A review of The Aftermath of Aid: Medical Insecurity in the Northern Somali Region of Ethiopia, by Lauren Carruth.
In The Aftermath of Aid, Lauren Carruth draws on historical and contemporary experiences of recurrent but temporary humanitarian endeavors in the Somali region of northern Ethiopia to highlight the multiple, and often novel, ways that these fleeting engagements impacted sociality, citizenship, and expectations of biomedicine. This nuanced study brings the experiences, logics and concerns of Somalis into conversation with the practices and imperatives of humanitarian aid institutions and their employees. Importantly, Carruth explores the impact that temporary provisions of biomedical services and goods have “on local social relations of illness and healing, health behaviors, local health systems, extra-legal transnational healthcare economies, and the governmental and nongovernmental humanitarian regimes built to respond to crises” (p. 19) One of the most critical contributions of this dissertation is its emphasis on the importance of trust, and the ways that intermittent experiences of humanitarian aid impact the standards and suspicions by which Somalis evaluate care.
The Introduction outlines the major arguments, summarizes methods and methodology, and situates the study within previous anthropological work on disasters, wars, and humanitarianism. Carruth argues that, rather than merely attending to the “bare life” of victims, temporary medical assistance and relief efforts have had concerning long-term effects on people’s expectations of biomedical therapies, heightening their sense of health disparities. Due to their provision of high-technology biomedical intervention, humanitarian endeavors further exacerbated Somalis’ experiences of medical insecurity, increasing anxiety and mistrust of Ethiopian generic drugs and healthcare personnel. As a result, Ethiopian government efforts to improve access to services have been undermined, as Somalis undergo long medical migrations or refuse treatment at local healthcare facilities due to experiences of racism and vulnerability.
Chapter 1 takes the reader from the capital city, Addis Ababa, to the field sites of Aysha woreda (district) of the rural northern Somali Region of Ethiopia, in which the study took place. This section details and historicizes Somali pastoralist and agro-pastoralist livelihoods, experiences of displacement, economic activities, reliance on food aid, and migratory motivations, while outlining humanitarian interventions in the region, and the health resources available at the time of the study. These broader histories informed the antagonisms between Somalis and Ethiopians in the region, hardening animosities that had important impacts on Somali health-seeking behaviors and their views and expectations of government institutions and services. Carruth also describes the extralegal economies through which medications move in Ethiopia.
Chapter 2 outlines the methodological framework and describes the methods used in the study. Carruth’s methodology combines a “biographical approach to pharmaceuticals” with “commodity chain analyses” in order to draw attention to the ways that medicines impact social relations and meaning, while attending to the structural inequalities and political economic systems of exchange — both transnational and local — through which these medicines travel. In so doing, Carruth demonstrates how biomedical technologies become appropriated into the practices and ideas of both laypersons and non-biomedical healers. She argues that “the exchange of medicinal products, services, and information [is] central to particular local commodity markets, humanitarian aid practices, the Government of Ethiopia’s policy practices, and personal notions and strategies of care-giving” (pp. 107-108). Somalis understood medicines and humanitarian assistance not as a gift or privilege, but as their right. Beyond participant observation, archival research, and interviews, Carruth employed a variety of novel methods in this study, from adopting a nomadic existence to trace population movements, to employing mapping exercises, and card and medicine sample sorting exercises among laypersons, healers and pharmacists to understand ideas about maladies and their remedies.
In Chapter 3, Carruth describes indigenous ideologies of illness and healing, in which there was no easy division between biomedical and other therapies and healers. This Chapter ethnographically charts main themes undergirding Somali management of illness and health, including the importance of managing digestive bile with camel milk, pain in women’s reproductive organs, spirit possession and the role of Qur’anic healing, local views on pharmaceuticals, and the increasing attractiveness of biomedical diagnostic tests. In this Chapter, Carruth includes rich ethnographic descriptions of the flexible ways that biomedical and other modalities of illness and healing informed one another in practice.
In Chapter 4, Carruth discusses Somali’s experiences with what she terms “medical insecurity,” in which they are unable to access adequate, trusted and lasting medical care. Storytelling, rumors, and jokes — among both the Somali and the entities (NGOs, policymakers, and healthcare providers) charged with providing for their needs — are critically important to Somali health seeking behaviors. Ultimately, when health crises arose, Somalis sought advice and support from their kinship networks. Rather than valuing the primary care provided by the government, an outcome of Somalis’ experiences with relief efforts was a strong preference for more and better diagnostic tests. As a result, Somalis drew on their social networks to be able to avoid local government clinics in favor of long travels to places where such standards of care could be met. In the Somali region, government efforts to expand primary care through community health providers, generic medications, and new rural health posts, were met with avoidance and suspicion, rather than being celebrated.
Chapter 5 demonstrates how relief efforts become entrenched into wider political, economic and social structures by discussing the convergence of kinship, mobility, migration, and experiences with humanitarian interventions. Kinship informs and is informed by engagements with humanitarian and development efforts, experiences with illness and healthcare seeking, and daily survival strategies in the wake of food insecurity and drought. Contrary to popular and humanitarian policy assumptions that Somali kinship ties are detrimental to stability, Carruth argues that family plays a critical role in the flexible strategies Somalis employ to access aid, healthcare, and employment. Frequent Somali migrations across long distances were highly meaningful and historically significant, making borders between neighboring countries porous. Somali border personnel frequently allowed Somalis to cross into Djibouti or Somaliland, particularly in cases of medical crisis or death. Kinship networks were critical to people’s success in their medical migrations, creating deep disparities between those who could migrate and pay for services due to their deep clan ties, and those whose networks were insufficient to meet those needs.
In the last ethnographic chapter, Carruth outlines how humanitarian efforts in the region impacted notions of citizenship and belonging among Somali in Ethiopia. She argues, “what it means to be a member of the transnational network of Somalis, a Somali Regional State citizen, and Ethiopian citizen, a ‘patient,’ and even a foreign aid ‘beneficiary’ are all being forged within the walls of various clinical facilities and medical humanitarian operations” (p. 282). Particularly intriguing is Carruth’s description of the convergence of humanitarian efforts with regional and federal governance regimes, as government entities were funded by, and also critical to, relief efforts. Policy, humanitarian and government efforts prioritized “vulnerable groups” (largely pregnant and lactating women and their young children), and importantly, raised Somali expectations of biomedicine while offering limited prospects for enacting enduring change in primary healthcare, education, and infrastructure. Yet the narrow targeting of these foreign- and government-supported humanitarian efforts were ironically the means by which Somalis were enacting new relations with the state. As government-employed individuals like mobile team nurses worked to put humanitarian agencies’ programs into practice, they also drew upon local leaders’ knowledge of individuals excluded from “vulnerable groups” who needed care, thereby expanding the narrow population focus of the programs to meet needs on the ground. As actors representing the government and relief agencies simultaneously, these health providers’ efforts impacted Somali expectations of both biomedicine and the government as a whole. Carruth suggests that in this way, a set of policies privileging the preservation of “bare life” ironically contained the potential to enact more meaningful governance structures. Through medical aid endeavors and the increased trust they engendered, Somalis cautiously fashioned ideas of the possibilities of healthcare and citizenship.
In her Conclusion, Carruth returns to the ways that long histories of ethnic-based violence, disparities in healthcare access, and racism undermine humanitarian efforts, while highlighting how these interventions exacerbate medical insecurity by raising Somali’s expectations of biomedicine and standards of care. Accordingly, “humanitarian programs and budget structures… focused on providing the stuff of medicine and clinics more than ensuring the integrity and excellence of care” (p. 332, emphasis in original). Carruth asserts, “if a real effort to improve healthcare is to be made, trust must be a primary mission” (p. 335). One of the most remarkable aspects of her concluding chapter is a set of practical recommendations on how global health policy, humanitarian efforts, and clinical care could foster trust in practice, and thus be made more meaningful within the region. Evading any easy separation between theory and practice, following the concluding chapter, Carruth also provides intriguing appendixes on Somali health and disease terms, and recommendations for improving education for Somali health professionals.
Carruth’s major contribution is to the understanding of the long-term effects of humanitarian endeavors (including medical and food aid) on the individuals who are supposed to benefit from these interventions. In contrast to the ahistorical character of relief efforts, Carruth situates histories and experiences of punctuated humanitarian aid, and outlines their profound impacts on political, economic and social structures that move beyond the scope of notions of health and healing. Her argument is complex and nuanced, demonstrating “that Somalis’ experiences of humanitarian crises and ethnic-based violence as well as their historical marginalization from Ethiopian sources of power shape how they perceive and negotiate medical choices and expertise” (p. 151). Yet within her nuanced and rich ethnographic work, Lauren Carruth demonstrates creative engagements and untapped possibilities at the interstices of Somali populations and the humanitarian and state efforts to attend to their needs.
Global Health Studies and Anthropology
Twelve months of ethnographic fieldwork in Aysha woreda (district) and Addis Ababa, Ethiopia including participant observation and 193 interviews with 146 individuals in Ethiopia
Archival research of periodicals, unpublished papers and policy documents Attendance at policy and briefing meetings among aid organizations
University of Arizona. 2011. 402 pp. Primary Advisor: Mark Nichter.
Image: Photograph by David Machledt.