This piece was published in the Spring Issue Print Edition (Volume 11)
Introduction
Humanitarianism has been often lauded as a form of compassion, solidarity, and, of course, a way to save lives. Especially in the health sector, it is an appealing mantra. However, others remain skeptical of the dominance of humanitarianism both as a practice and an idea in the modern world. Here, humanitarianism does not just refer to intervention (through aid or military action) abroad (often by the Global North in the Global South). Instead, following Didier Fassin, it can apply to all agents who offer support to the ‘needy’ at home or abroad based on the idea of humanitarianism.[1] The lion’s share of criticism towards humanitarianism has focused on the activities of international organizations and operations. Some, including Costas Douzinas, have even posed that one step towards a positive transformation of humanitarianism as we know it would be to rely first and foremost on “those whose lives have been blighted by oppression or exploitation and who have not been offered or have not accepted the blandishments and rewards of political apathy.”[2]
One area of the world where both humanitarianism and those blighted by oppression but unaccepting of apathy are omnipresent is the Gaza Strip. There, the land, air, and sea blockade imposed by the Israeli government has presented a significant challenge to the area’s development and the inhabitants’ welfare. The healthcare sector is no exception. Demographic trends and disease incidence do not show the typical hallmarks of a health crisis, such as high infant mortality and a low life expectancy. Rather, the so-called epidemiological transition has already taken place in Palestine.[3] This means the primary causes of morbidity and mortality are instead chronic diseases. Though this transition can be viewed as a welcome development, treating this category of diseases requires a strong healthcare system with ample resources, which the Gaza Strip lacks.
This situation partly explains the proliferation of medical humanitarian aid in the Gaza Strip. Medical non-governmental organizations (NGOs) have sought to fill the gaps left by the Ministry of Health (MoH), the United Nations Relief and Works Agency (UNRWA), and the private sector. The vast majority of these NGOs are led and created by Gazans, as the Hamas government has been unwilling to let international medical NGOs operate independently (to the frustration of Médicins Sans Frontiers (MSF)).[4] As a result, the Gazan health sector is an excellent environment to study the practices and knowledge of grassroots humanitarian organizations.
There are three general critiques of humanitarianism that can be gleaned from a literature review: the reduction of aid recipients to victims, the alliance between state power and humanitarian organizations, and the dynamics of depoliticization and dehistoricization.[5] Various more specific criticisms can be pinpointed in the literature, yet these three dynamics dominate throughout the field. The cases chosen in studies of humanitarianism reveal a preoccupation with critiques of transnational humanitarian operations. Moreover, exceptions still feature humanitarians providing aid to others, primarily refugees in their country.[6] The Others have just come to them instead of vice versa. Simultaneously, Costas Douzinas has suggested that grassroots action might come closer to humanitarianism removed from and resisting state violence. Actual studies of grassroots NGOs are however notable by their absence. This paper seeks to contribute to the critical literature on humanitarianism by focusing on an understudied area – grassroots humanitarianism – to challenge the existing approaches.
Thus, the question to which we will turn here is: what can Gazan grassroots medical NGOs’ response to chronic diseases specifically show us about critiques of humanitarianism? Central to the argument is the expansion of our understanding of the way grassroots operations are able and unable to subvert conventional humanitarian knowledge and practices problematized in the literature. This process not only entails applying existing theoretical approaches to an understudied type of case but also challenges those theories, seeking to reveal their limitations by confronting them with a new actor – the grassroots NGO. As Srilatha Batliwala has shown, the term “grassroots” is complicated by the process of globalization.[7] Here, it will be understood as including those NGOs established and run by Palestinians, which draft the majority of their staff from the local population. The analysis performed can also contribute to a better understanding of NGO practices in the realm of chronic disease in Gaza. Chronic diseases are limited here to diabetes, cardiovascular disease, and cancer.
It will become clear that a dominant thinker in this field is Giorgio Agamben, whose critique will be the basis of the theoretical approach, along with Eyal Weizman’s. The latter might be called a post-Agambian critique, using some of his insights but refining and even rejecting others. The avenues these authors offer for “resistance” are also touched upon. These approaches are operationalized through a dispositif analysis, which permits the inclusion of both discursive and non-discursive practices. The empirical material is accumulated from interviews with NGO volunteers and directors, as well as the online presence of the three main NGOs in the medical field. The analysis constructs from the practices and materialities of the NGOs their dispositif, which is then considered in light of the two scholars’ critiques of humanitarianism. In the conclusion, it will be argued that the grassroots NGOs’ embeddedness in the global humanitarian system reinforces a prioritization of humanitarian over political considerations. This leads to treatment of Gazan chronic diseases as primarily medical-humanitarian problems, risking complicity with the forces rendering the occupation possible. The questions raised by this case regarding the theoretical approaches are also discussed, along with avenues for further research.
Agamben and Weizman: Between Violence and Resistance
Given the myriad of approaches to the critique of humanitarianism, it is necessary to narrow down the ones foregrounded in this article. Because its purpose is not to develop a wholly new critique but to apply existing ones to an understudied type of actor, established scholars will be relied on. The first of these is Agamben, whose perspective is well-complemented and refined by Eyal Weizman, who in turn has been influenced by Agamben but significantly diverges from him in several areas. Their perspectives are particularly relevant for several reasons elaborated on below. In the analysis, these perspectives will be confronted with the empirical material.
Bare Life, Humanitarianism, and Violence
Fundamental critiques of humanitarianism as an idea rather than merely a practice arose as the subfield on humanitarianism matured. An important scholar in this development was Giorgio Agamben, with whose work many other critiques have subsequently engaged. Agamben’s fundamental critique of humanitarianism is as follows: “[…] humanitarian organizations […] can only grasp human life in the figure of bare or sacred life, and therefore, despite themselves, maintain a secret solidarity with the very powers they ought to fight.”[8] This bare life is a condition in which the human being as a biological body (zoe) is stripped of its political qualities (bios), creating a zone of indistinction between the two.[9] According to Agamben, the sovereign is constituted through the decision on who is rendered bare life through exclusion from the political.[10] Placed in (what is termed) the state of exception, a person becomes homo sacer (bare life), someone who can be killed without punishment, but not sacrificed.[11] By configuring the recipients of humanitarian aid as bare life, humanitarianism affirms the status they have been given under the sovereign ban. This critique has been mobilized to understand a variety of cases of transnational humanitarianism.
There are pertinent voices who engage with Agamben’s work more critically. This is frequently on either or both of two interlinked grounds. First, Agamben’s conception of humanitarianism is as an antipolitics, which is then complicit in biopolitics predicated on death (further elaborated on below). Others, notably those with a more traditionally Foucauldian understanding of biopolitics, view humanitarianism as a certain type of politics. Didier Fassin proposes that “humanitarian reason” is a part of our current mode of politics. He places it as a third pillar alongside Foucault’s police state and liberal economy, this pillar providing a moral sentiment to politics.[12] Humanitarianism is a politics of life, and thus an enigmatic example of biopolitics.[13]
The second critique comes out of Agamben’s proposition that the camp – the state of exception – is devoid of power relations. Agamben argues that the distinction between forms of life by the sovereign today has led to “the radical transformation of politics into the realm of bare life”.[14] The sovereign state has become increasingly involved with every aspect of life, expanding the realm of biopolitics until it encompasses all of human life. Biopolitics, an originally Foucauldian concept, represents politics in which the primary concern lies within the care for the biological life of the nation. Agamben, however, reconsiders Foucault’s understanding of the concept and turns it around. Biopolitics is no longer concerned with the preservation and optimization of life, but rather with the power to decide upon its end, at which point the subject becomes bare life.[15] He identifies the concentration camp as the ultimate expression of biopolitics, and its prisoners – as the ultimate form of bare life.[16] This divergence from Foucault gives way to another one, namely the lack of power relations in Agamben’s work and the lack of politics.[17] The sovereign ban operates via relations of violence instead of power relations. This is due to the placement of bare life outside the political realm. There are no proper power relations between the sovereign and bare life since there is no way for homo sacer to directly challenge his displacement from outside the political realm.
This explains why those rendered bare life have little to no way of resisting the sovereign to Agamben. As controversial as this point seems, it has an advantage in the analysis of grassroots humanitarianism. This form of humanitarianism is seen as potentially preferable because it can empower those rendered bare life. Thus, in approaches focusing on relations of power rather than violence, local NGOs are plausibly more easily identified as resisting state power. By contrast, Agamben’s emphasis on relations of violence permits a forceful critique of even grassroots humanitarianism. This sets a high bar for an actor of which it has been suggested that he is a positive replacement for international NGOs (INGOs). Simultaneously, Agamben’s work does not completely preclude a resistance of sovereign power. Besides the approach’s substantial benefits, the dominant role Agamben plays in the field is in itself a reason to include his arguments here. As a new actor is studied in an area of scholarship, it is sensible to take into account the work of one of the dominant voices in that field.
Political Agency in the Humanitarian Present
If Agamben’s perspective can be accused of marginalizing the agency of those excluded from the political realm, Weizman seeks to foreground their political resistance. It is the reason why the inclusion of his approach in the analysis of grassroots humanitarianism is invaluable next to Agamben’s. It serves to add nuance to the position of those reduced to bare life by the occupation, which are excluded from politics according to Agamben. Weizman, on the other hand, views them as the “vanguard of political struggles.”[18] Thus, Weizman serves as one of Agamben’s harshest critics, arguing that the camp is the prime place for politics, rather than one devoid of it. The inclusion of both perspectives is crucial to fully appreciate humanitarianism led by the vanguard in the camp. Surprisingly, Weizman himself does not consider explicitly the possibility that the vanguard might itself engage in humanitarianism. Bringing these two authors in conversation with the case, the goal is to understand what a grassroots humanitarianism means for a theoretical approach to humanitarianism with a highly limited degree of agency on one hand, and a strong emphasis on agency on the other hand. Despite their divergent ideas, t he two scholars are simultaneously not incomparable, as Weizman directly engages with Agambian insights, and they both draw on similar authors, such as Hannah Arendt.[19]
Weizman conceptualizes the current period as the humanitarian present. It is characterized by “the condition of collusion of humanitarianism, human rights, and humanitarian law with military and political powers.”[20] Especially the second chapter of his book on the topic delivers a forceful critique of the narrative of “the lesser evil.” This idea is frequently deployed by humanitarians to justify their complicity in and enabling of violence perpetrated by the regime.[21] The argument claims that it is better to be complicit than to be denied access to an area where relief is direly needed. Here, Weizman critiques the unwanted collaboration between totalitarians and humanitarians, as well as the wave of humanitarian organizations “taking sides” (between “liberalism” and “authoritarianism”).[22] An impasse was reached because humanitarianism sought to either evade politics (via the lesser evil) or rally against authoritarianism as a sort of pure evil. These ideological dilemmas, if you will, are what Weizman engages within his proposed “solution:” a recentering of the politics and agency of the oppressed.[23] This way out of the impasse also responds to another common critique of humanitarianism, namely the victimization it creates.
A Different Humanitarianism
From both Weizman and Agamben, a positive vision for different humanitarianism can be derived. This allows for an analysis that goes beyond the question of whether a form of humanitarianism is complicit in state power. Instead, it encourages consideration of how resistance could be accommodated or even enacted by the medical humanitarian organizations themselves. Equally, their diverging visions further illustrate the overlap and differences between the two thinkers.
Edkins and Pin-Fat have teased out two paths towards resistance in an Agambian conception of modernity. This requires a return of power relations between the sovereign and the excluded. The first way to return power is to refuse to make the sovereign distinction between the included and excluded from politics. This means taking the position that there should be no sovereign ban.[24] The second path, which presumes the first, involves taking up bare life as a form of life. Refugees sewing together their lips is given as an example of this: “They are assuming the very bare life that sovereign power imposes on them in order to demonstrate the relationship of violence in which they have been placed.”[25] This demonstration is read as relational: it is a political act aimed at those outside the sovereign ban.
Weizman proposes radically neutral humanitarianism, which solely concerns itself with securing the biological wellbeing of aid recipients, their bare life. This humanitarianism has several advantages. Specifically in medical humanitarianism, it allows for the return of the doctor-patient relationship, thus removing more value-laden descriptors like victim, savior, and perpetrator. Equally, this humanitarianism is self-consciously apolitical, rather than unknowingly becoming complicit in state violence through a lesser evil narrative.[26] Most importantly, it re-centers the political wishes of aid recipients by sidelining the question of what values humanitarianism should espouse (anti-totalitarianism, anti-capitalism, liberalism).[27] What both approaches here have in common is the recognition of aid recipients as having been reduced to bare life and, in a sense, using this state to resist oppression. However, whereas Agamben almost prescribes this to the excluded as their only possible form of resistance, Weizman suggests that humanitarianism concerns itself with bare life, leaving the mode of resistance of the excluded for them to choose.[28]
Conclusion
Both Agamben and Weizman identify problems in the knowledge from which humanitarian organizations operate. In Agamben’s case, it is the preoccupation of humanitarianism with bare life that reproduces the sovereign distinction, leading to victimization, depoliticization, and above all, an uneasy alliance with state power. Weizman also problematizes the marginalization of aid recipients’ subjectivity. Yet, it is to him a result of attempts to locate the lesser evil, whether lesser than authoritarianism or allowing forcibly displaced Ethiopians to starve.[29] To both, better humanitarianism would foreground the body of the aid recipient, which allows for a return to power relations, and thus for resistance. However, Weizman emphasizes the agency of the aid recipient throughout his work, whereas Agamben’s bare life barely implies any at all. The theoretical approaches above both require an operationalization befitting a social critique of the underlying logic and practices of humanitarian organizations. This operationalization will be outlined in the following section.
Dispositif analysis
The approaches to humanitarianism outlined previously will be applied to a case study that comprises the prevention and treatment of chronic diseases by grassroots NGOs in the Gaza Strip. To facilitate this, a dispositif analysis will be used, rooted in the practice turn.
The dispositif is a Foucauldian concept. In his words, it refers to: “[…] a thoroughly heterogeneous ensemble consisting of discourses, institutions, architectural forms, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral and philanthropic propositions – in short, the said as much as the unsaid. Such are the elements of the apparatus. The apparatus itself is the system of relations that can be established between these elements.”[30] Analyses of a dispositif are especially suitable for critiques of humanitarianism because they take into account both discursive and non-discursive elements. Jäger identifies three domains of analysis: discursive practices, non-discursive practices (actions), and material objects. The latter two are analyzed via discourse analyses just as the first. What is central to the analysis of a dispositif is the way these non-discursive practices and objects are both reinforced by and themselves reinforce the underlying knowledge of the dispositif. The discourse analysis of non-discursive elements thus focuses on the meaning attached to them.[31] All three elements form a heterogeneous network. This network is perpetually shifting due to movements in the relations among the various elements. For instance, the unintended effects of actions might cause tensions in the dispositif, forcing a realignment of its elements. A dispositif is also self-sustaining: it produces power relations that reinforce it.[32] Finally, it is important to note that the dispositif responds to an urgent need. This is itself not an objective need but constituted through discursive and non-discursive practices.[33]
In order to operationalize Agamben and Weizman in the case of grassroots medical NGOs in Gaza, the dispositif of the latter in relation to chronic diseases will be studied. Studying a dispositif is possible via various routes. Here, the emphasis will be on the internal tensions among elements of the dispositif of chronic disease management in these NGOs.[34] This angle is selected because violent dimensions of humanitarianism have already been identified as in conflict with humanitarianism’s explicit goals. After all, humanitarianism’s aim is not to make possible violent relations of subjectification. A tension will thus be central to the analysis regardless of the approach.
It can be argued that Weizman, in his analysis of humanitarianism in Ethiopia, traces the shifting elements of MSF’s humanitarian dispositif as it responds to internal contradictions between its values and the unintended consequences they produce. Indeed, his “forensic analysis” seeks to “tease out the political forces, cultural habits, forms of knowledge, skills and expertise that were folded into [material objects’] organization and form.”[35] An Agambian understanding of the dispositif does not inhibit its use in this analysis either. If anything, his proposition that “anything that has in some way the capacity to capture, orient, determine, intercept, model, control, or secure the gestures, behaviors, opinions, or discourses of living beings” can be a dispositif leaves one assured that a humanitarian dispositif of chronic disease treatment can be located.[36] The assertion of the way these dispositifs create subjectivities – here, doctors and NGO directors – reminds us that humanitarianism’s logic goes beyond the individual NGOs’ practices.
The mapping of a dispositif relies on the collection of data from the infinite archive of knowledge and practices it is generated by.[37] The primary data consist of interviews conducted with employees and directors of two out of three key medical NGOs, as well as the reports, websites, and social media pages of the three main grassroots medical NGOs in Gaza (identified as such in previous research).[38] The network of heterogeneous elements emerging here will then be considered from the theoretical perspectives outlined above. Within the dispositif, the focus will be placed on the urgent need that the NGOs respond to, their understanding of their role, and their interaction with global humanitarianism. The first two reflect the “core” of the dispositif as a strategy, namely the problem responded to and the shape this response takes. The inclusion of global humanitarianism is informed by the theoretical approaches. These conceive of humanitarianism not solely as a variety of separate practices but as a global approach or perceived alternative to politics.
Due to the emphasis on the NGOs’ understanding of the problem and their response, the primary sources reflect a preoccupation with their outward portrayal towards the public and the researcher (in interviews). This results in little effort being made to understand the perspective of the patient or aid recipient. This perspective has been foregrounded in other research on humanitarianism and is equally valid and valuable. It reflects a different avenue taken towards problematization than the one opted for here. Interviewees were required to sign an informed consent form beforehand regarding the purpose of the research and the interviews’ conditions. For those less comfortable with the English language, an interpreter was present during the call. Interviewees were encouraged to ask questions about the interview and conduct research before and after substantial questions were discussed. Verbal consent was required before interviews were recorded. In acknowledgment of the way research is situated in a wider political context, the names of the NGOs have been replaced by identifiers A, B, and C.[39]
A Grassroots Humanitarian Dispositif to Counter Chronic Disease?
As Jäger points out, dispositif analysis does not have a strict method of analysis.[40] Given that it is the reconstruction of a heterogeneous ensemble, neither is there a set order in which to examine discourses, actions, and materials. Thus, the dispositif analysis will commence with an examination of the urgent need to which the dispositif responds. The analysis is guided by the contradictions and tensions found within the discourses and practices. This continues throughout the subsections on the self-understanding of the NGOs and their situation in global humanitarianism. The final section consists of a confrontation between the outlined dispositif as a whole and an Agambian and Weizmanian perspective. What is first required, however, is an overview of the situation in which the dispositif operates: in this case, the occupation and blockade of the Gaza Strip from 2006 onwards. The dispositif can, after all, be characterized as a strategy, and strategies are not formed in a vacuum.
Gaza: The State of Exception
The blockade of Gaza since 2006 has a significant impact on its healthcare provision, as well as society as a whole. The following sketch of the situation cannot be considered “objective.” Rather, it is part of the dispositifs with which the dispositif of humanitarianism interacts. As mentioned, the statistics, reports, and narratives are all part of the archive from which dispositifs form. Because they interact, this minimal reflection on the context is needed. Furthermore, humanitarianism according to Agamben is a response to an emergency formed by the placement of people in the state of exception. The situation will in part be explained through this lens to accommodate the later confrontation between Agamben’s approach and the empirical case.
Since its conquest in 1967, Israel faced significant difficulties governing the Gaza Strip area. Through the Oslo Accords of 1994, the Israeli authorities relinquished most of the responsibility for internal affairs to the Palestinian Authority (PA). However, Israeli security checks and tight military control gradually closed off the territory. In 2005, Israel withdrew completely from Gaza, removing settlers and military personnel. To Azoulay and Ophir, this abandonment turned Palestinians into non-citizens.[41] The High Court has ruled that Israel does not owe Gazans anything but the minimal humanitarian aid needed for subsistence. After Hamas’ election in 2006, the territory was put under a land, air, and naval blockade. A single border crossing, Erez, is currently open at Israeli discretion for the import and export of goods, as well as the movement of people.[42] While the state has relinquished responsibility for the population, it possesses an important power: to take life. By closing the Erez crossing, it can cause a humanitarian crisis. Various authors have pointed out that this resembles the state’s ability to put one under the sovereign ban and turn one into homo sacer.[43]
Similarly, it is important to understand the Gazan economy in which these NGOs operate. Economic growth and development are hampered by both the blockade and Hamas’ label as a terrorist organization. These make Gaza a uniquely unappealing destination for investment.[44] Most projects are organized by INGOs or their donor governments. These groups are often not allowed to be in touch with Hamas, leading to not only a stifled but also a poorly coordinated economy.[45] The abovementioned factors have conspired into high levels of poverty (53% in 2019) and more than half the working population being unemployed.[46] The economy is highly dependent on the humanitarian aid sector, in addition to the smuggled goods coming from Egypt and the PA’s deposits to fund Gaza’s public sector.[47]
An Urgent Need
A dispositif emerges around an urgent need, which is in turn constructed through discursive and non-discursive practices. Here, it is not the need for chronic disease treatment that is central, but precisely the need for local NGOs (rather than solely the Ministry of Health) to treat and prevent these diseases. This is where the first source of tension occurs. Discursively, the primary “raison d’être” of the NGOs is the occupation. However, because of what might be called pragmatism, as becomes apparent throughout this analysis, discursive and non-discursive practices reveal a prioritization of conventional biomedical concerns over politics.
The short mission statement of two out of the three examined NGOs contains a reference to the blockade. The third, NGO C, seemingly takes a different approach. The blockade remains more implicit, as its own mission is “contributing to community empowerment in healthcare and promoting the comprehensive healthcare concept in the Gaza Strip.”[48] What all three emphasize is that the blockade is a primary cause of challenges faced in the health sector, particularly for chronic disease patients. Some examples include the shortages of certain drugs (such as anti-diabetic and anti-inflammatory medications), the complete unavailability of novel treatments (such as immunotherapy and certain new generations of drugs), and dysfunctional equipment due to a ban on spare parts entering the territory. Poverty is also linked to ill-health and is causally traced to the occupation. The contribution some Israeli actions might make to chronic disease development is also acknowledged. The severity of the blockade in the dispositif should not be underestimated: one interviewee described it as a chronic emergency.
The belief existing parallel to this is that a lack of knowledge about healthy living among Gazans gives rise to chronic diseases. This was affirmed in interviews, but is also reflected in the discursive practices on the NGOs’ social media pages. For all three, educational (rather than activist) posts dominate. This awareness problem is reflected more clearly in the NGOs’ programs. Their emphasis on prevention and non-medicinal management makes optimal use of the proximity between patients and medical professionals. Home visits are organized to distribute hygiene kits, instructions, and (when funding allows for it) food baskets. Specifically for chronic disease sufferers, education on nutrition is provided, including cooking classes. An NGO B doctor mentioned that Gazans suffering from type II diabetes are first educated on nutrition and lifestyle changes prior to medical treatment. A variety of workshops and online content seek to change individual behavior.
These practices, while they may be viewed as empowering, could create a sense of personal responsibility and self-blame in the face of poverty, stress, and malnutrition. For example, the rates of stunting in Gaza are unusually high, which increases the risk of chronic disease development later in life.[49] Is this due to a lack of education among parents or the conditions in which they are forced to raise their children? Food basket distribution does reflect an acknowledgment of these dynamics, as do discursive practices aimed against the occupation.
The tension between the perception of the occupation as the main reason for the NGOs’ work and the predominance of practices focused on behavioral change is explained pragmatically. As the director of NGO A pointed out, the demand for healthcare services far outweighs what can be provided with limited resources due to the occupation. This in turn leads them to emphasize health education. There is a limit to what treatments can be offered, but far less so to what one can teach everyday Gazans about a healthy diet.
“We Are Doctors.”
In light of the theoretical approaches selected, the self-understanding of the NGOs is a relevant part of the dispositif to consider. The above has already hinted at a tension between the humanitarian and medical versus the political dimension of the NGOs’ work. This is mirrored in their self-conception. On the one hand, there is an emphasis on neutrality and the humanitarian character of the NGOs’ work. This became very clear when an NGO B interviewee, upon being asked, insisted that his work had nothing to do with politics, served solely humanitarian purposes, and benefited everyone in ill-health, regardless of their ethnicity, religion, or political affiliation. Another NGO B interviewee, when asked whether he saw his work as part of the resistance, said, “We are doctors, we are away [from this] resistance.” In NGO C reports, there is an emphasis on managerial and medical data, revealing a functional logic, for instance, in its display of the increased use of its services.[50] This gets portrayed as an improvement. While it might mean those in remote areas are better-reached, it does not mirror the logic of a political movement striving to render itself redundant. In other discursive practices, too, the medical and humanitarian practices of the organizations dominate.
This humanitarian and medical self-identification is also reflected in non-discursive practices. There is a division of labor between human rights organizations and medical NGOs. For example, patients are frequently referred to hospitals outside the Gaza Strip, because the required treatment is unavailable due to the blockade. Upon the rejection of the referral or even the arrest of the patient at the Erez crossing, it is human rights organizations that sound the alarm. Secondly, the programs set up by NGOs do not generally have a political component. Political advocacy and medical programs are separated.
It is noteworthy that a limitation of the humanitarian role to that of “doctors” is not inherently benign. Modern medicine creates a relationship of doctor and patient wherein the doctor is perceived as the knowledgeable party.[51] This power dynamic is potentially strengthened by the notion of charity. Some of the treatments and programs offered by NGOs are free. Others require ‘symbolic’ payments far below those found at the MoH. This creates a dependency of the most vulnerable on these NGOs’ services. A distinction from the dependency and hierarchy found in international humanitarianism must however be made. Gazan doctors and patients are victimized by the same blockade. The power dynamics created by NGO practices is one of doctor-patient, educator-student, and donor-receiver, yet not that of victim-savior highlighted in much of the literature on humanitarianism. In discursive practices, a relation of solidarity is emphasized. Social media posts in Arabic might refer to a doctor’s service to his ša`b, meaning “people” but also “nation.”[52]
This brings into view a deeply political dimension to the discursive, non-discursive, and material elements of the dispositif. All three NGOs speak of a right to healthcare, calling on the responsible authorities to provide it. Several professionals interviewed identified their work as a way to promote the resilience of their communities in the face of occupation. Both in interviews and online, there are calls for the international community to take action. The director of NGO A put it as follows: “[As] Palestinians, it is too difficult to differentiate between political issues and our lives, especially when […] I am working in the health NGOs or health organizations.” The ability to do advocacy work was also identified by interviewees as an advantage of being a Palestinian grassroots NGO rather than an INGO.
These beliefs give rise to and are reinforced by a variety of practices. Although cooperation with human rights organizations is reflective of a division of labor, it also shows an intersection. These are acknowledged not to be separate struggles. In the realm of chronic diseases, everyday practices are given a political dimension due to the above discursive practices. There is no direct communication with the Israeli authorities on the import and export of medicines and supplies. This is perceived as improper while under occupation. The referral process involves an inherent interaction with the blockade. By requesting a patient be let out of Gaza to receive treatment, the lack of freedom of movement Gazans experience is challenged. The materials used in treatment also gain a political dimension. There is a distinct awareness that machines are not subpar or dysfunctional by nature, but become such due to the ban on spare parts and certain equipment (for example, that for radiation).
Global Humanitarianism
The dispositif of local NGOs cannot be completely separated from the global humanitarianism that makes it possible. Each of the organizations considered is funded largely through foreign donations from governments, partner INGOs, individuals, and international organizations. Donors are acknowledged in social media posts and official reports of specific projects. The knowledge of this dependence on donors, which is largely implicit, is reinforced by the acceptance of donor influence over some projects. These donors provide funding for specific projects (rather than contribute to the core budget) and co-design them with the NGO. Contact is also maintained with a variety of core budget donors. Some of them are governments, others are solidarity organizations in primarily the Islamic and Western world.
The international medical humanitarian community is also drawn upon for non-financial means. One of the effects of the blockade is the restriction on the freedom of movement of doctors. This poses an obstacle to the continual improvement of specialists’ knowledge. Thus, online solutions are found to supplement rare live delegations. A UK charity, for example, helps NGO B set up regular consultations between Palestinian and UK specialists on breast cancer cases.
On the other hand, there is a persistent awareness of problematic donor policies. NGO A pointed out that donors prefer to fund emergency responses, rather than on-going and development projects. International NGOs are perceived as less independent, primarily because they need to take into account the interests of the Israeli side. There is a widespread frustration with the policies of some of the donor organizations and the international community, including donor governments. Condemnations of the occupation are seen as insufficient, sporadic, and half-hearted. In short, the displacement of political support by humanitarian aid is problematized. This frustration is not made explicit in public discursive practices, however. A donor government might be acknowledged with gratitude on one page, whereas on the next, the international community (which it is part of) is condemned for its apathy.
Encountering the Theory
The above discussion of some of the core discourses, practices, and objects in the dispositif reveal an internal tension between the humanitarian aspects of NGOs’ work and its political dimension. Deploying both Agamben and Weizman’s core critiques and conceptions of resistance can aid in understanding the core of the dispositif, as well as its repercussions.
Read through an Agambian lens, grassroots humanitarianism can indeed only grasp human life as bare life, despite its best efforts to contextualize the threats to this life. Depoliticization and dehistoricization are curbed by the keen awareness of the effects of the blockade, especially on the healthcare system. In fact, these challenges constitute in large part the urgent need to which these NGOs respond. It is also acknowledged that the economic situation reinforced by the blockade has detrimental effects on health. Yet, the practices aimed at prevention and treatment focus on personal behavioral changes. The reason for this is simple, though implicit: political advocacy will not help improve the physical health of patients at the moment. This reveals a prioritization of biological life. This is perhaps more forcefully shown in the interaction with donors. It is acceptable in a biopolitical age that INGOs and states support humanitarian efforts helping the populations harmed by their own political quietude and complicity.
These international actors are offered the possibility of displacing durable political action against the occupation by ‘apolitical’ humanitarian aid.[53] When NGOs must choose between saving lives and drawing a political red line (for example, by refusing cooperation with politically pro-Israel states), biological life is prioritized. This shows that in the end, the dispositif of these NGOs is a humanitarian one. That even grassroots NGOs become complicit in the very state power they seek to fight against fits well within Agamben’s rather agenciless conception of bare life. It is so subjected to the relations of violence rendering it bare life that proper power relations have become impossible. In this case, complete independence is obstructed by dependence on financial support.
Weizman’s insights add nuance to this totalizing perspective and point out its limitations. Centering the health of the population – here, the mitigation of chronic diseases – is not inherently problematic. It could even help avoid some risks that accompany humanitarian action. Most importantly, a self-conscious exclusion of politics in order to focus on the physical well-being of patients takes the eye off the politics of the humanitarians to “the political capacity for self-government” of the locals. Indeed, this is how some NGO employees perceive their role: to contribute to the resilience of their people. By separating their medical programs from advocacy, they also reserve agency for chronic disease sufferers to make up their own minds on political matters. Moreover, the creation of their humanitarian programs is in itself perceived as a political act and thus an expression of political agency.
However, the NGOs still find themselves in the uncomfortable position of accepting the aid of states and organizations that politically oppose their emancipation. Agamben’s awareness of the embeddedness of humanitarians in the global biopolitical system might be considered a strength over Weizman. Yet, Weizman seems implicitly aware of the inherent limits state power places upon humanitarianism’s independence. He suggests that the oppressed might refuse aid “at a time of their choice.”[54] This would give the occupied the chance to fully independently construct spaces, self-govern, and make political demands, away from the global humanitarian apparatus they have been subjected to. The “secret solidarity with state power” in Agamben’s words, would be removed then.
Would the subsequent shortages of insulin, disinfectant, or cancer treatments, and the inability to conduct a variety of life-saving surgeries result in the restoration of proper power relations? This refusal of aid is reminiscent of the assumption of bare life, as it makes the relations of violence created by the occupation visible. This form of resistance introduced by Agamben is applied by Jenkins and Pin-Fat, who show that the state is no unworthy adversary: “It is more than likely that a relation of violence will be reaffirmed, with such a protest being read not as a political action but in other ways.”[55] Indeed, Arabs, Muslims, and especially Gazans are already entangled in less than favorable discourses. The international community is unlikely to have a change of heart when they begin to die of ordinarily manageable chronic diseases.
Conclusion
This article set out to answer the question of what Gazan grassroots medical NGOs’ response to chronic diseases can show about critiques of humanitarianism. This question was formulated in the context of the existing debates among critical theorists on the logic of humanitarianism, along with the scholarship on the Gazan medical sector. Of the former, Agamben’s and Weizman’s were further considered. This allowed for an analysis taking into account crucial thinkers in the field, as well as conceptions of the politically excluded with both little and large degrees of agency. These approaches also invited positive reimaginings of humanitarianism. They were operationalized through a dispositif analysis of the practices of grassroots NGOs in Gaza preventing and treating chronic illnesses.
The analysis of the dispositif has shown that while there is a keen understanding of the effect of the occupation on healthcare services, humanitarian logics still dominate the practices of the NGOs. The medical (humanitarian) programs and political advocacy are not integrated. The limited effectiveness of advocacy to increase resources gives way to a shift towards health education. This risks responsibilizing the chronic disease sufferer despite their socio-economic conditions. Finally, the prioritization of the humanitarian over the political is displayed in the willingness to rely on donors whose foreign policies contribute to the endurance of the occupation. Thus, the embeddedness in the logic of global humanitarianism leads to the reproduction of Gazan chronic diseases as biological problems first.
This finding is in line with Agambian skepticism about both humanitarianism’s ability to evade the logic of bare life and the ability of those rendered bare life to resist this state. Even medical humanitarianism led by the population – the refugees themselves – cannot evade a global dispositif complicit in state power. Among critical approaches to humanitarianism, this is a controversial conclusion. The ability of the population subjected to the sovereign ban to resist is often affirmed in contrast to Agamben, for example by Weizman. The latter’s position, suggesting that power in the hands of Gazans themselves is the solution, is enriched by the recognition that even these Gazans operate within global humanitarianism. In that sense, Weizman’s proposition that the most radical departure from the humanitarian present could be the refusal of aid is compelling. It represents an already tacit understanding of the limits of the “local,” the “independent,” and the “grassroots.”
This rather grim conclusion is made more nuanced by a full appreciation of the practices found in the dispositif. Some of these can be interpreted as significant challenges to the occupation. Further, apart from the problematic elements mentioned, the self-administration of aid ensuring survival already approaches Weizman’s vision of a better humanitarianism conducive to expressions of agency. Especially the knowledge in the dispositif that the NGOs contribute to resilience is telling. In this sense, the conclusions reached do not suggest that grassroots action is not preferable to INGOs providing care, nor do they seek to do so.
There are methodological limitations to this study. A first limitation is its relatively broad scope. Everything from foreign funding to health education has been taken into account. This should have facilitated a more comprehensive view of both the dispositif and the humanitarianism practiced by these NGOs. However, it renders this study rather exploratory, and more detailed problematizations would be of value. Secondly, the Gazan context is unique in many of its characteristics. This observation, in conjunction with the exploratory nature of this paper, should encourage further research into grassroots NGOs in various contexts.
Finally, the very project embarked on in the past pages must be questioned. Indeed, the deployment of an Agambian critique on grassroots humanitarianism reveals a problematic element within his approach. Grassroots humanitarianism has been criticized here for its entanglement with the international system that contributes to its necessity. It has become apparent that there is no way for the NGOs to collect the required resources without this complicity. This suggests, particularly combined with Agamben’s model of resistance, that Gazans’ health must suffer for them to mount an independent, “pure” challenge to the occupation. By condemning these NGOs for keeping Gazans in good health, one risks reproducing the same relations of violence condemned previously. Thus, it is imperative to bring in Weizman’s stance in order to emphasize that the form and timing of Gazans’ resistance are wholly their own.
References
[1] Didier Fassin, “The Predicament of Humanitarianism,” Qui Parle 22, no. 1Special Issue: Human Rights between Past and Future (Fall/Winter 2013): 37-38.
[2] Costas Douzinas, “The Many Faces of Humanitarianism,” Parrhesia 2, no. 1 (2007): 10.
[3] Abdullatif Husseini, Niveen M. E. Abu-Rmeileh, Nahed Mikki, Tarik M. Ramahi, Heidar Abu Ghosh, Nadim Barghuthi, Mohammad Khalili, Espen Bjertness, Gerd Holmboe-Ottesen, and Jak Jervell, “Cardiovascular Diseases, Diabetes Mellitus, and Cancer in the Occupied Palestinian Territory,” The Lancet 373, no. 9668 (April 2009): 1041.
[4] The claim that Hamas is very reluctant to allow international NGOs to work independently was made by one of the interviewees. This claim could not be confirmed independently.
For MSF’s problems, see Caroline Abu-Sada, “Gaza Strip: A Perilous Transition,” in Humanitarian Negotiations Revealed: The MSF Experience, ed. Michael A. Neuman, Fabrice Weissman, and Claire Magone (London: Hurst & Company, 2011), 99-100.
[5] For examples of the reduction of aid recipients to victims, see Ilana Feldman, “Gaza’s Humanitarianism Problem,” Journal of Palestine Studies 38, no. 3 (Spring 2009): 22-37; B. E. Harrell-Bond, Imposing Aid: Emergency Assistance to Refugees (New York: Oxford University Press, 1986).
For examples of the alliance between state power and humanitarian organizations, see Lisa Bhungalia, “Managing Violence: Aid, Counterinsurgency, and the Humanitarian Present in Palestine,” Environment and Planning A 47 (2015): 2308-2323; Yves Winter, “The Siege of Gaza: Spatial Violence, Humanitarian Strategies, and the Biopolitics of Punishment,” Constellations 23, no. 2 (November 2015): 315; Jenny Edkins, “Humanitarianism, Humanity, Human,” Journal of Human Rights 2, no. 2 (June 2003): 255; Didier Fassin, Humanitarian Reason: A Moral History of the Present (Los Angeles: University of California Press, 2012).
For examples of depoliticization and dehistoricization, see Ariella Azoulay and Adi Ophir, “Abandoning Gaza,” in Agamben and Colonialism, ed. Marcelo Svirsky and Simone Bignall (Edinburgh: Edinburgh University Press. 2012), 185; Liisa H. Mallki, “Speechless Emissaries: Refugees, Humanitarianism, and Dehistoricization,” Cultural Anthropology 11, no. 3 (August 1996): 398; Suzan Ilcan and Kim Rygiel, ““Resiliency Humanitarianism”: Responsibilizing Refugees through Humanitarian Emergency Governance in the Camp,” International Political Sociology 9, no. 4 (December 2015): 348.
[6] See for example Miriam I. Ticktin, Casualties of Care: Immigration and the Politics of Humanitarianism in France (Los Angeles: University of California, 2011); Robin Vandevoordt and Gert Verschraegen, “Subversive Humanitarianism and Its Challenges: Notes on the Political Ambiguities of Civil Refugee Support,” in Refugee Protection and Civil Society in Europe, ed. Margit Feischmidt, Ludger Pries, and Celine Cantat (Cham: Palgrave Macmillan, 2019).
[7] Srilatha Batliwala, “Grassroots Movements as Transnational Actors: Implications for Global Civil Society,” Voluntas: International Journal of Voluntary and Nonprofit Organizations 13, no. 4 (2002): 396.
[8] Giorgo Agamben, Homo Sacer: Sovereign Power and Bare Life, trans. Daniel Heller-Roazen (Stanford: Stanford University Press, 1998), 133.
[9] Ibid., 109.
[10] Ibid., 89.
[11] Ibid., 83.
[12] Fassin, “Predicament of Humanitarianism,” 39.
[13] Didier Fassin, “Humanitarianism as a Politics of Life,” Public Culture 19, no. 3 (2007): 499-520.
[14] Agamben, Homo Sacer, 120.
[15] Mika Ojakangas, “Impossible Dialogue on Bio-power: Agamben and Foucault,” Foucault Studies no. 2 (2005): 18.
[16] Agamben , Homo Sacer, 184-185.
[17] Jenny Edkins and Véronique Pin-Fat, “Through the Wire: Relations of Power and Relations of Violence,” Millunnium 34, no. 1 (2005): 9.
[18] Eyal Weizman, The Least of All Possible Evils: Humanitarian Violence from Arendt to Gaza (London: Verso, 2011), 61.
[19] See for example Weizman, Least of All Possible Evils, 35-36 and Agamben, Homo Sacer, 126-127.
[20] Weizman, Least of All Possible Evils, 4.
[21] Ibid., 38.
[22] Ibid., 40-41.
[23] Ibid., 62.
[24] Edkins and Pin-Fat, “Through the Wire,” 14.
[25] Ibid., 21-22.
[26] Weizman, Least of All Possible Evils, 54-55.
[27] Ibid., 62.
[28] Ibid.
[29] Ibid., 38-39.
[30] Michel Foucault, The History of Sexuality, Volume I: An Introduction, trans. R. Hurley (New York: Vintage Books, 1980), 194.
[31] Siegfried Jäger, “Discourse and Knowledge: Theoretical and Methodological Aspects of a Critical Discourse and Dispositive Analysis,” in Methods of Critical Discourse Analysis, edited by Ruth Wodak and Michael Meyer (London: Sage Publications Ltd, 2009), 58.
[32] Claudia Aradau, Martin Coward, Eva Herschinger, Owen D. Thomas and Nadine Voelkner, “Discourse/Materiality,” in Critical Security Methods: New frameworks for analysis, ed. Claudia Aradau, Jef Huysmans, Andrew Neal, and Nadine Voelkner (Abingdon: Routledge, 2015), 65-66.
[33] Ibid., 68.
[34] Ibid., 65.
[35] Weizman, Least of All Possible Evils, 4.
[36] Giorgio Agamben, What Is an Apparatus? and Other Essays, trans. David Kishik and Stefan Pedatella (Stanford: Stanford University Press, 2009), 14.
[37] Philippe Bonditti, “Act different, think dispositif,” in Research Methods in Critical Security Studies: an Introduction, ed. Mark B. Salter and Can E. Mutlu (Abingdon: Routledge, 2013), 101-102.
[38] For the existing research, see Médicins du Monde France, Violence against Healthcare in Gaza: Violence against Palestinian NGOs Healthcare Personnel, Vehicles and Medical Structures during the 2018 “Great March of Return” Demonstrations (Médicins du Monde, 2018), http://www.euromed-france.org/wp-content/uploads/2019/02/MDM-Report-Violence-against-Healthcare-in-Gaza-2018.pdf, 12.
[39] As a result, websites and social media pages of these NGOs are not referenced in the endnotes of this paper. To preserve the scientific replicability of the research, the researcher can be contacted for the obtainment of the names, webpages, and social media accounts of the NGOs analyzed, as well as the transcripts of interviews. The report of NGO C is accessible to the public and can thus be found in a note.
[40] Jäger, “Discourse and Knowledge,” 60-61.
[41] Azoulay and Ophir, “Abandoning Gaza,” 181.
[42] Winter, “Siege of Gaza,” 309.
[43] See for example Azoulay and Ophir, “Abandoning Gaza,” 183; Honaida Ghanim, “Thanatopolitics: The Case of the Colonial Occupation in Palestine,” in Thinking Palestine, ed. Ronit Lentin (London: Zed Books Ltd., 2008), 77.
[44] Tamer Qarmout, Delivering Aid Without Government: International Aid and Civil Society Engagement in the Recovery and Reconstruction of the Gaza Strip (Cham, Switzerland: Springer, 2017), 18.
[45] Ibid., 124.
[46] United Nations Conference on Trade and Development, “Palestinian socioeconomic crisis now at breaking point,” September 10, 2019.
[47] Qarmout, Aid Without Government, 19.
[48] Union of Health Work Committees, Annual Report: January – December 2016 (Al Nasser: Union of Health Work Committees, 2017), 4.
[49] Husseini et al., “Cardiovascular Diseases, Diabetes Mellitus, and Cancer,” 1045.
[50] Union of Health Work Committees, Annual Report, 7.
[51] Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A.M. Sheridan(Taylor & Francis e-Library: Routledge, 2003), 96-97.
[52] Transliteration from Hans Wehr, A Dictionary of Modern Written Arabic: Third Edition, ed. J. Milton Cowan (Ithaca, NY: Spoken Language Services, Inc., 1976), 472.
[53] This dynamic has been acknowledged by, amongst others, Weizman in other contexts. See Weizman, Least of All Possible Evils, 50.
[54] Ibid., 62.
[55] Edkins and Pin-Fat, “Through the Wire,” 21.