Humanitarian politics presents itself as a resolute bias in favor of “victims.” The world order as portrayed by this politics comprises the strong and the weak. Humanitarian workers operate in the space between the two, assisting the weak while denouncing the strong.
Didier Fassin, Humanitarian ReasonHowever, in aligning itself with universality and relative neutrality, the unmarked-because-hegemonic identity also associates tolerance with this standing and, conversely, associates objects of tolerance with particularity and partiality… . the tolerating and tolerated are simultaneously radically distinguished from each other and hierarchically ordered accord to a table of virtue.
Wendy Brown, Regulating AversionIn February 2017, a prominent medical humanitarian association, which I hereafter refer to as “Medical Relief for Syria” (MRS), held an annual workshop in Los Angeles, California to discuss the state of their work in the ongoing Syrian civil war.Footnote 1 In attendance were dozens of healthcare professionals who had recently conducted volunteer missions inside Syria and in surrounding refugee camps in Jordan, Lebanon, and Turkey. Boasting hundreds of active members across the United States, this association gathers two to three times a year in order to exchange stories about the war, present case studies with recipients, and refine, through peer dialogue and critique, emergency medical aid procedures under extreme conditions of scarcity or violence. During a session on the legal rights of international aid workers, a white American woman lawyer with expertise in the Geneva Conventions gave a presentation that left an indelible mark on all those present that day. Mid-way through her talk on the dangers of providing medical aid in war zones, she advised the audience—comprised mostly of Syrian doctors and medical volunteers—to “remain neutral” during overseas missions. “To not remain neutral,” she emphatically warned the group, “to remain emotionally tied to one group in the conflict could mean the loss of your protection, the loss of your rights to neutrality under the Geneva Conventions.”
This speaker was clearly concerned for her audience's welfare during dangerous overseas missions in what has become an incredibly complex and turbulent war. In seeking to ensure the safety of aid workers, she urged them to refrain from publically declaring allegiance to any “one side” of the Syrian conflict. According to her caveat, humanitarian workers should be neutral subjects. In other words, they should be people who voluntarily thrust themselves into crisis zones with the sole objective of saving human life in its barest form.Footnote 2 Politics, she intimated for the sake of all those present that day, should play no part in global medical aid work. In many ways, her depoliticizing message is not new. It echoes much of the dominant discourse circulating around contemporary humanitarianism today, which assumes a stark separation between humanitarian intervention and politics.
This call to “remain neutral” generated a wave of rumbling and commotion in the audience. Doctors shifted in their chairs; the excitement in the room was palpable. Some glanced over at each other from across the room, others whispered into the ears of their neighbors, and several stood up and approached the microphone positioned at the center of the hotel ballroom for audience questions. Once the lawyer's presentation concluded, a young doctor who was first in line at the microphone raised a question that challenged the speaker's discussion of medical neutrality. Holding a little black notebook in his hand where he had written down his question, he addressed her an earnest, serious tone:
In Syria, I'm considered an enemy of the state just because I treat populations devastated by the bombs the government is dropping. How can I remain neutral when the government sees me [his emphasis] as not neutral?
Before she could address this question, the next audience member in line approached the microphone and raised a different yet interrelated question on the subject of neutrality. In a passionate tone, he pleaded:
Why can't they make it easier for us doctors to travel to provide this help? What can we do to get immunity from these policies so we can do our duties? We are completely exposed and vulnerable to this legislation and no one is supporting us. Some even call us terrorists!
This doctor was referencing President Donald Trump's recent travel ban on flyers from several Middle Eastern countries, emphasizing its exclusionary effects on him and other members of the association. From his seat, another audience member joined in after hearing this statement. He shared the same concern, mentioning to the speaker and gesturing to all those around him that in the United Kingdom, the majority of medical students, fresh from training, embark on international medical aid missions without proper experience, but also without the same obstacles or discriminatory policies preventing their travel. Unlike the experienced Syrian-American doctors in this association, he explained, those young (read white, western) doctors can travel effortlessly to conduct aid work as they please. Those doctors, he pointed out, are not viewed as threatening suspects or potential terrorists.
In an effort to further problematize the speaker's call for medical neutrality, another doctor approached the microphone to share a personal story. He spoke about a tragic experience he witnessed on a recent medical mission, during which he was volunteering inside a makeshift hospital located in one of Syria's most besieged areas. He explained: “The last time I conducted a mission, our hospital got bombed. Now, I have no problem saying the bombing happened because the bomb caused harm. So, am I being biased by saying that happened?” In asking the speaker if talking about the violence that occurred in the hospital is “biased,” this doctor was highlighting a humanitarian conundrum, one that suggested that medical workers who bear intimate witness to political violence should remain “objective” in the face of that violence as well as the human suffering that results from it. Should they as healthcare workers, he intimated, not even acknowledge the source of a bomb, even as they frantically care for its victims? What if, as his story suggests, they, too, are targets of that bombing?
Although the speaker expressed solidarity with these doctors’ predicaments, citing shifting discriminatory border policies and recognizing the limits of the Geneva Convention in protecting healthcare workers in war zones, I believe the concerns raised by the doctors that day point to a larger, unexplored question about the identities of aid workers and the complex nature of global medical aid work in the Syrian Civil War. The members of this association provide both emergency and long-term medical care to Syrians who, due to the war, lack access to emergency healthcare as well as other basic needs, including water, food, shelter, and safety. As the doctors quoted earlier asserted, they are sometimes perceived as “enemies of the state” inside Syria because they save the human lives the government bombs intended to kill. They are also vocal about their condemnation of the sources of violence. At the same time, their mobility is restricted by US and UK travel policies that construct them as a threat because of their Muslim and Syrian identities.
In stark contrast to doctors who are permitted to travel internationally “without borders” as expatriates engaged in global medical relief, the members of this association—the largest provider of medical relief in and around Syria today—must travel, work, and live their daily lives within borders. As Peter Redfield notes in an ethnographic study of doctors who work for the French organization Médecins Sans Frontières (MSF), to work without borders is to confront the basic territorial logics of the nation-state as well as the legacy of western imperial expansion. In this view, “a borderless world retains the ruins of earlier frontiers, across which some people move far more easily than others.”Footnote 3 This means that the identities of aid workers matter, both in terms of their movement across borders and their relationships with recipients during aid encounters. White Americans and Europeans, as Adia Benton rightly observes, dominate global health and humanitarian industries, and it is their experiences and narratives that feature most prominently in public discourse and scholarship on aid givers.Footnote 4
This is especially the case for medical humanitarianism. It is the white western doctor who stands as the cultural prototype and dominant figure through which medical humanitarianism is practiced and rendered legitimate. It is assumed that he (and I intentionally use the gendered he) remains situated at the top of a hierarchy of global aid workers—a seemingly heroic, objective, and neutral figure possessing the technical skills and ethical drive required for emergency intervention in a borderless world. This figure stems from the history of international humanitarianism itself and the logics driving global intervention; both are rooted in European legal traditions, beginning with the UN Charter that established a right for humanitarians to intervene in conditions of extreme violence and war.Footnote 5 The rise of MSF in the 1970s, a global medical humanitarian organization that remains culturally “French,” further established global medical humanitarian action as a white European endeavor, one that was also based on masculinist logics such as the “heroic aggressiveness” of doctors and swift “warrior-like” medical action.Footnote 6
This article complicates dominant conceptualizations of this figure. MRS stands apart as a unique and culturally “Syrian” association, therefore I am most interested in examining who these doctors are and what motivates their work practices. More broadly, what are their political rationalities and humanitarian reasonings?Footnote 7 In exploring these questions, I join other scholars who have recently begun to focus more extensively on the lives and aspirations of aid workers rather than those of aid recipients.Footnote 8 As this new work has shown, this shift in ethnographic focus, from aid receivers to aid givers, is critical if we are to gain a richer and more holistic understanding of the machinations and effects of contemporary forms of global humanitarian governance.Footnote 9 But these inquiries are particularly urgent in the context of the contemporary Middle East. As a region, it currently hosts what the UN is calling the world's largest humanitarian upheaval since World War II. Arab aid workers, both local and global, have been on the front lines of humanitarian crises in countries such as Syria, Iraq, Palestine, and Yemen. While risking their own personal safety, they continue to provide life-saving care to the most vulnerable victims of conflict, displacement, and structural violence. Yet in-depth studies documenting their care-giving practices and everyday personal experiences remain scarce.
Based on over four years (2014–18) of intermittent fieldwork and interviews with MRS workers in the United States, I suggest that the members of this organization are positioned precariously within a global hierarchy of humanitarians that deems some global aid workers' lives more worthy of mobility, protection, and status than others. Here, I am borrowing the concept of a “hierarchy of humanity” from anthropologist Didier Fassin, who has interrogated the inherent inequalities in humanitarian politics today. As Fassin notes, there is an “asymmetry of lives” between the givers and receivers of aid, and between foreign aid workers and local staff. However, I suggest we also look more carefully to asymmetries among global medical humanitarians as well. Global medical aid workers hail from diverse cultural, economic, and social backgrounds, and it is the nuances and inequalities among them I wish to draw attention to in this research. I argue that MRS doctors are situated along a hierarchy of medical humanitarians on at least two major fronts. First, they are vulnerable to the western border politics that they must negotiate as Muslim-American immigrants traveling to Syria and nearby countries. These policies mark them as racialized and religious subjects. Next, as Syrian immigrants, they are bound to the country of conflict in both physical and emotional ways—they are physically vulnerable to attacks waged against them in camps or clinics in a context where the conflict rages on, and they are also, as I will show later on in this work, emotionally affected by their intimate witnessing of bodily violence and the destruction wrought on their “homeland.” Both fronts complicate how we approach the figure of the medical humanitarian, as well as the concept of medical neutrality and hierarchal privilege in global aid work.
SYRIAN DOCTORS AS LIMINAL HUMANITARIANS
In his critique of humanitarian reason, Fassin draws attention to the inner workings of large-scale, global health and humanitarian organizations and especially the relationships between various kinds of aid workers within them. Fassin problematizes the distinction between foreign (western) humanitarian aid workers and local (native) aid professionals who belong to the societies receiving aid, emphasizing that most global aid is delivered by the latter.Footnote 10 Despite this configuration, much attention is placed by scholars on foreign doctors while the plight, sacrifices, and vulnerability of local workers and national staff are often overlooked. In attempting to focus on these workers and their predicaments more critically, Fassin traces the various professional roles humanitarian workers have occupied, from the birth of the International Committee of the Red Cross (ICRC) to the emergence of MSF. In doing so, Fassin developed the notion of a “hierarchy of humanity,” which he defines as a terrain in which two groups are constituted unequally by humanitarianism—those whose expatriate status protects the sacred character of their lives and those who are excluded from this protection, the local and national staff. Fassin's concept is useful in helping us understand how humanitarian organizations unwittingly establish a “dual inequality” even as they call for a politics of human solidary. He explains, “first is the inequality between the active givers of aid and the vulnerable sufferers who receive it, and next is a distinction in life itself and political status between expatriates and local employees.Footnote 11
This notion of hierarchy is fruitful for analyzing the conceptual boundaries between “foreign” and “national” aid worker. However, in this article I take Fassin's concept of hierarchies a step further to question the distinctions in life among foreign aid workers. The doctors of MRS trouble the binary Fassin writes of in his analysis of “expatriate” and “national” staff. Indeed, we can view them as occupying both positions simultaneously. As American citizens residing in the United States, MRS doctors are powerful and “heroic” foreign providers of aid, who voluntarily travel from the global north to a crisis zone in the Middle East in order to deliver urgent, life-saving care to wounded and suffering groups—those who need help but have no other source of care. Yet as Muslim-Americans who remain personally and politically tied to Syria, they occupy a minority status at home in the US and retain deep sentiments of belonging and obligation towards Syria and Syrians as a national population. This liminality, neither foreign nor local in the traditional sense, grants MRS doctors an aura of authority, protection, and privilege in the global encounter but also situates them in a structurally disadvantaged location with respect to white western counterparts, or those who face less discrimination and travel restrictions when embarking on medical missions. This liminality, I contend, disrupts the singularly privileged location and sense of national “detachment” we typically afford to global aid workers. Moreover, it contributes to the notion that humanitarian work, like most organizational practices, is culturally and socially hierarchal and produces a range of experiences for aid workers that are not only about the west servicing the rest.Footnote 12
In terms of their liminality, MRS doctors view themselves as simultaneously within and outside of Syria, the society receiving aid. Many describe themselves as firmly attached to Syria yet culturally wavering between “east” and “west,” and their fluency in English and Arabic reflects this ambiguous social status. While some were born in the United States to Syrian parents, the majority are immigrants, having moved to the United States after completing medical school or establishing families and professional careers in Syria. MRS doctors range in age from early thirties to late sixties, and despite the active inclusion of women physicians, nurses, and administrators, the majority of the members who conduct international medical missions to Syrian are male. All of the MRS doctors I interviewed were united in their opposition to violent attacks against civilian populations by the Syrian government. Additionally, many MRS members are Sunni Muslims who are vocal about this opposition and who hail from—and still have extended families in—some of Syria's besieged regions. For example, Samir, an active MRS member who regularly travels to Lebanon to provide aid in Syrian refugee camps, immigrated to the United States in the early 1980s, right after he completed basic medical training in Damascus. He is a Sunni Muslim who grew up in Homs, an area where years of violent clashes between government forces and various sectarian factions took place. In our conversations, Samir condemned the regime for its atrocities against civilians in Homs and elsewhere in Syria. This Sunni opposition to the Syrian regime has deep roots in Syria's geo-political history.Footnote 13 Decades of corruption and favoritism for the Alawite sect placed the country's Sunni population in a disadvantaged position, leading to generations of systemic inequality in areas including but not limited to formal employment, education, and social services. This structural inequality was compounded upon with intermittent violent government crackdowns in predominantly Sunni neighborhoods believed to be Muslim Brotherhood strongholds. These national-religious-political divisions mark Syrian identity today and extend transnationally with populations that have immigrated.
MRS defines itself as a global medical relief organization working on the frontlines of war in Syria, as well as a global health organization servicing vulnerable populations in neighboring countries that lack access to public healthcare. In colorful pamphlets and brochures, their mission statement is clear and concise: to alleviate suffering and save lives. Since the start of the Syrian crisis in 2011, MRS has, according to its publications, serviced millions of vulnerable Syrians outside of the country's government or ISIS-controlled areas. In 2017 alone, they reported aiding a total of over five million patients inside Syria, along its borders with Jordan, Lebanon, and Turkey, and in other countries such as Greece. The majority of MRS funding comes from France, the United States, and Germany, but additional substantial funding is acquired from individual donations from the public and from its own association members.
MRS was founded in 1998 as a professional society with the purpose of uniting Syrian-American doctors for networking and cultural services. Since then it has transformed itself alongside the intensifying violence in the region. Today MRS members consider themselves part of a “global medical relief” organization mainly targeting suffering and displaced Syrians. MRS currently boasts roughly 1,500 members across the United States who affectively maintain twenty-five active chapters. Together, they conduct medical missions abroad, sponsor hospitals and ambulances, assist healthcare personnel inside Syria who are at constant risk of military attacks, fundraise, and pay salaries to healthcare workers in the region who are risking their lives to save others. Most recently, with continued US and European economic support, the organization expanded its reach to provide care to other vulnerable groups. MRS members recently constructed volunteer clinics for refugees on Greek Islands and have opened new clinics in the impoverished areas of other Arab countries, such as Egypt. Over the course of approximately two decades, therefore, MRS gradually expanded from a professional association to a medical relief organization providing aid to Syrians, to a sprawling global medical humanitarian organization focusing more and more on sustained, long-term medical care for populations in the Middle East. In commenting on its redefinition from an association that targeted Syrians to a global relief organization aiding other groups, a prominent board member noted in a pamphlet that MRS is there for anyone in need, or “whoever needs medical services and doesn't have funds. We are just giving back to humanity.” Thus, like other major global health organizations, MRS promotes a discourse of universal humanity in its work mission—the notion that all human beings are part of a shared community and should enjoy universal human rights, the right to health being one of them.Footnote 14 Even as this universal message undergirds its formal aims, the organization still remains firmly rooted in a Syrian identity, with the suffering of Syrians wounded or displaced by war its primary preoccupation.
MRS is a rare example of a professional association turned global aid organization that does not fit neatly into the binary of first world vs. third world politics. The discourses and practices of MRS doctors complicate dominant notions of who medical humanitarians are and what motivates them. In the next section, I capture the narratives of some of these doctors and explore how they have established themselves as medical aid workers in the context of the Syrian Civil War through discourses of national belonging and medical professionalism.
BETWEEN NATIONAL OBLIGATION AND PROFESSIONAL SOLIDARITY
As I strove to learn more about how the doctors saw themselves as Syrian-Americans and as global aid workers, I asked them why they engaged in medical humanitarian work in the Syrian Civil War. Two interrelated themes emerged from my interviews that deserve mention. The first, and strongest theme, was that of national “duty,” in which MRS doctors emphasized their Syrian identities, heritage, and enduring love of “homeland.” In other words, their medical humanitarian practices refracted onto what it meant to be a good Syrian citizen in a time of national crisis. Often, this duty was articulated in the form of a debt repayment, where doctors described the ways in which they “owed something” to other Syrians or to the nation itself, and therefore chose to provide relief to populations most affected by the war.
The second theme was similar to a finding shared by anthropologist Liisa Malkki in her study of Finnish Red Cross workers, in which international humanitarians expressed a sentiment of “professional solidarity” with each other. For Red Cross workers, this solidarity structured and sustained their humanitarian sensibilities and desires to help others around the world. For MRS doctors, similar discourses of professional solidarity, specifically the impulse to work together to improve care and do “better medicine” drove their work. They drew on their privileged status as American-based physicians operating with a wealth of resources and a vast network of expertise to cultivate more advanced humanitarian practices. The cultivation of this expertise took place in meetings, conferences, and workshops, in which doctors shared their aid practices and re-established themselves as ideal experts on the Syrian crisis. These pedagogical exchanges also worked to reinforce a strong sense of professional and political solidarity. Together, doctors aspired to better tailor future medical missions to extreme conditions of war. Most of the case studies presented during meetings were of injuries inflicted directly from aerial bombardment, such as severed limbs, while other cases focused on the structural conditions of extreme poverty in refugee camps and the illnesses that result, including infections from lack of proper heating, water, and sanitation. These two registers, of Syrian love of and debt to homeland and of professional solidarity, were distinct in the doctors’ narratives but also closely interconnected, reinforcing one another and reflecting back on what it meant to be an MRS doctor: neither detached in terms of national affiliation nor local and living within the society receiving aid.
I began my interviews by asking doctors why they joined MRS and engaged in overseas missions on behalf of Syrians. Many cited the personal gratification they received when working with aid recipients in their home country and with other members of the association. As mentioned earlier, all of the MRS doctors I interviewed condemned the government, the brutality of which some have witnessed first-hand while growing up and studying in Syria. They discussed a sense of solidarity that could only exist among other doctors who have lived in the country and who have experienced the regime's oppression, a “shared suffering” that they recognized in other MRS members who immigrated to the United States yet remain attached to Syria. This shared suffering was sometimes discussed through discourses of nostalgia and alongside memories of childhood. One doctor, while discussing with me the importance of the association in his life, emphasized this sense of shared suffering. He spoke about the devastating emotional effects the conflict engendered for him, stating that, “We are all emotionally drained by this war.” Holding out his arm as if to reveal an imaginary wound, he continued, “If someone cuts me right here right now, nothing will come out.” His statement implied a literal draining of the blood inside his body, an emptiness left inside due to ongoing violence and countless deaths that he and other Syrian doctors had witnessed.
Similarly, many MRS doctors described experiencing “trauma” as a result of the intersections of their national attachment and professional obligations. At one medical workshop, for example, I witnessed a presentation about healthcare during conflict by Dr. Hani, a long-time MRS member. He began his presentation by greeting the audience in Arabic, “al-salāmu ʿalaykum.” Before delving into case studies from a previous medical mission, he shared a slide show set to solemn music featuring Syria's most famous landmarks and majestic landscapes. The final images of the slide show were dramatically different from the initial ones, reflecting postwar destruction of buildings and an image of a Syrian boy whose face was mutilated by a bomb. The juxtaposition of the initial images, reflecting national beauty and ostensible peace, alongside the final ones that conveyed destruction, as embodied in the figure of the wounded Syrian boy, seemed to deeply impact the audience. As a witness to the presentation that day, and as someone who had visited many of the sites featured in the slide show, I too was deeply moved by this juxtaposition. It conveyed a sense of nostalgia for homeland, a longing for a return to a different time, to a prewar Syria. Scouring the solemn faces around him, with music still playing, Dr. Hani posed a series of questions to MRS members, “How many of you have ever dreamt that you were inside Syria experiencing this tragedy? How many of you feel shaken by your nightmares, by these dreams?” He reiterated a love of Syria as a shared homeland and then asserted that many of the MRS members in the room experienced a form of “second-hand Post-traumatic Syndrome Disorder (PTSD).” This condition, he stated, stemmed from treating innocent victims of war while also bearing witness to the violence while living abroad. “Like second hand smoke,” he explained, “second hand PTSD is a form of trauma we experience through our patients.” Here, Dr. Hani underscored a shared suffering that MRS members experience collectively through their sense of national belonging and medical professionalism.
Dr. Wael is a psychiatrist who resides in the American Midwest. Originally from Damascus, he lived most of his adult life in Lebanon before immigrating to the United States, and still has extended family in both Syria and Lebanon. When I first met him at an MRS conference, he had just returned from a trip to a Syrian refugee camp in Lebanon where he conducted trauma care with children over the course of one summer. As he was describing the deplorable economic conditions in this refugee camp, he explained why he became a member of MRS:
I do this work because I have a sense of debt to repay. My education was practically free in Syria. Here, I see medical students pay hundreds of thousands of dollars for their education. I feel I have to pay this back by helping [Syria]. I feel I have to do something.
Another doctor, Ibrahim, echoed the discourse of “duty” in describing why he chose to become active in medical aid work with the association once the war broke out. Specifically, he spoke about feeling “close” to the recipient population culturally by sharing the sentiment of “warmth.” Here, warmth implies more than mere proximity to aid recipients. For him, it connotes cultural adequacy, which Syrian aid workers are well equipped to provide to Syrian aid recipients:
Syrian doctors and the Syrian population are very close. We have not been born with a silver spoon in our mouths. Maybe this factor makes us more humble. It's easier for us to go there and be accepted, we sit on floors, eat off of one plate with our hands, we show emotional warmth.
Majed, a younger physician who also resides in the Midwest, shared his perspective on cultural adequacy and emphasized national citizenship. As he put it, “When you love your country, you love your people, and when you see your people being killed, even though its by your people, you just can't help but help those who need it.”
In addition to feeling culturally “close” to the population receiving aid, MRS doctors talked about the professional ethics that guide their humanitarian work, and here they highlighted the concept of medical neutrality and emphasized their desire to service “all of humanity” impartially. As physicians trained to uphold and save universalized human life, they talked about how even the figure of the dreaded “soldier”—often invoked when referring to the regime—failed to trouble this impulse. As Ibrahim elucidated:
We are in the business of saving lives, and we save lives. As doctors, we treat even soldiers without question. We are not equipped to decide who is friend or enemy. We work on saving lives and this is a universal attitude. Human life is human life.
Majed reaffirmed this statement by also describing how he strove to ensure that his national politics did not interfere with his professional obligation to treat anyone who is suffering, even a soldier, and to save human life universally:
I was trained to help whoever needs the help. Even the soldier. I'm not a lawyer or a judge, I don't do legal work. I have an obligation to help people first as a physician, and second as a national of my country.
In Majed's articulation, professional obligation—saving human life—trumps national sentiment; one comes “first,” as he stated, while the other is “second.” Ibrahim also explained how he navigates the conceptual distinction between politics and universalized medicine. He spoke about this through the metaphor of “putting on” and “taking off” his white doctor's coat, which signifies a transition in identity from Syrian citizen to professional doctor:
When I am a doctor, I am a doctor. When I take off my coat and just wear my clothes, I can conduct my civic duty. Now if I have a political agenda or make a political statement, I cannot be a doctor, so I do not wear my coat. You cannot have a conflict of interest and let your political views dictate you [as a doctor]. That is against our profession.
As these quotes make clear, the cultural liminality MRS doctors experience, the sense of attachment they have towards Syria, the emotional burdens they endure due to the violence, and the professionalism they adhere to in order to save universal human life all work together to produce a unique set of challenges that, for them, problematize the concept of medical neutrality, a subject to which I devote the next section.Footnote 15
HUMANITARIAN CHALLENGES TO MEDICAL NEUTRALITY
Even as MRS doctors strive to uphold the discourse of professional impartiality, as Ibrahim asserted in his clear distinction between civic and professional duty, they struggle to remain politically “neutral” during overseas missions, much like other aid workers who are embedded in crisis zones. This relationship to neutrality does not, I wish to emphasize here before proceeding, pertain to how doctors respond to recipients of aid who are injured or sick and seek assistance. Rather, it pertains to how MRS doctors must improvise care in extreme conditions, how they manage to achieve successful medical outcomes with limited resources or in damaged infrastructures, and how they act in the world as cultural subjects who are at risk of being injured or killed by political factions. For MRS, these challenges intersect with a discriminatory global geo-political landscape that positions them on a “lower rung” in a hierarchy of humanitarians as compared to their counterparts. Let me clarify some of the specific tensions that arise in the concept of medical neutrality for MRS, first by outlining what medical neutrality is in theory, and then by discussing how, in the context of crisis in the Middle East, the concept has been repeatedly challenged by medical aid workers.
Medical neutrality, scholars note, is a “universal norm” rooted in the history of western biomedicine.Footnote 16 It assumes a separation between biomedicine and the so-called grounded, messy world of politics and culture. It also holds that medicine should be practiced “impartially” to anyone who needs it, and indeed many of the MRS doctors I have interviewed hold this idea sacred and have striven to uphold impartial care during overseas medical missions and in their professional lives at home. Medical neutrality rests on the universalized moral imperative to save human life in its most basic, biological form. In this view, the human body is universalized, and biomedicine is presumed to be culture-free and traveling around the world in the same way with the same effects. It is through these universal logics that biomedicine, as Peter Redfield contends, acquires its “aura of moral purity and apolitical ambition.”Footnote 17
Recently, however, anthropologists of the Middle East have interrogated the idea of medical neutrality with ethnographic data, revealing how it functions in everyday life as a political, social, and cultural tool or stance advanced by doctors.Footnote 18 Sherine Hamdy and Soha Bayoumi, for example, have focused on how physicians in Egypt appealed to medical neutrality in the face of state violence.Footnote 19 As they explain, doctors in Egypt have had to grapple with their dual roles as political actors and as impartial medical practitioners. They often have to take a political stance that directly challenges state authorities, yet at the same time they cultivated an ethic of neutrality. Like MRS members, such doctors are situated paradoxically between aspirations of neutrality—of being outside of politics and culture—and the grounded, real world conditions that require them to engage in politics, especially in the face of egregious inequalities and harm to human life propagated by states.
Aid workers are uniquely situated between tensions within medical neutrality and political action. Like their patients, they have not been immune from deadly attacks in war zones, protest sites, or in spaces of care that come under fire. Patricia Omidian and Catherine Panter-Brick have illustrated how for the case of Pakistan local medical aid workers who were employed by large, global aid organizations were the subjects of targeted killings, kidnappings, and systematic harassment precisely because of their native status and attachments to western (imperial) institutions.Footnote 20 These workers sought work in the global health industry because they were driven by a desire to help fellow citizens who desperately needed assistance or they had a need to secure better paying jobs. Whatever their reason for engaging in aid work, they lived in constant fear for their lives and many have had to cultivate emotional resilience towards the ongoing professional danger they faced.
Targeted, strategic attacks on medical workers (both local and global) and medical facilities have been a defining feature of the Syrian Civil War.Footnote 21 Now in its eighth year, the war has claimed over 450,000 lives, displaced over twelve million Syrians, and spurned what experts call the world's worse humanitarian upheaval since World War II.Footnote 22 Its roots stem from a series of public protests that took hold in 2011 in Syria, following mass uprisings in Tunisia and Egypt, and what would later become known as the region-wide Arab Spring. One recent humanitarian report stated that, “Attacks on healthcare facilities and personnel in Syria have become the norm.” This same report traced a rate of attacks against healthcare facilities in Syria from January to September 2015 as one attack per four days, and in Aleppo alone during November 2016 one attack per day.Footnote 23 The continual bombardment of healthcare facilities during the Syrian war, in addition to the wide-scale collapse of basic healthcare infrastructure, has propelled the creation of new informal medical arrangements such as underground clinics, or what my research informants call “cave hospitals”—hospitals constructed underground in response to anticipated aerial bombardment. Under these conditions, international laws that were designed to protect medical personnel in war zones have been rendered irrelevant.
Therefore, MRS doctors navigate a position between political engagements and commitments to medical impartiality. Even after completing overseas medical missions, they continue to provide transnational assistance to local doctors in refugee camps and informal clinics that routinely come under attack. They do so by using improvisational medical methods that rely on innovation, creativity, and technology. For instance, they use mobile phones or applications such as Skype or WhatsApp to communicate with local healthcare providers. Samir, whom I mentioned earlier in this article, continually engages in this kind of transnational aid work. In our interview, he called the practice “Telehealth,” whereby he and other doctors use Skype to guide emergency surgeries from the United States. For MRS doctors, telehealth has, indeed, saved vulnerable lives in the worst of conditions. In one of our conversations, Majed described how he guided an emergency surgery in a besieged area of Syria via his cell phone. The procedure was being performed by, in his words, “a nurse,” because no other healthcare provider was available.
In these ways, for MRS members the medical humanitarian encounter resembles a protracted, potentially dangerous, and transnational set of practices guided by a professional impulse to save human life impartially; and yet it is action that is grounded in real-world conditions that require doctors act in politically constituted ways. In this view, MRS doctors, like other global humanitarian workers, are powerful, resource-rich givers of aid in relation to their vulnerable recipients and local doctors in the country of conflict. At the same time, however, they remain vulnerable to attacks in crisis zones, suffer emotional trauma due to their national attachments to homeland and their proximity to war victims, and are situated on a lower rung within a global hierarchy of medical humanitarians. These intersecting factors work to trouble the notion of medical neutrality in new ways.
CONCLUSION
In this article, I have examined the liminal location of Syrian global medical humanitarians and their care-giving strategies in the context of the ongoing Syrian Civil War. My overall aim was to situate these medical humanitarians culturally while further challenging the concept of medical neutrality in relation to war and violence. In addition, following Liisa Malkki's work on how global aid work is always still rooted in place, I hope to have further unsettled the assumption that all global medical aid workers are, as she writes, “universally mobile and operating from a position of national anonymity in relation to their aid recipients.”Footnote 24 On the contrary, the narratives of MRS doctors illustrate their complex and multidimensional needs and desires. They are mobile professionals who are marked as Other by western border politics yet privileged experts and aid givers to vulnerable groups in and around Syria.
In sharing the narratives of MRS doctors, I have called attention to their vulnerability as immigrants who have experienced the war in their home country from afar while conducting ongoing volunteer medical missions from within. Understanding this status of distant observer yet entrenched expert in war highlights critical inequalities of life that exist among and between global medical humanitarians. MRS doctors understand their work as situated between a set of interrelated obligations, wavering between national obligation, religious-political attachments, professional solidarity, and medical impartiality. Since the start of the Syrian crisis, they have faced a set of physical and emotional challenges that few, if any other, global aid workers experience with respect to the Syrian Civil War. For them, medical humanitarianism is not only about a universal impulse to save human life in its most universal biological form, echoing biomedicine's apolitical ambition. It is also about love of homeland, cultural affiliation, resistance to a perceived illegitimate regime, and the construction of a “good” Syrian self. As Muslim-Americans who oppose Syria's long-standing Assad government, they are approached as potential threats in the US, UK, and Syria, albeit in different ways and with different effects.
Consequently, MRS doctors have experiences and sentiments that differ from those of other doctors who traverse national borders with greater ease in order to conduct medical aid work from a position of ostensible universality and national anonymity—from a place of perceived neutrality. This difference sheds light on social and racial inequalities within aid work. We know that much of aid work presents a kind of “escape” for white western medical humanitarians. Global aid conducted in far-away lands “over there” can take one away from the familiar, it can be a route to self-transformation, or a means to reject a life of northern wealth and excess.Footnote 25 Such aid workers are typically perceived as universal and culture-free actors, as global citizens. But Wendy Brown has masterfully shown in a critique of liberal tolerance how this discursive “trick” erases power from global relationships and assumes that unmarked categories (such as white and western) are cosmopolitan, open, and unattached to any particular place or “culture”—hence operating from a position of superiority—while marked categories (such as native or minority) are attached to place, closed-off, and partial—and therefore inferior, inadequate, or unable to achieve universality. This view, as Brown agues, “purifies the first” category of its own intolerances, violence, and attachments to politics and “saturates the second … with difference.” In pointing out how this dualism operates in relation to MRS doctors and their work practices, I hope to have demonstrated the dangers with configuring some doctors differently as cultural subjects who are more attached to place and therefore hierarchically disadvantaged within global humanitarian industries.Footnote 26 As Brown suggests, our task is to situate all actors socially and culturally, as attached to politics and place.
At the time of this writing, violence and destruction persists in Syria. Global healthcare and emergency medical aid have become more of a permanent fixture both inside Syria and in surrounding refugee camps. When we consider the everyday lives and experiences of MRS doctors, and others who are similarly positioned as neither foreign nor local, we can gain a more nuanced understanding of how medical aid unfolds on the ground and how it reshapes the contours of contemporary crisis itself. We also come to appreciate how medical humanitarianism is always political and never outside of history, culture, or economics, and how doctors must work with national borders.
While we continue to foreground the inequalities of life that persist among aid recipients where violent crisis persists, we should remain attuned to the various hierarchies of life that exist between humanitarians. Both sides of the medical humanitarian encounter warrant attention, and in turn intervention, if we are to understand the cultural logics and everyday effects of life-saving aid across borders in the Middle East.
