The subjects and objects of relief

how local aid workers articulate and remake what it means to be humanitarian

http://publicanthropologist.cmi.no/2018/10/01/the-subjects-and-objects-of-relief-how-local-aid-workers-articulate-and-remake-what-it-means-to-be-humanitarian/

“Allah will help the one who gives. If I have even one Birr [Ethiopian currency], I try to give it to him, the man in need. Most people do this. It is our culture. We share what we have. That is who we are. We are the same people, all of us, the same blood. And when you do this, the people will know. People would see if I was doing this work at [the relief NGO] professionally and not living it. What you are doing and saying in the community, it has to be what you are. If I am not practicing, they will know. … You should not go to a hotel, but you should sleep there with them, and then they will know you are serious.’ Mussa, a Somali man from Ethiopia who works for a European relief organization.

This essay introduces one part of my larger ethnographic project to investigate “humanitarianism” as it is enacted by local aid workers like Mussa in the Somali Region of Ethiopia. In this, I address the following questions: Who is a “humanitarian” — and therefore whose work is deemed vital and benevolent in emergencies? What counts as a “humanitarian” intervention, for aid workers as well as people in communities where crises recur? And finally, how do various forms of humanitarianism evident in the Somali Region differ from and also shape the legally recognized international humanitarian system, governed mostly be international law, wealthy donor governments, and multinational organizations?

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Opinion: The hustle for data: Side gigs that change science, policies, and lives →

The health of people around the world depends on the knowledge and data that researchers gather about diseases, economies, living conditions, and the quality and availability of medical care. Yet in many of the world’s least-developed countries, the expertise and hard work of local staffers — the people tasked with collecting and reporting these data — remain invisible and undercompensated.

As the World Health Organization celebrates the Sixth Annual World Health Worker Week this month, we must also advocate for improvements to the working conditions, legal protections, and compensation packages for the legions of informal and temporary workers that make research and data collection possible for global organizations, including the WHO.

Around the world, opportunities to help with data collection offer a relatively lucrative side gig for many people, especially in communities with high unemployment. International aid agencies and global research firms hustle to hire logistics coordinators, drivers, language translators, survey enumerators, and key informants.

Local staffers — who are often themselves aid beneficiaries and residents of impoverished and crisis-affected communities — are vital to the implementation of health and humanitarian aid programs and policies, as well as to the needs assessments, demographic, and health surveys, food security studies, clinical research, randomized control trials, famine early warning systems, disease surveillance systems, donor appeals, and monitoring and evaluation protocols that inform these programs and policies.

I have worked in the Somali Region of Ethiopia for more than 10 years, as health and humanitarian relief organizations have come and gone. My latest article in Medical Anthropology Quarterly shows how data collection funded by international aid agencies presents intermittent — but critically important — employment and research opportunities and at the same time, offers local residents and beneficiaries the opportunity to contribute to the policies and programs that can potentially have lasting effects on their own communities.

Rising demands within the international aid and global health industries for accountability and localization have further increased the need for participatory and intensive research methodologies. Aid workers and policymakers in eastern Ethiopia are inundated with data — of highly variable quality and usefulness — and the vast majority of the people I know in the Somali Region have in some way been part of generating these datasets. Indeed, while many people I have spoken to report that they cannot count on adequate amounts of food in the ration — or on the tanker truck to deliver potable water on time, or on cholera vaccines to be distributed, or on enough amoxicillin to treat local outbreaks of infectious diseases — they can count on regular data collection in their communities.

Residents are usually hired for a few days or weeks as drivers for researchers and aid workers traveling for site visits, needs assessments, and project evaluations. Local families rent their SUVs to the national and expatriate staff of NGOs, private research contractors, and even university researchers. Folks who can speak a combination of Somali, English, French, and Amharic are frequently recruited as language interpreters by international organizations and companies headquartered in Addis Ababa, Djibouti City, or Nairobi. These language interpreters also serve as more general translators of and experts in local cultures, local political circumstances, and the procedures and expectations for obtaining permission and support from local leaders.

For example, many of these local staffers are like my friend Mussa (his name has been changed to ensure his anonymity), a Somali resident of Ethiopia in his mid-30s and a respected mullah in a rural town close to the Djibouti and Somaliland borders. In his latest data collection gig in 2016, he was paid 700 birr per day (at the time worth $35) for five days translating research instruments and administering a survey for a major international NGO that contracted with a private research firm headquartered in the capital city of Addis Ababa.

Reflecting on his employment, Mussa said, “You cannot just have people from Addis [Ababa] fly in and do the research. They do not know us, and the people here will not like that. They will not answer your questions, or they will just answer however they feel and not truthfully. No, that was my job. They trusted me. They know me. And I convinced them that this was okay; the project was okay. They could tell me things, and I could come inside their house.”

Local hires like Mussa never sign legal contracts for their employment; many lack negotiating power over the terms of their compensation; many work in dangerous field situations without adequate security or safety resources. Most people I know fail to parlay their temporary gigs into long-term careers in the aid or research industries.

Furthermore, the gig economy that results from international aid and research is not equitable. Data collection side gigs disproportionately employ young men who are both literate and fluent in multiple languages. Persons with disabilities and caregivers to dependent children and parents — mostly women — cannot easily travel or work far from their homes and families, and are much less likely to fill these posts.

Part-time employees like Mussa are the backbone of nearly every international aid and research initiative. Their knowledge and expertise make these projects happen. It is time that they were recognized, compensated adequately, and fully integrated into professional aid and research industries.

Want to end TB? Diagnose and treat all forms of the disease

Tuberculosis should be a specter of the past, something only our great-grandparents feared and died of. Alas, although almost all cases of TB today are both preventable and treatable, several different strains and manifestations of the disease still sicken and kill millions of people every year.

Global tuberculosis interventions are usually tied to larger HIV/AIDS programs. As such, billions of dollars are spent every year improving medical care for people living with HIV and fighting the opportunistic infections – foremost, tuberculosis – that continue to kill so many AIDS patients.

And yet, a growing proportion of new TB cases occur in people without HIV. According to the World Health Organization, every year, over nine million people around the world who do not also have HIV are sickened and die from several different forms of tuberculosis.

Tuberculosis is much more than simply a complication of HIV/AIDS, and it is definitely not a disease of the past. As we observe World Tuberculosis Day, it’s worth looking at some of the most threatening and yet neglected forms of TB, as well as the struggles many people still face getting the right diagnosis and medical care.

TB from animals a growing concern worldwide

A majority of TB patients around the world suffer from strains of the contagious pathogen Mycobacterium tuberculosis in their lungs. Mycobacterium tuberculosis (or M. tuberculosis, for short) usually causes painful and long-lasting coughs, weakness, weight loss and fevers.

But as I detail in a recent article in The Lancet, there are several additional pathogens that cause TB disease. These additional mycobacteria species are a rising threat as the number of new M. tuberculosis cases around the world declines.

The most concerning of these mycobacteria are “zoonotic” – or transmitted to humans from animals. Human Mycobacterium bovis infection, for example, was once very common around the world but has been almost completely eliminated in North America and Europe, thanks to regulation of the dairy industry and introduction of pasteurized milk. But M. bovis is still a major public health problem in rural communities that lack adequate health services and agricultural regulations.

n addition to M. bovis, several other species of zoonotic mycobacteria can cause TB in livestock and wildlife, but we do not know much about the risk these pathogens pose to humans. Because people are often infected by consuming unpasteurized milk, M. bovis and other zoonotic mycobacteria are thought to cause more “extrapulmonary” tuberculosisin humans – or TB infections outside the lungs. These patients experience different symptoms, and their disease is more likely to be misdiagnosed or missed altogether.

The neglect and invisibility of these lesser-known mycobacteria, zoonotic forms of tuberculosis and extrapulmonary TB cases result, paradoxically, from the incredible success of global TB control efforts focused on the elimination and treatment of pulmonary cases of Mycobacterium tuberculosis and on TB in populations with a high HIV/AIDS burden.

Difficult to diagnose

One of the biggest challenges to broader TB control is, in many places, the lack of adequate diagnostic tests.

After a person is diagnosed with TB, molecular typing of the pathogen can determine exactly what kind of mycobacteria the patient has, determine if there is resistance to any medications, and optimize their treatment regimen. But this level of testing is unavailable in many low-income countries and in most of Africa. In other words, most people with zoonotic tuberculosis live in communities that lack the kinds of diagnostic tests required to determine that’s what they have.

There is also little disease surveillance or research on zoonotic TB, even in the pastoralist African populations thought to be at highest risk. The lack of knowledge about the existence and spread of zoonotic mycobacteria is largely due to the fact that they remain some of the most difficult pathogens to detect. Testing technologies are prohibitively expensive and unreliable without state-of-the-art laboratories, and there is still no way to easily detect mycobacteria in milk. Also, only expensive blood tests can tell if someone has an active tuberculosis infection or if they have merely been exposed to a tuberculosis-causing agent, such as the bacille Calmette-Guérin (BCG) vaccine.

Zoonotic TB also requires different treatment regimens: M. bovis is intrinsically resistant to pyrazinamide, a key, first-line anti-tuberculosis drug, so patients need some alternative medications and a longer treatment duration. Plus, many extrapulmonary infections are now resistant to one or more first-line TB drugs, which may contribute to its higher mortality rates.

Zoonotic TB threatens global TB control

Drug-resistant TB is itself a growing problem, and may be a result of substandard diagnostic tests and treatments for people, as well as the overuse of antibiotics in livestock husbandry. Rising rates of drug-resistant TB strains portend serious future challenges in TB treatment and control.

Zoonotic TB is a global problem. A few people infected with zoonotic TB in Africa have presented with active tuberculosis in the United States and Europe, and as refugee and migrant flows continue, these cases will undoubtedly increase. But it remains to be seen if the global health community will act now on zoonotic tuberculosis, or if investments will be made only once the disease more seriously threatens populations outside the African continent.

As a first step, rapid and affordable diagnostic tests and disease surveillance are desperately needed in communities at highest risk of the disease.

Beyond this, we need new investments in research on a range of pathogenic mycobacteria–not just M. tuberculosis–as well as new investments toward the development of field-ready and inexpensive diagnostic and drug-resistance tests. In addition, we need creative ideas about how to design and implement health care and food safety interventions that are responsive to the lives, economies, and diets of pastoralists and other rural livestock holders.

The donor community’s focus on M. tuberculosis and on TB among AIDS-affected populations has unintentionally resulted in the invisibility and neglect of other forms of TB disease. The number of people contracting and suffering from zoonotic tuberculosis is probably much higher than we think.

Broadening our global health attention to include investments in developing better diagnostics and offering better clinical recognition and treatment for zoonotic TB not only would help those who suffer, but is necessary to end the scourge of tuberculosis once and for all.

Wealthier nations can learn from how tiny Djibouti welcomes refugees

Earlier this month, in Djibouti, we were conducting research in the Office of National Assistance for Refugees and Displaced Persons (ONARS). In response to our questions about effects of President Trump’s executive orders (also known as “travel bans”) on refugee resettlements, Hussein Chardi, the director of refugee camps at ONARS, carefully described his country’s raison d’être:

In Djibouti, we have a big heart. We open our hand. Refugees should stay here and work with dignity.

As the United States and some European countries add ever more isolationist policies, closed borders, and dramatic curtailments in the number of refugee resettlements, what can we learn from how this small country facing considerable security and economic threats from abroad treats humans on the move?

Djibouti is a tiny, coastal country that has for centuries been situated at the confluence of numerous and multidirectional flows of traders, travelers, scholars, laborers, and refugees back and forth between the Arabian Peninsula and the African interior. The Red Sea’s Bab el Mandeb Strait, between Djibouti and Yemen, is only 20 miles across in places, enabling relatively easy intercontinental travel. With a population of fewer than 900,000 people, today Djibouti hosts 22,640 refugees and asylum-seekers. That equals 2.5 percent of its entire population.

Djibouti was founded as a host country for persons seeking refuge. It won independence from France in 1977, just three weeks after the Ogaden War began between Ethiopia and Somalia. Tens of thousands of refugees, mostly fellow ethnic Somalis from Ethiopia, flooded across the border, seeking safety, food and water. All refugees were welcomed, according to one man we met at the ONARS office, Abdellahi Hargeye, whose family fled from Ethiopia to Djibouti in 1977. Eight years later, when famine and conflicts in the Horn of Africa intensified, hundreds of thousands more refugees poured across the Djiboutian border.

Government officials in Djibouti proudly cite this history, a national ethic of hospitality, and the economic advantages of population movement and diversity as all central to the country’s new refugee law. The law includes newly promulgated regulations ensuring refugees, asylum-seekers, and Djiboutian citizens equal rights to education, health care, work, and even movement outside refugee camps.

Today, migrants in Djibouti include Yemeni refugees fleeing war, Somalis fleeing political insecurity and drought, and Ethiopians escaping political persecution and grinding poverty.

Djibouti today also acts as a conduit through which economic migrants — mostly Ethiopians — venture to Saudi Arabia and other Persian Gulf states for work. Men and women travel through Djibouti’s sweltering desert landscape, sometimes packed into vehicles and sometimes walking on foot for several days. They are then smuggled or trafficked across the Red Sea in crowded, makeshift boats, furtively guided through war-torn Yemen, and finally let into Saudi Arabia. As conflict spikes in Yemen, in the last year thousands of these migrants have been deported or evacuated through Djibouti en route either to their countries of origin or illegally back to the Arabian Peninsula again.

However, despite recent legal and programmatic attempts on the part of Djiboutian federal agencies to promote local integration, protection and assistance, these are not panaceas. Refugees, economic migrants and trafficked persons continue to face discrimination and difficult conditions inside camps and along their myriad routes through the country. Many refugees and migrants in Djibouti struggle to find jobs, learn French, and compete with local residents for scarce resources.

But rather than building walls, policing borderlands, and litigating access to services, Djibouti’s government remains most concerned with providing anti-discrimination protections and humanitarian assistance to people on its soil. As an International Organization for Migration (IOM) representative told us, “Djibouti could actually close off their borders. They are so small. But they don’t.”

With all the attention on the Trump administration’s travel ban and its legal challenges, two key things have been drowned out: first, in addition to voiding the possibility of resettlement for individuals and families from select countries entirely, the executive orders cut the United States’ refugee resettlement program in half. Second, the recent proposed budget from the administration guts foreign international development assistance through the State Department, endangering previous U.S. commitments, for one, to the United Nations High Commission for Refugees (UNHCR), which provides protection and assistance to the hundreds of millions of people seeking refuge and asylum all over the world.

Today only 1 percent of all the world’s refugees are resettled. Most refugees and asylum seekers spend years in camps or temporary accommodations, awaiting durable solutions. Under the 1951 Refugee Convention and subsequent protocol, durable solutions include: repatriation, resettlement or local integration.

This is what thousands of Somali refugees have found in Djibouti. Somalis make up the third largest group of refugees in the world today, and they have been refugees the longest, as decades of political instability have prevented them from safely returning home. Somalis we met in the Ali Addeh refugee camp in Djibouti were born and lived to adulthood in the camp. It is now their home in every way.

Perhaps nothing symbolizes Djiboutian hospitality more than what we were told by Ethiopian migrants, walking along the rocky coastline of Djibouti, to catch boats to Yemen. These young men carried no water, no food, and no backpacks, yet they said their journeys took at least four days from the border.

We asked, how did they survive? Nomads gave them biscuits and water, they replied — life-saving gifts from some of the world’s poorest communities, people who themselves receive only weekly deliveries of water rations from the Djiboutian government on which their own survival depends.

Djibouti presents an alternative to isolationism: hospitality and protection from the community and the nation, as an intentional response to regional insecurity.

Lahra Smith is a political scientist and associate professor in the School of Foreign Service at Georgetown University. 

Lauren Carruth is an anthropologist and assistant professor in the School of International Service at American University.