Health and the Body Politic

In the wake of this summer’s Beirut port explosion and Lebanon’s ongoing financial crises, hundreds of doctors have left the country for greener pastures, and many more are following. It is hardly the first time a Middle Eastern country has suffered a mass exodus of doctors in the wake of political, economic and social instability. As with Iraq and Syria, their departure is symptomatic of a greater unraveling of health care across the region.

Health and health care have become increasingly ungoverned over the past few decades, in tandem with a broader breakdown of the body politic. Health care workers are finding it increasingly difficult to work in settings of violent conflict and insecurity, rapidly declining health care systems, pervasive corruption and economic mismanagement, amidst the waning capacity of states to improve the health and wellbeing of their populace. While the Middle East region trains a lot of doctors, few end up staying.

This issue of Middle East Report explores the interactions of the body politic with health and medicine and examines the entanglements of physical bodies in the institutional and political processes that govern them. The articles explore a range of different landscapes and ecologies of politics and health care. In this way, we aim to bring the questions and problems of health and illness into the analysis of geopolitics and political economy, while situating the Middle East in broader global health conversations.

Highlighting how health is embedded within societal processes, the essays illuminate and trace the changing political landscape in relation to the changing biosocial realities of everyday life. In doing so, they veer away from the top-down technocratic frameworks and discourses that often depoliticize public health and medicine.

Health care has always been implicated in the history of state practices. During past eras of state-building, national governments in the region invested heavily in health care, as part of post-colonial socialist experiments. Today, however, the sector is undermined by a perfect storm of negative forces: the enforced neo-liberal reduction of state responsibilities and capabilities, continuous militarized violence and refugee crises, the exodus of talented medical staff, environmental degradation contributing to long-term chronic conditions, takeover of the public sector by a commercially motivated private sector and a nearly complete collapse of the state’s social security net. The pervasive corruption in all government sectors and an ongoing diversion of investments away from health care, education and environmental sustainability also plague the region. Over the past decade, investments in health and social protection have dwindled, while imports of arms have increased by close to 60 percent. In fact, the Middle East constituted 35 percent of total global arms imports over the past five years. This trend highlights the importance of understanding the current situation of deteriorating health in the region as shaped by regional militarization and the legacies of the never-ending, so-called Global War on Terror.

The present burdens of disease and affliction are the embodiment of long histories of political apathy and wounding. As various state structures have been undermined, populations continue to bear the double burdens of deteriorating health care and security. Our focus in this issue on health and health care in conflict highlights the generative experiences of health care workers and communities. While capturing how health has become increasingly ungovernable, we highlight how state and health care breakdown is a “form of life,” embedded in social relations, environmental processes and the struggle of patients and doctors to make sense of, as well as respond to, these predicaments.

As in many other parts of the world, the pandemic is a diagnostic event, revealing underlying vulnerabilities, structural weaknesses and the uneasy relations between politics and health care. While the region’s case reporting and mortality rates fell below the global average during the early months of the pandemic, recent trends are reversing this premature optimism. The political responses of states to the pandemic have had varied outcomes. As authors in this issue show, the pandemic has magnified preexisting chronic problems that shape the experiences of communities and citizens.

In our interview with Ghassan Abu Sittah, he explains how war injury and disability have become an endemic problem, with long term consequences for societies dealing with decades of war and protracted conflicts. He also highlights the importance of turning the experiences of local health care workers into expertise that will serve communities suffering from conflict more effectively than relying on foreign volunteer doctors. In Iraq, the state health structure has completely collapsed under decades of war and neglect, leaving patients with cancer diagnoses to collectively navigate their access to quality care. Mac Skelton explains how those experiences have created an ambivalence toward hospitals, which have become increasingly dangerous and toxic, and the consequences of patients’ distrust of the health care system now during the COVID-19 pandemic.

Meanwhile, Egypt continues to suffer from a generation of under-investment in preventative and curative health care, which Jennifer Derr explains is made worse by the current crackdown on social and political dissent, including arrests and violence against health care workers. The essays by Aula Abbara and Noura Chalati reveal the terrible realities of Syria’s fragmented health care under almost a decade of civil war, while Nihal Kayali investigates the health care landscape for Syrian refugees who remain displaced in Turkey. Osama Tannous explains how conflict-related afflictions in the Gaza strip caused by recurrent Israeli assaults are more well-known but less prevalent than serious chronic ailments, which are compounded by the continuing siege that obstructs access to proper care and the deep cynicism of humanitarian aid practices.

Protests have re-emerged in Lebanon, Algeria, Morocco and Iraq, where more than 800 protestors have been brutally killed by local militias and more than 5,000 have been injured over the past year. The recent revitalization of protest across the region, despite the ongoing threat of the pandemic, is highlighting state violence and corruption, along with the lack of life-sustaining health infrastructure, as primary ailments affecting the body politic.

What is to be done? Going forward, scholars, activists and policymakers should understand that health and health care are deeply political matters. Health analyses need to be tied to the everyday realities of individuals and communities. While health reforms are connected to political and economic change, there is an urgent need to restore public health as a public good, by striving toward better access and coverage as well as by addressing the social and political determinants of ill health.Moreover, a focus on environmental sustainability and cleanup is central to addressing broader global health and planetary issues, such as climate change, and to confronting the drivers of chronic disease and toxicity. The central role of the long-term impacts of war and conflict must be reckoned with when planning future health care in the region. In an era of widespread state collapse, it is high time to revive and reclaim the right to health as a social movement. In the midst of such a great unravelling, no other policy prescription makes sense, as waiting for today’s dysfunctional states to come to society’s rescue is like waiting for Godot.

 

[The editors of issue 297, “Health and the Body Politic,” are Nabil Al-Tikriti, Kevan Harris and Graham Cornwell with Guest Editor Omar Dewachi.]