Dr. Kasturi Sen is a social and political scientist by training, specializing in political economy, sociology, public health and the political economy of conflict. She has, over the past two decades, taught and researched at London, Cambridge, and Oxford Universities. She has held visiting Professorships in India (JNU, Delhi, ISI Kolkata) and in the UK (Liverpool) and is a regular guest lecturer at several European Universities including Bocconi, Milan and Bologna focusing on the triggers of conflict and the war on terror.
She helped to establish graduate courses at London and Oxford Universities on public health and development and has mentored students at Oxford from several regions of the world. She has edited and coauthored several books on a wide range of subjects including global health, health policy, and on the securitization of development. She is currently based at Wolfson College (CR), University of Oxford, working on the conflict in Syria with a focus on the invisible war of sanctions and in India on the political economy of universal health coverage.
Where do you see the most important research happening in your field?
Challenges to established scientific methods for the study of population health and of health services has witnessed a merger of different disciplines, notably social science medicine and epidemiology. Over the past two decades and more, this has been both an exciting and significant development in the field of public health, enabling us to have a better understanding of the social context of ill health and disease.
The work of physician and demographic historian McKeown played a significant role in promoting a broader approach to understanding health and disease, although it continues to generate both support and criticism until today. However, the persistence of gaps in life expectancy by socio economic class is at the core of McKeown’s case and remains the base of social epidemiology. My own background is broad based – methodologically and thematically – and fits into a holistic approach toward understanding health and illness in different contexts, including in global political economies, health policies, and finance as illustrated in several books I have edited and co-authored.
How has the way you understand the world changed over time, and what (or who) prompted the most significant shifts in your thinking?
My thinking has altered concurrently with the struggles and challenges facing each region (South Asia, the Middle East, and Europe) where I have lived through the ominous rise of populist and far right politics. Those such as AK Bagchi and Aijaz Ahmed in India, or David Harvey at NYC among others, are inspiring to many of us for their ability to analyze critically the different phases of corporate capitalism and its social and political consequences, as in the engendering of communitarianism. Most of all, there is a continued need for inter-disciplinary approaches (politics, economics, anthropology and social epidemiology) to understand contradictory phenomena and provide us and future generations with hope for the future.
Why or how did you get interested in the healthcare and political economy of war zones?
My experience of working during conflict in Lebanon (1980s) and the Occupied Palestinian Territories (1990s) left a lasting and compelling impression. I was responsible as part of a team for coordinating emergency health programs as destruction reigned all around us (in Lebanon in particular). I worked with public health physicians to provide logistical and moral support to medical teams in hospitals, primary health care centers, and most of all for traumatized civilians. The courage and resilience particularly of health workers, doctors, and nurses in the field was remarkable.
In Lebanon, I also witnessed first-hand an opportunistic shift from a publicly driven healthcare system (whatever its weaknesses) towards commercialization, which took over in the aftermath of its civil war (and increasingly so now also in the OPTs). In my view, this is taking place to the detriment of access to care, and at a high cost both to the state (mostly subsidizing it) and to its citizens. I am closely engaged in studying similar processes in Syria prior to and during the current conflict.
What is the state of Syria’s healthcare system now, given the intensity of the conflict?
Little was known about the health system in Syria until the recent conflict. As a result of the conflict, both the economy and health sector have retreated by decades. Once a middle-income country in the region with a relatively high standard of living, large parts of the country have now been reduced to rubble. Two-thirds of public hospitals have been damaged or destroyed whilst less than a fifth (130) of the once flourishing health centers (832) are functioning. This has devastating consequences for the population remaining inside, who are mostly ignored. Among its manifold effects, one is for pregnant women: they are undergoing high rates of caesarian sections reported due to fear, insecurity, and a lack of regular access to hospital and clinics. The negative impact on infant mortality rate and maternal mortality rate will only be realized in the coming years. The conflict has also taken its toll on life expectancy which has been reduced from 75.9 years (in 2010) to 55.7 years (in 2014) with some 11.5 % of the population (23 million in 2010) estimated to have been killed and thousands more injured up to this year. These figures are UN estimates but actual figures could be much higher.
The lack of clean water is leading to the emergence of diseases eradicated many years ago (e.g. polio) with outbreaks of others that are infectious and dangerous especially for children and infants, such as cholera and respiratory tract infections. More than half of all health workers had left by 2015, whilst several hundred have been killed or injured with more than 175 killed in 2015 alone.
One major concern is that economic sanctions are causing further havoc to population health. The cost of food has escalated tenfold for essentials (since 2011) in many areas and is out of reach for most of the population, with many living in poverty in women-headed households. Likewise, many needed medicines are out of reach due to lack of availability and cost (as well as hoarding). The loss of millions of jobs and the collapse of salaries due to the devaluation of currency has also created abject poverty; more than 80% of the population is living in poverty with 69% of these in extreme poverty. This could never have been foreseen prior to the conflict.
How are the gaps in healthcare provisions resulting from the war filled by the state, if at all?
The World Health Organization (WHO), the International Committee of the Red Cross (ICRC), and the Ministry of Health (MOH) have made remarkable attempts to fill the gaps particularly for routine health care (vaccinations, surveillance, hygiene awareness without clean water, control of epidemics such as cholera). However insecurity generated by conflict has made this an uphill struggle. INGOs working in opposition-held areas are also working under extreme conditions. A recent WHO report suggests that some 25,000 people are injured each month in Syria but with most hospitals and clinics partially or totally destroyed, you can only imagine the challenges of treating people under such conditions, even in the most basic ways. Many simply die without the needed medical attention or are faced with life-long, avoidable disabilities. There are, however, several innovations taking place in field clinics, hospitals, and community based services (such as for the mental health of the traumatized in the midst of this war) that are much needed and innovative.
What is the role of a healthcare system in the peace building process?
Pilot interventions undertaken in east Timor and conflict regions of East Africa suggest that providing basic health care in the aftermath of prolonged conflict can serve as a mechanism for healing rifts between warring factions. For example, people in Timor queued up to vaccinate their children and to receive treatment for chronic conditions: all essential needs that are neglected during conflict. These successful pilot programs have been derived from grass roots clinician and health worker activity, rather than from state-led initiatives.
In the case of Syria, similar interventions may already be taking place. However, until the country is rid of privatized armies and warlords, this may not be an easy task. There are several hundred armed groups throughout the country causing death and devastation to economic and healthcare infrastructure and who are not interested in building peace. Their existence relates to regional rivalries that have little or no concern for the suffering of civilians at large. For them, the perpetuation of conflict is of political and economic benefit.
Despite these enormous challenges, health work is highly significant in zones of conflict because it can initiate and spread peace through conflict management, solidarity with indigenous health workers, and helps to rebuild and strengthen a shattered social fabric. As viewed by the UN and most policy-making bodies, peace building is not just a “political” process.
Regarding your current research, what would you say are the effects of economic sanctions on war economies and healthcare?
We as a group of public health scholars from the UK, Syria, and Iraq were among the first to point out that economic sanctions act as collective punishment and are against international humanitarian law in Syria, as was the case in Iraq. Viewed as a “soft option” to military intervention, they increasingly have a clear purpose as a “tool” for regime change. Global policies on sanctions are a mess because not only are they applied selectively to some countries and not to others, they are also not monitored for their effects on the economy and on civilians. Sanctions tend to perpetuate conflict and disregard international humanitarian law. The latter is already seriously undermined in this region by most parties engaged in conflict and sanctions make it worse in the case of fragile states such as Syria.
Despite the terrible experience of Iraq under sanctions (1991- 2003) where an estimated half a million children died from lack of food, medicine, and health care, the same has been applied to Syria since 2011. The machinations behind sanctions against Iraq during the 1991 to 2003 period and their devastating consequences for civilians is highlighted in the excellent work of philosopher Joy Gordon at Fairfield University, Boston. Gordon raises moral, political, and ethical questions that focus on the experience of Iraq and describes sanctions as a modern version of siege warfare (Gordon 1999). The failure of sanctions as a tool of foreign policy and regime change is evident, but simply ignored in geopolitical circles.
It is remarkable how little is gleaned from history with regard to the civilian suffering caused by sanctions. Among other factors, they have contributed to strengthening the position of radical Islamists and to the running of economies of plunder, in Syria. Public assets such as water and electricity have been seized and resold to beleaguered citizens at extortionate rates. In 2012, the EU lifted sanctions against some “opposition” groups to speed up the downfall of Assad. It is evident that sanctions need to be evaluated for their humanitarian impact and not simply used as a tool for punitive posturing.
How effective would you say sanctions generally are as tools for preventing conflict?
Sanctions are not a benign alternative to military intervention as is widely perceived. As a tool of foreign policy, sanctions have achieved little and have instead mostly entrenched the positions of power holders. In Syria, they have strengthened disparate groups, which has contributed further to social and economic fragmentation. They have also failed in most cases as a tool for implementation of international humanitarian law.
In the case of Syria, they have compounded the deteriorating context by strengthening economies of plunder and acting as a bonus for groups such as ISIS, among other Islamists. These groups successfully recruit from unemployed youth, many of whom are from destitute families, where the main breadwinner has been killed or injured. The experience of Syria over the past five years is well documented in a series of reports from the United Nations Development Programme and the Syrian Center for Policy Research (SCPR). So to answer this question, sanctions in this case are not simply immoral but they perpetuate conflict and misery.
What is the most important advice you could give to young scholars of social and political science?
The most important advice one can provide to students is the need to improve knowledge and understanding through interdisciplinary approaches to studies. Understanding how international relations are affected by both the formal and the informal, for example, requires the prism of more than one discipline. Most notably, the significance of agency and the voice of the marginalized is particularly relevant, and not just in the study of elites or of hard power which dominate the field of IR and political science. It is so important to be prepared to challenge dominant narratives and stereotypes in relation to “ethnic” stratification and conflict in the Middle East and North African region. Most of all, for those of us based in special institutions in the western world, it is important to retain a sense of empathy and humility with those in the front line of struggle.
This interview was conducted by Atrin Toussi. Atrin is an Associate Features Editor at E-IR.