics and BP-5 biscuits to several elders in town. Accordingly, because of their affability, their efforts to distribute aid to elderly and disabled residents of

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Elahelay and their willingness to forge familiar caregiving relationships outside the walls of clinical spaces, Abdul and Hussein were interpolated into community life and local relations of reciprocity as well. By late November 2008, the mobile team operation in Elahelay was in full swing. One hundred or so women, children, and infants—all wrapped in brightly colored scarves and hijabs and cotton dresses—swarmed the clinic on the windy, hazy Sunday morning. Abdul and Hussein rapidly saw a succession of patients: two anemic young women, an elderly woman showing signs of hypertension, several coughing and moderately malnourished children, and a series of pregnant women stopping in for checkups. Halfway through the morning, Yonis, an emaciated older man with thin white hair, slowly climbed into the crowded space, coughing beneath his left hand. Everything about him was tired: his sagging and threadbare khaki vest, his ancient leather sandals, and his distant eyes. He was helped up the two steps into the facility and over to the mobile team’s table by Roble, a proud but quiet town leader. Abdul quickly grabbed Yonis a chair, as the man’s legs nearly gave way, and, squeezing past a few mothers and children ahead of him, Roble addressed Hussein at the far end of the table. ‘‘He’s had TB before,’’ Roble whispered to us, matter-of-factly. He had been treated in the hospital years earlier but was again coughing profusely. Hussein nodded and quietly led the old man into an adjoining room to hear his lungs and his story in peace. Yonis squatted on the ground before Hussein but could hardly breathe through the mess in his lungs. Hussein beckoned me over to listen and learn. Without a word he nodded again, and together we cleaned off the examination table in the room and helped Yonis rise and rest nearby. Back in the main room, Roble, Hussein, and Abdul whispered to each other discreetly, ‘‘Is it?’’ ‘‘Yes, probably.’’ Roble said, ‘‘He is my subclan but only very distantly. He has no family left’’—no one to transport him to the hospital and no one to care for him and feed him once he arrived there. A few minutes later, despite Yonis’s official exclusion from UNICEF’s program to treat mothers and young children, Hussein gave him several packages of BP-5 biscuits and a regimen of amoxicillin.4 Hussein finally said to me, ‘‘This is all we can do—the mobile team cannot do anything more. He has no family . . . he wants to stay here.’’ Despite a few additional trips Hussein made to visit Yonis’s home during the next weeks and despite some supplements of food and medications, Yonis passed away before the next monsoon rain.

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Back in the clinic, an hour or so after Yonis and Roble departed, a young woman named Maryan approached Abdul’s side of the intake table, set down a meter-long piece of rusty rebar, and gestured to an infant wrapped tightly in several scarves at her waist. Abdul nodded to the mother, signaling his desire to take a look at the baby, and she consented. He carefully lifted one layer of the scarves aside and smiled down at the child’s face. ‘‘My God! Beautiful!’’ he exclaimed, telling me she had had the baby only a few days ago and that she had been to see him in the weeks beforehand. He asked her when the birth had taken place and if the delivery had gone as expected. She answered, and he continued probing to ensure she didn’t exhibit any signs of infection or injury. He slipped her a few packages of BP-5 biscuits as well. Once Maryan was outside again, he leaned over to me and whispered that the mother seemed afraid of jinn or the evil eye on her young baby—she carried the rebar with her for protection, he assumed, and obviously did not want to fully unwrap the child in public. But she came to see him anyway, and that made him happy.

Somali Clanship and Constructions of Issa Versus Ogaden Loyalty to family (reer)5 and clan (reer or qabiil) is characteristic of Somalis and central to their personal and social identities. Somalis’ social activities and family structures in the Horn of Africa are, in many ways, structured by a patrilineal, patriarchal, segmentary kinship system (Lewis 1994). But notions of clan and genealogy are more complicated than bloodlines and are continually reimagined and reconstructed by individuals over time (Barnes 2006, Lulling 2005, Abdalla Omar 1995). In my experience, their uses of the word reer are more indistinct and layered than they are literal, linear, or deterministic. Most used the term broadly and variably to refer to a collection of lineages, a family, an ethnic group, or even a cooperative herding group. Besides alliances between descendants within male lines, important ties exist across clan divisions through intermarriage, trade relations, seasonal travel, and migrations for wage labor, between a son and his mother’s clan, and, perhaps most critically, between an individual and his or her mother’s brother (abti). Just as Ubay’s medical encounter began with questions about Abdul’s clan and kinship affiliations, the mobile team and my Somali research colleagues were all asked numerous times to detail our

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own lineages. Rather than revealing each other’s differences or genealogical distances, however, these conversations typically ended with relish in longlost or previously unknown family ties. At the same time, distinctions and antagonisms between various clan formations have long been central to politics, livelihoods, and social life in the Horn of Africa. The Issa-Ogadeni dichotomy is paradigmatic. A vast majority of the residents in the northern Somali Region of Ethiopia identify as ethnically Somali, and most also belong to the Issa clan (Reerka Ciise). Issas are the dominant and most populous Somali clan in Djibouti but are a minority in Ethiopia. Most Issas reside in the northeastern corner of the Somali Region and were often described as, in general, ‘‘closer’’ and ‘‘more cooperative’’ with the federal government in Addis Ababa although sometimes marginalized within the Somali Region as a whole. As Ubay pointed out, Issas frequently racialized clan categories by distinguishing themselves from Ogadenis and other Somalis farther south based on physical characteristics: Issas described themselves as relatively darker-skinned, shorter, stockier, and, among men, balder. In Ethiopia, the Ogaden clan (Ogaadeen) is more populous and historically powerful; it is the majority clan group in most of the Somali Region, and likewise, more Ogadenis now hold elective office and bureaucratic positions at the regional and federal levels of government. The Somali Region of Ethiopia is still sometimes referred to as ‘‘The Ogaden’’ (Ogaadeeniya), and the Ogaden-dominated southern districts are renowned for fertile pastureland and important international trade routes. The Ogaden clan is also infamous for its association with the Ogaden National Liberation Front (ONLF), a rebel army that fights for Somali autonomy and secession from rest of Ethiopia. Both of the mobile team nurses in Elahelay were Ogadeni: Hussein spent most of his life in the rural southern Somali Region while Abdul grew up in Jijiga, the regional capital. Yet when I spoke with individuals who had received care or advice from the mobile team, clan differences or affiliations were never said to be important in assessing or accessing care. Instead, nearly universally, persons receiving care from the mobile team lauded the nurses’ respectfulness, geniality, and knowledge of medicine. Within governmental and civil society structures in the Issa-dominated Aysha district, alternative distinctions between individuals superseded divisions and alliances based on clan and kinship. Distinctions were more often marked as between those who had lived in cities and abroad and those who

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were still ‘‘rural’’ or nomadic (baaddiye). Being a nomadic herder was not always associated with less wealth—indeed, many pastoralists owned thousands of dollars in camels and cattle—but instead indexed disparate access to formal education, the ability to speak the English language, experience with expatriates, the use of monetary savings and bank credit, knowledge of and reliance on biomedicine versus ‘‘traditional medicine’’ (dawo dhaqmeed), and year-round settlement in one community. As such, pastoralistcosmopolitan distinctions in the northern Somali Region, more than clan divisions, traced the contours of persons’ differential abilities and desires to access medical care. Kinship and clan responsibilities were, however, central to Somalis’ personal experiences of illness and healthcare; family ties were key to paying for, accessing, negotiating, and understanding various forms of medicine. For example, families frequently and informally redistributed monetary and livestock holdings within subclan, close cousins (ilma adeero) and restitution (mag—‘‘blood money’’) units to pay for medicine, hospital visits, Qur’anic healing, or, more rarely, travel abroad for care. Residential family groups (qoys), brothers, and uncles (both by blood and through close friendship with a patient’s father), in particular, frequently stepped in to grant logistical support and give advice when formal state safety nets, social services, transportation infrastructure, and healthcare facilities were absent or unreliable. More than half of the households in Elahelay housed and provided food and care for parents or other elderly members of their extended family, especially widows and older men who could no longer herd livestock. And in general, understandings of illness and health were typically dialogically constructed and acted on collectively through pluralistic and variable local systems of healthcare, healing, and religious practice (Carruth 2014). Consequently, what it meant to be a ‘‘patient,’’ a ‘‘caregiver,’’ and even a professional ‘‘healthcare provider’’ were all understood and discussed through the networks and language of kinship.

Conflicts and Alliances Beyond the Somali Clan The northeastern Somali Region of Ethiopia has been located, at different times, in the margins and on the frontlines of several ethnic-based irredentist movements and interstate wars. For the most part, these conflicts have eclipsed levels of violence resulting from interclan rivalries in Ethiopia and

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have frequently brought Somalis of different clans together in opposition to outside powers. For example, following colonial independence in 1960, Somalia’s socialist military leader, Siad Barre, attempted to unify Somali populations in the Horn of Africa, including Somalis living within the boundaries of the Ethiopian Empire, into a new ethnic national state centered in Mogadishu called ‘‘Greater Somalia’’ (Soomaaliweyn). Then, throughout the 1970s, the Somalian government financially and militarily supported local cessation movements against the Ethiopian Empire, including in what is now the district of Aysha. Because Aysha is located along the eastern and northernmost boundaries of Ethiopia, for much of the later twentieth century various Ethiopian military units were stationed in barracks there to defend the border, enforce Ethiopian law, and extinguish any potential rebellions. Decades later, during the time period in which research for this chapter was conducted, elder Somali residents vividly recalled numerous and regular acts of violence and intimidation by these Ethiopian military forces against civilians as well as customary and religious leaders. Furthermore, these historical conflicts continue to reverberate in public discourses and private conversations about the ongoing peace talks between the ONLF and the Ethiopian administration and about disputes between Somalis and other Ethiopians farther south in Somalia and Kenya. In 1991 the Tigray6 People’s Liberation Front, with assistance from other ethnic-based militia groups in Ethiopia, led a coup that toppled Ethiopia’s socialist regime based in Addis Ababa and deposed its centralized dictatorial administration. In the wake of the revolution, an alliance of ethnic groups from across the country formed the Ethiopian People’s Revolutionary Democratic Front (EPRDF), led by Tigrayan military commander Meles Zenawi.7 The EPRDF strategically sought to unite the disparate and oppositional ethnic groups in Ethiopia under one ethnic federalist state (Samatar 2005). The embrace of ethnic diversity and national selfdetermination was, on the surface, an effort to provide an antidote to the history of absolutism and violent assimilation. However, the politicization of kinship and ethnicity through the expansion of the Federal Democratic Republic of Ethiopia and the construction of a unified Somali National Regional State are incomplete and contested projects and have been major engines of continuing instability there (Hagmann 2005: 519).8 In April 2007 the ONLF attacked a Chinese oil installation in the southern Somali Region, killing more than seventy Chinese and Ethiopian civilians. The Ethiopian government responded by launching a systematic

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counterinsurgency campaign in predominantly Ogaden communities in the southern Somali Region, and the ONLF retaliated with attacks on Ethiopian forces. Thus after April 2007, relationships between Somalis—not just ONLF supporters or Ogaden-clan members but many Somalis throughout the region—and the Ethiopian government deteriorated, and in the southern Somali Region they turned violent. During the period of the research for this chapter, Human Rights Watch (2008) accused Ethiopian police and military forces of numerous attacks on civilians and civilian livelihoods in the Somali Region ‘‘that amount[ed] to war crimes and crimes against humanity.’’ Peace talks between the ONLF and Ethiopian government have, so far, failed to bring about a resolution. Somali Ethiopians were thus unevenly integrated into multiple, fluid, and often antagonistic political organizations: on one hand, they are incorporated as one administrative unit within the Ethiopian state; on the other, residents of the Somali Region interact, travel, and trade with Somalis living in Djibouti, Somaliland, Puntland, Somalia, northern Kenya, and the swelling Somali diasporas abroad. According to Issa clan leaders in Ethiopia, the construction of a Somali Regional National State has, with increasing effectiveness, subsumed alternative forms of cooperation and identity within the northeastern Somali Region, including clan and subclan alliances, trading and grazing alliances that seep over international borders, transnational credit and business cooperatives, and customary legal and political structures. And although residents of Aysha were Somali Ethiopians, there was growing animus toward Habasha Ethiopian soldiers, police, and representatives of the government. Following the increases in violence and counterinsurgency efforts in the Somali Region, local apprehensions about the justness of the Ethiopian government and the reliability of political alliances with the EPRDF were on the rise. Reified clan divisions and hostilities (such as Issa versus Ogaden) in many respects were declining, while tensions between Somalis as a contingent and the Ethiopian government in Addis Ababa increased. Political insecurities, marginality, and contested processes of ethnicity-based regional governance have delimited what it means to be a Somali in Ethiopia. Since the institution of ethnic federalism, clan divisions and even ethnic differences have been (unevenly) subsumed in local and regional efforts to create and maintain a cohesive Somali contingent. In the midst of these processes, I argue that the mobile team, for one, also shifted the subjective ways in which Issa Somalis in and around Aysha

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regarded their historically antagonistic Ogadeni neighbors to the south and, more broadly, increased the saliency of a cohesive Somali Region in contrast to an unstable amalgamation of distinct clans or a unified Ethiopian nation-state. The mobile team was important because, finally, for a period of time, residents could access high-quality medical care from other Somalis—even Somalis from outside their clan—rather than from Ethiopian public healthcare facilities or Habasha providers.

Trust and Caregiving in Humanitarian Emergencies While discussing the character of clan relations, a man from Elahelay named Osman quoted a popular Somali proverb: ‘‘Don’t say the man was closer in blood relation to me. Say that he was good to me—people will not forget that.’’ Many displaced residents of the Somali Region mourn the loss of their nomadic, fiercely independent lifeways and identity. Two generations of interstate wars, ongoing violence between Somali civilian populations, the ONLF, and Ethiopian military forces, a lack of reliable safety nets, and a lack of infrastructure development and other meaningful investments have dissuaded many Somalis from depending on the federal government for help during humanitarian emergencies. And while international relief agencies are often present in the aftermath of crises, humanitarian programs are typically inadequate and mercurial. In the vacuums left as various governmental and relief programs recurrently recede from people’s lives, strong kinship-based supportive networks within and between Somali groups have remained. Clanship, for northern Somalis, is an antidote to their shared histories of crisis, even as various constructions of ‘‘clan’’ are also at times fodder for nationalist and other political maneuverings, especially farther south. The mobile team’s efforts to reconfigure patterns of triage and resource distribution in Elahelay were, I argue, modeled on the supportive features of clanship, including a sense of duty to care for family and obligations to share resources and skills within flexible kinship groups. As Ogadeni Somalis working in Issa territory, Abdul and Hussein were able to undermine divisions between Issas and Ogadenis and construct new lines of alliance and support through their participation in these vital kin-based systems of reciprocity, responsibility, and care.

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Humanitarian relief has long been critiqued for its shortsighted focus on relieving immediate bodily suffering at the expense of lasting engagement or reform. Most medical humanitarian organizations remain steadfastly focused on efficiently relieving immediate physical suffering —applying so-called Band-Aids to those deemed by relief organizations to be in greatest medical need (Redfield 2013). Medical humanitarian aid relies upon the maintenance of neutrality in conflicts, and healthcare providers during emergencies work hard to fortify clinics as peaceful spaces within violent environments (Walker and Maxwell 2009). Mobile teams are emblematic of this kind of aid. However, even these ephemeral and brief lifesaving interventions are imbued with intense emotion and potential for social change beyond the walls of clinics and the timelines of relief programs. During chaotic humanitarian relief operations like the UNICEF-funded mobile team in the Somali Region, patients may be faced with frightening illnesses or injuries; they may feel vulnerable to discrimination, neglect, or misunderstanding; and they may be either destitute or simply desperate for help. Such circumstances require both compassion and comprehension on the part of providers. Trust between providers and patients is fundamental to proficient medical practice and healing, I argue, especially in the midst of humanitarian crises for persons who have faced prior breaches in trust during medical encounters and for those who have more generally faced political marginalization and violence. Even though Abdul and Hussein were ethnic Somalis, able to speak the Somali language, and able to understand most folk models of affliction, medical encounters were still frequently awkward simply because they involved the discussion of personal problems with relative strangers and the negotiation and distribution of limited resources. As described in Maryan’s case, in order to assuage their patients’ anxieties and timidity, Abdul and Hussein were, as much as possible, sensitive to relevant gender and privacy norms. In order to respond to local determinations of need, they dispensed food and medicine to elderly and disabled persons, like Yonis, who were perceived to be unfairly excluded from UNICEF’s aid. These strategies were profound: they allowed providers and residents to coconstruct how individual providers should prioritize and manage healthcare for sick patients and their families, as well as how, potentially, the Somali Regional National State should manage care for its citizenry. Despite the potential for distrust and disagreement between patients and providers,

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in this case between Issas and Ogadenis, the rigid architecture of UNICEF’s intervention was bent in response to local expectations, contingencies, and health cultures. Residents of Elahelay were grateful for Abdul and Hussein’s exceptional medical practices; their gratitude derived not simply from the fact that they gave out free medications and food or because they were affable and outgoing but because they learned about and were integrated into familiar systems of care. In so doing, they unraveled local stereotypes of Ogadenis as arrogant and imperious, and they appeased popular apprehensions about past Issa-Ogadeni antagonisms. These shifts were part of larger political and social changes in the Somali Region of Ethiopia, and they are sure to affect future humanitarian and health programs. Medical humanitarian aid has long been a part of local systems of healing and popular health cultures in communities, like Elahelay, where health and humanitarian crises recur. People in Aysha expected a lot from aid and the mobile team; and the mobile team, for the most part, lived up to and even surpassed expectations. However, despite their popularity, six months after arriving Abdul and Hussein departed to respond to crises elsewhere. While particular aid programs like the mobile team come and go over the years, the reverberations of these interventions continue. The memories of particular interventions and particular providers—despite the brevity and limited scope of humanitarian missions—shape enduring social dispositions as well as health subjectivities. After the mobile team’s intervention, people desired more Somali healthcare professionals, more educational opportunities for Somalis in the health sciences, and more sustainable forms of locally controlled medical and humanitarian responses. Despite seemingly continual crises in unstable regions of the world like the Horn of Africa, this sketch of a relief operation demonstrates how medical humanitarian encounters can provide moments in which bodily as well as societal healing occur. In emergency situations and chronically underserved places where demands are enormous, building relations of trust may be challenging and time-consuming—the very antithesis of rapid response. Prior breaches in trust, histories of violence, or histories of institutionalized health disparities may make trust within clinical encounters and relief operations even more difficult. However, if a real effort to improve healthcare and promote healing is to be made, trust must be a primary mission of medical humanitarian response and an integral aspect of postconflict reconstruction, postconflict reconciliation, and medical practice.

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Notes 1. All names of persons have been changed to maintain anonymity. 2. These findings are based on ethnographic research in the Somali Region of Ethiopia conducted between July 2007 and October 2009 and on work with UNICEF and the World Food Program in Ethiopia between 2003 and 2009. 3. ‘‘Habasha’’ is an ancient term that previously referred to persons who were part of the Axumite then Abyssinian empires but is today colloquially defined as persons of mostly Amhara or Tigrinya ethnicities residing in Ethiopia or Eritrea, or persons whose first language is either Amharic or Tigrinya. The term ‘‘Habasha’’ for many rural Somalis in eastern Ethiopia indexed not just ethnicity and language group but political support of the current Ethiopian government, although many Habashas object to this usage and association. 4. Tuberculosis medications were not available and Directly Observed Therapy (DOTS) was not possible given the limited mission of the mobile team. I did not investigate further why Yonis received amoxicillin, but in the Somali Region, it is the most common and expected treatment for acute respiratory illnesses. 5. The word qoys, not reer, refers to the immediate family living together in one house or homestead. 6. Tigray is an ethnic group residing predominantly in northern Ethiopia along the border with Eritrea. 7. Meles Zenawi retained power from 1991 until his death in September 2012. The Ethiopian Parliament elected him prime minister in 2005 and again in 2010. 8. For example, Somali nationalist and secessionist social movements have long attempted to undermine divisions based on clan in order to unite Somalis in the Horn under collective memories of colonization, forcible conscription of ethnic Somalis into Ethiopia’s wars with Somalia, the dispossession of nomadic pastoralists, generalized economic and social inequality between ethnic Somalis and other ethnic groups, and marginalization from the current Ethiopian democratic system (Hagmann 2005, Samataar 1992). These have had limited success.

References Abdalla Omar, Mansur. (1995) ‘‘The Nature of the Somali Clan System.’’ In The Invention of Somalia, edited by Ali Jimale Ahmed, 117–134. Trenton, NJ: Red Sea Press. Barnes, Cedric. (2006) ‘‘U Dhashay—Ku Dhashay: Genealogical and Territorial Discourse in Somali History.’’ Social Identities 12 (4): 487–498. Carruth, Lauren. (2014) ‘‘Camel Milk, Amoxicillin, and a Prayer: Medical Pluralism and Medical Humanitarian Aid in the Somali Region of Ethiopia.’’ Social Science & Medicine 120: 405–412. ‘‘Ethiopia: Malnutrition Critical in Somali Region.’’ (2009) Integrated Regional Information Networks (IRIN). July 16. http://www.irinnews.org/PrintReport.aspx?Re portId⳱85304. Accessed December 1, 2010.

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Federal Democratic Republic of Ethiopia Ministry of Health (FDREMH). (2011) ‘‘HSDP IV: Annual Performance Report.’’ Addis Ababa, Ethiopia. Federal Ethiopian Ministry of Health. (2008) ‘‘Disease Classification for National Reporting and Case Definitions.’’ Government of Ethiopia HMIS Reform Team. Good, Byron J. and Arthur Kleinman, eds. (2007) Subjectivity: Ethnographic Investigations. Philadelphia: University of Pennsylvania Press. Government of Ethiopia. (2008) ‘‘Revised Humanitarian Requirement for 2008.’’ Addis Ababa: Federal Government of Ethiopia. Hagmann, Tobias. (2005) ‘‘Beyond Clannishness and Colonialism: Understanding Political Disorder in Ethiopia’s Somali Region, 1991–2004.’’ Journal of Modern African Studies 43 (4): 509–536. Human Rights Watch. (2008) ‘‘Collective Punishment: War Crimes and Crimes Against Humanity in the Ogaden Area of Ethiopia’s Somali Regional State.’’ http:// www.hrw.org/sites/default/files/reports/ethiopia0608_1.pdf. Accessed January 14, 2010. ———. (2010) ‘‘Development Without Freedom: How Aid Underwrites Repression in Ethiopia.’’ http://www.hrw.org/sites/default/files/reports/ethiopia1010webw cover.pdf. Accessed Januaryn14, 2010. IRIN. (2009) ‘‘Ethiopia: Malnutrition critical in Somali Region.’’ July 16. http://www .irinnews.org/PrintReport.aspx?ReportId⳱85304. Accessed January 14, 2010. Provided by the UN Office for the Coordination of Humanitarian Affairs. Lewis, Ioan M. (1994) Blood and Bone: The Call of Kinship in Somali Society. Lawrenceville, NJ: Red Sea Press. Lulling, Virginia. (2005) ‘‘Genealogy as Theory, Genealogy as Tool: Aspects of Somali ‘Clanship.’ ’’ Social Identities 12 (4): 471–485. Redfield, Peter. (2013) Life in Crisis: the Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Samatar, Abdi Ismail. (1992) ‘‘Destruction of State and Society in Somali: Beyond the Tribal Convention.’’ Journal of Modern African Studies 30: 623–641. ———. (2005) ‘‘Ethiopian Ethnic Federalism and Regional Autonomy: The Somali Test.’’ Bildhaan: An International Journal of Somali Studies 5: 44–76. UNICEF. (2009) ‘‘Mobile Health & Nutrition Team Annual Review 2008.’’ Jijiga, Ethiopia: UNICEF and the Ministry of Health. ‘‘UNICEF Humanitarian Action Report: Ethiopia in 2008.’’ (2008) http://www.unicef.org/har08/files/har08_Ethiopia_countrychapter.pdf. Accessed March 12, 2014. Walker, Peter and Daniel Maxwell. (2009) Shaping the Humanitarian World. London: Routledge. Whyte, Susan Reynolds. (2009) ‘‘Health Identities and Subjectivities: The Ethnographic Challenge.’’ Medical Anthropology Quarterly 23 (1): 6–15.

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PA R T I I

The Architecture of Humanitarian Knowledge, Ethics, and Imperatives

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Chapter 4

Evidence and Narratives: Recounting Lethal Violence in Darfur, Sudan Alex de Waal

This chapter is a political ethnography of information concerning violence in Darfur, Sudan, during the period 2008–2009. During this period, four years after the intense war and massacres of June 2003–January 2005, the armed conflict in Darfur had undergone an important but ill-understood transformation, with the consequence that the most common popular and political labels for such a conflict, such as war and genocide, and the mostused scholarly indices have questionable value. The chapter draws upon data for patterns of lethal violence for 2008– 2009 based upon the incident reports of peacekeepers in Darfur, which provide a rigorous empirical account of who is killing whom, suggesting that at this stage the conflict did not readily fit into the available categories of war, genocide, interethnic conflict, or rampant criminality. The pattern was rather a complex fusion of diverse elements, in some respects redolent of ‘‘anarchy.’’ It then turns to information that can be garnered from public opinion surveys and consultations with community leaders to investigate Darfurians’ own framing of the conflict. Darfurians had divergent and changing views but agreed that it was a complex, multilayered, and changing violent contestation. Their views on the nature of the situation are also reflected in their proposed solutions, both internal to Darfur and concerning Darfur’s relation to the central state. Finally, this chapter traces the international policy debate in the United States and United Nations in 2009 over how to characterize the armed violence, showing that this debate was

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poorly connected with the data for lethal violence and with Darfurians’ own narratives. As Mamdani (2007) points out, how we name a conflict has profound consequences for how we respond. On September 9, 2004, Secretary of State Colin Powell bowed to pressure from advocacy groups, corralled together as the Save Darfur Coalition, and testified before the Senate Foreign Relations Committee that ‘‘genocide has been committed in Darfur and . . . the government of Sudan and the Jingaweit [sic] bear responsibility—and genocide may still be occurring’’ (Dagne 2010: 19). Powell made this determination but then proceed to dash the Darfur campaigners’ hopes, saying that it required no change in U.S. policy. But five years later, even though the conflict had changed and far more was known about its details, peeling off the ‘‘genocide’’ label proved extraordinarily difficult. I do not address the question of whether the mass killings and displacement of 2003–2005 constitute genocide. Rather, I look into how that intense conflict, characterized both by battles between rebel and government armies and by mass atrocity against civilians, subsequently transmuted into a different kind of conflict. What label is best used to describe the conflict during 2008–2009: is it war, genocide, intertribal conflict, rampant criminality, or anarchy? I suggest that after 2005, the nature of the violence had shifted from a ‘‘Schmittian’’ contest along sharply drawn political and ethnic lines to something more akin to a ‘‘Hobbesian’’ conflict characterized by the breakdown of central authority (cf. Tarrow 2007), in which violence was organized by intermediate leaders such as heads of militia, provincial administrators, tribal chiefs, and military entrepreneurs. Meanwhile the underlying political question of Darfur’s relation to the Sudanese state remained unresolved. This chapter is also an appeal for political scientists and anthropologists to engage with each other on issues of organized violence. Having taken a turn toward analysis of microlevel data for violence (following Kalyvas 2006), political scientists are advised to seek an intellectual partnership with ethnographers to develop the appropriate frames for making sense of these data. By the same token anthropologists should engage with the political science of violence in civil conflict, now that the latter has moved on from its rather sterile approach to armed conflict as little more than a problem of incentive and opportunity (cf. Collier 2009). And finally, just as public health practitioners would not dream of designing a program for emergency community health without first attending to the epidemiological data

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for patterns of disease, this chapter is an appeal for peacekeepers and practitioners of conflict resolution to gather and analyze data for the epidemiology of lethal violence as a requirement for designing their interventions and measuring their performance.

Darfur’s Drama, 2003–2009 Darfur was the location of a fierce war and one-sided violence against civilians from June 2003 to January 2005. The vast majority of the killings that took place during the conflict were committed in the course of two extensive counteroffensives mounted by the Sudan Armed Forces (SAF) and allied militia during June–September 2003 and November 2003–March 2004 (Flint and de Waal 2008). The best estimates are that at least thirtyfive thousand civilians were killed during armed violence in that period (U.S. Government Accountability Office 2006, Degomme and Guha-Sapir 2010). In response to a decision by the rebels of the Sudan Liberation Army (SLA) to widen the war to southern and eastern Darfur in mid-2004, the government launched a third counteroffensive between August 2004 and January 2005. This killed a significant but smaller number of people in areas that had hitherto been relatively quiet. All in all, approximately 90–95 percent of the lethal violence in Darfur between the date conventionally used for the outbreak of conflict (February 2003) and the arrival of UNAMID, the African Union/UN Hybrid operation in Darfur, on December 31, 2007, occurred between June 2003 and January 2005. The unfolding of lethal violence during this period is represented in Figure 4.1. During 2004, the mortality rate from hunger and disease peaked and then declined in a pattern and at a rate comparable to that of other crises in which there had been no impediments to the delivery of relief aid (Guha-Sapir and Degomme 2005). By 2008, although armed conflict continued, the nature of the conflict had changed and levels of violence had substantially decreased.

Lethal Violence in Darfur 2008–2009: What the Data Show I now present empirical data for levels and patterns of violence in Darfur during the nineteen months from January 2008 to July 2009, drawing upon

Frequency of killings

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2003

2003

2003

2003

Figure 4.1. Overall magnitude of killing in Darfur, 2003–2006. Note that this graph underestimates the killings before April 2004 because there were no monitors on the ground and so reporting was less reliable. A truer representation would have the first two peaks approximately twice as high. Source: International Criminal Court, Prosecutor’s Application Under Article 58 (7), Annexe 3, reproduced from Flint and de Waal 2008: 151.

data generated by UNAMID’s Joint Mission Analysis Centre (JMAC). These data consist of reports submitted to UNAMID from a combination of sources, including UNAMID itself, UN agencies, international nongovernmental organizations (NGOs), Sudanese police reports, and others. They include both initial reports and follow-up investigations. UNAMID provided the data set to the African Union High Level Panel on Darfur (AUPD) (AUPD 2009: Appendix B). The data have been subject to careful cleaning and cross-checking for duplications and inaccuracies (de Waal et al. 2014). This analysis is necessarily limited. It includes only violent, direct mortality, that is, fatalities that could be immediately linked to violent events. These data exclude deaths due to hunger and disease, sexual violence, robbery, and forced displacement, as well as other harms. The main rationale for this is that fatalities are the best-reported form of harm. During this period there were approximately 120 violent fatalities per month. The pattern over time was ‘‘spikey’’—there was intense bloodshed over relatively short periods of time followed by significant and persistent decreases in violence. The numbers of killings are disproportionately attributable to a relatively small number of incidents that brought about large numbers of fatalities (a ‘‘power law’’ distribution).

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Approximately one-third of the deaths occurred in combat between organized armed groups, mainly SAF, associated irregular militia, and the rebels. The ‘‘armed groups’’ fall into two categories, namely those that signed the Darfur Peace Agreement (SLA-Minawi) and the associated ‘‘Declaration of Commitment’’ (two groups known as SLA-Free Will) and therefore joined the government, and those that refused to sign any agreement (SLA-Abdel Wahid and the various fragments into which it broke, as well as the Justice and Equality Movement [JEM]) and therefore remained antigovernment rebels. Approximately one-third of violent deaths occurred during asymmetric violence, in which civilians were killed without reciprocal killing of armed men. A final third of the deaths falls under the classification of ‘‘intertribal’’ violence. This forms a distinct category within the situation prevailing in Darfur at that time, consisting overwhelmingly of cases in which Arab groups or other tribes armed by the government fought one another, sparked by disputes over land or livestock.1 Table 4.1 should be read in the following way: the perpetrators (those who are doing the killing) are in the left-hand column; the categories of victims (those whom the perpetrators are killing) are listed horizontally across the top row of the table. Within the data set, the victims and perpetrators can be clearly identified in 1,909 individual cases (about 85 percent of the total). These can be grouped into categories, reflecting an intermediate level of sociopolitical organization, below the state but above the individual or family. The most important point about this table is that it is confusing! It is not what we would expect at all. Just about every group is engaged in armed conflict with every other group. If the pattern were predominantly fighting the government and its enemies, the boxes representing the intersection of the pro-government and antigovernment forces categories would have high values. If the pattern were one-sided violence, the killings would be concentrated in the civilian victims column. By contrast, the actual violence as represented in Table 4.1 has a highly distributed pattern. It looks a bit like anarchy—everyone killing everyone. In fact, the killing is complex and volatile but nonetheless structured. We can note several striking aspects. First, there are entries in all of the nine lightly shaded boxes in the upper left-hand part of the table, namely those that include the violence among SAF, the pro-government irregulars, and the former rebels now with the government. In other words, officially pro-government forces were fighting one another, at least intermittently.

Table 4.1. Who Is Killing Whom? (2008–2009)

Dying

Regular forces

Killing

Irregular forces

Pro-govt. movements

Tribes

Total

Bandits

Civilians

14

131

294

Governmental forces

Governmental forces

Rebel armed movements

15

24

26

76

27

84

2

1

85

199

8

9

48

12

203

280

Rebel armed move ments

259

35

19

2

36

364

Regular forces Irregular forces Pro-government movements

Tribes

4

Bandits

16

Civilians

4

1

333

153

Total

3

98

8

13

621

614

91

635

14

81

97

51

56

585

1,909

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The central government’s authority over its own forces appeared to have broken down, in part. Second, all of these pro-government forces fought the rebels and vice versa; that is, there was a war with rebels fighting the government, and rebel actions mainly targeted the government’s regular forces. Third, all these groups killed civilians. In fact, the government forces (including the SLA-Minawi) predominantly killed civilians rather than rebels. Fourth, banditry was widespread but a relatively minor source of fatalities. And fifth, conflicts between groups identified as ‘‘tribes’’ accounted for fully one-third of the fatalities. How does Darfur during these years fit into existing definitions of conflict? The Uppsala Conflict Data Program (UCDP 2013) deems a conflict to be active if there are at least twenty-five battle-related deaths per calendar year in one of the conflict’s dyads. The figures from Darfur are both ambiguous and fluctuating: the 2008–2009 data suggest that there may be as many as seven distinct conflict dyads that meet this threshold— and arguably ten if the three major intertribal conflicts are coded separately. The Correlates of War Project (CoW) uses a threshold of one thousand battle-related fatalities within a twelve-month period (Sarkees 2010), according to which Darfur (in aggregate) would just qualify in these years. There is no numerical threshold for defining genocide (it is a legal term that hinges on the intent of the perpetrator), and quantitative definitions of mass atrocity suffer the same arbitrariness as those for conflict. Scale is one of the considerations in deeming an event a mass atrocity, but questions of number, proportion of the target population that is killed, and time period complicate the analysis. The UCDP uses ‘‘one-sided violence’’ to refer to both large-scale massacres and small-scale campaigns that meet the fatality threshold of twenty-five reported deaths in a calendar year. It is now evident that Darfur in 2008–2009 is likely to have multiple such instances of one-sided violence, committed predominantly by the SLA-Minawi, by Arab militia, and by the army, in several distinct episodes in which people of different ethnicities were killed. The question then arises as to whether these should count as a single aggregate mass atrocity, instantiated in half a dozen incidents, or as a dozen separate dyads. These patterns represent a few frames in a much longer film. The patterns in previous and subsequent years were also different, ranging from very high levels of violence, both one-sided and in combat, during 2003– 2005, and varying morphologies of armed contestation in succeeding years,

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with a marked increase in lethal violence, principally in combat between rebels and government forces, during late 2012 and into 2013.

Narratives from the Ground We would expect the people who experience violence to have useful explanations for it, and indeed they do. Different groups in Darfur held different and sometimes opposing narratives of the origins and pattern of the conflict. Not only do they have subjective accounts, arising from lived experience and anchored in a cultural archive (cf. James 2007), but many local people also have a good sense of scale, patterns, and trends of violence. One reason for this is that community leaders manage what we might call ‘‘the political epidemiology of lethal violence.’’ Darfurian society is largely organized on lineage and local ‘‘tribal’’ units, according to a system of administrative tribalism. Among the responsibilities of members of the ‘‘native administration’’ hierarchy are keeping records of individuals within their group. They routinely record violent deaths and seek recompense from their peers in the counterpart tribal units or from the authorities. From their counterparts they seek blood money (diya) through a process of mediation and arbitration (judiya) in which each party presents its catalogue of human and material losses. From the government they seek assistance in convening such a judiya process, as well as perhaps direct compensation. The native administration system has endured. In displaced camps, it has been reconfigured with younger men rising to positions of authority but nonetheless taking on similar titles and responsibilities. The neighborhood bosses in Fur-dominated camps have taken on traditional chiefly titles. Whether in villages, nomadic camps, or towns or camps for refugees and the displaced, the leaders of the native administration are in regular contact with one another at meetings of the local administration and conflict resolution councils. They share information and analysis among themselves and with the authorities to demand redress and remedy. Their knowledge is both empirical (derived from cataloguing incidents and recording names) and instrumental (derived from their experiences of what works and doesn’t work in interactions with one another and the authorities).

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It is therefore unsurprising that there is a considerable awareness of patterns of conflict, both quantitative and qualitative, embedded in Darfurian society. This knowledge has not been rigorously drawn upon, but there are some interesting indications of where this might lead. In this section I present information from four sources: a public opinion survey of refugees in Chad, a pilot study of opinions inside Darfur, a study of community views after the failure of the Darfur Peace Agreement, and the community consultations conducted by the African Union Panel on Darfur (AUPD). The first source is an extensive public opinion survey conducted among Darfurian refugees in Chad (Darfurian Voices 2010), which provides important information about people’s experiences and views on a range of key questions. Between April and July 2009, researchers for the organization 24 Hours for Darfur interviewed 1,872 adult civilians in all twelve Darfurian refugee camps in eastern Chad and conducted in-depth interviews with 280 tribal, civil society, and rebel leaders. The interviewees were from non-Arab tribes, and most of them had fled Darfur during the height of the violence in 2003–2004. They emphasized the government’s responsibility for the disaster that befell Darfur: ‘‘Nearly all respondents attributed a degree of responsibility for the violence that has occurred in Darfur to the Government of Sudan and the Janjaweed [Arab militia]. Only twenty percent of respondents attributed any responsibility for the violence to rebel groups. When asked whom they believed was most responsible for the violence, over eighty percent of respondents answered the Government of Sudan or President Bashir. Just under twenty percent assigned primary responsibility to the Janjaweed’’ (Darfurian Voices 2010: 20). Most refugees saw the conflict in moralized ‘‘Schmittian’’ terms, as a struggle between friends and evil enemies. The refugees were drawn entirely from non-Arab groups that were directly victimized by the atrocities of 2003–2004. They had not been directly exposed to the changing nature of the conflict subsequently. Our second source is the Center for Global Communication Studies, in partnership with the Stanhope Centre and Albany Associates, which conducted a pilot study inside Darfur. The political environment precluded a large, rigorous, and transparent study. They collected 135 oral histories of the conflict and semistructured interviews (Taylor et al. 2008). Interviewees came from a range of ethnic groups. Darfurians traced the roots of the conflict to the famine of 1984 and its devastating impact on the social fabric, while also blaming successive governments for neglecting the region.

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They specifically blamed the government for failing to address three problems, namely Arab tribes seizing land, endemic banditry, and intertribal conflict (much of it fueled by government manipulation) (Taylor et al. 2008: 11). Researchers found deepening distrust of outsiders, including the international community, as well as the Sudanese government. The most persistent Darfurian demand was for security, including the disarmament of all groups. This was followed by demands for compensation, reconciliation, the involvement of all groups in a Darfurian-led process of political reconstruction, and punishment of those who had committed crimes. The overall picture is thus more varied and more nuanced than that illuminated in the views of refugees. A third insight into Darfurian vernacular explanations of the violence is provided by Abdul-Jabbar Fadul and Victor Tanner, who traveled throughout Darfur in late 2006. Their analysis reveals people’s awareness of the changing nature of the violence (Fadul and Tanner 2007: 295): It was becoming clear to Darfurians that the ubiquitous lawlessness was the result of government policies rather than just intertribal tensions. This distinction was echoed by Hausa displaced people in South Darfur: ‘‘the problem is not tribal, it is anarchy (fawdha).’’ Fawdha is a word loaded with meaning in Arabic. Fawdha is what happens when there is no government—at all. It is a state far worse than being under a repressive government (zulm). In other words, for people in Darfur, the government had brought the worst kind of governance to Darfur: the absence of government. In 2004, by contrast, it was not uncommon to hear Darfurians say that all they wanted was heibat ad dawla, literally the reverence of the state. In other words, they expressed the hope of once again living under the protection of the state. In 2006, that expression, heibat ad dawla, was not heard once. The significance of this study is that it demonstrates how Darfurian opinion changed over time. A fourth source of information is the work of the AUPD, drawing on the author’s participation in the work of the panel. In 2009, the AUPD held forty public consultations on the conflict (AUPD 2009). More than 3,100 representatives of diverse community and groups, including displaced

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persons, tribal authorities, leaders of civil society organizations and women’s groups, political parties, and armed groups, were asked to present their views on peace, justice, reconciliation, and Darfur’s position within Sudan. Consultations were held throughout Darfur. Representatives came meticulously prepared. Many had lists of people who had been killed and property that had been stolen or destroyed. In most cases, they knew the perpetrators of the violence. Arab communities preferred to use the terms ‘‘war’’ (harb) and ‘‘troubles’’ (mashakil), while Fur and Masalit regularly used the terminology of ‘‘genocide’’ (for which they used the term ibada, ‘‘uprooting’’).2 Darfurians of all political colors also spoke of anarchy (fawdha). They described different circles of conflict, among Darfurian communities, between the rebels and the army and pro-government militia, and between Darfur as a whole and the Sudanese state. Attributions of blame diverged: displaced people blamed the government, tribal leaders attributed responsibility equally to the government and rebels. Views on the role of the international community differed sharply: while camp leaders in the town of Zalingei—the heartland of the Fur people who comprised the backbone of the SLA forces loyal to the rebel group’s founder, Abdel Wahid al Nur—wanted UNAMID replaced by ‘‘an effective international force,’’ some Arab leaders blamed the United States and France for sustaining the war. Community leaders were sensitive to the different phases of the war. For example, in the rebel-held village of Ain Siro, Omda Abdalla Shallali indicated how relations between the local command of the rebel SLA and the neighboring Arabs had changed: ‘‘Arabs were our enemies in the recent past, when the Sudan government saw them as its right arm. We went through burnings, killings, rapes. Who directed them? It was the government. It was the mistake of the government, not them. . . . We currently live side by side with our neighbors. We cannot prevent anyone from finding water. We all share the basic needs of water, fire.’’3 In South Darfur, an Arab leader made a subtly complementary statement from a different political standpoint: ‘‘When the problem in Darfur started everyone in the world was aware of it. When the fragmentation of the armed groups took place we began to doubt that they were fighting for Darfur and thought they were fighting for their personal interest and to bring Darfur to the international table.’’4 Darfurians converged upon a two-level prescription for resolving the crisis. Within Darfur, they agreed that communities in conflict could

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resolve their differences through negotiation, typically mediated by a neutral committee of elders (ajawid). However, they also concurred that such conflict resolution would be meaningless unless the government were, first, to refrain from meddling in these affairs and, second, were to attend to its tasks of providing services including policing and social and economic development. The violent fractionalization of Darfurian society was thus simultaneously attributed to governmental neglect and interference. This was a hard-learned lesson in the ways in which the security services operated in a cynical manner of hiring the loyalties of provincial elites using divide-and-rule tactics. Darfur was neglected by governmental institutions— especially those that provided services—and at the same time interfered with by manipulative security officers. Darfurians regretted the destruction of the ‘‘Darfur consensus,’’ which was envisaged as a pact, primarily between Fur and Arabs, to share the land. Modernity was cast as a dream betrayed—something to which Sudanese had credibly aspired in the past but was now a fading dream. Parts of that remembered modernity were a capable police and an impartial judiciary. The decay of institutionalized governance was already well set in before 2003, but that disaster accelerated the decline. Darfur was now ruled by disparate armed groups, not by anything worthy of the respect due to a government.

International Narratives The Darfur conflict was highly unusual in that the international narrative for the crisis was set by a Western advocacy campaign that framed the problem as genocide and the challenge as international intervention, both military and judicial. In the 1990s, specialists on Africa became familiar with—and frustrated by—relief organizations’ capacity for defining civil conflicts as humanitarian crises demanding a charitable response. Many advocated international policies geared toward political solutions (de Waal 1997). In the Darfur case, both humanitarians and those concerned with conflict resolution were sidelined by an unprecedented, and unanticipated, public campaign in America (Hamilton 2011). The American campaign on Darfur began in April 2004. The narrative was framed by the failure of Rwanda a decade earlier. According to Samantha Power’s influential book ‘‘A Problem from Hell’’ (2002), the United

Darfur, Sudan: Evidence and Narratives 89

States bore moral responsibility for that genocide because of its failure to intervene to stop it. A study of eighty-three editorials and op-eds on Darfur appearing in major U.S. journals from March to September 2004 found that most referred to Rwanda and were concerned with whether America should intervene, assuming that any such involvement would resolve the problem (Murphy 2007). Hence the campaigners’ narrative and demands: the U.S. government should label the atrocities there as ‘‘genocide’’ and thereby be compelled to intervene. In September the Bush Administration named it genocide but did not change its policy. Nonetheless, the power of the narrative of American obligation and capacity and the strength of the model of antigenocide mobilization were such that the Save Darfur campaign continued with its foundational narrative. Over the following four years, American advocates routinely insisted that ‘‘things are getting worse.’’ A tabulation of 134 statements from a number of the most prominent activists and advocacy groups between April 2005 and August 2007 found that variants of this refrain—assertions or predictions of deterioration—accounted for all but seven statements. Just six identified an actual or possible improvement. These statements did not correlate with increased violence or most other monitorable indicators (de Waal and Rosmarin 2007). Rather, they tracked the campaign’s own mobilization efforts, reaching a peak with the international day for Darfur on September 17, 2006, when the actor George Clooney addressed the UN Security Council at the invitation of the U.S. Permanent Representative to the United Nations and predicted millions of imminent deaths, telling the council that Darfur represented ‘‘your Rwanda, your Cambodia, your Auschwitz’’ (Clooney 2006). His performance was powerful and his narrative was almost entirely fictional. But if his argument was accepted—there was a genocide in Darfur in 2004, America had not (yet) intervened, and things were getting worse—how could it not be otherwise? In a textual analysis of the prose and argument of the Save Darfur campaign, Jane Blayton described the writings of Darfur advocates in the United States, especially of Eric Reeves, an influential Massachusetts-based writer, who never visited Darfur, as ‘‘the first draft of the indictment’’ (Blayton 2009). There is indeed a close parallel between Reeves’s columns and the public application for an arrest warrant by Luis Moreno Ocampo, prosecutor of the International Criminal Court (ICC), against President Omar al Bashir on charges of genocide, war crimes, and crimes against humanity in July 2008 (ICC 2008).

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Moreno Ocampo argued that Bashir had a longstanding genocidal intent against the ‘‘African’’ population of Darfur, stretching back to the 1980s, and had designed a ‘‘two-stage’’ genocidal campaign consisting of, first, a murderous onslaught during 2003–2005 and, second, a gradual program of annihilation in IDP camps (Moreno Ocampo 2007). He went so far as to compare Bashir to the Nazis. The application for an arrest warrant is not only hyperbolic but riddled with factual errors and non sequiturs (de Waal 2009a). The ICC judges considered the application for eight months and issued the warrant in March 2009, though they dropped the genocide charges. Moreno Ocampo appealed the judges’ decision not to uphold the genocide charges and the ICC later reinstated them. The U.S. government found itself in the ironic position that, although it was not a member of the ICC, it was the only government that had officially determined that what had happened in Darfur constituted genocide. The U.S. Permanent Representative to the United Nations, Susan Rice, championed this position. Well-known for a longstanding antipathy toward the government in Khartoum, Rice took the view that the 2004 genocide determination remained U.S. policy, and in January 2009, she said that there was ‘‘ongoing genocide’’ (United States Mission to the United Nations 2009). However, as the situation in Darfur changed, other senior U.S. officials who were directly engaged with Darfur argued that it was time to reconsider the genocide determination. Andrew Natsios, the president’s special envoy for Sudan during 2006–2007, studiously avoided using the word ‘‘genocide’’ with reference to current events and was pilloried by members of Congress as a result (Hamilton 2011: 106–107). In 2009, his replacement as special envoy, Scott Gration, took a similar line, saying, ‘‘What we see is the remnants of genocide. . . . It doesn’t appear that it is a coordinated effort that was similar to what we had in 2003 to 2006’’ (Taylor 2009). Gration was publicly contradicted by Rice. At the time when the ICC judges were coming to a decision on Ocampo’s application, in March 2009, the question of ‘‘ongoing genocide’’ had special salience. Perhaps because of the weaknesses in the prosecutor’s case for genocide, his advocates at the Security Council were not keen to see their narrative challenged. For this reason, when the head of UNAMID, Rodolphe Adada, traveled to New York to present his report to the UN Security Council in April, the meeting took on particular significance. The data presented earlier in this chapter provide a picture of the kind of complicated conflict occurring in Darfur at this time. As it happened,

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intertribal fighting in Southern Darfur escalated in March 2009, with clashes between three tribal groups, all of which were politically aligned with the government. Civil affairs officers from UNAMID made preliminary investigations of the fighting on April 2 and 3, finding that four major clashes had occurred. They obtained death estimates that ranged from 45 to 220 but advised that all numbers were preliminary and possibly exaggerated.5 These incidents were duly included in the report of the UN Secretary General to the Security Council on Darfur (UNSG 2009), but the relevant paragraph of the report (no. 15) cited only the highest estimates for fatalities and made no mention of the cautionary notes from the staff in the field. In New York, UN officials were inclined to believe the worst about what was happening in Darfur. This report set the stage for a confrontation between several members of the Security Council, notably Susan Rice, and Rodolphe Adada on April 27. A mathematician by profession, Adada decided to make a presentation of JMAC statistics for lethal violence a central part of his presentation to the Security Council. In doing so he not only refuted the descriptions provided by Ocampo but also challenged the alarming uptick in violence noted in the Secretary General’s report. Adada concluded that Darfur at that time represented a ‘‘low intensity conflict’’ and a ‘‘conflict of all against all’’ (de Waal 2009b). There is no commonly accepted definition of or numerical threshold for ‘‘low intensity conflict,’’ but it is a plausible description of the levels of violence (approximately 1,500 violent fatalities per year) prevailing at the time. Adada’s presentation angered Rice. In a closed session, she grilled the head of UNAMID, insisting that the Sudanese government remained responsible for an ongoing campaign of genocide. Shortly thereafter, the UN renewed Adada’s contract for just six months, an unusual decision that he interpreted as a vote of no-confidence and led to his resignation. When narrative confronted data, narrative won.

Conclusion The Darfurian conflict was complicated, geographically varied, and fluid. The narratives of violence adopted by the Save Darfur campaign became rapidly outdated and after early 2005 became increasingly ill suited to the changing nature of the conflict. Nonetheless it is evident that the Save

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Darfur narrative was more influential in driving international policy than was evidence derived from field reports or the various opinions, analyses, and prescriptions of the Darfurian people themselves. We are fortunate that for the period 2008–2009, incident data compiled by UNAMID provide a robust empirical check on the scale and pattern of violence. These data indicate that no single conventional definition fits the conflict at that stage: it was not obviously genocide, war, intercommunal conflict, or organized crime. Neither was it strictly anarchy. Perhaps most important, the violence changed in both scale and morphology, from centrally directed ‘‘Schmittian’’ violent contestation between enemies to turbulent quasi-‘‘Hobbesian’’ conflict characterized by the breakdown of central authority, in which control over violence is devolved to lower levels of the political and administrative hierarchy and privatized. However, the multisided nature of the ongoing violence should not mean that the fundamental political questions that animated mobilization for war in 2003 were no longer relevant. The morphology of violence in 2008–2009 poorly mapped the fundamental political contest over the position of Darfur within the Sudanese polity, as well as the nature of that polity (AUPD 2009). Darfurian vernacular explanations of the violence are not only legitimate and valid in their own terms but strikingly consistent with the quantitative data. Evidently Darfurians were better informed about the nature and scale of the conflicts they were facing than were outsiders. Not only did they possess firsthand experience of violence in its many forms, but many local leaders understood the conflicts in quantitative and analytical terms and were deeply aware of—and frustrated by—the ways in which local violent contests were obscuring deeper political claims. The single most salient lesson of this chapter is that local people in Darfur possess a more sophisticated, nuanced, and flexible understanding of their conflicts than do outsiders. The perspectives and data presented in this chapter indicate the need for a reformed international approach to peacemaking, protection of civilians, and humanitarian action. Sensitivity to local understandings should be a sine qua non for engagement with conflict-affected societies such as that in Darfur. This is, first of all, a matter of exploring and utilizing local frameworks when designing peace processes, peacekeeping missions, and humanitarian assistance strategies and, second, of bringing to bear data on the epidemiology of lethal violence. Over recent decades, relief and development organizations have learned that sensitivity to local knowledge and perspectives not only engenders better communication with local partners

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and beneficiaries but is a requirement for designing a good program. So too for peacemaking and peacekeeping: the first task in resolving an armed conflict is enabling the affected people to define that conflict, and a second task is rigorous examination of data on violence within that conflict. Notes 1. In Sudan, the term ‘‘tribe’’ refers to an administrative unit based on the 1920s ‘‘native administration’’ ordnances, as revived by the current government in the 1990s. 2. For example, the consultations in Zamzam camp, al Fashir, May 19, Kalma camp, Nyala, May 20, and Hamadiya camp, Zalingei, June 22, 2009. 3. AUPD consultation in Ain Siro, June 16, 2009, author’s notes. 4. AUPD consultation in Nyala, June 21, 2009, author’s notes. 5. Personal communication, civil affairs staff, April 2009.

References African Union High Level Panel on Darfur (AUPD). (2009) ‘‘Darfur: The Quest for Justice, Peace and Reconciliation.’’ Addis Ababa: African Union Commission, PSG/AHG/2(XXVII). October. http://fletcher.tufts.edu/World-Peace-Foundation/ Activities/⬃/media/Fletcher/Microsites/World%20Peace%20Foundation/AU%20 Darfur%20Report.pdf. Accessed December 5, 2014. Blayton, Jane. (2009) ‘‘Human Rights Reporting on Darfur: A Genre That Redefines Tragedy.’’ Making Sense of Darfur. August 21–24. http://africanarguments.org/ 2009/08/24/human-rights-reporting-on-darfur-a-genre-that-redefines-tragedy-3/. Accessed May 10, 2013. Clooney, George. (2006) ‘‘Presentation.’’ http://www.americanrhetoric.com/speeches/ georgeclooneyunitednations.htm. Accessed February 6, 2013. Collier, Paul. (2009) Wars, Guns, and Votes: Democracy in Dangerous Places. New York: HarperCollins. Dagne, Ted. (2010) Sudan: The Crisis in Darfur and Status of the North-South Peace Agreement. DIANE Publishing. Darfurian Voices. (2010) ‘‘Documenting Darfurian Refugees’ Views on Peace, Justice and Reconciliation.’’ 24 Hours for Darfur. http://www.darfurianvoices.org/ee/ images/uploads/DARFURIAN_VOICES_DocuVoices_Report.pdf. Accessed February 13, 2013. Degomme, Olivier and Debarati Guha-Sapir. (2010) ‘‘Patterns of Mortality Rates in Darfur Conflict.’’ Lancet 375: 294–300. de Waal, Alex. (1997) Famine Crimes: Politics and the Disaster Relief Industry in Africa. London: James Currey. ———. (2009a) ‘‘A Critique of the ICC Prosecutor’s Case Against President Bashir.’’ Making Sense of Darfur. January 27. http://africanarguments.org/2009/01/27/a -critique-of-the-icc-prosecutors-case-against-president-bashir/. Accessed May 10, 2013.

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———. (2009b) ‘‘UNAMID and the Security Council: Evidence for Policy.’’ Making Sense of Darfur. April 4. http://africanarguments.org/2009/04/29/unamid-and -the-security-council-evidence-for-policy/. Accessed April 2, 2013. de Waal, Alex and Sam Rosmarin. (2007) ‘‘Are Things Getting Worse in Darfur? There Is No Simple Answer.’’ Making Sense of Darfur. June 20. http://africanargu ments.org/2007/06/20/are-things-getting-worse-in-darfur-there-is-no-simple-an swer/. Accessed March 24, 2013. de Waal, Alex, Chad Hazlett, Christian Davenport, and Joshua Kennedy. (2014) ‘‘The Epidemiology of Lethal Violence in Darfur: Using Micro-Data to Explore Complex Patterns of Ongoing Armed Conflict.’’ Social Science and Medicine 120: 368–377. Fadul, Abdul-Jabbar and Victor Tanner. (2007) ‘‘Darfur After Abuja: A View from the Ground.’’ In War in Darfur and the Search for Peace, edited by Alex de Waal. Cambridge MA: Harvard University Press. Flint, Julie and Alex de Waal. (2008) Darfur: A New History of a Long War. London: Zed Books. Guha-Sapir, Debarati and Olivier Degomme. (2005) ‘‘Darfur: Counting the Deaths: Mortality Estimates from Multiple Survey Data.’’ Louvain: Center for Research in the Epidemiology of Disasters. Hamilton, Rebecca. (2011) Fighting for Darfur: Public Action and the Struggle to Stop Genocide. New York: Palgrave Macmillan. International Criminal Court, Office of the Prosecutor (ICC). (2008) ‘‘Prosecutor’s Application for Warrant of Arrest Under Article 58 Against Omar Hassan Ahmad AL BASHIR.’’ The Hague. July. James, Wendy. (2007) War and Survival in Sudan’s Frontierlands: Voices from the Blue Nile. Oxford: Clarendon Press. Kalyvas, Stathis. (2006) The Logic of Violence in Civil War. Cambridge: Cambridge University Press. Mamdani, Mahmood. (2007) ‘‘The Politics of Naming: Genocide, Civil War, Insurgency.’’ London Review of Books 29 (5): 5–8. Moreno Ocampo, Luis. (2007) ‘‘Statement of Mr. Luis Moreno Ocampo, Prosecutor of the International Criminal Court, to the United Nations Security Council Pursuant to UNSCR 1593 (2005).’’ December 5. http://www.amicc.org/docs/LMO %20Security%20Council%20Briefing%205%20December%202007.pdf. Accessed May 10, 2013. Murphy, Deborah. (2007) ‘‘Narrating Darfur: Darfur in the U.S. Press, March– September 2004.’’ In War in Darfur and the Search for Peace, edited by Alex de Waal. Cambridge, MA: Harvard University Press. Power, Samantha. (2002) ‘‘A Problem from Hell’’: America and the Age of Genocide. New York: Basic Books. Sarkees, Meredith Reid. (2010) ‘‘Defining and Categorizing Wars.’’ In Resort to War: A Data Guide to Inter-State, Extra-State, Intra-State, and Non-State Wars,

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1816–2007, by Meredith Reid Sarkees and Frank Whelon Wayman. Washington, DC: CQ Press. Tarrow, Sidney. (2007) ‘‘Inside Insurgencies: Politics and Violence in an Age of Civil War.’’ Perspectives on Politics 5 (3): 587–699. Taylor, Caitlyn. (2009) ‘‘Sudan Envoy: Darfur Experiencing ‘Remnants of Genocide’— Says Aid Capacity Back near 100%.’’ ABC News, June 17. http://abcnews.go.com/ blogs/politics/2009/06/sudan-envoy-darfur-experiencing-remnants-of-genocidesays-aid-capacity-back-near-100/. Accessed March 24, 2013. Taylor, Maureen, Monroe Price, Iginio Gagliardone, Anthony Foreman Susan Abbott, and Libby Morgan. (2008) ‘‘Researching Attitudes Towards Peace and Conflict in Darfur: An Analysis of a Research Initiative, from February 2007 to October 2008.’’ Philadelphia: Center for Global Communications Studies and London: Stanhope Centre. http://global.asc.upenn.edu/fileLibrary/PDFs/SudanFinalReportNov2008.pdf. Accessed March 24, 2013. United Nations Secretary General (UNSG). (2009) ‘‘Report of the Secretary-General on the African Union–United Nations Hybrid Operation in Darfur, 14 April 2009.’’ S/2009/201. http://www.un.org/en/ga/search/view_doc.asp?symbol⳱S/ 2009/201. Accessed December 4, 2014. Uppsala Conflict Data Program (UCDP). (2013) ‘‘Definitions.’’ http://www.pcr.uu.se/ research/ucdp/definitions/2013. Accessed April 1, 2013. U.S. Government Accountability Office. (2006) Darfur Crisis: Death Estimates Demonstrate Severity of Crisis, but Their Accuracy and Credibility Could Be Enhanced. Washington, DC: U.S. Government Accountability Office. http://www.gao.gov/ new.items/d0724.pdf. Accessed March 24, 2013. United States Mission to the United Nations. (2009) ‘‘Statement by Ambassador Susan E. Rice, U.S. Permanent Representative, After Presentation of Credentials to the Secretary General, at the United Nations Stakeout.’’ New York, January 26, 2009. http://usun.state.gov/briefing/statements/2009/january/127019.html. Accessed on December 4, 2014.

Chapter 5

Life Beyond the Bubbles: Cognitive Dissonance and Humanitarian Impunity in Northern Uganda Tim Allen

International humanitarians work within bubbles. There are bubbles within bubbles and multiple overlapping bubbles. Humanitarians rely on rules and norms—from laws or principles, to religious and biomedical values, to best practice and ethical guidelines. The rules and norms create apparently coherent and predictable spaces. They are reassuring and sometimes empowering. They are the basis of what Nicholas Stockton, the former emergencies coordinator of Oxfam, has called the humanitarian ‘‘confidence trick’’ of neutrality (Stockton 1997). They also allow for thinking that lessens individual responsibility for impossible decisions, ones that can mean the difference between life and death. For humanitarians in the field, they establish spaces in which the horrors they sometimes witness can be observed from a distance or even—sometimes—not be seen at all. That latter tendency is reinforced by life in compounds, in which a strange semblance of life at home is replicated. I recall a Me´decins Sans Frontie`res (MSF) base in northwest Uganda in the 1980s with fences inside fences. As one moved within, one passed from a place where Madi and English were spoken to somewhere very French. I visited once with a Madi friend and he heard a lively exchange between two French nurses. He was amazed. ‘‘Is that language?’’ he asked me. Inside the house at the compound’s center was a large room made to look like a bohemian Parisian

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bar. It was an appealing refuge from a world beyond—a world populated by very hungry, sick, and desperate people. However, as the MSF staff recognized, it set more than physical barriers. There was little connection between them and their patients except in ward rounds at the local hospital or at the end of an immunization campaign needle. This is not meant to sound cynical. To work in the war zones of central Africa requires drawing a line between empathy and self-preservation. In many ways, the issue is even more acute for an anthropologist who wants to be accepted as a social person by people experiencing extreme—and maybe extremely violent—circumstances but certainly does not want to share in all of their suffering. The MSF compound was a place of welcome respite for me, too. Humanitarians will always need to institutionalize engagement and, in effect, excuse disengagement. That is acutely so for those promoting health and well-being where such things are close to impossible goals. The compounds and expatriate bars, like the rules and norms, set necessary limits to altruism. However, there are obvious dangers. As Zoe Marriage has argued, humanitarians can have remarkable levels of cognitive dissonance, whereby they explain their actions and interpret events in ways that may be strangely separated from observed realities (Marriage 2006). Often this is recognized by humanitarians themselves. Yet they still do it. In practical terms, emphasis is placed on the intention to assist, and that can be at the expense of engagement in local complexities or assessment of what exactly is being achieved. As a consequence, humanitarians may become counterproductively imbued with a sense of probity and moral authority and, on occasion, benefit dangerously from what Alex de Waal has termed ‘‘humanitarian impunity’’ (de Waal 1998: 179). Cognitive dissonance and humanitarian impunity in the war zone of Acholiland in central northern Uganda are the focus of this chapter.

Returning to a Place Transformed by Spirit Cults, War, and Humanitarian Assistance In 2004, I returned to northern Uganda for the first time in more than a decade. Arriving at Gulu, the largest town in the region affected by the Lord’s Resistance Army (LRA), I found the place almost unrecognizable.

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The lodge where I had stayed in 1989 was still there, although it was now rather smarter. I had traveled with a Madi friend, Ronald Iya, and we had shared a room with single beds, much to the annoyance of the manager, who had also wanted to provide us with sex workers. The big Catholic hospital and mission complex of Lacor, a few miles outside of town, where I had slept in 1988, was still there too, but now it was the site of a large night commuter center run by MSF. Each evening there was the extraordinary sight of thousands of children walking from nearby internally displaced person (IDP) camps to sleep there, fearing abduction from their homes by the LRA during the night. Despite my best efforts, however, I could not locate the house in town where I had spent Christmas in 1984. It had been rented by a development project that was somewhat quixotically promoting self-reliant farming and marketing groups. I also failed to find the place I had slept two years before, where I had drunk hot millet beer through long straws with a Iteso priest. We had listened to the continuous sound of drums from nearby se´ances, run by possessed healers known as ajwaki, and he had much to say about the local Acholi people and their spirits. At the time, neither of us could have anticipated the role some of those spirits and their ajwaki were going to play. Two years after our conversation, events had taken everyone by surprise. Following the takeover of the Ugandan government by Yuweri Museveni in 1986 and the attempt to pacify the northern part of the country with an army from the south, several ajwaki took on a different kind of therapy. Most notably, Alice Auma, a young woman whose father was a possessed Anglican catechist, had become possessed herself and had called for social healing and purification through resisting Museveni’s forces. She proved to be a highly charismatic figure, linking ideas drawn from Christianity and biomedicine with Acholi notions of ritual cleansing and metaphysical realities. Her spirits taught through her that war was a means of purification. Those who followed her commandments, which were adapted from those in the Bible, would be saved (Allen 1991). That year Museveni’s forces encountered hundreds of naked people walking toward them, glistening with the oil with which Alice Auma had anointed them. Bullets, it was believed, would not affect them as long as they had truly adopted the new life they had been offered. Those who died were the impure. Those who remained would inherit a better world. War, Alice is reported to have proclaimed, is a means of removing ‘‘wrong

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elements’’ on both sides. Alice came to be known as lakwena, the messenger, and her followers the Holy Spirit Mobile Forces. After incidents around Gulu in which Museveni’s terrified soldiers ran away at the sight of Alice’s followers, the Holy Spirit movement began to attract large numbers, including veterans of the former Ugandan army who had previously been fighting Museveni in the region just north of Kampala called Luwero. In 1987, Alice marched south with perhaps as many as eight thousand. In October, they reached the swamps close to shore of Lake Victoria, not far from Jinja. I was in Jinja at the time, having been asked to attend a conference funded by the Libyan government on the future of education in Uganda. In the course of the meeting we could not help noticing that the population appeared to be leaving the town, although information about Alice’s proximity was not shared with the Libyan delegates. In the ensuing battle, she and her followers were pinned down and largely wiped out. Alice herself escaped and spent the rest of her life as a refugee in Kenya. Museveni declared victory, but things proved more complicated and much more intractable. Other spirit mediums continued to resist. Alice’s father, Severino Lukwoya, possessed by God the Father, led a campaign, until his capture, and a young man called Joseph Kony, who claimed to be a cousin of Alice and who came from a family of male ajwaki, continued to operate in locations close to Gulu. Several of the former Ugandan army veterans who had been attracted to Alice or had fought in more secular rebel factions joined this latter group, which toward the end of the 1980s came to be known as the LRA. The lessons of Alice’s defeat had been learned, and right from the start, Kony’s followers operated more strategically, using small groups of combatants to devastating effect in hit-and-run tactics. Always more violent than the Holy Spirit Mobile Forces, Kony nevertheless drew on similar ideas from Christianity and later Islam, mixing these with more traditional Acholi notions, including ideas relating to the fearful or amoral qualities of olum, the bush and forest, the realm beyond the home (gang). As time passed, and especially after its main bases were relocated across the border in what is now South Sudan, the LRA used terror ever more readily, including against Kony’s own Acholi people. Collaboration with Museveni was a crime to be punished. As Kony explained during a brief period of peace talks in the mid-1990s: ‘‘If you picked up an arrow against us and we end up cutting off the hand you used, who is to blame? You

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report us with your mouth, and we cut off your lips. Who is to blame? It is you! The Bible says that if your hand, eye or mouth is at fault, it should be cut off’’ (Allen 2006a: 42). Persistently underestimating the LRA, Museveni found it impossible to crush the group once and for all. It became a personal issue for him. He asked his brother to take a lead in the mid-1990s, and he even took command himself at one stage during the Iron Fist campaign of 2002. These operations help explain the extraordinary transformation of Gulu. The reason why it was so hard to recognize places in Gulu in 2004 was because the town had been invaded by international aid agencies, the vast majority with a humanitarian focus. They had been falling over each other to find accommodation for their expatriate staff and to create compounds. From a low-key engagement at the time I visited in the early 1990s, the humanitarian presence had become overwhelming. In 2003, the coordinated appeal by relief organizations working in the region had resulted in more than US$120 million. Over a hundred agencies had been involved in that process, and most of them had a presence in Gulu (UNOCHA 2005). In addition to the main UN agencies, there were religious organizations, countless international nongovernmental organizations (NGOs)— including MSF, Caritas, the Association of Volunteers in International Service (AVSI), Save the Children, World Vision, War Child, and Oxfam— and numerous internally funded Ugandan civil society and human rights organizations. Gulu was also now the site of multiple night commuter centers, in addition to the one at Lacor, as well as reception centers, ostensibly for the thousands of children who had spent time in LRA captivity. In addition, Gulu appeared to have become a major center for programs dealing with HIV/AIDS. Indeed, it proved impossible to discover how many institutions were engaged in projects responding to HIV/AIDS. There were signs everywhere advertising different initiatives, and there was a spectacular new multistory building under construction for The AIDS Support Organisation (TASO). All around town, new bars and restaurants had opened to cater to a clientele with money to spend. Several boasted satellite television. The most expensive hotel was owned by an army commander and was the main hangout for UN officials, ambassadors, and visiting journalists. The profits were being plowed into the construction of a swimming pool and a wellequipped gym. Whereas back in the 1980s and early 1990s the only means

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of communication with my family was through the rather haphazard postal service, now I was able to talk to my wife on my mobile phone. I could report on the action in an Arsenal football match taking place close to where we live in London, because it was being shown on televisions in the towns of northern Uganda’s war zone to enthusiastic local football supporters. It seemed bizarre and became more so as I investigated further.

Population Displacement and ‘‘Moral Outrage’’ When I had traveled to Gulu in 1988, it had been by motorbike from Moyo, the Madi-speaking district west of Gulu. I was accompanied by an MSF logistician. For much of the journey we were surprised by the lack of people. From Atiak, near the border with Sudan, we saw hardly anyone except at the small township of Pabbo. There was no sign of the Ugandan army until we reached our destination. Even Lacor hospital, located just outside of Gulu, was left unguarded, and we were told that the LRA would sometimes arrive there at night in search of medicine, as well as new recruits. The reason for the absence of soldiers along the route was apparently because the LRA had attacked the barracks at Bibia (near the border township of Atiak) a few weeks earlier. They had put the garrison to flight and had carried away a large quantity of weapons. When we arrived in Gulu we were promptly arrested by two men in dark glasses who turned out to be army security officers. We were taken to the barracks where we were interrogated for several hours, accused of being Red Cross spies. Apparently no one was driving on the road to the Sudan border except the Red Cross, who were alleged to be assisting the LRA. In the end we were released, after offering motorbike driving lessons to the commander. Later in 1988, the army carried out a series of anti-insurgency operations in the course of which people still living in their villages were abused by soldiers, and ever larger numbers were encouraged or compelled to take refuge near Gulu or one of the other large towns. However, by the time I returned to Gulu in September 1989 with my Madi friend, the troops had returned to their urban barracks and had been roundly criticized in the Ugandan press because the LRA had managed to launch an attack in Gulu town itself and release prisoners from the jail. The road was again largely empty, although we did come across a small group of soldiers at one point. We also encountered a huddle of people standing by a car parked in the

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middle of the road. They flagged us down with obvious relief. It turned out to be a senior district official and his staff. Their car had run out of fuel and it was already late afternoon. They were frightened about being stuck on the road at night, anticipating that they would be an LRA target. We provided them with gasoline from a reserve supply we were carrying. Perhaps, as a consequence, during that visit we had no problem with the army, and we were able to spend time interviewing staff members of agencies involved with relief and assistance activities. Alice Auma’s father, Severino Lukwoya, had recently been captured, and in expectation that Kony would also soon be defeated, efforts were being made to encourage thousands of displaced villagers, dependent on food handouts around Gulu, to return home. The few aid organizations working in the area at the time were active in encouraging such a return by cutting rations and supplying seeds. In retrospect this was connected with the tragedy that followed, turning northern Uganda into what Jan Egelund, UN Under-Secretary General for Humanitarian Affairs and Emergency Relief Coordinator, was to call in November 2003 ‘‘the biggest forgotten, neglected humanitarian emergency in the world’’ and ‘‘a moral outrage’’ (‘‘War’’ 2003). When I was conducting research in northern Uganda in 2004 and 2005, it was not hard to see why he had been so appalled. By that time, a policy of encouraging the population to leave Gulu and return to their farms had become a massive operation. In 1996, the Ugandan government adopted a policy of compelling the population to settle in these camps. Beginning in September that year, numerous serious abuses were reported by human rights groups, including the bombing of villages and the burning of homesteads and granaries (Amnesty International 1999). However, cultivation of land around the camps proved to be unsafe so, far from resolving dependence of food relief, an international humanitarian role had become ever more essential. This was recognized right from the start by humanitarian agencies on the ground. A UN Department of Humanitarian Affairs report noted in December 1996: ‘‘ ‘Whether or not protected villages develop over the coming weeks will also depend on the ability of aid agencies to provide the services which are lacking, and certainly beyond the means of the local authorities’ ’’ (‘‘Uganda’’ 1996, quoted in Branch 2008, Branch 2011: 93). The choices aid agencies made at that point and the continued assistance provided to these so-called protected villages over the coming years

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are what made the mass forced displacement of over a million people a possibility. In essence, humanitarians were drawn into an anti-insurgency strategy by the Ugandan government and its army. That strategy combined discouraging settlement in the bigger towns with removing the population from their homes so that they could be contained and controlled. It would appear, too, that leading humanitarian agencies, including the UN Department of Humanitarian Affairs, were well aware of what was happening and decided to go along with it. At that time, President Museveni’s Uganda was viewed very positively by international aid donors, and there was doubtless reluctance to draw attention to problems in the north. In addition, the LRA was easy to demonize. By late 2004, the road north of Gulu to Atiak, like other parts of the war-affected region, was dotted with what were now termed IDP camps, including an enormous one at Pabbo. As predicted in 1996, the provision of services by aid agencies was crucial to sustaining them. They were entirely dependent on regular distributions from the World Food Programme (WFP). It had become a huge logistical exercise. The language of protected villages had been set aside, as had the circumstances of their origin. For aid agencies and for the government, the camps were explained as a direct result of LRA atrocities. Each was supposed to be allocated an armed guard, usually of local defense units rather than formally recognized soldiers and mostly made up of very young men with little interest in actually fighting. In effect, the camps were internment centers, and residents found outside of them were at risk of being treated as LRA sympathizers. The vast majority of IDP camps were located far from Gulu town. They were also not easy to reach without army escorts. The international aid staff members that went out to them had to travel in convoy, with expatriates mainly in cars provided with ballistic blankets. Visiting some camps required the use of bullet-proof armored vehicles, helmets, and flak jackets. It was considered dangerous to be outside of Gulu at night, and international staff were strongly discouraged from doing so. This meant that the IDPs tended to be reached for brief periods in the middle of the day. Food and other supplies were delivered, and then the humanitarians would quickly return to base. If the original military strategy for establishing settlements was to forcibly isolate the Acholi people from the LRA and prevent the rebels from assessing food, it failed. After a distribution, the LRA would be expected to come for their share during the night. They would also

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recruit, often by force. Thousands of children and young adults were taken away, many of whom were never seen again. The consequences of not collaborating could be dire. In May 2004, for example, an FM radio broadcast from Gulu about the welcome given to former LRA combatants who had surrendered at Pagak prompted an LRA response. During the night, approximately twenty young mothers were taken to the edge of the camp with their babies tied to their backs. They were made to lie in rows, facedown in the bush scrub, and then had their heads smashed, one after another—their babies, too. This was one of the incidents investigated by the International Criminal Court (ICC), resulting in warrants for the LRA leadership the following year (Allen 2006a: 182–195). No warrants, however, have been issued for those responsible for establishing the IDP camps in the first place or sustaining their existence. Many have asked, why not? By 2004, there were more than 200 of these camps, concentrating more than 1.3 million people in dreadful conditions. Several were truly appalling places. Indeed, reported mortality rates were higher than I had encountered anywhere in my years of working in African war zones. Surveys conducted by MSF in five IDP camps found a crude mortality rate (CMR) of 2.8 deaths per 10,000 people per day for the general population (MSF 2004). The mortality rate was even more alarming among children under five years of age: 5.2 deaths per 10,000 children a day, with the rate as high as 10.5 deaths per 10,000 children a day in one location where people were living side by side with overflowing pit latrines. I visited that place myself; people were covered in their own excrement. The MSF survey found that the three main causes of illness were malaria/fever (47 percent), respiratory diseases (28 percent), and diarrheal diseases (21 percent). At some camps, such as the huge one that had sprung up at Pabbo, cholera was a constant threat. In 2005, a larger survey was carried out in collaboration with the World Health Organization (WHO) that was designed to be representative of all IDP camps. The report confirmed the seriousness of the situation, describing excess mortality as ‘‘staggering.’’ The overall CMR was assessed to be 1.54 per 10,000, and CMR for children under five was 3.18 per 10,000 (WHO 2005). The response among most of the humanitarian personnel based in Gulu, as well as by the Ugandan government, to the publication of these data was skepticism. The MSF survey in particular was dismissed by most

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of those government officials and aid staff interviewed in Gulu as exaggerated and not based on appropriate sampling. The camps, it seemed, were not viewed as that bad. After all, a host of agencies were providing them with food and other items. However, whatever the merits of criticisms about the survey methods used by MSF, this seemed an oddly confident point of view, given the brief visits that most urban-based government officials aid workers made to locations outside of Gulu. Because staying the night in a camp was generally viewed as too risky, the perceptions of almost all international humanitarian workers were based on daytime encounters and on stories circulating in the Gulu bars that took on the status of obvious facts. What follows are three examples of the ways in which readily available evidence and humanitarian perceptions diverged.

The Example of HIV/AIDS An issue raised by some of those wanting to dismiss the MSF (2004) survey was the fact that HIV/AIDS morbidity and mortality were not emphasized. An almost universally accepted view among humanitarians in Gulu was that the pandemic was out of control because of the LRA and the Ugandan army. This was also reported in the international media as well as in aid agency reports (e.g., Wallis 2004). A BBC report at the time stated that ‘‘doctors say’’ about half the girls who escape from the rebels are found to be HIV positive (BBC 2004). Such concerns about HIV/AIDS were mentioned to explain the presence in Gulu of so many organizations with a focus on the disease. But it appeared that very few of them were doing any systematic monitoring, and even staff interviewed at TASO had no clear idea about local incidence or prevalence rates. Most mentioned a World Vision report, and this was also cited in some of the media accounts. World Vision had been working in Gulu for many years and ran one of the two largest reception centers for people returning from periods with the LRA. An investigation of their records in 2005 suggested that approximately ten thousand former abductees and former combatants, a high proportion of them children, had been processed at the World Vision center. Most were said to have been reunited with their families. In 2004, World Vision published a substantial overview on the situation in northern

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Uganda, highlighting the role they had played in providing care and assistance. With respect to HIV/AIDS it made the following claim: protracted civil war threatens to unravel the country’s dramatic improvements as AIDS rates skyrocket in the country’s northern region. . . . [T]he 18-year war between the Ugandan government and the rebel Lord’s Resistance Army (LRA) . . . has increased the HIV rates in parts of the north to 11.9%—nearly double the rest of the country. . . . Many women, especially those in the displacement camps, find that they can only get food, soap or money in exchange for sex. Girls who are abducted by the LRA are often given to commanders as ‘‘wives’’ and sex slaves. Those who ‘‘night commute’’ and sleep in the cities to avoid abduction are often raped there. (World Vision 2004) However, the World Vision reception center had no testing facilities for HIV/AIDS and had not collected any prevalence data. So where did this information come from? An author of the report, based in the United States, was passing through Gulu at one point, so I asked her. She seemed annoyed when I raised the issue. When pushed, she admitted that she had found it on the Internet. I observed that it seemed to be a problem that international media organizations were now making statements about HIV/ AIDS in northern Uganda, based on a World Vision report that itself was derived from an unreferenced Internet source. She robustly disagreed. She was not an academic researcher but someone trying to deal with real issues, and it was perfectly acceptable to use statements about HIV/AIDS for fundraising purposes. An alternative perspective was that it would be better to be more cautious about foregrounding HIV/AIDS, not because it was unimportant but because it deflected attention from other acute health problems in the camps and led to misleading ideas about the LRA and the war. People were obviously dying, but equally obviously AIDS was not the main reason. My visits to the IDP camps made me wonder why cholera was not more commonly reported than it was. There were repeated outbreaks in Pabbo, but elsewhere there appeared to be inadequate monitoring of what was happening. What was obvious, however, to anyone who was willing to see was that people were being forced to live without adequate sanitation on an appalling diet in overcrowded conditions. Mortality rates were shockingly high, but it was hard to understand how HIV/AIDS could possibly be the main cause.

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One Italian humanitarian medical program, AVSI, was doing its best to counter the established views, although it seemed to have little effect on the approaches of the other NGOs. AVSI, which is aligned with the Catholic Church, has a long-term commitment to the region and was doing rather more serious work on HIV/AIDS. It was working closely with HIV-positive people and in particular attempting to limit mother-to-child transmission, which was a relatively new approach at the time. AVSI activities were linked with various hospitals, including the Catholic mission hospital at Lacor, which was also collecting information on the HIV status of its patients. World Vision’s figure of 11.9 percent was doubtless derived in some way from antenatal surveillance at Lacor, where that rate had been recorded in 2002. This was slightly higher than at other sentinel surveillance sites in the country during that year and double the national average for all Uganda’s sentinel surveillance sites. However, the 2002 Lacor rate actually indicated a dramatic decline from the rate of 27.1 percent recorded at that site in 1992 (Allen 2006b). In addition, antenatal surveillance carried out by AVSI at hospitals elsewhere in the region revealed that the rates recorded at Lacor were not the norm. Data collected between 2002 and 2004 indicated prevalence rates from 4.6 to 9.9 percent (Ciantia 2004). There was, moreover, little to suggest that rates of HIV were directly connected with the LRA. The LRA certainly did terrible things, and abducted adolescent girls were given to commanders as ‘‘wives.’’ However, there were also rules about sexual behavior within the LRA, which seem to have been followed most of the time. Although the reception centers in Gulu did not carry out systematic testing, one based in Lira town did do so. The rate of those found to be HIV-positive was less than 1 percent. Overall, the readily available evidence suggested that although atrocious sexual abuses had occurred, military activities and rape were not leading to a rise in HIV/AIDS rates. On the contrary, the mass forced displacement of the population in camps had coincided with a recorded decline in infection. Anti-insurgency strategies were actually containing the spread of HIV and the most serious risk factor was not abduction by the LRA but proximity to urban locations. An implication was that rates might be driven up by an end of the war, and the resulting movement of IDP populations toward towns (Allen 2006b). Additionally, all available evidence indicated that the most immediate and serious public health concerns related to living conditions in the IDP camps. However, those issues appeared not to be a priority for medical humanitarian activity; indeed they were in practice largely

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ignored. It was hard not to draw the conclusion that the proliferation of humanitarian agencies running HIV/AIDS projects, most of which seemed to be doing almost nothing, was a product of the availability of funds and only marginally related the immediate and very acute needs of the population.

The Example of the Really ‘‘Invisible Children’’ Another example of humanitarian cognitive dissonance was perhaps the most sensational aspect of the situation, at least in terms of media coverage. The Invisible Children YouTube documentaries have provided emotionally charged images of children coming into Gulu for the night, and every journalist who visited the town wanted photographs of the phenomenon. In 2004, an estimated twenty thousand children were taking refuge nightly in eleven of the biggest commuter centers, including the one mentioned earlier run by MSF at Lacor hospital. They were a primary focus of international humanitarian activity in the town even though there was awareness among those running them that fear of the LRA in the immediate vicinity of Gulu was not the only factor prompting these nocturnal migrations and not necessarily the most important. Adults wanted privacy in cramped living spaces at home, and electricity at the centers meant that children could do homework there and socialize. However, there was something else that made the concentration on night commuting as a strategy very peculiar indeed. It was manifestly obvious that there were hundreds of thousands of children living in camps too far from the town to walk. They remained isolated in the dark, surrounded by olum (the bush), that haunt of the LRA who might arrive at any moment. There was a curious lack of interest in these children, perhaps because they were less easy to see. They were real invisible children. Also in Gulu were the reception centers mentioned earlier. More of them were located in other towns in the region, notably Kitgum, Lira, and Pader. They were funded by international aid and in most cases run directly or indirectly by international NGOs. Data collected from all these reception centers in 2005 established that approximately thirty thousand returnees from the LRA had passed through them (Allen and Schomerus 2006). The majority of the reception centers, and the two biggest in Gulu, were meant to deal specifically with children. This was because so much funding was

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available for children, particularly for child mothers—the abducted girls given to LRA commanders as wives. Partly as a result of the night commuter issue, the LRA war was perceived as a conflict largely involving very young people who had been forced to take up arms or who had been viciously abused. In fact, as already noted, there were old army veterans in the LRA ranks and, according to readily available UNICEF data collected from local councils, most of those abducted or choosing to join the LRA were young adults. The majority of these never passed through a formal reception center, which proved to be a complication with respect to issuing amnesty certificates. In addition, even the reception centers that were supposed to deal only with children in practice received numbers of adults, too, some of whom still asserted their LRA rank among the inmates. According to those reception centers’ own records, the average age of arrivals was eighteen. Nonetheless, there certainly were thousands of children passing through the centers, and there is no doubt that a considerable portion of them had been forced to perform dreadful acts. It was common for those who had survived and returned to have severely beaten or killed their own close friends and relatives. One boy told me that when he refused to do so, the heads of LRA victims were cut off and hung around his neck. More were added until he agreed to kill someone himself. A few described being made to beat their own parents to death. During the reception process, the army handed returnees over to the staff of the walled centers. They could not leave without permission and were prepared for a return to the ‘‘community.’’ They were fed and clothed and given ‘‘psychosocial’’ support, usually for a few weeks (Allen and Schomerus 2006). The type of psychosocial treatment that returnees received varied from center to center. At the World Vision center in Gulu, it involved regular group meetings where inmates were encouraged to talk about what had happened to them. It also entailed quite a bit of collective praying. At other centers, there was an emphasis on externalizing trauma by reenacting events and drawing pictures. However, in almost all cases, psychosocial treatment was not administered by trained therapists. Once the children and adults were deemed to have adjusted adequately, the policy was to take them home and reunite them with their families. I was told that this was usually the right thing to do because family reintegration was ‘best practice’ according to the Cape Town Principles (UNICEF 1997). A few returnees resisted this prospect, particularly child mothers whose children

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were the offspring of senior commanders in the LRA, including Joseph Kony himself, but most had no option. In practice, reuniting returnees with their families meant taking potentially very disturbed people to one of the IDP camps and leaving them there. In 2004, at the World Vision center alone, records for about ten thousand returnees were found. They were stored in cupboards, some of which were locked and the keys lost. They had never been looked at since being collected, and there had been no individual follow-up. Thousands of similar records were found at the other centers. In the overwhelming majority of cases there had been no follow-up at all. Vulnerable young people, including children, had mostly been left in the IDP camps to fend for themselves, surrounded by relatives who might well know what they had been made to do. Was this really ‘‘best practice’’? Perhaps it could be argued that thousands of returnees could not be housed at reception centers in Gulu and the big towns indefinitely, but did that justify dumping them in locations that were too dangerous to visit except in the middle of the day and with a military escort? I was able to find a few such returnees (Allen 2006a). The boy who had been burdened with severed heads was living with his mother in a camp near the South Sudan border. A few feet away lived a woman. At each corner of her cramped compound was a grave of one of her children. Sitting with her as it became dark, I asked her if she forgave those who had murdered her babies. She said she did. I told her I would not be able to do that. We sat quietly for a while. Then I noticed she was crying. She murmured, almost beyond hearing, that she could not look on people with bad eyes, but she knew who had done those things. That night there was an LRA ambush on some soldiers nearby. The gunfire made some cry out. They said it made them remember things. It was at that moment that the boy who had been made to carry the severed heads told me that he, too, had killed people. In 2005, I led a team that tried to systematically track down a 10 percent sample of those who had been sent out to the camps from the reception centers (Allen and Schomerus 2006). We found many living like this boy, next to bereaved neighbors. Others had disappeared without trace.

The Example of Mato Oput There are many other examples that could be used to highlight how the humanitarian agencies in Gulu seemed to operate in a self-reverential and

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contained space in which realities were kept at bay. However, what struck me as the weirdest example of all was the obsession with a certain ritual called mato oput. One reason I returned to northern Uganda in 2004 was to investigate the implications of the formal referral of the situation in northern Uganda to the ICC by President Museveni’s government. This had occurred in December 2003 and had opened up the possibility of international criminal prosecutions in The Hague for individuals accused of the most serious crimes perpetrated in the region. I was amazed to find almost all the humanitarian agencies on the ground opposed to that process (Allen 2006a). Some were vociferous, arguing that to impose formal judicial processes would only endanger those most vulnerable, notably abducted children. Among other things, it was suggested that the LRA would have no incentive to release the children, because they might end up testifying against the group’s commanders. The way forward, it was proposed, involved drawing on Acholi customs of forgiveness, healing, and cleansing. In particular, there was a focus on mato oput, a ritual in which someone who had committed a terrible crime would drink a concoction made from bitter roots and a slaughtered sheep, together with a representative of the victim’s family. Numerous humanitarian agencies were funding these ceremonies as well as supporting the performance of other rituals, such as one that involved stepping on eggs, which were sometimes confusingly grouped under the same name. They were also funding the establishment of a council of traditional chiefs to implement these processes and were involved in the selection and eventual crowning of an Acholi paramount chief, a position that had never previously existed. Although I was fascinated by the rituals and the debates about their meanings, much of this struck me as absurd. I had lived among Acholi people for two years in the mid-1980s, and I had never come across mato oput. It seems to have been linked to specific clans and had been foregrounded in a report written by the anthropologist and Christian activist Dennis Pain in the late 1990s (Pain 1997). Pain had argued the following: Acholi traditional resolution of conflict and violence stands among the highest practices anywhere in the world. After factual investigation, it requires acknowledgment of responsibility by the offender, followed by repentance and then payment of compensation, leading to reconciliation through mato oput, the shared drinking of a bitter

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juice from a common gourd. This practice of reconciliation lies at the heart of a traditional approach to ‘‘cooling’’ the situation and healing the land and restoring relationships, far beyond the limited approaches of conservative western legal systems and a formal amnesty for offences against the state. . . . All Acholi know that because of atrocities, particularly against children. . . . all involved must go through mato oput reconciliation. By no means was everyone convinced about this approach (Bradbury 1999). Nevertheless, Pain’s assessment proved appealing to humanitarian organizations and even to some human rights activists. Following Pain’s advice, a system of alternative governance was promoted, grounded in ideas about patriarchal chiefs known as rwodi. By the time I returned to the region in 2004, these rwodi and the paramount chief elect were performing various public rituals with funding from international agencies. It proved a popular idea with journalists. As an article in the New York Times reported: ‘‘The International Criminal Court at The Hague represents one way of holding those who commit atrocities responsible for their crimes. The raw eggs, twigs and livestock that the Acholi people of northern Uganda use in their traditional reconciliation ceremonies represent another’’ (Lacey 2005). These performances, mostly paid for by international agencies, were intended to lead to a welcoming back of abducted children, alongside the LRA commanders who would be ritually cleansed and forgiven. At one level it was hard to take the idea very seriously, but some of those supporting it were passionate about it and did not take criticism lightly. Even drawing attention to earlier literature on Acholi culture was considered provocative. As I have pointed out in detail elsewhere, there was a great deal of what Hobsbawm and Ranger called the ‘‘invention of tradition’’ occurring (Hobsbawm and Ranger 1992, Allen 2008). Cognitive dissonance on the issue was extreme, or at least seemed to be. Although there were certainly a few activists who thought that institutionalizing and formalizing a particular ritual was the best chance of drawing the LRA out of the bush, it is hard to believe that most were genuinely convinced. It did not take much probing to find other reasons for promoting the strategy. One explanation, which a few of those interviewed were willing to state openly, was that there was a need to have some sort of voice for the local population that was not mediated by the Ugandan government. Another was that the LRA emphasized its own version of Acholi

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traditions, and so traditional authority figures might draw them into negotiations. To some extent that proved to be the case. The Acholi chiefs, including the newly created paramount chief, were much involved in the negotiations with the LRA that commenced in 2006. So was Ronald Iya, the Madi friend who visited Gulu with me back in 1989. One fallout of the funding to establish traditional systems among the Acholi was that some neighboring groups were also drawn into the process. Iya became the equivalent of the Madi paramount chief and was in the group that met Kony during the peace talks, including the last meeting, just before the U.S.backed attack on the LRA base in the Democratic Republic of Congo in 2008. However, it is hard to avoid the conclusion that there was another reason why many humanitarians in Gulu were enthusiastic about a concocted hybrid form of traditional justice and were hostile to the ICC. That reason relates to the practical implications of the ICC’s mandate to end impunity for the worst of crimes. For some of the agencies on the ground, there were things they had done that would not stand up to scrutiny if rigorously investigated according to such a criterion, particularly if the ICC turned its attention to how the situation had come about. Mass forced displacement of the kind that occurred in northern Uganda potentially falls under the ICC’s jurisdiction, and humanitarian agencies had been involved in facilitating it for years.

Conclusion: Life Beyond the Bubbles Describing life beyond humanitarian bubbles can be threatening to those living within them; many have found my analyses presented in this chapter controversial. The reaction of the World Vision author mentioned was a mild example. Others have been furious. When my book on the ICC was published (Allen 2006a), an article in New Vision, the main governmentowned newspaper in Uganda, noted: ‘‘He has not got it yet, but many in Gulu believe London School of Economics researcher Tim Allen, deserves the title of most unpopular foreigner in town’’ (Were 2006). However, I am by no means the only one making these points, and some have gone much further than I have. For instance, Chris Dolan has described the IDP camps as a ‘‘social torture’’ (Dolan 2011) and Sverker Finnstro¨m has called them ‘‘enforced

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domination’’ (Finnstro¨m 2008). Both have been scathingly critical of the ways in which humanitarian agencies effectively ended up supporting and funding systematic and large-scale abuse. Dolan describes in detail in his book ‘‘interventions with the stated intention of doing good and the observed impact of doing considerable harm’’ (Dolan 2011: 18). Adam Branch has documented the process through which humanitarians became complicit in doing such harm (Branch 2008, Branch 2011: 92–98). He shows how in 1996 the World Food Programme and other agencies, including MSF, Oxfam, World Vision, and UNICEF, were well aware that the camps had military objectives and knowingly, if reluctantly, became involved. He and Dolan also show how, in the course of time, the LRA atrocities allowed humanitarian agencies to ‘‘rewrite’’ events. No longer was the need for IDP camps questioned, but it was accepted as a fact and blamed on the rebels. Ideologically, violence and death were reframed as a purely humanitarian problem to be solved by foreign aid agencies (Dolan 2005: 335, Branch 2008: 157, Branch 2011: 99). Branch argues that humanitarian impunity in such circumstances is unacceptable and that ideally there should be criminal prosecutions (Branch 2011: 112–113). Perhaps this pushes the point too far. After all, the same humanitarian agencies supported my research and that of other critics, and they have not actually discouraged us from doing further fieldwork—far from it. Does that mean that we as researchers are in some way accountable, too? Also it was MSF that reported the mortality rates in the camps, highlighting humanitarian failure and implicitly questioning the organization’s own continued engagement. Similarly, it was another medical organization, AVSI, that published more accurate assessments of HIV/AIDS, making claims of other agencies look spurious, to the say the least. Mistakes were certainly made, and apparent cognitive dissonance was doubtless partly a defensive response to recognizing that fact. When asked in subsequent years why things had become so tragically absurd, some of those involved talked about the pressures of keeping donors happy and making impossible choices on a daily basis without much space to think strategically. One shrugged and remarked: ‘‘We meant well.’’ There was no intent to harm. Nevertheless, it was a situation in which humanitarians working in their bubbles and meaning well allowed terrible things to occur. Olara Otunnu, former UN Under-Secretary General and Special Representative for Children and Armed Conflict, is even more extreme than Branch in his criticism. His

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ire is primarily directed at the Ugandan government rather than the humanitarian agencies, but in his view, the IDP camps and the process of maintaining them constituted genocide (Otunnu 2009). The case he has made has been largely ignored, even though it is in many respects stronger than the case made for calling what occurred in Darfur genocide (Allen 2011). How can it be possible that in Sudan we have a warrant issued by the ICC for the arrest of President Bashir while in Uganda, President Museveni was able to host the International Criminal Statute Review conference near Kampala in 2010, with hundreds of international agencies enthusiastically participating? Is it unreasonable to suggest that part of the reason is that many of those international agencies were directly and indirectly complicit in large-scale abuses linked to anti-insurgency responses to the LRA? Visiting northern Uganda now, it all seems like a bad dream. The LRA, having lost access to their bases in South Sudan, moved to the Democratic Republic of Congo and the Central African Republic. Joseph Kony continues to terrorize, far from his home, in locations where there are many other marauding factions. Back in Gulu, life is transforming again. There is a new supermarket, and cafe´s where it is possible to have a cappuccinos. The camps outside the town have disappeared or turned into small towns. Among the Acholi people, there is often now a reluctance to dwell on the details of what happened—or rather a ready resort to a standardized narrative. But most know very well what they experienced, and they have to negotiate the consequences. Moral norms and modes of arbitration remain issues of concern, although there is much less talk of mato oput. The agencies funding the rituals have mostly lost interest or left. As the population returns to old farms, land disputes are intense and social controls difficult to regulate. Rape is, if anything, more prevalent now than before. A recent anthropological study by Holly Porter found that of the 187 randomly selected women she interviewed in two villages, one located close to Gulu town and the other in a more rural area, 76 had been raped, several more than once (Porter 2013). Many live near their rapists, under pressure to preserve a degree of social harmony. Meanwhile, HIV rates have started to rise with the relative improvements in living standards and increased migration into urban areas. According to a study of pregnant women in Gulu, the rate of HIV infection rose from 9.4 percent in 2008 to 16 percent in 2009 (Mascolini 2010). Other studies confirm the trend (Kitara et al. 2013). However, humanitarian agencies with a myopic focus

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on HIV/AIDS and the LRA during the war have mostly moved on elsewhere or shifted priorities to reconstruction and development. In the summer months, scores of college students arrive in Gulu from North America and Europe. They come to understand the situation they have seen in the Invisible Children videos and end up wondering where that situation has gone. Indeed, unless one knows about the history of reception centers and night commuters, one might imagine those things happened somewhere else or perhaps simply long ago. It appears that everyone wants to move on, including the government, which is now looking for votes in the north with a passion. Almost all international aid staff are new. They are mostly young, enthusiastic, eager to help, and poorly informed. As elsewhere, the lived memories of international humanitarians operating in northern Uganda are short, and institutionalized amnesia prevails. There is impunity in that, too. References Allen, T. (1991) ‘‘Understanding Alice: Uganda’s Holy Spirit Movement in Context.’’ Africa 61 (3): 370–399. ———. (2006a) Trial Justice: The International Criminal Court and the Lord’s Resistance Army. London: Zed Books. ———. (2006b) ‘‘AIDS and Evidence: Interrogating Some Ugandan Myths.’’ Journal of Biosocial Science 38 (1): 7–28. ———. (2008) ‘‘The International Criminal Court and the Invention of Traditional Justice in Northern Uganda.’’ Politique africaine 107: 147–166. ———. (2011) ‘‘Is ‘Genocide’ Such a Good Idea?’’ British Journal of Sociology 62 (1): 26–36. Allen, T. and M. Schomerus. (2006) A Hard Homecoming: Lessons Learned from the Reception Center Process on Effective Interventions for Former ‘‘Abductees’’ in Northern Uganda. Washington, D.C. and Kampala: USAID/UNICEF. Allen, T. and K. Vlassenroot, eds. (2010) The Lord’s Resistance Army: Myth and Reality. London: Zed Books. Amnesty International. (1999) Breaking the Circle: Protecting Human Rights in the Northern War Zone. London: Amnesty International. Bradbury, M. (1999) An Overview of Initiatives for Peace in Acholi, Northern Uganda. Cambridge: Collaboration for Development Action. Branch, A. (2008) ‘‘Against Humanitarian Impunity: Rethinking Responsibility for Displacement and Disaster in Northern Uganda.’’ Journal of Intervention and Statebuilding 2 (2): 151–173. ———. (2011) Displacing Human Rights: War and Intervention in Northern Uganda. New York: Oxford University Press.

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British Broadcasting Corporation (BBC). (2004) War Threatens Uganda AIDS Success. BBC News. September 27. http://news.bbc.co.uk/2/hi/africa/3694372.stm. Accessed June 25, 2013. Ciantia, F. (2004) ‘‘HIV Seroprevalence in Northern Uganda: The Complex Relationship Between AIDS and Conflict.’’ Journal of Medicine and the Person 2 (4): 172–175. de Waal, A. (1998) Famine Crimes: Politics and the Disaster Relief Industry in Africa. Oxford: James Currey. Dolan, C. (2011) Social Torture: The Case of Northern Uganda, 1986–2006. New York: Berghahn Books. Finnstro¨m, S. (2008) Living with Bad Surroundings: War, History, and Everyday Moments in Northern Uganda. Durham, NC: Duke University Press. Hobsbawm, E. and T. Ranger. (1992) The Invention of Tradition. New York: Cambridge University Press. Kitara, David L., Anet Nakitto, Judith K. Aloyo, and Amos D. Mwaka. (2013) ‘‘HIV/ AIDS Among Youths in Gulu: A Post-conflict Northern Uganda.’’ Pacific Journal of Medical Sciences 12 (1): 10–23. Lacey, M. (2005) ‘‘Atrocity Victims in Uganda Choose to Forgive.’’ New York Times, April 18. http://www.nytimes.com/2005/04/18/international/africa/18uganda.ht ml?ex⳱1271476800&en⳱ccda03f538f39e24&ei⳱5090&partner⳱rssuserland& emc⳱rss&_r⳱0. Accessed December 4, 2014. Lunde, H. (2005) Night Commuting in Gulu, Northern Uganda: From Spontaneous Strategy to New Social Institution. Fafo-Report 549http://www.childtrafficking .com/Docs/fafo_06_night_commut_0109.pdf. Accessed January 23, 2015. Marriage, Z. (2006) Not Breaking the Rules, Not Playing the Game: International Assistance to Countries at War. London: Hurst & Company. Mascolini, Mark. (2010) ‘‘HIV Prevalence Rising Sharply in Uganda’s Gulu Province Since 2008.’’ International AIDS Society. June. http://www.iasociety.org/Default .aspx?pageId⳱5&elementId⳱12727. Accessed December 4, 2014. Me´decins Sans Frontie`res (MSF). (2004) Life in Northern Uganda: All Shades of Grief and Fear. http://www.msf.org.au/uploads/media/uganda04.pdf. Accessed December 4, 2014. Nibbe, A. A. (2011) ‘‘(In)visible Children.’’ http://www.hpu.edu/CHSS/SocialSciences/ IMAGES/Faculty/Nibbe/Invisible_Children.pdf. Accessed January 23, 2015. Otunnu, O. (2009) ‘‘The Secret Genocide.’’ Foreign Policy, October 19, 2009. http:// foreignpolicy.com/2009/10/19/the-secret-genocide/. Accessed January 23, 2015. Pain, D. (1997) ‘‘The Bending of Spears’’: Producing Consensus for Peace & Development in Northern Uganda. London: International Alert and Kacoke Madit. Porter, H. (2013) ‘‘After Rape: Justice and Social Harmony in Northern Uganda.’’ Ph.D. diss., London School of Economics. Wallis, Daniel. (2004) Uganda HIV/AIDS Rate Soars in War-Torn Northern Uganda.. Reuters NewMedia: UNICEF. September 27, 2004.

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Stockton, N. (1997) ‘‘The Role of the Military in Humanitarian Emergencies: Reflections by Nicholas Stockton.’’ Refugee Participation Network, issue 23. January– April. http://www.fmreview.org/RPN/23.pdf. Accessed January 23, 2015. ‘‘Uganda: UNDHA IRIN Humanitarian Situation Report 12/4/96.’’ (1996) http:// www.africa.upenn.edu/Hornet/irin_120496.html. Accessed January 23, 2015. United Nations Children’s Fund (UNICEF). (1997) ‘‘Cape Town Principles and Best Practices.’’ Cape Town: UNICEF. http://www.unicef.org/emerg/files/Cape_Town _Principles%281%29.pdf. Accessed January 16, 2015. United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA). (2005) ‘‘Consolidated Appeal Process: Uganda 2005.’’ Geneva: UNOCHA. http:// ochadms.unog.ch/quickplace/cap/main.nsf/h_Index/CAP_2005_Uganda/$FILE/ CAP_2005_Uganda_SCREEN.PDF?OpenElement. Accessed January 23, 2015. ‘‘War in Northern Uganda World’s Worst Forgotten Crisis.’’ (2003) Agence FrancePress. November 11. http://reliefweb.int/report/uganda/war-northern-uganda -worlds-worst-forgotten-crisis-un. Accessed January 23, 2015. Were, J. (2006) ‘‘Will the ICC Be Buried in Northern Uganda?’’ New Vision, Kampala, December 19. http://www.newvision.co.ug/PA/8/459/538751. Accessed January 23, 2015. World Health Organization (WHO). (2005) ‘‘Health and Mortality Survey Among Internally Displaced Persons in Gulu, Kitgum and Pader Districts, Northern Uganda.’’ July. http://www.who.int/hac/crises/uga/sitreps/Ugandamortsurvey.pdf. Accessed January 23, 2015. World Vision. (2004) Pawns of Politics: Children, Conflict and Peace in Northern Uganda. Washington, DC: World Vision.

Chapter 6

Staging a ‘‘Medical Coup’’? Me´decins Sans Frontie`res and the 2005 Food Crisis in Niger Jean-Herve´ Je´ze´quel

At the end of 2004, serious tensions over food prices started to affect cereal markets in Niger. At that time, observers linked these tensions to a recent locust infestation as well as to insufficient rainfall. Initially both local and international experts were uncertain as to the severity of the situation, but most were confident that the local system of crisis prevention and mitigation, the dispositif national de gestion et de prevention des crises (hereafter the dispositif), could manage it. This confidence collapsed during the summer of 2005. A state of emergency was declared while tons of food aid was sent to Sahel. Niger became the humanitarian crisis of the summer, attracting mass media attention from all over the world. Neither the food crisis nor the collapse of confidence in the dispositif was a ‘‘natural’’ process. Among humanitarian actors, Me´decins Sans Frontie`res-France (MSF-France) played a key role by attracting media attention to the ‘‘severity’’ of the crisis and by pointing out the crucial shortcomings of the dispositif. MSF-France’s response to the food crisis in Niger was one of the most ambitious operations in its history. In 2005, the organization treated more than forty thousand severely malnourished children just in Niger, compared to a total of twenty-two thousand children in all of its programs during the previous year. This crisis also placed MSFFrance at the center of debates that received worldwide media coverage during the summer of 2005. This attention, however, came at a price: in 2005 top-level Nigerien politicians and experts from the dispositif accused

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MSF-France of inventing the food crisis. Some even blamed the organization for bypassing the sovereignty of the state of Niger. By 2008, former president Tandja had prohibited MSF-France from operating in Niger. This chapter deals with MSF-France’s attempts and the efforts of other key players (development programs, UN agencies, the government of Niger) to ‘‘define’’ the scope, nature, and severity of the 2005 crisis in Niger and the legitimate solutions required to address it. It aligns with recent works pertaining to the rise of ‘‘humanitarian governmentality,’’ defined as a unified mode of government characterized by biopower forms of regulations, states of permanent emergencies, and a moral economy dominated by compassion (Fassin 2011, Bornstein and Redfield 2011). It pays particular attention to the internal tensions and uncertainties that characterize this ‘‘governmentality.’’ In the case of Niger, it particularly stresses how development experts, emergency workers, agronomists, and medical experts fought over whether to describe the situation as a crisis that had gotten out of control or as one that was serious yet manageable. Afterward, there were valid reasons to describe MSF-France’s strategy and action in Niger as a planned ‘‘medical coup.’’ But a closer look at both field and headquarter levels reveals a great deal of uncertainty in the unstable balance of power that eventually shaped what became the 2005 crisis in Niger. Xavier Crombe´ and I began to address some of these issues in an edited volume published in 2009 (Crombe´ and Je´ze´quel 2009). But in the following pages, my narrative adopts a different perspective. The ‘‘making’’ of the 2005 crisis is not analyzed from a general and outside point of view. Instead I base my comments on my experience as an ‘‘expert’’ sent by MSF-France to the field during the crisis. Reflecting on my time in Niger, I try to illuminate the various tensions that eventually produced MSF-France’s position on malnutrition and food insecurity in Niger.

Selecting the ‘‘Expert’’ The following phone conversation took place in January 2005, a few months before the food crisis: The MSF desk officer in Paris: Hi, Herve´. Would you like to go to Niger? There is something like a famine going on there, our feeding centers are already full with malnourished children,

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and we expect many more to come in the coming months. We don’t understand what’s going on there, the government says that the situation is under control, that there is no famine, but we believe they underestimate the severity of the coming crisis. . . . I am sure you could help clarify the situation for us. The author in his office at Emory University: Hmm. . . . I’m not sure I can help. I have never been to Niger, I don’t know a damn thing about food security. . . . I can give you a few names of colleagues who could do a very good job for you. The MSF desk officer: Well . . . we’re not really comfortable working with other guys. You know us, you know MSF, it’s better to work together. Why don’t you go? We need you, you know us. At this time, I was teaching African history at Emory University in Atlanta. My experience with MSF-France had started a few years earlier when the organization sent me to Guinea and Liberia to ‘‘analyze’’ conflict situations: analyze the situation in the Guinean forest where MSF-France wanted to initiate a new project; analyze the situation in refugee camps in the Mano River region because MSF-France wanted to publicly criticize the manipulation of international assistance (my first failed report); and analyze the political and humanitarian situation in Liberia for the Centre de re´flexion sur l’action et les savoirs humanitaires (CRASH), MSF-France’s research center, as it prepared a new volume of its Population in Danger series. My identity and my assignment in the field were often unclear to many MSF-France staff. They gave me various names including the ‘‘spy,’’ the ‘‘journalist,’’ the ‘‘researcher,’’ and, the worst nickname for an historian, the ‘‘anthropologist.’’ Between 2001 and 2005, I regularly went on missions for MSF-France, producing reports on political situations and humanitarian crises in the Mano River region (Liberia, Sierra Leone, and Guinea). It happened that the desk coordinator in charge of Liberia at MSF, who recruited me for my first MSF mission in 2001, was also responsible for the MSF-France projects in Niger in 2005. Along with the CRASH coordinator, he approached me to conduct a short research project on the situation in Niger. I reluctantly accepted the offer. Not only was I ignorant about children’s malnutrition and food issues in Niger, but I was also worried about my academic career. French scholars like to stress the distance that separates academic literature production from consultants’ and other experts’

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work. A scholar can work for an organization, but he must be careful to maintain his distance from it. At this moment of my career, I was convinced of the sharp difference between these two professions. I eventually came to believe that the distance is actually much less than we assume. In January 2005, when I offered to put MSF-France in touch with some of my colleagues who worked in Sahel, MSF never really took these recommendations seriously. MSF insisted on working with me because I was already ‘‘familiar’’ with the organization. I finally accepted after several calls, long discussions, and probably a few drinks. What does this tell us about the relationship between ‘‘analysts’’ (scholars or consultants) and medical humanitarian organizations such as MSF-France? It demonstrates that humanitarian organizations try to build specific relationships with ‘‘experts’’ who help them not only to ‘‘understand’’ local situations but also to legitimate the forms and modalities of their involvement in foreign countries. MSF-France recruited me not because I knew Niger—I knew almost nothing about it—but because I was familiar with the organization and its modes of intervention. As suggested by James Ferguson with regard to Lesotho, neither development experts nor humanitarian workers are ignorant of local situations (Ferguson 1990). They are actually very selective in choosing the kind of expertise that facilitates and/or legitimates operations. NGOs are often looking for forms of knowledge production that reflect—albeit not necessarily in a very conscious way—their expectations and therefore support their projects. Missing from this analysis is the simple fact that by the beginning of 2005, MSF-France had no clear agendas or unequivocal ambitions in Niger. There was no coherent message on Niger yet, and it was not even a central concern for the organization. The MSF-France headquarters in Paris was still focused on a controversy over the operational impact of the recent tsunami in Indonesia. Tensions existed within the organization about what should be done with the MSF-France operations in Niger. Some argued that Niger was a country at peace that did not require MSF-France presence anymore and supported closing their projects in Niger by the end of 2005. Others stressed that the country offered the best site to advocate for MSF’s new curative approach to children’s malnutrition (based on Ready-to-Use Therapeutic Food [RUTF] and ambulatory treatment). These debates were part of routine discussions about the MSF-France strategy in Niger. By the end of 2005, the mise a` plat (strategic planning session) of MSF-France was addressing the option of making malnutrition more visible on the agenda

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of developers and humanitarian agencies in Niger. But in January 2005, no one anticipated the scope of the coming crisis. To be sure, something was to be planned for Niger, but MSF-France did not have a clear vision as to what the plan should look like.

(Re)discovering Malnutrition in Niger At this point, I need to briefly enlarge my narrative to describe the context and the tensions that characterized the aid industry in Niger in the mid2000s. Indeed, drawing lessons from the failed management of the Sahel famine in the 1970s and early 1980s, rural development experts came to play a central role in Niger’s food security policies in the last two decades of the twentieth century. They criticized previous free food distributions for being both short-term and ineffective policies. Insisting on the need to address the root causes of food insecurity in Sahel, they instead advocated merging food security goals with those of long-term rural development. Emergency relief aid, while not entirely ruled out, was to be reserved for exceptional circumstances; in any event it should not be permitted to disrupt ongoing development efforts. This trend affected the whole Sahel area, but in Niger it had specific effects: in the late 1990s, Western donors— especially France and the European Union—invested more in Niger than in any other western African country in building up a modern and efficient national food crisis prevention and mitigation system. Co-administered by the government and major international donors, the dispositif was officially in charge of managing food crises and more generally food security issues in Niger. Compared to other western African countries, the Nigerien dispositif was elaborately structured and coherently organized, and it had an impressive set of data-gathering techniques at its disposal. In 2005, the dispositif was fairly confident in its ability to manage the food security challenges. But during the summer of 2005 it increasingly came under fire over its handling of the situation. Indeed in the early 2000s, another set of actors was trying to reassert its role in the field of food aid industry in Sahel. Medical experts like nutritionists were rarely included among the the range of legitimate experts asked to address food security issues, and they were about to make an astonishing comeback through the treatment of childhood malnutrition in Niger. In the late colonial period, French doctors had played a role in making children’s

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malnutrition visible to colonial authorities and in promoting large-scale treatment protocols based on the distribution of high-protein food such as skim milk and/or enriched peanut paste. Yet for various reasons—including colonial and postcolonial priorities given to agrarian productivism, the failure of the ‘‘protein gap’’ theory, and the discovery of aflatoxin on peanuts seeds in the early 1960s—the medical approach to treating malnutrition became marginalized in Sahel while food security issues became the uncontested monopoly of ‘‘agrarian experts’’ (agronomists, rural economists, rural developers, etc.). In the early 2000s, the medical experts on malnutrition started to slowly reappear through their connections with emergency humanitarian actors. This alliance was all but natural. Indeed, emergency NGOs and most aid practitioners have long regarded the treatment of childhood malnutrition as a ‘‘logistical nightmare.’’ It implied long periods of hospitalization, which required immense logistical support and the capacity to manage the serious risk of nosocomial infection. More important, in contexts such as Ethiopia in the 1980s or South Sudan in the 1990s, the discrepancy between the number of children who needed assistance and the number of children who could practically receive it was so great that it discouraged many organizations from intervening. If the colonial moment was the phase of the medicalization of hunger and malnutrition, the postcolonial ‘‘humanitarian decades’’ led to an opposite process of demedicalization (Vaughan 1991, Worboys 1988, Briend 1998, 2009). Medical knowledge and techniques did not seem to be able to inform large-scale policies that could efficiently address an issue such as childhood malnutrition. In many contexts, agronomists, who promised self-sufficient and well-fed peasant communities, took over the responsibility for addressing malnutrition in the long term, leaving almost no room for short-term strategies (Crombe´ and Je´ze´quel 2009). Therefore, beyond specific contexts like civil wars, childhood malnutrition came to be seen as a problem of economic development rather than as a medical issue. While in Niamey in June 2005, I had a conversation with a senior official from an international organization in charge of humanitarian assistance. Although he acknowledged that he did not know a great deal about the scope of childhood malnutrition, he believed Niger’s poverty could largely be attributed to high fertility rates. In his opinion, it was not very useful to spend scarce resources on rescuing uneducated and debilitated Nigerien children from malnutrition. The local economy was already

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unable to care for the children who survived. Preparing a better future for Nigerien kids seemed to make more sense than treating severely malnourished children in the short run. The moral economy of human survival in Niger began to change as new knowledge about nutrition and new medical techniques opened the door to the large-scale treatment of malnourished children in the first decade of the twenty-first century (Briend 1998, 2009). Not only was malnutrition once again considered a medical issue, but the fight against childhood malnutrition came to be regarded as a global issue (a process closely linked with the rise of the Millennium Development Goals [MDGs] and more specifically with MDGs 1c and 4a). The 2005 food crisis in Niger was a key stage on which these changes were taking place, and MSF-France proved to be one of the leading actors in this process. MSF-France undoubtedly played a central role in causing humanitarian workers to once again devote attention to malnutrition in Niger. Treating malnutrition has always held an important place among the medical activities of MSF-France in humanitarian emergencies. The possible development and validation of a new protocol that would result in more effective treatment of malnutrition could benefit MSF-France’s more classical medical relief activities. In addition, the issue of malnutrition lay at the crossroads of emergency relief and another type of activity carried out by MSF since the second half of the 1990s: the development of pilot projects to improve treatment of major endemic diseases such as AIDS and tuberculosis. There is not enough space here to elaborate on the complex ways through which RUTF made its way through MSF. From 2002 through 2004, MSF operations in Maradi, Niger, were a medical as well as technical success. It convinced NGOs of the usefulness of RUTF in zones affected by high rates of childhood malnutrition. At the time, MSF was the only organization running a handful of therapeutic feeding centers in Niger and the number of patients was soaring. In Niger, the problem of malnutrition had been practically invisible until 2005. For instance, the dispositif was focused on measuring volumes of cereal production in Niger but was almost entirely blind to the health status of the Nigerien population. Consequently, there was a great deal of data on the status of the cereal and livestock markets, harvests, and rainfall, but until 2005, data on the nutritional status of Niger’s population were scarce. Although malnutrition was not completely ignored, it was mainly

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described as a structural problem linked to chronic poverty and ‘‘African’’ cultural biases (irrational food taboos, inadequate weaning practices, and a lack of education among women). Therefore, addressing malnutrition required long-term and multisectorial approaches. Educators and rural development experts were needed to improve mothers’ knowledge of proper nutrition and eradicate ‘‘wrong’’ behaviors and to guarantee peasant communities’ access to sufficient levels of food or the equivalent in cash. There was no serious discussion of a large-scale medical answer to childhood malnutrition in Niger. Until 2004, MSF did not place a high priority on communicating the results of its nutritional operations in Niger, and its actions were mostly ignored by other actors, including the dispositif. In turn, MSF teams had no real interaction with food security experts in Niger, and most MSF staff probably ignored the dispositif. MSF-France perceived Niger as a politically stable country in which it could experiment with the scaling up of a new therapeutic approach to malnutrition with the local authorities’ agreement. By 2004, the dispositif reported great satisfaction with an exceptionally large harvest that resulted in ‘‘very limited food insecurity’’ in Niger. The very same year, the MSF Maradi region nutritional centers treated ten thousand children with severe malnutrition—the most they had ever encountered. Yet neither MSF nor the dispositif compared its respective figures and assessments of the situation. MSF is often portrayed as the paradigmatic medical humanitarian agency, but its position on how it is situated in the relationship between development and emergency relief has shifted many times. For instance, in the late 1990s and early 2000s, fighting epidemics and working in war zones were largely perceived as MSF-France’s core activities. Engaging teams in different contexts was often viewed with suspicion and as a waste of resources. In those years, mission volunteers often said that ‘‘a case of malaria does not interest MSF; a case of malaria in a war zone does.’’ This might sound harsh, but it also reflects the absolute need to draw lines between where MSF should get involved and where it should not; where the organization believes it makes a difference and where it does not. But these lines are not uncontested and monolithic. In the 2000s, MSF operations increasingly moved toward longer-term operations in countries that were not necessarily affected by large-scale conflicts. The AIDS epidemic is probably one of the main reasons for such a change; malnutrition is another. But the process was slow: in 2005, engaging in large-scale operations

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to treat malnutrition in poor but stable countries was far from being an obvious move for MSF-France teams.

Growing Tensions in Niamey . . . and Paris In the first months of 2005, the unusual release of nutritional data by both MSF and Helen Keller International (HKI), along with increasingly troubling reports of rising millet prices, bred tension inside the Niger food security system. More and more attention was being paid to agricultural zones not centrally featured in the food vulnerability maps the dispositif routinely generated. And an increasing number of actors—MSF, HKI, and soon Action against Hunger (Action Contre la Faim [ACF]) and other humanitarian organizations—were beginning to focus on a problem—the nutritional crisis—to which the food security system, preoccupied with cereal production totals, had given scant attention. When I landed in Niger in June 2005, the country was thus experiencing an unsettling mixture of tension and uncertainty. There was discord among NGOs, donors, and the Nigerien government over the assessment of the country’s situation: was the country going through a food crisis, and if so, what was its severity? It may sound naı¨ve, but it took me some time to understand that the ‘‘severity’’ and more generally the ‘‘nature’’ of the crisis were not elements to be discovered or simply evaluated. Indeed, they were to be built by experts and humanitarian workers. MSF-France was among a number of organizations and institutions—including the state of Niger—engaged in different discursive constructions about the 2005 crisis. None of them was completely disconnected from local dynamics, but none merely reflected Nigerien reality. They all included political dimensions about what and who should be included in aid policies. On the one hand, members of the dispositif—including the government of Niger—claimed that the situation was severe but not exceptional and therefore did not require a contingency plan other than the usual mitigation interventions. On the other hand, MSF teams and a few other organizations claimed that the severity of the crisis was being underestimated. According to them, if nothing were done, the situation in Niger could end up being a large-scale disaster. Those in the latter group were tempted to call for free food distribution, something the former group considered not

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only inappropriate but counterproductive because it bred a dependency that would wreck the country’s future; they in turn were accused of sacrificing Niger’s youth on the altar of the free market and sustainable development. Nigerien authorities and other key members of the dispositif were putting a lot of pressure on MSF teams. An MSF field coordinator was even deported for refusing to accompany a Nigerien high official during her visit to an MSF Therapeutic Feeding Center. But MSF was eventually successful in forcing its way through Niger. It mostly imposed its own reading of the crisis as well as the legitimate medical solutions to address it. Meanwhile, the consensus that existed within the dispositif was shattered as the World Food Program crossed a ‘‘red line’’ by unilaterally organizing free food distributions. To some observers, MSF succeeded in carrying out what appeared to be a ‘‘medical coup’’ that temporarily superseded local sovereignty over food and nutrition security. A posteriori, I recognize how the different positions relied on thin and uncertain evidence. Local experts and well-established anthropologists I interviewed in June–July 2005 pointed to the absence of ‘‘refugees’’ in urban centers as the clearest evidence that there was no major crisis in the country. Indeed, they shared a common memory of past ‘‘famines’’ in the 1970s and early 1980s during which desperate, starving families abandoned their land to look for some assistance in the cities. Despite the wide range and modernity of their technical instruments, supporters of the dispositif, most of whom were urban dwellers, relied on this fragile sign to evaluate the seriousness of the situation in the rural countryside. This is nothing new, as Vincent Bonnecase has demonstrated how contingent the data produced in times of food crisis in the Sahel area truly are (Bonnecase 2011). Meanwhile, MSF-France, recently joined by the Belgian and Swiss arms of the organization, was desperately looking for reservoirs of malnourished children. They organized separate exploratory teams in rural areas that brought back mixed and uncertain results. An assessment mission conducted by MSF-Belgium in the Zinder area revealed no nutritional emergency. These results contradicted the HKI survey conducted a few months earlier in a neighboring area. I remember the surprise and dismay expressed by the French team when they received the results. Yet some were quick to react: they claimed that the ‘‘naı¨ve’’ Belgian team had been manipulated by local authorities trying to hide malnutrition. Some among MSF-France simply disregarded these results; malnutrition had to be found.

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Tensions arose between different MSF headquarters as well. In Paris and Brussels, the Belgian results also shed some doubt on the scope and severity of the situation in Niger. Those in Paris and Brussels who opposed malnutrition programs pointed to these results to assert that MSF had nothing to do in Niger and should redirect its resources to war zones and ‘‘real’’ crisis situations. Supporters of the malnutrition program strongly opposed them, and some went as far as accusing unbelievers of acting like ‘‘serial child killers.’’ For both sides, understanding the dynamics of malnutrition in Niger was central in the struggle for the redrawing of MSF legitimate perimeters of action. I did not understand what was at stake until the day of my debriefing: back from Niger, I discussed my initial results in front of an unusually large number of MSF officials at the Paris headquarters. It was not my first debriefing, but usually I was lucky if I could attract a handful of members from the operation department. Before the mission I knew nothing about Niger; after the mission, I started to wonder whether I knew anything about MSF. I slowly came to understand that my mission was to build MSF’s position on the crisis not only by ‘‘analyzing’’ the situation but also by providing supporting arguments. Nutritional surveys were proving insufficient for producing a significant change in the ‘‘course of events,’’ and a decision was made in Paris to elaborate a political reading of the crisis. My report was part of this move. This report was a piece in a series of discourses and actions that allowed MSF-France to elaborate a more aggressive position in Niger. Indeed, by the end of June, MSF-France had come to believe that ‘‘the aid system was not seen as simply late or out of tune with the emergency; its very logic led it not only to deny the emergency could exist but also to aggravate it more surely than any natural cause’’ (Crombe´ and Je´ze´quel 2009: 71). However useful my report might have been at the time, the organization did not ‘‘swallow’’ it entirely. For instance, a large part of my report also focused on economic dynamics and described the growing levels of debt that threatened peasant communities in southern Niger. This part was largely ignored by MSF-France during the summer. Indeed, it did not fit in with the idea that 2005 was an exceptional year, requiring exceptional measures. This selective reading of my report demonstrates how forms of knowledge circulate from ‘‘scholars’’ and ‘‘experts’’ to medical humanitarian organizations. Following James Ferguson’s comments on development,

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this confirms that what is problematic is not the ignorance of foreign NGOs but their selection of what they consider, consciously or not, as relevant and useful knowledge. But it is inaccurate to blame MSF, as some did, for ‘‘creating’’ the crisis to serve its own ambition. In June and July 2005, I found that the organization was still unclear about what was to be done in Niger. There was no Machiavellian plan, skillfully conceived right from the beginning. MSFFrance built its case in Niger through a long series of internal as well as external debates.

‘‘Can’t We Get Along?’’ Disputes over the Normal and the Pathologic in Niger Several postcrisis reports have highlighted the need to restore consensus and improve coordination among food security and nutrition actors. Indeed, dangerous scars remain from the disputes of 2005 (Delpeuch 2006). Some chose to blame the media’s coverage of the crisis for shattering the consensus. Much has been said about the excesses of the media, suggesting that journalists hunted for sensationalism and/or were manipulated by certain NGOs and thus produced a highly simplistic view of the situation in Niger. This coverage was blamed for panicking the dispositif’s member agencies into taking measures of doubtful utility on the ground in order to appease public opinion abroad. Others pointed to the lack of communication between organizations like MSF-France and those working under the dispositif’s umbrella. When I went back to Niger in 2008, a French advisor working for the dispositif ’s executive committee told me that misunderstanding and lack of dialogue explained the tensions and the poor management of the 2005 crisis. She particularly blamed MSF-France for not trying to collaborate with the dispositif and more generally for its ‘‘go it alone’’ position. However, disagreements did not arise in 2005 because of lack of communication but because different organizations had conflicting agendas and diverging analyses. What was more particularly at stake was a redrawing of the line between the normal and the pathologic, the acceptable and the intolerable (Bourdelais and Fassin 2005). For the dispositif, a high level of childhood malnutrition was ‘‘normal’’ (or ‘‘usual’’) in one of the poorest

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countries in the world. It was also acceptable, as nothing could be done to address the problem in the short term. Only long-term strategies such as educating the population and developing the economy could solve the problem. For MSF, the high level of malnutrition among children was ‘‘abnormal’’ and expressed a massive ‘‘pathology’’ that required immediate action. It was also unacceptable, as efficient curative protocols were available and could prevent tens of thousands of children from dying. The 2005 crisis allowed medical expertise to reassert its role in a context of chronic poverty such as Niger. This process was controversial, as other development experts resisted conceding any legitimacy to medical humanitarian organizations. In the aftermath of the crisis, some scholars questioned the relevance of the opposition between developers and emergency humanitarian organizations. For instance, in the book I edited with Xavier Crombe´, the Italian anthropologist Benedetta Rossi described the opposition between developers and humanitarian assistance as an almost senseless clash between two forms of ‘‘institutional thinking,’’ both driven more by internal dynamics than by close observation of the situation in Niger (Rossi 2009). The analysis is accurate, but the clash did, nevertheless, make it possible to reopen important political discussions in Niger: What was the human cost of the priority given to long-term and agrarian development? What levels of childhood mortality were deemed normal or not, tolerable or not, and so forth? Jean-Pierre Olivier de Sardan, a leading figure in French anthropology and longtime Niger specialist, claims that the opposition between developers and humanitarian assistance is misleading and constitutes a ‘‘fauxde´bat’’ (Olivier de Sardan 2011/13). Indeed, local populations did not differentiate between developers and humanitarian workers when trying to access assistance. Moreover, local coping strategies proved to be much more effective than did foreign aid. For instance, Olivier de Sardan convincingly asserts that local communities got much more assistance from migrants’ networks in Nigeria or Libya than from the dispositif or from humanitarian organizations. Yet what is missing in this analysis is the qualitative dimension of assistance. Severely malnourished children in Niger could not survive by receiving bags of millet; they needed medical treatment. In 2005, only humanitarian organizations provided RUTF that could make a difference. To this extent, medical humanitarian actors and agrarian developers draw different lines between who is included in aid policies and who is not.

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Were these struggles superfluous? Was it not possible to combine shortterm medical interventions with long-term development policies? Resources to address the problem of Sahel societies were and are still limited. Therefore there is often more competition than collaboration between different experts and their respective diagnoses of the situation. In 2012 the aid system, in which the dispositif is still a major component, routinely distributed curative treatments to more than three hundred thousand severely malnourished children. Yet donors express their concern over the cost of such massive operations that save lives but do nothing to address the root causes of malnutrition. A few years after the 2005 crisis, the balance between the doctor and the agronomist, between the humanitarian worker and the developer, had changed a great deal but still appeared quite contentious and unstable.

Conclusion MSF shaped one of the leading interpretations of the 2005 crisis, but the process was too complex and uncertain to have been controlled by a single actor. As Crombe´ points out, MSF operations in Niger ‘‘were shaped by the complex dynamics of the crisis, just as the crisis was shaped by the ‘activism’ of MSF’’ (Crombe´ and Je´ze´quel 2009: 80). In the process, experts and scholars played a significant role in analyzing the situation and putting forth arguments that were used in the debates and struggles that characterize aid policies in Niger. But it is also important to understand the complicated relationship between producers of academic knowledge and medical humanitarian organizations such as MSF. The latter are far from being ignorant and have learned to be highly selective in their use of academic knowledge; the former should not be regarded as external or neutral actors as they sometimes play important roles in shaping aid policies. What does this narrative of uncertainties, tensions, and struggle tell us about the rise of humanitarian governmentality and global forms of biopolitics in Sahel? First, it might suggest that the depoliticizing effects of both development and humanitarian interventions also experience ‘‘eclipses,’’ brief but intense moments of repoliticization when crises and confrontation arise. In James Ferguson’s phrasing, the pre- and post-2005 dispositif probably functions as an ‘‘anti-politics machine’’ (1990). But in 2005, political discussions reappeared about legitimate forms of interventions and the

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(re)definition of the local moral economy of the (un)acceptable. It might be disappointing that local Nigerien voices appear marginal in this process, but it was not a zero-sum game for them, at least for those under the age of five. As suggested by Vincent Foucher in his comment on Mark Duffield’s work on development and international security, humanitarian intervention can also end up producing politicization (Foucher 2012). Second, this narrative invites us to reflect on the idea of humanitarian governmentality defined as a ‘‘consistent logic at work in the contemporary treatment of human suffering’’ (Guilhot 2012: 84). The 2005 crisis in Niger suggests that this form of governmentality is enmeshed with more messiness, contingency, and uncertainty than is often assumed by scholars. For instance, Pandolfi’s notion of mobile sovereignty might appear well suited to describe MSF-France’s intervention in Niger (Pandolfi 2000). But this notion also makes invisible the multiple tensions and ambiguities of MSFFrance’s involvement in 2005. Contrasting state and NGO forms of sovereignty tell nothing of the other important lines of contention such as debates between emergency workers and developers, medical technicians and agrarian experts, and so forth. Some may well argue that these local tensions and uncertainties have only limited impact on the more global deployment of humanitarian governmentality. This is a debate that goes beyond the scope of this chapter. But taking into account local tensions and ambiguities in the deployment of medical humanitarianism does not necessarily lead to a radical criticism of the notion of humanitarian governmentality. Instead it begs for more in-depth investigation of the heuristic impact, the evident gains as well as the hidden costs, of such a strong and seductive notion. References Bonnecase, V. (2011) La pauvrete´ au Sahel: Du savoir colonial a` la mesure international. Paris: Karthala. Bornstein, E. and P. Redfield, eds. (2011) Forces of Compassion: Humanitarianism Between Ethics and Politics. Santa Fe, NM: School for Advanced Research Press. Bourdelais, P. and D. Fassin, eds. (2005) Les constructions de l’intole´rable: E´tudes d’anthropologie et d’histoire sur les frontie`res de l’espace moral. Paris: La De´couverte. Briend, A. (1998) la Malnutrition de l’enfant. Des bases physiopathologiques a` la prise en charge sur le terrain. Bruxelles: Institut Danone. Briend, A. (2009) Treating Malnutrition: New Issues and Challenges. In, A Not-SoNatural Disaster: Niger 2005, edited by X. Crombe´ and J.-H. Je´ze´quel. New York: Columbia University Press.

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Crombe´, X. and J.-H. Je´ze´quel, eds. (2009) A Not-So-Natural Disaster: Niger 2005. New York: Columbia University Press. Delpeuch, F. (2006) Evaluation du dispositif de pre´vention et de gestion des crises alimentaires du Niger. Niamey: Institut de Recherches et d’Applications des Me´thodes de De´veloppement (IRAM). Fassin, D. (2011) Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press. Ferguson, J. (1990) The Anti-Politics Machine: Development, Depoliticization, and Bureaucratic Power in Lesotho. Minneapolis: University of Minnesota Press. Foucher, V. (2012) ‘‘Autour d’un livre. Development, Security and Unending War: Governing the World of Peoples de Mark Duffield.’’ Politique africaine 125: 215–233. Guilhot, N. (2012) ‘‘The Anthropologist as Witness: Humanitarianism Between Ethnography and Critique.’’ Humanity: An International Journal of Human Rights, Humanitarianism, and Development 3 (1): 81–101. Je´ze´quel, J.-H. (2005) ‘‘ ‘Ici, l’enfant n’a pas de valeur’: Se´curite´ alimentaire, malnutrition et de´veloppement au Niger.’’ MSF internal report. July. Olivier de Sardan, J.-P. (2011/13) ‘‘Aide humanitaire ou aide au de´veloppement? La ‘famine’ de 2005 au Niger.’’ Ethnologie franc¸aise 41: 415–429. Pandolfi, M. (2000) ‘‘Une souverainete´ mouvante et supracoloniale.’’ Multitudes 3: 97–105. Rossi, B. (2009) ‘‘The Paradox of Chronic Aid.’’ In A Not-So-Natural Disaster: Niger 2005, edited by X. Crombe´ and J.-H. Je´ze´quel. New York: Columbia University Press. Vaughan, M. (1991) Curing Their Ills: Colonial Power and African Illness. Stanford, CA: Stanford University Press. Worboys, M. (1988) ‘‘The Discovery of Colonial Malnutrition Between the Wars.’’ In Imperial Medicine and Indigenous Societies, edited by David Arnold. Manchester: Manchester University Press.

PA R T I I I

Strong States, Weak States, and Contested Health Sovereignties

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Chapter 7

What Happens When MSF Leaves? Humanitarian Departure and Medical Sovereignty in Postconflict Liberia Sharon Abramowitz

In the years just after the conclusion of the Liberian Civil War in 2003, the ability of the Liberian state to assume responsibility for the Liberian citizenry was on everyone’s mind. Liberia’s thirteen-year-long civil war resulted in the death of approximately 250,000 Liberians (nearly 10 percent of the population), the displacement of a million people into refugee and IDP camps, the dismantling of the national economy and infrastructure, and the destruction of an effective Liberian state. To fill the void, a United Nations Peacekeeping Mission arrived in 2003, bringing a vast global apparatus of humanitarian assistance organizations to provide relief and aid, as well as a large military peacekeeping body to help demobilize armed groups and restore peace. In free and fair elections Ellen Johnson Sirleaf was elected president of Liberia in 2005; the following year, the international community was looking for an endgame to transition Liberia from emergency to development. This chapter demonstrates how the problem of transitioning the Liberian state from humanitarian management to a vague, ill-defined development trajectory became particularly visible in the medical sector during the early years of Liberia’s postwar recovery. After the end of the war, international nongovernmental organizations (NGOs) like Me´decins Sans Frontie`res, Me´decins du Monde, and World Vision ostensibly worked in partnership with Liberia’s postwar Ministry of Health and Social Welfare

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(MOHSW), but in reality, they effectively acted in lieu of the Liberian state. Independently, they had been sustaining the Liberian population’s health at a very basic level by providing emergency medical care, primary care, vaccination campaigns, and epidemic control measures across the country through an independent network of clinics and hospitals. ‘‘The afterlife of intervention’’ (see Chapter 11) beckoned as a dimly lit future for the health sector transition, and the Liberian state’s assumption of responsibility for the health of its populace, to take effect. The health sector was not alone in this regard. Few governmental institutions had the capacity to effectively work as state institutions. For several years, Liberia’s Ministry of Defense was managed by foreign bodies while the U.S. private military contractor DynCorp trained its leaders in matters ranging from basic literacy and numeracy to the institutional ethics, principles, and practices of a civilian-run military. In the stead of Liberia’s Ministry of Education, a U.S.-based NGO worked with government leadership to develop basic curricula, compensation structures, and administrative capabilities while continuing to pay the salaries of many Liberian teachers. At the MOHSW, a small handful of key leaders, including Minister of Health Walter Gwenigale, Chief Medical Officer Bernice Dahn, and Deputy Minister Tornolah Varpileh, strained to consult with the international community on matters of national health policy, national health systems financing, local epidemic management, and infrastructure rehabilitation.

The Problem of Medical Sovereignty Approximately five years after the end of the war, from 2007 to 2008, I investigated the gritty nuts and bolts of the practice of medical humanitarian withdrawal at clinics and hospitals as a side project of my core study of trauma and postconflict reconstruction (Abramowitz 2014). My research focused upon the particular problem of medical humanitarian withdrawal during the first several years after the war’s end, when the sudden decision by Me´decins Sans Frontie`res-France (MSF-France) to withdraw from Liberia left the entire humanitarian medical sector and the MOHSW leadership in disarray, without a plan for transitioning to a postconflict medical structure. This chapter focuses specifically upon the after-effects of MSFFrance’s process of medical humanitarian withdrawal from 2006 to 2008, as well as MSF-Belgium’s decision to depart from a single hospital,

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Redemption Hospital, which fell under siege by local medical professionals in 2004. This chapter focuses on ‘‘the magic’’ of humanitarian medicine—on humanitarian medical NGOs’ capacity to construct an effective institutional apparatus, on an ongoing basis, that can sustain the delivery of basic and complex health services, surgical care, and public health intervention in an environment of extreme flux. Rarely seen were the grizzled, scarred, and sometimes odious logisticians’ contortions to procure bandages, medication, medical and surgical equipment, generators, and fuel through closed ports and borders. Invisible to the eye were the certified public accountants who blandly funneled global funds into steel boxes of local cash while saving their danger pay for retirement. Almost unknown were the human resource officers who took care of hiring, firing, training, and compensating expatriate and local employees. Travel agents in distant cities silently managed the movements of ‘‘heroic’’ expatriate doctors and nurses, while local mechanics invisibly managed and maintained the transportation fleets, satellite phones, Internet connections, and two-way radio systems that keep NGOs safe, mobile, and connected. The locally hired bodyguards who controlled access to humanitarian clinics and hospitals were nearly always rendered invisible, as were the behind-the-scenes negotiations between NGO workers and local military and civilian leaders over community access and terms of service. Without these systems of support, any medical system that is dependent on external goods, expertise, and financing will collapse. When medical humanitarian NGOs decide to leave the scene of a humanitarian crisis, it is this ‘‘behind-the-scenes’’ institutional world of medical humanitarianism— the bureaucratic, technical, financial, and logistical infrastructure of medical humanitarian action—that disappears. Usually the core of the medical encounter—Liberian medical providers and Liberian patients—continue to be present, but the ability to practice medicine effectively disappears without electricity, drugs, bandages, and laboratory testing capacities. When medical humanitarian NGOs decided to withdraw from Liberia, what local health, security, and bureaucratic considerations did they take into account, and what were they able to disregard? Whom did they have to consult, and whom could they ignore? What happened when these structures, capabilities, and institutions withdrew from Liberia in the transition from ‘‘crisis’’ to peace, and what can we learn about humanitarian migrant sovereignty and health sovereignty by observing their departures?

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Scholars have defined ‘‘health sovereignty’’ as a state’s ability to independently manage the health needs of its population (Chen, Evans, and Cash 1999, Kickbusch and de Leeuw 1999). In contrast, anthropologists like Mariella Pandolfi have proposed that humanitarian organizations (especially those embedded in military-humanitarian complexes, like those in Liberia) carry an aspect of ‘‘migrant sovereignty,’’ or ‘‘the intricate network of the humanitarian-political-military complex that is superimposed as a migrant sovereignty network.’’ She adds that humanitarianism ‘‘does not conceive any strategy of negotiation with its political, institutional, and social actors’’ (Pandolfi 2003: 369). However, medical humanitarian NGOs, like MSF, have offered a powerful counternarrative to both concepts by telling riveting stories of global humanitarian negotiations over entrance, healthcare provision, population access, and their ability to persistently stay in conflicts and disasters against tremendous political and military opposition (Magone, Neuman, and Weissman 2011). They also share complex narratives of uncertain mandate, ambiguous diplomacy, state and humanitarian competition, and moral and ethical uncertainty (see the case of Niger in Crombe´ and Je´ze´quel 2009, and Chapter 6). Do NGOs—in coordination with each other, with donors, and with global health-directed ‘‘vertical interventions’’ (Calain 2007, Wendland 2012)—act like a state? Are they capable of carrying the weight of the state’s health sovereignty until such time as the state determines that the NGOs are no longer welcome, alternative health institutions intercede, or NGOs decide to leave? It would seem that humanitarian organizations operating in the distinctive time frame of emergency (Calhoun 2010) manifest a form of ‘‘custodial sovereignty’’ (Scholtz 2008)—the arrogation of responsibility to provide healthcare and use preventive public health measures, when the empirical capacity of the state is perceived to be absent.1 A focus on the concept of custodial sovereignty pairs well with its aspired outcome—empirical sovereignty—in which the state has the will, the capacity, and the resources to provide domestic governance, or in this case, healthcare governance, to its population (see Barnett 1995). The concept of custodial sovereignty suggests an interpretation of sovereignty that is consistent with ‘‘the right to self-determination’’ over its clinics, administration, and policies. Custodial sovereignty is, however, inconsistent with an understanding of sovereignty as a ‘‘right to rule’’ or the right to exert authority over local populations; impose its presence; define its terms of entry; and independently determine the conditions for its tenure. By recognizing that

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empirical sovereignty is the tacit goal of medical humanitarian NGOs and most UN peacekeeping missions, the mobile sovereignty of humanitarian aid organizations can be recognized as both indisputable and highly conditional upon historical circumstances. As the following cases from Liberia make clear, medical humanitarian organizations have relatively little sovereignty, in the sense of having a ‘‘right to rule,’’ but they find significant sovereignty, in the sense of having a ‘‘right to self-determination’’ in the moment of departure. In making a determination to enter a crisis or disaster, they are compelled by factors as diverse as media coverage of a crisis, the strength of the state (see Chapter 8), local security conditions, donor willingness or fatigue, local populations’ and militias’ willingness to act as a host, and current moral and ethical discourse within the organization regarding the rightness to intervene. (These factors do not even begin to account for the sheer health needs that comprise a justification for medical humanitarian intervention.) Once medical humanitarian organizations like MSF arrive on scene, they are bound in speech and action by negotiations with local power brokers, local security conditions, the limits of their mandate, the sheer human and resource limitations of their institutional capacity, and the competing claims of other medical humanitarian organizations seeking to stake out ‘‘territory’’ in humanitarian space. It is, however, when these institutions leave that these many factors do not need to be taken into account, nor do the economic, health, and infrastructural aftermaths of their decision to depart.

Redemption Hospital The story of what happened at Redemption Hospital was a popular morality tale of Liberian ‘‘wickedness,’’ corruption, and ingratitude for humanitarian assistance that was shared widely across the Liberian state health bureaucracy and Liberian NGO workers at the war’s end in 2003. Redemption Hospital in Monrovia stood in the middle of a bustling peri-urban neighborhood on the far side of the sole, congested bridge that connected two sides of Monrovia. In 2003, at the height of the last conflict, MSFBelgium took over Redemption Hospital and transformed the bulletridden, roofless shell of a hospital into a pristine, freshly painted, fully

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operational inpatient facility with the capacity for surgery, emergency care, a maternity ward, and a functioning morgue. Then MSF-Belgium suddenly abandoned the hospital. As former MSF employees at Redemption Hospital, other MSF officials working in the area, and MOHSW employees reported to me from 2007 to 2013, over time the Redemption Hospital staff were reported to have created a hostile climate, had engaged in violence and extortion, and had stolen medications and supplies. There were signs of labor discontent as well: poor attendance was a persistent problem, and hospital workers regularly went on strike. After a spiraling series of contentious negotiations between MSF and the Redemption Hospital staff, the conflict finally escalated into violence. One morning, in the usual course of business, expatriate and local staff drove to the gate of the hospital and found the staff armed against them, behind locked gates. The staff chanted, ‘‘If you think you will enter inside the hospital, we will kill you. We will kill you.’’ When expatriates tried to force open the gates, they were attacked and had to leave. Shortly afterward, MSF-Belgium, which had been administering the hospital under a mandate from the MOHSW, summarily returned the hospital to the authority of the ministry with a temporary supply of medications, supplies, and a month or two of wages. But in local parlance, MSFBelgium left because the staff made ‘‘too much mischief.’’ MSF-Belgium, however, did not depart Liberia altogether. Instead, MSF-Belgium claimed that their mandate had changed and that they now had to deliver services to a more needful population: urban children. They then opened a new pediatric hospital not far from Redemption, called Island Hospital, in New Kru Town. Although the transition was otherwise made peaceably, the MOHSW did not want the hospital back under its authority, as it was fundamentally incapable of running the institution as a hospital. Under MOHSW management, the hospital suffered from dereliction and maladministration. Redemption could not afford the fuel to run their generator for lights, equipment, refrigerators, and the morgue, and medications and medical supplies were dependent upon state procurement pathways and were therefore both inconsistently provided and of questionable quality. Eighty percent of the staff had left. Redemption had the feel of being abandoned in the same way that Vita has been described as a zone of abandonment (Biehl 2005); it seemed to be institutionally, financially, and medically estranged from the core operations of sustaining life that characterized other, more

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thriving medical humanitarian establishments across the region. This was amplified by the obvious gloom and sadness of the place, which was quite different from the purposive brightness and cheerfulness of MSF hospitals and clinics. In interviews, ministry officials tried to save face about the event by obfuscating the reasons for MSF’s departure. They first asserted that the reason MSF-Belgium had left Redemption Hospital was because the ministry was ready to take it over. They then claimed that there was a problem with the MSF-Belgium mandate and that they were obligated to open a pediatric hospital somewhere else—there was an official imperative from MSF headquarters in Europe. Although neither excuse was accurate, two key truths come to the fore: the Liberian government had very little authority over MSF-Belgium’s decision to withdraw from Redemption Hospital, and it lacked the institutional legitimacy to constrain Redemption’s workforce (which was technically under the MOHSW’s authority). In the case of Redemption, several themes concerning the sovereignty of humanitarian medical organizations come to light. First, we observe that medical humanitarian organizations are highly dependent upon local populations’ (including local staffs’) willingness to subordinate themselves to MSF administrative procedures. In the absence of a general, voluntary acceptance of humanitarian rules and policies, the ongoing presence of the organization becomes either absurd or untenable. Far from being ‘‘sovereign,’’ the MSF administrative apparatus is entirely dependent upon and vulnerable to local adherence, acceptance, and will. While the actions of the Redemption Hospital staff may now be morally sanctioned in public opinion, the environment of cooperation surrounding MSF and the apparent financial incentives to ‘‘go along to get along’’ were relatively powerless in the face of hostile local resistance. Second, we see that, unlike the conditions of negotiation with the MOHSW that shaped MSF-Belgium’s mandate to take over and manage Redemption Hospital, MSF-Belgium was able to make a completely independent internal assessment of the situation at Redemption Hospital and choose to depart with relatively few consequences. In order to stay in Liberia, they had to identify another, face-saving mandate for delivering healthcare, but in an institutionally devastated environment like postwar Liberia, this would not have been difficult to do. MSF’s decision to leave Redemption was entirely a matter of internal, sovereign self-determination, and not the money invested, the legal mandate, the MOHSW’s inability to assume

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effective authority, the impact of their departure on the health conditions among the local adult population, or any other factor had the power to sway that decision.

Foya Hospital The freedom to leave was a fundamental condition of engagement for all medical humanitarian institutions in Liberia, not just for MSF-Belgium in the case of Redemption Hospital. To consider further the meaning and effects of humanitarian departure, I’d like to turn to 2006, when rumors circulated across Liberia that MSF-France would soon be closing its hospitals. The rumors turned out to be true, and the pending departure of MSFFrance aroused intense anxiety. Many Liberians feared that MSF-France’s departure, and the closure or scaling back of its hospitals and clinics, meant a widespread health tragedy for a Liberian population that had come to depend on MSF’s delivery of healthcare—especially in some of the regions most destroyed by the conflict. In 2007, Lofa County’s Foya Town was a large, pretty, quiet area with rolling hills and verdant forests. That same year, MSF-France closed Foya Hospital after several years of operation. The region, near the Sierra Leonean and Guinean borders, had been devastated during the war, but it had received generous postwar reconstruction support from humanitarian NGOs in the aftermath. When MSF-France closed the doors of Foya Hospital, they explained that the country was no longer at war and that MSF’s mandate did not extend to peacetime healthcare. Local officials said that they understood. The mayor and his advisors explained to me that ‘‘MSF works in emergency situations. Now that Liberia is calm, they were tired, their mandate has expired.’’ Liberian perceptions of MSF’s departure were particularly important at this moment because, in an environment of tentative political and military stabilization, the presence of medical humanitarian hospitals created an important subjective space for the creation of a sense of ‘‘health security.’’ Liberians across the country were convinced that if there was a medical emergency like a problematic birth, a swollen and painful abdomen, a bullet wound or a machete cut, or a sick baby, and one could get to an NGO hospital, there was a good possibility that someone could do something for

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you. The drugs, materiel, and skilled labor were there, and the hospitals had the institutional support to effectively deliver emergency and preventive care. MSF called their departure a ‘‘handover’’ to the MOHSW, but it was experienced as a hospital closure. The gates closed, most instrumentation was removed, and healthcare services were no longer provided. Residents were fearful of increasing medical scarcity. Many Liberians doubted the state’s ability to provide medical and public health services without humanitarian support, and state-sponsored medicine had few equivalent alternatives in the private medical sector. In every conversation I had and in every interview I conducted on the subject with Liberians and expatriates alike, they voiced real doubts about the nascent Liberian state’s ability to deliver the main elements of a state health bureaucracy: the complex salaries, logistics, infrastructure, communications, and material resources that were required to provide emergency and preventive treatment to hundreds of thousands of Liberians. To compel MSF-France to return, the Foya community engaged in a remarkable act of good citizenship in a cash-poor time. They pooled some funds and purchased more than thirty brand-new foam mattresses for MSF beds, hoping that it would demonstrate gratitude and compel MSF to return. Meanwhile, the burden of healthcare for the region fell to an outpatient clinic called the PMU InterLife Clinic,2 which had historically served the local population as a missionary institution for decades and provided basic primary care, maternity services, and public health education. According to data from the PMU InterLife Clinic and the reports of local community members, the closure of the MSF-France hospitals in Foya and in Kolahun led to a decline in health across the region and an increase in demand for scarce medical resources. The PMU InterLife Clinic was overwhelmed with patients. Its patient load doubled, and staff members told me that the rate of deaths due to malaria, dysentery, fevers, and complicated deliveries they observed within the clinic had increased substantially since the closure of MSF’s hospital. In a kind of ‘‘emic epidemiology,’’ town residents tracked deaths by observing families walking to the clinic with living people and leaving with the dead. Dr. Howard, the Liberian physician running PMU, noted that mortality had increased by a factor of five. The problem of Foya Hospital was talked about across the region as a clear health crisis. MSF’s decision in Foya points us to one form of humanitarian sovereignty: medical humanitarian organizations’ freedom, or right of selfdetermination, to make a decision without regard for the medical or public

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health consequences of their departure (or, so it appeared to the MOHSW, the PMU InterLife Clinic, and the local population). MSF-France, which has its own distinctive profile for certain hard-line stances even within the MSF community, was able to make the sovereign self-determination to depart Liberia, irrespective of local sentiment, local health needs, or epidemiological consequences. Their decision was made based on political events. The conflict had ended, elections had successfully been held, and there was a government in place. Thus there was no longer a mandate to continue to provide healthcare.

Sanniquellie Hospital Let us turn to the story of MSF-France’s withdrawal from Sanniquellie Hospital, in Nimba County, in the northeast region of Liberia. This case highlights both the macroeconomic significance of MSF’s presence and withdrawal for the postconflict Liberian economy and the microeconomic considerations that medical humanitarian NGOs’ national employees make in the aftermath of departure. Sanniquellie Hospital is situated in a town that was at the heart of rebel operations in Nimba County. On my arrival in the hilly, isolated city, a student protest was underway and the atmosphere was grim. In 2007, as today, student protests still had substantial potential for violence. The sign pointing to the hospital had the words ‘‘Me´decins Sans Frontie`res’’ scratched off. The hospital itself was a rambling, yellow, colonial-style structure with more than sixty staff. All had worked for MSF until April 1, 2007, when MSF-France transferred the hospital to the MOHSW. In the aftermath of the Liberian conflict, the Liberian population was returning to homes and communities decimated by neglect and warfare, or it was resettling in new urban centers. Many things can and have been said about the conditions facing the postwar Liberian population, but one truth was paramount. Cash was scarce, and money was needed to rebuild homes and businesses, buy clothes and food, and pay school and occupational training fees. With the economic sectors most able to yield cash returns (rubber, iron, diamonds, gold, cocoa, and coffee) shut down for regulatory restructuring,3 humanitarian NGOs were the single best source of cash income in the postwar Liberian economy.

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Table 7.1. MSF Expenditures in Liberia, National Staff Expenditures (2004–2011)

Year

Program expenditures (in 1,000 Euro)

National staff expenditures (in 1,000 Euro)

Liberian GNI (in 1,000 Euro)1

MSF national staff expenditures as % of total Liberian GNI

2004 2005 2006 2007 2008 2009 2010 2011

13,513 13,608 14,746 10,069 7,634 6,700 4,137 3,178

4,445 5,168 5,599 2,313 3,058 3,143 2,010 607

302,50 357,342 420,835 491,731 557,635 628,330 684,621 782,062

44.5 3.8 3.5 2.0 1.3 1.1 0.6 0.4

Source: World Bank Data Bank; MSF International Financial Reports 2004–2011. 1. Converted from USD at constant 2,000 exchange rate.

Table 7.1 demonstrates a correlation between diminishing MSF program expenditures and a decrease in Liberia’s overall Gross National Income (GNI), suggesting a possible interpretation of medical humanitarian expenditures as an example of ‘‘custodial sovereignty.’’ Through salaries, infrastructure reconstruction, and medical, transportation, and technological imports, medical humanitarian NGOs functioned as a kind of Keynesian economic stimulus in the postwar Liberian economy. As the largest site for effecting direct financial transfers from ‘‘First World’’ to ‘‘Third World’’ populations, humanitarian organizations were an outsized employer in the Liberian market, and medical humanitarian NGOs were prominent among these employers. Working from publicly available World Bank data and MSF’s International Financial Reports, Table 7.1 demonstrates that early in the postconflict recovery period, MSF’s net program expenditures alone were equal to nearly 5 percent of Liberia’s total GNI, with national employee salary expenditures comprising 33–37 percent of total program expenditures. In 2007, After MSF-France’s withdrawal from Liberia, this proportion fell to 25 percent, and overall MSF program expenditures fell by one-third, giving an indication of the macroeconomic force of MSF-France’s presence, and its withdrawal, in the postconflict Liberian context. These numbers are sobering and are generally ignored in debates over humanitarian impact in postconflict environments. While attention paid to humanitarian institutions often focuses on efficacy, policy, ethics, and

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neutrality, the availability of capital through the employment of the local labor force constitutes one of the biggest but least noticed effects of humanitarian aid in postconflict contexts like Liberia. Humanitarian organizations constitute important sources of direct cash transfers that create liquidity in cash-poor contexts. In turn, the creation of vast pools of individually distributed incomes, at scale, constitutes a medical humanitarian labor economy that often enables the emergence of regional and national middle classes (a key economic force in postwar stabilization). Furthermore, humanitarian labor economies help structure relations of dependence and reciprocity, professional aspiration and administrative redistribution, and even human mobility in major ways. Ethnographic observations of humanitarian withdrawal make these economic forces powerfully evident, especially the cumulative impact of NGO closures, transitions, and cutbacks. To return to Sanniquellie: In a technolegal twist of humanitarian-state cooperation, the MOHSW refused to allow MSF-France and other medical humanitarian NGOs to formally ‘‘hire’’ Liberian medical workers. Instead, international medical NGOs were authorized to pay their staff ‘‘incentives’’ to ‘‘volunteer’’ their labor at a rate of approximately $170–200 per month. This salary was considered to be excellent, and it afforded a middle-class salary that allowed Liberian staff the ability to sustain a rural middle-class lifestyle. Through incentives, MSF-France was urged to avoid giving the appearance of distributing salaries so as to avoid the impression that the MOHSW would hire MSF-France’s several hundred workers, or match their salaries, after MSF-France departed. Consequently, of MSF-France’s several hundred Liberian personnel, just a few dozen were also on the MOHSW’s employee register. (Many of MSF’s Liberian staff in Sanniquellie started working for MSF as refugees in neighboring countries or had followed MSF to the hospital in Sanniquellie from MSF clinics in other regions of Liberia.) Government salaries, when they did arrive, came to about $20–30 per month, or enough for two sacks of rice. MSF-France departed Sanniquellie for the same reason it had left Foya: according to its mandate, MSF-France was a humanitarian organization and had no role in providing medical services in a peacetime society. In MSF-France’s view, it was the Liberian government’s responsibility to manage the population’s health. However, the Sanniquellie Hospital was one of the only medical outlets in the region, and the MOHSW was clearly unable to support it. So, in the aftermath of MSF-France’s withdrawal, the International Rescue Committee (IRC), which had previously been involved in

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solely nonmedical activities like education, gender-based violence, and civil society initiatives, scrambled to obtain an emergency grant of US$1.9 million to take over the hospital and keep it afloat for about six months. In the gap period between MSF withdrawal and the IRC’s takeover, the Liberian staff at Sanniquellie Hospital continued to show up to work every day, despite early signs of the scarcity that could result in hospital mismanagement. Salaries were not paid. Gas vouchers to fuel generators were promised but never arrived. The hospital ambulance was out of commission, and there were no resources to repair it. But the staff remained hopeful. Representatives of IRC had paid a visit a month earlier and had asked all staff interested in staying on to sign their name on a list. The Clinton Foundation, working on HIV/AIDS projects, continued to have a presence in the hospital. Pharmaceutical supplies were available, but their supply was somewhat disrupted. But for Sanniquellie’s Liberian staff, the routine process of showing up at work, doing their jobs, treating patients, managing files, and maintaining infrastructure created a kind of environment of self-affirmation that reassured hospital staff that the bureaucratic stability they had lost would soon be reinstituted. In the absence of administration or effective regulation from MSF, hospital staff worried about meeting the legal requirements to have the lights on in certain wards a certain number of hours per day, keeping the ambulance service working, sustaining pharmaceutical supplies, and ensuring that their colleagues were punctual, responsible, and effective. The hospital staff set for themselves a strict expectation that they would continue to live up to MSF standards and that they would not fall into medical and administrative ineptitude as had happened at Redemption Hospital. In the interim period, the Liberian hospital staff was forced to ask critical questions about the implications of MSF-France’s disappearance for their futures. In my interviews with Sanniquellie medical staff, many insinuated that there was a pervasive crisis of confidence, and they asked me, and each other, what opportunities lay ahead if IRC’s bid for funding failed. With their livelihoods in question, staff members had essentially four options: none perfect, all tenable. The first option was to relearn how to work within state-sponsored healthcare systems. This would require refamiliarizing themselves with the need to jockey for politically motivated government appointments, work with shortages of goods, equipment, salary, and medicines, and revive other entrepreneurial activities (see Wendland

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2010). Some staff found this option to be viable but inconsistent with their MSF professionalism. Second, Sanniquellie staff could leave Sanniquellie Hospital and use their MSF credentials to find work at another humanitarian NGO. This would allow them to continue to provide high-quality healthcare services, gain professional experience, and enjoy some continuity in salary—but it would almost certainly require physical relocation. They might also have to abandon medicine and take up some other form of humanitarian programming. A third option was to enter the private healthcare market. This option was both feasible and financially lucrative, but it had substantial challenges. As private nurses or medical practitioners, Sanniquellie’s Liberian staff would have no access to laboratories, surgeries, X-rays, or diagnostic materials, and they would be forced to procure medications from local markets, where drug quality was inconsistent. (Research conducted in 2009, 2011, and 2012 found that more than 60 percent of medications available on the Liberian black market were counterfeit.) The fourth option for Sanniquellie staff was to pursue new careers or migrate to another country, a common route taken by African medical professionals (see Johnson 2005). Fortunately, soon after my research, IRC did obtain emergency funding to take over the Sanniquellie Hospital. But one must ask, what was the meaning or value of MSF-France’s departure in a context in which another humanitarian NGO, and international donors, had to step in to fill the gap so as to avoid the creation of a new healthcare crisis in a fragile state? Moreover, why are the macroeconomic and microeconomic consequences of NGO withdrawal not evaluated routinely in NGOs’ decisions to depart? While every NGO has its own distinctive process for making determinations about entry and departure, it seems clear that NGOs are not bound to the needs of the population, to the capacities of the state, or to the burdens imposed upon the international community in making their decision to leave.

Conclusion Much has been said how NGOs adhere to different philosophies, missions, and scopes of care in the development literature. For MSF, this concern emerged most often with the statement, ‘‘MSF is focused on emergencies, and not on development.’’ Often this fact alone is used to justify, and even

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support, MSF’s decisions to depart tenuous situations, and a critique of this precept is characterized as unfair (see Abramowitz 2014a). But according to the literature on MSF (Magone, Neuman, and Weissman 2011, Redfield 2013, Ticktin 2011) and interviews and email communications with expatriates from MSF-France, MSF-Belgium, MSF-Spain, and MSF-Switzerland, as well as senior Liberian MSF staff, MSF workers contest decisions as to whether or not to depart Liberia and often feel that these decisions are subordinated to a broader set of internal political and ethical arguments. One MSF manager noted that ‘‘as an organization, if you are overstretched in your resources, you have to make choices. Either leave so you can go to the next one [conflict], or stay in postconflict. We agreed to leave . . . it’s at the right time. . . . We will come back if there are epidemics or conflict, but I don’t want it to happen. I don’t want to think about it. I think they have suffered enough.‘‘ But a senior official in MSF-France acknowledged that ‘‘MSF-France operational policy was particularly dogmatic in the years 2005–2008, with a focus on ‘victims of violence,’ which led to a lot of aberrations.’’ Many people involved with MSF were pessimistic about the Liberian state’s ability to assume responsibility, or effective health sovereignty, for the healthcare of Liberians, but they felt that this must be done so as to prevent an ongoing situation of dependency upon humanitarian NGOs and global donor institutions. MSF felt that Liberia had to assume empirical sovereignty for the care of its population if it was ever going to succeed as a state. Although throughout their tenure in Liberia the various MSF branches had explicitly avoided coordination with the UN Mission in Liberia and the Liberian state, the state played a large role in MSF’s vision for Liberia’s medical future and was a crucial determinant in its decision to leave. Liberia was a sovereign nation and needed to be treated as such by international institutions. Paying lip service to national sovereignty, while failing to foist national responsibilities onto the state, was regarded as a lesser disservice to Liberia than imposing self-rule (and its public health and economic consequences) upon the postwar Liberian population. Given ‘‘objective’’ historical indicators of peacetime stabilization, MSF-France, as an institution, felt that its decision to withdraw was both principled and ethical, but also morally compromised. In Liberia, the arrival of medical humanitarian institutions is a social fact that can be consciously engaged, negotiated, challenged, and even rejected, most unlike the disciplines and the discourses that constitute the

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foundations of Foucault’s ‘‘right to rule’’ (Foucault 1980, Foucault, Senellart, and Ewald 2009). These institutions’ tenure is short, authority is limited and contentious, and the structuration of the humanitarian sphere is premised upon a radical kind of cultural materialism that shapes human interaction in a much more transactional way than we currently allow for. Even so, MSF’s decision was fraught with moral uncertainty and ethical ambiguity. MSF expatriates would have known that health conditions were likely to deteriorate in Foya, that the Liberian government would be unable to step in in Sanniquellie, and that their substantial investment in Redemption Hospital would be lost. Although many MSF expatriates might not have understood the macroeconomic implications of their departure, they might have been aware of their Liberian colleagues’ uncertain futures in life after MSF. While ignoring these concerns challenges MSF’s ethic of te´moinage (Redfield 2008), MSF staff knew that if the state failed (as was expected), other international organizations were likely to step in to prevent emergent medical humanitarian crises. Healthcare delivery is intensely connected to people’s understandings of their own security in the everyday, and consequently, it is, above all, political. So were MSF’s decision to depart and other institutions’ decisions to intervene. MSF-France made a political statement about medical sovereignty by choosing to leave, but the institutions that assumed authority in its absence, like PMU InterLife and IRC, made alternative political decisions about postconflict securitization and the international responsibility to engage in custodial sovereignty as part of the global ‘‘responsibility to protect’’ vulnerable populations. Finally, it is important to reconsider the nature of sovereignty with regard to humanitarian institutions themselves. The cases outlined here challenge the utility of Pandolfi’s concept of ‘‘migrant sovereignty’’ for medical humanitarian organizations, especially in the context of understanding their withdrawal. One point at which medical humanitarian organizations exert authentic sovereignty, in the sense of radical selfdetermination without regard for external or local considerations, is in the process of humanitarian withdrawal. The withdrawal of MSF-France from Liberia and of MSF-Belgium from Redemption Hospital both indicate that the moments when humanitarian organizations have the most right—to turn a blind eye to local staff and beneficiary will, to local health concerns, to the resulting epidemiologic burden of MSF’s departure, and to the economic implications of their institutional presence—were also the moments when they have the least rule—when they choose to withdraw.

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Notes 1. Scholtz introduced the concept of custodial sovereignty to discuss the reconciliation of national sovereignty and global environmental and biodiversity challenges, but here I extend the term to include the humanitarian ‘‘right to rule’’ in the context of global and regional health crises. 2. According to the Georgetown University Berkeley Center for Religion, Peace, and World Affairs: ‘‘Founded in 1965, PMU InterLife is the humanitarian and economic development arm of the Pentecostal Alliance of Independent Churches and its international wing, the Swedish Pentecostal Mission. Education and health care are key areas of work, and today PMU InterLife and its partners work in 61 countries. PMU InterLife receives most of its funding from the Swedish International Development Cooperation Agency (SIDA) and the European Commission’s Humanitarian Aid Department (ECHO); it recently developed a project manual to help churches and local partners better align their project management practices with SIDA and ECHO guidelines’’ (http://berkleycenter.georgetown.edu/organizations/pmu-interlife, accessed February 1, 2015). 3. Most of these sectors were shut down for regulatory restructuring because of the role that export commodities played in financing the Liberian and Sierra Leonean conflicts or because (as in the case of rubber and mining) they required physical rehabilitation.

References Abramowitz, Sharon. (2014a) ‘‘Medicine, Money, and Community: A Study of Humanitarian Agency in Liberia’s Health Sector Transition.’’ Unpublished paper. ———. (2014b) Searching for Normal in the Wake of the Liberian War. Philadelphia: University of Pennsylvania Press. Barnett, Michael. (1995) ‘‘The New United Nations Politics of Peace: From Juridical Sovereignty to Empirical Sovereignty.’’ Global Governance 1: 79–97. Biehl, Joa˜o Guilherme. (2005) Vita: Life in a Zone of Social Abandonment. Berkeley: University of California Press. Calain, Philippe. (2007) ‘‘From the Field Side of the Binoculars: A Different View on Global Public Health Surveillance.’’ Health Policy and Planning 22 (1): 13–20. Calhoun, Craig. (2010) ‘‘The Idea of Emergency: Humanitarian Action and Global (Dis)order.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 29–58. New York: Zone Books. Chen, Lincoln C., Tim G. Evans, and Richard A. Cash. (1999) ‘‘Health as a Global Public Good.’’ In Global Public Goods, edited by Inge Kaul, Isabelle Grunberg, and Marc Stern, 284–304. New York: Oxford University Press. Crombe´, X. and J.-H. Je´ze´quel. (2009) A Not-So-Natural Disaster: Niger 2005. New York: Columbia University Press.

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Fassin, Didier and Mariella Pandolfi. (2010) Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions. New York: Zone Books. Foucault, Michel. (1980) Power/Knowledge: Selected Interviews and Other Writings, 1972–1977. New York: Random House. Foucault, Michel, Michel Senellart, and Franc¸ois Ewald, eds. (2009) Security, Territory, Population: Lectures at the Colle`ge de France, 1977–1978. Vol. 4. New York: Macmillan. Johnson, James. (2005) ‘‘Stopping Africa’s Medical Brain Drain.’’ BMJ 331 (7507): 2–3. Kickbusch, Ilona and Evelyne de Leeuw. (1999) ‘‘Global Public Health: Revisiting Healthy Public Policy at the Global Level.’’ Health Promotion International 14 (4): 285–288. Magone, Claire, Michael Neuman, and Fabrice Weissman. (2011) Humanitarian Negotiations Revealed: The MSF Experience. New York: Columbia University Press. Me´decins Sans Frontie`res. (2004–2011) International Financial Reports. http://www .msf.org/international-financial-reports. Accessed December 16, 2014. Pandolfi, Mariella. (2003) ‘‘Contract of Mutual (In)difference: Governance and the Humanitarian Apparatus in Contemporary Albania and Kosovo.’’ Indiana Journal of Global Legal Studies 10 (1): 369–381. Redfield, Peter. (2005) ‘‘Doctors, Borders, and Life in Crisis.’’ Cultural Anthropology 20 (3): 328–361. ———. (2006) ‘‘A Less Modest Witness.’’ American Ethnologist 33 (1): 3–26. ———. (2008) ‘‘Doctors, Borders, and Life in Crisis.’’ Cultural Anthropology 20 (3): 328–361. ———. (2013) Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Scholtz, Werner. ‘‘Custodial Sovereignty: Reconciling Sovereignty and Global Environmental Challenges Among the Vestiges of Colonialism.’’ Netherlands International Law Review 55 (3): 323–341. Ticktin, Miriam I. (2011) Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press. Wendland, Claire L. (2010) A Heart for the Work: Journeys Through an African Medical School. Chicago: University of Chicago Press. ———. (2012) ‘‘Moral Maps and Medical Imaginaries: Clinical Tourism at Malawi’s College of Medicine.’’ American Anthropologist 114 (1): 108–122. World Bank Data Bank. http://data.worldbank.org/indicator/NY.GNP.MKTP.PP.CD. Accessed February 1, 2015.

Chapter 8

Humanitarianism and ‘‘Mobile Sovereignty’’ in Strong State Settings: Reflections on Medical Humanitarianism in Aceh, Indonesia Byron J. Good, Jesse Hession Grayman, and Mary-Jo DelVecchio Good

The Indian Ocean Tsunami and the Humanitarian Response Taufik recalled that just days after the Indian Ocean earthquake and tsunami of December 26, 2004, the very first foreign aid to arrive on the devastated shores of Meulaboh, a provincial town midway down the west coast of Indonesia’s Aceh province, was from the U.S. Navy. Taufik said he was fearful upon their arrival at first. The Navy’s awesome ships could land on the beach. Enormous jeeps came out of the ship’s hull, driven by imposing sailors redeployed from Iraq and stacked with boxes filled with unknown contents. ‘‘Grenades,’’ Taufik thought. One of the sailors, Wilson, asked Taufik to be the guide for his jeep, and he readily agreed once he saw the boxes were full of bottled water and other emergency aid supplies. Despite his initial apprehension, Taufik spent four intense and rewarding days with Wilson and three other American sailors on that jeep, taking them to every makeshift camp of tsunami survivors he could find. Among the other sailors was Jack, who routinely went into inexplicable fits of rage, throwing water bottles and food packages to the ground. ‘‘Don’t worry,’’ Wilson assured Taufik, ‘‘it’s trauma from Iraq,’’ which Taufik translated easily enough for anyone who witnessed Jack’s disturbing behavior. The

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word ‘‘trauma’’ had long been absorbed into the vocabulary of Acehnese,1 who had been living under martial law since May 2003 while Indonesian security forces carried out a massive counterinsurgency campaign against Aceh’s separatist rebels in the Free Aceh Movement (Gerakan Aceh Merdeka [GAM]), a protracted conflict that was launched in 1976 and intensified in the late 1980s. According to Taufik, tsunami survivors gratefully accepting American aid afforded Jack’s ‘‘trauma’’ symptoms a wide measure of tolerance, implicitly recognizing scars of war they lived with every day in Aceh. The unlikely presence of American military forces on Indonesian soil during the earliest days of the tsunami emergency and the imposing sight of navy aircraft carriers, destroyers, cruisers, and other American ships of war anchored in Indonesian territorial waters along Aceh’s west coast were powerful images for survivors and humanitarians who witnessed them, as well as for the Indonesian nation. The ships were dispatched under the banner of Operation Unified Assistance, the largest humanitarian assistance and disaster relief mission ever undertaken by U.S. armed forces, featuring a ‘‘Team of Teams’’ approach that coordinated assistance from thirty-three sovereign military forces, the United Nations, and several international nongovernmental organizations (NGOs) during the tsunami emergency period (McCartney 2006). Near the next major town of Calang heading northwest up Aceh’s coast, an Acehnese Indonesian Ph.D. student named Saiful Mahdi, who returned home from the United States to look for family members and stayed on to assist during the emergency, described a scene that captures how both civilian humanitarians and aid recipients viewed and compared American and Indonesian forces. When I got to Calang via a helicopter owned by an international NGO, I saw right away that the [Indonesian] marines were the ‘‘owners’’ of Calang and a large portion of the west coast . . . the IDPs [internally displaced persons] live in the hilly region around Calang. . . . [The IDPs] stated that they were afraid to get too close to the marines . . . they were free to receive humanitarian aid only if foreign troops were present. I myself saw how refugees swarmed down from the hills to the Calang coast to get the aid they needed when the United States Navy unloaded it from the USS McHenry in hovercrafts. They were busy choosing clothes, food, and drink, which they were free to take as they liked. . . . But as soon as the foreign troops left, the IDPs immediately went back to their camps. (Mahdi 2005)

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The Indian Ocean earthquake and the resulting tsunami have been described as Indonesia’s ‘‘first democratic natural catastrophe’’ (Siegel 2005). Whereas most disasters in Indonesia (flash floods, volcano eruptions) disproportionately affect the poor, the tsunami killed more than 180,000 people in Aceh and displaced an additional 500,000 persons along hundreds of kilometers of Aceh’s coasts in minutes, making no distinction between Acehnese villagers or members of the military stationed on the coast (approximately 25,000 of whom were killed), between rich and poor, farmer and professional. It laid waste to whole villages and towns, to complete sections of the capital, Banda Aceh, to all transport, and to all basic infrastructure. Despite these heavy losses, reports by Mahdi and others confirm that Indonesian security forces quickly regrouped and secured their urban landscapes, even the flattened Calang plain. Taking place in a setting of protracted violence, the tsunami emergency in Aceh did not just suspend the normal; it transformed and intensified Aceh’s ongoing state of emergency from a neglected chronic crisis into an acute humanitarian imperative, introducing a wide range of national and global humanitarian actors who over time had to negotiate and accommodate to the policies and bureaucratic procedures of a rapidly reconstituting Indonesian state. The scope of the humanitarian response was unprecedented. By the end of February 2005, just two months after the tsunami, the UN’s Humanitarian Information Center in Banda Aceh listed 320 organizations working in Aceh (Hedman 2008). With the signing of a peace agreement between the government of Indonesia and GAM in Helsinki on August 15, 2005, just eight months after the tsunami, the role of national and international agencies and humanitarian groups was dramatically increased in scope. Whereas the tsunami relief focused on the coastal communities, the peace process focused on communities up in the hills of Aceh, where the violence had been most intense. While the peace process extended the humanitarian presence, it also initiated a reconsolidation of the Indonesian state. The peace agreement represented a formal renunciation of GAM claims to the independence of Aceh; it began a process of redefining Aceh’s place as a province with a ‘‘special’’ status in the Indonesian state structure. It reintegrated former militants into the Indonesian political process and initiated a period of new investments in the Acehnese bureaucracy and infrastructure as well as the private sector. It was in this context that the humanitarian process unfolded, with the

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initial crisis response giving way to more basic development processes over a five-year period.

Humanitarianism in Strong State Settings In this chapter, we draw on our experience working in Aceh to explore the claim that humanitarian interventions work quite differently in strong state and weak state settings and that many of the assumptions that underlie both the prevailing modes of humanitarian governance and the critical analyses of those modes assume that such interventions are taking place in settings with weak or nearly nonfunctioning state institutions. Our reflections are based on five years of working with humanitarian organizations, primarily as scientific consultants (BG and MJDG) and research staff (JHG) for the International Organization for Migration (IOM) in post-tsunami and postconflict Aceh. From 2005 through 2010, we were deeply engaged in postconflict mental health programs in Aceh, where we worked actively with IOM and host government institutions to guide the development of a major set of psychosocial needs assessments and subsequent mental health interventions. For two of us (BG and MJDG), this engagement grew out of nearly a decade of research in Indonesia’s health sector before the tsunami and continues a decade after the tsunami with mental health projects in Aceh and in Yogyakarta. The deceptively simple claim that humanitarian organizations function quite differently in ‘‘weak’’ and ‘‘strong’’ state settings is relevant to a number of recent critical debates about the changing role of humanitarian agencies and, in particular, about the legitimacy of a growing focus on trauma, psychosocial interventions, and the development of mental health services within humanitarian work.2 In a series of essays, Vanessa Pupavac, Mark Duffield, and Derek Summerfield have developed a broad set of arguments about contemporary humanitarianism as embedded in a network of economic development theories and policies that view violence as emerging in settings of poverty, weak states, and underdevelopment and as requiring liberal development aid and the reconstruction of societies as its remedy.3 Duffield focused critical analysis on the emergence of aid in the post-Cold War era as a ‘‘tool of global liberal governance’’ and a ‘‘moral justification for intervention’’ (Duffield 2002: 1049, cf. Duffield 2009). Pupavac (2001: 358, cf. Pupavac 2002, 2012) linked these arguments to the claim that

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‘‘psycho-social interventions’’ serve to promote a ‘‘new form of international therapeutic governance.’’ Pupavac (2001) and Summerfield (2004, cf. Summerfield 1999) took up anthropological criticisms of the use of ‘‘trauma’’ and posttraumatic stress disorder (PTSD) as means of medicalization and professionalization of suffering in settings of violence and suggested that claims of widespread trauma are used to pathologize whole populations and justify interventions aimed, in some cases, at the wholesale remaking of societies. In a related set of anthropological essays, Mariella Pandolfi (2003, 2008) has drawn on the writings of Italian philosopher Giorgio Agamben to describe the history of the emergence of global humanitarian agencies as constituting a form of ‘‘mobile sovereignty.’’ With the linking of human rights discourses with more classic humanist framing of humanitarian work, the claims of the ‘‘right of interference’’ and the ‘‘responsibility to protect’’ came increasingly to shape humanitarian interventions, constituting a ‘‘gray zone’’ linking the humanitarian and the military. ‘‘Complex emergencies’’ open a space described by Agamben as ‘‘states of exception,’’ a space increasingly filled by transnational agencies. As Pandolfi has written, ‘‘Developing Arjun Appadurai’s notions of mobility, deterritorialization, and sovereignty (1996), we can define these transnational formations as mobile sovereignties. Developed by specific ‘epistemic communities,’ these mobile sovereignties seek to link transnational forms of domination to local political practices’’ (2008: 163). She developed these ideas in analyzing her ethnographic research in Albania, Kosovo, and Bosnia, settings in which joint military operations and the humanitarian industry combined to create what she described as a ‘‘laboratory of intervention.’’ Both of these formulations are critical for anthropologists engaged in medical humanitarian work as participants, researchers, or critics. The question of the relevance of forms of trauma treatment developed in North American clinical settings to managing mental health problems related to violence against whole communities in Africa or Asia is extremely important. However, Pupavac, Duffield, and Summerfield developed their arguments by focusing primarily on critical readings of development policies rather than studies from the field. Pupavac (2001:258), for example, argued that psychosocial interventions jeopardize local ‘‘coping strategies’’ but provided no data to support this claim. Here we suggest that these arguments be turned into a set of researchable questions. How are ‘‘psychosocial interventions’’ or trauma treatments actually deployed by humanitarian

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agencies in diverse settings? Can they actually be implemented on a wide enough scale to be relevant to public health needs? Are they feasible and effective, and if so what accounts for their effects? What actually constitutes ‘‘mobile sovereignty’’ of nonstate organizations such as international humanitarian organizations? How indeed are ‘‘transnational forms of domination’’ linked to ‘‘local political processes’’ (Pandolfi 2008: 163)? In this chapter, we advance the idea that many of the arguments about ‘‘therapeutic governance’’ or ‘‘mobile sovereignty’’ grow out of the work of humanitarian and aid agencies in weak state settings, where issues of sovereignty are highly contested, state agencies are ineffective or weak, and humanitarian organizations become proxies for states. We argue that in reality, the sovereignty of humanitarian organizations and the whole complex of humanitarian interventions are enormously varied across settings in which they operate, that such sovereignty operates differently over time, and that issues of therapeutic governance and the sovereignty of transnational organizations are very different in strong state and weak state settings. It is not our goal in this chapter to provide a full narrative account of our work with IOM in Aceh. We have argued elsewhere that engagement provides a particular vantage for ethnographic observation, that ‘‘intervention’’ may serve as a ‘‘mode of inquiry’’ (Good 2012: 527). It is from that vantage that we reflect on some characteristics of medical humanitarianism in Aceh.

Medical Humanitarianism in Post-Tsunami Aceh We arrived in Banda Aceh, capital of the province, in June 2005, six months after the tsunami, to begin consulting with IOM about the development of a strategic plan to provide mental health services for those affected by the disaster. Although much of the city was utterly devastated, the Indonesian security apparatus was evident in full force. The counterinsurgency forces were not engaging in open military operations, but martial law, dating back to 2003, was still in place, and the conflict was ongoing. All newcomers had to bring complete documents and register with the police. All intergovernmental organizations were operating under the highest security status, although there was little sense of threat by GAM forces as claimed by Indonesian security forces. Any travel outside of the capital had to be authorized

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by both IOM and the Indonesian authorities, requiring convoys and routine radio contact. At the same time, the proliferation of humanitarian organizations meant that any real coordination or control of their activities was impossible. Many of these activities were undertaken in a way that resonated far more with Pandolfi’s account of ‘‘mobile sovereignty’’ than Pupavac’s ‘‘therapeutic governance.’’ We recall well our first trip down Aceh’s decimated west coast by motor caravan. The trip required five hours to travel fewer than one hundred kilometers from the provincial capital of Banda Aceh to the little town of Lamno. The sea had claimed part of the road, and much of it was totally destroyed. We drove over the cement slabs of what had been village houses, saw tent villages where survivors lived, and passed by some of the initial barracks meant to house displaced persons until new communities were built. In Lamno, we visited a local primary care clinic under the temporary management of a well-known international medical NGO. This organization trained eight nurses and psychologists from outside the clinic (i.e., who were not civil servants) to work as ‘‘primary care mental health specialists,’’ teaching them how to diagnose mental illnesses and prescribe medication and how to manage emergencies locally rather than refer patients to the psychiatric hospital in Banda Aceh. There was no commitment from the Ministry of Health to hire these newly trained staff, although leaders of the program suggested vaguely that they believed they would be hired, and it remained unclear where and how the staff would continue their work when the organization stopped paying their salaries. More than this, nurses, psychologists, and paramedics are expressly forbidden by Indonesian law to make diagnoses and provide medications—to practice medicine. While the program was in part a response to emergency needs, the program manager we met in Lamno and his supervisor in Banda Aceh expressed disdain for Indonesian mental health professionals and a particular hostility toward the services provided at the psychiatric hospital in Banda Aceh. In this program and in others we observed, medications that are not part of the national formulary for essential drugs in primary care were used to treat persons in community-based mental health programs. This was our initial introduction to the ways in which the structuring of international humanitarian activities in post-tsunami Aceh depended upon a suspension of legal norms and bureaucratic procedures. Some of the early activities, such as Operation Unified Assistance or efforts to

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reopen hospitals flooded by the tsunami, were genuinely based on the exigencies of acute emergencies. But the suspension of Indonesian legal norms became apparent over time in other, less urgent ways. Healthcare workers from around the world came to practice medicine and train local providers without any procedures to evaluate credentials or to ensure adherence to national regulations. While working more intensely in Aceh over the ensuing several years, we visited many psychosocial and mental health programs that were based solely upon the capabilities and imagination of particular organizations, as well as upon their ability to find funding. An extraordinarily diverse set of psychosocial programs for children and adolescents, for ‘‘trauma healing,’’ for group therapy, and for community-based ‘‘reconciliation’’ activities in villages were carried out in the tent villages, the barracks, and, after the peace agreement was signed, in the villages, largely outside of the mandate and control of the provincial health or social welfare offices. Organizations conducted countless training programs, paying health workers and other professionals to attend and participate. Many programs operated independently of the existing Indonesian healthcare system, bypassing the bureaucracy and its elaborate regulations. Eventually many of these programs would leave Aceh without serious evaluation or documentation of what they had done and without any sustainable handover to the government or local NGOs.

Inside the Humanitarian Organization We spent the next five years learning about the inner, administrative workings of the humanitarian world (see Grayman 2012 for a full analysis, cf. Good, Good, and Grayman 2010). The arcane procedures of writing applications and seeking support from donor agencies and of implementing projects, organizing evaluations, and writing project reports, as well as the knowledge and assumptions that made these activities possible, indeed creates a network of institutions that Pandolfi (2008: 163) labels ‘‘epistemic communities.’’ IOM does not belong to the United Nations. It was initially established in 1951 as the Intergovernmental Committee for European Migration to help resettle people displaced by World War II and to this day maintains its independence. It is an intergovernmental organization with 149 member states, plus 12 states holding observer status. Although IOM

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is independent, its headquarters are in Geneva, and its administrative structure and bureaucratic procedures largely mirror those of the UN agencies. It was precisely this larger epistemic community of international aid with which we became engaged. IOM proved to be massively bureaucratic, in many ways operating with a stereotypical self-image of humanitarian sovereignty, with complex rules that govern all aspects of program implementation and commitment of funds, including hiring consultants and developing subcontracts, employing workers, procuring goods and services to be used in programs, reporting and documenting outcomes, and interacting with donors, other humanitarian organizations, and government agencies. One of our projects, a small World Bank supplement to our mobile mental health team project, provided support for ‘‘livelihood’’ activities for a subset of persons identified with mental illnesses and treated by the outreach teams. The development of a ‘‘procurement plan’’ to buy thirty goats for a program in one village held up funding of the entire program for more than six months. (Procurement plans are designed to ensure transparent purchasing of goods and contracted services after a process of open and fair competition. It proved impossible to bypass this requirement for even such a small purchase.) IOM’s programs were profoundly donor driven, generating tremendous competition with other aid organizations and undercutting efforts to coordinate programs and services. Not long after the tsunami, the Provincial Health Office (Dinas Kesehatan Propinsi) organized weekly coordinating meetings of all humanitarian agencies carrying out health or psychosocial programs. Only a small subset of organizations—primarily the largest—sent representatives, and it quickly became clear that little real information about plans for new projects could be shared with agencies that were essentially competitors. The implementation of programs was also dependent upon the disbursement of funds from organizations such as the World Bank, the Asian Development Bank, and the aid agencies of donor nations; in Aceh, the largest donor nations were from Europe and North America, as well as Japan. As we wrote in an essay for Contemporary States of Emergency (Fassin and Pandolfi 2010), programs were organized according to ‘‘donor time’’ rather than timetables based on local needs or on reasonable assumptions about what is necessary to organize teams of local workers, keep them employed from one funded project to the next, and carry out meaningful activities (Good, Good, and Grayman 2010). For one of our major mental

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health outreach programs, described briefly later in the chapter, the World Bank publicly announced they would fund the program in June 2007. They allowed IOM to start the program in January 2008 using its own funds. World Bank funds for the program did not reach IOM until November. Medical staff for the program were in unpaid limbo for four to six months. When formal permission was given to IOM to start the program after months of waiting, old staff had to be rehired, new staff recruited, and project activities launched under extreme time constraints.

The Reconstitution of Strong State Sovereignty in Aceh, Indonesia On the day before our trip to Lamno in June 2005, Mr. Fahrul, a longtime civil servant at the Provincial Health Office, came to speak with us at the IOM office in Banda Aceh. The Provincial Health Office had recently put Fahrul in charge of mapping and coordinating the myriad psychosocial interventions currently working in tsunami recovery zones all across Aceh. Describing what we eventually discovered in Lamno, Fahrul detailed incoming reports of NGO activities in the mental health sector from across Aceh, noting that some government clinic workers and volunteers were receiving three, four, even five different trainings in mental health and trauma treatment by various organizations. He said all NGOs working on mental health issues needed to report to him so that he could calculate how many patients were receiving treatment, how many were referred to district and provincial hospitals, what counseling methods were being used, and how effective they were. Fahrul expressed genuine frustration with the chaos in the field and the apparent impossibility of completing his task. Indeed, the number of international organizations that were granted access to work in Aceh immediately after a natural disaster of such unprecedented proportions would have exceeded any government’s capacity to efficiently manage the effort. Nevertheless, Fahrul’s visit at the end of June, which we assume occurred at every major humanitarian organization’s office based in Banda Aceh with a mental health program, represented an effort by state bureaucrats to assert their authority over all NGOs that were officially working in Aceh, formally at the invitation of the government of Indonesia.

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In fact, by June 2005 the Indonesian state had embarked upon at least three consequential macrolevel strategies to regroup and reassert its authority over Aceh since the early days of the tsunami emergency, when Indonesian security forces improvised their crude ad hoc means to secure Aceh’s urban areas along the coast before delivering aid to survivors. The first was the Indonesian military’s establishment of nightly curfews for the humanitarian community as well as the demarcation of conflict-area ‘‘black zones’’ where humanitarians were forbidden to travel or provide assistance. The UN Department of Safety and Security coordinated closely with the military to ensure that all agencies adhered to these regulations and enacted strict security clearance protocols for daytime travel authorization outside coastal city limits—as we experienced during our trip to Lamno. In addition to donor restrictions on how NGOs could disburse their aid to tsunami survivors only, this early collaboration between humanitarian agencies and Indonesian security forces established the baseline structural conditions that resulted in what some organizations would later critique as an equity divide in the availability of aid between tsunami- and conflict-affected populations in Aceh (Waizenegger and Hyndman 2010, Zeccola 2011). Second, in mid-April 2005 Indonesia’s president, Susilo Bambang Yudhoyono, established the Rehabilitation and Reconstruction Agency (Badan Rehabilitasi dan Rekonstruksi), a temporary ministerial-level agency based in Banda Aceh that had a five-year mandate to exclusively coordinate and channel all aid for post-tsunami recovery efforts, headed by Yudhoyono’s close confidante Kuntoro Mangkusubroto, a senior Javanese technocrat who reported directly to him. The third strategy the Indonesian government embarked upon before we arrived in Aceh was a serious diplomatic commitment to peacefully conclude GAM’s separatist rebellion in order to spare Aceh’s population from additional suffering after the tsunami. By the time we arrived in Aceh, four out of five rounds of negotiation between the government of Indonesia and GAM had been held in Helsinki, facilitated by the Finnish NGO Crisis Management Initiative under the leadership of Finland’s former president Martti Ahtisaari. GAM and the government of Indonesia agreed upon the terms of a draft Memorandum of Understanding at the last round of negotiations in mid-July and signed a final draft on August 15, 2005, bringing a tentative end to more than twenty-eight years of sporadic but widely devastating violence across the province. The Helsinki agreement granted GAM the right to contest district- and provincial-level elections in Aceh, with wide

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provisions for provincial autonomy, in exchange for relinquishing their independence demands. Even before the first elections were held in late 2006, the government quickly appointed senior GAM figures to prominent positions within the Rehabilitation and Reconstruction Agency and other government ministries, embarking upon a mutually beneficial elite-level integration of GAM leadership into Indonesian-style patrimonial politics (Aspinall 2009). These political developments not only facilitated the reconstitution of Indonesia’s strong state authority in Aceh by co-opting the GAM conglomerate into formal and informal governance structures but also raised the question of what happens after the emergency period concludes, humanitarian exit strategies are implemented, and the remaining agencies turn to ‘‘development’’ strategies rather than emergency operations. We argue here that development of postintervention state sovereignty should be subject to ethnographic research and nuanced analysis with as much urgency as studies of mobile sovereignty of the humanitarian apparatus. In Aceh, the election of Irwandi Yusuf, a former GAM leader, as governor in late 2006 was celebrated as a genuine return of sovereignty to the Acehnese, with the oversight of the international community, initiating a period in which, in Mary-Jo DelVecchio Good’s terms, Aceh served as a ‘‘laboratory for new modes of governance’’ and for new modes of relating Indonesia’s provincial peripheries to its Javanese and Jakarta center for the whole country (Good and Good 2013). But long after humanitarians had left and Aceh’s peace process was declared a success, the election as governor in 2012 of Zaini Abdullah, a member of the older GAM leadership who spent much of the conflict period in exile in Sweden, though democratic in form, represented a negotiated relationship between GAM’s political vehicle, the Aceh Party (Partai Aceh), and a critical part of the old GAM structure on the one hand and the Indonesian military and parts of the Jakarta elite on the other, suggesting that this period of ‘‘new modes of governance’’ may be coming to an end and that an older form of elite politics and negotiated militarycivilian relationships is returning.

Assessing and Delivering Public Mental Health Services in Postconflict Aceh The Helsinki peace agreement opened another door of opportunity for humanitarian and donor agencies in Aceh. IOM was in a particularly strategic position to become involved. Even before the tsunami, IOM already had

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a presence in Aceh providing support to the Indonesian Ministry of Justice and Human Rights for the relocation of communities forcibly displaced during the martial law period. Given their earlier and trusted relationship with state institutions, IOM was not only able to provide some of the largest recovery and reconstruction assistance after the tsunami but also well positioned to provide reinsertion and reintegration assistance to the three thousand GAM ex-combatants and two thousand amnestied prisoners specified in the peace agreement, as well as recovery assistance for the worst conflictaffected communities. In the earliest weeks of the program, when the outcomes of the peace process were far from certain, Indonesian government representatives overseeing implementation of the peace agreement expressed concerns that nationalist observers (in the military, or certain political parties in the national parliament, for example) would express outrage that the reintegration of ex-combatants was managed by an international humanitarian organization. To assuage these concerns, IOM designed a neutral brand for its ten postconflict program field offices across Aceh, calling them Information Counseling and Referral Service (Pelayanan Informasi Konseling dan Rujukan) offices and choosing locations in coordination with (and mostly based at) the district-level Indonesian Department of Social Welfare. While many tsunami recovery programs in Aceh required an Indonesian government agency logo next to the logo of the sponsoring international organization, for the first few months of IOM’s postconflict program, all staff were under strict orders not to use or show IOM attributes at the field offices—as though the humanitarian assistance provided to conflict survivors came exclusively from the Indonesian government. Each field office had a full-time staff of at least eight Indonesians, including one medical doctor and one nurse, responsible for delivering the various components of IOM’s postconflict program. As our own work with IOM in late 2005 shifted to the postconflict sector, we were invited to develop a psychosocial needs assessment for civilian populations in former high-conflict areas and later a mental health intervention.4 IOM doctors and nurses at the field offices proved to be pivotal actors not just in our research but also in securing government support, without which none of our work would have been possible. At IOM’s office in the GAM heartland district of Bireuen, it was Dr. Andi, head of the field office, who introduced us in early 2006 to Dr. Mirna, head of the Family Health Section, where the portfolio of mental health programs resided at the District Health Office. Seven months after Fahrul’s exasperated effort to register all NGOs working

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on psychosocial issues in Banda Aceh, Dr. Mirna presented a striking contrast as she welcomed us with enthusiasm and confidence when Dr. Andi escorted us to her office so that we could report our research agenda to her. Dr. Mirna outlined for us the ways in which her NGO partners helped the Bireuen District Health Office provide complete mental health coverage across her district, and she saw an opportunity for IOM’s postconflict program to be the first to collaboratively map and then meet the mental health needs in Bireuen’s conflict areas. Tsunami areas were already well covered. To underscore her point, when Dr. Mirna told us that she had heard about some Doctors Without Borders (Me´decins Sans Frontie`res [MSF]) clinicians delivering mental health services to conflict survivors in the interior subdistricts of Bireuen without any coordination with her office, she added that she could not vouch for their activities or guarantee their safety if they never bothered to tell her what they were doing.5 The linchpin of Dr. Mirna’s plan was to increase the number of trained community mental health nurses—through a new curriculum developed with support from the World Health Organization (WHO) and the University of Indonesia recently implemented in Aceh’s tsunami areas, the first of its kind in Indonesia—to cover all of Bireuen’s subdistricts. With these explicit expectations on the table and an agreed-upon recognition of the unknown and unmet mental health needs in conflict areas only recently open to nonsecurity actors, Dr. Mirna wholeheartedly supported our research. When the findings from our psychosocial needs assessment exceeded even our baseline expectations about the levels of traumatic violence experienced and the relationship between past conflict violence and present psychiatric symptoms, IOM faced the politically sensitive challenge of publishing the results in a way that would attract donor support for an intervention without offending their government hosts.6 First, even though Aceh observers understood that most human rights violations against civilian populations were perpetrated by Indonesian security forces, IOM country mission managers in Jakarta asked us to remove all specific references to perpetrators, to write only about ‘‘combatant groups’’ instead of the military, police, or GAM. Second, IOM leadership invested a significant amount of their energy toward procuring a letter of introduction and support from the minister of health to provide political cover for the research findings. Only with the minister’s buy-in would IOM publish our findings. Once again IOM’s careful investment in developing key relationships with leading figures in its partner government agencies paid off. Just as

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IOM’s Dr. Andi cultivated an ongoing partnership with Dr. Mirna in Bireuen, so too did a team of Indonesian doctors and nurses based in IOM Jakarta cultivate relationships at the Ministry of Health, including the SubDirector General for Mental Health, Dr. Pandu Setiawan. We had met with Dr. Pandu at previous workshops in Banda Aceh, designed to develop a master plan for mental health services all of Aceh, which he strongly supported. Dr. Pandu comes from a family of Javanese intellectuals in Yogyakarta, which may explain why he expressed a quiet support for our work that was quite different from Dr. Mirna’s endorsement. Dr. Pandu not only secured an endorsement letter from the minister that would preface IOM’s publication of our preliminary research findings, but he ultimately endorsed our emerging model for intervention: mobile mental health clinics in which IOM’s Indonesian doctors and nurses would visit former conflict villages together with nurses from the nearest public clinic. Our collaborations with IOM necessarily included the Indonesian government, particularly the Ministry of Health, in order to produce successful outcomes. In February 2006, the IOM teams conducting the initial psychosocial needs assessment survey identified one village that had suffered such extensive traumatization at the hands of the Indonesian military that they strongly urged our team to organize a special mental health visit to the village. Working through the IOM bureaucracy, we organized a special mental health outreach team, formed by field office staff and an Acehnese psychiatrist on the IOM staff, to visit the village and provide services. This visit was so successful—though scheduled as a single visit—that we returned the same day to the District Health Office to discuss the development of a program of mental health outreach teams. This experience served as the model for what was to become the signature IOM contribution to mental health services in Aceh. Our first psychosocial needs assessment report, officially released in September 2006, recommended the development of mobile mental health outreach teams. The launching of such a program would require closing down the medical services in each field office and refocusing the work among a subset of the field doctors and nurses to develop a pilot model of mobile mental health services in Bireuen. This required, first, a major political struggle within the IOM management structure and, second, when this was successful, an agreement with the Bireuen District Health Office to build a collaborative program using IOM teams of general practitioners and nurses, trained and supervised by the Acehnese psychiatrist on staff

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with IOM. The pilot phase of the program was launched in January 2007. The teams, working collaboratively with the Acehnese psychiatrist, community mental health nurses from the primary care clinics, and psychiatrists from the University of Indonesia Jakarta, with our providing technical assistance, essentially had to create a new model of mobile services into remote villages most severely affected by the conflict. Teams developed methods of case-finding (identifying persons with mental illness in rural communities), provided supervised treatment using pharmaceuticals that were part of the public health system formulary, conducted home visits, counseled patients, and piloted community-based support groups. The success of this mobile mental health program in twenty-five villages led the World Bank to commit funds for an expansion of this program into fifty new villages. This second phase was launched in January 2008 and concluded in October 2009. We were deeply involved in the project from its conception, developing proposals for funding, providing technical assistance for the implementation of the program, designing a formal evaluation component for the program as it was expanded in its second phase, and using data from the research—which documented extremely positive outcomes for persons treated by the mental health outreach teams—to advocate for this model of providing mental health services within the public health system.7 The mobile mental health clinics embodied elements reflecting the ‘‘suspension of rules’’ associated with the emergency period, but the team and leadership worked extremely closely with the public health system. On the one hand, Acehnese physicians employed by IOM who were not part of the civil service system provided medical care in collaboration with the public health system. In the extension phase of the program, based on technical advice from a World Bank team, the program used selected medications that were not part of the essential drug list for the primary health care system. On the other hand, the program was deeply involved in the politics of mental health care in the Indonesian public health system. IOM focused on building close working relationships with two district health offices. Although the program inevitably got caught up in local politics within these local government offices, it worked closely with the public system to build capacity for delivering mental health care. By building a model of mobile mental health outreach teams that was not part of the ‘‘Aceh model’’ developed at the provincial level—which relied exclusively on the community mental health nurses and village volunteers treating persons with psychotic

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illness—the IOM program became involved in one of the critical structural conflicts resulting from the nationwide decentralization program launched shortly after the fall of the Suharto regime. Decentralization defined district-level autonomy for the development of programs, leading to disputes within the hierarchical system of the bureaucracy, including efforts by provincial offices nationwide to maintain their control over district offices. The IOM mental health outreach programs were developed, as we have indicated, as the Indonesian state was reestablishing its authority following the shock of the tsunami, then as it was developing new forms of governance that acknowledged Aceh’s status as a ‘‘special’’ province with distinctive forms of autonomy. In this setting, framing the development of mental health services as ‘‘therapeutic governance’’ by international organizations makes little sense. There is some logic to interpreting the transnational humanitarian agencies as representing forms of migrant or mobile sovereignty, but in this strong state setting such sovereignty was limited more to the development and funding of programs than to their implementation. The implementation relied on Indonesian actors, both within IOM and in local and national governments, and the success of the mental health outreach teams with which we worked was the result of the extraordinary efforts of committed Acehnese doctors, nurses, and officials.

Conclusion By mid-2006 Aceh had just reached its peak period of tsunami reconstruction. At the end of July, the U.S. Navy humanitarian ship Mercy, with complete hospital facilities onboard, returned to Aceh on a mission through Southeast Asia nearly a year and a half after it first came to Aceh during Operation Unified Assistance. The ship was anchored just a few kilometers off the coast of Banda Aceh’s Ulee Lheue harbor, where the terraforming reconstruction of the land and waterscape was well under way. This time, unlike the ship’s first visit, no massive landing craft put down on Indonesian soil, American physicians’ and medical staff members’ access to Aceh was severely limited, and Acehnese patients’ access to the Mercy’s medical services was limited to a small number of specialized cases. The second visit demarcated the symbolic reassertion of Indonesian state sovereignty. What, then, does the case study of humanitarian interventions in posttsunami, postconflict Aceh contribute to recent critical discussions of

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humanitarian agencies in relation to global governance? Four brief observations conclude our discussion. First, any a priori claims about international humanitarian organizations representing forms of liberal governance or mobile sovereignty need to be subject to empirical research rather than philosophical assertion. The same is true for Agamben’s claim that states of exception necessarily become the norm. We suggest that these processes occur very differently in settings with strong state structures such as Indonesia than in settings with weak or collapsing state structures. However, this overly broad claim needs to be subject to more fine-grained analysis. Second, the critiques of the development of trauma-related psychosocial or mental health interventions as modes of ‘‘therapeutic governance’’ need also to be submitted to empirical investigation rather than asserted. Terms such as ‘‘trauma’’ and ‘‘stress’’ have long made their way into many local cultural and political settings. Understanding how these terms and particular forms of trauma treatment are deployed in specific settings, with a particular focus on what is effective in reducing suffering in postconflict or postdisaster settings, is critically important. Recent critiques of the global deployment of trauma treatments have the potential to undercut efforts to place mental health on the global health agenda. Although attention to trauma and psychosocial needs has become an accepted part of humanitarian work (see, e.g., IASC 2007), the commitment of international organizations to the development of mental health services remains limited. Strong critiques of mental healthcare as a new form of ‘‘international therapeutic governance’’ provide a rationale for not giving priority to mental health services in the funding of global health. Third, our case study suggests the critical role humanitarian interventions should play in building capacity in societies in both public and private sectors—in this case, capacity to provide mental health services. This involves not only educational programs but the development, implementation, and evaluation of new models of services. Humanitarian organizations too seldom provide real documentation of the effectiveness of the services they provide and the relevance of their models of care for the future development of services in local societies. Finally, we argue simply that no single analysis of humanitarianism or humanitarian agencies will do. Organizations and programs are incredibly diverse, as are the settings in which they work. While theorists and policymakers debate strategies, ethnographic analysis is critical to understanding

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how programs work on the ground, assessing the short-term and long-term effects of such programs, and describing the gaps between intended and unintended effects. There are important spaces for anthropologists working as engaged researchers in such settings. Notes 1. For an analysis of the emergence of ‘‘trauma’’ as a category in Indonesia, see Dwyer and Santikarma 2007. 2. The contrast of ‘‘weak’’ versus ‘‘strong’’ states is obviously rhetorical, suggesting extremes rather than a real analytic divide. 3. Chandler (2001) argued that linking humanitarianism to the human rights agenda led to a reorientation of the stance of ‘‘neutrality’’ of classic humanitarian ethics to what he called ‘‘military humanitarianism.’’ 4. The psychosocial needs assessment was a survey of the level of traumatic experience, psychological symptoms, and types of services sought. IOM was the contractor, and the three authors of this chapter were the primary consultants (BG and MJDG) and project coordinator (JHG). The findings of the study, which began with three districts (surveyed in February 2006) and expanded to fourteen districts (in July 2006), are available in Good et al. 2006 and Good et al. 2007. 5. Throughout 2006, we never learned of MSF work in Bireuen, but MSF-Belgium and MSF-France ran programs in the conflict areas of Pidie district, which borders Bireuen to the west. MSF-Holland ran programs in the conflict areas of North Aceh district, which borders Bireuen to the east. Dr. Mirna may have been referring to any of these programs, which may have unknowingly or surreptitiously crossed over into Bireuen communities, especially in the interiors where the district borders are less discrete. 6. A discussion of the politics of publishing the findings is found in Good, Good, and Grayman 2010. 7. See Good, Good, and Grayman 2013, 2014 for reports on the findings of this research. See also Good 2011.

References Appadurai, Arjun. (1996) Modernity at Large: Cultural Dimensions of Globalization. Minneapolis: University of Minnesota Press. Aspinall, Edward. (2009) ‘‘Combatants to Contractors: The Political Economy of Peace in Aceh.’’ Indonesia 87: 1–34. Chandler, David. (2001) ‘‘The Road to Military Humanitarianism: How the Human Rights NGOs Shaped a New Humanitarian Agenda.’’ Human Rights Quarterly 23: 678–700. Duffield, Mark. (2002) ‘‘Social Reconstruction and the Radicalization of Development: Aid as a Relation of Global Liberal Governance.’’ Development and Change 33: 1049–1071.

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———. (2009) ‘‘Complex Emergencies and the Crisis of Developmentalism.’’ IDS Bulletin 25: 37–45. Dwyer, Leslie and Degung Santikarma. (2007) ‘‘Posttraumatic Politics: Violence, Memory and Biomedical Discourse in Bali.’’ In Understanding Trauma: Integrating Biological, Clinical, and Cultural Perspectives, edited by Laurence J. Kirmayer, Robert Lemelson, and Mark Barad, 403–432. Cambridge: Cambridge University Press. Fassin, Didier and Mariella Pandolfi. (2010) Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions. Cambridge, MA: Zone Books. Good, Byron J. (2012) ‘‘Theorizing the ‘Subject’ of Medical and Psychiatric Anthropology.’’ Journal of the Royal Anthropological Institute 18: 515–535. Good, Byron J., Mary-Jo DelVecchio Good, and Jesse Hession Grayman. (2013) ‘‘A New Model for Mental Health Care for Indonesia?’’ Inside Indonesia, January. http://www.insideindonesia.org/feature-editions/a-new-model-for-mental-health -care. Accessed December 23, 2014. ———. (2014) ‘‘Is PTSD a ’Good Enough’ Concept for Post-Conflict Mental Health Work?: Reflections on Work in Aceh, Indonesia.’’ In Culture and PTSD, edited by Devon Hinton and Byron J Good. Ithaca, NY: Cornell University Press. Good, Byron J., Mary-Jo DelVecchio Good, Jesse Hession Grayman, and Matthew Lakoma. (2006) Psychosocial Needs Assessment of Communities Affected by the Conflict in the Districts of Pidie, Bireuen, and Aceh Utara. Jakarta: IOM. Good, Mary-Jo DelVecchio. (2011) ‘‘Trauma in Post-Conflict Aceh and Psychopharmaceuticals as a Medium of Exchange.’’ In Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, edited by Janis H. Jenkins, 41–66. Santa Fe, NM: School for Advanced Research Press. Good, Mary-Jo DelVecchio and Byron J. Good. (2013) ‘‘Perspectives on the Politics of Peace in Aceh, Indonesia.’’ In Radical Egalitarianism: Local Realities, Global Relations, edited by Felicity Aulino, Miriam Goheen, and Stanley J. Tambiah, 191–208. New York: Fordham University Press. Good, Mary-Jo DelVecchio, Byron J. Good, and Jesse Hession Grayman. (2010) ‘‘Complex Engagements: Responding to Violence in Postconflict Aceh.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Intervention, edited by Didier Fassin and Mariella Pandolfi, 241–266. New York: Zone Books. Good, Mary-Jo Delvecchio, Byron J. Good, Jesse Hession Grayman, and Matthew Lakoma. (2007) A Psychosocial Needs Assessment of Communities in 14 ConflictAffected Districts in Aceh. Jakarta: IOM. Grayman, Jesse Hession. (2012) ‘‘Humanitarian Encounters in Post-Conflict Aceh, Indonesia.’’ Ph.D. diss., Harvard University. Hedman, Eva-Lotta E. (2008) ‘‘Back to the Barracks: Relokasi Pengungsi in PostTsunami Aceh.’’ In Conflict, Violence, and Displacement in Indonesia, edited by Eva-Lotta E. Hedman, 249–274. Ithaca, NY: Cornell Southeast Asia Program Publications.

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Inter-Agency Standing Committee (IASC). (2007) ‘‘IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings.’’ Geneva: WHO. Mahdi, Saiful. (2005) ‘‘Calang: The Influence of Humanitarian Aid.’’ Indonesia 79: 161–164. McCartney, Stephen F. (2006) ‘‘Combined Support Force 536: Operation Unified Assistance.’’ Military Medicine 171: 24–26. Pandolfi, Mariella. (2003) ‘‘Contract of Mutual (In)difference: Governance and the Humanitarian Apparatus in Contemporary Albania and Kosovo.’’ Indiana Journal of Global Legal Studies 10 (1): 369–381. ———. (2008) ‘‘Laboratories of Intervention: The Humanitarian Governance of the Postcommunist Balkan Territories.’’ In Postcolonial Disorders, edited by Mary-Jo DelVecchio Good, Sandra Teresa Hyde, Sarah Pinto, and Byron J. Good, 157–186. Berkeley: University of California Press. Pupavac, Vanessa. (2001) ‘‘Therapeutic Governance: Psycho-social Intervention and Trauma Risk Management.’’ Disasters 25: 358–372. ———. (2002) ‘‘Pathologizing Populations and Colonizing Minds: International Psychosocial Programs in Kosovo.’’ Alternatives: Global, Local, Political 27: 489–511. ———. (2012) ‘‘Global Disaster Management and Therapeutic Governance of Communities.’’ Development Dialogue 58: 81–98. Siegel, James T. (2005) ‘‘Peduli Aceh.’’ Indonesia 79: 165–167. Summerfield, Derek. (1999) ‘‘A Critique of Seven Assumptions Behind Psychological Trauma Programmes in War-Affected Areas.’’ Social Science & Medicine 48 (10): 1449–1462. ———. (2004) ‘‘Cross-Cultural Perspectives on the Medicalization of Human Suffering.’’ In Posttraumatic Stress Disorder: Issues and Controversies, edited by Gerald M. Rosen, 233–245. Chichester, West Sussex: John Wiley and Sons. Waizenegger, Arno and Jennifer Hyndman. (2010) ‘‘Two Solitudes: Post-tsunami and Post-conflict Aceh.’’ Disasters 34: 787–808. Zeccola, Paul. (2011) ‘‘Dividing Disasters in Aceh, Indonesia: Separatist Conflict and Tsunami, Human Rights and Humanitarianism.’’ Disasters 35: 308–328.

Chapter 9

The British Military Medical Services and Contested Humanitarianism Stuart Gordon

I had worked in or for the British Armed Forces for over fifteen years when I saw my first wounded enemy combatant receiving medical treatment from another soldier. In 2003, as a lieutenant colonel in the British army, I was attached to U.S. forces in Baghdad. Shortly after the collapse of the Saddam regime, the bomb-ravaged city was in chaos. All elements of public authority had fled and crowds of Iraqis, many in vehicles and even more on foot, converged on public buildings like swarming fire ants, stripping them of office equipment, picture frames, light fittings, and even the electrical cabling that ran through the plastered walls. American military convoys hastily wound their way around the bombed-out palaces and public buildings and through the crowded streets but were invariably powerless in the face of the voracious crowds; the soldiers avoided intervening for fear of provoking more violence. The U.S. troops inside their flimsily armored Humvees, the iconic military vehicle of the decade, were often dangerously exposed. Consequently their convoys scurried as quickly as possible through the streets, determinedly seeking ways around the traffic snarl-ups and crowds of looters. As the vehicles moved one could see anxious soldiers curling over their guns, shrinking into the smallest possible spaces in their vehicles to avoid presenting a target and nervously scanning the swarming people and the myriad buildings that overhung the big routes or the busy alleyways that bisected the main arterial roads. Occasionally one would hear shouted warnings or see vehicle-mounted machine guns spinning on their

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rooftop cupolas and converging fixedly on a distant point as someone glimpsed a gunman or heard the crackle of small arms fire in parallel roads. At this stage Iraqi gunmen were relatively few and far between and labeled ‘‘former regime elements’’ for fear of provoking, or acknowledging, a wider insurgency. But the maze of side streets and tall buildings was their territory, offering potential snipers impossibly numerous vantage points and bolt holes and creating an omnipresent threat to the U.S. soldiers patrolling the increasingly volatile streets. Within weeks of the collapse of the Ba’athist Party the whole atmosphere around the U.S. soldiers had transformed from one of relief, liberation, and swaggering victory into one pregnant with threat and murder. One convoy of three Humvees took the central route through Baghdad, a fast freeway that arose in the mass of streets around the occupied Green Zone and snaked away toward what was then labeled Sadr City, the largely Shia section of Baghdad. The route was often less choked with traffic, but the stretches of open road tended to periodically dip and rise through the tunnels and under the overpasses that punctuated the open stretches of road. If there was no traffic, this route offered convoy leaders relative safety in speed and movement. But commanders traded speed for the risk that gunmen could use the overpasses as vantage points to fire into the vehicles below. One day in early May a small convoy of three Humvees left the relative safety of the military-controlled Green Zone and within minutes was fired on by a single gunman lodged high above on the overpass. The first U.S. vehicle was caught in the spray of gunfire, and both the driver and front-seat passenger were wounded before the vehicle slewed across the freeway to an abrupt and smoking halt. The second vehicle braked, immediately spilling troops onto the road who, darting for cover, returned a murderous fire. In seconds the gunmen collapsed behind the concrete parapet, almost certainly shot by the team doctor who, himself wounded in the arm, leaped into the first U.S. vehicle and began to administer first aid to the wounded. Minutes later, content that these U.S. troops were in stable condition, the doctor nervously ventured onto the overpass and, exposed and vulnerable once more, administered medical aid to the fatally wounded Iraqi gunman. Over the next few weeks the doctor occupied an almost exalted position within the military community of the Green Zone. He had triumphed in the rite of battle, something not expected of a military physician. He had become a warrior, something more than either man or doctor. He favored

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his wounded arm in a makeshift and dusty sling and carried a short automatic rifle slung over his shoulder, both raw reminders of the bloody fight but also powerful symbols of his own transformation. The younger soldiers, mainly infantry and combat arms, welcomed him as one of their own, and those who had not been a part of the bloody fight to Baghdad during the invasion were often both overawed by and drawn to him, often clumsily seeking ways to draw the story from him or just basking in his ‘‘presence.’’ In some ways he became a totemic representation of the transformation and masculinity that they aspired to or felt that they had gone through in different ways. For me it awakened a recognition of the role of military medical professionals in the conflict. Technically noncombatants, they carried weapons for self-defense and the protection of their patients. A part of the armed forces of a state at war, they also cared for the wounded and sick among captured enemy combatants and in this sense were both integral to and distanced from the combatant branches of the military. Increasingly I became aware of the incongruity of this role, seeing bloodied Iraqi insurgents treated in precisely the same U.S. military medical facilities as those used by the U.S. soldiers who had either wounded the Iraqis or been wounded by them. Several years later, as I became more involved in studying the war in Afghanistan’s Helmand Province, I saw even more evidence of this incongruous, dual identity but also became increasingly aware that such dualism was not new or unique to the wars in Iraq and Afghanistan. In interviewing nearly a dozen of the most senior military doctors (and most of those who reflected on their profession in academic journals) in the British army I became increasingly aware that military doctors have always had a dual and complex identity—dual in the sense of being both a military and a medical professional, complex in being a noncombatant in a military uniform while also being a medical professional who may be required, in certain contexts, to both share the risks of the battlefield and to ‘‘fulfill their duty of care to the injured by, for example, securing the immediate area from further attack’’ rather than immediately ‘‘attending directly to the medical needs of the injured’’ (British Medical Association 2009). While the military medical services were in many cases born out of the very same historical experiences that led to the emergence of the civilian Red Cross societies, particularly the International Committee of the Red

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Cross, the underlying purpose of the military medical services was simultaneously and fundamentally different; it was as much about the preservation of the fighting power of a force as it was the relief of wounded soldiers’ suffering on the battlefield. In this sense military medicine had always been caught between strategic and collective duties—facilitating the rapid return of soldiers to the fighting in order to increase organizational fighting power—and humanitarian and individual responsibilities to both the wounded and the sick victims of armed conflict regardless of the latters’ state affiliation. This raises obvious questions about the extent to which military doctors share the same sense of professional identity as civilian humanitarians. In some ways the war in Afghanistan blurred the boundaries between military and civilian humanitarianism. A counterinsurgency campaign of the type waged in the deserts and mountains of Afghanistan is fought to win the ‘‘hearts and minds’’ of the civilian population and to deny this support to the enemy insurgents. Partly to support this war for ‘‘legitimacy,’’ the U.S. and UK military expanded the categories of people using military medical facilities, broadening the list to include civilian contractors, soldiers and paramilitary forces from supported nations, wounded detainees, and Afghan civilians. This increased the demand for the limited hospital space available to Afghans. While civilian humanitarian medical ethics are infused with the idea of universal and impartial care, military physicians recognize the inevitability of differential levels of treatment. Major General Michael Bertele, Director General of the Army Medical Services, pointed out how current UK military medical doctrine for the care of wounded British military personnel was based on echeloned treatment leading to repatriation for surgical cases to First World hospitals in the UK or formerly in Germany. He described a system that provided only essential treatment delivered in the combat theater of operations, to minimize the medical footprint, followed by evacuation to what he labeled ‘‘Role 4’’ facilities in the UK (provided by the National Health Service) as soon as practically and clinically possible. Current policy is to evacuate British wounded for surgery typically within fortyeight to seventy-two hours. However, unlike wounded British soldiers, Afghan soldiers and civilians were not entitled to transfer to a British hospital in the UK and, once stabilized, were transferred to the rudimentary Afghan healthcare system. These

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facilities were generally not able to continue the level of care provided in the field hospital. The inability of the Afghan system to continue the treatment protocols of the field hospital delayed patient transfer and raised the risk that the ‘‘treatment of civilian casualties will consume scarce resources, block access to high dependency beds, and poses wider ethical dilemmas when further specialist treatment is required but is not available from the deployed medical resources’’ (Von Bertele interview 2013). This meant that physicians were forced to make hard choices, and British physicians were not alone in this. In an extremely powerful interview with Wayne Kondro (Kondro 2007) for the Canadian Medical Association Journal, one Canadian Forces’ physician, Lieutenant-Commander Dr. John Macdonald, recalled the types of decisions he was called upon to make while serving with the NATO International Stabilisation Assistance Force (ISAF) when it had a Role 3 (tertiary care) multinational medical unit in southeast Afghanistan from March to May 2006. The facility was designed to provide enough emergency surgical treatment for NATO’s European and North American soldiers so that they could be stabilized and transferred rapidly to ‘‘a modern, fully equipped military hospital in Landstuhl, Germany.’’ The facility also provided care for Afghan soldiers and policemen ‘‘when there’s a threat to their ‘life, limb or eyesight.’ ’’ In contrast to the NATO troops, the Afghans were not entitled to transfer to modern hospitals in Europe but would instead be taken to Mirwais Hospital, some ten kilometers away in Kandahar, when their medical condition enabled them to travel. This created stark ethical choices. Macdonald recalls the poignant stories of the ‘‘humanitarian aid’’ cases turned away at the door because of the limited capacity of the makeshift, eleven-bed plywood-framed military hospital, with an intensive care unit comprising just three beds. There was also the inexorable pressure to just ‘‘stabilize and move [patients] along,’’ because beds had to be kept open in the event Coalition soldiers from Western nations needed treatment, knowing that Afghani patients were being transferred to a hospital in Kandahar that does not have the ability to mechanically ventilate to keep the patients alive and that their chances of survival were decidedly slim. One particularly harrowing case involved a young Afghan soldier who arrived at the field hospital with extensive vascular bleeding.

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I said to the surgeon, where are we going with this guy? His vessels were just all torn in the abdominal region, major vessels. This guy is not going to do well. We can either continue on for hours and hours and see what we can get to, or if you guys don’t think this is going to be successful, let’s not use all of our resources because there are a lot of conflicts going in the area. And so a decision was made to stop at that point. At the time, it was just a fairly analytical decision and it wasn’t until after the fact that you start going, wow, the enormity of this. This guy, he was a healthy young guy. If he landed in our OR [operating room] here, we would go at him all day and all night and do everything and get him to the ICU. He may well then die of complications a few days after but still, you’re not going to make that conscious decision in the operating room. Daniel Sokol recorded an interview with Kevin Patterson, a Canadian doctor posted to Afghanistan: [During] a mass casualty incident involving a mixture of coalition personnel and Afghans . . . the doctors were told not to intubate any of the Afghans with burns exceeding 50 percent. Without a burns unit, those patients would be doomed. The coalition patients, on the other hand, could be repatriated to their home countries to obtain high quality burn care. Such divergent treatment is hard to bear and highlights the need to develop local healthcare infrastructure, but what are the immediate alternatives? (Sokol 2011) The patient transfer issue has created similar challenges across other ISAF troop contributors. Brigadier Martin Bricknell, a former ISAF Chief Medical Officer, suggested that the process of transferring patients from ISAF medical facilities is fraught with practical and ethical challenges. Bricknell concludes that two clinical scenarios in particular presented difficulties: the treatment of burns and head injuries, especially in children: ‘‘The management of the acute phase in severe cases is within the clinical capability of the majority of ISAF medical facilities but, for survivors, is likely to lead to substantial challenges in long-term care and rehabilitation that may be beyond the capability of local medical facilities and beyond the financial resources of the patient’s family.’’ He suggests that this leads to difficult choices in triage and a recognition that ‘‘a pain-free, dignified

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death locally within the family environment might be better than a long, drawn-out demise with possibly a complicated patient transfer to a distant hospital away from relatives and the consequent challenge of burial in accordance with religious customs.’’ I also interviewed Major Chris Bulstrode, a reserve physician deployed with British Forces in Helmand (2009), while he rested in the military base at Lashkargar in the heat of the fighting season. Bulstrode argued that in addition to the obvious clinical issues, patient transfers raised a range of nonmedical complications such as ‘‘the movement of the patient’s relatives to provide personal care in the receiving hospital, confirmation that the family can pay for any drugs needed [as about 70 percent of drugs are purchased by patients], and a plan for the return of the patient to their home location after completion of care. Our experience of a number of patient transfers proved that, in spite of our best efforts, even the simplest thing can go wrong.’’ Such challenges forced ISAF medical officers to make difficult triage decisions and take stock of Afghan medical capabilities and provide basic or critical equipment through military quick-impact project budgets in order to improve Afghan healthcare facilities’ capacities, to reduce bed blocking, and to increase the probability of an early and successful referral (Bricknell and Hanhart 2007, Bricknell 2008). In effect, the military role extended into that of strengthening Afghan civilian health systems, far from a traditional military role, both to prevent bed blocking and to prevent the types of ethical dilemmas of dealing with the more seriously injured Afghans. The expectation of differential treatment based on calculations of resources and effectively prioritizing NATO troops is firmly built into current UK Ministry of Defence (MOD) policy. This dictates that the aim is to provide treatment outcomes comparable to the normal peacetime standards of the receiving country, although this should be tempered with realism if effective medical support is to be delivered within available means. A balance between providing care that is technically possible and that which is appropriate should take into account the availability of follow-up capabilities, own means, and the requirement to preserve sufficient capabilities for supporting own troops. (UK MOD 2007) ‘‘Own means,’’ argues Colonel Ewan Cameron, a senior medical administrator, refers to a wide range of factors: the ‘‘overall capacity of the medical

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unit and the time and material resources demanded by a new patient in relation to the numbers of others that can be saved in that time as well as logistical and practical factors such as evacuation options, medical resupply schedules and space availability’’ (Cameron interview 2013). It could also extend to the levels of exhaustion of the medical staff themselves. Again, the UK is not alone in formalizing this approach. The U.S. Department of Defense’s Manual of Emergency War Surgery states, ‘‘Triage is the dynamic process of sorting casualties to identify the priority of treatment and evacuation of the wounded, given the limitations of the current situation, the mission, and available resources (time, equipment, supplies, personnel, and evacuation capabilities).’’ Prioritizing scarce medical resources is the essence of medical triage in both military and civilian mass casualty contexts, and there are striking similarities between humanitarian and military physicians’ experiences in managing what amounts to an epidemic of trauma. Giannou and Baldan, both ICRC surgeons, clearly believe that even for humanitarian organizations such as the ICRC, the ‘‘surgery of mass casualties and triage has little to do with the routine emergency department triage of a major civilian trauma centre: war triage has a ‘leave to die in dignity’ category unheard of in everyday civilian practice’’ (Giannou and Baldan 2002). There are also striking parallels in the context of triage decisions. Both the ICRC and military physicians tend to work in conditions of austerity and remoteness and engage with limited host nation healthcare systems, particularly in conflict contexts. There are also similarities in triage processes. While the ICRC recognizes and uses a METTAG variant of triage priorities (involving four categories of patient: immediate, delayed, minimal, expectant) similar to those employed by the UK military medical services, they have also employed a simpler, two-tiered system for settings where no surgical care is available locally. This methodology simply ‘‘divides casualties by determination of whether they require surgical intervention. Those needing surgery and who are anticipated to survive a journey are transported to the nearest available surgical facility, while nonsurgical and expectant casualties are provided care by existing resources’’ (Gerhardt et al. 2012). For both ICRC and other medical nongovernmental organizations (NGOs) such as Me´decins Sans Frontie`res (MSF), the aim in a mass casualty situation is to do the best for the most, not everything for everyone. Effective triage processes involve establishing a dynamic equilibrium between needs and resources in ways that are similar to those of the

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military physician (see also Baldan and Giannou 2002, Adams 2008, Coupland 1992, Coupland, Parker, and Gray 2006). There are other parallels between civilian medical humanitarians and military physicians, particularly in terms of the way in which care is provided. Most interviewees explained how the Defence Medical Services (DMS) has found ways of ‘‘projecting forward’’ medical skills to the point of wounding on the battlefield with the aim of conducting critical damagecontrolling surgery as soon as possible after injury (Hodgetts interview 2013, Cameron interview 2013). The ICRC has adopted similar procedures, deploying field surgical teams (FSTs) as close to the point of wounding as possible in situations as diverse as Somalia (1992), southern Sudan (2000), Darfur (2005), and, more recently, Afghanistan and Libya (2011). However, the aims of the FSTs are subtly different from those of their military equivalent (Salmela, Stening, and Zetterstro¨m 1998, Gray 1994a, 1994b). They both provide medical care but also ‘‘protection of non-combatants and wounded fighters who no longer participate in hostilities and who would otherwise have no access to surgical care’’ (Giannou and Baldan 2002). In essence the act of medical provision and the protection of access to surgical care are rooted in the core principles of the ICRC as both a neutral and impartial humanitarian actor (Giannou and Baldan 2002). In this latter characteristic, and notwithstanding significant overt similarities, the differential treatment of casualties based on nationality does seriously distance the military physicians’ responses from those of the civilian humanitarian physician. Clearly the issue of differential treatment regimens presents the military physician with ethical challenges, but these are not legal issues per se. While articles 55 and 56 of Geneva Convention IV do demand that occupying powers make provision for the healthcare of the state that has been occupied, it loosens this injunction by demanding that occupying powers provide medical services and supplies to the civilian population ‘‘to the fullest extent of the means available to it.’’ The inclusion of that phrase clearly demonstrates the intention of the convention’s authors not to disregard the material difficulties with which the occupying power might be faced in wartime. Article 56 effectively sets limits to the occupying power’s obligations by stating that the duty of medical care is a shared one, effectively becoming one of ensuring and maintaining ‘‘with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory, with particular

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reference to the adoption and application of the prophylactic and preventive measures necessary to combat the spread of contagious diseases and epidemics.’’ The phrase ‘‘the cooperation of national and local authorities’’ was intended to rule out the possibility of occupying powers being forced to assume sole responsibility for the wholesale provision of hospitals and health services. The commentary on the Geneva Convention makes it clear that it was ‘‘above all a task for the ‘competent services of the occupied country itself’’ albeit with support from the Occupying Power ‘‘to the fullest extent of the means available to it’’ (Lubell 2012).

Spare Capacity The need to preserve medical capacity to deal with unexpected surges in the numbers of military wounded also created a sense of unused capability, making for difficult triage choices. Many interviewees suggested that the combination of increased medical need among civilians in conflict situations and this spare capacity within the military medical service acted as a driver of military involvement in direct health provision among the Afghan civilian population. Major Chris Bulstrode (Bulstrode interview 2009) argued, ‘‘Any well-equipped military force should have adequate medical support to cover most eventualities. This will inevitably mean that in all but the most ‘kinetic’ situations there will be spare capacity to take on other perceived needs, such as providing medical care to the local population. The sight of the illness and poverty in a Third World country makes all military personnel [both medics and non-medics] eager to do something to help.’’ Furthermore, the existence of significant medical capabilities with significant (albeit temporary) spare capacity alongside weakly regulated discretionary quick-impact project funding appears to create powerful opportunities for military medical branches to become involved in even national health policy issues and health system regulation, both for humanitarian reasons and to ease bed blocking in the Role 3 facilities. Brigadier Martin Bricknell phrased this in terms of an obligation, stating that ‘‘Afghanistan has amongst the worst population-level health indicators in the whole world. As an institution, the ISAF military medical services are one of the largest international medical organizations operating in Afghanistan. The use of this capability in support of health sector reconstruction

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and development is both a military task and a professional obligation’’ (Bricknell 2008: 48). In effect, this parallels the sense of humanitarian imperative felt by civilian humanitarian physicians.

The Relationship Between Military and Civilian Humanitarianism While there is a clear humanitarian imperative within the community of military physicians, several interviewees were uncomfortable with the apparent rejection by the civilian humanitarian community of the military medical services’ humanitarian credentials in all circumstances. While most of the interviewees accepted the need for ‘‘humanitarian space,’’ several were skeptical that military delivery of assistance ‘‘blurred the boundaries’’ between military and humanitarian responses or was directly responsible for the contraction of humanitarian space—blaming instead rejection by conservative, radical Islamic groups, predatory criminal behavior by nonstate armed groups, and the confused behavior of some multimandate humanitarian organizations that adopted the normative protection of the Red Cross principles but simultaneously engaged in state building and emergency assistance. Not only did the civilian humanitarian community’s pursuit of humanitarian space complicate the relationship between military physicians and civilian humanitarian, but several interviewees, like Ewan Cameron, appeared to harbor a sense ‘‘that the humanitarian community had co-opted a particular and exclusivist humanitarian identity that did not have a place for military physicians.’’ This was resented by some, especially as increasingly military physicians recognized that the term ‘‘humanitarian’’ could apply to an individual military physician’s ethical framework even while the organization to which they belonged was not ‘‘humanitarian.’’ Colonel Tim Hodgetts, for one, argued that ‘‘the treatment during conflict of an individual civilian patient by military medical personnel can be regarded as ‘humanitarian,’ even though ‘organizationally’ the military medical system may not be able to respond to the universal needs of the civilian population.’’ In effect once an individual was drawn into the military medical system, his or her treatment would be made exclusively on medical grounds, and this was sufficient to be considered humanitarian. There was

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also recognition that in some circumstances the military medical organization itself could behave in ways that were humanitarian. General Louis Lilywhite argued that ‘‘the idea that the military are excluded from humanitarian action in all circumstances simply doesn’t match reality. In some circumstances the military may be under civilian direction and given an exclusively humanitarian role in which the DMS will play a major part and offer a humanitarian service. In other circumstances the military are clearly an instrument of the state and deployed with combat in mind. In those situations the DMS will be in support, providing medical care to the wounded soldiers’’ (Lilywhite interview 2013). Hodgetts drew similar distinctions to that of the former surgeon general, suggesting that organizationally even the military are capable of being humanitarian according to the strictest of criteria, especially when the military were tasked with responding directly to humanitarian disasters. Nevertheless, several interviewees agreed that the ethics of treating noncombatants were not the same nor were they interchangeable for military and civilian humanitarian organizations. Rather, the idea of neutrality sat uncomfortably with military physicians’ status as members of a uniformed service that was itself an instrument of state power. Rowland Gill speculated, ‘‘I suppose our role is in essence not a neutral one; at its core we are about supporting an army in its effort to win a war. Surgeons, nurses, and combat medics support an army’s ability to fight and the morale of its troops. By supporting fighting capability in this fundamental way we clearly are not neutral in the traditional sense.’’ So in what ways can they be considered neutral? General Lilywhite considered that the medical organization and medical personnel shared different spaces even while the latter was a component of the former. He noted, ‘‘Medical personnel have immunity on the battlefield and when confronted with them will treat the wounded without distinction. In this sense they are neutral. Whereas while the organization as a whole shares this immunity, it makes clear choices as to what groups of wounded and sick are priorities. It is difficult to link this with neutrality in the traditional sense. I think one could argue that immunity is a better and more accurate label than neutrality’’ (Lilywhite interview 2013). Ewan Cameron narrowed this idea, suggesting that the reality is more nuanced: ‘‘The DMS is set up primarily to focus medical care largely on the wounded from one side. It will clearly treat enemy wounded and civilians in some circumstances, but its organizational priorities and resources are

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designed with one thing in mind: the treatment of wounded soldiers from the home team’’ (Cameron interview 2013). In effect, there is a recognition that the professional identity of military physicians recognizes the way in which the organization is configured in support of one combatant group even if the individual doctor provides care exclusively on the basis of need. However, it was the issue of impartiality that was most difficult to reconcile with a humanitarian identity. Rowland Gill suggested that the idea of ‘‘impartiality was potentially inconsistent with the demands placed on the military medical practitioner. When the military as a whole wanted the military doctors to engage with a particular community in order to gain support and increase the overall security for the military, that sits uncomfortably with the idea of universal and impartial care’’ (Gill interview 2013). There is a similar rejection of a military humanitarian role evident in the discourses of the civilian medical humanitarian community. While the role of medical practitioner to the armed forces of a state is clearly recognized by civilian humanitarian organizations, NGOs such as MSF systematically separate and reject the notion of military engagement in humanitarian activities and the occupation of ‘‘humanitarian space’’ in conflict settings, claiming this for independent, civilian humanitarian organizations. While civilian humanitarians have frequently and vociferously questioned the mandate, the skills, and the appropriateness of military involvement in the civilian health sector, this is also already being formalized into some NATO nations’ operating concepts and, as described by General Lilywhite, is ‘‘just happening.’’ Yet many military doctors see the dismissal of military humanitarianism as a legitimate, albeit hybridized, form of humanitarianism as premature. They argue that this reflects an underestimation of the normative power of medical ethics and, within the civilian humanitarian community, a failure to accept the implications of a parallel and broad fragmentation of civilian humanitarian identities and the emergence of multiple ‘‘humanitarianisms.’’ This also raises the question of whether military physicians are genuinely able to realize as well as to conceive of themselves as an autonomous moral actor separate from the mainstream combatant military. These identities also explain military physicians’ resentment of efforts by civilian humanitarians to re-create an impervious bright-line distinction between military and civilian notions of humanitarianism. These are viewed by many within the military medical establishment as essentially ahistorical,

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parochial, and deeply flawed—neglecting obvious commonalities in favor of stark and exaggerated distinctions.

Conclusion Although there is an inherent paradox in the idea that a soldier can be both a member of a military profession dedicated to ‘‘wounding’’ and a member of a medical profession dedicated to ‘‘healing,’’ military medical professionals find themselves occupying precisely that space. While military medical officers are members of a largely civilian medical profession, with norms related to healing and saving life, they are simultaneously part of a military profession that accepts the necessity and legitimacy of a role that includes wounding and killing enemy combatants and the probability of civilian casualties as collateral damage. Thus they have a professional identity that, Janus-faced, delivers both healing and wounding functions. This blending of medicine and war is also reflected in many of the metaphors that are used to explain both contemporary warfare and medicine, particularly as the former redefines itself in the slipstream of international terror and the Global War on Terror. The metaphorical depiction of medicine as war, and war as medicine, and the imperative to wage a no-holds-barred total war of eradication in response to both new medical threats and international terror have clear implications for the professional identities of military medical practitioners. References Adams, Marcus P. (2008) ‘‘Triage Priorities and Military Physicians.’’ In Physicians at War: The Dual-Loyalties Challenge, edited by F. Allhoff, 215–236. International Library of Ethics, Law, and the New Medicine 41. The Hague: Springer. Baldan, Marco and Chris Paul Giannou. (2002) ‘‘Basic Surgical Management of War Wounds: The ICRC Experience.’’ Annals of Emergency Medicine 49 (3): 275–281. Bricknell, M. C. M. (2008) ‘‘Reflections on Medical Aspects of ISAF IX in Afghanistan.’’ Journal of the Army Medical Corps 153 (1): 44–51. Bricknell, M. C. M. and N. Hanhart. (2007) ‘‘Stability Operations and the Implications for Military Health Services Support.’’ Journal of the Army Medical Corps 153 (1): 18–21. Bricknell, Martin, Brigadier. (2012) Interview.

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British Medical Association. (2009) ‘‘Armed Forces: Ethical Decision Making.’’ http:// bma.org.uk/practical-support-at-work/ethics/armed-forces-ethical-decision-mak ing-toolkit/introduction-to-toolkit. Accessed June 6, 2014. Bulstrode, Christopher, Major (2009). Interview. Cameron, Ewan, Lieutenant Colonel. (2013) Interview. Coupland, R. M. (1992) ‘‘Triage of War Wounded: The Experience of the International Committee of the Red Cross.’’ Injury 23 (8): 507–510. Coupland, R. M., P. J. Parker, and R. C. Gray. (2006) ‘‘Evolution of Triage Systems.’’ Journal of Emergency Medicine 23 (2): 154–155. Gerhardt, Robert T., Robert L. Mabry, Robert A. De Lorenzo, and Frank K. Butler. (2012) ‘‘Fundamentals of Combat Casualty Care.’’ In Combat Casualty Care: Lessons Learned from OEF and OIF, edited by Eric Savitsky and Brian Eastridge. Falls Church, VA: Office of the Surgeon General Department of the Army. http://www .cs.amedd.army.mil/borden/book/ccc/UCLAFrontMatter.pdf. Accessed December 16, 2014. Giannou, C. and M. Baldan. (2002) War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence. Vol. 1. Geneva: International Committee of the Red Cross. http://www.icrc.org/eng/assets/files/other/icrc-002 -0973.pdf. Accessed December 16, 2014. Colonel Rowland Gill (2013) Gill, Rowland, Colonel. (2013) Interview. Gray, R. (1994a) ‘‘Triage.’’ In War Wounds: Basic Surgical Management, 17–19.Geneva: International Committee of the Red Cross. ———. (1994b) ‘‘Patterns of Injury.’’ In War Wounds: Basic Surgical Management, 12–16. Geneva: International Committee of the Red Cross. Hodgetts, Timothy, Colonel. (2013) Interview. Kondro, Wayne. (2007) ‘‘Where’s the Health in Afghanistan’s Reconstruction?’’ Canadian Medical Association Journal 177 (3): 233. Lilywhite, Louis, Lieutenant General. (2013) Interview. Lubell, Noam. (2012) ‘‘Human Rights Obligations in Military Occupation.’’ International Review of the Red Cross 94 (885). http://www.icrc.org/eng/assets/files/review/ 2012/irrc-885-lubell.pdf. Accessed December 16, 2014. Richmond, Alan, Colonel. (2012) Interview. Salmela, J., G. F. Stening, and B. Zetterstro¨m. (1998) ‘‘Triage and Reception of Large Numbers of Casualties.’’ In Surgery for Victims of War, 13–18. Geneva: International Committee of the Red Cross. Sokol, Daniel K. (2011) ‘‘The Medical Ethics of the Battlefield.’’ British Medical Journal 343: d3877. doi: 10.1136/bmj.d3877. Accessed June 6, 2014. UK Ministry of Defence. (2007) Medical Support to Joint Operations. Joint Doctrine Publication 4–03 (JDP 4–03). 2nd ed. January. http://indianstrategicknowled geonline.com/web/MEDICAL%20SUPPORT.pdf. Accessed January 24, 2015. Von Bertele, Michael, Major General. (2013) Interview.

PA R T I V

The Afterlives of Intervention

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Chapter 10

Anthropology and Medical Humanitarianism in the Age of Global Health Education Peter Locke

As ‘‘global health’’ is consolidated as an interdisciplinary field of inquiry and intervention, flush with new money and motivation to address disparities in disease burden and inadequate or ailing health systems, mental health researchers and professionals have been working to advocate for the importance of what they have taken to calling ‘‘global mental health,’’ drawing on burden of disease data grounded in the controversial disabilityadjusted life years (DALYs) metric to argue that mental illness constitutes a ‘‘hidden epidemic’’ in poor countries (Becker et al. 2013, Prince et al. 2007, Miller 2012, Koplan et al. 2009). This burgeoning subfield is animated by intense debate between psychiatric epidemiologists-turned-advocates like Vikram Patel who argue that, in general, Western and international diagnostic frameworks for mental illness can and should be applied across cultures and contexts, and provocative social critics like psychiatrist Derek Summerfield who characterize mental health efforts in the postcolonial countries of the Global South as a kind of ‘‘medical imperialism’’ (Bemme and D’souza 2012, Summerfield 2008). Anthropologists of health and humanitarianism, for their part, have both critiqued the discourse, assumptions, and practices of humanitarian psychiatry and related international mental health interventions (Fassin and Rechtman 2009, Pandolfi 2010, cf. Pupavac 2010) and engaged directly in assessing mental health needs and working to scale up and destigmatize

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mental health care in underserved areas—as in the work of Harvard University faculty Byron Good and Mary-Jo DelVecchio Good in collaboration with the International Organization for Migration (IOM) in Aceh in the wake of conflict and natural disaster there (2010). These two lines of engagement with global mental health research and intervention—the one an exercise in critical social analysis, the other a project of applied expertise and advocacy—seem also to be indicative of the currently prevailing alternatives for anthropological scholarship in and about the booming field of global health in general. As charismatic figures like Paul Farmer and Jim Kim and academic communities like Harvard’s Department of Global Health and Social Medicine carved out an unabashedly activist medical anthropology in the 1990s and 2000s that engaged directly in medical humanitarian projects, institution-building, and broader health policy debates, anthropologists like Didier Fassin and Mariella Pandolfi were developing what has become an influential and sweeping critique of modern humanitarianism—inclusive of the world of global health interventions— as a form of mobile biopolitical sovereignty deeply complicit with the expansion and consolidation of a neoliberal world order (Fassin 2012, Fassin and Pandolfi 2010). Meanwhile, new global health centers, programs, and institutes have been growing rapidly at universities across the United States to engage a new generation of students driven both to understand international health disparities and to do something significant about them—a generation examined with deep critical insight, for example, in physiciananthropologist Claire Wendland’s recent work on ‘‘clinical tourism’’ at Malawi’s medical school (2012). The demand among medical students (and, I would add, undergraduates) for ‘‘global health experiences’’ has exploded so quickly that universities are struggling to keep up, often bracketing thorny questions about the equity of new international partnerships along the way (Crane 2013). This trend, Wendland notes, is ‘‘only one manifestation of a larger push for service-learning projects in poor places that blur easy distinctions between humanitarian action, educational experience, and adventure travel’’ (2012: 110). This ‘‘push for service-learning’’ is situated in and shaped by a longer history of what Wendland calls ‘‘moral pilgrimages’’ by elite Western students, in the contexts of, for example, the missionary medicine of the eighteenth and nineteenth centuries and the colonial public health apparatuses of the late nineteenth and early twentieth centuries.

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In this chapter, I describe my efforts to understand these trends and transformations together—the growth and consolidation of global health and global mental health as fields of research and intervention, along with the boom in student engagement and interest—within the same frame and fieldwork project. I am beginning to study a small, precariously funded medical humanitarian organization that I call ‘‘Global Alliance for Health’’ operating in a rural area of postwar Sierra Leone, exploring the intervention’s entanglement with and impact on multiple domains of medicine and caregiving, from mental illness and food security to HIV/AIDS, traditional healing networks, and maternal and child health. At the behest and encouragement of the global health education program that employs me at the time of this writing, I am including small groups of undergraduate global health students in my summer trips to the field and engaging them in collaborative field research according to their disciplinary backgrounds and interests, attempting to harness anthropology to enhance experiential learning and develop reflexivity and critical thinking skills in future global health leaders. I now turn to a brief history of Global Alliance for Health, focusing particularly on their recent foray into basic psychiatric care to consider a few of the moral dilemmas and tensions generated by the convergence of global mental health agendas, medical humanitarianism, and the evolving forms of transnational movement through global health education in which I have become immersed. As this convergence indicates, both analytical and empirical boundaries around the categories at hand—‘‘global health’’ and ‘‘medical humanitarianism’’ especially—are blurry, and a vital contribution of ethnographic work may be to demonstrate how they serve as overlapping or floating signifiers that allow actors in the field, including both researchers and practitioners, to frame and justify their projects. The chapter highlights the difficulties of carefully bounding the anthropologist’s and the students’ roles amid these blurring categories of engagement and vis-a`-vis an improvised partnership with an institution governed—like the field of ‘‘global health’’ more generally—by a powerful sense of moral urgency and humanitarian emergency. I suggest that what sociologist Craig Calhoun has called the ‘‘emergency imaginary’’ of contemporary humanitarianism (2010) is converging with a range of transnational resource flows, institutional collaborations and engagements, and the powerful example set by figures like Paul Farmer to create the conditions of possibility for new, multiplying forms of small-scale experimentation with healthcare delivery in resource-poor settings.

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Global Alliance for Health Global Alliance for Health defines itself as a medical humanitarian organization guided by the belief that ‘‘healthcare is a human right.’’ It was cofounded in the mid-2000s by an American physician, at that time in his mid-twenties and working toward his MD; a few of his family members and supporters in the United States; and a Sierra Leonean doctor who had just completed his studies at the medical school in Freetown. The American physician, whom I’ll call Jeff, had taken advantage of a global health fellowship offered by his university to visit and spend short periods of time working in clinics and hospitals in several locations in sub-Saharan Africa. The conditions in Sierra Leone, burdened by deep and widespread poverty and still gravely impacted by the war of the 1990s, struck him as the most dire he had seen: very limited public health infrastructure, goods, and services outside of major population centers and maternal and infant mortality rates that continue to rank among the highest in the world. Through connections Jeff met the Sierra Leonean doctor with whom he would partner (I’ll call him Tamba), and they initiated an intense—and sometimes turbulent— friendship grounded in what they each perceived to be a shared commitment to provide quality healthcare to Sierra Leone’s worst off. In their assessment, this turned out to be the country’s many amputees—people who had had fingers, hands, and/or entire limbs cut off by Revolutionary United Front (RUF) forces during the war—along with their dependents (Berghs 2010). A few hundred amputees and their families had been resettled near the capital of a rural district in very basic homes in what are locally called ‘‘amputee camps,’’ constructed and occasionally maintained by a Scandinavian aid organization not long after the war ended. Very few of the amputees had paying work of any kind, often because of their diminished capacity to do manual labor as a result of their injuries, and were scraping by on small-scale subsistence gardening, street begging, and dwindling food aid from organizations like World Vision. Because workers at the woefully understaffed and under-resourced local government hospital regularly charged prohibitively high user fees for treatment and often required patients to find and purchase any drugs they needed from local private pharmacies, the amputees and their families— nearly penniless and consumed each day with figuring out where their next meal would come from—essentially had no access to medical care.

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Jeff and Tamba decided to build a small clinic near the camps to serve the amputees and their families. Global Alliance for Health was officially registered, and Jeff’s family members and supporters in the United States contributed the necessary funds to build and equip the first basic clinic structure. Tamba staffed the operation with Sierra Leonean nurses and lab technicians he knew from large international nongovernmental organization (NGO) projects he had worked on and stocked their small pharmacy with inexpensive Indian generics he or one of his employees purchased periodically in Freetown. The clinic has provided care to all amputees and their family members for free and over time has extended its services to a much wider range of people by charging small fees for those who can afford to pay and through unsystematic fund-raising in the United States. In the process, Global Alliance has effectively become the main provider of safe and affordable basic medical care in a district with no more than three doctors for about six hundred thousand people and where government health facilities experience chronic shortages of essential drugs and other supplies. Dozens of individuals and families from surrounding villages begin lining up as early as 4 a.m. each day to await the clinic’s opening, hoping for the chance to consult a nurse—each of whom sees forty to fifty patients a day—about ailments ranging from the ubiquitous malaria and parasite infections to more complex problems that likely have little chance of successful treatment within the district—or anywhere in the country. Since the beginning, the organization—in its early days run essentially only by Jeff and Tamba, with ad hoc support from friends, family, and colleagues—has struggled to raise money, build capacity, and expand its services. It has often been troubled by tensions over guiding priorities. Research is arguably more highly regarded than clinical care in Western academic medicine’s hierarchy of worthy professional engagements, and Jeff has to varying degrees embodied and applied this hierarchy in his efforts in Sierra Leone. While early on Jeff and Tamba had focused their efforts on clinical capacity, more recently Jeff has searched for ways to implement randomized studies that could demonstrate efficacy to donors and further his own research aspirations. Tamba, who grew up in deep poverty and experienced considerable hardship and loss on his road to a medical education during Sierra Leone’s civil war, is passionate about ideas of social justice and serving the poor—following Jeff’s recommendation, he has been devouring Paul Farmer’s books and is considering

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graduate school in medical anthropology—and sometimes bristles at Jeff’s interest in mobilizing clinic patients as experimental subjects for health research. Indeed, their relationship seems to have become more fraught with time, as Jeff has proceeded with a range of well-intended studies and initiatives without, Tamba feels, adequately eliciting or respecting his local knowledge. Not surprisingly, many of Jeff’s projects end up causing controversy among Tamba, clinic staff, and patients, as well as raising concern among supporters in America. Here the dilemmas and ethical conundrums posed by the ascendancy of ‘‘evidence-based medicine’’ as a model for public health research and intervention play out in the ups and downs of a friendship, with real consequences and side effects for the people Jeff and Tamba are working to serve. In Jeff’s world, randomized controlled trials (RCTs) have become the ‘‘gold standard’’ for research, and investigators are under intense pressure to conform to it. As medical anthropologist Vincanne Adams argues (2013a), the growing dominance of RCTs for program evaluation in the worlds of global health and development may profoundly narrow the range of evidence that may be considered—and hence of the critical thinking that may be pursued—in the consideration of global health initiatives and triggers a proliferation of hard-to-resolve tensions between the often dueling imperatives of service delivery and the production of ‘‘rigorous’’ statistical evidence. In Jeff’s view, his arguments with Tamba have been driven by the latter’s limited awareness of the ‘‘benefits of research.’’ In a recent conversation, Jeff emphasized that since beginning a public health degree in the United States, Tamba ‘‘now understands the type of research more’’ and the disagreements between them have ‘‘disappeared.’’ The fact that this rapprochement has been mediated by American public health education, however, may underscore the importance of the original tensions as symptomatic of broader debates over international hierarchies of expertise and evidence production in global health today.

Where There Is No Psychiatrist In an organization as small and as fragile as Global Alliance, the vicissitudes of personalities and interpersonal relationships seem to take on an outsized importance and dramatic force, embroiling everyone in the NGO’s orbit

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in the production and management of conflict and moral dilemmas anchored in differing assumptions about epistemology and care, that is, by what methods the needs of local people are to be assessed and addressed and by whom. These dynamics were in full force during a small controversy provoked by Jeff’s attempt to implement a ‘‘pilot community psychiatry program’’ based at the clinic. Very few effective and humane psychiatric services are available in Sierra Leone, and in the region where Global Alliance works, people who show signs of psychosis often suffer from stigma and poor living conditions. Hoping to begin to address this situation, to impress potential supporters interested in mental health, and in part inspired by Vikram Patel’s book Where There Is No Psychiatrist: A Mental Health Care Manual (2002)—which provides guidance on the provision of basic mental health care by community health workers in areas without trained mental health professionals or formal psychiatric services—Jeff decided that the Global Alliance clinic should implement a mental health program of its own, even as it continually struggled to shore up its most basic medical services and resources. Jeff had had some interaction with traditional healers known for treating instances of what was locally referred to as ‘‘madness’’ or ‘‘kraze’’ and was dismayed to discover that their methods commonly included chaining patients by the legs to trees or heavy logs for extended periods of time. He became convinced that providing basic psychiatric care could be as morally and medically urgent—a ‘‘humanitarian emergency’’ in its own right—as the other services delivered by the clinic. A clinic neighbor who worked as a faith-healing pastor encouraged Jeff to construct a simple shelter for mentally ill patients as a ‘‘locally appropriate’’ setting where they could consult with and be treated by both clinic staff and the local traditional healers with whom Global Alliance hoped to partner. With Tamba’s agreement, Jeff constructed a makeshift structure containing a few basic beds that he called a ‘‘mental health stabilization center’’ next to the main clinic building using blue tarps and bamboo poles and spread the word around town and over the radio that Global Alliance was looking to help people with mental problems and/or seizures. He brought a stock of generic versions of the antipsychotic Haldol (haloperidol) and the anticonvulsant and mood stabilizer carbamazepine to the clinic. A psychiatrist practicing in the United States who had grown up in and emigrated from Sierra Leone visited the site for a few weeks with Jeff and advised him in his initial encounters with mental health patients. When she

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returned home, Jeff continued to consult by phone with psychiatrists and psychiatry residents in his professional network. He diagnosed at least two dozen cases of schizophrenia and as many of epilepsy and prescribed trial courses of haloperidol for the former and carbamazepine for the latter. Global Alliance’s friends and supporters in America—including me and the students who had spent time in Sierra Leone—worried a little about the speed of the development and implementation of Jeff’s psychiatric intervention. We were partly reassured by his consultations with mental health professionals in the United States but wondered whether he should reach out to transcultural psychiatrists to discuss the risks and special challenges of prescribing psychopharmaceutical treatment for people living in extreme poverty in a place like Sierra Leone. Soon other questions began to simmer. Did Global Alliance really have the capacity to support and sustain patients taking antipsychotics and to manage side effects as they arose? Did Jeff have plans to make a formal study out of the program? Were conditions in the tarp structure safe or even humane, and how long were patients staying there? In this as in most of his other projects, Jeff’s approach to addressing health inequalities is primarily pharmaceutical, using medicines not normally available to Sierra Leone’s rural poor to cure easily treatable diseases and mitigate chronic symptoms while understanding the broader social determinants of health to be mostly beyond the realm of his expertise and responsibility. How would the impact of his mental health work be shaped by the fact that Jeff did not (and likely could not, given the limited resources at his disposal) incorporate much in the way of counseling, education, or forms of regular social and economic support into his approach? Attempts to partner with a local U.S.-funded psychosocial support NGO had seemed to fizzle. Finally, we wondered how the program compared to the regulation and oversight of psychiatric diagnosis and psychopharmaceutical treatment in primary care settings in the United States and other rich countries. While American primary care physicians are indeed trained to treat general mental health concerns while referring special cases to psychiatrists, it seemed important to ask whether Jeff’s project might also exemplify an evolving trend of well-intentioned medical students and young doctors using ‘‘global health’’ engagements to try out forms of medical treatment that would be more carefully supervised in their countries of origin. Wendland, for example, notes how some of the visiting Western physicians and

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medical students she observed in Malawi’s teaching hospital ‘‘cherry-picked procedures of interest, those they would never see—or be allowed to do—at home’’ (2012: 111). Students and others in the United States voiced these basic concerns to both Jeff and Tamba. Some of the email exchanges about the program became angry and heated, I’m told, which often happened when differences of opinion arose about Global Alliance initiatives. All parties were especially concerned that the clinic might lack the capacity to provide patients the full support they would need to benefit from the medications and manage side effects. In the end, Tamba and Jeff agreed that no new mental health patients should be taken on, while allowing those who had been prescribed medications and seemed to be benefiting from them to continue the course of treatment. The tarp structure was vacated and eventually dismantled.

Local Landscapes of Health and Care In the meantime, the work I did with students over two months in Sierra Leone during the summer that immediately followed the end of the psychiatric program has helped build a basic understanding of how mental illness is situated in a broader sociocultural landscape of care and survival strategies. For example, while Jeff and Tamba knew that ‘‘traditional healers’’ were present and commonly enough consulted in the district and that traditional birth attendants were being actively incorporated into a new and ambitious maternal and child health program, one student—employing good anthropological techniques of snowballing interviews and accompanying patients in their therapeutic itineraries—encountered an organized union, complete with a governing board, chairman, downtown headquarters, and a range of official documents and rules, that claimed a membership of approximately four hundred such caregivers in the region. The chairman maintained that the healers practiced a range of specializations and were enmeshed in a network of referrals that brought them into collaboration with biomedically trained nurses and community health workers at small government clinics known as peripheral health units. Visits to healers at their homes (where they generally practiced) showed that the actual degree to which they interacted with and held themselves accountable to

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the union varied; but more important, the discovery of the union and subsequent encounters with traditional healers reminded us of the diversity of local healing practices and how heavily people in the region respected and relied on them. Any global mental health paradigm of research and intervention would likely benefit a great deal from understanding and engaging such diverse strategies of caregiving and care-seeking—which have a very long history in sub-Saharan Africa and scholarship about it (Vaughan 1994, cf. Langwick 2008, Igreja, Dias-Lambranca, and Richters 2008)—asking, as we are encouraging our students to do, what the range of approaches to health engaged by target communities is offering over and beyond the medical technologies and pills of encroaching biomedical systems. We also tried to follow up with many of the patients the clinic had treated with antipsychotics or anticonvulsants. For those diagnosed and treated for schizophrenia, it was hard to gauge the impact of such brief courses of treatment with haloperidol; some families enthusiastically reported reduced symptoms and better social functioning, while others seemed less interested in the specific effects of pills and more hopeful that the pharmaceutical intervention foreshadowed new possibilities on the horizon for a sustained relationship of aid and care with an organization like Global Alliance. For the epileptics we met, on the other hand, the treatment was—almost without exception—significantly and positively life altering. The benefits of anticonvulsants were amplified in the context of a local universe of meaning in which seizures are often heavily stigmatized as a form of madness resulting from demon possession or witchcraft, leading to abuse and ostracism. With the elimination of one young man’s seizure activity, for example, opportunities for mobility and care that had long been denied to him—schooling, work, romantic relationships—suddenly opened up. This and similar cases convinced us that, despite aspects of the program that had initially worried us and the complexities of translating psychiatric diagnostics across cultures, our anthropological critique had to be carefully balanced with constructive dialogue about how mental health services—including psychopharmaceuticals—could be responsibly integrated into medical humanitarian projects in places like Sierra Leone (see Good 2011).

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Conclusion In opening up these realities for Global Alliance, the anthropological work and thinking of the American students has revealed new possibilities of intervention and collaboration, even if they offer no easy or quick technical fix for addressing mental illness. Many global health scholars and practitioners have witnessed or been directly a part of such tinkering with initiatives, partnerships, and forms of community engagement around health. For me, our work with Global Alliance in Sierra Leone is raising large questions about who sets the parameters and monitors accountability for these emergent processes and collaborations and how authority is to be distributed among different professional roles and forms of expertise. As Wendland found in her study of Malawi’s medical school, encounters between rich-country medical students on ‘‘global health electives’’ and local medical students can trigger profound soul-searching about the nature of medical caregiving and its translatability across health systems, culturally diverse understandings and experiences of illness, and immense resource inequities. At the Global Alliance clinic in Sierra Leone, the interplay between Jeff’s biomedical training and research methodologies, Tamba’s local knowledge, visiting students’ research projects and moral passions, and the plurality of local approaches to health and healing generates both conflict and creativity and unsettles international hierarchies of expertise. The picture becomes all the more complex when we recognize the ways in which global health education initiatives inevitably and more or less ambivalently become a part of the phenomena they study. As medical anthropologists and other health scholars engage with this rapidly expanding and evolving landscape of global health research and services, how are we to juggle the often conflicting roles of expert consultant—asked, like the Goods in Aceh, to harness social scientific methods to the design and authorization of new and ambitious public health interventions—and more distanced social critic, concerned, like Fassin and others of similar orientation, to probe contemporary medical humanitarian discourse for its unstated assumptions and complicities with power and to situate ‘‘global health’’ in a longer and profoundly mixed history of racialized missionary and colonial medicine? Is there a path to be charted between these poles? In this we can look for inspiration, at least, to recent ethnographic work that

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aims to bring the complicated, unfolding, on-the-ground realities generated by public health, medical, and disaster recovery interventions—and especially the perspectives and critiques of ‘‘target communities’’—directly to bear on concrete questions of politics, pharmaceuticals and medical technologies, and caregiving at local, national, and global scales (Biehl and Petryna 2013, Biehl 2007, Adams 2013b, Garcia 2010). Indeed, as Jeff and Tamba continually called on the students and me to consider disputes big and small over research methods and modes of care delivery, the lines between critical social scientific distance and direct support to interventions in-the-making were constantly blurring. As numerous small-scale community health NGOs are built by a new generation of students inspired by university global health programs and by charismatic public intellectuals like Farmer, we must carefully consider what professionals or institutions—institutional review boards, faculty advisors, local or international government bodies or authorities—are to ensure accountability and prudence in day-to-day experimentation with forms of health research and care in a wide range of complex and difficult contexts. Here the challenges of accountability in international humanitarianism and research come together. The vexed question of appropriate and feasible mechanisms of oversight and accountability for humanitarian engagements large and small is, to be sure, not a new one. Initiatives from the ‘‘1994 Red Cross Movement and NGO Code of Conduct in Disaster Response’’ and the Sphere Humanitarian Charter to the Humanitarian Accountability Partnership’s more recent Standard in Accountability and Quality Management have all attempted, with varying degrees of limited success, to provide effective, universal guidelines of responsibility to affected populations and forms of self-regulation for humanitarian practice (Stockton 2005, cf. Darcy 2004, HAP 2013). And in the realm of transnational research processes, Adriana Petryna has highlighted how orthodoxies of evidence-based clinical science are problematically translated into a modus operandi of ‘‘experimentality’’ and ‘‘ethical variability’’ when new pharmaceuticals and medical technologies are tested overseas (2009). While her analysis pertains specifically to the globalizing of generally large-n clinical trials, Petryna’s reflections seem just as apt for much smaller-scale research and intervention partnerships like the one I have discussed here. Petryna urges us to attend to ‘‘gaps between international ethical guidelines and the social and political realities of research,’’ asking, ‘‘what work is to

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be done to guarantee accountability and to link experimental biologies to regimes of protection?’’ (2009: 7). What work, indeed? And what work for anthropology, in particular? Consequential differences in how key actors (physicians, social scientists, policymakers, community health workers, ‘‘traditional’’ caregivers) get to know and understand intended beneficiaries—as data points, moralized abstractions (‘‘poor Africans’’), or complicated individuals caught up in webs of structural and physical violence and evolving local strategies of health, healing, and survival—raise the stakes for anthropological engagement in evidence production and intervention. While questions of ethics and accountability in research and ‘‘service-learning’’ entanglements may be vexing, the alternative—to not engage or to assess from an ‘‘armchair’’ position—is much more difficult to justify. Our students, to be sure, will not allow us the luxury of an overly cynical critical distance. As one wrote recently in his senior thesis, based on three summers in Sierra Leone working with Global Alliance, ‘‘how do we see and learn from other lives if we don’t engage them, and process them in relation to our own evolving forms of self and social awareness? If previously unavailable experiential engagements with the realities of healthcare in the developing world are creating new moral framings, pragmatic considerations and ways of thinking about humanitarian engagement, then this is, perhaps, a welcome move in a field that has only recently been touched by ethnographic empiricism.’’1 Our students—future caregivers, humanitarians, and scholars, and some likely to be all three at once—hold anthropology accountable for harnessing and marrying its ethical and empirical-scientific strengths to the twinned challenges of understanding and addressing the appalling global health disparities of our era—disparities that they refuse to write off as intractable, however complexly conditioned they might be by deep colonial histories, cultural difference, and the global political economy that implicates us all. Notes Except in cases where individuals or institutions chose to be identified, I have maintained their anonymity to the greatest degree possible through the use of pseudonyms and the omission of other identifying features. 1. Unfortunately I cannot cite this thesis directly without compromising the broader anonymity of Global Alliance for Health.

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References Adams, Vincanne. (2013a) ‘‘Evidence-Based Global Public Health: Subjects, Profits, Erasures.’’ In When People Come First: Evidence and Innovation in Global Health, edited by Joa˜o Biehl and Adriana Petryna, 54–90. Princeton, NJ: Princeton University Press. ———. (2013b) Markets of Sorrow, Labors of Faith: New Orleans in the Wake of Katrina. Durham, NC: Duke University Press. Becker, Anne, Anjali Motgi, Jonathan Weigel, Giuseppe Raviola, Salmaan Keshavjee, and Arthur Kleinman. (2013) ‘‘The Unique Challenges of Mental Health and MDRTB: Critical Perspectives on Metrics of Disease.’’ In Reimagining Global Health: An Introduction, edited by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico, 212–244. Berkeley: University of California Press. Bemme, Doerte and N. D’souza. (2012) ‘‘Global Mental Health and Its Discontents.’’ Somatosphere. http://somatosphere.net/2012/07/global-mental-health-and-its-dis contents.html. Accessed May 1, 2013. Berghs, Maria. (2010) ‘‘Embodiment and Emotion in Sierra Leone.’’ Third World Quarterly 32 (8): 1399–1417. Biehl, Joa˜o. (2007) Will to Live: AIDS Therapies and the Politics of Survival. Princeton, NJ: Princeton University Press. Biehl, Joa˜o and Adriana Petryna, eds. (2013) When People Come First: Critical Studies in Global Health. Princeton, NJ: Princeton University Press. Calhoun, Craig. (2010) ‘‘The Idea of Emergency: Humanitarian Action and Global (Dis)order.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 29–58. New York: Zone Books. Crane, Johanna. (2013) Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca, NY: Cornell University Press. Darcy, James. (2004) ‘‘Locating Responsibility: The Sphere Humanitarian Charter and Its Rationale.’’ Disasters 28 (2): 112–123. Fassin, Didier. (2012) Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press. Fassin, Didier and Mariella Pandolfi, eds. (2010) Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions. New York: Zone Books. Fassin, Didier and Richard Rechtman. (2009) The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton, NJ: Princeton University Press. Garcia, Angela. (2010) The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande. Berkeley: University of California Press. Good, Byron. (2011) ‘‘The Complexities of Psychopharmaceutical Hegemonies in Indonesia.’’ In Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, edited by Janis H. Jenkins, 117–144. Santa Fe, NM: School for Advanced Research Press.

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Good, Mary-Jo DelVecchio, Byron Good, and Jesse Grayman. (2010) ‘‘Complex Engagements: Responding to Violence in Postconflict Aceh.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 241–268. New York: Zone Books. Humanitarian Accountability Project (HAP). 2013. Guide to the 2010 HAP Standard in Accountability and Quality Management. Geneva: HAP International. Igreja, Victor, B. Dias-Lambranca, and A. Richters. (2008) ‘‘Gamba Spirits, Gender Relations, and Healing in Post–Civil War Gorongosa, Mozambique.’’ Journal of the Royal Anthropological Institute 14: 353–371. Koplan, Jeffrey, T. Christopher Bond, Michael Merson, K. Srinath Reddy, Mario Rodriguez, Nelson Sewankambo, and Judith Wasserheit. (2009) ‘‘Towards a Common Definition of Global Health.’’ The Lancet 373: 1993–1995. Lachenal, Guillaume. (2010) ‘‘The Doctor Who Would Be King.’’ The Lancet 376: 1216–1217. Langwick, Stacey. (2008) ‘‘Articulate(d) Bodies: Traditional Medicine in a Tanzanian Hospital.’’ American Ethnologist 35 (3): 428–439. Marcus, George. (2010) ‘‘Experts, Reporters, Witnesses: The Making of Anthropologists in States of Emergency.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 357–378. New York: Zone Books. Miller, Greg. (2012) ‘‘Who Needs Psychiatrists?’’ Science 335: 1294–1298. Pandolfi, Mariella. (2010) ‘‘From Paradox to Paradigm: The Permanent State of Emergency in the Balkans.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 153–172. New York: Zone Books. Patel, Vikram. (2002) Where There Is No Psychiatrist: A Mental Health Care Manual. London: Gaskell. Petryna, Adriana. (2009) When Experiments Travel: Clinical Trials and the Global Search for Human Subjects. Princeton, NJ: Princeton University Press. Prince, Martin, Vikram Patel, Shekhar Saxena, Mario Maj, Joanna Maselko, Michael Phillips, and Atif Rahman. (2007) ‘‘No Health Without Mental Health.’’ The Lancet 370: 859–877. Pupavac, Vanessa. (2010) ‘‘Between Compassion and Conservatism: A Genealogy of Humanitarian Sensibilities.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 129–152. New York: Zone Books. Stockton, Nick. (2005) ‘‘The Accountable Humanitarian.’’ Humanitarian Accountability Partnership. http://hapinternational.org/pool/files/the-accountable-humanitar ian-2-12-05.pdf. Accessed December 16, 2014. Summerfield, Derek. (2008) ‘‘How Scientifically Valid Is the Knowledge Base of Global Mental Health?’’ BMJ 336: 992–994. Vaughan, Megan. (1994) ‘‘Healing and Curing: Issues in the Social History and

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Anthropology of Medicine in Africa.’’ Social History of Medicine 7 (2): 283– 295. Wendland, Claire. (2012) ‘‘Moral Maps and Medical Imaginaries: Clinical Tourism at Malawi’s College of Medicine.’’ American Anthropologist 114 (1): 108–122. Werner, David with Jane Maxwell and Carol Thuman. (1992) Where There Is No Doctor: A Village Healthcare Handbook. Berkeley: Hesperion Health Guides.

Chapter 11

The Creation of Emergency and Afterlife of Intervention: Reflections on Guinea Worm Eradication in Ghana Amy Moran-Thomas

In 2008, there were approximately 4,619 cases of guinea worm left in the world. Of those, 501 were in Ghana; and one was emerging from Obed Ibrahim’s left ankle. The soft-spoken man looked rather unconcerned by the commotion of our arrival, the marks on his cheeks creasing into three parallel lines when he smiled. He wore a denim floppy cap and sat alongside the village chief. A few dozen men relaxed on a mat woven from reeds, while clusters of women sat on a bench under a baobab tree. A Carter Center worker peered under Obed’s bandage to make sure the emerging parasite was an authentic specimen, the worm itself part of the phenomenology of their dialogue. ‘‘It’s real,’’ another staffer for the Guinea Worm Eradication Program confirmed, and the meeting commenced with great formality. Later, I was caught off-guard when the chief asked me—the only woman traveling with the campaign staff—to make a speech to the women in the village about using the guinea worm water filters. I felt torn— wanting to be collegial out of respect for the dedication and clear moral commitment of the campaign workers who had brought me down impassable roads on the back of their motorcycles to be there, but at the same time worried by a sense that there was something unsettling about the nylon filters being promoted, which strained out only guinea worm larvae

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but left the water still unsafe to drink. I attempted to explain that I was only observing the eradication campaign. But the chief pressed me. Finally I said a few awkward words to be translated, which I can no longer remember. Afterward the women applauded politely and gave us several hardboiled eggs, which someone wrapped in a photocopied map. Toward the end of the meeting, the community bookkeeper handed over the thin notebook charting disease and deaths by month, a surveillance project for several key illnesses that the guinea worm campaign hoped might expand its vertical model. The man looked tired, and I could not help reflecting on the reality that we had come to collect information about the only disease in the painstakingly kept data book that doesn’t typically kill anyone. Later, as we prepared to leave the village, people gathered around the motorcycles with other wounds, including an ulcer apparently caused by diabetes. But the ulcer went unattended because it wasn’t a guinea worm ulcer; there were no outreach programs for these other conditions in the village. (This incident and others like it made such a deep impression on me that, after reflecting on all the priorities and assumptions that seemed crystallized in that moment, I later switched my dissertation topic to write about the diabetes epidemic instead.) Holding a calabash ladle, one woman offered me water from the bright plastic tub across which her nylon guinea worm filter was stretched. When she pulled back the cloth I saw that her filtered water was still too murky brown to view the bottom of the container. Later I could not decide whether the offer was an act of hospitality or an effort to make me see. In the district capital of Tamale, many surfaces were plastered with bright, red-rimmed decals of the parasite emerging from someone’s foot, edged with the words ‘‘GUINEA WORM IS A MEDICAL EMERGENCY.’’ Such urgent messages were once printed on stickers, billboards, postage stamps, backpacks, and T-shirts distributed throughout the region, reminders of the fact that it took years for the campaign to convince many people with guinea worm that they needed treatment (Watts 1998). The threefoot-long female guinea worm is visually grotesque to anyone unaccustomed to seeing it as it slowly bores its way through human skin over a period of days, after an intricate one-year migration through the human body. Yet it is not fatal, unlike many other waterborne diseases in Northern Ghana, and was long accepted by many people as a seasonal part of their lives, a natural part of their anatomy, or a supernatural message from ancestors (Bierlich 1995). The Guinea Worm Eradication Program’s earliest

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Figure 11.1. Decal: ‘‘Guinea Worm Is a Medical Emergency.’’ Photo by author, 2008.

efforts thus focused not on addressing a widely recognized need, but on creating a sense of urgency in order to shape a new policy priority. Today, after more than two decades of intervention efforts spearheaded by the Carter Center, guinea worm eradication is supported by a powerful coalition of transnational institutions including the Centers for Disease Control (CDC), the World Health Organization (WHO), UNICEF, the Red Cross, and the Bill and Melinda Gates Foundation. In 2015, the guinea worm is firmly poised to be the second disease (and first parasite) ever eradicated from the world. There are countless news stories and journal articles celebrating the fact that the guinea worm is on the verge of extinction, and even a new documentary on the subject narrated by Sigourney Weaver. But as an ethnographer, I approach this social history from a somewhat different perspective, in the belief that what Nancy Leys Stepan (2011) calls the ‘‘useful ambiguities’’ of eradication policy can teach us something important. In a moment when guinea worm eradication is now being taken up as a model for approaching other diseases through vertical ‘‘magic

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bullet’’ campaigns, it is crucial not just to celebrate a success story but also to reflect carefully on the campaign’s uneasy crossroads and setbacks, as a way of asking what else the next generation of global public health campaigns might become. ‘‘Counter-histories’’ (Gallagher and Greenblatt 2001) may also suggest alternate futures. Transgressing the thin and unstable borders between development initiatives and medical humanitarianism, guinea worm eradication raises questions about the underlying suppositions and hazy circumscriptions of these sectors. How does emergency shape the way conditions fall in and out of these domains? Through what techniques is urgency professionalized and managed to impact the health priorities of a country, and how have such logics and temporalities fundamentally altered the meanings of relief and care over time? Reflecting on the military economies and conflicts that became embroiled in this campaign, we are pushed to probe the shifting boundaries of intervention, humanitarianism, and war more broadly— asking how one specific condition was produced into a particular kind of crisis and querying this campaign’s afterlife—what Craig Calhoun (2010) might call its ‘‘emergency imaginary.’’ In drawing from the anthropological tradition of critical inquiry, I remain concerned that the dedicated campaign workers who helped make my research possible would feel uncomfortable hearing this. Certainly, I feel uncomfortable writing it. I have genuine admiration for their deep commitments and creative negotiations, and (in a reversal of the anthropologists’ usual role) I relied heavily on their local knowledge, longitudinal engagement, community connections, and firsthand accounts to conduct this work. Yet there were also campaign workers who themselves shaped and shared many of these questions through casual jokes, wry selfcriticisms, and longtime experience about the painful pragmatic limits and compromises of aid work in practice. By remaining attentive to a multiplicity of truths and perspectives, this is a juncture of guinea worm eradication where there are ethical questions worth asking, technical approaches worth debating, and ethnographic realities worth charting. Throughout the reflections that follow, filtering also becomes an implicit analytic. For in the moral economy that drove this campaign, what was being constantly filtered and refiltered was not just water but information—about what health and humanitarianism mean, how countries and priorities are composed, and what people in them need. The politics of filtering show a working-through of borders between pathogens,

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people, states, aid, markets, and technoscience. And in a context of emergency, time itself becomes unevenly filtered. My ethnographic findings unfold in dialogue with arguments that vertical policies and programs for conditions like guinea worm—while holding vital potentials and resources—often meet dissonance on the ground for deeply meaningful reasons that require careful listening and serious pause for critical reflection (Allen and Parker 2012). Massive corporate donations of devices (including mosquito nets and guinea worm filters) and chemicals (drugs and larvicides) are rolling out with a meticulously choreographed urgency that at times may distort nations’ own health priorities and reallocate resources needed for basic care services, in ways that can shape styles of living and even ways of dying. For example, I will never forget going in a single morning from observing the bustling guinea worm program office—where several dozen campaign staff, Ghanaian Ministry of Health officials on laptops, and American Carter Center consultants were debating how to best locate a woman with guinea worm who had run away so as not to receive treatment—and then traveling a few minutes across town to the once-weekly regional diabetes clinic in Tamale, where more than thirty patients waited for hours in the light September rain for a doctor who never arrived. When I met with the government doctor the next week, he explained he had been called away on another emergency and spoke of the difficulty being the only doctor assigned to treat diabetes in a region of 1.8 million people. He told me sadly that the weekly clinic felt much different than when it first opened; many of his patients now had amputated limbs or had died. Once there had been dozens of children with Type 1 diabetes among his patients for the Friday clinic, but by 2009 all except one had died from interruptions in their insulin therapy. Neglected tropical disease philanthropy becomes a different picture when thinking of these two clinical scenes (and countless others like them) as co-terminus realities, drawing from the same limited pool of government healthcare workers and monies spliced into vertical programs. Such segmentations and inequalities are profoundly contoured by ‘‘how both scientists and the lay public understand the nature and consequences of infection, how they imagine the threat, and why they react so fearfully to some disease outbreaks and not others at least as dangerous and pressing’’ (Wald 2008: 3). Here, I examine the production of urgency that underpinned one such regime by thinking through the war metaphors and military technologies

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operationalized in the guinea worm eradication campaign. I offer some brief questions about the ethical complexities of these dense repertories of emergency (Redfield and Bornstein 2010), their lived effects, and the ways that technologies and diseases (like eradication itself) always mean more than just one thing. The aim is to query priorities alongside the exclusions that they normalize and to read history alongside the intervals from which it would break—but ultimately to still keep a sense of unexpected possibilities and generative afterlives at play. In short, this chapter relies on the capacity of an ethnographic mesh to unsettle abstractions—whether in idealized public health narratives or academic theorizing—and to filter things otherwise.

The Production of Emergency Guinea worm first became a global health priority during the ‘‘Water Decade’’ of the 1980s, when the World Health Assembly’s steering committee resolved that the worm’s eradication would stand as a lasting legacy of their efforts. Since the guinea worm’s survival depends on people first drinking infected ‘‘water flea’’ vectors (which are easily visible even to the naked eye and can be strained out with any common cloth), and then later submerging their blistering ulcers into a water source, the disease should be extraordinarily easy to interrupt with even the most basic standards of water sanitation. For this reason the World Health Assembly assumed that eradicating the parasite would be a natural consequence of improved water supplies and an index of their success toward achieving their primary goal to bring clean water to every village in the world (Brieger et al. 1997: 354). ‘‘The Water Decade provides a vehicle aimed already at insuring disease-free water,’’ UN health expert Dr. Peter Bourne wrote in the early 1980s (Bourne 1982: 3). ‘‘[I]f the Decade is only 6–7 percent successful in achieving its overall goal it should still be sufficient to eliminate guinea worm’’ (2). In 1982, Jimmy Carter—fresh out of his presidential term and determined to dedicate his political clout toward humanitarian works—was searching for a cause toward which to dedicate his efforts. If guinea worm soon gained a champion in Carter and his colleagues (including CDC eradication powerhouse Dr. Donald Hopkins), the nascent Carter Center also found a perfect totem in the guinea worm. This choice of focus forever politicized the worm and simultaneously solidified Carter’s new foundation

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under its banner, as the Carter Center (still called ‘‘Global 2000’’ then) made it its mission to continue with guinea worm program efforts after the Water Decade ended. Yet the original intent behind eradication was fundamentally altered when the guinea worm became a primary policy target unto itself, rather than an index gauging the underlying issue of clean water. Anthropologist Didier Fassin notes that ‘‘in interstices of disagreement, a certain truth gets told that would not be told otherwise’’ (2010: 42). I would like to examine one such disagreement that became visible surrounding guinea worm in Ghana, where notable experts in the National Health Service believed clean water access should be their policy priority in guinea worm eradication, rather than ‘‘targeted’’ filters and chemicals that removed only guinea worm vectors and left dirty water behind for people to drink. Some important headway was being made with this approach. For example, when 159 wells were constructed in the Nanumba District of Ghana’s Northern Region as part of a Japanese rural water supply project in 1988–1989, the incidence of guinea worm was dramatically reduced by 77 percent throughout the district in the course of a single year (Hopkins 1992: 630). Yet when national actors in Ghana continued to prioritize the slow and messy work of drilling wells and installing clean water systems, emphasizing ‘‘a fundamental right to clean water’’ while struggling with external underfunding (see Cairncross, Taylor, and Korkor 2012), they were publically scolded by President Carter himself. ‘‘It became increasingly obvious to me that a basic problem was that Ghana’s officials, from field workers to the president, considered the drilling of deep borehole wells as the primary solution to the Guinea worm problem,’’ President Carter wrote (Carter Center 2004), pressing for them to instead emphasize measures such as nylon filters and ABATE chemicals that would eliminate guinea worm but not other conditions. His diplomatic language acknowledged a long-term role for ‘‘the borehole dream,’’ but Carter’s immediate message was clear: ‘‘this is not the way to eradicate the disease’’ (Carter Center 2004). We might see this as a fundamental disagreement about what the emergency actually was. While guinea worm eradication began as an index of unsafe water as emergency, its symbolism seemed to overtake itself (parasitically, perhaps). Instead of a ‘‘test disease’’ for ‘‘improved and safe water supplies’’ (USAID 1992), guinea worm eradication became slated as the more pressing crisis, an urgent target unto itself.

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‘‘Here as elsewhere in global health, the vocabulary of emergency hinges on a temporality that insists upon a break from the past,’’ Joa˜o Biehl and Adriana Petryna write (2013: 28). It was this construct of emergency that allowed guinea worm eradication to break with its own policy origins, a fundamental paradigm shift away from ‘‘more ecologically informed’’ (Lederberg 2000) clean water frameworks. This transformation was additionally fueled by the campaign’s grotesquely photogenic nemesis and arguments that the guinea worm not only emblematized inequality through its link to disease-ridden water (a symptom of poverty), but directly contributed to its pathologies (as a significant cause of poverty). The technical director of the Carter Center’s campaign worked with World Bank economists to develop economic rate of return estimates that predicted the parasite’s eradication would make local agriculture significantly more profitable, thus improving local economies and bringing rural poverty a key step closer to alleviation. With rare exceptions, the Carter Center’s usual policy was not to fund infrastructural water projects directly—and while a bricolage of approaches and donations have been used over time and across countries, the eradication program placed particular emphasis on ‘‘surveillance’’ tactics, ‘‘targeted’’ guinea worm filters, and use of larvicide chemicals during their community outreach. In short, it became a war on the worm. The ‘‘war metaphor’’ that molecular biologist Joshua Lederberg (2000) memorably critiqued has often been explicitly evoked in guinea worm eradication, such as the title ‘‘Fighting On: The War Against Guinea Worm in Southern Sudan’’ (Carter 2010). As Egon Bittner famously noted in his study of policing, the rhetorical shift from control to war ‘‘signifies the transition from a routine concern to a state of emergency’’ (1980: 48). Such military language has been picked up in turn by the international media, where it circulates robustly: a recent sampling of headlines includes ‘‘Winning the Worm War’’ (New York Times), ‘‘War on a Worm’’ (Worchester Telegram & Gazette), ‘‘Jimmy Carter’s Successful War’’ (The Globe and Mail), and ‘‘Carter’s War on Guinea Worm’’ (The Independent). These expressions are more than figures of speech; they speak of deep framing logics and very specific tactics and tools. While ‘‘magic bullets’’ have become part of global health scholars’ accepted vernacular, here I want to pause and briefly reexamine this term in the context of guinea worm eradication. The term ‘‘magic bullet’’ was popularized by Paul Ehrlich, a cancer researcher (1854–1915) who pioneered chemotherapy techniques by developing highly selective pharmacotherapies intended to kill only the organism targeted. In oncology, of

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course, this is precisely the goal—to create drugs that go after culprit cancerous cells without touching any of the surrounding tissue. Yet as the term ‘‘magic bullet’’ migrated from clinical medicine to global health, the phrase has become one of serious critique (see Cueto 2007), a watchword of vertical campaigns that use ‘‘targeted’’ technology to go after one specific pathogen. (The term usually also implies wry skepticism, suggesting the problem will not be simple to eliminate with a chemical or device after all.) The eradication program’s ‘‘targeted’’ guinea worm water filters were developed by scientists at DuPont Corporation especially for the Carter Center campaign, a tough nylon mesh that would last longer and drain faster than cotton (fine enough to catch the guinea worm’s copepod vectors but too porous to strain out any other pathogens, such as microscopic vectors of fatal waterborne diseases). Between 1990 and 1997, DuPont donated over $14 million worth of this specialized guinea worm filtration cloth. The materiality of this technology is worth pausing to consider for a moment, being that the campaign’s ‘‘magic bullets’’ first came from a company that, rather strikingly, established its reputation by manufacturing actual bullets. Since it first became America’s key supplier of gunpowder, for over two centuries DuPont Corporation has been central to U.S. war equipment industries. The nylon fabric materials it would later adapt its guinea worm filters from, for example, were initially developed as a ‘‘strategic material’’ during World War II (as synthetic materials were necessary to replace interrupted supplies of silk from Japan), a development described on their official website’s corporate chronology shortly before producing plutonium for the atomic bomb (DuPont 2012). During the Vietnam War, this material was developed into ‘‘ballistic nylon’’ for flak jackets and flame-proof parachutes. In general, DuPont’s products are for ‘‘emergency situations,’’ its corporate timeline explains. Sherry Turkle reminds us how the artifacts of science become ‘‘things we think with’’ (2007). Given that the ‘‘targeted’’ filters were donated by DuPont to the guinea worm eradication effort, it is important to ask what kind of humanitarian thinking these material objects reflected or instantiated. After all, the nylon water filters were designed and manufactured by scientists trained in inventing for emergency states, mobility, war, and defense. This is a very different paradigm of water processing, for example, than other filter models that are designed as a piece of furniture for the home or as a lifestyle model. But for all the tremendous efforts and resources entailed in developing and manufacturing the synthetic filters in

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Figure 11.2. Two types of water filters in Northern Ghana. Left: Nylon filter distributed by guinea worm campaign being used in Northern Ghana, which protects only against guinea worm. Photo by the author, 2009. Right: Ceramic filter being used in Northern Ghana, which protects against guinea worm as well as polio, cholera, typhoid, hepatitis A, intestinal worm infections, and diarrheal diseases. Photo by author, 2008.

an American laboratory, and in hiring campaign staff to distribute them to remote villages around the world and spend years educating people about their use, it remains an uncomfortable truth that a different water filter— ceramic for instance—distributed through the same channels to the same households could have prevented guinea worm and at the same time protected against the many other, far more deadly pathogens that often inhabit guinea worm–infected waters (Brieger et al. 1997). Among these are polio, cholera, typhoid, hepatitis A, various intestinal worm infections, and the common diarrheal diseases that kill at least 1.5 million children in the world each year. Given this context, the campaign’s choice to develop specialized water filters that single out and protect against just one waterborne disease might be viewed as a downright iconic example of ‘‘magic bullet’’ technology. Like the words ‘‘campaign’’ and ‘‘surveillance,’’ ‘‘targeted’’ is a public health term borrowed from contexts of war, implying an exit strategy. In contrast to clean water projects where the guinea worm is expected to spontaneously die out on its own over time—as it did in Latin America, for example—a targeted model of security and crisis entails different approaches. In Ghana, ‘‘dam guards’’ were bankrolled in each village to protect water sources from being entered by anyone infected with guinea

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worm; people were taught to police each other for emerging worms and report them to authorities; and in the final stages of eradication, a bounty of up to $112 per ‘‘hanging worm’’ was offered in Ghana. The region was labeled and mapped into territories of ‘‘endemic’’ or ‘‘nonendemic’’ communities and terrains, and intelligence and monitoring at times became contested even on national levels (for example, in 2004 President Carter reported that a large guinea worm outbreak on Lake Volta was deliberately hidden from his staff by the Ghanaian government). In multiple cases across various countries, local people tried to conceal the location of their drinking water so that it wouldn’t be treated with the larvicide (McNeil 2006) or even met eradication program staff attempting to apply the chemicals with armed resistance (Moran-Thomas 2013). Perhaps seeing this trope of crisis operationalized in a scenario of a nonfatal disease helps destabilize some of the usual truth claims of emergency and begins to shed light on some of its seams, engines, and contradictions—not to mention reversals. For in the final years of the guinea worm eradication campaign, the program’s rhetoric of exception came full circle. Although many in the Ghanaian Ministry of Health remained critical of (and yet, via international media, publically accountable to) this powerful crisis model of eradication that reshuffled national priorities, by learning to traffic in this same language of crisis, it became possible to put clean water projects back onto the eradication program’s agenda. When the ‘‘Emergency Response Hydraulic Team’’ was proposed, it was difficult to deny its moral urgency. In the guinea worm staff meetings I attended in Tamale, the Water Team was represented by several Ghanaian technicians charged with bringing specialized tool kits, replacement parts, and engineering knowledge to surrounding communities to tinker with broken water systems unmaintained by the aid organizations that built them, showing both the promise and the discontinuities of humanitarianism in sharp relief. In 2009 alone, Ghana’s ‘‘Emergency Response’’ Team repaired 125 broken borehole wells (Afele 2009).

Afterlives of Intervention Anthropologists have written vividly of the ‘‘social lives of medicines’’ (Reynolds Whyte, van der Geest, and Hardon 2002), while doctors speak of their biological half-life. But if Walter Benjamin was right, all things in

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translation have both a life and an afterlife—and the original is altered in turn by the ways its translations are taken up across languages, personalities, imaginaries, and generations (1968). In examining how war terms and military technologies migrate into humanitarianism interventions (and vice versa), then, we might also consider how these afterlives shape and shadow each other in the multiplicities at play. In 2013, the new country of South Sudan—just emerging from decades of civil war—remained the last bastion of the guinea worm, containing 96 percent of the world’s remaining cases (also see Hopkins and Withers 2002). Back in 2004, Carter even used his diplomatic clout to broker a ‘‘Guinea Worm Cease-Fire’’ between the warring parties in Sudan, distributing nylon guinea worm filters and filter-straw necklaces during what must have been a surreal pause in decades of violence. ‘‘It is discouraging to hear people complain that we didn’t bring them food when we came to educate them about Guinea worm,’’ one Carter Center regional coordinator reflected during this era (Carter Center 2003). Complexly, such employees were tasked with providing outreach for a nonfatal disease in circumstances of starvation and mass death where they were at times the only humanitarian presence. Local staff members working in Sudan during that time traveled in pairs or convoys unless they had military escort, after the last Sudanese national hired by the Carter Center as regional coordinator for guinea worm eradication was murdered in 1998. When South Sudan officially became a new nation in 2010, ending the war, Carter published a CNN article about guinea worm eradication in the country with a section titled ‘‘War Waged to Vanquish the Fiery Serpent,’’ calling on the country’s ‘‘foot soldiers of Guinea worm eradication’’ to ‘‘fight on’’ (Carter 2010). In South Sudan, 444 of the 463 villages reporting guinea worm cases in 2011 did not have a single source of safe drinking water (WHO 2012: 184). The last known guinea worm in Ghana emerged in Diare village in May 2010. Yet since then, the political value of the guinea worm has persisted and even grown, its intimacy and its absence remained layered with other social meanings. False or suspiciously unverifiable reports of guinea worm sprang up in places thought to have eliminated the parasite—247 such false reports were logged in Ghana in 2011 alone (WHO 2012: 185), as people learned that they could use the politicized worm to make claims for longneeded clean water supplies. Many people are surprised that guinea worm is actually gone from their country and speak of what else might be possible—if the Carter Center does it. Others told me their lives have not

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changed much, but spoke approvingly of Jimmy Carter’s ‘‘groundnut’’ (peanut) farming, a profession many Dagomba proudly shared. ‘‘How will we get soap once the Carter Center is gone?’’ another concerned volunteer wondered, expressing hopes the institution would find another disease to fight so their community would continue receiving piecemeal fringe benefits. This also points toward a deeper question of exchange: in contrast to well-paid eradication program staff, unpaid community volunteers gave many hours but were largely expected to view the intervention itself as their compensation (see also Samsky 2011). Over time, some volunteers themselves began testing: what was the value of their work? I was told that in Togo, guinea worm village volunteers approached their eradication program supervisors to announce they had formed a union. They threatened strike, lobbying for formal incorporation into the Ministry of Health, plus bicycles, notebooks, and raincoats. What is the afterlife of intervention (McKay 2012)—for those who live with the residue of emergency, or for those able to move in and out of its topos? The Guinea Worm Eradication Program trained literally hundreds of thousands of village volunteers during the course of its campaign, a brittle network of health workers that may inflect claims to other futures. I wonder, will the bookkeepers continue their record work in the face of death? Who will collect it? Although some people envisioned that the community surveillance books might be part of the eradication program’s legacy in Ghana, speaking in the language of ‘‘integration’’ and hoping that the national government would continue working with this tool to monitor other diseases, the question was supercharged by years of tension between guinea worm and other government programs that received much less funding and international fame for their public health efforts. But at the same time, such relics hold meaning and can continue to shape realities whether or not they become part of a larger policy change. I once watched a ‘‘Red Cross mother’’ practicing guinea worm educational material with a small circle of children, though the parasite had died out there years earlier. She was teaching them to read with the nicest children’s book in her village. These traces also marked a much broader ‘‘projectized’’ landscape (Good, Good, and Grayman 2010)—like the research study numbers written as if they were addresses on the doorways of many village homes, then crossed out again and different numbers repainted, palimpsests of intervention that became people’s coordinates in larger worlds. Many villages throughout Ghana still feature murals about guinea worm on the chipped

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mud walls of houses and market squares, often lasting for years after the parasite itself has been eliminated from a community—artifacts of an emergency’s moving frontier. Some communities even requested permission to repurpose former guinea worm ‘‘case containment centers’’ as the first school or clinic in their village. As people engage or inhabit the roles, residues, ephemera, and even ruins of intervention, life unfolds on other intervals. Since I left Northern Ghana, victory over guinea worm has been declared, but the emergency of everyday life goes on. It is estimated one in three children in Gushegu District has kwashiorkor (Gyebi 2010), and approximately 80 percent of the rural population does not have access to clean water (World Bank 2011). The Northern Region’s six ‘‘witch camps’’ now house over ten thousand refugees driven from their villages by accusations of paranormal practices, which David Tait traces to the political insecurity in the years leading up to the first national coup, as people ‘‘fear the disappearance of the school, hospital, and other services’’ (1963: 145; c.f. James 2010). There have been repeated outbreaks of ethnic violence, including the 2011 nomad killings that became known in the media as the ‘‘Fulani massacre.’’ It was hoped that eliminating guinea worm would help recuperate the economy and stabilize precarious existence in the area. But the number of poor in Ghana’s Northern Region increased by 0.9 million in the years corresponding with guinea worm eradication—insecurity due in no small part to international trade policies that flood local markets with cheap imported food, making it increasingly difficult for local farmers to sell their crops (what some social scientists have called the ‘‘tapeworm of neoliberalism’’). Approximately 68 percent of people in rural Northern Ghana now survive on less than a dollar a day, poverty rates between double and quadruple those in the south of the country (World Bank 2011). Although guinea worm nylon filters and chemical larvicides were intended as a ‘‘quick fix’’ technology to interrupt transmission in twelve months and serve as a temporary exception to the need for infrastructural clean water projects, in Ghana the eradication campaign ultimately stayed for twenty-three years—an extended war against a single target that at times drained resources from other priorities and became part of a long-term presence on the ground. In this, and its attendant community relationships charged with ambivalent meanings that continue to shape-shift over time, perhaps the fight against guinea worm has unfolded on an interval much like any other war.

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Note I am very grateful to Ghana Health Service, the Ghana Guinea Worm Eradication Program, and members of the Carter Center in both Tamale and Atlanta for their early support of this research. This ethnographic description of the campaign’s social complexities and ambiguities—anthropological interpretations that are mine alone, and for which I accept full responsibility—are offered here in the spirit of mutual care and critical inquiry, with respect for their dedication and difficult work. This research was approved by the Ghana Health Services Ethical Review Committee and the Princeton University Institutional Review Board. Fieldwork was funded by the West African Research Association, the Princeton Center for Health & Wellbeing, the Princeton Health Grand Challenges Initiative, and the Princeton Development Grand Challenges Initiative. I thank Joa˜o Biehl, Carolyn Rouse, Jim Boon, Carol Greenhouse, Emily Cohen, Sharon Abramowitz, Catherine Panter-Brick, and all the participants of the University of Florida workshop for their thoughtful readings. Warm thanks to the Department of Anthropology at Princeton and to the many people in Tamale and the surrounding communities of Northern Ghana who shared their hospitality, reflections, and experiences with me.

References Afele, Mawusi. (2009) ‘‘Countdown to Wipe Out Guinea-Worm in Ghana.’’ Bulletin of the WHO 87: 649–650. Allen, Tim and Melissa Parker. (2012) ‘‘Will Increased Funding for Neglected Tropical Diseases Really Make Poverty History?’’ The Lancet 379 (9821): 1097–1098. Benjamin, Walter. (1968) ‘‘The Task of the Translator.’’ In Illuminations, 69–82. New York: Harcourt Brace Jovanovich. Biehl, Joa˜o and Adriana Petryna. (2013) ‘‘Critical Global Health.’’ In When People Come First: Critical Studies in Global Health, 1–22. Princeton, NJ: Princeton University Press. Bierlich, Bernhard. (1995) ‘‘Notions and Treatment of Guinea Worm in Northern Ghana.’’ Social Science & Medicine 41 (4): 501–509. Bittner, Egon. (1980) The Functions of the Police in Modern Society. Bethesda, MD: National Institute of Mental Health. Bourne, Peter. (1982) ‘‘Global Eradication of Guinea Worm.’’ Journal of the Royal Society of Medicine 75: 1–3. Brieger, William, Sakiru Otusanya, Joshua D Adeniyi, Jamiyu Tijani, and Muyiwa Banjoko. (1997) ‘‘Eradicating Guinea Worm Disease Without Wells: Unrealized Hopes of the Water Decade.’’ Health Policy and Planning 12: 354–362. Cairncross, Sandy, Ahmed Taylor, and Andrew Seidu Korkor. (2012) ‘‘Why Is Dracunculiasis Eradication Taking So Long?’’ Trends in Parasitology 28 (6): 225–230. Calhoun, Craig. (2010) ‘‘The Idea of Emergency: Humanitarian Action and Global (Dis)order.’’ In Contemporary States of Emergency: The Politics of Military and

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Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 29–58. New York: Zone Books. Carter, Jimmy. (2010) ‘‘Sudan Can Rid World of a Horrible Disease.’’ CNN International Edition. http://edition.cnn.com/2010/OPINION/04/06/jimmy.carter .disease/index.html. Accessed July 15, 2011. Carter Center. (2003) ‘‘Guinea Worm ‘Warrior’ Fights Disease in Southern Sudan.’’ http://www.cartercenter.org/news/documents/doc1478.html. Accessed August 3, 2011. ———. (2004) ‘‘Reflections from Africa, February 3–5: Ghana.’’ Carter Center: News & Publications. http://www.cartercenter.org/news/documents/doc1608.html. Accessed January 8, 2009. Cueto, Marcos. (2007) Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975. Baltimore: Johns Hopkins University Press. DuPont. (2012) ‘‘History of DuPont & the Government.’’ www2.dupont.com/Govern ment/en_US/gsa_contracts/Government_Projects.html. Accessed November 15, 2012. Fassin, Didier. (2010) ‘‘Noli Me Tangere: The Moral Untouchability of Humanitarianism.’’ In Forces of Compassion: Humanitarianism Between Ethics and Politics, edited by Erica Bornstein and Peter Redfield, 35–52. Santa Fe, NM: School for Advanced Research. Gallagher, Catherine and Stephen Greenblatt. (2001) Practicing New Historicism. Chicago: University of Chicago Press. Good, Mary-Jo DelVecchio, Byron J. Good, and Jesse Grayman. (2010) ‘‘Complex Engagements: Responding to Violence in Postconflict Aceh.’’ In Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions, edited by Didier Fassin and Mariella Pandolfi, 241–266. New York: Zone Books. Gyebi, Edmond. (2010) ‘‘Ghana: One Out of Three Children Suffers Kwashiorkor in Gushegu.’’ The Chronicle, January 28. http://allafrica.com/stories/2010012807 53.html. Accessed January 28, 2011. Hopkins, Donald and P. Craig Withers. (2002) ‘‘Sudan’s War and Eradication of Dracunculiasis.’’ The Lancet 360 (s1): s21–22. Hopkins, Donald. 1992. ‘‘Honing in on Helminthes.’’ American Journal of Tropical Medicine and Hygiene 46: 626–34. James, Erica. (2010) Democratic Insecurities: Violence, Trauma, and Intervention in Haiti. Berkeley, CA: University of California Press. Lederberg, Joshua. (2000) ‘‘Infectious History.’’ Science 288 (5464): 287–293. McKay, Ramah. (2012) ‘‘Afterlives: Humanitarian Histories and Critical Subjects in Mozambique.’’ Cultural Anthropology 27 (2): 286–309. McNeil, Donald G. (2006) ‘‘Dose of Tenacity Wears Down Ancient Horror.’’ New York Times, March 26. Moran-Thomas, Amy. (2013) ‘‘A Salvage Ethnography of the Guinea Worm: Witchcraft, Oracles, and Magic in a Disease Eradication Program.’’ In When People

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Come First: Critical Studies in Global Health, edited by Joa˜o Biehl and Adriana Petryna, 207–239. Princeton, NJ: Princeton University Press. Redfield, Peter and Erica Bornstein. (2010). ‘‘An Introduction to the Anthropology of Humanitarianism.’’ In Forces of Compassion: Humanitarianism Between Ethics and Politics, edited by Erica Bornstein and Peter Redfield, 3–30. Santa Fe: School for Advanced Research Press. Reynolds Whyte, Susan, Sjaak van der Geest, and Anita Hardon. (2002) Social Lives of Medicines. Cambridge, UK: University of Cambridge Press. Samsky, Ari. (2011) ‘‘Since We Are Taking the Drugs: Labor and Value in Two International Drug Donation Programs.’’ Journal of Cultural Economy 4 (1): 27–43. Stepan, Nancy Leys. (2011) Eradication: Ridding the World of Diseases Forever? Ithaca, NY: Cornell University Press. Tait, David. (1963) ‘‘A Sorcery Hunt in Dagbon.’’ Africa: Journal of the International African Institute 33 (2): 136–147. Turkle, Sherry. (2007) ‘‘Introduction: The Things That Matter.’’ In Evocative Objects: Things We Think With, 3–11. Cambridge, MA: MIT Press. USAID. (1992) ‘‘Helping Communities to Eradicate Guinea Worm: A Training Guide.’’ Water and Sanitation for Health Project Report No. 322. Prepared by William Brieger on behalf of U.S. Peace Corps and USAID. Washington, DC. http://pdf.usaid.gov/pdf_docs/PNABN813.pdf. Accessed January 8, 2014. Wald, Priscilla. (2008) Contagious: Cultures, Carriers, and the Outbreak Narrative. Durham, NC: Duke University Press. Watts, Susan. (1998) ‘‘Perceptions and Priorities in Disease Eradication: Dracunculiasis Eradication in Africa.’’ Social Science & Medicine 46: 799–810. World Bank. (2011) ‘‘Republic of Ghana: Tackling Poverty in Northern Ghana.’’ PREM 4/AFTAR Africa Region. Accra, Ghana. http://documents.worldbank.org/ curated/en/2011/03/14238095/tackling-poverty-northern-ghana. Accessed September 9, 2012. World Health Organization (WHO). (2012) ‘‘Dracunculiasis Eradication: Global Surveillance Summary, 2011.’’ Weekly Epidemiological Record 87: 177–188.

Chapter 12

Medical NGOs in Strong States: Working the Margins of the Israeli Medical Bureaucracy Ilil Benjamin

Anthropological literature on medical nongovernmental organizations (NGOs) and states has often emphasized their discordant relationship. The retreat of developing states from medical and welfare services in the wake of late twentieth-century structural adjustment programs is regularly presented as an important catalyst for the global humanitarian aid industry. Anthropologists, in turn, have keenly examined how NGOs operating in weak or war-torn regimes can inadvertently delay the creation or repair of governmental healthcare systems by serving as indefinite, and often unwilling, stopgaps or crisis attenuators (Feldman 2009, Redfield 2012). Such research, while acknowledging close interactions among governmental and nongovernmental actors, has tended to stress tensions among them. This chapter, while grounded in these tensions,1 explores not the tensions themselves but rather the daily aid collaborations that take place among governmental and nongovernmental actors, sometimes in secret. In what follows, I use the case of Israel and its population of roughly sixty thousand sub-Saharan asylum seekers to exemplify how nongovernmental aid practitioners in strong-state settings can make use of both nongovernmental and governmental resources to obtain medical services for excluded migrant and refugee populations. I argue that in Israel, this process involves neither simply creating a parallel healthcare system nor

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diverting governmental resources on the sly. Rather, it involves a complex array of both opaque and transparent agreements between NGO staff and governmental actors. It is important to note that these alliances rarely disturb the public impression of ideological rivalry between governmental and nongovernmental spheres. Anthropologists of medicine have long been interested in therapeutic itineraries, which Vinh-Kim Nguyen defines as ‘‘heterogeneous and uneven congerie[s] of practices and techniques’’ that people undertake in an effort to obtain medical and healing treatment (2005: 126). Globally, what we might think of in strong-state contexts as ‘‘improvised’’ medical practices are not the exception but the norm. For example, as Helle Samuelsen (2004) shows, villagers in rural Burkina Faso obtain treatments through a mixture of local healers, diviners, marketplace peddlers of Western pharmaceuticals, and sparsely equipped, poorly attended governmental clinics. In the occupied Palestinian West Bank, residents in search of specialized treatment must negotiate a bewildering array of private clinics, foreign NGOs, local civil society organizations, Palestinian Authority hospitals, and hospitals run by the United Nations Relief and Works Agency (Schoenbaum, Afifi, and Deckelbaum 2005). Since these are not well-coordinated systems, navigating among them often poses a considerable challenge for patients, as knowledge about which source provides what care is rarely centralized, and the offerings themselves are ever-changing. Finally, even in the United States, which to date lacks a single-payer public healthcare system, medical practitioners and patients alike find both leniency and loopholes in both public and private insurance policies in an effort to secure treatments (Horton 2006). Improvising medical services outside the bureaucratic state, then, is by no means exceptional on a global scale. Yet it poses an important ethical dilemma for NGOs who participate in this economy, as their participation can encourage state healthcare systems to remain stagnant or exclusionary. This dilemma is often referred to the aid literature as NGOs’ ‘‘double bind’’ problem (Redfield 2012) or ‘‘fig leaf’’ problem (Castan˜eda 2011). Heide Castan˜eda (2011) illustrates how NGO doctors in Germany, whose publicly funded healthcare system does not extend to undocumented migrants, come to realize that their work is not a temporary exception but rather an indefinite replacement for the governmental system. Sarah Willen (2011, 2012) and Gottlieb, Filc, and Davidovitch (2012) demonstrate how agonizing such a realization can be for NGO practitioners in Israel, some of whom

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insist that alleviating mass suffering themselves will sabotage any possibility of governmental policy reform, as others counter that sick or dying people should not have to wait in vain for governments to change their policies. Scholars like Castan˜eda, Willen, and Gottlieb and colleagues focus primarily on the ethical dilemmas accompanying humanitarian medicine in strong states. But less is known about how treatments are actually improvised in these settings on a day-to-day basis. In this chapter, therefore, I seek to give an example of how a medical NGO actually operates in parallel to a highly developed medical bureaucracy in an effort to provide lifesaving medical care to patients officially excluded from it. Where do the treatments come from? How are they negotiated? What tacit alliances and loopholes are necessary to obtain diagnostic tests, medication, and surgical treatments via unofficial channels?

Governmental and Nongovernmental Healthcare in Israel I use Israel as a strong-state example because it has a well-established public healthcare system with clear policies of inclusion and exclusion. Healthcare in Israel has been regulated since 1994 by a universal taxation-based insurance system that extends to all Israeli citizens and permanent residents but to date largely excludes undocumented migrants and asylum seekers (Filc 2009). The latter two groups are entitled unconditionally to emergency treatment in government hospitals (for which they are later billed) but not to any state-sponsored primary or secondary care—unless they can pay for it up front.2 To illustrate nongovernmental humanitarianism in this political space, I draw on ethnographic fieldwork that I conducted in 2011–2012 in an Israeli human rights NGO I call AHE (Activists for Health Equality).3 Medical volunteers at the AHE clinic are not the short-term expatriates we might expect to find in larger global NGOs. Rather, crucially, they are primarily Israeli medical professionals with current or previous day jobs in either public or private Israeli hospitals that are all overseen by the Ministry of Health. Their day jobs give them vital access to resources and contacts within the state medical system that make their after-hours humanitarian work possible. I argue in this chapter that despite AHE’s staunch public opposition to working with the government on everyday solutions rather than on policy

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reform, providing aid is indeed often a matter of finding allies within the system who are willing to overlook or stretch the rules. Aid at AHE involves semipublic collaborations with government actors that resemble what Michael Taussig (1999) has called a ‘‘public secret’’—something many people know about but are hesitant to articulate in certain public spheres. I begin by describing some of these agreements. Next I attempt to show that even though governmental healthcare is often deemed anchored in policy, while nongovernmental aid is seen as dependent upon charity and humanitarian compassion of volunteers and donors, in practice, questions of compassion and charity matter considerably in both the governmental and nongovernmental spheres. Collaborations among them, therefore, question the conventional distinction made between official and unofficial channels of medical care in the Israeli context.

AHE and Asylum Seekers in Israel Since the mid-2000s, more than sixty thousand asylum seekers and undocumented migrants have entered Israel through the Sinai desert, many of them fleeing violence and forced conscription in Sudan and Eritrea, respectively (Gottlieb, Filc, and Davidovitch 2012, Willen 2011). Despite being a signatory to the 1951 United Nations refugee convention, the Israeli Ministry of Interior (MOI), operating in a climate of growing public xenophobia and concern about non-Jewish migration, has either rejected or declined to adjudicate the vast majority of asylum claims filed during in this period. However, mindful of UN warnings about state oppression and ethnic violence in Sudan and Eritrea, the MOI has hesitated to deport asylum seekers outright, granting the majority of them three-month visas without work or healthcare rights (Nesher 2012). In mid-2013, the Israeli government also began deporting thousands of asylum seekers and imprisoning thousands of others, including women and children, sometimes in closed detention centers and sometimes in open-air facilities that were nominally open during the day but were in effect prisons. AHE is the largest and most prominent medical NGO in Israel. Founded in 1988, AHE has always combined medical aid to uninsured populations residing in Israel with longstanding advocacy campaigns for governmental healthcare reform, founded upon a commitment to healthcare as a universal human right and an accompanying critique of the Israeli

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government’s exclusion of noncitizens from this right. AHE’s high-profile and outspoken campaigns have often put it in fractious relations with the Israeli government and with certain sectors of the Israeli public. AHE’s walk-in medical clinic, which opened in 1998, initially aimed to care primarily for migrant workers from South and Southeast Asia and Eastern Europe. But by the mid-2000s, the clinic, now staffed by several hundred rotating physicians, nurses, physical therapists, mental health professionals, and medical students, had also become the primary healthcare provider for tens of thousands of sub-Saharan asylum seekers and economic migrants, many of whom lived in cramped conditions or even on the streets in south Tel Aviv and without access to governmental healthcare or work permits. By 2012, AHE’s free clinic had treated over thirty thousand patients, averaging about forty-five per night since 2007. Although the clinic receives some funding from the United Nations High Commissioner for Refugees and from various foreign governments, the money is not nearly enough to tend to the medical needs of the uninsured population in Israel. Those who require specialized treatment and cannot afford to pay for it thus pose a crucial problem for AHE volunteers. Acute cases can be sent to local hospital emergency rooms, but chronic or terminal illnesses cannot be routed through state bureaucratic channels. Therefore, it is up to AHE volunteers to find medical allies throughout the country to take these patients pro bono or to negotiate discounts or free treatments in local hospitals under varying degrees of secrecy and deception. The clinic was initially set up in 1998 only to provide limited primary care to uninsured residents of Israel and to gather information on their medical needs for advocacy purposes. Treatment for chronic and terminal illnesses was not part of the original plan; this was considered not only too ambitious but also the rightful province of government, not a poorly funded humanitarian nongovernmental clinic. But over time, as the clinic’s current caseworker for oncological patients, Luisa, explained, many of the clinic’s volunteers began to regularly seek out treatments for chronic and life-threatening illnesses. Their growing successes reflected not only their unwillingness to forsake dying patients but also the growing strength of their increasingly intricate networks of allies. As Luisa explained, ‘‘We can’t let the man die while he’s waiting for an answer [from the government]. We’ll get him a combina and at the same time go to the Ministry of Health.’’ The word combina (plural: combinot)

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in Hebrew is a common colloquial term meaning roughly ‘‘to bend the rules’’ or to persuade a bureaucrat to look the other way. The term is invested with a particular Israeli flavor: in such a small country, combinot are often bolstered by knowing your target of persuasion directly or indirectly through friends, family, or past army service. Whatever combinot AHE volunteers managed to enact on behalf of their patients were owed to their day jobs in governmental medical institutions and hence to the goodwill of key colleagues, friends, and bureaucrats. What began as a series of fitful improvisations by tenacious volunteers became over time a system of extensive, though fleeting, arrangements spanning the entire country. In what follows I describe some of these arrangements, focusing primarily on oncological (cancer) treatments because of space considerations.

Sneaking Patients into Hospital Emergency Rooms In 2009, a young Eritrean asylum seeker arrived at the clinic with a malignant brain tumor. AHE volunteers, unaccustomed to seeing cancer in this young, relatively healthy population, were at a loss at first. Although the diagnosis itself was possible thanks to a donated brain scan, the organization had no funds to pay for surgery, radiation, or chemotherapy treatments. Moreover, they could not simply refer him to a local hospital for this kind of condition. According to Israel’s 1996 Patient’s Rights Act, any person presenting at a hospital emergency room (ER) with a condition that poses immediate threat to life or limb must be treated without regard to their ability to pay (Filc 2009). But even metastatic cancer does not count here as immediately life-threatening unless death is imminent. Without AHE, the only thing a patient without insurance and without money for private care could do in this situation was wait until his cancer caused an immediate threat to life or limb or until ‘‘he would die from it literally tomorrow,’’ as one volunteer once put it with a glimmer of dark humor. But by then, the cancer would also likely have spread throughout his body and saving his life might become impossible. Furious at this possibility, Sandra, an energetic thirty-something AHE volunteer, began to make phone calls to colleagues and hospitals all over the country. Eventually she found a sympathetic colleague at work willing to do her a favor and fib to his superiors that the man was suffering from

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intracranial bleeding thanks to the tumor, a false but plausible diagnosis certain to satisfy the Patients’ Rights Act constraints. The young patient was immediately admitted to the emergency room and then into brain surgery, where his tumor was removed. Recounting the story to me a couple of years later, Sandra went to great lengths to explain that this was not a matter of simple deception. Rather, she saw in it an example of benevolent complicity among doctors and sometimes also hospital administrators. For Sandra, although the system looked exclusionary on paper, most of its workers did not share these convictions, and it was thanks to them that AHE could quietly obtain a good deal of lifesaving treatment for uninsured patients: ‘‘The lie is never between a doctor and doctor. The lie is a tiny lie in the entry to reception. Again, this is a patient who without surgery would eventually become emergency room worthy, but [using this excuse] we could prevent metastasis and help save his life. The administrators often understand this, but the government and the Ministry of Health don’t understand this. It requires basic cooperation between people. Everyone knows the name of the game and plays it.’’ Although Sandra’s description here suggests a well-oiled machine of quiet collaborations among eager, like-minded professionals, AHE volunteers’ ability to negotiate treatments like Sandra did was in fact fraught with contingency and failure. For example, although surgery was indeed sometimes immediately obtainable under the pretense of emergency, longterm treatments like chemotherapy were more complex to obtain since they took time to administer and thus more easily evoked hospital bureaucrats’ suspicions that a patient had a life-threatening but not emergency condition. Well-connected hospital insiders, moreover, were a rare asset, and even allies often hesitated to sneak patients into the ER more than once or twice for fear of risking their jobs. Luisa, the AHE caseworker for oncological patients, once showed me an email from a physician and trusted friend working in the emergency ward of a nearby hospital. They corresponded regularly, and he had often helped her personally or connected her to empathic colleagues. One day she sent him the diagnostic details of an oncological patient needing surgery but still at a relatively early stage of the disease. She did not ask him outright if he would sneak the man into the emergency operating room. Instead she wrote, as usual: ‘‘Can you please have a look at the attached case and tell me what you’d recommend for treatment?’’ The physician, immediately savvy and sympathetic to her plight, answered with an equally subtle but brief response, saying he was

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sorry but it (the still unnamed favor) would be too risky and maybe she could find another insider to help out. Luisa showed me his email and said, ‘‘Look, see? This is how he puts it. Sometimes I feel more like a petty bureaucrat at the Ministry of Health, sitting here in this office, typing things up and telling patients no.’’ Other barriers to the hospital emergency room complicated AHE’s work still further. For example, in violation of the Patient’s Rights Act, receptionists in numerous public hospitals were often instructed by their superiors to demand advance payment or payment guarantees from uninsured migrants, which caused many asylum seekers to leave the hospital even when in need of emergency treatment. And even before reaching the reception desk, armed security guards at each hospital were a fearsome sight for many asylum seekers and undocumented migrants, who were known to flee for fear of being reported to immigration police. When AHE volunteers were successful at getting uninsured patients into hospital emergency rooms (whether for immediate life threats or for other illnesses presented as emergencies), those treatments were given immediately and billed to the patient later on. Most of these bills went either entirely or mostly unpaid. Hospitals knowingly absorbed these costs and then negotiated their debt grievances, often unsuccessfully, with the Ministry of Health. But nonemergency treatments usually required advance payment or a guarantee of payment from uninsured patients. In such cases, AHE volunteers would try to find specialists who would agree to perform procedures for free or for a large discount, leaving only the surgical rooms, equipment, and medications to pay for. If willing specialists were indeed found, patients themselves were sometimes able to pay some of the remaining costs with their wages or with the help of relatives or friends. If such patients could not acquire any funds, AHE might chip in, although its budget for medical procedures was very limited, and choosing which cashstrapped patients to help in this way invariably involved heart-wrenching decisions. Sandra, meanwhile, was sometimes able to circumvent the hospital system altogether, using, for example, donated chemotherapy pills that could be administered outside hospital settings. Over time, she developed a wordof-mouth reputation as a hoarder of pills for refugees, and oncologists all over the country began sending her surplus medications, some of them happily donated by relatives of deceased patients in the hope that they would save others. In one case, Sandra even administered chemotherapy

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injections herself, including most notably a young Hodgkin’s lymphoma patient, who received the injection every morning on the sidewalk below the north Tel Aviv construction site where he worked. AHE volunteers sometimes found hospital administrators who would waive a fee or consider a patient’s debt paid once a small percentage of the payment had been provided. But such acts of compassion were difficult to predict. AHE volunteers could rarely estimate how many patients had been saved or how many they might save in the future because policies, treatment prices, and contact networks were frequently changing, making it difficult to codify past successes in a way that could serve future efforts. Discounts were temporary, and most contacts within the governmental system were often a result of the connections of a few charismatic AHE members like Luisa or Sandra. This gave an overall air of worry and impermanence to daily work at AHE, raising questions about what would happen to hundreds of seriously ill patients if Sandra or Luisa were to leave. And despite the latter two’s best efforts, many patients did languish for months or longer without treatment, causing them considerable suffering and dismaying AHE volunteers who spent countless hours making anguished pleas on their behalf.

Hospital Lines of Credit Over time, what had begun at AHE as painstaking, rarely successful efforts to obtain complex treatments for uninsured patients gradually transformed into semiroutine strategies, though still marked by high rates of failure. Given the frequency with which access to treatment failed for one reason or another, any news of success was commonly greeted at AHE with a grateful sense of a narrow escape. Some strategies did take on a quasiinstitutional regularity: ‘‘He has condition X? OK, refer him for bloodwork at Hadassah hospital, we currently have an 80 percent discount with them.’’ Meanwhile, other techniques or arrangements just as easily dissipated without warning or explanation; some volunteers greeted this situation with cynicism while others responded with a redoubled determination to find other sources of treatment. One day Sandra approached several of her hospital’s senior administrators, furious about the recent death at the hospital of an asylum seeker with severe asthma who had been refused lifesaving treatment there for financial

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reasons. ‘‘I’d written a letter to the head honcho [at the hospital],’’ Sandra later recounted to me, ‘‘and told him politely that I thought he was responsible [for her death]. She died because of twenty thousand shekels, which is nothing. And really,’’ she added, ‘‘it’s not twenty thousand shekels. Because when hospitals price things, they charge you for electricity and for the water in their toilets [too]. The actual procedures don’t cost that much.’’ The senior administrator, she said, was ‘‘basically a good man’’ and agreed to open a silent line of credit at the hospital for Sandra for free oncological treatments for asylum seekers and economic migrants. As she explained, the line of credit was ‘‘not official, since a governmental hospital can’t say it’s donating public funds. It’s not the hospital’s money. So honestly, it’s the good motivation of a lot of people willing to broaden the boundaries of what’s allowed. But it’ll never be in the newspaper. So I always tell AHE staff ‘don’t publicize it, it needs to be quiet.’ But inside the hospital I’m no longer quiet. I already have a fund I know I can use and that it’s procedurally okay. All these little lies—I don’t have to do those anymore.’’ This line of credit presented an interesting ambiguity concerning the role of secrecy in AHE volunteers’ work. On the one hand, high-ranking hospital administrators knew about this line of credit and approved it. On the other hand, this practice employed public funds in defiance of government policy to deny noncitizens publicly funded healthcare. This line of credit thus became a ‘‘public secret’’ (Taussig 1999). Though several individuals knew about it, some of whom had to sign documents and provide verbal or written approvals to enable it to operate, official policies or written protocols were out of the question. These actors had to walk a fine line between discussing and keeping silent about such arrangements. For example, Tom, AHE’s executive director, was happy to describe the line of credit to me but asked me not to interview hospital administrators out of concern that too many questions might cause the funds to disappear. Uncertainty persisted, moreover, over whether this quasi-official line of credit was a matter of routine or exception. As Sandra put it, ‘‘It’s an agreement where I bring people in and the hospital approves. How much? I don’t know. What’s the limit? I don’t know, it’s not official. If I stretch the line too much it’ll rip.’’ Indeed, while Sandra’s fund lasted throughout my time at AHE, unofficial funds in other hospitals periodically dried up with little or no warning, forcing AHE volunteers to find alternative solutions quickly or report the sad news to their patients.

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Another AHE volunteer, Avi, an internist, oversaw a different sort of fund at another hospital. Whereas Sandra’s line of credit emerged in the wake of her patient’s preventable death and reflected in her estimation at least partly the temporary contrition of her superiors, the ‘‘Avi fund,’’ as it was regularly called among AHE volunteers, owed its existence to a more stable arrangement among governmental and nongovernmental actors. As both Avi and Tom put it, the ‘‘Avi fund’’ reflected a logic of cost containment (Filc and Davidovitch 2005). Reasoning that acute care was more expensive than preventive care, some hospitals would habitually give uninsured patients a certain amount of free diagnostic testing each month— primarily blood and imaging tests—to ease traffic in their emergency rooms later on. Cost-containment justifications were easier to discuss publicly than funds like Sandra’s or slapdash emergency room break-ins. Indeed, in its campaigns for healthcare reform, AHE always cited governmental research showing that including asylum seekers in a comprehensive governmental healthcare plan would save the Israeli Ministry of Health money in the long run, since emergency room expenses for this population would then decline significantly. Media reports on refugees in Israel likewise occasionally mentioned the same economic arguments, lending them additional public legitimacy (Even and Nesher 2013). Still, such discounts, it is important to add, were not given in every hospital. Hospitals that did consent to such arrangements often had to have compassionate bureaucrats situated in high places or ones who knew the loopholes in their own systems. For those among them who either had a broad commitment to universal healthcare or felt compassion for uninsured populations, opening a line of credit was sometimes just a matter of persuading the right colleague that this was a good idea, knowing how much debt the hospital could absorb and stretching the boundaries a bit more, or, if all else failed, justifying the discount to superiors on cost-containment grounds. If cost-containment exceptions were less of a secret than sneaking patients into an ER, then exceptions made for public health reasons were even easier to discuss openly and to sell to the Israeli public as lying within the interests of the Jewish state. In January 2013, the Ministry of Health released an extraordinary statement claiming that ‘‘the absence of [governmental] medical support for refugees could impact the local population and the Israeli public at large’’ (Even and Nesher 2013). Such a statement was taken at AHE as a significant advocacy milestone, for it marked a rare

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admission by the Israeli government of its own medical responsibility toward the asylum-seeking population. However, the claim also elicited widespread fear throughout Israel of potential outbreaks of malaria, tuberculosis, and other illnesses long considered extinct in Israel but sporadically found in the asylum-seeking population. Such xenophobic outbursts notwithstanding, it is public health considerations like these that have prompted the Ministry of Health to give free tuberculosis (TB) tests to anyone seeking them, regardless of their legal status in the country. AHE volunteers would routinely use this policy to their advantage—but not just for TB. For example, in early 2012 when a young male patient arrived at the clinic with suspected broken ribs, two whimsical AHE volunteers promptly sent him to the governmental TB clinic for a chest X-ray under the pretext of suspected TB. They did not suspect TB, but neither he nor AHE could afford to pay for a standard chest X-ray, and they knew a TB chest X-ray would work just as well. When another patient soon arrived with a suspected broken wrist, the volunteers joked that it was a shame they couldn’t have him go there as well and stick his wrist in the X-ray machine while undergoing the chest exam.

Limits to Humanitarian Compassion Despite the nearly banal routine apparent in many of these arrangements, hospital lines of credit and colleagues’ willingness to work pro bono followed their own particular ethical logics. It was common knowledge among AHE volunteers, for example, that life-threatening illnesses like cancer elicited more sympathy and were thus easier to obtain treatments for than were chronic but non-life-threatening conditions. It was important for many AHE volunteers to know that they had saved lives. But fewer of them were willing to expend as much time or personal resources to treat conditions that merely limited a stranger’s quality of life. For instance, a middle-aged economic migrant once arrived at the clinic with chronic ankle problems that limited her ability to work as a cleaner. She tearfully begged Luisa, the caseworker, to raise the money for her to have ankle surgery. Luisa responded dispassionately that there was little chance she’d be able to raise that money or find a surgeon who would operate for free. ‘‘Orthopedic cases are the hardest for find funding for,’’ Luisa later told me with frustration, an opinion that other AHE volunteers confirmed. ‘‘Who’s going to care about this one refugee’s ankles?’’

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With orthopedic cases, Luisa said, a patient usually got lucky only if an orthopedist somewhere happened to find his or her case interesting enough to take on pro bono. Such constraints show that despite many AHE volunteers’ in-principle commitments to universal healthcare as a human right, humanitarian compassion is more limited and capricious. For most volunteers, saving a life was much more interesting, pleasurable, heroic, and altogether worth the trouble than fixing an arthritic joint. Luisa was reminded of this fact every day as she fielded desperate requests from patients for non-lifesaving care. Care that depended so much on individual generosity, instead of being enshrined in law, Luisa told me, could precisely for this reason never become a sustainable solution to these refugees’ plight. When treatments could not be obtained, patients often remained under follow-up until enough money could be raised for treatment—either by donations or by patients themselves. If neither became possible, patients’ conditions sometimes deteriorated enough to merit emergency care under the Patient’s Rights Act. But emergency room care did not always treat the underlying conditions successfully. ‘‘Most of them die silently,’’ Sandra once speculated regarding oncological patients who didn’t know AHE existed or who failed to obtain treatment there. ‘‘Or they end up at the ER after metastasis has occurred and get only palliative care.’’ As we have seen, AHE volunteers regularly sneak patients into hospital emergency rooms, reach out to colleagues for pro bono treatments, negotiate temporary lines of credit in certain hospitals, and appeal to costcontainment and public health logics as rationales for financing treatments using government money. Hospital administrators, invariable employees of the state, usually remained oblivious to such arrangements, but sometimes they compassionately enabled or even encouraged them under varying degrees of secrecy, blurring to an extent the boundaries between official and unofficial channels of care. Nevertheless, resources remained scarce, and ethical hierarchies of deserving (Willen 2011) limited who got what kinds of care. For the most part, it has been in AHE’s interest to keep these arrangements quiet in order to maintain AHE’s image as an unyielding fighter for policy reform rather than an instigator of Band-Aid solutions like discounts at hospitals. Should such arrangements become widely known, they would not only harm AHE’s public image but also potentially impair its advocacy efforts by dulling the appearance of crisis. In the final part of the chapter, I

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speculate briefly regarding the degree to which AHE’s strategies could be found in other strong-state contexts.

Conclusion: Humanitarian Medicine in Strong States To what extent are these improvised strategies unique to Israel? What are their limits? Could the same kinds of loopholes and deals be obtained in other strong-state contexts? These are important questions that warrant additional empirical research, but here I will simply speculate. First, a significant percentage of the improvisations described here were possible only because most AHE volunteers were themselves employed within the state medical bureaucracy. Thus this chapter can say little about what strategies and knowledge would be required of short-term expatriates or noninsiders working in settings where they possess little local expertise or power. At the same time, while this chapter is ethnographically grounded in Israel, it may still shed considerable light on other strong-state contexts. As shown in Heide Castan˜eda’s (2011) and Miriam Ticktin’s (2006) studies of medical humanitarianism in Germany and France, respectively, workable margins exist in all state healthcare systems. Their size varies, but NGOs everywhere learn to exploit them to save lives and alleviate suffering, with greater or lesser degrees of cooperation from low- and high-ranking government employees. During volunteer work in a free clinic in upstate New York in late 2012, for example, I was happy to find that its American volunteers, like AHE’s volunteers, possessed their own vast knowledge of nearby hospitals’ discount programs and of regulatory loopholes in the labyrinthine American healthcare system, which they used to help uninsured patients find lifesaving treatments, though often with greater transparency and bureaucratic approval than in the AHE case. AHE volunteers would not have been surprised. In Holland or Germany, Luisa once speculated, she would not have been able to sneak as many patients into a public hospital’s emergency room, but she might have found other ways to collaborate. For example, Italy’s AHE counterpart, Tom reported in 2012, was collaborating with the Italian government to help undocumented migrants in clinics partly funded by the government. Meanwhile, AHE volunteers credited their own successful combinot mainly to Israel’s relatively small medical community, where it was not uncommon

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for an oncologist to know every other oncologist in the country. In this sense, AHE should perhaps be considered not an alternative to the governmental system but a mirror of it, for AHE’s brand of lifesaving has been possible largely because ‘‘everything in Israel works on the combinot system,’’ as Tom put it. Indeed, in June 2013, The Marker, an Israeli newspaper, ran a critical story about the growth of private healthcare in Israel, which increasingly operates in parallel to the public system (Linder-Ganz 2013). Some treatments were migrating to the private system, which low-income patients could not afford. Aghast, several physicians now reported having to ‘‘activate personal contacts’’ to obtain treatments or to ‘‘refer their patients to emergency rooms’’ in ways they saw as ‘‘inappropriate.’’ One AHE volunteer laughed at the article, telling me, ‘‘Don’t they already do this?’’ His humorous reaction suggested that the AHE, in its efforts to work the margins despite operating in a zone of legal and regulatory exception, modeled itself after widespread local norms of practice. Notes 1. These tensions are not meant to imply that aid collaborations between governmental and nongovernmental actors are unique or rare; they are not. See Ticktin 2006 and Redfield 2012 for excellent treatments of these complex relationships. 2. Similar, though divergent, restrictions on migrants exist in the European Union (Castan˜eda 2011). 3. AHE and all personal names and patient numbers in this chapter are pseudonyms.

References Castan˜eda, Heide. (2011) ‘‘Medical Humanitarianism and Physicians’ Organized Efforts to Provide Aid to Unauthorized Migrants in Germany.’’ Human Organization 70: 1–10. Even, Dan and Talila Nesher. (2013) ‘‘After the Storm of Migrant Separation in Ichilov: The Ministry of Health Opens a Refugee Clinic in South Tel Aviv.’’ Haaretz, January 3. Feldman, Ilana. (2009) ‘‘Gaza’s Humanitarianism Problem.’’ Journal of Palestine Studies 38: 22–37. Filc, Dani. (2009) Circles of Exclusion: The Politics of Health Care in Israel. Ithaca, NY: Cornell University Press. Filc, Dani and Nadav Davidovitch. (2005) ‘‘Health Care as a National Right? The Development of Health Care Services for Migrant Workers in Israel.’’ Social Theory & Health 3: 1–15.

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Gottlieb, Nora, Dani Filc, and Nadav Davidovitch. (2012) ‘‘Medical Humanitarianism, Human Rights and Political Advocacy: The Case of the Israeli Open Clinic.’’ Social Science & Medicine 74: 839–845. Horton, Sarah. (2006) ‘‘The Double Burden on Safety Net Providers: Placing Health Disparities in the Context of the Privatization of U.S. Health Care.’’ Social Science & Medicine 63: 2702–2714. Linder-Ganz, Ronny. (2013) ‘‘Private Medicine Is Taking Over the Hospitals: A Private Appointment—4 Days, [While] a Public One—Two Months.’’ The Marker, June 3. Nesher, Talila. (2012) ‘‘Netanyahu: Israel Could Be Overrun by African Infiltrators.’’ Haaretz, May 21. Nguyen, Vinh-Kim. (2005) ‘‘Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship.’’ In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, edited by Aihwa Ong and Stephen J. Collier, 124–144. Malden, MA: Blackwell. Redfield, Peter. (2012) ‘‘The Unbearable Lightness of Expats: Double Binds of Humanitarian Mobility.’’ Cultural Anthropology 27: 358–382. Samuelsen, Helle. (2004) ‘‘Therapeutic Itineraries: The Medical Field in Rural Burkina Faso.’’ Anthropology & Medicine 11: 27–41. Schoenbaum, Michael, Adel Afifi, and Richard Deckelbaum. (2005) Strengthening the Palestinian Health System. Santa Monica, CA: Rand Corporation. Taussig, Michael. (1999) Defacement: Public Secrecy and the Labor of the Negative. Stanford, CA: Stanford University Press. Ticktin, Miriam. (2006) ‘‘Where Ethics and Politics Meet: The Violence of Humanitarianism in France.’’ American Ethnologist 33: 33–49. Willen, Sarah S. (2011) ‘‘Do ‘Illegal’ Im/migrants Have a Right to Health? Engaging Ethical Theory as Social Practice at a Tel Aviv Open Clinic.’’ Medical Anthropology Quarterly 25: 303–330. ———. (2012) ‘‘How Is Health-Related ‘Deservingness’ Reckoned? Perspectives from Unauthorized Im/migrants in Tel Aviv.’’ Social Science & Medicine 74: 812–821.

Conclusion

A Measured Good Peter Redfield

Medical Humanitarianism To begin an ending, I return to this volume’s title: medical humanitarianism. By now it appears an innocuous phrase, common enough to forget its relative novelty on the historical stage.1 Moreover, the term serves as a category within the taxonomy of international aid, one embraced and embodied by a generation of practitioners and encountered by populations worldwide. From the slower perspective of anthropology, however, such a compound designation itself raises a number of questions. What to make of this dual term? Given that humanitarian action generally describes a relation of care and the practice of medicine generally addresses human suffering, one might reasonably see their union as a natural one. But even if the component parts fit like fingers in a glove, why stitch them together? Is there something at stake in the juncture between healthcare and the urgent end of aid that merits analytic attention? What might focusing on an explicitly medical form of humanitarianism reveal? Rather than quarreling over definitions, this collection wisely takes up these questions as an ethnographic challenge. Its contributors follow a varied set of contemporary actors engaging aspects of health and human wellbeing, not all of which neatly align. Together, though, they clarify the extent to which medicine—particularly expert biomedicine—now plays a preeminent role in defining humanitarian action. However historically variable a term, ‘‘humanitarianism’’ has increasingly stabilized around the figure of

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emergency, as exemplified in conflict and disaster settings (Barnett 2011, Calhoun 2008). Within this conceptual terrain, medical attention has come to define not just the appropriate form of care but action itself. Whereas the Italian women aiding the Red Cross visionary Henry Dunant soothed a church full of wounded soldiers with pure water and a compassionate gaze (Dunant 1862 [1986]: 63), their successors deploy a much larger apparatus in an attempt to save lives and psyches, often with cursory regard for cultures, beliefs, and political interests. One might suggest that humanitarianism has not just grown professionalized but also effectively medicalized. At the same time, the expanding field of emergency response increasingly confers moral standing within medical endeavors. As several of the chapters demonstrate, even nonemergency projects may present themselves through a language of suffering and urgent action. Thus if humanitarianism appears caught in the sway of medicine, medicine, too, has acquired new humanitarian aspirations of the heroic mode. Here I would like to suggest yet another sense in which an explicit appeal to medicine might prove valuable with regard to examining humanitarian practice as well as humanitarian reason (Fassin 2011). When considered abstractly as principle or policy, humanitarian action too often appears a matter of moral purity, whether cast as absolute virtue or abject failure. By contrast, medical action implies clinical practice, grounding an impassioned impulse such as care in a gray world of routines, procedures, and lingering uncertainty. When approached at the level of individual bodies and specific cases, medical knowledge appears resolutely imperfect. Even in the best-equipped hospital, diagnosis remains a fluid art, full of trial and error, not to mention periodic impasses. Treatment likewise exhibits an experimental edge; even wonder drugs rarely elicit precisely the same response across a population. The vast apparatus of science and technology now devoted to human health has stumbled across occasional magic bullets like penicillin. Its statistical record keeping attests to the general success of public health sanitation on a mass scale. But as any experienced patient knows, the medical encounter frequently offers more in the way of odyssey than panacea. Medicine, then, might be good to think with when considering humanitarianism. Shifting the title of this collection from a static, descriptive term into an active analogy not only reveals the extent to which medical humanitarianism describes a space of cultural inquiry but also underscores its critical relation to practice. As the editors of this volume emphasize in their

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introduction, a serious ethnographic engagement with the topic requires attention to specific dynamics of encounter and material effects. By acknowledging the complexity of practice at the outset and extending its study through a wider comparative frame, collaborative work such as this provides a valuable counterweight to more general pronouncements. If taken seriously, the medical analogy moves discussion beyond both the heroic melodrama of aid as compassion and its simple condemnation as a soft form of power. Just like medicine, humanitarian assistance may well involve both. But it does not always do so equally or in precisely the same way; effects as well as motivations vary. The different parties in any given encounter share a common ground of interaction, and may even have overlapping interests or desires, but they do not all read from a single script (Abu-Sada 2012). Nor do they always agree on the same definition of the problem at hand, let alone on what might constitute a positive resolution. Framed by a comparative sensibility and focused on the details of specific conditions, the research contained in this collection recognizes diversity and plurality of form. It also presents a range of critical perspectives, if transposed into a minor key. Although its findings may at times prove discomforting to practitioners, the discomfort is more likely to stem from recognition than any sense of shock or surprise. Many of the themes that emerge are all too familiar: programs that either collapse into a vacuum or build self-perpetuating institutions, tensions between national and international personnel, a potent mix of naivete´ and moral energy, unintended consequences of well-intended action. Yet their combined presentation does not lend itself to sweeping denunciation or a general, alternative prescription. Rather, an ethnographic focus mirrors the clinical scale in exploring small truths. If hard to generalize into sweeping theory or policy, its findings nonetheless offer a reminder of the fluid, relational sense in which people experience aid in action. They are in that sense radically empirical and situated, and therefore immediately real.

The Humanitarian Pharmakon To push the medical analogy further, I will add another reference within it: the polyvalent, irreducibly ambiguous Greek term pharmakon, which can translate as both remedy and poison (Derrida 1981). Beyond gesturing to the intriguing linguistic complex connecting ancient sacrifice and modern pharmaceuticals, the pharmakon literally recalls the vital importance of

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practice. A substance can save you or kill you, depending on the amount and manner consumed. In medical terms the thin line between help and harm finds its measure in dosage and the careful calibration of a compound to particular bodies, as understood through concepts of population and history. When taken in tandem multiple additives can interact, further complicating any sense of balance and requiring a trade-off between desirable and undesirable states. At its very core, the practice of medicine involves compromises, adjustments, and imperfect goods. Approaching humanitarianism in these terms alters the field of expectations around it. Even elemental concerns of basic human survival—food, water, shelter—appear less as timeless matters of sheer presence and absence and more as evolving problems of calibration. What sort of food? How much? For how long? When viewed through the shifting prism of the pharmakon, these are not simply technical questions, however much they might call deeply and repeatedly on instrumental knowledge. The moral stakes of humanitarian action stretch beyond any certain code of conduct into the lived ethics of relations, where political judgment remains unsettled. The focus shifts away from pure intentions and principles and toward contingent actions and effects. One worries less about evil and more about mistakes and malpractice. At the same time an appeal to the pharmakon works against the unbridled hubris of expertise and technical responses. Medical treatment can help alleviate maladies, but it also can have little impact or even cause iatrogenic harm. The magic bullet that misses its target might fall flat or wreak havoc through a population as well as a single body. Similarly a humanitarian program that appears successful in one context might stall or fail in another. Rather than an ever-growing store of sure remedies, dispensed with effective measures for impact, we are left with a partly contradictory set of ‘‘lessons learned’’ as well as altered lives and expectations. Under such scrutiny, humanitarian practice—like any form of practice—grows less clear or simple. Taken together, the chapters in this volume paint a varied and complex tableau of humanitarianism in action. They insert the ambivalence of experience into more general accounts, adding cautions, nuance, and the uncertainty of specific dilemmas. As the editors note in their introduction, however, this emphasis on context includes common threads, such as a dynamic understanding of human relations and a material conception of practice. It thus does not entail a simple rejection of the humanitarian enterprise or its relevance—indeed, quite the opposite. This ethnographic

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approach recalls how medical humanitarianism involves supplies and instruments as well as projects, situated persons and their interactions as well as organizations. Those dispensing and receiving aid may be acutely aware of this when engaging in their respective roles, but such details rarely feature in either public representation or formal analysis. Nonetheless they do matter acutely in practice. As the chapters included here demonstrate, there is no final solution to the continual cascade of humanitarian dilemmas. Instead the challenge appears to be one of adjustment and ceaseless recalibration, recognizing effects and missteps with appropriate humility. Widening the focus on humanitarian actors to include national staff and national medical professionals brings other questions to the fore. As Patricia Omidian and Catherine Panter-Brick remind us, in many settings the delivery of humanitarian aid involves large numbers of people working in the context in which they also reside. Relying on national staff for the provision of healthcare might mitigate some problems, reducing the exposure of expatriates to kidnapping and damping anticolonial anxieties about occupation, but it also increases the level of risk and stress these local humanitarians experience. The program the authors describe in Pakistan responds to a need created by the practice of aid itself. They also recognize the significance of dignity, often the poor cousin to health in humanitarian initiatives. Rather than a rhetorical, floating conception of human worth, here dignity appears an intimate matter of daily work and its purpose. Laura Wagner addresses related tensions in Haiti, where an influx of foreign professionals, particularly following the 2010 earthquake, affects the status and livelihoods of Haitian doctors and even e´migre´s. While aid projects may seek to foster a transition to sustainability and development at a policy level, at an experiential level their presence evokes a complex range of emotions and expectations. How to be a self-respecting Haitian professional, provide for a family, and not work for an international nongovernmental organization (NGO)? Personal feelings and relations offer opportunities as well as dangers. From a perspective in Ethiopia, Lauren Carruth observes how peacebuilding might depend as much or more on a delicate fabric of trust woven across ethnic lines by skilled national staff as on any formal agreements. Working slowly, and relying on situational judgment, patience, and charisma, a tiny mobile medical team might accomplish as much as a phalanx of diplomats armed with official protocols. Attending to details can also reveal the illusions hidden in larger humanitarian stories, along with the powerful current of sentiment that

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sustains them. Alex de Waal introduces simple accounting into the moral clamor surrounding Darfur, demonstrating how the actual pattern of deadly violence has followed a different distribution and timeline than international commentary about genocide would indicate. Perception may prove the most intractable component of any emergency, just as a diagnosis may have its own, complicated afterlife independent of particular symptoms. On the basis of his long engagement in northern Uganda, Tim Allen finds a parallel confluence that produced inverse results. Operating within a highly circumscribed understanding of the context and its problems, international organizations focused on HIV/AIDS and abducted children while ignoring their own de facto participation in a vast internment program of civilians in displacement camps. The camp, that emblematic figure of both humanitarianism and genocide, can offer either remedy or poison. Once inscribed in a self-reinforcing emergency narrative, however, such ambiguity vanishes in the face of moral certainty. Questions about who constitutes a worthy recipient of aid, and who feels an obligation to provide it, soon recall the porous frontier between ethics and politics. Jean-Herve´ Je´ze´quel further complicates this border zone by describing how an NGO might at times resemble a wandering leviathan. Recounting MSF’s efforts to respond to famine in Niger with a massive infusion of therapeutic food, he underscores the contingency of decision making and the uncertainty of authority, including his own position as expert analyst. Although the intervention might appear like a coup of sorts, it proved a limited and temporary one. The immediate focus on saving lives did not address the more general problem of governing the country or ensuring longer-term food security. Humanitarian intervention thus disrupts the logic of state sovereignty, but not always fully or in the same way. Focusing on the legacy of Me´decins Sans Frontie`res (MSF) in Liberia, Sharon Abramowitz documents the vacuum that can appear when large projects close following the formal end of conflict. The very scale and efficiency of an NGO medical intervention can undermine faith in state capacity, even as organizations reserve the right to withdraw and deploy resources elsewhere. If the humanitarian apparatus does not achieve its own form of sovereignty, it certainly remains resolutely mobile and invested in the exceptional logic of emergency. A stronger state, however, quickly curbs such exceptions to its rule, as Byron Good, Jesse Grayman, and Mary Jo DelVecchio Good illustrate in their chapter on posttsunami Aceh, Indonesia. Here humanitarian mobility runs aground on

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bureaucratic regulation and the imposition of military curfews. To operate, NGOs must cooperate with established authority to a far greater degree, and their projects remain in the shadow of the state rather than the other way around. Whether or not such conditions are more desirable for the civilian population in a long-running insurgency, however, remains an open question. The sword of state sovereignty can cut both ways. If nonstate actors sometimes appear to claim the crown, robust agents of state power can also pursue humanitarian ends. Stuart Gordon reminds us that the terrain of medical humanitarianism includes military doctors and that they play an inherently conflicted role, caught between dual dictates of medical and military priorities. Healthcare conducted by forces of war, openly aligned with state interests and equally equipped to pursue violence, epitomizes the ambiguities of intervention. It is precisely in such conditions that civilian humanitarians rediscover their claims to neutrality, however positioned or compromised such principles might become in application. The fulcrum of practice humbles even the clearest precepts and the most triumphal results. Who could argue against the need for medicine to attend to evidence? And yet what if the norms of ‘‘evidencebased medicine’’ cut into the actual distribution of healthcare delivery? Peter Locke explores this quandary in Sierra Leone, where a small, wellintentioned, transnational clinical venture seeks legitimacy and sustainability and yet simultaneously raises questions about its ethics and accountability. On a different scale, Amy Moran-Thomas tells a similarly discomforting story, showing how a great triumph of global health—the near eradication of guinea worm—looks less certain when facing a cup of unclean water and an inadequate diabetes clinic in Ghana. Whether large or small, projects reflect choices about priorities. In settings with a surplus of suffering, the diversion of funds and attention in one direction reveals gaps in another. Ilil Benjamin describes a similar balancing act with regard to nongovernmental medicine and the treatment of noncitizen immigrants in Israel. Poised between offering humanitarian assistance and advocating human rights, volunteers for an Israeli NGO balance the well-being of individual patients against the assertion of a more general claim for justice. They also engage in a complex dance with government hospitals over payment, while recognizing limits and guarding the public profile of their cause. In sum, the volume charts a complex and uncertain terrain, offering more in the way of aporia (Fassin 2011) than denunciation. Once down in

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the dust and the details we see lots of disturbing effects and few clear strategies, let alone recipes for success. Following another analogy introduced by Moran-Thomas, perhaps humanitarian efforts resemble the fog of war more than formal politics. At the very least we should begin to recognize such healthcare as a shifting and plural endeavor.

Pluralism and the Limits of Medicine If medicine may be good to think with regard to humanitarianism, the inverse is just as true. Anthropologists have long recognized medical pluralism in terms of competing healthcare systems. Alongside biomedicine, other inherited practices have acquired the designation of ‘‘traditional’’ medicine, even as some have experienced their own reinvention and globalization (e.g., Langford 2002, Zhan 2009). From the perspective of many patients in the world, healthcare is field of options, not a single form. In these moments of comparison, however, it grows easy to overemphasize the unity of biomedicine itself. The actual diversity of biomedical practice—not only its own understanding of human variation and bodily forms but also the divergent traditions, engagements, and assumptions it encompasses—fades from view (Berg and Mol 1998, Good 1994, Lock and Nguyen 2010). In achieving hegemonic primacy, the vast, sprawling endeavor of modernist healthcare projects a false sense of unity. Once turned to humanitarian ends, however, biomedicine reveals its diversity in action. The medical sense of emergency itself provides a pivotal point of intersection and divergence. Although now so conceptually linked with medicine that it is hard to imagine one without the other, emergency in the lifesaving sense of resuscitation only took shape about a century ago (Nurok 2003). The emergency room of contemporary hospitals and the specialty of emergency medicine are even younger, roughly paralleling the rise of a new aid regime following World War II. In this space biomedical specialties meet: the emergency room functions as a heterogeneous intake filter, in which all manner of maladies present themselves. A broken leg, a gunshot wound, a burst appendix, heart palpitations, a strange rash, dementia, accidents, rising fevers—the emergency physician deals with ailments across a spectrum of specialties (Sklar 2010). This convergence, however, remains strictly temporary. When the critical moment passes, a bed opens, a surgical slot appears, then the course of treatment returns to an established track of

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specialization. And here the diversity of biomedicine quickly grows apparent. The sensibilities of surgery are hardly those of psychiatry; their sense of intervention and engagement, of patient history and medical relationship diverge starkly in practice. Internal medicine operates at a different scale than does public health, one focusing on individual bodies where the other engages populations. In humanitarian aid settings, with porous boundaries and limited opportunities for referral, this diversity emerges starkly into view. Like emergency medicine, medical humanitarianism has its roots in war. However, a large organization like MSF may now sponsor projects drawing on all manner of traditions and extending well beyond conflict settings. These entail different personnel and technical infrastructure and operate with different spatial and temporal expectations. Diseases, moreover, have their own specificities: where cholera is quick, HIV/AIDS is slow. In endeavoring to treat the latter as well as the former, MSF also changed itself (Redfield 2013). At the level of practice medical humanitarianism appears increasingly plural. Indeed, the actors described in the pages of this book undertake a wide variety of activities in the name of care: operating rural clinics and urban hospitals, offering malnourished children therapeutic food, providing mental health services, conducting an international campaign to eradicate a parasitic disease, and even training aid workers to relieve their own stress. As Foucault (2000) once noted, health operates as an inflationary concern, having no internal principle of limitation. Here we come to a final point: the worn observation that humanitarianism, like medicine, has limits. As innumerable critics have noted— academic and practitioner alike—humanitarian aid cannot escape politics. Indeed, humanitarianism may reflect a contemporary mode of government, one that invokes a discourse of suffering and yet cannot evade the violence and inequality to which it responds (Fassin 2011, Ticktin 2011). However much a clinical analogy may prove helpful for returning our analytic focus to practice, it never implies an antiseptic remove. Medical care is ever partial, even when delivered impartially, and often contested. Its form of resuscitation, moreover, proves ultimately temporary. In the ethnographic frame of this volume, humanitarianism likewise seems at once crucial and dangerous, sometimes unsettling, often unsatisfying, and ever uncertain. It appears, in short, a measured good. Note 1. According to the radar of Google’s amassed book data, the phrase appears as a blip following World War II and then takes off precipitously near the end of the

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twentieth century (Google Ngram viewer. http://books.google.com/ngrams/graph? content⳱medicalⳭhumanitarianism&year_start⳱1800&year_end⳱2008& corpus⳱15&smoothing⳱3&share⳱ Feb 1, 2015).

References Abu-Sada, Caroline, ed. (2012) In the Eyes of Others: How People in Crises Perceive Humanitarian Aid. New York: MSF-USA. Barnett, Michael. (2011) Empire of Humanity: A History of Humanitarianism. Ithaca, NY: Cornell University Press. Berg, Marc and Annemarie Mol, eds. (1998) Differences in Medicine: Unraveling Practices, Techniques and Bodies. Durham, NC: Duke University Press. Calhoun, Craig. (2008) ‘‘The Imperative to Reduce Suffering: Charity, Progress and Emergencies in the Field of Humanitarian Action.’’ In Humanitarianism in Question: Power, Politics, Ethics, edited by M. Barnett and T. Weiss, 73–97. Ithaca, NY: Cornell University Press. Derrida, Jacques. (1981) ‘‘The Pharmakon.’’ In Dissemination, edited by B. Johnson, 95–117. Chicago: University of Chicago Press. Dunant, Henry. (1862 [1986]) A Memory of Solferino. Translated by T. b. A. R. C. 1939. Geneva: International Committee of the Red Cross. Fassin, Didier. (2011) Humanitarian Reason: A Moral History of the Present Times. Berkeley: University of California Press. Foucault, Michel. (2000) ‘‘The Risks of Security.’’ In Power: Essential Works of Foucault, 1954–1984, edited by J. Faubion, 365–382. New York: The New Press. Good, Byron J. (1994) Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press. Langford, Jean. (2002) Fluent Bodies: Ayurvedic Remedies for Postcolonial Imbalance. Durham, NC: Duke University Press. Lock, Margaret and Vinh-Kim Nguyen. (2010) An Anthropology of Biomedicine. Boston: Wiley-Blackwell. Mol, Annemarie. (2002) The Body Multiple: Ontology in Medical Practice, Science and Cultural Theory. Durham, NC: Duke University Press. Nurok, Michael. (2003) ‘‘Elements of the Medical Emergency’s Epistemological Alignment: 18th to 20th Century Perspectives.’’ Social Studies of Science 33 (4): 563–579. Redfield, Peter. (2013) Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Sklar, David. (2010) La Clinica: A Doctor’s Journey Across Borders. Albuquerque: University of New Mexico Press. Ticktin, Miriam. (2011) Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press. Zhan, Mei. (2009) Other-Worldly: Making Chinese Medicine Through Transnational Frames. Durham, NC: Duke University Press.

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Contributors

Sharon Abramowitz is an assistant professor of anthropology and African studies at the University of Florida. She earned her Ph.D. in medical anthropology from Harvard University, and completed an NIMH postdoctoral fellowship in psychiatric epidemiology at Johns Hopkins University. Her work on mental illness, postconflict reconstruction, and gender-based violence in postwar Liberia has appeared in African Studies Review, Culture, Medicine and Psychiatry, and Social Science & Medicine, and in 2011 she was awarded the Rudolph Virchow Professional Award for a Critical Anthropology of Global Health. Her first book, Searching for Normal in the Wake of the Liberian War, was recently published by the University of Pennsylvania Press. Tim Allen is Professor in Development Anthropology and head of the department of International Development at the London School of Economics and Political Science. He is also a Fellow of the Academy of Social Sciences and research director of the Justice and Security Research Programme, based at the London School of Economics with funding from the UK’s Department for International Development. He has spent more than thirty years working and researching in various parts of Africa, as well as writing on international issues. Some of his books include Poverty and Development into the 21st Century; The Media of Conflict: War Reporting and Representations of Ethnic Violence; and In Search of Cool Ground: War, Flight and Homecoming in Northeast Africa, as well as two books relating to the Lord’s Resistance Army: The Lord’s Resistance Army: Myth and Reality and Trial Justice: The Lord’s Resistance Army and the International Criminal Court. He has also published in numerous journals, including Health Research Policy and Systems, the Journal of Eastern African Studies, and the Journal of Biosocial Science.

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Ilil Benjamin is a doctoral candidate in science and technology studies at Cornell University and was a Visiting Fellow at Tufts University’s Feinstein International Center. Her work focuses on humanitarian mental health in contexts of forced migration and conflict, and she has conducted fieldwork in Israel and Palestine, looking at how local and transnational NGOs respond to growing calls for evidence-based interventions. Her current research has been funded in part by the Reppy Institute for Peace and Conflict Studies at Cornell University and by the National Science Foundation. Lauren Carruth is a postdoctoral fellow in medical anthropology at George Washington University. She recently earned a doctorate in sociocultural anthropology from the University of Arizona, a master’s degree in nutrition from Tufts University, and a certificate in humanitarian studies from a consortium program based at the Harvard School of Public Health. Since 2003 she has worked on various projects for UNICEF and the World Food Program in Ethiopia. Inspired by gaps in aid and aid research, since 2007 she has returned to eastern Ethiopia for extended ethnographic research, investigating both the lasting effects of episodic medical and humanitarian interventions and the lives and health concerns of displaced and pastoralist Somalis in the Horn of Africa. She has recently published in the journals Social Science & Medicine and Global Public Health. Mary-Jo DelVecchio Good is Professor of Social Medicine in the Departments of Global Health and Social Medicine, Harvard Medical School and Sociology, Harvard University, with institutional affiliations with the Asia Center, the Center for Middle Eastern Studies, and the Weatherhead Center for International Affairs. Her research focuses on the culture and political economy of biomedicine, biotechnology, and bioethics, including clinical realities and moral dilemmas encountered by physicians in the United States and globally (Indonesia, East Africa). She recently served as coeditor and contributor to the books Shattering Culture: American Medicine Responds to Cultural Diversity and A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities. Other recent publications include ‘‘Trauma in Postconflict Aceh and Psychopharmaceuticals as a Medium of Exchange’’ in J. H. Jenkins’s book Pharmaceutical Self; ‘‘The Inner Life of Medicine: A Commentary on Anthropologies of Clinical Training in the Twenty-First Century’’ in Culture, Medicine and Psychiatry; and ‘‘Medical

Contributors 255

Cultures’’ with Seth Hannah in the Handbook of Cultural Sociology, edited by John R. Hall, Laura Grindstaff, and Ming-Cheng Lo. Alex de Waal is executive director of the World Peace Foundation and a research professor at the Fletcher School at Tufts University. He is currently a Fellow of the Social Science Research Council and the Harvard Humanitarian Initiative, and from 2009 to 2011 he served as senior advisor to the African Union High Level Implementation Panel for Sudan. His academic research focuses on issues of famine, conflict, and human rights in Africa. Recent publications include the book AIDS and Power: Why There Is No Political Crisis—Yet and War in Darfur and the Search for Peace, as well as numerous articles in journals including Social Science & Medicine, The Lancet, International Affairs, and African Affairs. He was awarded an OBE in the UK New Year’s Honors List of 2009, was on the Prospect/Foreign Policy list of one hundred public intellectuals in 2008, and was on the Atlantic Monthly list of twenty-seven ‘‘brave thinkers’’ in 2009. Byron J. Good is Professor of Medical Anthropology and former Chair, Department of Social Medicine, Harvard Medical School, and Professor in the Department of Anthropology, Harvard University. Dr. Good is the director of Programs in Global Mental Health in the Department of Social Medicine. He is the director of the International Mental Health Training Program and codirector of the National Institute of Mental Health Training Program in Culture and Mental Health Services. Dr. Good’s present work focuses on research and mental health services development in Asian societies, particularly Indonesia, and has been collaborating with Dr. Mary-Jo DelVecchio Good and the International Organization for Migration (IOM) on developing mental health services in post-tsunami and postconflict Aceh (Indonesia). He is the coeditor of two recent volumes, A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities with Michael M. J. Fischer, Mary-Jo DelVecchio Good, and Sarah S. Willen, and Culture and Panic Disorder with Devon Hinton. He has also written numerous book chapters and journal articles, including ‘‘Phenomenology, Psychoanalysis and Subjectivity in Java’’ in Ethos and ‘‘Theorizing the ‘Subject’ of Medical and Psychiatric Anthropology’’ in the Journal of the Royal Anthropological Institute. Stuart Gordon is a lecturer in the Department of International Development (ID) at the London School of Economics. He served as a research

256 Contributors

fellow of the International Security and Global Health Security Programs at the Royal Institute of International Affairs, Chatham House, London, and coauthored the UK government’s Helmand Road Map, the UK’s diplomatic and military strategy for Afghanistan As a researcher with Tufts University’s Feinstein Center, he wrote the report Winning Hearts and Minds? Examining the Relationship Between Aid and Security in Afghanistan’s Helmand Province. Stuart specializes in the politics of conflict and development and has written widely on various aspects of these issues, principally stabilization, securitization of development and governance programs, peacekeeping, and peacebuilding. Jesse Hession Grayman is a senior lecturer in the University of Auckland’s School of Social Sciences in New Zealand. In 2013 he completed his Ph.D. in social and medical anthropology at Harvard University’s Graduate School of Arts and Sciences. He also holds master’s degrees in epidemiology and Southeast Asian studies, both from the University of Michigan. His dissertation, ‘‘Humanitarian Encounters in Post-Conflict Aceh, Indonesia,’’ is based on five years of fieldwork in Aceh with four different international humanitarian and development organizations involved in postconflict and post-tsunami recovery efforts there. He has managed or directed several large-scale mixed-methods research projects in Aceh and was also a longterm election observer with the Carter Center for Indonesia’s legislative elections in 2009. His research continues to examine Aceh’s long-term recovery, particularly through the lens of civil society, long after the humanitarian encounter has ended. Jean-Herve´ Je´ze´quel is Maıˆtre de confe´rences (assistant professor) at the University of Bordeaux and a former lecturer at the University of Michigan and Emory University. He teaches history and African studies in Bordeaux and at Sciences Po Paris. He is also a former research director at Doctors Without Borders (Me´decins Sans Frontie`res-France). He edited A Not-SoNatural Disaster, a book about the 2005 food crisis in Niger, and has written articles and reports on different humanitarian interventions in sub-Saharan Africa (Liberia, Guinea, DRC). Peter Locke is Assistant Professor of Instruction in Global Health Studies and Anthropology at Northwestern University. Prior to this, he worked as a postdoctoral research associate and as a lecturer for Princeton University’s

Contributors 257

Program in Global Health and Health Policy and earned his Ph.D. from Princeton’s Department of Anthropology. He has conducted fieldwork on postwar mental health services and medical humanitarianism in BosniaHerzegovina, highlighted in his dissertation, ‘‘City of Survivors: Trauma, Grief, and Getting By in Post-War Sarajevo,’’ and in Sierra Leone. His work has appeared in publications such as Current Anthropology. Amy Moran-Thomas is a Cogut Postdoctoral Fellow in International Humanities at Brown University, based in the Department of Anthropology and affiliated with the Science and Technology Studies Program and the Population Studies and Training Center. She received her Ph.D. in anthropology from Princeton in 2012. Her ethnographic work, which has appeared in such publications as the Annual Review of Anthropology (with Joa˜o Biehl) and When People Come First: Critical Studies in Global Health, examines metabolic and parasitic disorders as windows into health politics, environmental change, and the ethics of care more broadly. Her current book project focuses on the global diabetes epidemic. Patricia Omidian received a Ph.D. in medical anthropology from the University of California, San Francisco and Berkeley joint program. She has taught at universities in the United States, Pakistan, and Afghanistan, traveling to Pakistan in 1997 on a Senior Fulbright Award to conduct research on mental health and to teach at the Peshawar University. Having an interest in refugees and community mental health, she decided to stay in the region and continued to work there for fifteen years. She maintains ongoing research projects on trauma, psychosocial wellness, and the anthropology of emotions. During the course of her time in the region, she collaborated with others to develop culturally appropriate training programs that combine Focusing and various positive psychology techniques for teacher training, gender awareness, or peacebuilding as requested by various agencies and donors. Catherine Panter-Brick is Professor of Anthropology, Health, and Global Affairs at Yale University. Her research addresses issues of risk and resilience in contexts of poverty, homelessness, famine, armed conflict, and social marginalization. She has published extensively on hope, trauma, violence, and mental health in the form of systematic reviews and scientific

258 Contributors

articles and has coedited six books, most recently Pathways to Peace. For her work in humanitarian areas such as Niger and Afghanistan, she has been awarded the Lucy Mair Medal by the Council of the Royal Anthropology Institute of Great Britain and Ireland. This award honors excellence in the application of anthropology to the relief of poverty and distress and to the active recognition of human dignity. Peter Piot is the Director of the London School of Hygiene and Tropical Medicine. He was the founding Executive Director of UNAIDS and Under Secretary-General of the United Nations. Dr. Piot co-discovered the Ebola virus in 1976 and led research on HIV/AIDS, sexually transmitted diseases, and women’s health in Africa. He was a professor at the Institute of Tropical Medicine, Antwerp, the University of Nairobi, and the Colle`ge de France, Paris, and a Senior Fellow at the University of Washington and the Bill and Melinda Gates Foundation. He is a member of the US Institute of Medicine, the Royal Academy of Medicine of his native Belgium, and the Academy of Medical Sciences, UK. He has published over 550 scientific articles and 16 books, including No Time to Lose. He has received numerous scientific and civic awards, including the Calderone, Noguchi, Prince Mahidol, and Canada Gairdner Global Health Awards, and was named a Time Person of the Year 2014. Peter Redfield is an associate professor of anthropology at the University of North Carolina (UNC) and a Fellow at UNC’s Institute of Arts and Humanities. His research focuses on science and technology, global health ethics, and the politics of intervention, and he has conducted research in Europe, French Guiana, and Uganda. His books include Life in Crisis: The Ethical Journey of Doctors Without Borders and Space in the Tropics: From Convicts to Rockets in French Guiana; he has also coedited Forces of Compassion: Humanitarianism Between Ethics and Politics with Erica Bornstein. He has written several book chapters, appearing most recently in Didier Fassin and Mariela Pandolfi’s edited volume Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions and in Fassin’s A Companion to Moral Anthropology, and published widely in journals, including Public Culture and American Ethnologist. He received the Cultural Horizons Prize from the Society for Cultural Anthropology for his article ‘‘Doctors, Borders and Life in Crisis’’ in the journal Cultural Anthropology.

Contributors 259

Laura Wagner received her Ph.D. in anthropology from the University of North Carolina, Chapel Hill. Her research focuses on perceptions and experiences of post-earthquake aid and displacement, community formation, and everyday life amid crisis in Haiti. In addition to her academic work, she has published in Salon, Truthout, and other publications. Her first novel, set in post-earthquake Port-au-Prince, will be published by Abrams.

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Index

Page numbers with the letter f indicate a figure; page numbers with t indicate a table. Abdullah, Zaini, 166 Abramowitz, Sharon, x, 12–13, 247 Action against Hunger (Action Contre la Faim [ACF]), 127 Adada, Rodolphe, 90, 91 Adams, Vincanne, 198 Afghanistan: British forces in Helmand Province, 178, 182; differential medical treatments for ISAF coalition personnel and locals, 179–85; Focusing workshops for aid workers, 33, 38; healthcare system capacities, 179–80, 182; U.S.-led war in, 178, 179–86; war and insurgency in Afghan-Pakistan border areas, 25–26. See also military doctors and military humanitarianism; Pakistan African Union, 79 African Union High Level Panel on Darfur (AUPD), 80, 85, 86–88 Agamben, Giorgio, 159, 172 Ahtisaari, Martti, 165 AIDS Support Organisation (TASO) in Gulu, Uganda, 100, 105 Albany Associates, 85 Alexis, Jacques Ste´phen, 49–50 Allen, Tim, 12, 113, 247 anarchy, 77, 81, 86, 87, 92 anthropology, x; activist medical, 194; comparative ethnographies, x, 3–4, 15, 244; critical inquiry, 7–9, 193–94, 203, 212; local knowledge, 92–93, 212; on medical NGOs and states, 226. See also ethnography Appadurai, Arjun, 159

Asian Development Bank, 163 Association of Volunteers in International Service (AVSI), 100, 106, 107, 114 asylum seekers in Israel, 226–40; cancer patients and oncology treatments, 230–35, 238, 239–40; deportations and imprisonment, 229; exclusion from statesponsored healthcare, 228, 229–31. See also Israel Baldan, Marco, 183 Barre, Siad, 67 Bashir, Omar al, 85, 89–90, 115 Benjamin, Ilil, 14, 248 Bertele, Michael, 179 Biehl, Joa˜o, 216 Bill and Melinda Gates Foundation, 211 Bittner, Egon, 216 Blayton, Jane, 89 Bonnecase, Vincent, 128 Bourdieu, Pierre, 1–2 Bourne, Peter, 214 Branch, Adam, 114 Bricknell, Martin, 181–82, 185–86 British Army Medical Services: and contested humanitarianism in Iraq and Afghanistan, 13, 176–90; triage decisions formalized Ministry of Defence (MOD) policy, 182–83. See also military doctors and military humanitarianism Bulstrode, Chris, 182, 185 bureaucracies. See Israel; strong states and medical humanitarianism Burkina Faso, 227 Bush, George W., 89

262 Index Calhoun, Craig, 11, 140, 195, 212, 242–43 Cameron, Ewan, 182–83, 186, 187–88 Canadian Medical Association Journal, 180 cancer patients and oncology treatments: asylum seekers in the Israeli medical bureaucracy, 230–35, 238, 239–40; Haiti, 41–46, 54–55; ‘‘magic bullet’’ campaigns, 216–17 Cape Town Principles, 109–10 Caritas, 100 Carruth, Lauren, 11, 246 Carter, Jimmy, 214–15, 219, 220–21 Carter Center’s Guinea Worm Eradication Program, 14, 209–22. See also guinea worm eradication in northern Ghana Castan˜eda, Heide, 227–28, 239 Catholic Relief Services, 61 Center for Global Communications Studies, 85–86 Centre de re´flexion sur l’action et les savoirs humanitaires (CRASH), 121 Centre Hospitalier du Sacre-Coeur (PortAu-Prince, Haiti), 47 Chandler, David, 173n3 children: colonial medical experts on childhood malnutrition, 123–24; deaths and infectious diseases in northern Ugandan IDP camps, 104; LRA abductions of girls, 107, 109; Niger’s 2005 food crisis and MSF’s approach to malnutrition, 12, 122–23, 125–27, 131–32; night commuters and ‘‘invisible children’’ of northern Uganda, 100, 108–10, 116; treatment by military medical doctors, 181–82; UNICEF-funded Mobile Health & Nutrition Teams in Somali Region of Ethiopia, 62–64 cholera, 104, 106, 218, 250 civilian humanitarianism, 179–80, 184, 186–89. See also military doctors and military humanitarianism clans, Somali, 64–66, 69. See also Ethiopia clinical tourism, 194, 200 Clinton Foundation, 149 Clooney, George, 89 colonial medicine: medical approaches to childhood malnutrition in Niger, 123–24; and ‘‘moral pilgrimages’’ by Western students in global health, 194; postcolonial ‘‘medical imperialism’’ and mental health efforts, 193

combatants/non-combatants: Indonesia’s reintegration of GAM ex-combatants, 165–66, 167; medical and civilian humanitarianism and principles for treatment, 176–78, 184, 187; Red Cross principles for medical provision/surgical care, 184 comparative humanitarian ethnographies, x, 3–4, 15, 244. See also ethnography; medical humanitarianism Contemporary States of Emergency (Fassin and Pandolfi), 163 Correlates of War Project (CoW), 83 Crombe´, Xavier, 120, 131, 132 crude mortality rates (CMRs), 104–5, 106, 114 custodial sovereignty, 140–41, 147, 152, 153n1 Dahn, Bernice, 138 DALYs (disability adjusted life years), 193 Darfur conflict in Sudan, 12, 77–95, 247; administrative tribalism/native administration system, 84; anarchy (fawdha), 77, 81, 86, 87, 92; characterizations of the violence, 12, 77–95, 247; community leaders’ opinions on conflict resolution, 87–88; community leaders’ sensitivity to different phases of the war, 87; consequences of naming, 78, 83, 88–92; Darfur Peace Agreement and ‘‘Declaration of Commitment,’’ 81, 85; data for patterns of lethal violence (2008–9), 77, 79–84, 82t, 92; data on the unfolding of lethal violence (2003–9), 79, 80f; as ‘‘genocide,’’ 78, 83, 88–92, 115; implications for anthropologists and political scientists, 78, 92–93; importance of local knowledge and perspectives, 92–93; international narratives (over how to characterize the violence), 88–91; local groups’ narratives of the origins/patterns of the conflict, 84–88, 92–93; as ‘‘mass atrocity,’’ 83; and Moreno Ocampo’s application for Bashir’s arrest by the ICC, 89–90, 115; and nonArab Darfurian refugees in Chad, 85; as ‘‘one-sided violence,’’ 83; Save Darfur Coalition and genocide mobilization (2004), 78, 89, 91–92; shift from ‘‘Schmittian’’ contest to a ‘‘Hobbesian’’ conflict, 78, 92; UN policy debate, 77–78,

Index 263 89–91; UNAMID, 79, 87, 90, 91, 92; U.S. campaign and international policy debate, 78, 88–92 Darfur Peace Agreement, 81, 85 Davidovitch, Nadav, 228 de Waal, Alex, 12, 97, 247 Defence Medical Services (UK), 184, 187–88 Democratic Republic of Congo, 113, 115 development. See international development disaster response: Haitian earthquake (2010), 46–47; the Indian Ocean tsunami (2004), 155–58, 160–62, 171. See also emergency, humanitarian disease. See infectious disease Doctors Without Borders. See Me´decins Sans Frontie`res (MSF) Dolan, Chris, 113–14 double binds and medical NGOs, 227 Duffield, Mark, 133, 158–59 Dunant, Henry, 243 DuPont Corporation, 217 Duvalier, Franc¸ois, 49 DynCorp, 138 Ebola crisis in West Africa, ix, x Egelund, Jan, 102 Ehrlich, Paul, 216–17 emergency: medical sense of, 249–50; pretense of medical, 231–34 emergency, humanitarian, 242–43; and biomedical pluralism, 249; Calhoun and (‘‘emergency imaginary’’), 11, 140, 195, 212, 242–43; case studies of contested sources of moral authority in, 11–12; construction of, 216; Darfur conflict, 12, 77–95, 247; evocation of war metaphors and military rhetoric, 216–19, 220; guinea worm eradication and production of an emergency, 210–19; mass forced displacement and IDP camps of northern Uganda, 101–8, 113–14, 247; and medical NGOs’ custodial sovereignty, 140–41, 147, 152, 153n1; MSF-France and Niger’s 2005 food crisis, 12, 119–34; and provision of basic psychiatric care in postwar Sierra Leone, 199; and sensitivity to local knowledge and perspectives, 92–93, 212; and suspension of Indonesian legal norms in post-tsunami Aceh, 161–62. See also expert knowledge

empirical sovereignty, 140–41, 151 epilepsy, 199, 202 Eritrean asylum seekers in Israel, 229, 231 Ethiopia, 11, 58–73; clan and family responsibilities in illness and healthcare, 66; drought (2007–9) and UNICEF responses to children’s malnutrition, 61–64; ethnic federalism and politicization of kinship and ethnicity, 67–68, 72n8; Federal Democratic Republic of, 67–68; federal governmental refugee agency (ARRA), 61; governmental counterinsurgency response against Ogaden communities, 67–68; historic rivalries between Habasha Ethiopians and ethnic Somalis, 60, 68; history and context of medical humanitarianism in, 60–64; IDPs in, 60–61; pastoralistcosmopolitan distinctions, 65–66; peacebuilding and effects of humanitarian encounters on social dispositions and clan rivalries, 11, 58–60, 65–66, 68–71, 246; political and ethnic conflicts, 66–69; Somali clanship and Issa-Ogadeni dichotomy/rivalries, 64–66, 69; Somali Region of, 11, 58–73, 246; treatments of childhood malnutrition (1980s), 124; UNICEF-funded Mobile Health & Nutrition Teams, 58–64, 65–66, 68–71 Ethiopian People’s Revolutionary Democratic Front (EPRDF), 67, 68 ethnography, x, 1–4; comparative humanitarian, x, 3–4, 15, 244; value for humanitarian engagement, 8–9, 10, 15, 172–73, 195, 205, 244–46. See also anthropology European Commission’s Humanitarian Aid Department (ECHO), 153n2 evidence-based medicine, 198, 204, 248 expert knowledge, x, 6–7, 11–12; Darfur conflict in Sudan, 78, 92–93; food aid and medical experts on childhood malnutrition, 123–25, 131; and global health education, 197–98, 200–201, 203–4; how humanitarians’ perceptions diverged from available evidence in northern Uganda, 105–13; implications for anthropologists and political scientists in approaching armed conflicts, 78, 92–93; and professionalization of the humanitarian sector, 6–7, 243; relationship between analysts/

264 Index expert knowledge (continued ) experts and medical NGOs, 122, 129–30, 132–33; and sensitivity to local knowledge and perspectives, 92–93, 212 Fadul, Abdul-Jabbar, 86 Farmer, Paul, 45, 194, 195, 197–98, 204 Fassin, Didier, 194, 203, 215 FATA Secretariat and Women Empowerment Wing in the Social Sector (Pakistan), 26, 27–28, 33 Ferguson, James, 122, 129–30, 132 field surgical teams (FSTs), 184 Filc, Dani, 228 Finnstrøm, Sverker, 113–14 Focusing practices and humanitarian training workshops, 27–28, 32–36, 38 food aid: late colonial medical approaches, 123–24; medical experts on childhood malnutrition, 123–25, 131; and Millennium Development Goals (MDGs), 125; MSF’s approach to children’s malnutrition in Niger, 122–23, 125–27, 131–32; northern Ugandan IDP camps, 103–4; opposition between agrarian developers and emergency medical humanitarians, 124, 131–32; ready-to-use therapeutic food (RUTF), 62–64, 122–23, 125–27, 131–32; and the Sahel in the mid-2000s, 123–25; UNICEF Mobile Health & Nutrition Team responses to drought in Somali Region of Ethiopia, 62–64. See also Niger’s 2005 food crisis Foucault, Michel, 152, 250 Foucher, Vincent, 133 Foya Hospital (Liberia), 144–46, 152 Free Aceh Movement. See Gerakan Aceh Merdeka (GAM) Geneva Convention, articles 55 and 56 of Convention IV, 184–85 genocide: characterizations of the Darfur conflict in Sudan, 78, 83, 88–92, 115; and IDP camps in northern Uganda, 115; Rwandan, 88–89 Gerakan Aceh Merdeka (GAM): integration of leadership into the government, 165–66; peace agreement, 157–58, 165–67; security forces’ counterinsurgency

campaign against, 156, 160–61. See also Indonesia, post-tsunami/postconflict Ghana, 14, 209–25; IDPs and ‘‘witch camps,’’ 222; recent cases of malnutrition and outbreaks of violence, 222; rural poverty in, 216, 222. See also guinea worm eradication in northern Ghana Ghanaian Ministry of Health, 213, 219 Giannou, Chris Paul, 183 Gill, Rowland, 187, 188 global health, ix–x, 1–2, 5–6, 193–95, 203–5; ‘‘clinical tourism,’’ 194, 200; global health education and medical humanitarianism, 13–14, 193–208, 248; growth of the field, 7, 193–95, 203–5; guidelines and mechanisms of oversight and accountability, 7, 204–5; guinea worm eradication/emergency in Ghana, 210–19, 248; ‘‘magic bullet’’ campaigns, 211–12, 216–18; public health research and ‘‘evidence-based medicine,’’ 198, 204, 248; randomized controlled trials (RCTs) for program evaluations, 198; service-learning, 7, 194, 205; social critics of, 193–94, 203; tensions over guiding priorities and hierarchies of expertise, 197–98, 200–201, 203; the term ‘‘target,’’ 217–19; and traditional healers, 199, 201–2; ‘‘war metaphor’’ and military rhetoric, 216–19, 220. See also global mental health global mental health, 7, 193–95, 203–5; and DALYs (disability adjusted life years), 193; and field of global health education, 7, 193–95, 203–5. See also mental health programs and humanitarian psychiatry Global War on Terror, 189 Good, Byron J., 13, 158, 194, 247–48 Good, Mary-Jo DelVecchio, 13, 158, 166, 194, 247–48 Gordon, Stuart, 13, 248 Gottlieb, Nora, 228 Gration, Scott, 90 Grayman, Jesse Hession, 13, 158, 247–48 guinea worm eradication in northern Ghana, 14, 209–25, 248; the afterlives of intervention, 219–22; Carter Center’s program, 14, 209–22; and clean water/water sanitation issue, 209–11, 214–16, 219, 222; and the ‘‘Emergency Response Hydraulic Team,’’ 219; false reports, 220; as global

Index 265 health model for disease-eradication, 211–12, 216–18; larvicide chemicals, 213, 215, 216, 219, 222; metaphor and politics of ‘‘filtering,’’ 212–14; nylon water filters, 209–10, 215, 217–18, 218f; as primary policy target, 214–16; the production of a global health emergency (for a nonfatal disease), 210–19; surveillance notebooks, 210, 221; targeted ‘‘magic bullet’’ campaigns, 211–12, 216–18; and traditional understandings of the worm, 210–11; unpaid community volunteers, 221; urgent visual messages about the medical emergency, 210, 211f, 221–22; ‘‘war metaphor’’ and military rhetoric, 216–19, 220 Gwenigale, Walter, 138 Haitian earthquake (2010) and medical humanitarian response, 41–57, 56n2, 246; initial disorganization, 47; interactions between Haitian doctors and foreign medical volunteers, 43–45, 50–53; preexisting humanitarian apparatus and NGO presence, 47–49; U.S. aid, 46, 56n2 Haitian medical doctors, 11, 41–57; and creation of a more humane and sustainable medical system, 55–56; desensitization and numbing to plight of patients, 53–55; emigration rates and the sacrifice of staying in Haiti, 49–50, 54–56; and foreign medical NGO volunteers, 43–45, 50–53; foreign volunteers’ low professional esteem for, 52–53; necessity of charging for services, 43, 45–46, 47, 48–49; stereotypes of, 41–46, 48–49; as victims of the 2010 quake, 51–52 ‘‘handovers,’’ 145. See also humanitarian withdrawal Harage Catholic Secretariat, 61 health sovereignty, 139–40, 151 Helen Keller International (HKI), 127, 128 Helsinki peace agreement (Indonesia) (2005), 157–58, 165–67 HIV/AIDS in Africa, 105–8, 115–16, 126–27 Hobsbawm, E., 111 Hodgetts, Tim, 186–87 Hopkins, Donald, 214 human rights advocacy, 1, 4, 14; belief that healthcare is a ‘‘human right,’’ 196,

229–30, 238; and humanitarian ethics, 173n3; and the ‘‘responsibility to protect,’’ 8, 152, 159 Human Rights Watch (HRW), 68 Humanitarian Accountability Project (HAP), 204 humanitarian compassion, 237–39 humanitarian emergency. See emergency, humanitarian humanitarian governmentality, 120, 132–33; and intervention as ‘‘therapeutic governance,’’ 159–60, 161, 171, 172 humanitarian impunity, 97, 114 humanitarian medicine. See medical humanitarianism; medicine, humanitarian ‘‘humanitarian reason,’’ 7–9, 243–44 humanitarian withdrawal, x, 12–13, 137–54, 166, 247; and economic significance of NGOs in postwar economies, 146–48, 147t, 150; local perceptions and anxieties over, 144–45, 149–50; and medical humanitarian sovereignty, 138–41, 143–44, 151–52; MSF-Belgium, 138–39, 141–44, 152; MSF-France, 138–39, 144–52; MSF’s stated policy of focusing on emergencies, 144, 150–51; from postconflict Liberia, 12–13, 137–54, 247; from post-tsunami Indonesia, 166; and right of self-determination, 140–41, 143–44, 145–46, 152; and sovereignty of states, 151, 166. See also sovereignty and humanitarian aid organizations humanitarianism (as term), 1, 186–87, 242–43 humanitarianism, military. See military doctors and military humanitarianism improvisation: and Israeli medical NGOs providing nongovernmental aid for asylum seekers, 227–28, 231–37, 239; and therapeutic itineraries in strong-state settings, 227–28 Indonesia, post-tsunami/postconflict, 13, 155–75, 247–48; Aceh province, 155–58, 160–62, 164–66, 171; coordinated humanitarian ‘‘Team of Teams’’ approach, 156–57; Helsinki peace agreement (2005), 157–58, 165–67; and IDPs, 156–57; IOM’s psychosocial and mental health programs, 158, 160–64, 166–71; martial law and

266 Index Indonesia (continued ) counterinsurgency campaign against Aceh’s GAM, 156, 160–61; nightly curfews, 165; and post-Suharto decentralization program, 171; Provincial Health Office, 163, 164; reconstituted strong state sovereignty and strategies to reclaim authority, 164–66, 171; and trauma as category, 155–56; U.S. Navy ships and Operation Unified Assistance, 155–57, 161–62, 171; Yodhoyono’s Rehabilitation and Reconstruction Agency, 165–66. See also International Organization for Migration (IOM) and mental health programs in Indonesia Indonesian Department of Social Welfare, 167 Indonesian Ministry of Health, 161, 169 Indonesian Ministry of Justice and Human Rights, 167 infectious disease, x; cholera, 104, 106, 218, 250; clinic treatments in postwar Sierra Leone, 197; fatal waterborne diseases in Northern Ghana, 210–11; Geneva Convention IV on occupying powers’ measures to combat, 185; HIV/AIDS in Africa, 105–8, 115–16; Israeli medical bureaucracy’s justifications for providing aid to asylum seekers, 237; northern Uganda’s IDP camps, 104, 106; polio eradication campaign in Pakistan, 24; tuberculosis, 53, 72n4, 237; UNICEFfunded mobile teams’ responses to drought in Somali Region of Ethiopia, 61–64; and water filters, 218. See also guinea worm eradication in northern Ghana Inter-Agency Standing Committee (IASC), 4 Inter-American Development Bank, 46 Intergovernmental Committee for European Migration, 162–63 internally displaced persons (IDPs): AfghanPakistan border camp conditions, 28, 29–31, 38; crude mortality rates (CMRs) in northern Ugandan camps, 104–5, 106, 114; Darfur camps and the native administration system, 84; Ghana’s ‘‘witch camps,’’ 222; HIV/AIDS morbidity and mortality in camps, 105–8, 115–16; local aid workers as, 24; and mobile teams in

Somali Region of Ethiopia, 60–61; northern Uganda’s mass forced displacement and humanitarian emergency, 101–8, 113–14; post-tsunami Indonesia, 156–57; psychosocial treatment and family reintegration of, 109–10 International Committee of the Red Cross (ICRC): Code of Conduct, 9, 204; guinea worm eradication efforts, 211; in northern Ugandan war zones, 101; principles and military medical professionals, 178–79, 183, 184, 186; principles for access to surgical care, 184 International Criminal Court (ICC) at the Hague: Moreno Ocampo’s charges against Bashir, 89–90, 115; warrants for LRA leaders who committed atrocities against IDPs in northern Uganda, 104, 111 International Criminal Statute Review conference (2010), 115 international development, 1–2, 4, 8; and comparative ethnographies, 3–4; criticism of, 7–8, 131; funding for IOM mental health programs in Indonesia, 163–64, 170; and guinea worm eradication in Ghana, 212, 216, 222; infrastructure development in Somali Region of Ethiopia, 61; MDGs, 125; MSF and relationship between development and emergency relief, 126–27, 144, 150–51; and Niger’s 2005 food crisis, 120, 123–26, 129–30, 131–32; the opposition between developers and humanitarian assistance, 131–32; postconflict Liberia, 137–38, 150–51; post-quake Haiti, 46, 55–56, 56n2, 246; and sensitivity to local knowledge, 92–93, 122; and weak state settings, 158. See also strong states and medical humanitarianism International Donors’ Conference, 46 International Monetary Fund (IMF), 46 International Organization for Migration (IOM) and mental health programs in Indonesia, 158, 160–64, 166–71, 194; administrative workings and bureaucracy, 162–64, 169–70; collaboration with local doctors/district health offices, 167–71; and the ‘‘epistemic community’’ of international aid, 162–63; funding and donor nations, 163–64; and IOM’s mobile sovereignty, 163; ‘‘livelihood’’ activities and

Index 267 procurement plans, 163; mobile mental health outreach teams/clinics, 163, 169–71; psychosocial and mental health programs, 158, 160–64, 166–71, 194; psychosocial needs assessment surveys, 167, 168–70, 173n4; publishing politically sensitive research findings, 168–69; reintegration assistance for GAM excombatants, 167 International Rescue Committee (IRC), 148–50, 152 IOM. See International Organization for Migration (IOM) and mental health programs in Indonesia Iraq, 176–78. See also military doctors and military humanitarianism ISAF. See NATO International Stabilisation Assistance Force (ISAF) in Afghanistan Israel, 14, 226–41, 248; governmental and nongovernmental healthcare system, 228–29; medical bureaucracy and medical NGOs for asylum seekers, 14, 226–41, 248; Ministry of Health, 228, 232–33, 236–37; Ministry of the Interior, 229; negotiations for hospital lines of credit, 234–37, 238; oncological treatments, 230–35, 238, 239–40; orthopedic cases, 237–38; Patient’s Rights Act, 231–33, 238. See also strong states and medical humanitarianism Iya, Ronad, 98, 113 Je´ze´quel, Jean-Herve´, 12, 120–23, 129–30, 247 Justice and Equality Movement (JEM) (Sudan), 81 Keynesian economic stimulus, 147 Kim, Jim, 194 kinship: ethnic federalism and politicization in Somali Region of Ethiopia, 67–68, 72n8; Somali clans, 64–66, 69 Kondro, Wayne, 180 Kony, Joseph (northern Uganda), 99–100, 110, 113, 115 Lederberg, Joshua, 216 Liberia, postconflict, 12–13, 137–54; correlation between GNI and diminishing MSF expenditures, 147t; economic sectors shut

down for regulatory restructuring, 146, 153n3; empirical sovereignty, 151; health sovereignty, 151; Liberians’ anxieties over MSF’s departure, 144–45, 149–50; macroeconomic/microeconomic significance of NGOs in, 146–48, 147t, 150; Ministry of Defense, 138; Ministry of Education, 138; Ministry of Health and Social Welfare (MOHSW), 137–38, 142–44, 145–46, 148; MSF-Belgium and Redemption Hospital, 138–39, 141–44, 152; MSF-France and Foya Hospital, 144–46, 152; MSF-France and Sanniquellie Hospital, 146–50, 152; MSF’s withdrawal from, 12–13, 137–54, 247; national staff expenditures, 147t; national staff working for MSF-France, 146, 148–50; PMU InterLife Clinic, 145, 152, 153n2; UN peacekeeping and humanitarian assistance (2003), 137, 151 Lilywhite, Louis, 187, 188 Locke, Peter, 13–14, 248 Lord’s Resistance Army (LRA) (Uganda), 97–100, 101–9, 110–13, 115 Lukwoya, Severino, 99, 102 Macdonald, John, 180–81 ‘‘magic bullet’’ in global health campaigns, 211–12, 216–18 Mahdi, Saiful, 156–57 Malawi, 194, 200, 203 Mamdani, Mahmood, 78 Mangkusubroto, Kuntoro, 165 Marriage, Zoe, 97 Me´decins Sans Frontie`res (MSF), 4–5, 12–13, 137–54, 247, 250; clinical facilities in Somali Region of Ethiopia, 61; collapse of Port-au-Prince trauma center in Haiti, 46, 51; ethic of te´moinage, 152; expenditures in Liberia, 147t; International Financial Reports, 147; and medical humanitarian sovereignty, 138–41, 143–44, 151–52; medical triage policies/ priorities, 183; mental health services in postconflict Indonesia, 168, 173n5; Nobel Peace Prize, 4–5; northern Uganda, 96–97, 98, 100, 104–5, 108, 114; rejection of military humanitarianism, 188; relationship between development and emergency relief, 126–27, 144, 150–51;

268 Index Me´decins Sans Frontie`res (MSF) (continued ) tensions between different MSF headquarters, 122–23, 129; withdrawal from postconflict Liberia, 12–13, 137–54, 247 Me´decins Sans Frontie`res-Belgium: mental health services in postconflict Indonesia, 173n5; sovereignty of, 143–44; and the 2005 food crisis in Niger, 128–29; withdrawal from Liberia’s Redemption Hospital, 138–39, 141–44, 152 Me´decins Sans Frontie`res-France: mental health services in postconflict Indonesia, 173n5; postconflict Liberia, 138–39, 144–52; role in the collapse of confidence in Niger’s dispositif, 119–20, 126, 127–30; tensions between Paris headquarters and MSF-Belgium, 129; the 2005 food crisis in Niger, 12, 119–34, 247; withdrawal from Foya Hospital, 144–46, 152; withdrawal from Sanniquellie Hospital, 146–50, 152. See also Niger’s 2005 food crisis Me´decins Sans Frontie`res-Holland, 173n5 Me´decins Sans Frontie`res-Spain, 151 Me´decins Sans Frontie`res-Switzerland, 151 medical humanitarianism, ix–x, 1–10, 242–50; and afterlives of intervention, 219–22; the behind-the-scenes ‘‘magic’’ institutional world of, 139; belief in healthcare as a human right, 196, 229–30, 238; and biomedical pluralism, 249–50; the bubbles within which humanitarians work, 96–97, 113–16; the contested space of, 4–10, 186–89; critical relation to practice (action), 243–45; critical scholarship on problematic aspects of, 7–9; definition, 1, 242; emergence of regional subcultures, 6; emerging standards and guidelines, 6–7, 9–10, 204–5; examples of lines of inquiry and approaches, 1–4; exceptionality/states of exception, 5, 159, 172; fame and cultural recognition, 4–5; funding sources, 4; and global health education, 13–14, 193–208, 248; and global ‘‘intervention-scapes,’’ 10; and ‘‘humanitarian governmentality,’’ 120, 132–33; and the humanitarian pharmakon, 244–45; and ‘‘humanitarian reason,’’ 7–9, 243–44; and humanitarian withdrawal, 12–13, 137–54, 166, 247; and international development praxis, 1–2, 8;

and Keynesian economic stimulus, 147; limits of, 250; maturation, formalization, and professionalization of the sector, 6–7, 243; and medical triage, 183–84; opposition between agrarian developers and, 124, 131–32; relationships with analysts and experts, 122, 129–30, 132–33; servicelearning, 7, 194, 205; and sovereignty, 138–41, 143–44, 151–52, 158–60, 166, 171–73; teaching and training agendas, 3–4; therapeutic itineraries, 227–28; value of ethnographic study on, 8–9, 10, 15, 172–73, 195, 205, 244–46. See also global health; national staffs and medical NGOs; strong states and medical humanitarianism medicalization, 243; approaches to childhood malnutrition in Niger (mid2000s), 123–25, 131; colonial/postcolonial approaches to malnutrition, 123–24; and trauma category in psychosocial humanitarian interventions, 159 medicine, humanitarian, ix, 5–6, 14–15, 242–44; biomedical pluralism and the limits of, 249–50; and colonial medicine, 123–24, 193, 194; differential treatments and provision of care, 179–85; evidencebased medicine, 198, 204, 248; foreign volunteers’ low esteem for national doctors, 52–53; global health education, 13–14, 193–208, 248; service-learning, 7, 194, 205; therapeutic itineraries, 227–28; triage decisions and ethical dilemmas, 181–84, 185. See also global health; medical humanitarianism; military doctors and military humanitarianism mental health programs and humanitarian psychiatry: anthropologist-advocates, 193–94, 203–4; concerns about capacity to provide support, 200; global mental health field, 7, 193–95, 203–5; and interventions in strong states/weak states, 158–60, 166, 171–73; IOM’s mobile outreach teams/clinics, 163, 169–71; IOM’s programs in Indonesia, 158, 160–64, 166–71, 194; IOM’s psychosocial needs assessment surveys, 167, 168–70, 173n4; mindfulness and Focusing techniques, 27–28, 32–36, 38; prescribing psychopharmaceuticals, 199–200, 202;

Index 269 provision of basic psychiatric care in postwar Sierra Leone, 195, 198–201, 202; psychosocial treatment at reception centers in northern Uganda, 109–10; traditional healers and local landscapes of care, 199, 201–2 migrant sovereignty. See mobile sovereignty (migrant sovereignty) of aid organizations migrants: asylum seekers in Israel, 226–40; Haitian doctors’ emigration rates, 49–50, 54–56; IOM and mental health programs in post-tsunami Indonesia, 158, 160–64, 166–71, 194; northern Ugandan night commuters and invisible children passing through Gulu reception centers, 100, 108–10, 116. See also International Organization for Migration (IOM) and mental health programs in Indonesia military doctors and military humanitarianism, 13, 173n3, 176–90, 248; British Army Medical Services in Iraq and Afghanistan, 13, 176–89; Canadian personnel, 180–81; differential treatments and provision of care, 179–85; dual roles, 178–79, 189; field surgical teams (FSTs) and surgery close to the point of wounding, 184; and Geneva Convention on occupying powers, 184–85; idea of immunity and neutrality/impartiality, 187–88; and ISAF coalition personnel, 179–85; and multiple ‘‘humanitarianisms,’’ 188; patient transfer issue, 179–82; perceptions of civilian humanitarianism (and vice versa), 186–89; principles of treatment for combatants/noncombatants, 176–78, 184, 187; and professional identity, 179, 187–88, 189; Red Cross principles, 178–79, 183, 184, 186; relationship to civilian humanitarianism, 179–80, 184, 186–89; and spare capacity, 185–86; and treatment of children, 181–82; triage decisions and ethical dilemmas, 181–84, 185 military rhetoric and war metaphors, 216–19, 220 Millennium Development Goals (MDGs), 125 mindfulness techniques, 32–36, 38. See also Focusing practices and humanitarian training workshops

Minn, Pierre H., 45 Mirwais Hospital (Afghanistan), 180 mobile sovereignty (migrant sovereignty) of aid organizations, 133, 140–41, 152, 159, 160, 171, 172; and Agamben’s ‘‘states of exception,’’ 159, 172; differences in strong/weak states, 159, 160, 171, 172; and mental health treatment programs, 159–60, 161, 171, 172; Pandolfi’s concept, 133, 140, 152, 159, 194 mobile teams: IOM’s mental health teams in postconflict Aceh, 163, 169–71; in Somali Region of Ethiopia, 60–64; UNICEF’s responses to children’s malnutrition and diarrheal disease in Somali Region of Ethiopia, 61–64 Moran-Thomas, Amy, 14, 248, 249 Moreno Ocampo, Luis, 89–90 mortality: CMRs in northern Ugandan IDP camps, 104–5, 106, 114; northern Ugandan HIV/AIDS statistics, 105–8, 115–16 MSF. See Me´decins Sans Frontie`res (MSF) Museveni, Yuweri, 98–100, 115 National Health Service (Ghana), 215 National Health Service (UK), 179 national staffs and medical NGOs, 5–6, 161–62, 164, 167–71, 221, 233–37, 246; expat and local workforces, 5–6; guinea worm eradication in Ghana and unpaid community volunteers, 221; hiring and training, 161–62, 164, 221, 246; IOM’s collaboration with local doctors in postconflict Indonesia, 167–71; Liberian staff working for MSF-France, 146, 148–50; MSF expenditures and national staff expenditures, 147t; payment through ‘‘incentives,’’ 148; Redemption Hospital and MSF-Belgium, 142; risks for local staff/expat volunteers in Afghan-Pakistan border areas, 24 NATO International Stabilisation Assistance Force (ISAF) in Afghanistan, 180–86 Natsios, Andrew, 90 neoliberalism, 194, 222 NGO Crisis Management Initiative (Finland), 165 Nguyen, Vinh-Kim, 227

270 Index Niger’s 2005 food crisis, 12, 119–34; call for free food distribution, 127–28; and the dispositif, 119–20, 123, 125–32; and the food aid industry in the Sahel in the mid2000s, 123–25, 127; MSF and disputes over the normal and pathologic, 130–32; MSF-France’s selection of an expert to provide supporting arguments for its mission, 120–23, 129–30; MSF’s approach to children’s malnutrition, 12, 122–23, 125–27, 131–32; MSF’s role in collapse of confidence in the dispositif, 119–20, 126, 127–30; and Niger’s state sovereignty, 120, 128, 133; postcrisis calls for restoring consensus and improving coordination, 131; reappearance of medical experts on childhood malnutrition, 123–24; tensions over the extent of crisis, 127–30 nongovernmental organizations (NGOs), 4; Haiti’s pre-quake aid apparatus (as ‘‘republic of NGOs’’), 47–49. See also medical humanitarianism nutrition. See food aid; Ready-to-Use Therapeutic Food (RUTF) Ocampo, Luis Moreno. See Moreno Ocampo, Luis Ogaden National Liberation Front (ONLF), 65, 67–68 Olivier de Sardan, Jean-Pierre, 131 Omidian, Patricia, 10–11, 32–33, 246 Otunnu, Olara, 114–15 Oxfam, 96, 100, 114 Pain, Dennis, 111–12 Pakistan, x, 10–11, 23–40, 246; Baluchistan, 25; cultural prohibition against showing fear, 30–31, 34; culturally grounded Focusing techniques and training workshops, 27–28, 32–36, 38; the culture of emotions, 27, 33, 34–35, 38–39; differential risks for local staff/expat workers, 24; emotions and duress, 27, 28–29, 34–35, 37; fatwas on female workers, 24–25; Federally Administered Tribal Areas (FATA), 25, 28, 29–31; healthcare workers in Afghan-Pakistan border areas, x, 10–11, 23–40, 246; history of war and insurgency in border areas, 25–26; human dignity and resilience in face of adversity,

27, 32–35, 37–39, 246; IDP camp conditions and aid, 28, 29–31, 38; Khyber Pakhtunkhwa (KP), 23, 25; kidnappings, 31–32; killings of polio healthworkers, x, 24; responsibility to offer ‘‘service,’’ 29, 37; Secretariat and Women Empowerment Wing, 26, 27–28, 38; Taliban attacks, 24–26, 31–32; targeted killings and the landscape of local humanitarian aid, 23–26, 36–39; three personal narratives, 29–32 Palestine, 227 Pandolfi, Mariella: and ‘‘epistemic communities,’’ 159, 162; and mobile/migrant sovereignty, 133, 140, 152, 159, 194 Pandu Setiawan, 169 Panter-Brick, Catherine, x, 10–11, 246 Patel, Vikram, 193, 199 Patterson, Kevin, 181 peacebuilding and conflict resolution, 1, 5, 11; effects of humanitarian encounters on social dispositions and clan rivalries in Ethiopia, 11, 58–60, 65–66, 68–71, 246; international humanitarian involvement in Indonesian peace process, 157–58. See also postconflict reconciliation Petryna, Adriana, 204, 216 physician-patient interactions: Haitian doctors’ desensitization to patients’ plights, 53–55; military doctors and differential treatment, 179–85; stereotypes of Haitian doctors, 41–46, 48–49; triage decisions and ethical dilemmas, 181–84, 185 physicians, national: foreign volunteers’ criticisms of Haitians’ expertise, 52–53; and guinea worm eradication programs, 213; IOM’s collaborations in postconflict Indonesia, 167–71; postwar Sierra Leonean medical NGO and local doctor-partner, 196–98. See also Haitian medical doctors physician-soldiers. See military doctors and military humanitarianism Piot, Peter, ix–x Plumpy’nut, 12, 62 pluralism and medical humanitarianism, 249–50 PMU InterLife Clinic (Liberia), 145, 152, 153n2 Porter, Holly, 115 postconflict reconciliation: Acholi reconciliation ritual of mato oput in northern

Index 271 Uganda, 110–13, 115; Darfur Peace Agreement and ‘‘Declaration of Commitment,’’ 81, 85; Helsinki peace agreement (Indonesia), 157–58, 165–67; international humanitarian involvement in Indonesian peace process, 157–58 postconflict reconstruction: Liberia, 137–38, 151; macroeconomic and microeconomic significance of NGOs in, 146–48, 147t, 150. See also humanitarian withdrawal Powell, Colin, 78 Power, Samantha, 88–89 A Problem from Hell (Power), 88–89 professional identities: foreign volunteers’ low esteem for Haitian doctors, 52–53; of military doctors, 178–79, 187–88, 189; the professionalization of the humanitarian sector, 6–7, 243 Project Medishare (American NGO in Haiti), 43–44, 48 psychiatry. See mental health programs and humanitarian psychiatry psychopharmaceuticals: IOM’s mental health mobile outreach teams in Indonesia, 170; postwar Sierra Leone, 199–200, 202 psychosocial interventions: IOM’s programs in post-tsunami Indonesia, 158, 160–64, 166–71, 194; returnee reception centers in Gulu, Uganda, 109–10. See also mental health programs and humanitarian psychiatry ‘‘public secrets,’’ 229, 235; lying to Israeli hospital bureaucrats to get treatment for refugees, 231–34; quiet backroom deals for treatment for patients, 231–37; sneaking patients into ERs, 231–34, 238 Pupavac, Vanessa, 158–60, 161 randomized control trials (RCTs), 198 Ranger, T., 111 Ready-to-Use Therapeutic Food (RUTF): BP-5 supplementary biscuits, 62–64; MSF in Niger, 122–23, 125–27, 131–32; Plumpy’nut, 12, 62; UNICEF Mobile Health & Nutrition Team in Somali Region of Ethiopia, 62–64. See also food aid Red Cross. See International Committee of the Red Cross (ICRC) Redemption Hospital (Liberia), 138–39, 141–44, 152

Redfield, Peter, 14–15 Reeves, Eric, 89 resilience, 27, 32–35, 37–39. See also Focusing practices; mindfulness techniques Revolutionary United Front (RUF) (Sierra Leone), 196 Rice, Susan, 90, 91 right to rule: and custodial sovereignty, 140–41, 153n1; Foucault’s concept, 152 Rossi, Benedetta, 131 Rouzier, Gise`le, 48–49, 50–53, 54–55 Rwandan genocide, 88–89 Sahel. See Niger’s 2005 food crisis Samuelsen, Helle, 227 Sanniquellie Hospital (Liberia), 146–50, 152 Save Darfur Coalition, 78, 89, 91–92 Save the Children, 100 schizophrenia, 199, 202 Scholtz, Werner, 153n security interventions, 5, 6, 8; collaboration with Indonesian security forces in posttsunami Indonesia, 156–57, 160–61, 165; Darfur conflict and genocide mobilization, 78, 86, 89, 91–92; food security policies in Niger, 121, 123–27, 130, 133, 247; implications of MSF’s withdrawal from Liberia, 139, 141, 144–45, 152; and nations’ ‘‘health security,’’ 144–45; the ‘‘responsibility to protect,’’ 8, 152, 159. See also emergency, humanitarian Sierra Leone’s postwar medical NGOs, 195, 196–205; ad hoc supporters and funding, 197, 200; a community psychiatry program and makeshift mental health stabilization center, 195, 198–201, 202; ‘‘Global Alliance for Health,’’ 195, 196–205; psychopharmaceutical prescriptions, 199–200, 202; tensions over guiding priorities and hierarchies of expertise in global health, 197–98, 200–201, 203; and traditional healers, 199, 201–2; treatment of amputees and their families, 196–97 Sirleaf, Ellen Johnson, 137 Sokol, Daniel, 181 Somalia: clanship and Issa-Ogadeni dichotomy, 64–66, 69; the Ethiopian Empire’s military force against civilians, 67; ‘‘Greater Somalia,’’ 67; historic rivalries between Habasha Ethiopians and

272 Index Somalia (continued ) ethnic Somalis, 60, 68; the unified Somali National Regional State, 67–68, 72n8. See also Ethiopia South Sudan, 220. See also Sudan sovereignty and humanitarian aid organizations, 138–41, 248; custodial, 140–41, 147, 152, 153n1; empirical, 140–41, 151; and the ‘‘health sovereignty’’ of states, 139–40, 151; and ‘‘humanitarian governmentality,’’ 120, 132–33; and humanitarian withdrawal/departure, 138–41, 143–44, 151–52; medical NGOs, 138–41, 143–44, 151–52, 158–60, 166, 171–73; mobile/ migrant, 133, 140–41, 152, 159–60, 171, 172; MSF-France and the 2005 food crisis in Niger, 120, 128, 133; relevance to mental health services and psychosocial interventions, 158–60, 166, 171–73; and right of self-determination, 140–41, 143–44, 145–46, 152; and right to rule, 140–41, 152, 153n1; in strong state settings, 158–60, 166, 171–73, 173n2; and ‘‘therapeutic governance,’’ 159–60, 161, 171, 172. See also strong states and medical humanitarianism spare capacity, 185–86 The Sphere Project (Sphere Humanitarian Charter), 9, 204 Stanhope Centre, 85 states. See sovereignty and humanitarian aid organizations; strong states and medical humanitarianism Stepan, Nancy Leys, 211 Stockton, Nicholas, 96 strong states and medical humanitarianism, 13, 155–75, 226–40, 247–48; collaboration with local actors and national staff, 161–62, 164, 167–71, 233–37; costcontainment justifications, 236; deception and ‘‘public secrets,’’ 229, 231–37; double bind problem, 227; and the ‘‘epistemic community’’ of international aid, 159, 162–63; improvisations, 227–28, 231–37, 239; intervention as ‘‘therapeutic governance,’’ 159–60, 161, 171, 172; IOM’s psychosocial and mental health programs in Indonesia, 158, 160–64, 166–71, 194; Israeli medical NGO providing aid for asylum seekers, 14, 226–40, 248; and the

limits to humanitarian compassion, 237–39; and mobile sovereignty, 159–60, 161, 171, 172; negotiating hospital lines of credit, 234–37, 238; and postconflict Indonesia, 164–66, 171; public health justifications, 236–37; strong states/weak states, 158–60, 166, 171–73, 173n2; therapeutic itineraries, 227–28. See also Indonesia, post-tsunami/postconflict; Israel Sudan: asylum seekers in Israel, 229; childhood malnutrition treatments (1990s), 124; guinea worm eradication campaigns, 220. See also Darfur conflict in Sudan Sudan Armed Forces (SAF), 79, 81 Sudan Liberation Army (SLA), 8, 79, 81, 83, 87 Summerfield, Derek, 158–59, 193 Swedish International Development Cooperation Agency (SIDA), 153n2 Tait, David, 222 Taliban, 24–26, 28, 31–32 Tanner, Victor, 86 Taussig, Michael, 229, 235 therapeutic itineraries, 201, 227–28; defining, 227 Ticktin, Miriam, 239 Tigray People’s Liberation Front (Ethiopia), 67, 72n6 Togo, 221 traditional healers of Sierra Leone, 199, 201–2 training workshops for humanitarian workers, 3–4; Focusing workshops, 27–28, 32–36, 38; global health education, 13–14, 193–208, 248; Pakistani healthcare workers in Afghan-Pakistan border areas, 27–28, 32–36, 38 trauma: as category in psychosocial interventions, 158–60, 172; emergence as category in postconflict Aceh, 155–56; IOM’s psychosocial needs assessment surveys, 167, 168–70, 173n4; and Pakistani healthcare workers in Afghan-Pakistan border areas, 27, 28–29, 34–35, 37; posttraumatic stress disorder (PTSD), 159. See also mental health programs and humanitarian psychiatry

Index 273 triage: divergent care policies for ISAF coalition personnel and Afghan soldiers/ civilians, 181–84, 185; by Haitian hospital staff, 53; ICRC and METTAG categories, 183; and medical NGOs, 183–84; mobile teams in Somali Region of Ethiopia, 69; patient transfer issue, 179–82 tsunami, Indian Ocean (2004), 155–58. See also Indonesia, post-tsunami/postconflict tuberculosis, 53, 72n4, 237 Turkle, Sherry, 217 24 Hours for Darfur, 85 Uganda, northern, 12, 96–118, 247; Acholi reconciliation ritual of mato oput, 110–13, 115; Acholi rituals performed by rwodi and paramount chief, 111–13; Alice Auma’s Holy Spirit Mobile Forces, 98–99; crude mortality rates (CMRs) in IDP camps, 104–5, 106, 114; food aid, 103–4; Gulu commuter centers, 98, 100, 108; Gulu reception centers, 100, 105–6, 107, 108–10, 116; Gulu’s humanitarian infrastructure, 100–101, 114, 116; HIV/AIDS morbidity and mortality, 105–8, 115–16; how humanitarians’ perceptions diverged from available evidence, 105–13; humanitarian impunity, 97, 114; humanitarians’ cognitive dissonance, 97, 114; humanitarians’ complicity in tragedy of the IDP camps, 102–5, 113–15; the LRA, 97–100, 101–9, 110–13, 115; mass forced displacement and humanitarian emergency in IDP camps, 101–8, 113–14, 247; MSF in, 96–97, 98, 100, 104–5, 108, 114; Museveni’s government takeover, 98–99; night commuters/nocturnal migrations and ‘‘invisible children,’’ 100, 108–10, 116; psychosocial treatment and family reintegration of returnees, 109–10 UNICEF: guinea worm eradication efforts, 211; in northern Uganda, 114; and targeted killings of aid workers in the Afghan-Pakistan border areas, 24 UNICEF-funded Mobile Health & Nutrition Teams in Somali Region of Ethiopia, 58–64, 65–66, 68–71; amoxicillin and tuberculosis medications, 63, 72n4; community acceptance, trust, and high esteem for, 62–63, 70–71; effects of clinical

encounters on social dispositions and clan rivalries, 58–60, 65–66, 68–71; responses to children’s malnutrition and diarrheal disease (2007–9 drought), 61–64; therapeutic food and BP-5 biscuits, 62–64 United Kingdom. See British Army Medical Services United Nations and Darfur conflict in Sudan, 77–78, 89–91 United Nations Department of Humanitarian Affairs, 102–3 United Nations High Commissioner for Refugees (UNHCR): Afghanistan, 29–30; and IDP camps in Somali Region of Ethiopia, 61; and medical NGOs for subSaharan refugees in Israel, 230 United Nations Humanitarian Information Center in Banda Aceh (Indonesia), 157 United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), 4; Financial Tracking Service, 6 United Nations Peacekeeping Mission in Liberia, 137, 151 United Nations Refugee Convention (1951), 229 United Nations Relief and Works Agency, 227 United Nations Security Council, 89, 90, 91 United Nations-African Union Mission in Darfur (UNAMID), 79, 87, 90; Joint Mission Analysis Centre (JMAC), 80, 91 United States: Darfur policy debates and antigenocide mobilization, 78, 88–92; Iraq occupation, 176–78; Operation Unified Assistance to post-tsunami Indonesia, 155–57, 161–62, 171; post-quake Haitian aid response, 46, 56n2; triage policy and Defense Department’s Manual of Emergency War Surgery, 183 University of Indonesia, 168, 170 Uppsala Conflict Data Program, 83 U.S. Agency for International Development (USAID), 56n2 U.S. Centers for Disease Control (CDC), 211 U.S. Senate Foreign Relations Committee, 78 Varpileh, Tornolah, 138 violence: characterizing the Darfur conflict in Sudan, 78, 83, 88–92; Darfur data and patterns of, 77, 79–84, 80f, 82t, 92;

274 Index violence (continued ) genocide, 78, 83, 88–92, 115; Ghana’s 2011 nomad killings, 222; IDP camps in northern Uganda, 115; Rwanda, 88–89; targeted killings of aid workers in AfghanPakistan border areas, 23–26, 36–39; and trauma category in psychosocial humanitarian interventions, 158–59; and weak state settings, 158 Wagner, Laura, 11, 246 War Child, 100 water sanitation: and Ghana’s guinea worm eradication programs, 209–11, 214–16, 219, 222; World Health Assembly’s Water Decade (1980s), 214 Weaver, Sigourney, 211 Wendland, Claire, 194, 200–201, 203 Where There Is No Psychiatrist: A Mental Health Care Manual (Patel), 199 Willen, Sarah, 227–28 World Bank, 4; data on MSF expenditures in postwar Liberia, 147; estimates of Haitian

physicians’ emigration rate, 49; funding IOM projects in postconflict Indonesia, 163–64, 170; and guinea worm eradication in Ghana, 216; projects in Somali Region of Ethiopia, 61; and the 2010 Haitian earthquake, 46 World Food Programme (WFP), 103, 114, 128 World Health Assembly and the ‘‘Water Decade,’’ 214 World Health Organization (WHO), 4; guinea worm eradication efforts, 211; survey of crude mortality rates (CMRs) in IDP camps of northern Uganda (2005), 104; and targeted killings of aid workers in the Afghan-Pakistan border areas, 24; training mental health nurses in postconflict Indonesia, 168 World Vision, 100, 105–6, 110, 114, 196 Yudhoyono, Susilo Bambang, 165 Yusuf, Irwandi, 166 Zenawi, Meles, 67, 72n7