Medical Humanitarianism: Ethnographies of Practice

By Peter Piot

Medical humanitarianism—medical and other health-related initiatives undertaken in conditions born of conflict, neglect, or disaster —has a prominent and growing presence in international development, global health, and human security interventions. Medical Humanitarianism: Ethnographies of Practice features twelve essays that fold back the curtains on the individual experiences, institutional practices, and cultural forces that shape humanitarian practice.

Contributors offer vivid and often dramatic insights into the experiences of local humanitarian workers in the Afghan-Pakistan border areas, national doctors coping with influxes of foreign humanitarian volunteers in Haiti, military doctors working for the British Army in Iraq and Afghanistan, and human rights-oriented volunteers within the Israeli medical bureaucracy. They analyze our contested understanding of lethal violence in Darfur, food crises responses in Niger, humanitarian knowledge in Ugandan IDP camps, and humanitarian departures in Liberia. They depict the local dynamics of healthcare delivery work to alleviate human suffering in Somali areas of Ethiopia, the emergency metaphors of global health campaigns from Ghana to war-torn Sudan, the fraught negotiations of humanitarians with strong state institutions in Indonesia, and the ambiguous character of research ethics espoused by missions in Sierra Leone. In providing well-grounded case studies, Medical Humanitarianism will engage both scholars and practitioners working at the interface of humanitarian medicine, global health interventions, and the social sciences. They challenge the reader to reach a more critical and compassionate understanding of humanitarian assistance.

Contributors: Sharon Abramowitz, Tim Allen, Ilil Benjamin, Lauren Carruth, Mary Jo DelVecchio-Good, Alex de Waal, Byron J. Good, Stuart Gordon, Jesse Hession Grayman, Jean-Hervé Jézéquel, Peter Locke, Amy Moran-Thomas, Patricia Omidian, Catherine Panter-Brick, Peter Piot, Peter Redfield, Laura Wagner.

• Language: English
• Publisher: University of Pennsylvania Press
• Release date: Aug 28, 2015
• ISBN: 9780812291698

Book preview

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

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 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 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 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 face-to-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.

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 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’