The Politics of Medical Neutrality: Examining Bias in Humanitarian Aid

Defined as the “provision of limited forms of medicine by clinically trained medical practitioners in emergency situations” (Allen 2018, 207), medical humanitarianism is closely tied to the notion of ‘neutrality’. As representatives of a ‘new humanitarianism’, their focus on universal, recognisable and measurable suffering identifies medical humanitarians as a ‘collective doctor’ who independently delivers short-term medical assistance to avert emergencies outside of political or ideological struggles (Redfield 2010, 61; Ticktin 2011, 3). Despite this seemingly straightforward approach, diverging perspectives raise the question if medical humanitarianism can ever be neutral: for instance, the concept has been described as a ‘myth’ (Seybolt 1996), ‘impossible’ (Redfield 2010), and ‘contradictory’ with ‘perverse effects’ (Terry 2000, 2).

This essay argues that, although relief organisations seek to position their interventions within a humanitarian ‘space’ that is separate from political or ideological struggles, medical humanitarianism cannot ever be neutral. Instead, I argue that medical humanitarians enact political claims and practices that shape the understanding of, response to and experience of suffering. I discuss this argument from two perspectives. First, I look at neutrality as an ‘abstract principle’ and define medical humanitarianism as a specific ‘emergency claim’ (Rubenstein 2015) articulated by relief organisations. Medical humanitarians present emergencies as amenable to short-term and technical biomedical intervention, which competes with and obscures alternative perspectives and de-politicises interventions that perpetuate existing inequalities.  Second, I approach medical humanitarian intervention as an everyday practice and argue that it shapes power relations through the ‘political subjectivities’ (Krause and Schramm 2011) of people in need and humanitarians. In other words, medical humanitarianism shapes how people relate to governance and authorities and how they experience identity and belonging by shaping experiences of subjectification, sentiments of resistance, and strategies of adaptation. The argument draws on the cases of the humanitarian interventions during the 2008/09 cholera epidemic in Zimbabwe and the 2013-15 West African Ebola outbreak. While critiques of medical neutrality primarily focus on violent conflict or genocide (Benton and Atshan 2016), analysing epidemics illustrates the contradictory foundation of medical neutrality in constructing and managing seemingly straightforward biomedical ‘events’ (Rosenberg 1989).

The argument proceeds in two parts, each drawing on both case studies. First, I define medical humanitarianism as an ‘emergency claim’ which contests and complements other perspectives to shape emergency intervention. The example of the declaration of the Zimbabwean cholera outbreak as ‘national disaster’ illustrates that medical humanitarians contested and obscured alternative political economic understandings of the epidemic. Afterwards, I outline how during the West African Ebola outbreak, medical humanitarian and security perspectives converged to inadvertently perpetuate existing inequalities. In the second part, I analyse the everyday practices of humanitarian intervention and reveal their effects on the political subjectivities of people in need and humanitarians. For residents and medical responders within Harare townships during the Zimbabwean cholera outbreak, the relief intervention revealed the subjectification of township residents and sparked feelings of anger, resistance and impotence. Conversely, the case of a traditional healer who became a humanitarian broker during Sierra Leone’s Ebola response highlights that neutrality relied on and became a strategy, reproducing the unequal logic of the response.

Neutrality as Principle: Humanitarian ‘Emergency Claims’

Looking at medical humanitarian neutrality as an ‘abstract concept’ (Redfield 2013, 117) voiced by medical humanitarian organisations through ‘speech acts’ directed at other actors in international relations (Buzan, Wæver, and Wilde 2022, 27), I argue that medical humanitarianism can be defined as a particular ‘emergency claim’ (Rubenstein 2015). Rubenstein (2015, 102) defines emergency claims as describing an unexpected and sudden event, directed to persuade a given audience that something (people, things, states, or affairs) is valuable but threatened with imminent harm, which can be prevented or reversed through human action. Medical humanitarianism draws on the imaginary of a ‘humanitarian’ emergency: unexpected events that put vulnerable people at risk of harm and require immediate intervention to avert an impending disaster (Calhoun 2018, 83). By focusing on suffering that can be averted through biomedical care, the act of humanitarian intervention is rendered neutral towards political struggles (Ticktin 2011, 3). In other words, medical humanitarian neutrality rests on a claim that suffering is universal, recognisable, and measurable and morally demands a response that can disregard political constraints such as borders to access those in need (Ticktin 2014, 276; Allen 2018, 207).

However, as socially produced and situated representations, multiple emergency claims contest, support, and compete to form an authoritative emergency narrative about a situation (Rubenstein 2015, 101). I argue that this makes medical humanitarian neutrality a political claim that contests competing accounts of epidemics and obscures unequal material consequences as it shapes the form of relief interventions. Drawing on a constructivist perspective, I take epidemics as ideas possessing ‘multiple ontologies’ (Chigudu 2020, 22)whose representations are diverse and “historically, culturally and materially located” (Mol 1999, 75). In other words, while the word ‘epidemic’ commonly refers to “the occurrence in a community or region of cases of an illness, specific health-related behaviour, or other health related events clearly in excess of normal expectancy” (Last in Herring and Swedlund 2010, 14), I do not approach them as universally defined ‘events’ but multiple and overlapping phenomena with many meanings (Herring and Swedlund 2010, 14). Thus, I take international responses to disease not as reactions to objective conditions in the ‘real world’ but as socially constructed and reflecting ideas, interests and power of individuals and communities (McInnes and Lee 2012, 3). The eventual ‘outbreak narrative’, the account through which an epidemic gains meaning and that guides medical humanitarian action (Wald 2008, 18), reflects and reproduces dominant interests and social structures that underly the humanitarian response (De Waal 1997). This makes the articulation of medical humanitarianism as ‘neutral’ contradictory, as it contests and obscures other understandings of epidemics.

Cholera and the Politics of Declaring a ‘National Disaster’

The case of the 2008/09 cholera epidemic in Zimbabwe illustrates that the medical humanitarian perspective obscured and de-legitimised alternative understandings of the outbreak. Infecting over 98,000 people and causing over 4,000 fatalities, the cholera epidemic was the most extensive on record in Africa (Chigudu 2020, 1). Infection with the disease results from the consumption of water or food contaminated by faecal matter or free-standing bacteria or seafood living in water infected with the Vibrio cholerae bacteria. While many acquire asymptomatic or mild cases of the disease, vulnerable and untreated patients can die from the diarrheal disease within hours from acute loss of fluid. However, since treatment is cheap and effective through Oral Rehydration Treatment (ORT), fatalities are preventable (Echenberg 2011, 6–11). Despite this seemingly straightforward option of responding to an outbreak, the Zimbabwean epidemic was only declared a ‘national disaster’ to activate the UN Humanitarian Cluster system and enable foreign resources to manage the outbreak after three months of delay (Chigudu 2020, 89). While the organisation Médecins Sans Frontières (MSF) was quick to declare a humanitarian emergency, the declaration of national disaster was not an ‘objective’ statement but subject to competing perspectives (Chigudu 2020, 97). The contestations of different emergency claims illustrate that humanitarian neutrality reflected a political position that diverted attention from the political economic causes of the epidemic.

Being present in the country since before the cholera outbreak, MSF played a central role in shaping the outbreak narrative and the eventual relief response. Treating around 45,000 patients in the early stages of the outbreak, MSF drew on its principle of ‘witnessing’ to declare the scale and urgency of the outbreak (Chigudu 2020, 100). With a long history of ‘speaking out’ as a ‘collective doctor’, MSF claims to speak from a position of neutrality (Redfield 2010, 61). Issuing several press statements and reports, MSF acknowledged that the cholera outbreak had resulted from a ‘political crisis’ but did not name political choices or assign responsibility to specific actors for the causes of the epidemic (Chigudu 2020, 100). Instead, MSF demanded that the government facilitate access to a “’humanitarian space’ for independent aid organisations to carry out our [MSF’s] work” (MSF in Chigudu 2020, 100-101). The term ‘humanitarian space’ relies on the imaginary that humanitarian organisations can operate freely and outside of political or ideological struggles to deliver assistance to those in need (Spearin 2001, 22). In other words, MSF presented the outbreak as a ‘humanitarian’ emergency: by speaking out in the name of immediate suffering and calling for humanitarian intervention as the necessary response, MSF placed the outbreak response outside of local or international political struggles of the ‘political crisis’ and legitimised its exceptional role as leader of the intervention.

However, MSF’s emergency claim was contested by competing perspectives which draw attention to the structural causes and political choices that led to the rise of cholera cases in Zimbabwe. For instance, the organisation Zimbabwe Lawyers for Human Rights (ZLHR) defined the epidemic as “a result of official and criminal negligence” (ZLHR in Chigudu 2020, 101). The organisation’s perspective points to the political economic factors that coincided and made the cholera outbreak a ‘man-made’ disaster (Chigudu 2020, 29). Following the 1990s structural adjustment programmes and a severe HIV/AIDS epidemic, the Zimbabwean health system had all but collapsed. Health facilities faced shortages of key medicine, frequent electricity outages, and an exodus of health workers, which contributed to a lack of familiarity with cholera symptoms and treatment and a lack of national disease surveillance (Chigudu 2020, 67–68). Moreover, a post-2000s national political crisis translated into struggles between government institutions and opposition-run municipalities over the water supply system. Following the nationalisation of the water authority (ZINWA) without compensation for local government authorities, ZINWA lacked the technical, human and financial resources to supply water and maintain the sewage disposal system (Chigudu 2020, 73). In consequence, a persistent biofilm in pipes contaminated domestic and industrial pipes and large amounts of human waste were spilt into groundwater and the water delivery system (Chigudu 2020, 75–76). Finally, an ongoing economic crisis and hyperinflation led to a diminished middle class, emigration of skilled labour and “widespread, critical food shortages” (Chigudu 2020, 79). With more than two million Zimbabweans relying on food assistance by the end of 2008 (Chigudu 2020, 80), acute malnutrition shaped a population vulnerable to cholera infection. The complexity of the political economic origins of the cholera epidemic highlights that MSF’s position not to engage with Zimbabwe’s ‘political crisis’ is, in fact, highly political: it both contested the relevance of questions of political accountability while suggesting that short-term and biomedical intervention provided a sufficient solution to the epidemic.

Ebola and Intervention in the Name of Humanity

While the case of the Zimbabwean cholera epidemic outlined how medical humanitarianism can obscure perspectives that point to the structural causes of epidemics, the case of the West African 2013-15 Ebola outbreak illustrates that humanitarianism can complement and provide other emergency claims with a neutral disguise. De Waal (1997, 4) suggests that presenting humanitarian intervention as apolitical and ‘technical’ obscures how humanitarians reinforce dominant social and political structures.  In particular, the claim to humanitarian neutrality can inadvertently legitimise military and government intervention in the name of humanity (Chandler 2001; Allen and Styan 2000). Indeed, a shift of national security policies since the end of the Cold War towards ‘non-traditional security threats’ provided a potential source of funding for medical humanitarian interventions (De Waal 2014). These perspectives suggest that humanitarian emergency claims complement the ‘securitisation’ of global health issues by presenting epidemics as ‘existential threats’ and legitimise the taking of ‘extraordinary measures’ (Lakoff 2010; King 2002, 763; Chigudu 2016, 43). The case of Ebola in West Africa illustrates how this convergence can have unequal political effects.

First infecting a 2-year-old child in December 2013 in Guinea from contact with a bat, the haemorrhagic fever rapidly spread through direct contact with infected or dead bodies across Sierra Leone, Liberia and Guinea.  Before curves began to flatten by April 2015, the outbreak prompted the deployment of international NGOs and militaries (Leach 2015, 818). MSF played a central role in shaping the outbreak narrative of the epidemic, openly calling for civilian and military intervention (Benton 2017). After discovering the first cases of the Ebola virus in MSF treatment centres, the organisation warned of an ‘unprecedented outbreak’ on 31 March 2014. Nonetheless, such calls were objected to as alarmist by the World Health Organisation (WHO) and other global health actors (Medecins Sans Frontieres [MSF] 2015, 6). As the virus spread further, MSF deliberately escalated its language to spark international action, declaring by 21 June 2014 that the outbreak had become ‘out of control’. As described by one MSF doctor, such alarmist language was deliberately chosen to “make the world wake up and realise how out of control the outbreak had truly become” (MSF 2015, 7).

The turning point came in late July and early August as the first cases outside of Africa were recorded in the US and Spain, leading the WHO to declare a Public Health Emergency of International Concern (MSF 2015, 11). In the words of the MSF International President, Joanne Liu, Ebola became an international security concern:

When Ebola became an international security threat, and no longer a humanitarian crisis affecting a handful of poor countries in West Africa, finally the world began to wake up (MSF 2015, 11).

Despite the gradual construction of Ebola as a ‘security threat’, it wasn’t until September 2014 that MSF openly called on the UN to deploy civilian and military assets as a “desperate call of last resort’ (MSF 2015, 13) and that the UN Security Council declared Ebola as a ‘threat to international peace and security’ (Enria 2019, 1609). Drawing on its humanitarian mission, MSF asserted that military assets could be focused on providing essential care without the use of coercive actions (Benton 2017, 27; MSF 2015, 14). This highlights that MSF’s declaration of humanitarian emergency complemented and supported the emergency claim of Ebola as a security emergency, jointly legitimising the ‘extraordinary’ measure of deploying military forces.

However, by legitimising a securitised logic to the epidemic response, MSF inadvertently helped perpetuate existing inequalities (Benton 2017). While MSF’s emergency claim highlighted the lives at immediate risk, the security actors in the response ended up focusing on different objects at risk. Rather than providing care to Ebola victims, the foreign intervention troops prioritised the security of foreign nationals and the protection of international aid workers. In the words of the MSF president, the foreign military’s aim was ‘Zero risk. Zero casualties’ (Benton 2017, 33). Drawing on the protection of international troops, the presence of INGOs legitimised this logic. For instance, the introduction of troops meant that previously evacuated INGO staff were comfortable returning due to the additional source of safety and evacuation support for infected foreign nationals (Benton 2017, 35).

Simultaneously, the approach of domestic military forces enacted practices of coercion and criminalisation of marginalised populations. Emboldened by national states of emergency, domestic militaries were deployed to “maintain order, enforce borders, and control flows of people” (Benton 2017, 39).  Thus, transgressions from epidemic control measures faced a legitimate threat of force. For instance, Major Palo Conteh, the chief of the Sierra Leonean Ministry of Defence, remarked using a ‘carrot and stick approach’ to deal forcefully with people who “do the wrong things” (Benton 2017, 43). As expressed by an armed forces official, this logic repositioned infected communities as places of lawlessness and criminality:

In some chiefdoms that I don’t want to name, it was the lawlessness that made the sickness spread … Why do you think they [invoked] this state of emergency? […] It was not violence per se, but just for people to comply with the law and for them to be able to listen to the medical advice (Enria 2019, 1613).

This quote highlights that the domestic military response drew on the biomedical approach of the humanitarian response, but instead of focusing on relieving suffering, they saw the stability of the law as the object at risk. In consequence, the response rebranded what MSF considered ‘communities in need’ to potential places of criminality. This highlights that MSF’s call for military intervention to contain a humanitarian emergency complemented and legitimised the understanding of the Ebola epidemic as a security emergency, which inadvertently created an unequal logic of the response.

Neutrality as Practice: The Everyday Realities of Medical Humanitarianism

While the definition of medical humanitarianism as an ‘emergency claim’ illustrates the political struggles and inadvertent consequences of neutrality as an organisational principle, ethnographic perspectives highlight that official statements do not fully reflect other ways of interpreting, remembering and understanding disease (Herring and Swedlund 2010, 18). Thus, even though humanitarian organisations construct beneficiaries as apolitical and universal ‘victims’, this category may not be shared by the subjects of interventions (Fassin 2012, 232). Rather than assuming the existence of a humanitarian ‘space’ independent from politics, ethnographic studies suggest that humanitarian action takes place in a politicised ‘arena’ shaped by “multiple realities and understandings of what is going on and what needs to be done” (Hilhorst 2018, 31). From this perspective, I argue that medical humanitarian practice cannot be neutral as it impacts the ‘political subjectivities’ (Krause and Schramm 2011, 115) of affected individuals and humanitarian responders. This means that relief intervention influences how people relate to governance and authorities and shapes their sense of identity and belonging. Thus, this section highlights that medical humanitarian practice can simultaneously produce experiences of subjectification, sentiments of resistance, and strategies of adaptation.

Cholera in Harare Townships: Subjectification and Resistance

Focusing on the individual accounts of the Zimbabwean cholera epidemic by residents of Harare townships illustrates the political effects of humanitarian intervention. Redfield highlights that, translated into the everyday practices of humanitarianism, neutrality becomes a strategic everyday act of refusal to engage in political actions while focusing on the ‘apolitical’ suffering (Redfield 2010, 56). Abel Gumo from the Zimbabwean Red Cross summarised this priority of the humanitarian response during the cholera epidemic: “We look at saving lives and helping people where there is a problem. But the background to what is happening, we don’t usually want to hear that” (Chigudu 2020, 195). I argue that while this focus on relieving immediate suffering by treating cholera cases was welcomed, the response also shaped subjectivities by revealing the subjugation of marginalised people and sparking sentiments of anger and resistance.

Anthropological perspectives highlight that citizenship status is both a process of “self-making and being-made” (Ong 1996, 737). That is, the process of becoming a citizen is a contingent and iterative process of subjectification to power relations (Ong 1996, 738; Chigudu 2020, 15). The concept of ‘political subjectivity’ suggests that practices that bring subjects into being extend beyond the subjection to (state) power and include the experience of agency, claims to recognition by the state, and sentiments of identity and belonging (Krause and Schramm 2011, 126). As Anand (2017) highlights, one way of being recognised by the state is the safe and effective supply by water agencies.  Thus, rather than being seen as an ‘apolitical’ intervention, the humanitarian response to the cholera epidemic revealed the subjectification of affected communities into forms of unequal ‘graduated citizenship’ (Briggs and Mantini-Briggs 2003, 5). As outlined by one journalist, the government-led outbreak narrative created a sense of being punished and being seen as ‘waste’ by the state authorities:

And that was the dominant message that the state sent out was that you’re becoming diseased a) because of sanctions and b) because you’re dirty. […] And the final narrative that I picked up was that you’re getting sick because you voted for the MDC [opposition party] and this is punishment (Chigudu 2020, 163).

While the humanitarian response chose not to engage with the ‘political crisis’ in the country, it made obvious the lack of government services, which manifested in sentiments of anger and resistance. As one township resident described, the humanitarian response was welcomed, but it made obvious the neglect of the government:

Since people were helpless, they were actually relieved to receive help from people from outside. And they were feeling that the government was being negligent. In fact, the government should take care of its own people but when people are coming from outside to help that definitely means that there is lack of responsibility proper. You are the father of the house but food is coming from the neighbours. Your kids will be angry obviously (Chigudu 2020, 172).

Thus, rather than producing passive ‘victims’, the humanitarian response contributed to the forging of political subjectivities and demands for recognition by the state’s water authorities. However, as the humanitarian response also replaced actions taken by state authorities, the lack of structural change also led to a feeling of powerlessness, as one township resident expressed: “We were born in poverty, we live in poverty and we will die in poverty” (Chigudu 2020, 180). In other words, humanitarian response revealed but also reproduced ongoing forms of graduated citizenship, resulting in a sense of anger and impotence.

Nonetheless, humanitarian responders shared sentiments of political outrage. As suggested by Malkki (2015, 53), humanitarian workers’ personal beliefs can be challenged as they face contradictory situations, causing feelings of pain, helplessness and anger. In Zimbabwe, the account of Tunga, a 22-year-old medical student involved in the response, illustrates that individual health workers could not maintain an ‘apolitical’ disposition (Chigudu 2020, 142). Tunga described how responding to the enormous level of suffering produced a feeling of having ‘come of age’ from a “medical student to a ‘medical humanitarian, a professional caregiver’” (Chigudu 2020, 142). However, he also described the experience as ‘life-changing’ and transformative for his political beliefs:

I think from high school, I had always been a conformist. I always went with the system. I followed the rules. By that time, I began to question those in power at a level that I never ever have (Chigudu 2020, 146).

Thus, despite having been a supporter of the governing ZANU(PF) party for his whole life, witnessing the failure of the political system urged him to reconsider his perspective and question the legitimacy of the actions of the governing party:

[O]ur leadership has failed us. […] I used to have a lot of trust in the system. I don’t have trust in the system anymore at all because I saw it fail [during the cholera outbreak] […] I would no longer blindly follow or blindly believe (Chigudu 2020, 146).

Tunga’s experience suggests that the witnessing among humanitarians of diverging ‘hydraulic citizenship’ could not be reconciled through ‘neutral’ humanitarian intervention. Instead, this dissonance translated into feelings of anger, shaping his adapted and critical political subjectivity. This highlights that despite its practices of strategic refusal to engage in ‘political’ questions, medical humanitarianism has deeply political effects at the level of individual subjectivities.

Ebola in Kambia: Neutrality as a Strategy of Adaptation

Furthermore, the everyday practices of the Ebola response illustrate that the very principle of ‘neutrality’ reconfigured political subjectivities by relying on and producing opportunities for adaptation. In everyday practice, humanitarian fieldworkers need to interpret and translate organisational principles into specific contexts (Hilhorst and Schmiemann 2002, 490). This turns medical humanitarian neutrality from an abstract concept into a practice that is strategically performed by humanitarian workers to a given audience (Redfield 2010; Sutton 2018; James 2020). As Myfanwy James (2022) highlights in an ethnography of MSF national staff, medical humanitarian interventions rely on practices of brokerage and shapeshifting of local staff who shift between different identities to be perceived as ‘neutral’ by humanitarian agencies and communities in need. Navigating such identities means that humanitarians are not ‘disinterested observers’ (Redfield 2010, 55) but forge political subjectivities and identities in relation to the context they work in (James 2020).  Thus, focusing on the role of local brokers and mediators during the Ebola intervention highlights that medical humanitarian neutrality became a strategic practice for adaptation and survival. While this provided opportunities for empowerment, it also served to reproduce unequal logics of international intervention.

Enria (2019) illustrates this point through the story of a traditional healer, Pa Yamba, during the epidemic response in the Kambia region of Sierra Leone. Through strategic shapeshifting between identities, he became a ‘neutral’ broker for the humanitarian effort. During the response, the outbreak narrative guiding the response categorised the population into two groups: on the one hand, ‘Ebola heroes’, the active citizens and ‘community champions’ who accepted biomedical approaches and took central roles in the response (Enria 2019, 1614). On the other hand, those who did not engage with the responders became ‘dangerous bodies’ and needed to be contained (Enria 2019, 1615). Seen as a major conduit of disease, traditional medicine was banned under the state of emergency, and as a healer, Pa Yamba represented a potential ‘dangerous body’ for the Ebola response. However, to sustain his family and livelihood, he joined the burial team responsible for implementing the ‘safe and dignified burials’ medical guidelines (Enria 2019, 1616). Since the control of burials often faced community resistance, the team fulfilled an ‘in-between’ space, representing socially disruptive response measures while being able to engage with communities to humanise burials (Enria 2019, 1616–17). Brokering between the international response and local communities, Pa Yamba adapted to the epidemic by building a ‘neutral’ identity, which provided him with a central role in the response.

Pa Yamba described a situation which established his role as an essential broker for the humanitarian effort. When the burial team travelled to a village in the Kambia region, he noticed that local women were already preparing water to wash the dead body and risk infection. While Pa Yamba asked the team to proceed and discreetly note all names for contract tracing, he met a group of men in the backyard. Knowing the local language, he overheard plans to attack the team and managed to calmly react and ensure their escape from the attack. However, when leaving the village, they reported the situation to a nearby military checkpoint and returned with protection from the soldiers. While these forced the men on their knees, hitting them with the butts of their guns, the team buried the body safely. Pa Yamba described making the villagers hold out the Muslim burial cloth while he set it on fire, “half procedure, half punishment” (Enria 2019, 1617). In this account, Pa Yamba established his own identity as a credible and ‘neutral’ broker. As a traditional healer, he was originally a potential threat to the biomedically driven logic of the response. However, he portrayed himself as aligned with this approach by drawing on the response’s logic of ‘containment’. As he renounced traditional burial practices and helped punish the rebellious population, he performed the ‘neutrality’ of medical humanitarianism by distancing himself from local cultural beliefs, which inadvertently turned traditional practices into a potential danger to be contained.

Conversely, in another situation, Pa Yamba strategically shapeshifted to his identity as a cultural ‘insider’ to build trust and translate the logic of the humanitarian response to the Gbangbani society in Kambia. When seeking to engage the society, he predicted that the burial team members as society ‘outsiders’ would fail to build trust since they were from different ethnic groups and were not initiated ‘society men’ (Enria 2019, 1618). His prediction came true, and as a society man himself, Pa Yamba stepped in and managed to convince those responsible for the funeral that they would ‘play the society’ in the forest while the burial team would conduct the safe procedure (Enria 2019, 1618). Even though the team could hear the society’s performance in the forest, he assured them that he managed to ‘pacify’ society members (Enria 2019, 1618). This account suggests that rather than taking place in a humanitarian ‘space’ removed from local or national political struggles, performing ‘neutrality’ engaged and re-shaped everyday power relations by relying on the ‘local’ identity of Pa Yamba, who maintained his livelihood by forging his political subjectivity as an essential broker. However, to gain the identity as a ’neutral’ humanitarian, his acts of shapeshifting reproduced and enacted the logic of the response. To be seen as a credible ‘neutral’ humanitarian, he reproduced the divisions and practices of containment of the response, while his ‘local’ political identity empowered him as an essential and influential actor to shape the humanitarian response.

Conclusion

This essay has argued that although organisations seek to position relief interventions within an apolitical humanitarian ‘space’, medical humanitarianism cannot ever be neutral. Looking at neutrality as an abstract concept established through organisational speech acts, the essay defined medical humanitarianism as an ‘emergency claim’ that constructs epidemics as distinctly humanitarian emergencies which morally demand, short-term, apolitical biomedical intervention. However, by analysing two diverging claims of cholera as a ‘national disaster’ during the Zimbabwean 2008/09 epidemic, the essay illustrates that medical humanitarianism contests and obscures other emergency claims that draw attention to the political economy of suffering. Moreover, the merging of humanitarian and securitised emergency claims during the West African Ebola outbreak showed that medical humanitarianism can inadvertently complement interventions that perpetuate existing inequalities.

Examining medical humanitarianism through its everyday practices, the essay then argued that relief interventions shape political subjectivities and everyday power relations within experiences of subjectification, resistance and adaptation. In the case of township residents during the cholera outbreak, the humanitarian response revealed and reproduced forms of graduated ‘hydraulic citizenship’ that shaped a sense of anger, resistance and impotence among affected individuals and humanitarians. Lastly, the everyday performance of neutrality during the Ebola response illustrated that the very practice of medical neutrality relies on and offers possibilities of adaptation to the epidemics. While Pa Yamba strategically became an influential broker for the Ebola response, his shapeshifting to perform an identity as a ‘neutral’ humanitarian reproduced practices of containment of the response.

Although in both cases, medical humanitarianism contributed to the reduction of suffering, I have shown that its appeal to neutrality is actively productive and a central part of understanding, responding to and experiencing epidemics and suffering. Thus, rather than using neutrality as a ‘fig leaf’ (Omaar and De Waal 1994, 25) for harmful consequences of intervention, this essay implies a need for further investigating medical humanitarian ethics through questions of “global injustice, collective responsibility and social change” (Chouliaraki 2021, 263).

Bibliography

Allen, Tim. 2018. ‘Medical Humanitarianism’. In Humanitarianism: A Dictionary of Concepts, edited by Tim Allen, Anna Macdonald, and Henry Radice, 1st ed., 207–24. Abingdon, Oxon: Routledge. https://doi.org/10.4324/9780203486863-15.

Allen, Tim, and David Styan. 2000. ‘A Right to Interfere? Bernard Kouchner and the New Humanitarianism’. Journal of International Development 12 (6): 825–42. https://doi.org/10.1002/1099-1328(200008)12:63.0.CO;2-I.

Benton, Adia. 2017. ‘Whose Security? Militarization and Securitization During West Africa’s Ebola Outbreak’. In The Politics of Fear: Medecins sans Frontieres and the West African Ebola Epidemic, edited by Michiel Hofman and Au Sokhieng, 25–50. New York.

Benton, Adia, and Sa’ed Atshan. 2016. ‘“Even War Has Rules”: On Medical Neutrality and Legitimate Non-Violence’. Culture, Medicine, and Psychiatry 40 (2): 151–58. https://doi.org/10.1007/s11013-016-9491-x.

Briggs, Charles L., and Clara Mantini-Briggs. 2003. Stories in the Time of Cholera: Racial Profiling during a Medical Nightmare. Stories in the Time of Cholera : Racial Profiling during a Medical Nightmare. Berkeley, Calif.: University of California Press.

Buzan, Barry, Ole Wæver, and Jaap de Wilde. 2022. Security: A New Framework for Analysis. Boulder: Lynne Rienner Publishers. https://doi.org/10.1515/9781685853808.

Calhoun, Craig. 2018. ‘The Imperative to Reduce Suffering: Charity, Progress, and Emergencies in the Field of Humanitarian Action’. In Humanitarianism in Question, edited by Michael Barnett and Thomas G. Weiss, 73–97. Ithaca, NY: Cornell University Press.

Chandler, David. 2001. ‘The Road to Military Humanitarianism: How the Human Rights NGOs Shaped a New Humanitarian Agenda’. Human Rights Quarterly 23 (3): 678–700. https://doi.org/10.1353/hrq.2001.0031.

Chigudu, Simukai. 2016. ‘Health Security and The International Politics of Zimbabwe’s Cholera Outbreak, 2008-09’. Global Health Governance 10 (3): 41–53.

———. 2020. The Political Life of an Epidemic: Cholera, Crisis and Citizenship in Zimbabwe. Cambridge Core. Cambridge: Cambridge University Press.

Chouliaraki, Lilie. 2021. ‘Post-Humanitarianism: Solidarity as Lifestyle Politics’. In Routledge Handbook of Humanitarian Communication, edited by Lilie Chouliaraki and Anne Vestergaard, 253–68. Routledge.

De Waal, Alex. 1997. Famine Crimes: Politics and the Disaster Relief Industry in Africa. African Issues. Oxford: Currey.

———. 2014. ‘Militarizing Global Health’. Boston Review, 11 November 2014. https://www.bostonreview.net/articles/alex-de-waal-militarizing-global-health-ebola/.

Echenberg, Myron. 2011. Africa in the Time of Cholera: A History of Pandemics from 1817 to the Present. African Studies 114. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511976599.

Enria, Luisa. 2019. ‘The Ebola Crisis in Sierra Leone: Mediating Containment and Engagement in Humanitarian Emergencies’. Development and Change 50 (6): 1602–23. https://doi.org/10.1111/dech.12538.

Fassin, Didier. 2012. Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press.

Herring, D Ann, and Alan C Swedlund. 2010. ‘Plagues and Epidemics in Anthropological Perspective’. In Plagues and Epidemics: Infected Spaces Past and Present, edited by D Ann Herring, 11–27. New York: Berg.

Hilhorst, Dorothea. 2018. ‘Arenas’. In Humanitarianism: A Dictionary of Concepts, edited by Tim Allen, Anna Macdonald, and Henry Radice, 30–51. Abingdon, Oxon: Routledge.

Hilhorst, Dorothea, and N. Schmiemann. 2002. ‘Humanitarian Principles and Organisational Culture: The Case of Medecins sans-Frontieres, Holland’. Development in Practice 12 (3/4): 490–500.

James, Myfanwy. 2020. ‘Who Can Sing the Song of MSF?: The Politics of “Proximity” and Performing Humanitarianism in Eastern DRC’. Journal of Humanitarian Affairs 2 (2): 31–39. https://doi.org/10.7227/JHA.041.

———. 2022. ‘Humanitarian Shapeshifting: Navigation, Brokerage and Access in Eastern DR Congo’. Journal of Intervention and Statebuilding 16 (3): 349–67. https://doi.org/10.1080/17502977.2021.2002591.

King, Nicholas B. 2002. ‘Security, Disease, Commerce: Ideologies of Postcolonial Global Health’. Social Studies of Science 32 (5/6): 763–89.

Krause, Kristine, and Katharina Schramm. 2011. ‘Thinking through Political Subjectivity’. African Diaspora 4 (2): 115–34. https://doi.org/10.1163/187254611X607741.

Lakoff, Andrew. 2010. ‘Two Regimes of Global Health’. Humanity (Philadelphia, Pa.) 1 (1): 59–79. https://doi.org/10.1353/hum.2010.0001.

Leach, Melissa. 2015. ‘The Ebola Crisis and Post-2015 Development’. Journal of International Development 27 (6): 816–34. https://doi.org/10.1002/jid.3112.

Malkki, Liisa H. 2015. The Need to Help: The Domestic Arts of International Humanitarianism. Durham: Duke University Press. https://doi.org/10.1515/9780822375364.

McInnes, Colin, and Kelley Lee. 2012. Global Health and International Relations. Cambridge, UK: Polity Press. https://content.e-bookshelf.de/media/reading/L-3761235-68a52a6961.pdf

Medecins Sans Frontieres [MSF]. 2015. ‘Pushed to the Limit and Beyond: A Year into the Largest Ever Ebola Outbreak’. https://www.msf.org/ebola-pushed-limit-and-beyond.

Mol, Annemarie. 1999. ‘Ontological Politics. A Word and Some Questions’. The Sociological Review 47 (1): 74–89.

Omaar, Rakiya, and Alex De Waal. 1994. Humanitarianism Unbound?: Current Dilemmas Facing Multi-Mandate Relief Operations in Political Emergencies. Discussion Paper / African Rights ; No. 5. London: African Rights.

Ong, Aihwa. 1996. ‘Cultural Citizenship as Subject-Making: Immigrants Negotiate Racial and Cultural Boundaries in the United States’. Current Anthropology 37 (5): 737–62.

Redfield, Peter. 2010. ‘The Impossible Problem of Neutrality’. In Forces of Compassion: Humanitarianism Between Ethics and Politics, edited by Erica Bornstein and Peter Redfield, 53–70. Santa Fe, N.M.: SAR.

———. 2013. Life in Crisis: The Ethical Journey of Doctors without Borders. 1st ed. Berkeley: University of California Press. https://doi.org/10.1525/9780520955189.

Rosenberg, Charles E. 1989. ‘What Is an Epidemic? AIDS in Historical Perspective’. Daedalus 118 (2): 1–17.

Rubenstein, Jennifer C. 2015. ‘Emergency Claims and Democratic Action’. Social Philosophy and Policy 32 (1): 101–26. https://doi.org/10.1017/S0265052515000096.

Seybolt, Taylor B. 1996. ‘The Myth of Neutrality’. Peace Review 8 (4): 521–27. https://doi.org/10.1080/10402659608426005.

Spearin, Christopher. 2001. ‘Private Security Companies and Humanitarians: A Corporate Solution to Securing Humanitarian Spaces?’ International Peacekeeping (London, England) 8 (1): 20–43. https://doi.org/10.1080/13533310108413877.

Sutton, Rebecca. 2018. ‘The “Phantom Local” and the Everyday Distinction Practices of Humanitarian Actors in War: A Socio-Legal Perspective’. New Political Science 40 (4): 640–57. https://doi.org/10.1080/07393148.2018.1528061.

Terry, Fiona. 2000. ‘The Principle of Neutrality: Is It Relevant to MSF?’ In Discussion Paper for MINI-AGS. Medecins Sans Frontieres.

Ticktin, Miriam. 2011. Casualties of Care: Immigration and the Politics of Humanitarianism in France. 1st ed. Berkeley: University of California Press. https://doi.org/10.1525/9780520950535.

———. 2014. ‘Transnational Humanitarianism’. Annual Review of Anthropology 43 (1): 273–89. https://doi.org/10.1146/annurev-anthro-102313-030403.

Wald, Priscilla. 2008. Contagious: Cultures, Carriers, and the Outbreak Narrative. Durham: Duke University Press.

Further Reading on E-International Relations