Discharging Responsibilities

Luke Mogelson’s excellent New York Times Magazine profile of emergency medicine in Afghanistan is in some ways an exercise in indirection. At first, it looks like it’s going to be entirely an admiring profile of the admirable Italian NGO Emergency and its attempts to care for the injured regardless of what side they are on in the conflict.

Midway through the article, another story emerges. Mogelson describes how a 14-year old boy sitting outside his house with his cousins was gravely wounded by a NATO helicopter attack. His uncle took the boy to the hospital at Bagram Air Base, a major American-run facility. It turns out that if a civilian is injured by a NATO attack, they can be treated at Bagram if the injuries are life-threatening–or if they require amputations and/or eye surgery. The boy had his legs amputated and the surgeons performed major abdominal surgery on him that included removing a section of intestine. This left the boy with 54 metal staples in his abdomen, internal compression sutures, and a pouch for fecal matter until a later surgery on his intestines. He was discharged after 23 days with an instruction to go see the Red Cross to be fitted for a prostheses. His discharge papers said nothing about care for the staples (which needed to be removed soon by a surgeon to avoid infection), nothing about further abdominal surgeries, or anything else. Mogelson is polite about the load of utter bullshit that he gets served by the facility at Bagram: they claim to have secured permission from a local hospital that has no surgeons and no equipment for the removal of staples to have the boy referred there, they claim to have tried to call the uncle’s cellphone many times but it didn’t work (the same cellphone number that Mogelson is able to call multiple times without problems).

It’s easy to get angry about the callous behavior of the medical professionals in this story (which has a sort of happy ending, in that the boy survived because Mogelson helped him get admitted to the French Medical Institute for Children in Kabul). The Italian NGO Emergency is clearly angry about it, as they make clear to Mogelson that they won’t treat the boy after his discharge because they don’t want to be an accessory to what they think is outrageous conduct by the medical facility in Bagram–that they will treat badly wounded civilians long enough to stabilize them, then release them whether or not there are Afghan facilities able to carry out any subsequent operations and care that are needed. The more you think about it, however, the more baffling the whole thing is, revealing the deeper terrain of moral and structural rot of technocratic institutions.

The quick thing to obsess about here is whether NATO forces have an obligation to care for civilians injured by its own forces and thence to get hot under the collar about an attempt to evade or cheap out of that obligation. That would miss just how odd the behavior that Mogelson recounts really is. The medical care he describes Bagram as providing wasn’t cheap or slipshod. The operations performed on the boy were expensive, and the surgeons who see him later at the French Medical Institute agree that the initial work was done very well. Why spend so much money and effort saving a life only to be so staggeringly indifferent to putting that life at risk through an early discharge and a lack of planning for subsequent care?

You could argue that this is simply a faithful recreation of the American medical system in an exotic setting: expensive specialist care in an emergency medical setting combined with an idiotic disinterest in long-term primary care, bean-counters pursuing senseless cost-savings, bureaucrats practiced in misdirection and doublespeak being left to explain the whole thing. Or you could argue that the driving consideration here is to save lives of civilians injured in NATO attacks so as to keep them from being counted as casualties–if they die a few months later of infections or complications, they won’t be tallied as our fault.

Or both, since skewing ways of counting and ennumerating illnesses, mortality and causality is the heart of a vast legal-managerial complex as pervasive and fundamental as the military-industrial complex that Eisenhower warned us all about. James Scott has talked about how the high-modernist state reworked the material and procedural world around it so as to make human subjects more legible, visible and manageable. Whatever we want to call what has replaced that high-modernist state–it’s not “post”, it’s more like the Norma Desmond version of modernism, living slovenly on in the grotesque ruins of its dreams–whatever we call it, it is no longer devoted to making the world legible, but instead the exact opposite. It wants the human to remain illegible. To know the human in Afghanistan is to know that the war not only isn’t succeeding, it can’t succeed in the extravagant terms that a haunted modernism was forced to adopt as its own at the start of the conflict. To have to count its costs with any degree of moral or empirical subtlety is crippling. So states and their network of institutions hide what they don’t want to know, not just from prying outsiders, but from themselves. This isn’t info-war or propaganda. This is what technocracy does, it makes the world into quantities that set goals, meet quotas, prove productivity while making everything lived and felt and seen into externalities. It builds an endless line of fortresses and foxholes to defend an inner base of governmentality without being aware that the base has long since been deserted. Procedures and processes get made in order to protect institutions from fallible human judgment–and from intimate knowledge about being human.

So I don’t imagine that somewhere inside Bagram there’s a sensitive official who could magically turn the tide if only he or she will read Mogelson’s article. Neither do I imagine that there are bad people enacting bad rules or even banal people in Arendt’s sense. What we have are institutions and systems that have made a religion of not knowing, of rule-making, of counting for the lawyers and the higher-ups, a religion whose sacraments are briefing papers and communiques and protocols. Individual people in its observances, whether acting or acted upon, are pews and incense and candles, the material tools of ritual. They report or are reported, operate or are operated upon. Knowing those people as human beings takes something different: we don’t need better rules for who gets admitted to Bagram or for how long, or better numbers for how many people have been killed and by whom.

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