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Chapter 1 explains the initiation of the anthropological research in 2017, when the MSF programme in Amman entered its tenth year. Multiple questions about the patients’ wellbeing both in the hospital and after they returned home required answers. Simultaneously, the concept of a “patient-centred approach” was flourishing at MSF, and the RSP had declared it one of its main preoccupations. The chapter details the qualitative-research methodology used in my research. In-depth interviews with ninety-nine MSF staff members and seventy-four patients from Syria and Iraq were transcribed, coded, and analysed using a thematic-analysis approach. Furthermore, extended observations of participants both inside the MSF hospital and in patients’ homes, and internal MSF documents provided information used in the process of triangulation. I describe how my observations over the six months I spent in the RSP hospital grew out of my integrated position, embedded in the hospital microcosm. My constant presence there facilitated my formal and informal interaction with staff. The chapter concludes with reports from my fieldwork in Jordan and Iraq. My vantage point – inside the home countries and literally inside patients’ homes – gave me the unique opportunity to observe the intimate physical and social environments of my participants.
In Chapter 2, I follow patients and staff through their daily routines in the hospital. I describe the spectrum of emotions experienced by members of hospital staff, ranging from their personal motivation to the emotional impact on them of the daily support they provide to the victims of war. The hospital routine is marked by mutual informal interactions between patients and staff, lending a general sense of informality and friendliness to the institutional relationships. Nevertheless, providing a “healing environment” and remaining steady under the visual impact of deformed limbs carries a certain price. Interviews with staff suggest feelings of sadness, guilt, and generalized emotional distress. These overwhelming emotions are linked to the staff’s perceptions of patients. Patients are predominantly viewed as victims, lacking their own agency, and patronizing attitudes are sometimes imposed to justify the social order in the hospital. An enduring hospital culture of stereotyping is widespread. This became obvious through positive descriptions of Iraqi patients in contrast to derogatory portrayals of Yemeni patients, who are viewed as lacking proper hygiene practices, for example, or not understanding the Jordanian dialect of Arabic. Despite all of this, the hospital appears to be a successful melting pot, where cultures blend and transformation takes place. It becomes a place where a patient’s sense of self is gradually altered.
The Introduction opens with a description of the book’s intent and my position as an anthropologist examining the humanitarian field. I introduce the story of one war victim – Ismael – who presents in microcosm the unique aspects of the patients in the MSF Reconstructive Surgery Programme (RSP). I go on to explore the invisibility of the war-wounded, especially those who have never participated in combat. The Introduction continues with a discussion on the delivery of humanitarian surgery, a specific field in the larger world of humanitarian aid. I touch briefly on the history of MSF surgical programmes and capture some of the history of MSF’s surgical practices, which go back to the very origins of the organization itself. RSP is a programme that reflects the cumulative MSF experience. The Introduction concludes with an in-depth description of MSF’s RSP in Amman, Jordan. Currently, patients in the RSP, who often sustain critical injuries years before they are admitted to the hospital, have various levels of disability or have lived with significant post-surgical complications. The Introduction explores several of the aspects that make the RSP unique. Among them are surgical procedures focused on functional improvements, the months and sometimes years-long rehabilitation undergone by patients away from their home countries, the scale of the programme, and the multi-disciplinary treatment provided.
Chapter 3 examines events related to patients’ injuries and reports on typical incidents in the immediate aftermath of an injury. The chapter shows how patients carry a double burden: that of their injury and of the disruption to their family and social environment. We meet Ali, a Syrian patient. Retelling his personal history, Ali describes the risks taken by the wounded and by those who try to save them. Ali reports multiple losses: his health, social identity, loved ones, material objects, and sense of security and trust. Numerous scenarios experienced by other participants in the study tell of the ways their lives were changed in a matter of seconds. The majority of those injured in Syria were wounded in bombing raids from the air or by gunshot. Iraqis, in contrast, were mainly the victims of explosions. The narration style of each group indicates how they frame, understand, and feel about the injury event. But in all cases, the incidents related to the injuries certainly leave their mark. The subsequent struggle to access healthcare and a safe refuge adds to the toll. The chapter details the long and difficult journeys taken by the wounded leading them eventually to the RSP in Amman. They carry their painful, traumatized past with them.
Chapter 4 looks at patients’ reflections on the care they received in the RSP, told years after being discharged from the hospital. Aside from reporting on programme strengths, particularly in providing a healing environment, patients shed light on the gaps that need to be addressed if the programme is to achieve its goal of delivering patient-centred care. The reader is presented with patients’ expressions of relief and gratitude for the care they received at the hospital. They describe beneficial aspects of the treatment that extend far beyond medical care, encompassing the relationships developed in the hospital setting. Furthermore, the chapter re-examines the notion of “unrealistic” patient expectations. When framed from the patients’ perspective, this notion appears flawed. In contrast to staff perceptions, the vast majority of patients report being fully satisfied with their treatment. For those patients who did express some degree of dissatisfaction with the programme, it was mostly related to a mismatch of priorities they have with the RSP. They spoke primarily about what they perceive as a neglect of the aesthetic dimension of care and the RSP’s emphasis on functional improvements. These perceptions highlighted gaps in the patient-centred approach and questioned the dominant assumption that functional outcomes alone improve patients’ lives.
Chapter 5 responds to providers of care for patients with disabilities. It addresses questions about what takes place once a patient is discharged from hospital and how disabled patients live day-to-day. These issues led me to explore the notion of quality of life. Using the patients’ own definitions of quality of life, I examine how they perceive their lives today. The impact of treatment in the hospital on patients’ quality of life appears to be multidimensional. Many patients stress the immense difference the treatment made to their lives – talking about functional improvements that led to improved access to employment, for instance. Emotional relief was also reported, motivating my participants to become involved in more social interactions that, in turn, resulted in an improved sense of self-esteem and security. Improvements in the quality of life of the participants were, however, largely dependent on the participant’s own ability to adapt. Despite describing their struggle to find viable coping mechanisms, this chapter testifies to the great strength and resilience residing in each of them. It is obvious that participants do not look at their bodies purely through the lens of function. They attach a number of symbolic and social meanings to their injuries. Regardless of the role played by MSF or any other care provider, recovery is very much dependent on patient’s own agency, coping skills and creativity.
The Introduction opens with a description of the book’s intent and my position as an anthropologist examining the humanitarian field. I introduce the story of one war victim – Ismael – who presents in microcosm the unique aspects of the patients in the MSF Reconstructive Surgery Programme (RSP). I go on to explore the invisibility of the war-wounded, especially those who have never participated in combat. The Introduction continues with a discussion on the delivery of humanitarian surgery, a specific field in the larger world of humanitarian aid. I touch briefly on the history of MSF surgical programmes and capture some of the history of MSF’s surgical practices, which go back to the very origins of the organization itself. RSP is a programme that reflects the cumulative MSF experience. The Introduction concludes with an in-depth description of MSF’s RSP in Amman, Jordan. Currently, patients in the RSP, who often sustain critical injuries years before they are admitted to the hospital, have various levels of disability or have lived with significant post-surgical complications. The Introduction explores several of the aspects that make the RSP unique. Among them are surgical procedures focused on functional improvements, the months and sometimes years-long rehabilitation undergone by patients away from their home countries, the scale of the programme, and the multi-disciplinary treatment provided.
In this last chapter, the limitations of the research are presented and discussed in the context of the findings. I also describe the process of reflexivity, through which I examine how my personal background and experiences in war may have influenced the interpretation of the research results. The need for multiple rehabilitation components is also debated. We start by reflecting on the relationship between healthcare providers and patients in the two predominant theoretical models of disability, namely medical and social. Continuing with a brief overview of the change in attitudes towards disability over time, we note how attitudes in the humanitarian field have also transformed. We focus on the victims of war and their need for social recovery. This was an essential part of the rehabilitation process in past centuries but has been mostly forgotten in recent decades especially with regard to the care of civilian victims of armed conflict. The last component of rehabilitation that I discuss is symbolic healing, a component essential for the victims of war. The chapter concludes with an assessment of the potential for implementing the findings in the broader context of disability care and the proposed avenues for further research.
Rather than thinking of waiting only as a form of discipline, Chapter 3 takes a closer look at the figure of ‘the waiting subject’ by engaging with the narratives of three unemployed Latvians. The informants’ narratives reveal how the bond with the state, made visible through language, is more complex than the rhetoric of waiting recognises. By listening to how ordinary individuals talk about the state and themselves, the analysis probes the kinds of intimate tyrannies that link the subject and the state in the post-Soviet, post-totalitarian context. By examining how these intimate bonds tying individuals to the state become a target of questioning and anxiety, we also gain an insight into the ways in which the austerity state is being legitimised.
The Epilogue talks about freedom as a category without which we cannot successfully theorise the social reality. I consider how categories like democracy, freedom, and justice have become ‘compromised categories’ (Hemment 2015: 34) not only in former socialist societies but in social theory as well. And yet, as the ethnographic analysis presented in this book shows, the Latvian politics of waiting, produced by the austerity state, can only be understood if we recognise how this waiting has been offered as a sacrifice for freedom.