Monsoons and medicine: the biopolitics of crisis and state indifference in Gilgit-Baltistan

ABSTRACT

Through the medium of a hospital ethnography, this paper explores the debilitating impacts of the 2010 monsoon floods on Gilgit-Baltistan’s public health sector, and interrogates how its escalating harms coalesced with long-standing state neglects to generate medical precarity and loss, and spark debate concerning Pakistan’s responsiveness and commitments to this politically marginalized and remote region. In Gilgit Town, the region’s administrative capital, the state’s failure to adequately prepare for and offset the floods’ direct and indirect effects had catastrophic consequences for public sector hospitals, where healthcare providers worked without sufficient resources, treatment options were greatly diminished, and patients experienced significantly higher risks and worsened health outcomes. In providing ethnographic snapshots of the ways that the floods and disaster-related governance gaps shaped service provision at the region’s primary referral hospital, the paper centralizes healthcare providers’ accounts of the inadequacy of Pakistan’s response to the crisis, and their claims that the state’s failure to protect them from the floods’ worst effects was symptomatic of its historic lack of care for Gilgit-Baltistan and its peoples.

KEYWORDS:

• Gilgit-Baltistan
• Pakistan
• 2010 floods
• medicine
• biopolitics

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. See Varley, “Targeted doctors, missing patients,” “Medicine at the Margins,” “Exclusionary Infrastructures,” “Abandonments, Solidarities and Logics of Care.”

2. Feldman, “The Humanitarian Condition,” 157; and see Li, “To Make Live or Let Die?”

3. See Rabinow and Rose, “Biopower Today.”

4. See Mbembe, “Necropolitics”; Murray, “Thanatopolitics: On the Use of Death”; and “Thanatopolitics: Reading in Agamben.”

5. See Foucault, 1978, 193 in Rabinow and Rose, “Biopower Today,” 196.

6. See Berry, “Who’s Judging the Quality of Care?”; Pfingst and Rosengarten, “Medicine as a Tactic of War”; and Stevenson, “The psychic life of biopolitics.”

7. Jan, The Metacolonial State, 281.

8. Ibid., 281.

9. Varley, “Targeted Doctors Missing Patients.”

10. Varley, “Medicine at the Margins”; “Exclusionary Infrastructure”; and see Ali, “Outrageous State, Sectarianized Citizens.”

11. Although these claims have predominantly concerned Pakistan’s treatment of Gilgit-Baltistan’s Shia Muslim populations, my ethnography explored how in Gilgit Town the state’s more harmful impulses were perceived as percolating through government infrastructures and agencies to affect Gilgitis as a whole, regardless of sect. (See also Dawn, 27 August 2012.)

12. Mbembe, “Necropolitics.”

13. Li, “To Make Live or Let Die?” 66.

14. See Aciksoz, “Medical Humanitarianism Under Atmospheric Violence”; Hamdy and Bayoumi, “Egypt’s Popular Uprising and the Stakes of Medical Neutrality”; Panter-Brick, “Conflict, violence and health”; Pfingst and Rosengarten, “Medicine as a Tactic of War”; Shalev, “A Doctor’s Testimony”; Smith, “Doctors that Harm, Doctors that Heal”; Varma, “Love in the time of occupation”; and Wick and Hassan, “No safe place for childbirth.”

15. Cooper, “The Doctor’s Political Body”; Oka-Smith, “Unintended Consequences”; Rivkin-Fish, “Bribes, Gifts and Unofficial Payments.”

16. Such issues and concerns are not new to the region. Since Partition, Gilgit-Baltistan has been defined by its regional structural disadvantages (Benz, Education for Development in Northern Pakistan, 260). These have occurred notwithstanding the development successes achieved by many communities’ participation in broad-based, long-term non-governmental programmes and interventions, such as those implemented since the early 1970s in Ismaili and Shia-dominated Hunza-Nagar, Ghizer and Gilgit Districts by the Aga Khan Development Network and its many subsidiaries in particular (Benz, Education for Development in Northern Pakistan; “HRCP Report on G-B”; Mostowlansky, “Humanitarianism across Mountain Valleys”; and Settle, “The New Development Paradigm through the Lens of the Aga Khan Rural Support Programme”).

17. TRF and Government of Pakistan, 18th Constitutional Amendment.

18. Asia Times, “Gilgit-Baltistan: Drama in a Theater of Despair.”

19. Gilgit-Baltistan’s public health sector is ‘managed by the District Health Officer (DHO) who is assisted by deputy district health officers [and the] district coordinator/ Public Health Specialist of [vertical] national programmes’ (TRF and GoP 2012b, 6), such as the Maternal Newborn and Child Health (MNCH) and National Tuberculosis (TB) Control Programmes.

20. TRF and Government of Pakistan, 18th Constitutional Amendment, 4.

21. Prior to the 2009 Empowerment Act and region’s renaming as Gilgit-Baltistan, this branch of the federal government was known as the Ministry of Kashmir Affairs and the Northern Areas (KANA); and TRF and Government of Pakistan, 18th Constitutional Amendment, 5.

22. Ibid., 5.

23. Ibid.

24. Ibid.

25. Gilgit-Baltistan’s health budget is among the lowest in Pakistan. For instance, in 2014 Punjab’s health allocations comprised only 5.4% of its total budgetary expenditures, while Sindh’s were 7.3%, Khyber-Pakhthunkhwa’s 7.9% and Balochistan, a province with acutely problematic health indicators that are comparable to those of Gilgit-Baltistan, was 9.9% (Express Tribune, 14 November 2014).

26. Technical Resource Facility, Health Facility Assessment of Gilgit-Baltistan, 29.

27. Ibid., 30.

28. Ibid.

29. TRF and Government of Pakistan, Health Budget & Expenditure Analysis, 10.

30. The Kashmir News, “Pakistan pumps in illicit drugs in Gilgit.” It merits note that The Kashmir News’s Gilgit-Baltistan coverage relies on the active contributions of Gilgiti residents, including health system officials and physicians, and journalists, all of whom were quoted by and featured in the online media quoted here.

31. Visweswaran, Everyday Occupations.

32. Grieser, “When the Power Relationship is not in Favour of the Anthropologist.”

33. Express Tribune, “Stern Action Against Pharmacists”; and The Kashmir News, “Pakistan pumps in illicit drugs in Gilgit.”

34. In 2012, the region’s maternal mortality rate was estimated to be 600 per 100,000 live births (TOR and GoP 2012d: 17; Government of Gilgit-Baltistan: 2 February 2015), a rate far exceeding the already-high national average of 250 per 100,000 live births (Dawn: 6 May 2015).

35. Brooshal Times, “All DHQ hospitals in tatters”; IHROGB, “The heaps of garbage inside the City Hospital Gilgit”; Pamir Times, “Residents of Kashrote staged a protest demonstration”; and Right Now, “Protest Against MS City Hospital Kashrote.”

36. Dawn, “DHQ Hospital at Gilgit”; Express Tribune, “Victims complain of lack of facilities, harsh attitude”; IHROGB, “‘The heaps of garbage inside the City Hospital Gilgit’ and ‘The death of a mother and child from Nagar in DHQ Hospital Gilgit’”; Pamir Times, “‘Secretary of Health GB visits DHQ Hospital in Gilgit,’ ‘Pictorial: Inside and around the DHQ Hospital Gilgit’ and ‘A day without electricity at DHQ Hospital Gilgit.’”

37. Express Tribune, “113 Dead in Khyber-Pakhtunkhwa.”

38. GB Tribune, “Extensive Damage by Flood in Gilgit Baltistan.”

39. Ibid.

40. Ibid.

41. Fair, “What Pakistan did right”; and Other sources note that it was on 21 June 2010 that the Pakistan Meteorological Department first issued warnings that ‘urban and flash flooding could occur from July to September in the north parts of the country’ (http://www.pakmet.com.pk/MON&TC/Monsoon/monsoon.2010.html; 20 August, 2010).

42. World Wide Fund for Nature, Preliminary Rapid Flood Damage Assessment in Gilgit-Baltistan, 2010.

43. Space on these flights was prioritized first for Army staff and their dependents, followed by ‘foreigners’, ‘sick’, ‘government’, ‘down family’ (non-local ‘down-country families) and ‘local family’. Despite the allowances made for the transport of sick individuals, flights only very rarely included patients being shifted to better equipped government hospitals in the capital, Islamabad.

44. Warraich, Zaidi and Patel, “Floods in Pakistan.”

45. In my 11 August meeting with the region’s Chief Secretary, I was told that it could take upwards of four days to restore electricity to Gilgit Town, and two days to resume water supplies. Ultimately, it took nearly a week more before water was available at the DHQ again (Fieldnotes, 11 August 2010; Dawn, 12 August 2010).

46. By 9 August, petrol supplies in Gilgit were exhausted. As key commodities disappeared, a black market emerged to capitalize on Gilgit’s resource deficiencies, which meant that the costs for essential items skyrocketed (see Pamir Times, 18 August 2010).

47. Additional treatment delays and service avoidances followed from incidents of sectarian violence in the first few days of August, which were followed by killings sparked by fights over fuel shortages, and days of curfew starting from 24 August (Voice of Hunza, 24 August 2010).

48. Hamdy, “When the State and Your Kidneys Fail.”

49. Pamir Times, “Gais Village in Diamir Washed Away.”

50. Pamir Times, “Gais village in Diamir washed away.”

51. Pamir Times, “183 Killed in GB.”

52. Varley, “Fieldnotes excerpt.”

53. Pamir Times, “Gilgit City Turns Back to 1960s.”

54. Express Tribune, “Hanging on by a Tether in Gilgit-Baltistan.”

55. See note 51 above.

56. Varley, “Vulnerable patients in Gilgit-Baltistan”.

57. Technical Resource Facility, Health Facility Assessment of Gilgit-Baltistan, 8.

58. Express Tribune, ‘HRCP Report on G-B: People must know reason for decades of alienation’.

59. See note 51 above.

60. See Street and Coleman, “Introduction: real and imagined spaces”; and Street, Biomedicine in an Unstable Place.

61. Read, “Images of Care, Boundaries of the State.”

62. Not only did this lack evidence how little the Government of Pakistan had accomplished in terms of crafting disaster policy and legislation in the years following the 2005 earthquake that devastated northern Pakistan, but it illuminated the critical difference between ideal and real state forms and processes.

63. In early September, Gilgit-Baltistan’s appointed Secretary of Health, Zafar Lodhi, visited the Family Wing to evaluate the hospital’s post-flood condition. He called for an inquiry into ‘mismanagement and dilatoriness in the construction of DHQ’s women wing’, requested the hospital’s management to ‘present a report regarding the absence of employees’ and urged ‘strong action against the careless employees’ (Pamir Times, 3 October 2010), thereby confirming Family Wing staff concerns that the resource insufficiencies underlying their provision of medical services were invisible to health system officials, and the contexts and content of care itself were depoliticized. Nor were they ever to receive recognition for their usually successful efforts during the floods to alleviate death and debility among delivering patients and their newborns.

64. Feldman, “The Humanitarian Condition,” 157.

65. Aijaz, “’We should be resettled there,” 50.

66. Rabinow and Rose, “Biopower Today,” 203.

67. See Biehl, “Vita”; and Varley, “Abandonments, Solidarities and Logics of Care.”

68. Murray, “Thanatopolitics: Reading in Agamben,” 204.

69. Lemke, “A Zone of Indistinction.”

70. Murray, “Thanatopolitics: Reading in Agamben,” 205.

71. Mishler, “Patient stories, narratives of resistance.”

72. Stevenson, “The psychic life of biopolitics,” 593.

73. See Berry, “‘Who’s Judging the Quality of Care?’”; Stevenson, “The psychic life of biopolitics.”

74. See Kelm, “Colonizing Bodies.”

75. See Jaffré, “Towards an anthropology of public health priorities”; Keshavjee, Blind Spot; Kyungu, “Exacerbation of vulnerability in a hospital setting”; Masquelier, “Behind the dispensary’s prosperous façade”; Street, “Seen by the state”; Towghi, “Normalizing off-label experiments”; and Varma, “Love in the time of occupation.”

76. Larkin, “The Politics and Poetics of Infrastructures”; and Lokrem and Lugo, “Infrastructure: Editorial Introduction.”

77. On account of the hospital’s deficiencies, these were the individuals who risked being characterized as co-participants in the enactment of state neglects, and therefore sought to instead stress their role, alongside their patients, as victims of the government and its targeted evasions and exclusions.

78. Ali, “Outrageous State, Sectarianized Citizens”; and Varley, “Targeted doctors, missing patients,” “Exclusionary Infrastructures,” “Abandonments, Solidarities and Logics of Care.”

79. Harvey, “Cyanobacteria blooms,” 479.