A review of The Anatomy of Ephemeral Care: Health, Hunger, and Short-Term Humanitarian Intervention in Northwest Nepal, by David M. Citrin.
Just over a quarter century ago, Judith Justice (Policies, Plans, and People: Culture and Health Development in Nepal. Berkeley: University of California Press, 1986) critically examined the reasons behind the failure of the Nepali government’s health service sector and International Aid programs to reach much of the Kingdom’s rural population. Protracted dialogue with and participation in the daily life of those who make plans, enact policy, and live its consequences convinced Judith Justice that the kinds of analyses which anthropology provides could inform — and help reform — bureaucratic praxis more than it had theretofore. Justice’s analyses revealed a system working against itself at almost every stage, as expectations and evaluative measures decided upon at the planning stage (Nepali government, WHO) were formulated in a largely top-down manner. Plans and policies were largely ineffective (and often counter-effective) because they were designed to be implemented in ways amenable to the rural cultures of Nepal. Further, information and recommendations from those in the community would either be ignored or lost in transit as they were sent up through several layers of bureaucracy.
It is in this tradition of an anthropology animated by the need for critique and a concern for praxis that we welcome David Citrin’s The Anatomy of Ephemeral Care. Citrin presents us with an ethnographic case study comprised of several prolonged periods of fieldwork between the years 2006-2010, in the immediate wake of a decade-long Civil War punctuated by the Kingdom’s ostensible transition toward democracy in 2008. Citrin presents a nuanced, candid, and rich account of the interactions between the people of Nepal’s Humla region and the short-term medical and food aid groups that venture there hoping to alleviate some measure of suffering in this exploited and poverty-stricken region. Citrin accomplishes this by letting his gaze linger long after the camps have passed and the “voluntourists” have departed.
In Chapter 1, Citrin lays the groundwork for his analysis by recounting the history of the developments whereby Nepal was reconfigured in the global imaginary; a processes in which an hermetic Kingdom was transformed into a state requiring international aid and aggressive developmental measures. Following the Civil War, short-term relief efforts became the norm in Nepal, with several groups initiating projects — at times conflicting and at times overlapping — in developing regions. Such groups worked to set up cycles of short-term medical and food aid camps staffed by students and professionals. Staffer motivations ranged from looking to “give something back” by emulating Paul Farmer or Ivan Illich to the perhaps more pragmatic avowal of garnering a unique experience that would both hone their medical skills and adorn their resume. Reflecting on a series of candid interviews, Citrin shows that situations such “voluntourists” encounter (himself included) often trouble these motivations; the hunger, the poverty, the chronic misery, and the chaos prompt deep questioning of both self and world.
Chapter 2 leads us deeper into the “Hidden Himalayas,” tracing the history of the Karnali region as a scrimmage zone in the ongoing battle to shape Nepal into a modern nation-state. Military and administrative conscription into the nascent Nepali Kingdom of the late 1700s (leaving this remote region out of political and economic influence but open to exploitation) began the progressive disruption of Humla’s position as a vital node in a vast salt and grain trade route extending out from Tibet. Tracing the complex political, social, and cultural histories of the Karnali region, Citrin provides a cogent account of the multiplicity of effects which are conveniently overlooked by the several stakeholders when they present the region’s chronic poverty, hunger, and illness as being somehow an essential property of this rural community. Without this deep context (and thus without a sense that it can be otherwise), aid groups find easy justification in keeping their focus on serial short-term care. Consequently, when long-term projects are proposed, they are effectively sabotaged by the essentialist assumptions governing their implementation.
Chapter 3 Citrin offers us a glimpse of the quotidian in Humla, walking us through the district administrative center Simikot; an area so remote it can only be reached by several weeks’ journey or by harrowing flight (any echoes of James Hilton’s Lost Horizon are soon muted against the chronic poverty and unremitting harshness of this bafflingly remote node in a once thriving grain and salt trading caravan route). In this remote area, any village one is likely to encounter north of Simikot will be inhabited primarily by ethnic Tibetan speaking groups who were ascribed, for ease of census and caste scheduling, the last name “Tamang,” which they themselves have morphed into “Lama” (being more recognizable internationally as “Tibetan”; p. 101). In addition to their distinctive language, such communities were distinguished until quite recently by polyandry. Such a practice allowed for a consolidation of both labor and land in a region which maintained itself through agricultural and pastoral life-ways. With the decline of polyandry, so too the size of land holdings and families. Increasing fragmentation of land and family left such communities without the necessary social structures and practices by which they had withstood the harshness of the region for centuries. Trade continues, but the products are now timber, bowls, alcohol, and the “caterpillar fungus” demanded by China for its presumed aphrodisiacal qualities.
In Chapter 4, Citrin offers a portrait of the volunteers themselves set against the backdrop of global health politics and the arrival of bideshi (foreigners) venturing into rural Nepal, ostensibly to heal and civilize. Citrin’s account is significant because, although Nepal is often framed in the historico-political imaginary as Kingdom marked by a strict isolationist stance, Citrin follows Mark Liechty in suggesting that in fact the dynamic which governs Nepal’s interface with the international community is one of “selective exclusion” (Suitably Modern: Making Middle Class Culture in a New Consumer Society. Princeton: Princeton University Press, 2003). In other words, Nepali elites strictly controlled the kind and degree of foreign influence and investment in ways that benefited Katmandu but left the rest of the country prey to ever more efficient means of exploitation and neglect. It is in this milieu that health care and food aid programs begin to enter Nepal.
What Citrin is keen to show at this point in his investigation is that, however varied and laudable may be the intentions of the volunteers and however transformative the experience for the participants, we cannot ignore the iatrogenic dimensions of these short-term health care efforts when the social conditions necessary to sustain lasting improvement are not actively fostered by the government. Further, we can recognize that, while chronic poverty and hunger in the region are not among its essential features. Rather, they have been brought about by centuries of exploitation.
Citrin continues: while aid camps do in fact distribute medicines, there is no chance for follow up or compliance testing; surgeries may be performed, but complications arise from lack of post-operative management. And an often overlooked element of such interventions is that local health professionals are increasingly undermined precisely by these “shock and awe” type care-bursts and their work disrupted, reinforcing perceived “incompetence.” The result is an increased risk of mortality and complication as locals are increasingly inclined to wait for or walk to the camps (even if it involves several days’ journey) rather than seek aid from local health care workers or village healers.
In Chapter 5, David Citrin builds on the historical framework in the preceding chapter and asks us to consider today’s short-term camps within the context of biomedical interventions in South Asia broadly. Forced sterilization camps and “information” programs aimed at groups that had already been struggling beneath the yoke of centuries of exploitation provided, Citrin explains, the effective model on which the Nepali health services initially began their new phase of intervention. Although with a demonstrably more humane mission statement, this rebranded state apparatus was tainted further by its political and military associations, periodically intensified throughout the People’s War. Royalist and Maoist forces alike pressed family for food and pills. Consequently, at the camps individuals sought any and all medicines they could obtain and found more profit in selling or converting the nutritionally bankrupt (and often contaminated) aid rice to chang (beer). Building on Arjun Appadurai’s notion that another dimension of the social can be gleaned if we turn our attention from individuals to the “social lives of commodities” (The Social Life of Things: Commodities in Cultural Perspective. Cambridge: Cambridge University Press. 1998), Citrin explores the series of exchanges in which medicines and food aid become differentially valued and valenced depending on the contexts through which they move or for which they are intended.
Chapter 6 examines the ways in which food aid has impacted social structures in Humla. Such programs, by increasingly monetizing all social exchange, have helped to erode traditional life-ways. Citrin argues not for a return to some imagined past but for governments and aid groups to consider the effects these incomplete, short-term policies have had and continue to have on the lives of the Humla and how such policies perpetuate and exacerbate conditions of chronic poverty and hunger. Poor planning, like never-to-be-completed road projects that fail to pay a just wage and which keep villagers away from crops (and the youth from learning that way of life), results in several generations dearth of more nutritious grains by which the people of the Karnali region would be better served. Additionally, political interference in the trade routes stretching into Southern Tibet have effectively denied the Humla autonomy to trade and exchange for a wide variety of foods. In light of the above and the history presented to us in Chapter 5, the picture that begins to emerge from behind the rhetorical haze thrown up by insistent cries that “doing something is better than nothing” is that the policies regulating food and medical aid are clearly of great benefit to someone, just not those of the Karnali region.
Chapter 7 offers us a glimpse into the “social life” of an ethnography. Long after the anthropologists or “voluntourists” leave the field, they bear with them the material artifacts (photographs, journals, tokens of memory incidentally collected along the way) and immaterial traces (the subtle elision of place occasioned by the sound of rain; now here, now…where?) These remainders underscore how the attempt to offer a conclusion to such a journey can itself only ever be provisional, “leaving one still with the intolerable wrestle/with words and meanings” (T.S. Eliot, Four Quartets. New York: Harcourt, Brace, and World, Inc, 1943, p. 26; pp. 69-70). In the work to contextualize experience, the “voluntourists” struggle to convince themselves and others that at least it was “better than nothing;” the anthropologists are, at times, left asking whether what they have done is perhaps even “less than nothing?” What is there to do in such a case but patiently retrace one’s steps, to try to assemble the facts into a polyphonic whole; to not cover over the gaps and incongruities, places where understanding strains and words begin to fail? Citrin invites us to reconsider those places where for too long romantic monikers have veiled from us our own motivations and the state of the world (thereby affording a new resonance to “Hidden Himalayas”). With him, we retrace the way in which these tropes have contributed to the seeming intractability of chronic suffering in the area and the continued misapplication of even the best of intentions.
Citrin supplements his text with three appendices. Appendix A is as a helpful glossary of Nepali words employed in text. Appendix B offers several practical suggestions for individuals and aid groups working in Nepal. For example, exit interviews and online mentoring may help prepare future volunteers; a more deferential attitude on the part of “voluntourists” toward the local Nepali health care workers may go some way in helping to resituate local estimation of their own competencies and traditions; basic language and medical skills should be a prerequisite for selection. Finally, in Appendix C, Citrin offers a historically situated discussion of the role of caste and ethnic division that serves to frame a discussion in which shamanic practices are generatively read, following James C. Scott, as an ongoing form of “resistance” (The Art of Not Being Governed: An Anarchist History of Upland Southeast Asia. New Haven: Yale University Press, 2009).
David Citrin’s The Anatomy of Ephemeral Care is an often moving and always candid account beautifully illustrated throughout with photographs by the author. A welcome and needed addition to the growing literature on disastrous development policies and practices, one can only hope that Citrin’s exploration of the complex and unintended consequences of “doing good” in a region marred by decades of myopic interference will be heeded by those who most truly want to work in a way that produces lasting and regionally meaningful results.
Dylan T. Lott
Department of Anthropology
University of Illinois at Chicago
Himalayan Permaculture Group
Ministry of Health and Population, Kathmandu
United Nations Development Program, Nepal
World Health Organization
University of Washington, Seattle. 2012. 300 pp. Primary Advisor: Rachel Chapman.
Image: The sound of helicopters approaching alerts Humlis to the arrival of food aid rice. Photograph by David Citrin.