The story of Scovia
Abraham, a young South Sudanese man currently living under refugee status in one of northern Uganda’s many refugee settlements, is an active member of the Village Health Team (VHT). Abraham’s contracted work involves surveilling sickness within a defined zone of the refugee settlement, and reporting cases upwards to the International Rescue Committee (IRC), an official United Nations High Commissioner for Refugees (UNHCR) partner.1 Along with monitoring everyday afflictions, Abraham is tasked with responding to health emergencies. His work is vital to humanitarian actors, who travel to the settlements only for periodic “sensitization” and to respond to moments of crisis they deem to be severe. The rural settlement lies 60 kilometers from Arua City, where the regional offices of key humanitarian organizations are based.
One night at 1 a.m. in mid-August 2022, Abraham was called to attend to Scovia, a 26-year-old woman from South Sudan. Scovia’s sister knocked on Abraham’s door, asking for help. She explained that Scovia was three months pregnant and was experiencing severe chest and spine pains. Abraham responded quickly and called for an ambulance. As they waited for medical support to arrive, Scovia began to convulse. During this tense period, Abraham feared for Scovia’s life but also for how he would be seen within the community if Scovia passed away while under his care.
After being transported by an ambulance, Scovia spent just over an hour at a sub-county health center, the highest level of medical facility in the refugee settlement, before being transferred to Arua Regional Referral Hospital. Though Abraham stayed behind, he remained in continuous communication with the doctors and nurses via his mobile phone, using his own airtime to do so. The doctors informed him that if they were to save Scovia’s life, she would have to have a medically induced abortion. Scovia refused this line of treatment. Abraham guessed the context behind this refusal: Scovia had taken a long time to conceive. His discussions with her family revealed that she had had multiple miscarriages and paid for medical treatments to increase the chances of carrying a child to term. Scovia was not ready to risk the relational implications of losing this pregnancy. This was Scovia’s third husband, and failure to conceive would compromise her familial position, as had happened with her first two husbands who abandoned her for that reason. Over the three days that Scovia spent at the hospital, various medical staff could not convince her that this was the only way they could save her. By the time Scovia did offer her consent, there was little the medical staff could do to help her. Both she and the fetus tragically lost their lives.
The audit following Scovia’s death
The above account reflects the combined retelling of the events preceding Scovia’s death, which was shared during a maternal death audit conducted in English and convened by the IRC. The audit took place two weeks after Scovia’s death at the sub-county health center where she had received treatment. The audit was, in many ways, an exceptional event that broke with the balance of separation between external actors and South Sudanese people which characterizes everyday life in the settlement. Twelve people attended the audit. Those present included: Ugandan citizens representing the UNHCR, various decentralized state authorities, and medical bodies, a South Sudanese refugee leader, and Abraham. As a researcher embedded in the setting, Charlotte Brown was invited to attend by the Ugandan UNHCR staff member, James, who co-chaired the meeting with two Ugandan officials from the state and district level.
The audit was ostensibly convened to examine the events which had led to Scovia’s death. At the opening of the meeting, James noted that the audit had been organized with the following aim: to “prevent, minimize, or even eliminate” further deaths. He noted that the audit was not a “finger-pointing activity.” His co-chair, representing the district, echoed these sentiments. He said, “we have come as a family to understand.” Yet, perhaps tellingly, James later remarked in his address, “we have exonerated ourselves for all liability in the settlement.”
In this essay, we argue that the discourse of “trust” and “mistrust,” terms which were used continually throughout by the co-chairs, served as an alibi for the confluence of state and humanitarian actors responsible for refugee welfare in the settlement. Those leading the audit decried refugees’ lack of trust in their expertise, identifying mistrust as the main factor that led to Scovia’s death. At the same time, they failed to acknowledge the structural conditions that created that mistrust in the first place. In this complex context, their use of the language of mistrust distracted from their own repeated institutional failures to address the disconnects between the structures and goals of healthcare provision and refugees’ everyday lived experiences of lack of responsiveness to their needs. While using language that was suggestive of a desire to establish trust, humanitarian actors taking part in the audit disregarded the actual views of communities regarding the causes of their mistrust and sought to devolve responsibility for the labor of trust work to community health workers like Abraham.
Trust during a healthcare crisis
In order to understand the meanings that the word trust took on during the audit, it is important to acknowledge that Scovia’s death was not an isolated incident. Instead, it was part of a pattern of maternal deaths and disengagement from formal healthcare services in the area, which the external authorities explained as resulting from the community’s lack of trust in them. Although humanitarian actors in the audit avoided acknowledging the causes of the mistrust, they accurately identified the apprehension with which South Sudanese people view the humanitarian apparatus. While the Ugandan state and its humanitarian partners provide a semblance of security, the representatives of this state-humanitarian infrastructure are largely understood to be disinterested and obstructive to the lives of South Sudanese people registered within the settlements. Although shared kinship and linguistic connections across the border ease the alienation of the refugee experience in Uganda, the border region with South Sudan, where many of the settlements are based, has long been a space of deep tension permeated by conflict, rebel activity, and state collusion. Ongoing experiences of the failures of the humanitarian infrastructure around core issues, including food assistance, compound these apprehensions and periodically result in moments of acute crisis and conflict in the settlements. This adverse environment shapes refugees’ interactions with both state representatives and healthcare professionals.
Health services, which are understood by South Sudanese people in the settlement to be extensions of state infrastructure, are thus embroiled in these long histories of fear. Recent policies to graft health provisions for refugees onto pre-existing healthcare infrastructures designed for Ugandan citizens have only heightened these concerns. In this context, many South Sudanese people do not visit health facilities for routine check-ups or chronic pain, waiting for an emergency to seek assistance. Inadequate care, discrimination, language barriers and lack of confidentiality contribute to the widespread perception among South Sudanese that medical services in the settlement are of very poor quality. For expectant mothers, these fears are particularly acute and compounded by the knowledge that maternal mortality rates are extremely high in the country. Many South Sudanese women opt out of medical care during childbirth, preferring to deliver in the makeshift homes in the settlement.
Within this context, it was only in a moment of agony that Scovia and her relatives trusted Abraham’s directions to the healthcare facility. However, despite acknowledging this and the complex entanglement of factors that shaped Scovia’s decision-making, the co-chairs used a discourse of mistrust and misunderstanding throughout the audit to account for refugees’ refusal to engage with the humanitarian structure. As James, the UNHCR co-chair, commented, “Our community is quite a challenging one because they don’t always understand.” After having spent several hours combing over details of the case, they blamed Scovia’s death on what they saw as her lack of understanding of the risks involved in refusal the abortion. The co-chairs of the audit refused to confront the complexity behind Scovia’s circumstances, including the central importance of her social role as a wife and her experience of vulnerability before the Ugandan health professionals, thereby ignoring the role of the humanitarian system and the Ugandan state in perpetuating structural violence, which makes women like Scovia both reliant on relatives and scared of formal healthcare services. Rather than acknowledge the wider relational failings of the state and health providers, they used the language of trust and mistrust to blame vulnerable populations for structural failings in the humanitarian structure. Blame was continually individuated and represented as irrationality and poor decision-making to prevent an interrogation of colonial and postcolonial legacies of poor care that generated mistrust.
In this case, following Scovia’s death, UNHCR officials like James and state representatives sought to convince both themselves and the community representatives that the humanitarian-medical infrastructure was deserving of trust. Interactions between the audit participants thus served the function of validating the trustworthy character of the humanitarian structure. The anthropologist Alberto Jiménez defines trust as something which “creates its own preconditions of existence, which must, in turn, be certified as trustworthy.” Despite the tone of discourse, the arc of which was dominated by the co-chairs, the presence of community members in the audit contributed to this validation exercise by demonstrating the embeddedness and local connections of the apparatus. Having exonerated themselves from immediate liability, the co-chairs used the space of the audit to justify the practices of the humanitarian-state complex and demand trust from refugees, which the co-chairs positioned as an integral tool for ensuring better healthcare outcomes. To complete the work of legitimating the state-humanitarian infrastructure, Abraham, as a member of the VHT program, was tasked with delivering the audit’s conclusions to grieving members of the zone. The building of trust was thus devolved to Abraham, who was encouraged to mediate between a mistrusted humanitarian medical infrastructure and the other South Sudanese people living in his zone.
VHTs: the trust of the healthcare system
Integral to Uganda’s health infrastructure, the VHT program was first established in 2001 to help meet the challenges of a strained healthcare system. Whether in the village or refugee settlements, VHTs ostensibly serve as first responders and as health advocates. This builds on longstanding efforts undertaken in Uganda to devolve critical health services to local actors as part of a worldwide “localization agenda.” Despite the promises of this model, under the VHT system, community health workers often act as mediators and sole points of contact between a mistrusted medical infrastructure and would-be patients. Plainly acknowledging this, James explained, “You, as the community health worker, are the trust of the healthcare system.” Statements such as this result in refugees trusting certain individuals rather than the institution.
The very foundation of the VHT system builds on the idea that being refugees themselves, people embedded in the community have additional access to the refugee community that the broader medical system does not. Much like other marginalized communities, refugees often build their own spaces of protection through their social relations. In the context of these deep relational fractures between refugees and the humanitarian apparatus, community health workers thus appear to be a low-cost means of reconciliation. Despite the importance of this work for healthcare outcomes and perpetuating the humanitarian fiction of care to refugees, community healthcare workers like Abraham are compensated by the IRC at the paltry sum of $2.50 USD (equivalent) per month. As suggested by the anthropologist Andrea Muehlebach, volunteers like Abraham who attempt to build social solidarity and strengthen social ties within a community are exploited and put to work by neoliberal power structures. In this case, the humanitarian structure ultimately relies on this unpaid or scarcely paid voluntary work to function. James readily acknowledged this reality, saying to Abraham, “I want to encourage you, the incentives may not be there, but the benefits are far-reaching – generation after generation.” Such statements unrealistically shift the responsibility of caring for the well-being of the refugee communities to the shoulders of the community health workers.
James understood that the humanitarian infrastructure depended on Abraham’s work. “Please continue your work because they may not trust me, him, or her,” he said. Ignoring the broader context of late contact with medical facilities, James remarked that the trust that Scovia and her sister put in Abraham in calling for medical attention was a clear sign of their trust in Abraham and, by extension, in the humanitarian structure. This signaled a tacit expectation that VHTs do not simply alert the medical infrastructure to potential problems. VHTs are also expected to perform and fast-track the relational labor that the humanitarian and state infrastructure is unwilling to provide. Remarkably, the tragedy of Scovia’s passing was an occasion for auditors to champion these mechanisms. As the District official commented, “There is a very good coordination system and linkages between the VHT, the health facility, and the staff”. This imaginary of an otherwise well-functioning humanitarian machine avoids confronting the possibility of reform. On the contrary, by facilitating access to the community, VHTs paper over the cracks in a fractured relational space between refugees and humanitarian actors. However, if community health workers do not comply with humanitarian bureaucracies, their contracts can quickly be cut or the payment of their salaries arbitrarily delayed.
The labor of building trust
The labor of building trust often comes at great personal cost to members of VHTs. Long after the incidents and the audits, community health workers like Abraham continue to bridge the gaps and carry the weight of institutional failures in their villages. During the audit, as Abraham recounted the events that unfolded around Scovia’s death, he noted that by the time the case had reached the hospital, he “could not enter because that was beyond [his] capacity.” Abraham’s expression of his powerlessness in the face of structural barriers was palpable, as was his fear that he would be held somehow responsible for the death by other community members. This feeling of powerlessness is deeply embedded in the work of the community health teams. Despite this, Abraham was told that “even [beyond the settlement], they still rely on you as the community health worker.” The dependence of the humanitarian system on this poorly compensated and scarcely supported labor superseded Abraham’s concerns. By asking them to intervene in moments of extreme crisis, humanitarian officials place enormous pressure on community health workers, often when little else can be done.
(Mis)trust is manufactured through a complex political system and is embedded in the power relationship between refugees and humanitarian actors. Yet it is it is left to volunteers like Abraham to build trust. In this sense, trust relationships follow the directionality of power in the settlement. In this top-down model of trust, refugees must place their trust in the humanitarian actors. The humanitarian authorities impose this model on refugee communities and require them to act within it in order for them to access any degree of protection or care. By carrying out this political work, community health workers are thus co-opted into solving failures of institutional trust. This work results in a type of operational trust, which enables the basic provision of medical assistance; however, it is does not restructure social relationships or address the structural problems that underpin these challenges. The language of trust is duplicitous, masking the root causes of institutional failure and placing responsibility for the solution with community health workers.
NOTES:
All names have been changed.
1 A zone is one of the three spatial classifications used within the settlement structure. It is the middle tier which in this case concerns representation and governance of refugees over 12 villages.
About the Authors
Charlotte Brown is a Ph.D. student at the Department of International Development at the London School of Economics and Political Science (LSE). Her research focuses on the interfaces between state authorities and refugees in the West Nile region of Uganda.
Chiara Chiavaroli is a Ph.D. student at the Department of International Development at the London School of Economics and Political Science (LSE). Her doctoral research focuses on maternal health in contexts of toxic contamination in rural Colombia and builds on participatory and ethnographic methods.
This collaborative piece emerged from discussions we had reflecting on our fieldwork encounters with women’s experiences of maternal healthcare and their relationships with the state in marginalized communities in Uganda and Colombia, respectively. Though we ultimately chose to focus on one case, the blaming of community members and of individual women for poor maternal health outcomes by state actors was seen in both contexts. Where Charlotte led on the empirics of this particular case, Chiara supported with the writing in conversation with our understanding of narratives of trust and responsibility.
Funding Acknowledgments:
Charlotte’s and Chiara’s doctoral research programs are both funded by LSE studentships. Additional funds have been provided by an AHRC-DfID Collaborative Humanitarian Protection Research Programme, “Safety of Strangers: Understanding the Realities of Humanitarian Protection” (2019–2021) (AH/T007524).