Abstract
Using data collected over nearly three years of ethnographic fieldwork in the Gilgit-Baltistan region of northern Pakistan, my paper explores hospital spaces, clinical services and treatment encounters as conduits for the expression and propagation of conflictive Shia-Sunni sectarianism. Where my prior research has investigated the political etiologies (Hamdy in Am Ethnol 35(4):553–569, 2008) associated with Gilgiti women’s experiences of childbirth during ‘tensions’, as Shia-Sunni hostilities are locally known, this paper focuses on healthcare providers’ professional and personal navigations of an episode of conflict whose epicentre was at the District Headquarter Hospital, Gilgit-Baltistan’s foremost government hospital. Through critical evaluation of the impacts of Shia-Sunni tensions on the social, administrative and clinical practices and consequences of medicine, my paper analyses the complex ways that clinics in crisis serve as zones of contact (Pratt in Profession 91:33–40, 1991) and abandonment (Biehl in Soc Text 68(19):131–149, 2001; Subjectivity: ethnographic investigations, 2007), in which neglect and harm are directed along lines of sectarian affiliation to produce vulnerability, spectacular violence and death for healthcare providers and patients.
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Notes
This paper is based on ethnographic fieldwork conducted over five extended visits in 2004–2005 and between 2010 and 2013. The specific data discussed herein is derived from approximately three hundred primary interviews with Sunni, Ismaili and Shia healthcare providers, and my field-notes as they concern medical services in hospital settings. In order to ensure my interlocutors’ safety and to prevent narratives from being associated with specific individuals, I have taken precautions to avoid the inclusion of identifying information such as their exact professional designations and/or gender.
Located at the confluence of the Hindu-Kush, Karakoram and Himalayan mountain ranges, since Pakistan’s Partition from India, Gilgit-Baltistan has been defined by its political liminality. At Partition in 1947, Gilgit-Baltistan was originally excluded from Pakistan, considered instead to be a part of the Kashmir region whose ruler acceded to India in October of that year (Sökefeld 1998:64). On November 1, Gilgitis fought successfully to leave Indian-controlled Kashmir and join Pakistan, and on January 1, 1948 a ceasefire was declared between India and Pakistan (Ibid:66). Since then, Pakistan’s politicians have reasoned that until Pakistan and India resolve the larger Kashmir issue, of which Gilgit-Baltistan is considered an integral element, the region’s constitutional status will remain unresolved. Held hostage by the Kashmir crisis, unincorporated as a province to the state, and with its residents unable to vote and participate in the National Assembly, Gilgit-Baltistan and its capital, Gilgit Town, are at the neglected margins of Pakistan.
Gilgit Town’s population is comprised equally sized communities of Shias, Ismailis and Sunnis. Shias belong to the ‘Twelver’ and Ismailis to the ‘Sevener’ sects of Shia doctrine and practice. Gilgiti Sunnis are affiliated with the Sunni Deobandi Hanafi school of jurisprudence (fiqh). Despite sharing a common theological base, Shias’ and Ismailis’ cultural and religious practices differ, and Gilgiti Ismailis mark such differences by self-identifying simply as ‘Ismaili’.
For ethnographic accounts of Shias’ historical and contemporary experiences of marginalization and loss, and the evolution of Shia-Sunni enmities and conflict in Gilgit Town, see Ali (2008, 2010, 2012), Sökefeld (1997, 1998, 1999) and Grieser and Sökefeld (2014). Over the last 30 years, an estimated 3,000 people have been killed in regional sectarian attacks; most victims were Shias and Sunnis living in and around Gilgit Town (Interview: March 16, 2012).
In Gilgit Town, the ISO’s activities and mandates were paralleled by the actions of extremist Sunni organizations such as the militant and weaponized Sipah-e-Sahaba (SSP), which has been associated with violent protests and the target killings of Shias in Gilgit-Baltistan and across Pakistan.
During the Nisab Crisis, a number of the Sunni-owned and operated pharmacies and private clinics located near the DHQ relocated away from the area in response to security risks or threats of harm to proprietors and doctors. Shias who had been similarly dislocated by tensions from Sunni areas of town re-settled by the DHQ and filled the service gaps left by Sunnis.
As the wife of a Gilgiti Sunni, during active tensions my fieldwork was subject to many of the same restrictions concerning inter-sectarian sociality and socio-spatial mobility that affected my Sunni interlocutors, which limited my ability to interview across lines of sectarian affiliation and in the Shia community in particular. In the periods between conflicts, and because my in-laws, extended family, friends and former colleagues also come from Gilgit’s Shia and Ismaili communities, such frictions and uncertainties were reduced, allowing me resume inter-sectarian fieldwork and interviews.
The hospital’s administrators and staff refer to the Family Wing, which is situated separately from the main hospital complex and provides general and specialized medical services for women patients only, as the DHQ’s ‘Female Side’ or ‘Female Wing’. The hospital’s other wards, which are located within the main complex and provide mixed-gender Out- and In-Patient services, are referred to as the ‘Male Side’.
Maternity patients from across the sectarian divide, for instance, spoke of their ‘bad experiences’ with ‘incorrect’ pharmaceutical prescriptions, over-dosages, side-effects, allergic reactions, or blood-borne infections acquired from multiple-used syringes or IV-lines.
There was remarkable consistency in the degree of recall and content even in those accounts that were shared over considerable periods of time, which is suggestive of my interlocutors’ structured and routinized memorialization of key events and experiences.
On the morning of January 8th, an Ismaili government officer was killed after hiding a number of Sunni colleagues, who were also killed, at his home near the DHQ, thereby confirming that despite their broader neutralities, Ismailis were not exempt from being considered targets in the conflicts.
In her analysis of trauma and testimony following communal riots in India, Das attends to the temporal shifts evident in many conflict survivors’ narratives, whereby “events can be carried back and forth in time” (2003:302). Such oscillation between past and present, she argues, permits survivors to interpret and work through trauma, and platform the “eventedness of the everyday” (Ibid).
See Varley (2010) for a discussion of the impacts of the 2005 tensions on maternity patients’ ability to access and use the DHQ’s services, as well as their health outcomes.
The Kashrote Government City Hospital was first established in late January 2005 (see Varley 2010:67), and the Baseen Civil Hospital was initiated in 2006 and formally inaugurated in 2009. Not unlike the DHQ, Gilgit’s ‘Sunni’ hospitals are chronically underfunded and poorly resourced. It is worth noting that the building of ‘Sunni’ and more recently also ‘Shia’ hospitals (see Varley 2014) has occurred alongside numerous other sect-specific public and private sector developments, such as bazaars (markets), link roads, bridges, and transportation routes and services (see Grieser and Sökefeld 2014).
Sunni men receiving treatment at the DHQ were occasionally guarded by attendants, family or others, some of whom were members of Sunni religious and militancy organizations, including the Sipah-e-Sahaba (see footnote 5), as well as Shia relatives or colleagues, whose presence confirmed the on-site risks facing Sunnis and also evidenced the endurance of inter-sectarian sociality.
Elliott’s ethnography of impoverishment, homelessness, marginality, addiction and state neglect in Canada confirms that social or institutional spaces can be simultaneously and paradoxically sites of abandonment, “intense surveillance” and governance (2010:181).
Some Shia and Ismaili interlocutors’ avoidance or disavowal of Sunnis’ insecurities ran parallel to, and was in fact afforded by, a lack of political attention and media coverage concerning either Sunni deaths on January 8th or their vulnerabilities in the months and years which followed. Whether informally enabled or formally enacted, the suppression of Sunnis’ experiences has profoundly obscured the sectarian neglects and losses which can occur in hospital spaces, especially during tensions.
Chilas is the capital of the Sunni-majority Diamer District in southern Gilgit-Baltistan.
To this point, numerous interlocutors emphasized how the safeties inherent in Ismaili-Sunni relations contradicted Shia Markazi Tanzeem (Masjid Organization) rhetoric which characterized Gilgiti Sunnis as ‘threats’ not only to Shias, but also all religious minorities.
While my analysis centralizes the role played by ‘logics of care’, it merits note that this conceptual approach is often paired with the “logic of choice”, which entails recognition of the “individual, intellectual … economic” (Turrini 2010:75) and, in this case, sectarian factors that shape how patients understand and approach medical sites and services.
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Acknowledgments
I am grateful to Michael Lambek and Janice Graham for their guidance during the fieldwork on which this paper is based, and to Sherine Hamdy, Adia Benton, Sa’ed Atshan and Soha Bayoumi for their encouragement when the paper was presented at the conference they had organized, “The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval” (Brown University, 2014). I would also like to express my sincere thanks to Saiba Varma, Martin Sökefeld, Anna Grieser, Deborah Varley and two anonymous reviewers for their recommendations on the final version. Research was granted ethics approval by the University of Toronto’s Research Ethics Board (REB 12505; 2004–2005), Dalhousie University’s Office of Research Services (2010–2192; 2010–2012), and Bridge Consultants Foundation (2013). Research funding was provided by a SSHRC Doctoral Fellowship, an IDRC Doctoral Research Award, a Killam Postdoctoral Fellowship, and the Anthropology Department Research Committee (Lahore University of Management Sciences).
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Varley, E. Abandonments, Solidarities and Logics of Care: Hospitals as Sites of Sectarian Conflict in Gilgit-Baltistan. Cult Med Psychiatry 40, 159–180 (2016). https://doi.org/10.1007/s11013-015-9456-5
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DOI: https://doi.org/10.1007/s11013-015-9456-5