Cult Med Psychiatry

DOI 10.1007/s11013-015-9456-5

ORIGINAL PAPER

Abandonments, Solidarities and Logics of Care:

Hospitals as Sites of Sectarian Conflict in Gilgit-
Baltistan

Emma Varley1

 Springer Science+Business Media New York 2015

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 hos-
pital. 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 vul-
nerability, spectacular violence and death for healthcare providers and patients.

Keywords Hospital ethnography
Sectarian conflict
Deeply divided societies

Zones of abandonment
Logics of care
Gilgit-Baltistan
Pakistan

& Emma Varley

varleye@brandonu.ca
1
Department of Anthropology, Brandon University, Room 207 – Clark Hall, 270 – 18th Street,
Brandon, MB R7A 6A9, USA

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Introduction

For over a decade, my research has focused on the District Headquarter Hospital,1
which is located in a Shia neighbourhood in Gilgit Town, the administrative capital of
the Gilgit-Baltistan region,2 and staffed mainly by Shias and Ismailis and a minority
cadre of Sunni personnel.3 During sectarian tensions, the DHQ has provided treatment
for conflict-related injuries and has been a refuge for those fleeing local violence. As
this paper will explore, in January 2005, it also served as a space for political unrest,
religious protests and acts of terrorism occurring within the hospital and at its margins,
with Sunni physicians and patients targeted for attacks and death in retaliation for Shia
community losses. And in the unstable aftermath of the conflicts of 2005, even while
the threat of direct violence to Sunnis at the DHQ eventually abated, providers and
patients reported observing and experiencing subtler, yet still harmful, forms of Sunni-
directed enmity at the hospital, including patient neglect, mismanagement and
treatment exclusions. Consequently, the therapeutic bonds and solidarities once
imagined to bind the DHQ’s providers and patients to one another across lines of
sectarian affiliation have been destabilized, leading to uneven medical care and
sustained site-specific risks that persist up until the present day.
After introducing the recent history of sectarianism at the DHQ, the paper
explores the experiences of providers during an episode of sectarian conflict in
January 2005, when Sunni patients and a provider were killed at the hospital. In
evaluating the significance of this event and its after-effects, the paper centralizes
the providers’ narratives of conflict and is organized around three points of analysis.
First, I assess the providers’ claims that their experiences of conflict at the hospital
were illustrative of the government’s incapacity to alleviate the dangers faced by
providers and their patients. In this way, providers’ narratives of life and work at the
DHQ during crisis depicted the hospital as a zone of abandonment, in which
1
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.
2
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.
3
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’.

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institutional neglects took on life-threatening proportions. Recent ethnographies of

the moral, economic and political dimensions and dynamics associated with
abandonment (Biehl 2001, 2007; Elliott 2010; Marrow and Luhrmann 2012;
Povinelli 2011) support my contention that the institutionalization of, and
precarities arising from, medical and structural indifference in Gilgit’s hospitals
were not only ‘industrial’ in scale, but also intimately social in their production. In
turn, my interlocutors’ experiences with conflict at the hospital also confirm how the
DHQ operates as a ‘contact zone’, which Pratt describes as a social space rife with
asymmetrical power relations and imbalances (1991:34); an approach which I
extend to evaluate the ways that Gilgit’s sectarian actors, cultures and politics have
clashed through the medium of medical spaces and services.
Second, my analysis of the social instabilities and mistrust attendant on these
sectarian relations and clashes is enriched by the concept of ‘‘corrosive commu-
nities’’ which, as Miller argues for field-sites marked by acute instability, are
characterized by ‘‘social disruption, a lack of consensus [and] general uncertainty’’
(2006:366). Through this approach, I explore how the sectarian tensions unsettled
professional solidarities among providers, and the therapeutic, social and clinico-
ethical bonds between providers and patients. But my analysis is not limited to the
ways that crisis shapes the humanitarian impulses of providers and leads to the
selective mobilization of empathy, altruism and treatment. I also describe the
sectarian and inter-sectarian solidarities that were built up among and between
providers and patients during and after the 2005 hostilities.
Third, I discuss the sectarian medical infrastructures, assemblages and logics of
care which have emerged since 2005, the existences of which are reinforced and
justified by Gilgit’s ongoing, intermittent tensions. Through my interlocutors’
narratives, I evaluate how sectarian logics arise from sectarian imaginaries, the
‘‘normalized modes … of seeing and interacting with the sectarian other through
suspicion and resentment’’ (Ali 2010:739) which resonate through medical services
and encounters, and enable clinical sites to operate as mediums of sectarian discord
and violence. And it is because of the insecurity associated with medical encounters,
and the fear which drives Gilgit’s providers and patients toward or away from
sectarian sites or sources of care, that my paper also attends to my interlocutors’
narrated experiences of the violent atmospherics specific to conflict.
To this end, ethnographies of hospitals (see Anderson 2004; Brown 2012; Fassin
2008; Hadley et al. 2007; Hamdy 2008; Jaffre 2012; Malpas 2003; Zaman 2004)
support my analysis of the DHQ as an affective institution (Street 2012) in which
‘‘social orders emerge and are contested’’ (Pinto 2004:337), and where dynamic
forms of social inequality (Sullivan 2012), scales of marginality (Towghi 2007) and
‘‘complex relationships between order and disorder, stability and instability’’ (Street
and Coleman 2012:5) are generated or reified. Then, in seeking to disentangle the
conflicts’ pervasive effects on the provision and organization of Gilgit’s health
services, my work builds on the emerging medical anthropology of clinics in or
affected by crisis. In particular, my analysis is informed by ethnographies which
foreground the moral economies and proliferative symbolic and structural
inequities, neglects and violence inherent to health systems during insecurity and
warfare (see Giacaman et al 2005; Hassan-Bitar and Wick 2007; Ifthikhar ud din,

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Mumtaz and Ataullahjan 2012; Sousa and Hagopian 2011; Varley 2010; Varma
2012). As Pfingst and Rosengarten (2012) and Wick (2008) show for health
facilities and services in the at-siege Occupied Palestinian Territories, recent
medical ethnographies confirm how during warfare hospitals can be harnessed as
sites of biopolitical capital formation or targeted for necropolitical destruction. In
ways that are profoundly relevant to my analysis of strife and abandonment in
Gilgit’s hospitals, such research also illustrates how health systems can be
transformed from ‘‘geo-technological arrangements that make life possible … [to
arrangements which] undermine, obstruct or deliberately take life’’ (Pfingst and
Rosengarten 2012:99). In these instances, health institutions and services emerge as
agent-driven instruments of broader processes of conflict and may, under
exceptional circumstances, be imagined to operate as tactics of war (Ibid).
Such ethnographies also explore how conflict-instigated exclusions and harms
can enact lasting consequences for health services and outcomes, and for providers
and patients in the fraught days and months which follow active hostilities. Indeed,
because my fieldwork straddled conflict and post-conflict periods, my analysis also
attends to the residual impacts of the tension on the organization and distribution of
healthcare resources in the uneasy ‘‘not-war-not-peace’’ (Sluka 2009) interludes
between subsequent crises. Guided by the ethnographic precedent, my findings
confirm how the contestations and conflicts borne out through medical sites and
services were mimetic of the broader dissonances and distortions generated by
Gilgit’s 2005 tensions, and survive into the present through the imaginaries and
fears associated with hospitals and medical encounters (see Smith 2013:1). To this
point, my paper will be concluded by considering how my interlocutors’
commentaries on hospitals as spaces and vehicles of conflict allowed them to
reflect on and accord meaning to the embattled circumstances of medicine, as well
as the larger experience and condition of life in Gilgit.

Prelude to Crisis

The District Headquarter Hospital is a 250 bed tertiary-level referral facility which
is comprised of multiple Patient Wards and Administrative Blocks, and is located at
the intersection of several Shia-majority neighbourhoods and the lower edge of the
mountainside Shia village of Bermas. Because the DHQ provides general and
specialized services to a regional referral population of more than one and a half
million residents, the hospital often has higher admittance and treatment rates than it
has the capacity to reasonably manage. The DHQ’s services are therefore marked by
moderate to severe resource and staff shortages. During my 2004 and 2005
fieldwork, the hospital was Army-run and administered. While its Medical
Specialists were primarily Sunni and Ismaili, most of the DHQ’s General
Practitioners hailed from Shia, Sunni and Ismaili communities across Gilgit-
Baltistan. (A small minority of providers also came from Pakistan’s urban centres,
such as Islamabad and Lahore.) Paramedical staff, orderlies and volunteers were
also drawn on a roughly equal basis from among the region’s sectarian communities
with the exception of the Family Wing, the site for the majority of my fieldwork

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research, where gynaecological, obstetric and family planning services were

provided by predominantly Ismaili Nursing Staff, Lady Health Visitors and Dayas
(midwives). As was true for the other wards at the DHQ, the sectarian composition of
the Wing’s staff reflected differential investments in educational or occupational
fields by Gilgit’s sectarian communities. For instance, Ismaili women were more
often trained as paramedical providers than Shias or Sunnis due to their community’s
comparatively more liberal positions on the social acceptability and permissibility of
women working in public or desegregated settings. And within the professional
hierarchies populating the overall hospital and providing its services, the majority of
clinical responsibilities were designated to paramedical providers rather than
physicians. Despite the consequent risks associated with its services, because the
DHQ is a no- and low-cost facility, it has remained an essential recourse for patients
across the socio-economic and sectarian divides, many of whom cannot afford
Gilgit’s fee-based and less specialized private and non-governmental hospitals.
Up until the late 1980s and the start of the Shia-Sunni tensions that have come to
chronically destabilize or paralyse everyday life for Gilgit Town’s Shia, Sunni and
Ismaili communities, the DHQ and its services were described as symbolizing inter-
sectarian sociality, commensality and good-will. However, following the 1988
massacre of nearly 200 Shia civilians in several villages adjacent to Gilgit Town by
an armed lashkar (militia) of Sunnis from Diamer District, Gilgit-Baltistan and
Kohistan in the neighbouring Khyber Pakhtunkhwa Province, there was a gradual
cessation of inter-sectarian relationality in all areas of Gilgiti social, economic and
political life.4 By the late 1990s, my interlocutors described how the hospital’s
services and treatment encounters between Shia and Sunni providers and patients
began to reflect the chronic tensions affecting Gilgit’s broader social and political
economies. Then, in the summer of 2004, Gilgit was shut down by violent protests
and Army curfews as a result of what locals called the Nisab (Curriculum) Crisis.
Although Shias comprise the majority of the region’s population, the Nisab
signalled Gilgiti Shias’ demands for their religious beliefs and special status as a
national minority group to be incorporated into public sector educational curricula
and syllabi, materials which reflected doctrine specific to Pakistan’s majority Sunni
population. Nisab protests were staged at government offices and in Shia and also a
number of Sunni-majority mohallas (neighbourhoods) throughout Gilgit Town. The
tensions, violence, curfews and arrests which followed signalled the intensification
not only of Shia-State conflicts, but also of local Shia-Sunni violence. Indeed, the
Nisab Crisis capitalized on longstanding dissonance between the Sunni State and
Pakistan’s religious minorities, as well as between Shias, the self-described ‘original
people’ of Gilgit Town (Sökefeld 1998), and Sunnis, often erroneously character-
ized as ‘outsiders’ whose loyalties lay with the Sunni-dominated State rather than
with their fellow Gilgiti Shias and Ismailis. The kinship, economic and political
relationships which had hitherto ensured some degree of cooperation and alliance
4
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).

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between Shias and Sunnis, were imperilled by the Nisab Crisis, and by Shia and
Sunni politicians’ and clerics’ subsequent efforts to demarcate and seize sectarian-
specific control over local economies and electoral power.
The DHQ was affected by the expansion of sectarian governance and became a
medium through which Shia politicization began to be exerted. During the Nisab
Crisis, my interlocutors described how practices of sectarian distancing and
segregation started to infiltrate the day-to-day running of the hospital. Inter-
sectarian tensions accrued between the hospital administration and healthcare
providers, underpinned professional non-compliance between physicians and lower-
level providers, and were in notable instances observed to determine the degree to
which patients received care or if they received care at all. In turn, sectarianism was
expressed by Shia religious events, protests and graffiti throughout the congested
and heavily populated neighbourhoods and narrow winding roads adjoining the
DHQ. During the crisis, the Shia neighbourhoods surrounding the hospital were also
the scene for the burgeoning Shia militancy activities organized by, among others,
the Imamia Students Organization (ISO).5 Like the Nisab movement itself, the ISO
was led by Agha Syed Zia-ud-din Rizvi, the spiritual leader of Gilgit-Baltistan’s
Shia communities.6 Though some interlocutors described the ISO as a vibrant and
meaningful extension of Shias’ calls for insaaf (justice) and political recognition,
others argued that under the guise of an educational movement, the ISO was a
militarized and weaponized tool of Shias’ anti-state and anti-Sunni ambitions. The
ISO’s increasingly visible the presence at the hospital, and its members’ purported
involvement in the targeted killings of Sunnis, contributed to an overall atmosphere
of uncertainty and imminent danger for Sunni providers, staff and patients.
Although all my interlocutors experienced challenges or restrictions when trying to
access the DHQ during the Nisab protests and curfews, Sunnis faced the steepest risks
given that their insecurities were not entirely resolved or were sometimes exacerbated,
even after reaching the hospital.7 In 2005, Gilgit was populated by an estimated 80,000
residents, whose community histories and family genealogies overlapped across
sectarian lines of affiliation. For my Sunni interlocutors, this meant not only that many
of the people they encountered at the hospital site were already recognizable or known
to them in some way, but also that their own identities as sectarian actors were often
inescapable in situations of active conflict. Many Sunni interlocutors therefore spoke
of their fears while receiving on-site treatment. At the Family Wing, because men are

5
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.
6
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.
7
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.

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the primary targets for sectarian violence in Gilgit, maternity patients hastened their
visits for check-ups or even delivery, or postponed necessary treatment altogether, in
case the male family members accompanying them might be targeted for violence.
Without route- or site-based security, Sunni patients’ health-seeking began shifting
away from the DHQ to the few private clinics and hospitals available to them in Sunni
and Ismaili Mohallas. Although a small number of the DHQ’s Sunni physicians and
paramedical staff temporarily left the hospital during the Nisab Crisis, many remained,
arguing that their moral and professional obligation was to prioritize the needs of their
frequently impoverished patients ahead of their personal concerns for safety, and to
uphold the DHQ’s public sector mandate to treat all irrespective of ‘caste or class’. In
this way, my interlocutors emphasized their humanitarian impulse as having been in
alignment with the state and broader clinico-ethical rather than sectarian configura-
tions of care. But in 2004, neither providers nor patients had yet faced direct attacks or
threats to themselves, their patients, or the hospital site. By January 2005, providers’
mobilization of the humanitarian impulse across sectarian lines was to be radically
tested.

Crisis

On the morning of January 8th, 2005, the echoes of increasingly rapid successions
of gunfire from small arms, semi-automatic and automatic weapons heralded the
start of nearly ten hours of violent protest by members of the ISO and Shia civilians
in retaliation for Sunni assassins’ shooting of Agha Syed Zia-ud-din Rizvi. Before
Gilgit’s civil administration was able to call on the Army to impose curfew and re-
securitize the city that night, nearly all the government offices which lined the roads
by the DHQ, along with many of the Sunni businesses and homes adjacent to the
Shia Imamia Masjid, had been set on fire (Dawn: January 9 2005). While physicians
struggled at gunpoint to stabilize Zia-ud-din, who had been brought for emergency
treatment to the DHQ’s Operation Theatre (OT), the intersection beside the
Operation Theatre, adjacent to the hospital’s main gates and a minute’s walk from
the Family Wing, became the epicentre for the majority of killings. Approximately
ten Sunni civilians were shot at and near the DHQ in the first hours following Zia-
ud-din’s arrival at the hospital. Among the day’s victims was the Director of Health
(Dawn: January 10, 2005), who had been driving to assist at the Operation Theatre,
as well as several patients.
In the Family Wing, the sound of nearby gunfire and the arrival of panicked staff
from the DHQ ‘Male Side’8 led to a brief period of chaos during which patients and
providers struggled to determine the source and causes of the violence. Quickly, by
word of mouth and phone calls made before the hospital’s telephone lines were cut
by protestors, staff learned that it was Zia-ud-din who had been shot and perhaps
killed:
8
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’.

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I didn’t hear the shooting at first … At that time I was in the Medical Ward.
Somebody told me at twelve o’clock … that Agha died, and in the hospital the
wards were full of patients, Sunni, Shia, Ismaili. Everybody, every commu-
nity’s patients were there (July 2, 2010).
With the Nisab Crisis still only a matter of months behind them, each interlocutor
described being certain of the hazards facing Sunnis at the site, whether as patients,
attendants or providers. The Wing’s sole guard abandoned his post within minutes
of the attacks, leaving the all-female paramedical staff to quickly strategize ways to
ensure the safety of those now trapped at the site. Escape had become impossible
because heavily armed men had already fanned out along the narrow roads
surrounding the OT and Family Wing. Even though the Wing’s predominantly
Ismaili paramedical staff, like most Gilgiti Ismailis, self-identified and were indeed
historically seen by Sunnis and Shias as being neutral and uninvolved in local
tensions, the immediate dangers facing their Sunni colleagues and patients’
attendants required they ‘take sides’ in ways that risked them becoming targets as
well. One interlocutor narrated how Sunni staff, including the Wing’s Wardmaster,
Quartermaster and Medical Staff in-Charge, were collected together with the Sunni
OB-GYN, a woman, and then locked inside the Labour Room’s washroom, while
patients’ male relatives were locked in the staff washroom: ‘‘Some Sunni brothers
came [and] … they locked themselves in and were in there quietly’’ (Interview: July
26, 2005). Women-only clinical spaces, ordinarily restricted for staff and patient
use, now operated as precarious sites of refuge for both men and women, and
patients and non-patients. By capitalizing on the social and moral weight of Islamic
gender-segregation practices and the spatial boundaries to which they give rise,
Ismaili and Shia staff sought to deter the gunmen’s efforts to come into the Labour
Ward. This strategy was tested with the arrival of several men carrying pistols and
Kalashnikovs, whereupon staff members described taking it upon themselves to
meet and try to stop them from searching the premises. Their narrative framing of
the event conveyed, quite deliberately, the Ismaili community’s neutrality during
Shia-Sunni tensions.
Yes, Shia gunmen, maybe 5 or 6 of them, had come in wearing chador [veils]
around their faces, and asked … if any Sunnis were here, but [we] said, ‘This
place is for ladies only, why are you asking me this question? There are no
men here!’ Afterwards they left, and [we] had just been sitting … on the bed in
the staff room. We’re Ismaili, and not interested in this type of thing, you
know? We’re not like this (July 26, 2005).
Ultimately, only one staff member vocalized the impossible challenges
associated with staff members’ efforts to save Sunnis:
Sunni men [were] begging us to save their lives. If the terrorists had come in
and started shooting and killed them, what could we have done to help them?
(August 1, 2005).
Whether speaking of their experiences at the height of the crisis or in the years
that followed, many Ismaili and Shia interlocutors’ accounts carefully side-stepped

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emotive assessments of the events unfolding around them, their role in securing
Sunnis’ safety, and the dangers facing them. Nor did they address how, by
protecting Sunnis, Shia staff faced potentially even greater risks than Ismailis.
Rather, they affirmed in social, professional and also political ways, their
understanding of Sunnis as ‘kin’ and their lack of involvement in the violence.
The emotions attached to events at the Family Wing were instead expressed by the
Sunni colleagues they had hidden.
This is very hard to talk about, and I don’t want to talk about it too much,
alright? I was on-duty, and suddenly there was a lot of shooting, and smoke
and fires, people running here and there. It was a big disaster …. I can’t
discuss [it] … it’s too hard to remember (September 7, 2005).
It was often easier for providers to speak of patients’ fears than their own, such as
when one interlocutor described Shia patients’ terror for retaliatory violence by
Sunnis in the immediate aftermath of the attacks.
In the Surgical Ward, there [were] 10 or 11 patients …. Some of them became
‘psychiatric’ [sic] after that …. They were wondering what is happening
outside; ‘What is happening to our brothers?’ …. They were saying, ‘What
will happen to us, kya hoga [what will happen]? After what [Shias have] done,
those [Sunni] people will kill us!’ (July 2, 2010).
While staff attempted to save Sunnis in the Family Wing, in the Operation
Theatre 100 m away, the DHQ’s surgeons, many of whom were Sunni, worked to
save Zia-ud-din, fully aware of the potential for their own deaths as well as
widespread violence not only in Gilgit Town but across the region should he die.
When Zia-ud-din was in surgery … the anaesthesiologist intubated him and
resuscitated him. There was cardiac activity, but bad bleeding and a bullet in
his brain. Then gunmen with Kalashnikovs had walked into the surgery and
pointed a gun at the [doctor’s] head, saying ‘If he dies, then all will die.’ They
pointed to the four or five Sunni surgeons who were present (February 11,
2005).
According to several interlocutors, the surgeons fought to ensure Zia-ud-din
remained, or at least appeared, alive so as to postpone further bloodshed until either
the Police or Army could reach and secure the DHQ. Shia clerics and community
members soon arrived at the hospital to try and quell the violence: ‘‘Some of the
political people told the [gunmen] that, ‘He’s alive. You’re not supposed to … do
things like this. Killing’. They were trying to keep things calm’’ (Interview: July 19,
2010). Notwithstanding such efforts, elsewhere in the DHQ gunmen killed several
Sunni patients who were in their beds and unable to defend themselves or hide. And
in ways which came to inflect patients’ medical imaginaries and fuel their fears
concerning the site and Sunnis’ safety at the hands of non-Sunni providers, a Sunni
patient in the DHQ’s Emergency Room, who had been shot that morning in his
nearby office and brought in for treatment, was killed with the purported assistance,
some said, of a Shia member of the paramedical staff.

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He was my [cousin] and [a Sunni] doctor had operated on him, and had told
me, ‘Brother, he was totally ok.’ They kept him inside the Emergency Room
and somebody took his blood and he died due to the lack of blood. He died at
the bed, you know. He had [been] shot in the morning …. He got minor
injuries, but they reached the [DHQ] and the doctor told me everything, and
said ‘I did everything for [him], and we [started] the transfusion, but
somebody took out the transfusion’ (August 4, 2010).
News of his death had quickly circulated among his extended family and, in turn,
the wider communities in which they lived. During its retelling and reworking by a
succession of narrators, the story of his death took on additional, gruesome features.
The death came to be described as being either the result of exsanguination or
poisoning, with the latter being a not uncommon means of homicide or suicide in
Gilgit. Accounts soon settled exclusively on the cause of his death as being from a
‘‘wrong injection’’ (Interview: August 11, 2011), an explanation which was suitably
ambiguous and thus capitalized on Gilgitis’ already fraught experiences with and
uncertainties concerning medicine and its effects, at least in clinical terms.9 In such
renderings, medical techniques and technologies acted not only as mechanisms of
medical mismanagement, but also mediums of intentional harm. This has meant that
over the long term, and even up until my most recent fieldwork in 2013, the illnesses
and deaths seen to arise from regularly occurring and, some argued, normalized
practices of patient neglect and malpractice were popularly understood by Sunnis to
be iatrogenic extensions of the larger sectarian instabilities and injuries wrought on
the Sunni body politic. With post-mortems a rarity at the DHQ, such stories
resonated not only because they coalesced politically with and rationalized Sunnis’
collective concerns for their welfare during conflict, but also because they could
never be disproven.
The details of the killings of Sunni staff and patients were neither confirmed nor
denied by my interlocutors at the DHQ, but instead consigned to the realm of
rumour: ‘‘I heard that some of the patients died’’ (Interview: July 6, 2010). As it was
for Sunni civilians present to see but unable or unwilling to discuss the killings of
other Sunnis by gunmen outside the Operation Theatre, by purposefully building
uncertainty and ambiguity into their discussions of these deaths, and by disregarding
the otherwise testimonial style and evidentiary weight of their recollections
concerning nearly every other event that day, some interlocutors refused to bear
witness.10 Providers’ strategic silences confirmed the inexpressibility of trauma, and
the emotional, personal and professional risks attendant on the act of witnessing,
especially as it concerned the alleged ‘crimes’ ascribed to other providers. Crisis-
provoked narrative gaps were also attributable to the conditions of civil service,
which entail strict adherence to public sector codes of conduct, inclusive of the self-

9
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.
10
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.

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disciplining of speech, evasion of personal ‘opinion’, and protection of providers’

and patients’ confidentiality.
By the time advancing military units regained control over the city and
implemented a total curfew at the day’s end, nearly twenty Sunnis, including a
child, and one Ismaili had been killed in retaliation for the attack on Zia-ud-din.11
My interlocutors described how, late the same day, Mobile Police Units and the
Pakistan Army had arranged first for the safe transport off-site of the DHQ’s ‘Male
Side’ physicians and staff, followed by patients. At the Family Wing, it was not
until the second and third days that most patients, attendants and paramedical staff
were escorted home. While waiting, those trapped at the site went without supplies
of food, medicine, security or even communiques from the hospital’s administra-
tion. It was only on the third day that staff members were finally able to organize the
rescue of Sunnis from the Labour Room:
[We] talked to the Police In-Charge and … said that, ‘Some of our staff is
locked inside the bathroom, and they are in danger, so please make
arrangements for them.’ …. After shifting the patients and the attendants
[he] came and said, ‘Where are they?’ And [we] said: ‘You will bring … some
policemen, with guns, and escort them from the bathrooms.’ He said ‘ok’ and
he brought three or four young policemen. They came and he sent them … to
the Labour Room, and I opened the door and … with the help of the police, we
sent them (June 17, 2010).
My interlocutors’ professional resilience and selfless risk-taking at the Family
Wing was mirrored by Shia and Ismaili staffs’ successful efforts to save Sunni
providers and patients trapped elsewhere at the hospital. None of my interlocutors
spoke to the increasing dangers they had faced for each hour the removal of Sunnis
from the site was delayed, nor why it had taken so long to arrange for their rescue.
Even when speaking years later about the events of January 2005, in order to
emphasize the enduring nature of their insecurities, they described the government’s
disinvestments in their security and survival not only in the past tense, but also in
the present:12
Because there was no arrangement, there was nobody looking for us. Not our
security, nobody. There is no [guard], no administration, no MS [Medical
Superintendent], nobody is caring for us. Everyone looked only after
themselves. Nobody ever asked about us. No, no, no, nobody. We were stuck
over there … I wasn’t able to contact [my family] for three days. They said,
‘She’s dead in the tension. She’s dead in the tension’ (July 11, 2010).

11
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.
12
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).

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Shortly after the last of the patients was rescued, it was announced that Zia-ud-din,
whose body had been flown by the Army for treatment in Rawalpindi, had succumbed
to his injuries. The curfew imposed late on the 8th was to continue on a total and later
partial basis for a further three weeks, a period which entailed its own devastating
consequences for the day-to-day running of the hospital and patient welfare.

Aftermath

The events of January 8th heralded the start of ten months of episodic low- and
high-intensity Shia-Sunni conflict and protracted curfews. As during the 2004 Nisab
Crisis, throughout the 2005 tensions, the DHQ’s administration publicly maintained
their commitment to uphold the DHQ’s public sector promise of free services
equally available to all. However, the profusion of sectarian and medical hazards,
and the rumours and realities of Sunnis’ on-site targeting and death, resulted in the
lasting marginalization of Sunni patients13 and the exodus of Sunni providers,
including most of the DHQ’s Medical Specialists. It was the killings of patients that
likely had the most pervasive after-effects on patients’ use of DHQ services, the
weakening of their trust in providers, and Sunnis’ sectarian imaginaries concerning
the characteristics of, and threats posed by, their ‘enemies’ (dushman). I argue that
Sunnis’ fears for their security and treatment have persisted in part because of the
silences surrounding Ismaili and Shia providers’ prominent roles as rescuers on
January 8th. Providers’ heroisms have neither been publicized, nor do they figure in
most Gilgitis’ understandings of the events that day. Overall, these realities led to
the reconfiguration of existing health facilities and the establishment of new ones, as
well as to fundamental changes in patients’ health-seeking practices.
Starting from early 2005 and continuing until 2006, the Sunni community
organized to establish two 30 bed government ‘Sunni’ hospitals, first through
community donations and tithing and later government funding allocations, in
nearby Kashrote Mohalla and the village of Baseen on Gilgit’s western outskirts.14
In answering why the DHQ remained a site for exceptional rather than quotidian
recourse, and explaining the necessity of the Kashrote Government City and Baseen
Civil Hospitals, my Sunni interlocutors emphasized the manifold insecurities which
had become inextricably tied to the DHQ site. Since January 8th 2005, and even up
until the time of writing, rolls of barbed wire, sandbag emplacements and bunkers
were placed at the hospital’s eastern gates and the intersection by the Operation
Theatre and the Family Wing. Yet, despite its fortification and the on-site
deployment of Pakistan Rangers and Frontier Constabulary at the margins of the

13
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.
14
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).

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hospital’s ‘Male Side’ Wards, the DHQ remained unevenly accessible to Sunnis.
For example, because the Family Wing remained largely unguarded, its Shia and
Ismaili providers were vigilant to Sunni patients’ and attendants’ vulnerabilities in
the many recurrences of crisis since 2005. Whether during periods of peace or
instability, maternity patients described the dangers they felt ‘dehshatgard’
(terrorists) posed to the male relatives accompanying and ‘guarding’ them.15
Because the Family Wing’s staff continues to be predominantly Ismaili, maternity
patients were less concerned about, but not completely dismissive of, the possibility
of sectarian motivated neglect or malpractice. Among Sunnis admitted to ‘Male
Side’ Wards, some patients described their attempts to intuit or decipher Shia
providers’ ‘intentions’ during treatment encounters. Others were mindful of the on-
site presence of Shia religious and voluntary tanzeem (organizations), including the
Imamia Students Organization (ISO), whose members occasionally provided
additional patient support and on-site protection for Shias. Fueling Sunnis’ anxieties
in the years since 2005, attacks continue to occur at the DHQ notwithstanding
police, paramilitary and military security. In 2010, for example, an admitted patient
was assassinated (Pamir Times: July 20, 2010), and in 2012 militants organized a
violent raid on the hospital in order to free a detainee who was receiving medical
treatment (Express Tribune: March 28, 2012; Pamir Times: March 28, 2012).

Abandonments

Reflecting on the insecurities of January 2005 and the government’s failure to

adequately protect them and their patients, my interlocutors framed the DHQ as a zone
rife with diverse abandonments. Here, I use the term ‘abandonments’ to refer to
institutional sites characterized by life-threatening disregard for well-being, spaces
devoid of administration or surveillance, in which numerous types of neglect are
interpreted by those left behind to signal breaches of intra-professional and clinico-
ethical responsibilities to sustain and care for patients and providers alike. It was in
these zones, brought into being by conflict but made possible by longstanding hospital
insufficiencies and dysfunctions, that providers’ and patients’ invisibility and their
abandonment was effected. Since Biehl (2001, 2007) first introduced ‘zones of social
abandonment’ to denote the varied processes which culminate to produce spaces of
‘‘social death, where those who have no place in the social world … are left to die’’
(Marrow and Luhrmann 2012:494), the critical medical anthropologists, social
theorists and cultural geographers adopting this approach have focused on the ways
that abandonments occur in sites in which individuals ‘‘lose meaningful social roles
and are reduced to ‘bare life’’’ (Ibid:493). Influenced by Biehl’s ethnographic
elucidation of the ‘‘complex network of family, medicine, state, and economy’’
(2007:400) in which abandonment takes form, here my analysis situates abandon-
ments as being ‘‘integrated into local forms of governance,’’ and made possible by
15
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.

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Gilgit’s ‘‘institutional networks’’ and the ‘‘everyday practices that constitute … [the]
nonexistence’’ (Ibid:402) or violent devaluing of some sectarian actors, rather than all.
In ways which broadly paralleled the neglects experienced at other public sector
institutions in Gilgit during 2005, the tensions caused the DHQ’s already under-
resourced and hollowed-out services to become even more dangerously bereft of
necessary personnel, medicine, and essential provisions. The protracted curfews of
January resulted in frequent interruptions in the delivery of resources and the supply
of electricity and sometimes even water. And while the military and paramilitary
forces guarding the DHQ’s parameters during the January curfews had securitized
the site, they also inhibited patients’ and providers’ ability to easily access or leave
the hospital. Though the hospital’s external boundaries were protected, its interior
ward life was starved day by day of necessary administration, support, supplies or
on-site security; abandonments which in many ways affected everyone equally,
regardless of sect.16 It was then left to those actors stranded or serving at the DHQ to
offset or further exacerbate the risks which resulted from the state’s selective
attentions to the hospital, either through their efforts to save patients and colleagues
or set them aside. To an important degree, my interlocutors’ efforts to care for and
save Sunnis amid acute crises, and even despite the threat of death, served as a vital
counterbalance to the abandonments of the tension times, and confirmed that both
violence and safety proliferated along and across lines of affiliation.
During tensions, the DHQ therefore became a space in which medicine, care and
security could be structured, provided or withheld according to hierarchies of
identity and affiliation as well as therapeutic resort, with the effect that ‘‘social’’
and, more specifically, sectarian ‘‘death and selective life extension coexist[ed]’’
(Biehl 2001:137). In pointing out the irony of their situation in which assistance was
neither offered by nor forthcoming from the hospital’s administration or the
government, providers and patients reminded me of the Islamic dua (supplication)
written in bold red illuminated letters over the DHQ’s main entranceway: ‘‘Jub meh
bemar hota huh, toh woh Allah mujhe shifa deta hai (When I am sick, then God
heals me).’’ Others interpreted the dua as being less about their desertion by human
agents, and more about the ways deen (faith) underpinned their acts of bravery and
informed their niyat (intention) to save lives, with the expectation that divinely
guided intentionality would in turn save them.
For many interlocutors, the abandonments of January 2005 signalled the
destabilization of the already fraught professional allegiances and obligations
intended to bind government–employee relations and hold the hospital to protect its
staff. The tensions had also undermined intra-professional solidarities. In 2010, for
instance, the frictions between DHQ providers and the Sunni specialists who since
2005 had left to serve at other ‘safer’ hospitals were interwoven with and made
manifest through, the staffs’ hospital-based protests concerning regional public
sector health funding allocations and service structures. Many DHQ staff wore black
arm bands, which for some signified their disapproval of Sunni providers drawing

16
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).

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their salaries from the hospital’s meagre funding base even after they had been
reposted to the Kashrote or Baseen Hospitals. Other staff used the protests to
vocalize their discontent with Sunni service absences at the DHQ, which they said
evidenced providers’ uneven or failed commitment to patients. Another interlocutor
explained that the protests were less about money, and more about the Shia and
Ismaili staffs’ frustrations with Sunnis’ security needs being privileged through the
establishment of ‘Sunni’ hospitals, and Sunnis’ ‘lack of faith’ that their Shia and
Ismaili colleagues would save them in the event of another crisis at the DHQ. Such
arguments conspicuously avoided acknowledgement of Sunnis’ profound and
unresolved insecurities at the hospital.17
Aside from the concerns expressed by protesting DHQ staff, other interlocutors
addressed what they felt was Shia, Ismaili and Sunni providers’ deteriorating moral
obligation to provide a high standard and measure of care for patients across lines of
affiliation. For example, DHQ providers sometimes characterized their referrals of
Sunnis to the comparatively less specialized and resourced Kashrote Hospital, even
in the absence of imminent harm or tension, as ensuring their patients’ safety and
reducing their experience of fear and ‘suffering’ at the DHQ. Similarly, it was not
uncommon for the Kashrote Hospital’s Shia patients, who only rarely sought
medical care at the facility, to be referred or transferred to the DHQ for ‘safety’
reasons. Not spoken of by the patients’ treating providers, but witnessed by many,
were the ways that unnecessary or poorly timed referrals could lead to death. A
more critical analysis suggests that referrals could operate as practices of defensive
medicine, whereby providers strategically re-directed high-risk patients and the
liabilities, both sectarian and medical, which accompanied their treatment, to other
sites. Therapeutic solidarities and the humanitarian impulse were not only deflected,
they were sometimes wholly denied. A Sunni physician who provided emergency
surgical support to the DHQ, shared his observation of an incident of sectarian
exclusion and medical abandonment:
Some days before at night, one [Sunni] gunshot [victim] came [to the DHQ
OT] …. And [he had] just entered the theatre and a lot of Shia [surgical]
assistants and staff, they come inside, they asked what happened. And the
[Sunni] surgeon says, ‘This is a person from Chilas.18 He’s a policeman, and
he got a bullet injury in the thigh.’ [Then] all people left. He is alone in the
theatre. And only two [Sunni] doctors were left …. So they did all the things,
and stitched the wound, and we shifted [him] to the Ward. At that time we
don’t trust the people there, so we took him to the Kashrote Hospital.
[Otherwise] maybe they will enter, they will …. Maybe if he’s Shia, they will
do something [and] help (June 25, 2010).

17
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.
18
Chilas is the capital of the Sunni-majority Diamer District in southern Gilgit-Baltistan.

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Regarding such cases, an Ismaili provider described Shia-Sunni treatment

disunities thusly: ‘‘You know, Emma, what their real feelings are? They hate each
other, and they don’t have [any] respect for each other….It’s the height of their
hatefulness’’ (August 23, 2011). In this way, the social segregations and health
deprivations observed and imagined to be produced through the differential care
provided by patients’ sectarian others, and reinforced by acts of violence on hospital
sites, served as cogent markers of the inescapable influence of sectarianism on
matters of everyday life. Moreover, such realities destabilized popular understand-
ings of hospitals as ostensibly neutral facilities, capable of reconciling the
expanding social and political distances between Shias and Sunnis through care
guided by the therapeutic, rather than sectarian impulse.

Sectarian Solidarities, Assemblages and Logics of Care

Yet even as the tensions broke some inter-sectarian solidarities down, others were
built up. For many Ismaili providers, their experiences of January 8th had confirmed
and strengthened the peaceable bonds and social interactions which had generally
existed between themselves, Sunnis and Shias.19 And by pointing to their lack of
involvement in the January 8th violence and their altruistic roles as caretakers to all,
regardless of sect, the Family Wing’s Ismaili providers emphasized the significance
of their spiritual, social and political commitments to and practice of pacifism. Of
equal importance, Shia providers’ efforts to protect or rescue Sunnis at the DHQ
from harm, whether imminent or actual, demonstrated the durability of the same
inter-sectarian commensality which, in prior periods of tension, had moved Shias
and Sunnis to save each other from the dangers posed by enmity and revenge.
As sites of medical practice and community engagement, Gilgit’s ‘Sunni’
hospitals also contributed to the emergence of intra-sectarian professional and
patient solidarities, thus confirming how the failed unities of one hospital could
prefigure the birth of new solidarities at another. In these medical spaces, it was
observed that the solidarities among Sunni providers, and between providers and
patients, further built on, were reinforced by and made understandable through
‘traditional’ forms of shared affiliation, such as family, tribal and ethnic relatedness.
Following from Wick’s analysis of the contribution of health services to nation-
building efforts in the Occupied Palestinian Territories, where ‘‘deeply rooted
affinity groups and networks [became] … an essential element’’ of governance
formation (2008:333), my analysis found that in Gilgit, these affinity groups helped
delineate local sectarian communities’ socio-medical and political boundaries. In
essence, the structural effervescence of Sunni and also Shia medical economies
which began in the Nisab Crisis and was concretized by the 2005 tensions, produced
sectarian assemblages of care, which may be otherwise described as ‘‘culturally
informed arrangements of care’’ (Desjarlais 2014:101).

19
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.

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Arising at the intersection of medicine and conflict, such assemblages were

animated by sectarian logics of care. The logic of care concept was developed by
Mol (2008) to describe how care, particularly as it is shaped by neoliberal health
governance, is ‘‘less about understanding the relations of causality than working on
them’’ (Raineau 2013:47). Because Mol’s approach entails analysis of the ways that
patients’ bodies are ‘‘engaged in therapeutic practices’’ (Mol 2009:83 in Raineau
2013:47), anthropologists who use logic of care frameworks frequently also explore
and analyse the constitutive properties of ‘good’ medicine, as well as the value of
life, as they play out through treatment processes (see Molinier 2009:247 in Raineau
2013:56). Against this precedent, I employ sectarian logics of care to designate the
ways that Gilgit’s conflicts, and the sectarian segregations they produce, influenced
providers and patients to understand ‘good’, ‘safe’, and ‘moral’ or ‘right’ medicine
as hinging not only on same-sect clinical sites and encounters, but also the shared
ethical impetuses thought to accompany them. More than this, they were used to
determine who was to be included or excluded from care, thereby demarcating the
borders of treatment and establishing the grounds for differential or exclusionary
service provision. Bracketed by clinical protocols and infused with the cultural
sensibilities, moral economies, religious doctrines and political and social practices
particular to each community, sectarian logics were expressed through my
interlocutors’ emotive, ethical and medical evaluations of care sites, processes
and outcomes. In narrating their experiences of the DHQ, for instance, providers
from across the sectarian divide spoke to the moral and anxiety laden atmospheric
properties inherent in the hospital’s sectarian medical spaces and their professional
interactions.
[Shia and Sunni] staff are talking to each other, they are. They are helping, but
this thing and feeling is still in them, in their minds, that at any time they will
hurt each other. They don’t trust each other. At any time, kuch bhi ho sukta hai
[anything can happen] (July 23, 2010).
Fear and insecurity therefore served to give life to the imaginaries and economies
of recognition by which providers and patients, especially at the DHQ, read and
‘‘profiled’’ each other (Varley 2010:67–68; see Briggs 2003). They also influenced
how patients seeking care chose from existing hospital and treatment options.20 And
by supporting their identification and navigation of the benefits or harms accruing
from sectarian sources of care, these logics helped my interlocutors to answer and
develop infrastructural solutions to their concerns for the nature of medical practice,
the persons who populate hospital sites, and the quality of care in conflict-affected
facilities.

20
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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Conclusion

Ethnographic chronicling of the corrosive effects of conflict on the actual and

perceived dynamics of care described for Gilgit’s hospitals shows how sectarianism
plays out through both quotidian and crisis-inflected therapeutic engagements and
the conditions of medicine itself. With the DHQ serving as a zone of contact and
abandonment, Gilgit’s tensions came to be forcibly expressed and enacted through
the hospital site and its services in ways that have, at least in the imaginations of
providers, undermined their ability to practice medicine and protect their patients
from the extraordinary risks produced by conflict. And, inasmuch as patients faced a
high degree of danger during the tensions (Varley 2010), by their own testimony,
providers did not emerge unscathed from January’s hostilities. The tensions
endangered the providers’ personal and professional security and eroded their trust
in their colleagues, hospital administrators and the government itself, even as the
conflicts have also, sometimes simultaneously, served as the basis for renewed or
novel solidarities. Indeed, in response to the perils associated with sectarian events,
actors and inter-sectarian sites of care, my interlocutors’ narratives exemplify the
resourceful ways providers drew on ethically informed, tensions enhanced or
instigated solidarities in order to navigate the direct and indirect hazards facing
themselves and those under their care, thereby confirming the life-saving properties
of professional, therapeutic and sectarian solidarity and commensality.
Notwithstanding the undeniable importance of providers for healthcare services
and patients during crisis, little research has been done on their experiences of, or
perspectives on, medicine and hospitals as expressive sites of conflict. Because even
less has been said concerning providers’ roles in the perpetuation of crises in clinical
settings, this paper represents a preliminary effort to examine and theorize the
darker spaces and practices of medicine during conflict, particularly as they concern
the ways that risks are cultivated and proliferate, and how loss occurs along
sectarian lines. In addition to the tension times abandonments associated with the
DHQ’s services, my interlocutors’ narratives point to the ways that, for some
providers, the clinical mandate to heal was warped by conflict, thereby further
ensuring the hospital’s reputation as a space in which some sectarian bodies, more
than others, were liable to be harmed.
And as community-generated responses to the dangers posed by tensions, Gilgit’s
projects of sectarian medicine have done more than simply ensure the smooth or
safer delivery of care in contexts marked by strife and discord. The post-2005
emergence of ‘Sunni’ medical infrastructures evidences the ways that local sectarian
communities harness medicine, service provision and hospital sites in order to
achieve instrumental and political objectives, and respond to the security threats
which imperil the existence of individual sectarian actors on the one hand, and
sectarian body politics on the other. Yet even while sectarian hospitals are broadly
supportive of the providers’ safe provision of medical services and patients’ secure
access to care, they also represent the failure of regional governance to stem chronic
hostilities, counteract the impassability of sectarian spaces, or heal the ruptures and

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insecurities which fuel the social separation and spatial segregation of Gilgit’s
communities.
In turn, the sectarian imaginaries, assemblages and logics of care specific to
conflict animated my interlocutors’ understandings of clinical facilities, shaped their
intra-professional relations and suffused treatment encounters. It was in reflecting
on their experiences that my interlocutors worked to apprehend how hospitals, as
affective institutions and sites of sectarian experience, have contributed to the
emergence of unique biopolitical subjectivities and modes of biopower and health
governance which draw their impetus from conditions of conflict. In relation, the
emotional and moral evaluations arising from these imaginaries and logics, and
which were intrinsic to my interlocutors’ appraisals of medical services, emerging
infrastructures, and of self and sectarian others, oriented providers and patients
away from the unwieldy insecurities and dangers that continue to be bound up with
hospitals. I conclude by arguing that for my interlocutors, Gilgit’s hospital sites and
the practice and provision of medicine during tensions have served as the ‘‘site[s] of
terror and ‘point[s] of imagination and longing’’’ (Smith 2013:1) that guide and
reinforce their understanding and navigation not only of matters of life, death or
even survival, but also of the sectarian worlds in which they live.

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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