By Michelle Pentecost
Department of Global Health and Social Medicine, King’s College London
Department of Anthropology, University of Cape Town
Omar Dewachi’s Ungovernable Life is a timely and important book that will be of interest to medical anthropologists as well as scholars in development studies, postcolonial studies, and Middle Eastern studies. Dewachi crafts a history of the present to offer a critical account of the formation and fragmentation of state medicine in Iraq. The book spans the 19th, 20th and 21st centuries, focusing particularly on the colonial and postcolonial eras, in which the state health care infrastructure of Iraq constituted a colonial investment, a state-making project, and an eventual casualty of war and sanctions. Unlike the narratives of the neoliberal erosion of state health infrastructures that dominate histories of global public health elsewhere, the story of Iraq illustrates how wars have decimated the country’s prior successes in health and development.
Dewachi makes three critical interventions that push forward key discussions in medical anthropology. First, he approaches the tortuous history of healthcare in Iraq via the figure of the doctor. In a medical anthropological canon more often focused on the patient, and indeed criticised for its fixation on suffering (Robbins 2013), Dewachi inverts the gaze to focus on physicians as key players in the formation and deterioration of state healthcare infrastructures. Drawing on AbdouMaliq Simone’s notion of “people as infrastructure” (Simone 2004), Dewachi recounts the history of medical training in Iraq, of state allocations of doctors to rural provinces or state sponsorship of further training abroad in the 20th century, and of the tragic targeting of health care professionals of political violence in present day Iraq. Doing so, he reveals the centrality of medical professionals in war and statecraft. At the same time, Dewachi humanises Iraqi physicians and presents the contradictions inherent in framings of the doctor as a moral agent. The expectation at the height of healthcare development in Iraq—that doctors should both acquire specialist expertise with international training to rival their Western counterparts, and serve the rural populace—reveals a logic not unlike that documented in South Africa, where my own clinical work and ethnographic research is situated. There, too, doctors are portrayed as heroes, pioneers, scientists, healers and custodians for the poor, caught somewhere between pursuing technologically advanced medicine in the urban metropolis, and serving the most vulnerable in rural outposts (Pentecost and Cousins 2019).
The book’s second intervention is Dewachi’s masterful recasting of the centre-periphery dichotomy that so often mires accounts of postcolonial states. Through attention to the details of medical training as a key site of colonial and then state control, Dewachi offers a rich picture of the closely-knit transnational colonial and postcolonial networks that constituted medical infrastructure in Iraq. The colonial import of British staff, of English language instruction, and even of UK pathology museum specimens speaks to the deep imbrication of empire in mandatory medicine there. At the same time, Dewachi shows how the training of doctors was a state-making project for cultivating the modern Iraqi citizen. Dewachi’s ethnography of refugee doctors in the 21st century United Kingdom in the latter part of the book brings the story full circle, accurately contextualising the National Health Service in the imperial, colonial, and postcolonial histories that have ensured its survival. His account of the UK’s systematic disavowal of foreign doctors from former colonies is an indictment that reveals how anti-immigrant sentiment and racism in the UK have shaped healthcare there for decades. As I write this, the hashtag #YouClapForUsNow circulates on social media, as workers who are immigrants or descendants of immigrants ask for recognition of their value even after the clapping in COVID-times has passed (Marsh 2020).
This brings me to Dewachi’s third important intervention, which is his methodologically innovative approach. Dewachi combines meticulous archival work with multi-sited ethnography in Lebanon and the UK. The effect is to lend an immediacy to the histories laid out here. Like all good histories, Dewachi’s account of the tensions between development and public health in early twentieth century Iraq tell us something about our own predicaments. Dewachi devotes significant time to a discussion of the 1923 cholera epidemic, one of the waves of cholera that plagued Iraq every few years in that period. His discussion demonstrates the tensions between health and commerce, oppositely affected by the increased movement of people following the development of better transport links in early twentieth century Iraq. In 1923, pilgrimage for worshippers was only permitted if they held a “vaccination certificate,” not unlike those being imagined now, nearly a hundred years later, when the movement of people after COVID-19 may require “immunity passports” (Patel 2020). While the cholera vaccine eventually proved ineffective, Dewachi charts how the restriction on movement of people did seem to effect a decrease in deaths from cholera. In his words, “[p]ublic health practices could ‘immunize’ the state against the pathogens of development” (2017, 63). That we should view investment in public health as an essential “inoculation” is a historical lesson that has clearly been buried in the past few decades of neoliberalized health care, structural adjustment and avoidable wars.
There is little to detract from Dewachi’s quietly brilliant writing, but the archive is inevitably read with a particular voice in mind, amplifying one story over another. I would be very interested to learn more about the healthcare workers missing from this story: the nurses, physiotherapists, occupational therapists, midwives, radiographers and porters (among others) whose professions no doubt tracked along a similar history of development and decline in Iraq. While the political cachet of the doctor is clear, and chosen by Dewachi for that and other personal reasons, there are other unwritten histories here. I also hoped for more on the gendered nature of medical training in Iraq—the move from medicine as a preserve of men to the feminisation of the profession by the late twentieth century—but this is less a criticism than a call for more scholarship on this region. As Dewachi notes, restricted access to Iraq and a ravaged archive make for difficult anthropological work, but this elegant volume illuminates a path forward for further engagement with this understudied area.
Marsh, Sarah. 2020. “You Clap For Me Now: video hails key workers with antiracist poem.” The Guardian UK. April15. https://www.theguardian.com/uk-news/2020/apr/15/you-clap-for-me-now-video-hails-key-workers-anti-racist-poem-coronavirus. (Accessed April 15, 2020).
Patel, Neel V. 2020. “Why it’s too early to start giving out ‘immunity passports'”. MIT Technology Review. April 9. https://www.technologyreview.com /2020/04/09/998974/immunity-passports-coronavirus-antibody-test-outside/. (Accessed April 15, 2020).
Pentecost, Michelle, and Thomas Cousins. 2019. ” ‘The Good Doctor’: The Making and Unmaking of the Physician Self in Contemporary South Africa”. Journal of Medical Humanities https://doi.org/10.1007/s10912-019-09572-y.
Robbins, Joel. 2013. “Beyond the Suffering Subject: Toward an Anthropology of the Good”. Journal of the Royal Anthropological Institute 19: 447–62. http://onlinelibrary.wiley.com/doi/10.1111/1467-9655.12044/full.
Simone, AbdouMalique. 2004. ‘People as Infrastructure’. Public Culture 16(3): 407–29.