Rania Kassab Sweis, Paradoxes of Care: Children and Global Medical Aid in Egypt (Stanford University Press, 2021).
Jadaliyya (J): What made you write this book?
Rania Kassab Sweis (RKS): After spending two summers in Cairo interning in the offices of global aid organizations, where I was researching questions around medicine and globalization in the Middle East, I noticed how children and youth were so frequently the targets of global health and development projects. I began to follow these projects—their discourses, how they were implemented, their outcomes—at the bureaucratic level in these aid offices, spanning Cairo, Paris, London, and New York. Yet after moving past this discourse, which often speaks to state institutions or powerful donors, I ended up with more questions than answers regarding the full experiences of the children and youth who were the receivers of this help. That led me to conduct over two years of intensive ethnographic fieldwork with young aid recipients and aid workers in Egypt, culminating in the core data that comprises this book.
Yet there is another reason why I chose to write a book that looked critically at global aid and humanitarian interventions in Egypt. The Middle East is often framed as a violent, disaster-prone region, one that needs western intervention—be it military or humanitarian, or both. While recent scholarship in anthropology delved into humanitarianism in the region critically, exploring how the western urge to help people there can be beneficial for the givers of assistance, not only the receivers, little attention had been paid to children or child bodies, and this seemed tragic to me because children are often framed as the most vulnerable of vulnerable subjects in global aid discourse. Approaching the subject of global health for children in Egypt critically, therefore, seemed urgent to me, because, at a time when we were all grappling with the onset of the Covid-19 global pandemic, medical aid and global health projects needed to be approached not only as benevolent acts but as complex, political practices in which states, non-governmental institutions, individual healthcare workers, and medical care recipients all have stakes.
J: What particular topics, issues, and literatures does the book address?
RKS: The book sits at the intersection of multiple scholarly fields, including globalization studies, Middle East studies, healthcare studies and the medical humanities, and gender, childhood, and youth studies. It directly addresses literatures in these fields but also delves deeply into questions of structural violence, state violence, and poverty in the region.
The main issue the book addresses is the intimate biomedical humanitarian experience as it is lived by children who fall into two main recipient groups: “street children” and “out of school village girls.” Because the research method I employed throughout is ethnography, the book offers a deep look into how aid travels, in real time, from experts to recipients, and what it does, on the ground over time, for all groups involved.
J: How does this book connect to and/or depart from your previous work?
RKS: I am trained as a cultural and medical anthropologist and scholar of gender and transnational feminism, so this work extends my previous research focus on gender and the body by focusing critically on children, child subjectivity, and child embodiment.
J: Who do you hope will read this book, and what sort of impact would you like it to have?
RKS: In the book, I express my hope that not only students and researchers in the scholarly fields mentioned above will find the work useful to think or write with, but that humanitarian workers, medical practitioners, and people who donate to global humanitarian causes—be it their volunteer time or financial donations—find it helpful as well.
Because helping is a process that shapes both the receivers and givers of help, my hope is that more people will question how, and with what social effects, aid—especially medical assistance and global healthcare—really impact those who receive care, particularly those who remain extremely vulnerable yet possess a sense of agency over their lives and bodies, like children. With this broad readership in mind, I tried to make the book as accessible as possible.
J: What other projects are you working on now?
RKS: I am currently working on another ethnographic book focused on medical humanitarian aid in the Middle East. In this new work, I focus on the Syrian civil war and how Syrian global medical aid providers negotiate their aid work alongside relational ties and feelings of belonging to their “homeland.” This work will also explore Syria’s long-standing public health history, as well as its unraveling in various regions of the country due to war.
J: What surprised you the most during the process of conducting the research for this book?
RKS: As I was researching this book, there were two aspects of the ethnographic process that surprised me the most. The first was the resiliency and strength of children who were living in extreme conditions of structural violence. We can all imagine how these children, some as young as seven or eight, feel pain and suffer, but what was less apparent, and not commonly part of the global humanitarian narrative, is how they negotiate daily circumstances with incredible logic, understanding, and wit, like making decisions about what is best for themselves, without the assistance of adults. I ensured this aspect of the research, children’s agency, was a major part of the book’s overall argument.
The second aspect of the research that struck me as surprising was the critical and complicated role local medical aid providers play in the global aid process in Egypt. Over two consecutive years, I worked closely with, and got to know quite well, numerous Egyptian doctors and healthcare workers who struggled to manage global aid expectations with grounded realities, including resistant children, limited resources, or the police. I witnessed how they must often “fill in the blanks” left open by global aid projects, which they must “apply” to local settings that are always more complicated than the aid policy stipulates. In addition, these local aid workers share the unique social and political conditions their recipients navigate each day, so their lived experiences and medical knowledge is crucial to the success of the aid project. The great extent to which these workers struggle on the job and improvise their work on the spot, all with a drive to do the best work possible for young aid recipients, remains inspiring to me.
Excerpt from the book (from Chapter Three, “Healthcare on Patrol”)
PAIN AND MEDICAL NONCOMPLIANCE
Amir was eleven years old and a regular patient at the Shubra al Khaima stop. When I first met him, Dr. Mohamad had already been treating him in CCI’s mobile clinic for a year, for symptoms ranging from minor infections to general checkups. Clinic workers knew Amir’s history quite well. He had been working on the streets around the metro stop since the age of nine, when he left his household. This was also the age when he began smoking cigarettes. After entering the clinic, he greeted Abdou and me with a firm handshake and broad smile, but embraced Dr. Mohamad for several long seconds, a greeting that reflected their shared affection and familiarity with each other. Amir settled onto the examination table without hesitation, his thin legs dangled off the edge. Dr. Mohamad checked his vital signs and asked a set of routine questions about his health and overall status, saying, “Are you having any problems right now?” Amir quickly responded that he suffered from a recurring dry cough and sore throat. These were causing him tremendous pain, which, once the examination was under way and his vital signs checked, he expressed to us by grabbing his throat and speaking loudly in a hoarse, broken voice.
Looking into his throat, Dr. Mohamad questioned Amir about his ongoing smoking habits, which everyone in the clinic was aware of. Amir deflected the question away from his smoking by asking Dr. Mohamad for a bottle of cough syrup so that he could simply be on his way. Dr. Mohamad explained to Amir that he had an infection, one that required antibiotic pills, and that the cough syrup would not be enough to cure his condition or alleviate the pain. To this, Amir shook his head in defiance and expressed aversion to the antibiotics. He responded by repeating that he wanted the syrup, because it was the only medication that would produce immediate results. Craning his neck, he looked up directly into Dr. Mohamad eyes and said that “pills take too long,” and what he wanted was immediate relief.
Dr. Mohamad sighed and pulled a white box of antibiotics out of the medicine cabinet, along with a small bottle of herbal cough syrup. He placed both in Amir’s small hands, but not before proceeding to educate Amir on how antibiotics work: first by traveling through the blood, then by traveling to the throat, and finally curing the infection and providing lasting relief as oppose to the syrup’s temporary effects. Amir listened to this medical lesson with a smile, but halfway into it he shook his head in defiance and again asked for the syrup. His willful giggling and head shaking during Dr. Mohamad’s explanation was a sign of his resistance and medical noncompliance. Dr. Mohamad continued to attempt to educate Amir, his frustration with Amir growing more visible by the second. Eventually, he ended the encounter by sending Amir on his way with both medications.
Having witnessed the subtle sparring between Amir and Dr. Mohamad, I asked if Amir would eventually take the pills, throw them away, or if he would consume the entire bottle of cough syrup all at once in order to experience its intoxicating effects. Dr. Mohamad believed any of these things might occur. “Carrying a bottle around the city is troublesome for street children. They need to travel light, so he might drink the syrup all at once.” We were both unsure about how Amir would consume the medications he had received, or whether his painful throat infection would be cured. Dr. Mohamad said he strongly doubted that Amir would heed his advice about taking the pills. My unease at this unknown outcome and my concern for Amir’s welfare undoubtedly showed on my face. Dr. Mohamad attempted to reassure me by smiling, shrugging his shoulders, and claiming that this was business as usual with street children. In educating Amir and providing him with medication, he had reached the limits of his humanitarian intervention with Amir. He softly mumbled, “What else can I do?”
Gendered Solidarity and Police Violence
Like Amir, Walid was a regular patient of the mobile clinic at the Shubra al Khaima stop and knew all the mobile clinic aid workers very well. Workers told me he was nineteen years old when I met him. This meant that he did not fall into the formal category of “street child” as laid down in CCI policy—a person under the age of eighteen. Still, having procured care from Dr. Mohamad on and off for over two years, he regularly used the clinic, viewing it as a valuable source of assistance and male sociality. Workers welcomed him accordingly, happy to extend their work with older street children like him beyond the normative age of “childhood.” Typical of homeless boys who have lived on the streets for long periods of time, Walid was missing several front teeth. This showed in the big smile he put on immediately after he entered the clinic one night. Although the summer heat was intense, he wore a faded brown leather jacket over a ripped T-shirt and jeans. Thick, wavy brown hair hung over his face, and at over six feet tall, he had to duck to make his way into the clinic and onto the examination table. Extensive greetings were exchanged between him and Dr. Mohamad. Moments later, Abdou and Ramy joined in on the meeting and relished hearing about Walid’s life since the last time he had visited the clinic.
Aid workers have grown fondly attached to Walid over the years. They believed he was a brave young man, and were especially proud of his success at avoiding police detention. Despite the recent rights-based amendments to Egypt’s new child law, the police in Cairo continued to detain, intimidate, and physically abuse young men living on the streets. To avoid this, Walid had repeatedly inflicted wounds across his own chest and arms with a knife or razor when confronted by a threatening police officer. Although painful, this worked for Walid and, according to Ramy and Abdou, kept him from being detained. On the examination table, Walid lifted his T-shirt to reveal a tapestry of self-inflicted wounds, showing off what to him were signs of his manhood. I had never seen anything like Walid’s scars before—razor blade marks scattered across his arms and torso. As Dr. Mohamad examined the scars, he explained how they served an important function on the streets. To my surprise, he did not dole advice out to Walid about the dangers of creating such wounds. Instead, he identified danger as lying with the police. He justified the scars by explaining how the police sought to avoid accountability for “human rights abuses.” If a young man appeared to be bleeding, they passed him by so as to avoid responsibility for his suffering or death. For Dr. Mohamad, the state (al hakuma) produced the scars; its concern lay not in decreasing deaths on the streets but in decreasing collective public outrage and uprisings against it. Walid had been arrested and subjected to police abuse before. He had learned, in his eight years of living on the streets, that he could successfully mobilize his own body in this way in confrontations with the police to avoid detention.
By cutting himself, Walid used his body as a vehicle of “rhetorical performance” with the police, creating a spectacle of wounds in order to secure his own safety and freedom. The scars ran in multiple directions across his chest and arms, some fresh, some ancient, but each narrated a history of gender and class violence. In the clinic, Dr. Mohamad and Walid spoke about these wounds as a sign of masculine bravery and as a means of resistance to an illegitimate state. For them, they were a testament to the scale of terror young homeless men face on the streets. The night he visited the clinic, Walid did not have an urgent medical condition that needed attention. Rather, he had come simply to update aid workers on events in his life. As Walid socialized with us, Ramy and Abdou gave him information about where to travel in the city. They detailed the areas where they thought the police were less present, pointing Walid towards these safer neighborhoods. It had been twenty minutes since his arrival when Dr. Mohamad began a routine check of Walid’s vital signs. After exchanging more friendly banter, and before sending him off for the night, he handed Walid a gift bag, along with a small stack of ointments, bandages, and mild painkillers. Walid left just as Dr. Mohamad affectionately said, “And remember don’t smoke!” It was the one piece of advice he knew Walid would likely ignore.