Politics and practices of invisibility: an ethnography of the constituting of Chinese medical assistance in Rwanda

This thesis is the first ethnographic study of Chinese medical assistance in Rwanda and explores the implementation of Chinese medical programs in two Chinese-built hospitals: Kibungo hospital in Ngoma Eastern Province and Masaka hospital in Kigali. China initiated medical assistance in Rwanda after dispatching the first Chinese medical team from Inner Mongolia to Kibungo in 1982. Since then, Chinese medical programs expanded with the construction of the Kibungo and Masaka hospitals and connected road infrastructure, trade and donation of Chinese medicines, medical equipment, and training of Rwandan students and health professionals. However, despite encompassing a broad range of health interventions and existing for four-decades, Chinese medical programmes and the work of Chinese medical teams in Rwanda have virtually been unknown in the international aid community. Moreover, local hospital staff and patients broached the increasing disappearances of Chinese medicines from Rwandan pharmacies and the Chinese medical teams from local communities in and around the hospitals. Using a two-tiered theoretical approach to explain the constituting of Chinese medical programs, the thesis first imputes the marginalisation of Chinese medical assistance in Rwanda to the multiscalar governance system of Rwanda’s public health that is mainly directed by Western donors, undefined and excessive governance by the Rwandan state, and informal governing of Chinese doctors by local hospital staff. Secondly, it examines how practices of Chinese state and non-state actors contribute to reduce the visibilities of Chinese medical programs in Rwanda’s public health landscape. It addresses how certain Chinese foreign policy practices such as China’s non-intervention principle, the ‘hide and bide’ maxim and secrecy practices have contributed to produce Chinese absences from political fields in the international and global health communities. Furthermore, certain Chinese humanitarian praxis such as self-abnegation, self-effacing and self-sacrifice that are rooted in Confucian norms, encourage Chinese health workers to make themselves less visible while caring for others. Drawing from ethnographic material and the concept of “invisibility practices” i.e., actions to remain unseen or inscrutable, the thesis then illustrates how Chinese health workers in Rwanda used spatial barriers centred on the residence compounds and communication barriers that reduced their visibilities in and around the hospitals. These invisibility practices of the Chinese state and medical teams produced at least two paradoxical consequences for China’s reputations among locals in Rwanda. On one hand, absences of Chinese actors in Rwandan political fields fortified reputations of the Chinese government and Chinese health workers as impartial and reliable development actors in contrast to liberal Western actors that are perceived as more prominent but also inconsistent in their interventions. On the other hand, the spatial and communication barriers of Chinese health workers undermine social cohesion, medical collaborations in hospitals and elicit rumours and contempt from local hospital staff towards Chinese doctors and nurses. Simultaneously, Rwandan patients do not challenge the communication barriers raised by Chinese health workers due to preferences for impersonal doctor-patient interactions during medical treatments. Ultimately, this thesis makes original contributions to the scholarship of international aid and humanitarian interventions in the global South which hitherto is centred on Western actors. It unveils that spatial and communication practices of Chinese medical teams resemble many of the everyday practices of Western aid workers. However, Chinese medical teams differ from other international aid actors with a multiplication of their invisibilities towards the international community, locals and even towards other Chinese people in Rwanda