Kaveri Qureshi is Lecturer at the Global Health Policy Unit, Department of Social Policy, University of Edinburgh. She tweets @KaveriQureshi.
Review by Shruti Chaudhry, 8th October 2020.
Based on two rounds of fieldwork conducted over a decade, this rich ethnographic study of Pakistanis in East London is a heartbreaking and powerful account of what it means to live and cope with illness in a deeply unequal society. Pakistanis, as also Bangladeshis, are the ethnic groups most disproportionately afflicted by chronic illness in Britain (p.15). Locating diasporic studies at the centre in her attempts to unpack the ‘path specific inequalities’ that produce illness, Kaveri Qureshi shows how structures of class and race become ‘sedimented into the body’ (p. 7). Chronic Illness in a Pakistani Labour Diaspora provides useful insights on premature ageing and death, for chronic illness in a person’s 40s was described by the people Qureshi worked with ‘if not as an acceptable state of affairs, then as a normal one to be expected and, perhaps, put up with’ (p. 21). She sensitively documents experiences of chronic illness by building on three aspects of Julie Livingston’s (2005) work in Botswana on the ‘moral imagination’ triggered by chronic illness, structuring the book in three parts: the explanations offered for chronic illness; the questions it raises about our responsibilities towards one another; and why life has taken a particular trajectory rather than the one people had hoped for.
In Part One, Qureshi describes how the first-generation of post-war migrants explain their chronic illnesses as resulting from migration to Britain. She shows how illness narratives are not simply explanatory frameworks but serve a ‘performative’ function: ‘transforming bodily suffering into the morally legitimate product of having sacrificed the self, in the process of migration, for the benefit of kin’ (p. 26). Men saw their chronic illnesses as caused by performing ‘hard’ and ‘hazardous’ labour, as one informant put it: from ‘being made to work like a donkey’ in the bottom rungs of the industrial workforce (p. 62). For women, it was care and domestic responsibilities that had to be combined with paid employment and the experiences of childbearing (chapter three). Additionally, chronic illness was attributed to the misfit between the ‘traditional’ diet and the post-industrial way of life in Britain and to the stress and tensions emanating in the domestic domain (chapters four and five). Qureshi shows how most narratives speak not of familial support but of the precarity of kinship: decision-making around cooking reveal strains within gender and marital relationships, while family conflict, largely separation and divorce that has increased among Pakistanis (see Qureshi 2016), produces deeply embodied distress. The narratives draw attention to the patronising attitudes of health professionals about ‘unhealthy’ Pakistani diets (chapter four) and unexplained illnesses (chapter five) and how racism within health care can lead to misdiagnosis and deny access to services (chapter three). Qureshi finds that the expression of illness in somatic terms, which she interprets in terms of embodied metaphors concerning pressure, also circulates in the health services as a stereotype, and generates feelings of inequitable neglect when health professionals seem disinclined to take their symptoms seriously.
Part two documents the impact of de-industrialisation and the decline of the welfare state on chronically ill Pakistanis. Qureshi argues that the high levels of incapacity among first generation migrant British Pakistanis was not only due to chronic illness, but decline in health ‘that coincided with the decline of the manufacturing sector in East London’ (p. 144). Industrial restructuring forced those who were chronically ill out of the workforce. For this generation of men, the shift to self-employment offered few protections and introduced new risks. Qureshi also highlights the struggles of the younger generation in entering and sustaining jobs in the informal service-sector economy (chapter six). Incapacity made dependence on benefits a lived reality for many of her informants. She shows how the indignity of having to ‘battle’ with a punitive welfare system, necessitated ‘performances of ever-more disabling forms of illness’ (p. 171). In order to survive, people turned to friends and neighbours for financial support as dependence on kin was often more complicated and tied to cultural understandings of not losing face and maintaining one’s sense of dignity (chapter seven).
The focus of part three is on how people make sense of and cope with illness. Here Qureshi further develops Livingston’s ideas through her arguments about selfhood and agency. Chapter eight contains a fascinating discussion of sabar (patience) as moral and ethical becoming in the realm of a life lived with chronic illness. Though embodying sabar is spoken of in terms of being a good Muslim, Qureshi argues that for women, sabar was not only about bearing suffering internally that brought them closer to God. It was ‘intersubjective’ as the enactment of sabar demanded recognition from others – the family, husbands and children (p. 204). She extends this discussion on moral and ethical becoming through a focus on narratives about dreams and premonitions that tell of tragedies and deaths in the family. These narratives speak of connections with the divine that allow people to cultivate good Muslim selfhood and narratively plot or re-envision a sense of hope (chapter nine).
In detailing why health inequalities exist, persist and even worsen among successive generations of Pakistanis in Britain, Qureshi makes an important argument about chronic illness as social illness. She writes: “There is a tangible and enduring association between ethnic inequalities in chronic illness and ethnic inequalities in socio-economic position, and that to this day, these have not been addressed by the government in any comprehensive manner” (p. 15). This inaction in addressing the wider social determinants that create illness has been brought sharply into focus by the current Covid-19 pandemic and its disproportionate impact on BAME communities (Meer et al. 2020). Chronic Illness in a Pakistani Labour Diaspora is a timely and important contribution and deserves to be widely read.
Dr Shruti Chaudhry is a British Academy Postdoctoral Fellow in Sociology at the University of Edinburgh. Her research focuses on the relational lives of ageing South Asians (Indian Sikhs and Pakistani Muslims) in Scotland.