Healthcare as a demonstration of EPLF legitimacy

The social revolution, spearheaded by the healthcare program, was a crucial feature of the liberation struggle and laid the foundations for a new conception of national identity. The EPLF’s territorial nationalism necessitated the development of national unity that transcended ethnic and social divisions. Public participation, aimed at a “profound structural transformation of society,” legitimized the EPLF’s assertion of a national and democratic struggle (Houtart 1988:83). Yohannes Tseggay Berhe has argued that the provision of vital services in the post-colonial liberation war period was a demonstration of economic renewal and social justice that empowered communities to take an active role in healthcare (Reference Berhe2000:8).

The EPLF strove for “moral as well as military firepower” (Reid Reference Reid2009:210–11), not least against the ELF. During the civil war of the 1970s, as the EPLF splintered from and ultimately usurped the ELF, ideological differences emerged and crystallized between the two groups (Pool Reference Pool1980:34). Though social transformation took place on both revolutionary fronts (With Reference With1987:66), the EPLF used its social movements, and healthcare in particular, to define itself as the superior resistance movement. The EPLF sent out propaganda squads and barefoot doctors to liberated areas, and engaged directly with peasants at the village level. This provided a deliberate contrast to the ELF, whose propaganda was tailored to pastoral groups (Pool Reference Pool1980:46–47). The ELF’s zonal strategy also contributed to the hoarding of essential supplies (Kibreab Reference Kibreab2008:154), a problem overcome by the EPLF’s central administration. Furthermore, the ELF was criticized for confining women to traditionally female roles, while the EPLF defined itself as inclusive and supportive of women (Cowan Reference Cowan1983:143–51). Over the longer term, the EPLF asserted its identity as a nationalist force “impervious to social, ethnic, regional, tribal, religious and ideological divisions” (Pool Reference Pool2001:55), as opposed to the ELF, which was ultimately unable to transcend its ethnic and religious origins. Medical care and health education promoted social cohesion and national unity, as this article will go on to discuss, and formed a central tenet of the EPLF’s claim to moral superiority.

Furthermore, healthcare was a crucial way in which the EPLF emphasized its state-building against Ethiopian destruction. The identical medical treatment and rations given to Ethiopian POWs provided an opportunity not only for military intelligence but also for a moral victory over Ethiopia (Tekeste 2002:59–60). Furthermore, the EPLF extended the provision of healthcare into rural areas that had remained untouched by Ethiopian services during federation, developing the reach of the state-in-waiting further than its predecessor and adversary. However, this relationship was not as clear-cut as EPLF propaganda suggests, as early gains in EPLF healthcare came at the cost of Ethiopian services: Eritrean doctors smuggled out medicine, microscopes, and essential provisions from Ethiopian hospitals during the early stages of the war (Assefaw 2009:20).

In addition to the legacy of Ethiopia in Eritrea, healthcare provision also defined the EPLF’s social revolutionary ideology against “garrison socialism” and centralized medicine in Ethiopia during the war (Markakis Reference Markakis1981:7, 20). Ethiopia supplied its own rural population with health services beginning in 1946, with a focus on preventative healthcare and epidemic control. However, it was heavily reliant on external assistance, and funds allocated to primary health services in rural areas were frequently diverted to hospitals. Ethiopian health outcomes in 1974 were the lowest worldwide, with poor coverage and a focus on curative rather than preventative health. While the 1974 Ethiopian revolution brought rapid expansion in healthcare (Kloos Reference Kloos1998:506), and a pyramidal structure of services strikingly similar to the EPHP (Kloos et al. Reference Kloos1987:1003–19), Helmut Kloos has shown that modern health services remained underutilized, and villagers relied predominantly on traditional medicine. Though healthcare improved with external support in the 1980s (Reference Kloos1990:101–14), Ethiopian services continued to provide a striking counterpoint to the efficiency, coverage, and self-sufficiency of the EPHP.^{Footnote 1}

Healthcare was closely linked to modernity, and the denial of appropriate healthcare during Eritrea’s colonial period was portrayed as having intentionally hindered Eritrean development and self-sufficiency. During the Italian occupation, healthcare remained the preserve of colonists, despite devastating outbreaks of cholera, plague, and typhus in the 1920s and 1930s. EPLF publications explicitly invoked the neglect of Eritrean health during the colonial period, asserting that services excluded the rural population and were unsuited to its needs (Pateman Reference Pateman1998:220); one publication argued that Italian colonialists aimed “to push the Eritreans to extinction to give space to Italian settlers.” Though the situation improved marginally during the British occupation, services remained modest and some facilities were dismantled when the British left (Sabo & Kibirge Reference Sabo and Kibirge1989:678–79). Services further declined during federation to Ethiopia from 1952; though Haile Selassie built a large modern hospital in Massawa (Tekeste 2008:221), budgets were cut from 1956 to 1965, and many health clinics were closed or destroyed by fighting in the 1960s (Firebrace & Holland Reference Firebrace and Holland1984:103–4). Provision of a comprehensive, far-reaching healthcare service thus provided a favorable point of comparison between the EPLF and its predecessors.

Internationally, a successful healthcare system demonstrated the EPLF’s successful provision of state services and legitimized the state-in-waiting. As the war intensified, so too did the battle for international recognition for healthcare. The EPLF set up Departments for Research in 1977 to promote medical theory (Tekeste 2002:137), published the inaugural issue of the Eritrean Medical Journal during the Sixth Offensive in September 1982, and held the First Congress of the Eritrean Medical Association at Orota Central Hospital (Tekeste 2008:261, 334).

Healthcare was thus crucial to legitimizing the EPLF domestically and internationally, as the EPLF demonstrated its state capabilities against its civil war rival, the ELF, and against the previous Ethiopian occupation, as well as against contemporaneous services in Ethiopia. In addition, the EPLF also drew favorable comparisons between its service provision and that of its former colonizers, Italy and Britain.

Healthcare as a tool for politicization

The provision of healthcare was a political decision taken by the EPRP, as the former head of the civilian health service confirmed (interview with Assefaw, July 2018). Healthcare services were an important means of establishing links with local Eritrean populations, and they had the potential to function as a conduit for the social revolutionary ideology espoused by the EPLF. Several authors concur on its success: Lionel Cliffe suggested that free healthcare was a crucial way of “showing the people that the EPLF care[d] about them” (Reference Cliffe, Cliffe and Davidson1988:99), and Alemseged Abbay has argued that social services convinced peasants “that the EPLF were friends in need” (1998:118). The EPLF focus on Mother and Child health and Immunization brought the state-in-waiting into contact with Eritreans at the earliest possible opportunity (Berhe Reference Berhe2000:20). After areas were liberated, healthcare was often the first means of contact between the EPLF and the population, as barefoot doctors entered newly liberated villages with armed propaganda squads (Pool Reference Pool2001:100). Civilians in Azien and Barka received free medical care immediately after the cities were liberated (Houtart Reference Houtart, Cliffe, Davidson and Selassie1980:101; Wilson Reference Wilson1991:143), and EPLF practitioners provided healthcare in post-liberation Keren, including elective and minor surgeries, for free or at a nominal fee. Tekeste Fekadu argues that people “understood the true nature of the EPLF” after receiving healthcare (2002:173).

The EPLF pursued a similar policy with Eritrea’s pastoralist populations. In Sahel, MHUs delivered free healthcare to pastoralists starting in 1972, and hospitals and SHCs set up during conflict in the Barka province were used to provide care to pastoralists after liberation (Assefaw 2009:27–28). Similarly, agropastoralists in Wadi Lakba, who had remained almost untouched by the Ethiopian state, were incorporated into the EPLF sphere of influence by the medical and veterinary services provided by barefoot doctors (Pool Reference Pool2001:114–15). Assefaw Ghebrekidan has described how EPLF teams were initially restricted to treating serious medical conditions; repeated successes slowly won pastoralists’ trust and support, and EPLF teams progressed to providing primary, secondary, and tertiary care.

The delivery of healthcare created a relationship of trust and dependence with which the EPLF aimed to promulgate its political message and mobilize the population. As the EPLF became established in villages and among pastoralists, it used healthcare to deliver education aimed at developing Eritreans’ political consciousness (With Reference With1987:103; Connell Reference Connell2001:346). In the obligatory health education that preceded outpatient appointments, medical practitioners emphasized citizens’ “right to be healthy,” likening it to economic and women’s rights. They used politically charged language, emphasizing that basic healthcare education made Eritreans “masters of their health,” and that “free people don’t need to depend on others.” They also highlighted that “the colonizers never gave this to you; we are the first to do this as you are Eritreans and we are Eritreans” (interview with Assefaw, July 2018). Dan Connell agreed that health education encouraged people to associate positive change with the EPLF and impressed upon villagers their own ability to create lasting change (Reference Connell1993:64).

However, it is difficult to assess the extent to which those who used EPLF services and received the education and implicit political messages within them supported the EPLF’s (socio)political ambitions. As Assefaw noted, “people learned to listen, even if they didn’t like the content” (interview, July 2018). Much of the literature on the subject credits the health service with success; Connell suggests that medicine paved the way for the successful development of a political consciousness favorable to the EPLF among highland farmers (Reference Connell1993:62–63). Similarly, Pool suggests that healthcare generated significant support among the rural population “in a way that politicization through political education with its unfamiliar Marxist/Maoist class analysis did not” (Reference Pool2001:81). Assefaw related that civilians were grateful for the services they were offered, and did not routinely scrutinize the EPLF’s provision of medical care for political motivations. It is difficult to isolate the effect of health education before outpatient care in mobilizing hearts and minds for the EPLF, given that it formed part of a much broader program of increasing political awareness through local assemblies, education, free veterinary care, and other state services. Nevertheless, populations who encountered the EPLF through its social services did mobilize on behalf of the regime; for example, Tekeste argues that inhabitants of Keren “started to participate actively in different mass organisations” after receiving healthcare (2002:173). Assefaw confirmed that through healthcare, the EPLF “consolidated power and became accepted by the people,” but equally stressed that citizens felt a sense of ownership over the service. He cited the repeated delegations, sent after independence by groups from Sahel to Isaias in Asmara to report that they were short of resources and to request his intervention, as evidence of their faith both in the EPLF and in their political right to national resources (interview, July 2018).

In addition to raising political consciousness among the civilian population, healthcare practitioners also received political instruction themselves. The majority of foreign visitors reported a striking uniformity of political views among health workers, despite assurances to the contrary; Connell argues that “ambiguity was not part of the political culture” (Reference Connell1993:42). Tekeste describes an FSU giving “intensive medical and political lessons to its entire staff,” and recounts that “heated discussions” were a feature of hospital life. Tekeste reports that “criticism and self-criticism,” as well as “counselling and advising” were used to unify political views, and credits this and “political lessons” with improving service quality (2002:131, 2008:28–29, 191–95). In the EPLF, “criticism and self-criticism” denoted a Maoist-style session in which individuals were encouraged to detail their own and others’ failures to comply with party doctrine. Sessions were organized in various departments of the EPLF to allow members of the secret EPRP to attack political opponents. However, in the healthcare service, this was complicated by factionalism between two of its senior figures, Dr. Assefaw Ghebrekidan and Dr. Haile Metsun, who were members of the secret EPRP and differed “on matters of dogma.” These differences precluded any targeted action against medical staff, as each defended their supporters from political attacks. Medical staff were unaware of the deeper EPRP divisions at play, and Assefaw argued that this factionalism, combined with the medical department’s relative independence, protected staff from all but superficial political criticism.^{Footnote 2} Instead, meetings focused on providing constructive feedback about service provision (interview with Assefaw, July 2018).

Nevertheless, it is essential to emphasize the genuine nationalist and humanitarian motivations of what seems to be the vast majority of those involved in the provision of health services. Doctors gave up hard-won, lucrative careers in which they were treated “like Gods” in order to join the EPLF health service, where they made do without wages and on scant supplies (interview with Assefaw, July 2018). As Kibreab emphasizes, volunteers “wanted to sacrifice their lives in pursuit of the lofty ideals of democracy, justice, fairness, freedom, rule of law and independence. They wanted change for all the people, not only for those with whom they had affective social relations… These examples of commitment, dedication, devotion and reciprocal cooperation to public causes were nothing but incontrovertible expressions of a highly developed sense of public spirit and [civic] engagement” (2009:346). This is echoed by many textual sources, which emphasize the genuine enthusiasm and dedication of medical staff (Connell Reference Connell1993:37, 42; Tekeste 2008:176).

Furthermore, the medical service itself enjoyed comparative political independence. Isaias respected the achievements of the healthcare service, and frequently referred any questions from outsiders or the committee to Assefaw. The medical department was given full independence and authority, and senior members such as Dr. Nerayo, as head of the Eritrean Public Health Association, undertook annual trips to the U.S. and Europe to coordinate with specialists and buy medicine and equipment (interview with Assefaw, August 2018). In addition, village health workers and traditional birth attendants were not only elected by each village to form the Community Health Service but were also tasked with advocating for the village in matters of health (Leonard Reference Leonard, Cliffe and Davidson1988:130–31; interview with Assefaw, August 2018).

The EPLF employed healthcare as a means of accessing urban, rural, and pastoral populations and mobilizing them on behalf of the EPLF. Through the provision of vital services in newly liberated or previously isolated areas, the EPLF successfully won the trust of local populations and used this relationship as a vehicle for delivering political education directly to civilians. This pattern was replicated within the healthcare system, as its hierarchy functioned to homogenize political views. In some respects the Healthcare Department enjoyed relative political independence, and staff motivations certainly seem to have been humanitarian and nationalist rather than political in nature. Nevertheless, the EPLF used healthcare to promulgate its political views, recognizing the provision of medical services as an instrument not only of social cohesion, but also of mobilization.

Healthcare as a Vehicle for Social Change

The climate of the struggle was conducive to profound social change. As previously discussed, ethnic groups excluded from civil society during the Italian and Ethiopian occupations were assiduously reincorporated by EPLF policy, while the comparative lack of ethnic and class dimensions in the organization itself may have contributed to reducing existing social barriers. Though Eritrean nationalism emerged in the colonial period, a “common” national identity that transcended existing social divisions was engendered during the liberation war (Bundegaard Reference Bundegaard2004:32–33).

The healthcare service was crucial in facilitating this, not least by training a national network of around 5,000 villagers as healthcare professionals (Berhe Reference Berhe2000:21), who demonstrated exceptionally high cooperativity and resilience. Healthcare workers sacrificed wealth and status for a life in the field with no pay and limited resources, and a medical system which rejected the traditional hierarchy of doctors and nurses (Wilson Reference Wilson1991:144). Nevertheless, doctors reported that working in EPLF medical teams fostered a unique degree of dedication and cooperation. Members of the healthcare service recollected that they would sit together in the evenings and study to improve the medical services provided, and at times medics relied on blood donations by medical staff and stretcher-bearers for transfusions (Tekeste 2008:336). Teamwork was credited with achieving remarkable feats of medicine, including a successful craniotomy in an FSU tent (2002:62–64). For fighters, the effect of emergency surgery on reducing morbidity and mortality had a “tremendous psychological impact” (Kibreab Reference Kibreab2009:109); Tekeste suggests that the popular perception of head, chest, and abdomen injuries was transformed from a death sentence, to “if you arrive at the FSU (alive) you will survive” by 1977 (2002:102). Nevertheless, while Kibreab recognizes the highly-developed sense of public spirit and civic morality among EPLF volunteers, he argues that it is imperative not to over-state this harmony. He suggests that this “economy of affection” in which people set aside their differences was driven by necessity, and that some inevitable conflict and disharmony took place (2008:335–46).

In civil society, anecdotal evidence suggests that healthcare helped to foster cooperation between class and social groups and reduce historic divisions. Civilians in Debub and Ela’gemed donated animal products to medical staff, while female volunteers in the FSUs of Debub, Keren, and Karneshim assisted medical staff by preparing and delivering food, washing textiles, assisting in medical wards, and collecting firewood (Tekeste 2002:184–213). At the central hospital, volunteers built underground wards, transported laundry, tailored clothes, grew vegetables, and harvested grain to support the medical team and the liberation war more generally (Connell Reference Connell1993:36–37). Pastoralist support became essential to warfare in hostile terrain, particularly by providing camels to transport supplies and casualties. Furthermore, in 1977, a group of thirty volunteers from Sahel requested training in the diagnosis and treatment of common illnesses to reduce the strain on doctors, which was duly arranged (interview with Assefaw, January 2017). As Firebrace and Holland and Tekeste identify, the support and active participation of local populations shaped the experience of war for all those that took part, while mass inclusion provided the basis of the social revolution.

Ultimately, issues linked to the changing role of women engendered the most discussion and division. War often overturns traditional gender roles, and the EPLF took advantage of the dramatic societal flux generated by the struggle to drive through measures aimed at women’s liberation. The EPLF stressed a holistic approach that saw health services as interlinked with other goals including the emancipation of women (Wilson Reference Wilson1991:140) and legitimized the promotion of gender equality in line with policies of “maximum participation” and in light of military successes (Amanuel Mehreteab 2004:151–54). Changes in the role of women occurred rapidly, as the demand for personnel superseded any objections, and Mary Dines emphasizes that all kinds of traditionally male skills were attained by women (Reference Davidson and Cliffe1980:134, 139). Amrit Wilson’s account emphasizes the prevalence of women in medical service, from “young Eritrean women doctors in mobile units at the battlefront” to “traditional midwives with modern kits” (Reference Wilson1991:139). Healthcare certainly employed a large number of women; 80 percent of health workers, all TBAs, and 55 percent of medical staff were female (interview with Assefaw, July 2017). By the late 1980s, this was reflected in Department of Health, which had 49 percent female personnel (Tekeste 2008:164). Nicole Ann Cowan praises a nursery for fighters’ children in which male and female barefoot doctors cared for children from six to nine months of age. Though Cowan acknowledges that cooking and childcare were rarely undertaken by men in the civilian population, Cowan hailed the nursery as “one of the most convincing examples of the Front’s commitment to women’s emancipation” (Reference Cowan1983:149–51). Furthermore, testimonials from women have shown that perceived gender equality between EPLF members was one of the struggle’s greatest attractions (Burgess Reference Burgess1989:128).

Dan Connell argues that the EPRP used advances in health and other social and economic services to override objections to policies such as quotas on the number of female participants, suggesting that contesting women’s prominence was unpatriotic (Reference Connell2001:354). This allowed the EPLF to push through a central tenet of its “social revolution,” the liberation and equality of women, and thus employ the health service as a tool for women’s emancipation. However, some women were forcibly co-opted into services towards the end of the 1980s (Kibreab Reference Kibreab2008:316), and women remained underrepresented at the highest levels of the healthcare service. Amanuel Mehreteab is not alone in suggesting that women were constrained by a lack of education and experience (2004:153–54); however, the numerous accounts of highly-skilled female practitioners, thirty-year span of the Liberation War, and significant amount of education and training that took place limit this argument.

The EPLF also employed healthcare in its effort to eliminate female circumcision. Initially, the EPLF banned clitoridectomy, which was practiced in the Christian highlands, and infibulation, which was prevalent among lowland Muslim communities (Firebrace & Holland Reference Firebrace and Holland1984:107–8), with considerable international support. However, enforcement proved difficult: Assefaw recounted that infibulation preceded a feast, and was considered “a village event” and a “stepping stone in the child’s life.” At the inception of the Civilian Health service, pastoralist women were reportedly circumcised without exception (interview, July 2018). After significant backlash, the EPLF lifted the ban in favor of an educational program. Healthcare practitioners explained the medical objections to the practices, and stressed the risks of the surgery and subsequent complications (Wilson Reference Wilson1991:146). However, real progress was only made when the local sheikhs agreed to denounce the surgery (interview with Assefaw, July 2018). Ultimately these policies were highly successful, as female circumcision was reportedly eliminated among EPLF fighters and significantly reduced in EPLF-administered areas (Firebrace & Holland Reference Firebrace and Holland1984:107–8).

It remains difficult to quantify the extent to which the EPLF successfully integrated with rural communities and transformed society. Generally, Assefaw suggests that citizens trusted the EPLF to serve their interests, particularly in regions where there had previously been no provision for health or education (interview, August 2018). The healthcare system facilitated and accelerated social change and facilitated positive interactions between EPLF members and the communities in which they worked. Within the Health Service, there was an ostensible absence of class and social barriers, which contributed to an exceptionally high degree of teamwork and cooperation. Healthcare improved the position of women, who made up the majority of healthcare practitioners, though there were limits to women’s advancement. However, the EPLF also used healthcare to override social norms in its drive for national transformation.

Coercion & Compromise in Healthcare

Across the EPLF, Kibreab argues that the “democratic centralism” that made services effective prevented autonomy and ideological pluralism. As the civilian population in semi-liberated and liberated areas became dependent on the Front for healthcare, they became less autonomous and lost political leverage; this allowed the ELF and EPLF to ignore civilian demands without fear of political repercussions (Reference Kibreab2008:355, 374). Connell suggests that the EPLF’s descent into control was inevitable, given the persistent internal and external ideological, military, and physical threats to its existence (Reference Connell2001:362). Nevertheless, the intimate nature of healthcare necessitated close cooperation between the EPLF and local communities and required that the EPLF navigate existing structures of power.

As Carol Barker and Meredeth Turshen have shown, the successful implementation of primary healthcare both requires and facilitates a high degree of government control. As a result, citizens “trade some measure of individual freedom for improved individual health” (Reference Barker and Turshen1986:79–81). Complaints against doctors were extremely rare; medicine was a prestigious profession, and deaths were generally felt to be “god’s will” (interview with Assefaw, August 2018). Indeed, Tekeste notes that not having to obtain consent, combined with patient obedience to EPLF doctors, facilitated efficient treatment (2002:39). However, this violates widely held principles of bodily autonomy (Etchells et al. Reference Etchells1996:177–80). A similar compromise was adopted with women of the Rashaida ethnic group, who expressly prohibited male healthcare professionals from checking their throat or tonsils. As relations between the EPLF healthcare professionals and the Rashaida improved, qualified medical male doctors were allowed access into the women’s tent. Nevertheless, one barefoot doctor was believed to be the head of the hospital and thus allowed to treat Rashaida women (interview with Assefaw, July 2018). While this facilitated treatment, it could be seen to breach the standards of transparency and honesty expected of medical professionals.

However, cooperation with established healthcare traditions was crucial to the EPLF’s successful integration of existing social groups into the liberation war, despite early attempts to outlaw traditional medicine and practices. Officially, the EPLF preserved the “good” aspects of traditional medicine and rejected the “bad” wholeheartedly (Wilson Reference Wilson1991:140), although in practice this distinction seems to have been less clear-cut, and a complex system of mutual dependence developed. This was particularly true of Traditional Birth Attendants and traditional healers. Birth attendants were a pillar of village communities, with high community status and extensive client networks. The EPLF recognized that most births were reasonably priced and problem-free, and that attendants were highly experienced (Assefaw 2009:19–33). By training existing birth attendants in modern technique and presenting them with a modern delivery kit, the EPLF aimed to eliminate existing harmful practices, and incorporate traditional practitioners into the healthcare system.

A less formalized cooperative approach was adopted with traditional healers, after unsuccessful attempts to eliminate traditional medicine. The EPLF initially banned healers and sheikhs from practicing, decrying their prices as excessive and their treatments harmful. Several practitioners were arrested and jailed, and many went into hiding or sought refuge in their communities. However, traditional healers and sheikhs were deeply embedded in local societies, and traditional medicine remained popular throughout the liberation war to treat himam nebsi (spiritual causes), even among EPLF fighters (Tekeste 2002:135–36). Assefaw suggests that the ban was unsuccessful and undermined trust in the EPLF, prompting a shift from prosecution to cooperation (2009:27–28). As healers could see more than 150 patients a day, compared to around thirty attending a local clinic, some EPLF services worked with local healers to manage patients more effectively. As an EPLF surgeon, Assefaw formed an agreement under which he would refer patients with viral diseases, epilepsy, convulsions, and psychiatric problems to a local sheikh, and the sheikh would refer diseases such as tuberculosis to Assefaw’s surgical team. In practice, many patients saw both practitioners. There is a striking parallel between the EPLF’s experience and the ZANLA’s compromise between socialist idealism and traditional medicine in Zimbabwe, where the state cooperated with traditional medicine in order to maintain moral and political authority in the eyes of the rural population (Lan Reference Lan1985:146–49, 164–66). Nevertheless, Assefaw argued that the EPLF were never able to fully repair the damage caused by the initial persecutions and “arrogance of Western medicine” (interview with Assefaw, July 2018).

The phenomenon of “malingering” gives us an insight into those who found the harsh conditions and enormous social and political pressure of the Front harder to tolerate. It is difficult to ascertain how widespread this practice was, as it is absent from almost all literature on the period. Tekeste describes fighters who inflicted severe self-injury or feigned illness “for a few days rest in the hospital” after experiencing traumatic events, or out of dislike of the Front. Until 1979, doctors diagnosed patients with non-physical symptoms as “malingering” and sent them back to their divisions, where they were branded “cowards” or “opportunists” (Tekeste 2002:178). However, this resulted in more complex and well-researched presentations of illness, and there were worries that “malingering” patients might either disengage with medical services, or refrain from seeking treatment due to the risk of social stigma. From 1979, Tekeste’s team began to investigate the patient fully and diagnose the condition as inconclusive, while providing informal counselling and advice. This was an ad hoc initiative; there remained no official provision for any forms of post-traumatic stress disorder, and any fighter exempted from duty could be subsequently investigated (2008:180–90). These unofficial provisions echo arrangements in the civilian healthcare service described above; in the absence of resources for psychiatric treatment, patients with suspected mental illnesses were referred to local sheiks for traditional treatments (interview with Assefaw, July 2018). While Tekeste’s general statements about malingering emphasize the coercive nature of the EPLF, both senior figures describe the informal emergence of something akin to psychiatric care, complicating the picture of homogeneity among not only fighters, but also doctors. In a similar manner to the “self-criticism” described above, the biopolitical protocol for “malingering” patients seems to have been diluted by the realities of providing medical care.

Some groups appear to have been more critical of the service than others; Sahel pastoralists continued to question and criticize the EPLF. A crucial example of this is their exercise of the “right to candor,” a tenet of medical ethics mandating that patients receive candid information about medical errors. After a woman treated by the EPLF died during childbirth, a group of pastoralists raised a public complaint with senior figures in the service. They cited the service’s pronouncement that “if you do exactly as we tell you, no mother will die during labor,” and questioned the methods and authority of the EPLF’s modern medicine. The complaint resulted in a “full investigation.” Though the healthcare service was eventually exonerated, Assefaw revealed that the incident served as a “warning to be careful, even in the middle of war.” While far from standard practice in the EPLF system, this request highlights the ongoing negotiations between civilians and healthcare services during the war. The former director described the incident as evidence of the EPLF’s success in political education: citizens were “aware of their power” to the extent that they called the methods and authority of doctors into question (interview, July 2018).

Ultimately, the biopolitical manner in which the EPLF pursued healthcare delivery compromised individual rights, and facilitated the increasing incursion of (proto-)state power into Eritreans’ lives. However, the Front also met with significant opposition and traditional forms of healthcare that it was unable to eradicate. While successful healthcare was able to extend centralized control, the EPLF healthcare system succeeded only when it entered into dialogue with the communities it sought to change.

International Dimensions of Healthcare

Eritrea received “no more than a trickle” of international relief during the struggle (Dines Reference Dines, Cliffe, Davidson and Selassie1980:132), and at various points both the United States and the Soviet Union supported Ethiopia against Eritrea. As Assefaw remarked to the New York Times: “Our struggle has been a very isolated one. No superpower supports us. To the Soviets we are agents of imperialism. To the West we are Marxists. But there is some good about isolation. It steels us. We are self-sufficient” (Kifner Reference Kifner1988).

The EPLF also maximized the involvement of its diaspora. Salary remittances provided the economic support necessary for a viable healthcare system (Bundegaard Reference Bundegaard2004:33), and the diaspora also drove the formation of the EMA, the Research and Information Center on Eritrea, and the ERA (Leonard Reference Leonard, Cliffe and Davidson1988:111). The latter, a humanitarian organization established by Eritrean refugees, provided emergency relief and long-term development programs in EPLF-controlled areas, including medicines, raw materials, and medical equipment, from 1984 to 1992 (Berhe Reference Berhe2000:2–3, 12).

A predilection for underplaying the role of international partners by effusive journalists and the current PDFJ regime makes the exact contributions of foreign collaborators difficult to ascertain; this uncertainty has legitimized Eritrean claims of self-sufficiency at the expense of acknowledging its substantial and long-term international collaborations. Support for the EPLF was characterized by small-scale projects between individuals or small organizations rather than foreign governments. One such project was a microscope designed by Scottish doctor John McArthur in 1983 specifically for the EPHP, which revolutionized the diagnosis and treatment of malaria, tuberculosis, and intestinal parasites by barefoot doctors. The production of intravenous fluid was made possible by funds and technical assistance from the Belgian Support Committee, while the raw materials for tablet and capsule production were donated by British NGOs (Firebrace & Holland Reference Firebrace and Holland1984:114–15), and the hospital complex in Afabet was Swedish-built (Dines Reference Dines, Cliffe, Davidson and Selassie1980:134). In total, over thirty NGOs worked with the EPLF to fund the purchase of surgical equipment and anesthesia machines from overseas. International supporters from Denmark, Sweden, Italy, France, and Norway provided specialized teaching and training (With Reference With1987:155–59; Firebrace & Holland Reference Firebrace and Holland1984:104–5), and Eritrean barefoot doctors shared their expertise in hostile environments with foreign paramedics. Detailed reports on the health service were compiled and forwarded to the ERA’s NGO partners each month (Kibreab Reference Kibreab2009:109).

Praise by Western observers also shaped the service and the struggle, as glowing reports of the healthcare service legitimized the EPLF proto-state and drew attention away from deeper currents of coercion and increasingly centralized control. The EPLF’s achievements with regard to health “rarely failed to impress visitors, including doctors and other trained medical personnel” (Firebrace & Holland Reference Firebrace and Holland1984:102); John Kifner’s (Reference Kifner1988) effusive reports in the New York Times demonstrate how closely healthcare was linked to EPLF legitimacy. Kibreab argues that such “eulogistic observations” contributed to the EPLF leadership’s sense of infallibility and facilitated the creation of the present military state (2009:14).

The EPLF received remarkably little formal international support, and was reliant on remittances from diaspora Eritreans. In addition, the ERA and its NGO partners were instrumental in organizing supplies and international training for the healthcare program. Several informal international partnerships were conducted, which developed the healthcare service and improved its self-sufficiency. However, international media attention to the health service may have deflected critical assessments of the EPLF and contributed to the organization’s sense of infallibility.