at arm’s length

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Students and attendings at the Shatila Volunteer Outreach Clinic (VOC)

[R]epresentation, or more particularly the act of representing (and hence reducing) others, almost always involves violence of some sort to the subject of the representation.

–       Edward Said, “In the Shadow of the West” (2001a, p. 40)

Humans have an uncanny ability to hold terror and misery at arm’s length, especially when they occur in their own community and are right before their eyes.

 –       Nancy Scheper-Hughes, “Towards the Primacy of the Ethical: Propositions for a Militant Anthropology” (1995, p. 417)

Wrapping up almost two months in Beirut, and sitting down to reflect on everything that has happened, I’ve been struck by a number of things that I have yet to discuss on this blog. I find it in classrooms, the clinic, conversations over ‘arak, and, most strikingly, in discussions about medical diagnoses and management: discrimination. I’ve been struggling with this issue both back in Boston and here, albeit from a sectarian point of view. However, by spending considerable time working in the Palestinian refugee camps, rather than just public health programming and occasional visits to camps (as I did via an NGO during my last visit in 2010), I’ve had the opportunity to meet with amazing individuals both from and working in these communities.  Moreover, as someone rotating through a Lebanese institution, I’ve been privy to conversations from individuals on the other side of the citizenship boundary – their thoughts, opinions, and prognosis for a marginalized and dynamic group.

Seeing how discrimination manifests itself in the clinic space – against Lebanese, Syrian, or Palestinian – has been an incredibly challenging and cruel observation. A part of me becomes enraged at the blatantly stereotypical versions of the Orientalist Arab trope deployed in clinical management and care; but on the very same token, I am an outsider, and therefore feel that it is not my place to critique conversation or views about “the other.” Moreover, I think to myself, “Isn’t this much of the same that I hear on television in the States when pundits speak about ‘minorities’ and ‘Islam’, or in the halls of the hospital when we discuss who and who is not ‘compliant with care’?” This relativism bind – to speak up or not to speak up – and how by speaking up, I may be revealing myself, as a representative from the West, to be a hypocrite (simultaneously challenging one mode of oppression while being perceived as complicit in a grander one, both at home and abroad), has been a challenge, to say the least. [1]

Three important experiences have really pushed me to consider this question. One has been the rereading of a book I received from one of my high school teachers when I graduated in 2006 – Power, Politics, and Culture: Interviews with Edward W. Said (2001). I’ve always found his work extremely challenging from a purely intellectual point of view, but his call for activism and justice, combined with critical insight and “worldliness,” has always stuck with me. His meditations on the Palestinian question, power, knowledge, and justice have been important for me in this circumstance, especially with caring for protracted and new refugees.

How the literary and philosophical musings of Edward Said play into clinical care comes with my second experience. Some of the other individuals with whom I work in the camp are Lebanese in origin, coming from unique and different backgrounds. What I initially found shocking is that many of them had never been to the areas in which I work, both currently and in the past [2]. When speaking with one of my colleagues about where he or she lived, they had misheard me and thought I had asked if they lived in the Shatila refugee camp, where we had just come from. “Yeah, I live in Shatila. My whole family lives in a tent.” I was taken aback at this statement, not only because of its frank untruthfulness (Shatila has not been a “tented” refugee camp since its inception in the early 1950’s. See Sayigh 1994), but because of his or her use of a “refugee trope.” The men and women of the camp, whom we served all morning, were still seen in this individual’s minds as refugees, rather than living human beings in a community. The tented refugee camp, itself a remnant of media portrayals of refugee life throughout the world, stereotypically on the African continent and in post-war settings, became his or her contextualization for life in Shatila. However, the tone in which he or she uttered the phrase “my family lives in a tent” – biting, unforgiving – conjured up a sense of disgust and embarrassment directed precisely towards Palestinian and Syrian refugees. It was as if life as a refugee was a shameful and self-induced category, that agency somehow had a play in the marginalization and violence – historical, economic, and sociopolitical – wrought upon this community.

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Mural depicting al-Nakba (the exodus). Baadawi camp, taken July 2010

Finally, this week, I had the honor of meeting a Palestinian teacher at a UNRWA school, just outside of Sidon (Saida). We spoke about the ongoing Syrian crisis and the challenges of teaching grade-school children in different educational systems [3]. He related a story to me about the distribution of pens and paper for children at the school in which he works, which caters to both Lebanese and Palestinian children. An NGO donated pens and paper for children at the school; however, the individual in charge of the school system only allowed the pens and paper to be donated to Lebanese children. The teacher remembers getting frantic visits from parents, stating that their children were crying and horribly embarassed because they were singled out in the classroom precisely because they were Palestinian. The teacher agitated those in charge of the school system to change the policy. “It was just pen and paper. We’re not talking about the world here – just things that students need to learn with!” After about a month or so, pens and paper were distributed to the Palestinian students. “This is a marker of Palestinian life for our children. They feel this discrimination from a very young age,” he told me. The sense of exclusion described in this story, especially among school children, mirrors the feelings of Fawaz Turki’s (1974) in his reflection on his life as a Palestinian, both in Lebanon and the West, almost forty years later: “Hunger and the cold are a form of violence. So are alienation and exclusion, UNRWA and identity cards with an X next to nationality” (Turki 1974, p. 7).

In these three instances – reminiscing about Said, “my family lives in a tent,” and the children without pens or paper – I find the cold deployment of a rationality of discrimination in conversation and policy. Though this type of exclusionary power plays into discussions surrounding biolegitimacy and humanitarian reason – issues I’ve been dealing with a great deal here through my writings – I keep thinking about ways to combat these problems in the global and local setting. It’s well-documented that prejudice bleeds its way into clinical life, and can impact how we think about an individual illness or disease. As Randall Packard, in his study of tuberculosis in South Africa, reminds me:

Medical facts, like any other data, have no intrinsic meaning. They are rather the materials with which physicians and others construct hypotheses, theories, and conclusions. Although these interpretive processes are often viewed by medical practitioners and the communities they serve as involving impersonal and objective distillations of medical facts, they are unavoidably shaped by the social and intellectual environment in which they occur (Packard 1989, p. 32)

And, despite my concern about the plight of refugee lives in Lebanon, I can’t divorce myself from the issues I have seen and will, sadly, continue to see in the provision of care in America or elsewhere. Thinking of the use of culture and race to explain away problems of “compliance” or return to care, as I’ve seen and dealt with, only makes me angrier that physicians and others either blindly ascribe to agency in a neoliberal sense or that racist, misogynistic, and classist stereotypes enter the realm of the medical discussion. As a student, you want to fight against this with education or a change in tactics of care. But how do you deal with this? When do you stop thinking about this issue and speak up about it?

Here, Edward Said has a lot to say, especially in the Middle Eastern context. In an interview with Anne Beezer and Peter Osborne in 1993, he states:

The marginalization, the ghettoization, the reification of the Arab, through Orientalism and other processes, cannot be answered by simple assertions of ethnic particularity, or glories of Arabic, or returning to Islam an all the rest of it. The only way to do it is to get engaged, and to plunge right into the heart of the heart, as it were (Said 2001b, p. 223).

How this “plunging into the heart of the heart” goes is through Said’s notion of overlapping histories. Knowledge of another individual’s life is not a linear track, he argues. Rather, the life of a person, just like that of a text, is a set of overlapping modalities of power and struggle. Therefore, the ascription of a linear history is reductive, and does not allow for a fruitful, critical discussion of anything of relative value. In the case of the clinic, we ought to remind ourselves that the lives of those we serve – indeed, of the communities we serve – are not made up solely of cases of diabetes, traumatic brain injuries, or pregnancies. These are real people, with histories that intersect with wider geopolitical logic that is rooted, at times, in essentalist caricatures of people based on “race,” sex, gender, creed, and nationality. This can, as illustrated in the epigraph by Nancy Scheper-Hughes, contribute to the rationalization of violence, “a keeping at arm’s length” of horror and suffering.

The identification I am calling for is not solely a philosophical posturing or an attempt at a hollow-bodied solidarity, but the opening of a listening space. Instead of hearing what we want to hear – for many of us in a time crunch, it’s the signs and symptoms for a clinical diagnosis – we can push forward a critical attempt at understanding someone from a holistic perspective (Scheper-Hughes 1995) [4]. This is not a call for a humanist understanding of medicine – standing by the bedside, holding the patient’s hand – though that always has a role and should be emphasized. What I am considering, and what others have called for, is for advocacy and activism in the clinical space, beyond that of the biomedical. From this place, and from an open atmosphere, can we begin the arduous task of responding to discrimination and inequality in the very way we discuss and think of those for whom we have the honor of caring.

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Child with Palestinian flag during a march. Sabra/Shatila camp, July 2010

Bibliography

Deeb L. 2006. An Enchanted Modern: Gender and Public Piety in Shi’a Lebanon. Princeton, NJ: Princeton University Press.

Packard RM. 1989. White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa. Berkeley, CA: University of California Press

Said EW. 2001a. “In the Shadow of the West.” In Power, Politics, and Culture: Interviews with Edward W. Said, ed. Gauri Viswanathan. New York, NY: Vintage Books, pp. 39-52.

———-. 2001b. “Orientalism and After.” In Power, Politics, and Culture: Interviews with Edward W. Said, ed. Gauri Viswanathan. New York, NY: Vintage Books, pp. 208-232.

———-. 2001c. “Literary Theory at the Crossroads of Public Life.” In Power, Politics, and Culture: Interviews with Edward W. Said, ed. Gauri Viswanathan. New York, NY: Vintage Books, pp. 69-93

Sayigh R. 1994. Too Many Enemies: The Palestinian Experience in Lebanon. London, UK: Zed Books.

Scheper-Hughes N. 1995. The Primacy of the Ethical: Towards a Militant Anthropology. Current Anthropology36(3): 409-440

Turki F. 1974. To Be a Palestinian. Journal of Palestine Studies 3(3): 3-17

United Nations Relief Works Agency for Refugees in the Near East (UNRWA). 2013. UNRWA Syrian crisis response: January-June 2013 (access at: http://www.unrwa.org/userfiles/2012122163648.pdf)

Endnotes

[1] This has been all the more challenging given my name and skin color. In Lebanon, I’ve been mistaken for Haitian, Sudanese, Palestinian, Khalija (Gulf Arab), and Ethiopian. Many times, service (taxi) drivers will ask me, “Wheyn min ‘anta?” (Where are you from?). When I answer, they tend to have a confused look on their faces. I’ve learned to answer, “Bas, aa’ilatii min hindii” (But, my family is from India). My use of fusa, rather than the Lebanese Arabic dialect, confuses service drivers even more. To sum it up, a bearded Indian-American speaking broken fusa is riding in a service in Lebanon – beyond being the beginning of a joke, this confusing and conflicting identity has been a unique way to integrate into the communities in which I work. On one level, my dress and facial hair help me blend into the camps, as many of the shebab (young men) keep a short beard and have an affinity for skinny jeans (as I do). On another level, my status as an Indian-American working in a Palestinian camp can be a confusing and welcoming gesture, depending on whether the party in question is Lebanese or Palestinian. Many of those who I’ve spoken with in the camps and outside have a deep respect for India, particularly Mahatma Gandhi – in fact, there’s a street named for him in ras Beirut. On the other hand, many in both areas are confused as to why an American, with no ties to the region, suddenly finds himself in the middle of one of the worst examples of poverty and marginalization in the world. Truly, identity and representation are complex issues, and have impacted where I feel I can work and voice my opinions.

[2] I say “initially shocking” because when I contextualize the issue, its akin to saying, “Wait, you’ve never been to the South Side of Chicago? West Baltimore? Dorchester and Roxbury in Boston?” These stereotypically violent, low-income neighborhoods, made up of minority and im/migrant populations, hold a special and contradictory place in America’s imagination; similarly, the Palestinian refugee camps and al-Dahiyyeh (the suburb, locally known as “the Shi’a ghetto (Deeb 2006)) of Beirut occupy a similar space among those I’ve been privileged enough to work with.

[3] According to this teacher, Syrians are taught in a primarily Arabic system, which includes lectures and reading in fusa (Koranic Arabic). This emphasis is akin to classical Western humanist teaching in Latin, or Sanskrit in the Indian context. However, among Lebanese and Palestinians living in Lebanon, the school curriculum is taught in the English/French tradition. As a result, the incongruencies, combined with gaps in schooling secondary to the continued civil unrest in Syria, mean that many of the students are behind in their studies. Moreover, due to poor UNRWA funding in Lebanon and the political controversy surrounding hiring Syrians in a professional sector, there are no calls for the hiring of Syrian teachers, versed in the Syrian curriculum, for these students. As the recent UNRWA report for funding states, “PRS children continue their education through teaching in special classes based on the Syrian curriculum or are enrolled in regular classes,” but with no specific calls for the hiring of new teachers (UNRWA 2013, p. 14)

[4] “If their problem is going about the world and always finding their own ideas already there to meet them, my problem is going about the world and always finding a distorted picture of my political position there to meet me” (Said 2001, p. 74). In this way, having a finely-tuned ear in the clinical space can, at times, only greet us with what we want to hear; conversely, by critically asserting ourselves, via knowledge of our community, we can open our discourse to further possibilities and come to reject many of our initial assumptions.

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