Relational Harm: On the Divisive Effects of Global Health Volunteering at a Hospital in Rural Zambia

ABSTRACT Drawing on ethnographic research at a hospital in rural Zambia, I show how the presence of white Christian medical volunteers from the United States damaged relations between local health workers and patients. Working from a position of economic and racial privilege, medical volunteers received praise from many patients and residents. However, these positive attitudes incited resentment among many Zambian health workers who felt that their own efforts and expertise were being undervalued or ignored. Focusing on these disrupted relationships, I argue that it is crucial to understand how global health volunteering can produce enduring forms of “relational harm”.

As the district chief observed, the ceremony itself was a rare event.And yet the positive feelings, attitudes, and sentiments that were expressed during the ceremony were relatively common.As I began my research, I was often surprised to find such positive attitudes being directed toward the missionary couple at the center of this ceremony, in addition to many of the other medical volunteers who arrived on short-term trips from all over the US.These positive attitudes were not confined to formal settings such as the ceremony.They were a widely acknowledged and visible part of everyday life within the hospital -present in the conversations, interactions, and relations that emerged as Zambian patients, local residents, and staff members encountered missionary volunteers.
It is difficult to situate these positive attitudes in relation to recent critical discussions about global health volunteering.Within the past decade, anthropologists have participated in crucial debates about coloniality, inequality, racism, and what the writer Teju Cole (2012) has called the "white saviour industrial complex" (see also Banerjee 2023;Khan et al. 2023).Anthropologists have shown how medical volunteering reinforces economic and racial hierarchies and naturalizes the idea that people in the Global South need the help of white volunteers (Benton 2016;Fassin 2011;Sullivan 2018;Wendland et al. 2016).These anthropologists have shown how conditions of racial and economic inequality can also enable harmful practices, for example when white volunteers engage in medical procedures without the necessary qualifications, experience, or skills (Brada 2016;Sullivan 2018;Wendland 2012). 2  In many of these discussions, critical scholars have foregrounded the perspectives of people in countries in the Global South who regard international medical volunteers in morally and politically negative terms (e.g.Sullivan 2018).For critical scholars, positive attitudes of the kind that were on display at the ceremony described above are a somewhat awkward or troubling presence.These voices are therefore often absent from the discussion or, when they are included, are identified as evidence of an "ambivalent" response to medical volunteering (e.g.Rozier et al. 2017;Wintrup 2020).Positive attitudes are more likely to be highlighted in the scholarship of those who already endorse or support medical volunteering -or in the promotional material of organizations who advertise and fund these forms of volunteering (Nyahunzvi 2013).In this article, I argue that critical anthropologists should pay more attention to the positive attitudes that emerge in spaces of medical volunteering -not in order to contest the critiques of medical volunteering outlined above, but in order to strengthen and extend them.This is because the presence of positive attitudes can have divisive effects and lead to what I call "relational harm." This can be seen by returning to the ceremony.As I subsequently discovered, this event was more controversial than I had initially realized.With some notable exceptions -to be discussed belowmost of the Zambian health workers at the hospital refused to attend the ceremony.While some were busy working at the time, a large number did not want to attend an event that celebrated the presence of Christian missionaries.For these Zambian staff members, the positive attitudes expressed by patients, residents -and a few of their fellow colleagues -were an enduring source of frustration and resentment.These Zambian health workers felt that their own hard work was being consistently overlooked and undervalued.For many staff members this was personally demotivating.For some it provoked feelings of bitterness and resentment toward their colleagues and patients, while for others it raised questions about race, solidarity, and inequality.
Focusing on these positive attitudes brings the relational field (Seo 2016) of the hospital into view and makes it possible to see how medical volunteering can undermine and disrupt moral and emotional relationships within the hospital space.As Shona Lee et al. (2022) have recently argued, a significant amount of moral and emotional work is required to support and maintain relationships within healthcare settings -and these relationships can even be conceptualized as a kind of "relational infrastructure" that needs to be strengthened and repaired over time in parallel to the material infrastructure that makes healthcare possible (Lee et al. 2022;cf. Simone 2014).Just as these relationships need to be cared for over time, it is also possible for them to be damaged, undermined, and disrupted.Attending to relational harm therefore offers a way of thinking about the problems of global health volunteering, showing how the presence of volunteers can have divisive and damaging effects.
First, I show how these positive attitudes need to be understood in relation to material inequality and racial hierarchy.The positive attitudes of many patients emerged in the landscape of Zambia's historically underfunded public health system and the widespread perception (among many patients and their family members) that Zambian health professionals did not always "attend to" patients properly in their clinical encounters (cf.Berry 2008;Mulemi 2008).In this context, medical volunteers from the US occupied a position of extreme privilege: they arrived with new objects and devices (e.g.blood pressure cuffs, glucose testing kits, stethoscopes, and medical gloves) and they could offer gifts (e.g.travel money, books, and food).They were also able to devote an unusually large amount of time and energy to their clinical encounters.At the same time, as white volunteers, these medical missionaries occupied a position of racial privilege and were associated (in the eyes of some patients) with greater expertise and competence in comparison to Zambian staff members (cf.Benton 2016).Taken together, these dynamics created the appearance of high quality care, despite the fact that many of these volunteers were often unable to offer effective or appropriate forms of treatment (something keenly noted by many Zambian staff members themselves).
It was not only patients who expressed positive attitudes toward visiting missionaries.In the second part of the article, I consider the positive attitudes of a small number of Zambian health workers at the hospital.Some of these Zambian health workers became close to visiting missionaries and received favorable treatment from them, including even the possibility of future career advancement.This strained the relationships between health workers who were perceived to be "chosen" by volunteers from the US and those who were excluded from these opportunities.In the final section, I explore the effects of these dynamics on the relational field of the hospital by examining the experiences of two Zambian health workers at the hospital: Matthew and David.By focusing on their experiences, it is possible to understand how relational harm manifested and left enduring traces.
The fieldwork on which this article is based was carried out over 13 months between 2014-2016.The ethnographic material here is drawn from fieldwork conducted within different departments of the hospital and in the surrounding area -at rural health centers, homesteads, and other social settings.I also draw on interviews, informal conversations, and short encounters.During the period of my fieldwork, around twenty five Christian medical missionaries arrived at the hospital.A great deal of research has explored the motivations and experiences of volunteers from the Global North (e.g.Howell 2012;Malkki 2015;Wintrup 2021), but here I choose to bracket the experiences, motivations, and biographies of these Christian missionaries in order to foreground the lives, experiences, and relationships of Zambian patients, local residents, and health workers.

Medical volunteering and relational fields
Outsiders from the US and Europe have been arriving in rural Zambia to provide medical care from the mid-twentieth century to the present-day.During the colonial period, the majority of these medical volunteers were Christian missionaries of various denominations (Carmody 2003;Colson 1958).As historians and anthropologists have shown, contemporary global health and humanitarian programs have been enduringly shaped by the colonial origins of Christian missionary medicine (Redfield 2013;Vaughan 1991).Within the past few decades this longer history of Christian missionary intervention has intersected with the rise of global health volunteering (Lasker 2016;Wendland et al. 2016).In the aftermath of structural adjustment and the HIV/AIDS epidemic, philanthropic and global health organizations -particularly from the US -have come to dominate the landscape of healthcare provision in many countries in Africa.In southern Zambia, medical missionary volunteers therefore join a long tradition of missionary intervention in the region, even if they often identify themselves more strongly with contemporary global health imaginaries (Lasker 2016;Sullivan 2018).
The hospital where I conducted research -which I call here Matamba Mission Hospital -is a product of this intersecting history of missionary medicine and global health.Originally built during the late colonial period by Protestants from the United States, it was partially incorporated within the public health system during the independence period (see Kalusa 2014).During the past twenty years, the hospital has grown considerably as new departments have been built through the funding of successive volunteers and church groups who have decided to support global health initiatives.The hospital was made up of multiple departments, including a maternity ward, male and female wards, a laboratory, and an X-Ray department.The hospital had 130 beds for in-patients, and the only operating room in the area for a catchment population of over 300,000 people.At the time of my fieldwork, there were 50 Zambian staff members -a diverse group that included nurses, laboratory technicians, midwives, and clinical officers.
When Christian missionary volunteers arrived, they worked in different sections of the hospital.Some moved between departments -from the male and female wards to the maternity ward to the out-patient department (OPD) -while others remained more fixed in place, such as the surgeons and anesthetists who worked primarily in the operating theater.This meant that some volunteers interacted with a variety of Zambian health professionals, while others worked with only a handful of Zambian staff members during their stay.Although the presence of these missionaries was therefore differentiated and uneven within the hospital space, their arrival had a broader impact on the relational field of the hospital.
In recent years, anthropologists have explored the relational aspects of health interventions and hospitals in new ways.Rather than seeing health interventions as "stable" or "localised," anthropologists have highlighted the multiple, contingent, and unpredictable relations that emerge through these projects (e.g.Brada 2016;Lea 2020).In her work in Mozambique, Ramah McKay (2017) has shown how humanitarian and global health interventions produce a "multiplicity" of new relations and forms of care, many of which are often overlooked or "rendered external" to these interventions -such as the labor of volunteers and extended family members.These approaches resonate with work that has explored how hospital spaces themselves are relational fields that are charged with powerful and unpredictable emotions, affects, and feelings -such as fear, hope, and gratitude (Seo 2016:280) -and are composed of different historical layers and traces that produce distinctive "affective landscapes" (Street 2012; see also Chabrol 2018;Prince 2020).
Drawing inspiration from these approaches, in this article I am interested in how the presence of white volunteers from the US affected relations within the hospital space -particularly in light of the positive and negative attitudes that were incited by their arrival.Tracing the positive attitudes (gratitude, praise, and approval) as well as the negative attitudes (resentment, animosity, and frustration) reveals how the presence of volunteers shaped the relational field of the hospital in enduring ways.
For health workers, navigating complex relations within hospital spaces is often extremely challenging.As Shona Lee et al. (2022) have recently shown in their research on health workers in Sierra Leone in the aftermath of Ebola, the "relational work" undertaken by health professionals is morally and emotionally demanding (cf.Jakimow 2018).And yet this work is "often naturalised and devalued through the framings and rhetoric of heroism, duty, and selfless sacrifice . . .thus [falling] outside financial and professional systems of recognition and reward" (Lee et al. 2022:4131).By focusing on the relational dynamics of healthcare work, it is possible to think about how harm or damage can be done to these relationships.As I show in this article, the presence of global health volunteers created forms of division that made it more difficult for many Zambian health professionals to work with their patients and colleagues, ultimately producing long-lasting relational harm.Before exploring this relational harm directly, it is important to examine why the presence of medical volunteers produced positive attitudes.And this requires situating these attitudes within the ethnographic context of the hospital and the surrounding area.

A heart for patients
Beyond the setting of the ceremony described above, patients and residents expressed their positive feelings toward visiting missionaries in various ways.I noticed these positive attitudes early on during my fieldwork in conversations and interviews with patients and residents.A community health worker called Daniel -who lived many miles away from the hospitalexplained to me that visiting missionaries were popular in the villages where he worked: "If you visit the villages, then they are always talking about the good things that they [the missionaries] are doing . . .The people in the villages they are really appreciating . . .people are very happy with them."A young Zambian man called Adam who worked for a local NGO described the positive feelings of many residents: "When I am playing pool at the bar, I hear people talking and they are saying that these missionaries are so good."However, it was in conversations and interviews with patients themselves -many of whom had traveled for hours from the surrounding rural area to visit the hospital -that I encountered the strongest positive attitudes.
Sarah was a middle-aged Zambian woman who had walked many miles to visit a relative who had been admitted to the female ward overnight.She was keen to discuss a particular missionary doctor who was providing a high quality of care.During our interview, Sarah explained that this doctor "has a heart for patients."When I asked her what she meant by this, Sarah said that this doctor "doesn't look at who he is dealing with . . . he can be there for anyone."The idea of having a "heart" for medical work is a common idiom in the region.Claire Wendland (2010) has suggested that the term describes a form of imaginative connection and empathy for patients.I found the term was often used by patients to distinguish between health workers who had a "genuine" motivation to help others in contrast to those who were motivated by money or self-enrichment (cf.Minn 2016).As a woman called Mainza -who was visiting the hospital to see her daughter -said to me, "some are called to serve, while others are called for money.People come from different backgrounds.And the thing is, those who are there for money, they let people die."Zambian staff members who worked long hours and treated patients without favoritism were often therefore identified as having a "heart" for the work.
These positive attitudes were not only expressed in interviews and conversations.This is important to point out because my own position as a white anthropologist shaped my interactions and encounters with Zambian patients and residents.Although I explained (often at great length) that I was not a Christian missionary or a medical volunteer, it is possible that some people nevertheless assumed that I wanted to hear positive stories about these other white visitors. 3As Nathaniel Roberts has pointed out, "no anthropologist . . .[should] simply take flattering statements about foreigners at face value, at least not if she herself were foreign" (2016:76).This is why it is worth highlighting the many ways in which these positive attitudes were expressed outside of interviews and conversations.
Positive attitudes toward visiting missionaries were publicly visible in several ways.For example, many patients preferred to be seen by visiting missionaries or sought out second opinions from visiting missionaries if they felt they had not been treated properly by a Zambian staff member.In the out-patient department (OPD) of the hospital, patients who had seen a Zambian health worker and were unsatisfied with the encounter would sometimes wait to see a missionary volunteer -for example by rejoining the queue or approaching them elsewhere in the hospital.I observed this on many occasions and asked several patients about it.A woman called Mutinta explained this behavior in the following way: The missionary doctors have a heart for patients.The other doctors [the Zambian staff] can see the patient, but if we are not satisfied then we can go to [the missionary doctors] and . . .[then] they will prescribe us the correct medication that we need.
The positive attitudes of many patients were visible in these behaviors -which were noted by Zambian staff members.A health worker called Thomas who worked in the operating theater gave me a similar example: "A patient a few months ago came to see my [Zambian] colleague.My colleague said, 'I'll find you back in the OPD to book a date for your case' and the patient said, 'So that I can be seen by a missionary doctor?'"Thomas's colleague was insulted by the apparent eagerness of this patient to be seen by a white volunteer.Many Zambian health workers remembered similar interactions in which patients revealed their preference for visiting missionaries.
These positive attitudes were therefore highly visible -and memorable -to Zambian staff members.But before exploring how these positive attitudes shaped the relational dynamics at the hospital, it is important to consider why the presence of missionaries was associated with these positive attitudes.As I suggest below, it was not because they were able to offer medical treatment of a higher quality, but often had more to do with material wealth and racial privilege.

Lightness, heaviness, and inequality
When missionaries arrived at the hospital, they occupied an extremely unequal position -at the intersection of racial, economic, and educational privilege.Even as they worked within the same shared hospital space, their everyday lives were dramatically different to those of Zambian health workers and patients.Visiting missionaries lived parallel lives of material comfort within the "enclave" of the mission compound, located a short distance away from the hospital.It was here that they ate, slept, and socialized with one another (cf.Smirl 2015).During their time in Zambia, volunteers had no other responsibilities or social relationships to support or maintain and they were able to focus almost exclusively on their hospital work (cf.Minn 2016; see also Wintrup 2021).
To use the language adopted by Peter Redfield (2012) in his work on Médecins Sans Frontières (MSF), these missionaries, were both "socially light" and "materially heavy."Apart from the temporary relationships that they actively chose to develop, these visitors had few obligations or social ties to others in the surrounding area.Nor were they weighed down by any of the burdens or tasks of ordinary life -buying and cooking meals, caring for children, attending social events.The social lightness of these visitors had a number of consequences.Because they stood outside of the relations of dependence and obligation that shaped the lives of Zambian staff members (Englund 2008;Ferguson 2013) they could treat patients on the basis of their immediate needs and triage them in a way that was considered to be fair (i.e.without prioritizing particular patients over others).This was valued by patients who were used to public clinics and hospitals in which treatment was often selectively expedited for wealthier patients or those who were well-connected to Zambian staff members (cf.Hull 2012;Mkize 2007).This was reflected in the language used by patients and local residents who praised missionaries for "not looking at who they are dealing with" or being prepared to treat "any class of person." At the same time, these missionary volunteers were also "materially heavy."They arrived with medical objects and devices bursting from their bags: blood pressure cuffs, stethoscopes, syringes, and blood glucose testing kits.Missionaries were therefore able to offer patients things that were ordinarily unavailable within the hospital.This included even basic items such as medical gloves.Early during my fieldwork, I found a note attached to the door of the male ward which stated: "The hospital does not have any examination or sterile gloves . . .It is with regret that we have to ask our patients to buy their own gloves for use."This meant that missionaries who arrived with an abundant supply of medical gloves were able to save patients the personal cost of purchasing gloves at the same time as demonstrating their care.
In addition to arriving with medical devices, many missionaries also gave small gifts to patientshairbands, books, bibles, as well as drinks and food that were purchased outside of the hospital.Sometimes missionaries offered small amounts of "travel money" at the request of family members.When they gave these gifts, visiting missionaries were entering into what Hannah Brown (2012) has called the "domestic space" of the hospital.At the hospital, family members played a key role in caring for patients who were admitted to the wards: they sat by the beds of their relatives, fed them, gave them medication, and interacted with the hospital staff.When missionaries offered gifts of food or travel money -or even spared patients the expense of buying their own medical gloves -they were entering into this domestic space of care that usually remained differentiated from the clinical space of the hospital.This created emotional attachments and positive attitudes -even if transient -between certain missionaries and patients.At the same time, these practices differentiated missionaries (in the eyes of many patients) from Zambian staff members who could not afford to offer these kinds of gifts.Furthermore, because the boundaries between hospital supplies and gifts were blurred (e.g. in the case of medical gloves), many patients imagined that medical devices and objects from the US were actually hospital supplies that were ordinarily withheld or appropriated by Zambian staff members.This increased the admiration that many patients felt toward volunteers, while it simultaneously strengthened the suspicion that Zambian staff members were keeping supplies (particularly medicines) for their own use.In her research in a hospital in Tanzania, Adrienne Strong found similar suspicions among patients who accused staff members of corruption when they found that the hospital was lacking basic supplies (2017:221).
Patients who encountered visiting missionaries from the US compared them directly with Zambian staff members -who were, to reverse the metaphor, socially heavy and materially light.Public clinics in rural Zambia were chronically underfunded and under-resourced.Many staff members found themselves in difficult financial circumstances, particularly those who had large families and multiple dependents to support.As people with permanent jobs in a region of widespread unemployment and poverty, these Zambian health workers were routinely subjected to redistributive demands on their resources -from relatives, friends, and acquaintances (cf.Whyte et al. 2013;Ferguson 2013;cf. Street 2014:155).Consequently, some of these health workers gave preferential treatment to relatives, friends, and acquaintances when they arrived at the hospital requiring treatment.
For patients who were not connected to staff members, these forms of preferential treatment were regarded as deeply unfair.Patients complained that Zambian staff members would "choose" (kusala) particular patients for special treatment -a word that in Chitonga also means to privilege, favor, and prioritize. 4These patients did not claim that the hospital should be governed by values of bureaucratic anonymity or abstract equality but rather adopted a critical attitude to forms of favoritism that led to ordinary patients being neglected.The expectations of patients were also shaped by other experiences of healing.For example, in vernacular forms of healing in rural Zambia, it is important for patients to carefully narrate the broad circumstances of the emergence of their afflictions, including encounters and conflicts with others (Banda et al. 2007;Sugishita 2009).These interactions are therefore similarin form if not in content -to the kind of history taking that is involved in biomedical consultations (cf.Mogensen 2005).It is important to point this out because patients did not necessarily want to ensure that their afflictions had been made biomedically "legible," but rather valued being attended to carefully and asked multiple questions. 5 This is perhaps why some patients were dissatisfied when they had short or perfunctory interactions with Zambian staff members -interactions that might (from a clinical perspective) have been effective and efficient.
The positive attitudes of many patients toward visiting missionaries were therefore a result of the distinctive position of material wealth and privilege that volunteers occupied.Visiting missionaries were able to use new medical devices, distribute gifts, spend a long time in clinical interactions, and triage patients in a way that was positively valued.At the same time, their position as white volunteers also shaped how they were perceived by many patients.

White savior complexities
When missionary volunteers began working at the hospital, they entered a context in which whiteness and racial hierarchy shaped their experiences and encounters -often in ways that appeared entirely natural to them.As anthropologists have found in other settings, many white volunteers believe that they represent "real medicine" (Sullivan 2018;Wendland 2012) in opposition to the medical practices they encounter in the Global South, which they imagine as deviating from their own high professional standards.In this way, as Warwick Anderson has pointed out, biomedicine is associated with "an unmarked whiteness" (2006:464).Many volunteers assumed that, as medical professionals from the US, their own expertise and knowledge was inherently authoritative and superior (cf.Lasker 2016; Sullivan 2016). 6 It was not only volunteers who operated with these ideas.In her work in Ghana, Jemima Pierre (2012) has shown how white supremacy and racial hierarchy operate in African contexts in which the majority of the population are Black.Pierre has argued that processes of racialization -connected to global structures of power that valorize whiteness -affect the lives of Ghanaians in different social and political domains.As Pierre suggests, whiteness should thus be understood as an "ideology, trope and cultural practice" (2012:72) that is part of a global history of racialization.These insights have been taken up by anthropologists of humanitarianism.For example, Adia Benton (2016) has argued that whiteness has often been decentered in anthropological work on humanitarianism -where the focus has more often been on political and economic inequality.By contrast, Benton highlights the importance of racial hierarchy and white supremacy in humanitarian settings, drawing attention to the often-overlooked experiences of Black expatriate humanitarians in spaces in which expertise and authority are strongly associated with whiteness.Benton (2016) shows that Black humanitarian workers often experience racism when they are perceived to be less well-qualified than their white colleagues.Benton analyses these dynamics as a reflection of what she describes as "the global -if not universal -reach of ideas of black inferiority that prefigures black expatriates' reception in various places" (2016:7).As Benton suggests, Black humanitarian workers experience racism "whether the local population identifies with them racially or not" (2016:7).In other words, the "white saviour complex" described by Teju Cole (2012) is not an ideology, trope, or fantasy that is exclusive to white volunteers themselves. 7 At the hospital, I found that Zambian staff members -like the Black expatriate humanitarians described by Benton (2016) -felt that they were perceived by many patients to be less competent than their white counterparts.This was deeply resented by Zambian staff members who felt that junior or less well-qualified volunteers were seen by patients as more competent clinicians on account of their whiteness.This is not to say that ideas about whiteness were without ambivalence.In southern Zambia, people bring a variety of ideas and expectations to their encounters with white visitors.The afterlives of colonial rule and violence continue to shape perceptions of white people within southern Zambia.Writing during the late colonial period, the anthropologist Elizabeth Colson noted that many people in southern Zambia felt that white people were "unpredictable beings whose ways are difficult or impossible to fathom" and who often had "some ulterior motive for their behaviour" (Colson 1958:267).Similar forms of suspicion continue to surround white people today, including in medical settings (Wintrup 2020).And yet, within the domain of the hospital, the white medical volunteer was also a recognizable figure that was associated with clinical knowledge and expertise.
In order to understand the positive attitudes that were expressed toward visiting missionaries by many patients, they need to be contextualized in relation both to material inequality and racial hierarchy.Taken together, these dynamics shaped the reception of volunteers within the hospital space and led many patients to identify visiting medical volunteers with a higher quality of care.However, it is important to note that even when the care offered by medical volunteers appeared to be of a high quality, it was often inefficient or inadequate.

The appearance of care
In 2015, I spent some time with a short-term visiting missionary who was newly qualified in family medicine and who volunteered in the OPD for several weeks.During his first few days at the hospital, this doctor often spent an extremely long time in consultation with patients and their family members.During these consultations, the translator -a Zambian woman called Ruth -had to explain many of the hospital protocols to this doctor and advise him on a variety of questions about the living conditions of patients, their likely access to different types of food, the appropriateness of his advice, and a variety of other crucial issues.These clinical interactions were only possible through the labor of translators such as Ruth who did much more than simply "translate" (cf.Sullivan 2016). 8The sheer amount of time involved meant that these consultations ended up feeling exhaustive and thorough.In the case of the newly qualified doctor in the OPD, many patients thanked him afterward for taking so much time.However, even though the time spent was greatly appreciated -and was a sign of a certain level of conscientiousness on the part of this doctor -it was not always an indication that he was able to offer a high quality of care.
This was a common pattern when volunteers arrived.They typically worked at a much slower pace than their Zambian counterparts.Volunteers navigated misunderstandings as they spoke with patients through translators; they confronted the limitations of their epidemiological knowledge about afflictions that were present in rural Zambia but which they had not encountered in the US; they found themselves struggling to establish relevant information in patient medical histories; and they often remained unsure about hospital protocols.As several Zambian staff members pointed out, many volunteers were simply inefficient and took a long time to do things that Zambian staff members were able to do swiftly and intuitively.Several Zambian staff members pointed to the gap between the appearance of high-quality care and the reality.As one staff member said to me, "These international [volunteers] . . .they really look like they are better and even patients start to see a big gap.But it is not that Zambians are worse!"This is one of the reasons why staff members often felt that missionaries did not deserve the praise they received from patients and local residents.
In the sections above, we have seen how material inequality and racial hierarchy shaped how visiting medical missionaries were perceived.It is within this context that the positive attitudes of many patients should be situated and understood.However, it was not only patients who perceived missionaries in positive terms.A small number of Zambian staff members also regarded medical volunteers in positive terms -and the positive attitudes of these staff members also shaped the relational dynamics at the hospital in important ways.

Few are chosen
Situated next to the out-patient department, the hospital's dispensary was in the middle of a small courtyard at the center of which was a row of wooden benches, where patients could wait to collect their medication.The dispensary was staffed entirely by a single Zambian pharmacist named Nchimunya."I am doing the job of three people," he told me on the first day we met.Nchimunya had worked in the dispensary of the hospital for around two years.For several months, I sat alongside Nchimunya and helped him pack pills into the small plastic bags that were given to patients.We talked for many hours during this time -particularly when the queue of patients had finally receded, and it was possible to take a break.In the course of our conversations, Nchimunya told me about his background, his hopes for the future, and his relationships with many of the different Christian missionaries who had visited the hospital over the years.
Despite feeling overworked and occasionally finding certain missionaries personally difficult to deal with, Nchimunya expressed strong positive feelings toward them -indeed, he was one of the few staff members who attended the ceremony described above."I think the missionaries are good people and they should keep coming," Nchimunya told me in one of our conversations.Nchimunya's attitude was shaped by his distinctive experiences and encounters with medical volunteers from the US.After leaving school and working in short-term and precarious jobs, Nchimunya had decided to go back into education to train for a diploma in Pharmacy Technology.However he struggled to raise the money to cover the costs of this training and had to rely on the support of relatives.After finally gaining his diploma and working in a small rural hospital in a different part of the country, Nchimunya was transferred to Matamba Mission Hospital, where he encountered volunteers from the US for the first time.While working alongside these missionary doctors, two of them offered to pay for him to gain further training in pharmacology at a cost of around US $3000.Nchimunya was able to move to the capital city for three years and dramatically improve his career prospects through this new training.
It was not widely known among other Zambian staff members that Nchimunya's further training had been funded by visiting missionaries, but many staff members speculated that certain colleagues had been "chosen" by visiting missionaries and offered the chance for further training and education.Similar dynamics have been identified in other settings.In her research in Tanzania, Noelle Sullivan found that among health professionals who hosted international medical volunteers, patronage was "not expected" but "wished for -institutionally and personally" (2016:151).At the same time, Sullivan found that "no one seemed to know which staff members had managed to secure a sponsor from their volunteer guests" (2016:151).I found in Zambia that there was also uncertainty about whether certain staff members had been offered economic and professional opportunities, but those who were perceived to be "too close" to the missionaries were often rumored to be the beneficiaries of such opportunities.
A staff member who was close to the missionaries -but who had not (to my knowledge) received any support from them -described how his proximity to them incited this kind of suspicion: "I get on with many of the missionaries . . .and there have been people here who have asked me if the missionaries are paying me or my fees because they are muzungus [white people] and have money."In a context where wealth -particularly sudden wealth or good fortune -was carefully observed and monitored by others, the ability of certain staff members to move to the capital city for further training or to pursue other professional ambitions was highly conspicuous and widely discussed.
Staff members who had a positive attitude toward visiting missionaries -and who were "chosen" for privileged treatment -were often those who, like the missionaries themselves, were more "socially light" than many of their colleagues.For example, staff members who had a wider network of dependents to support and whose lives outside of the hospital were more demanding were less likely to be identified by missionaries as "hard-working" or "promising."When missionaries made the decision to offer economic assistance to certain staff members -such as Nchimunya -it was often because these staff members were able to spend long hours working at the hospital.Nchimunya himself was able to spend more time at the hospital because he did not have a large family to support.Staff members who were less likely to be offered help by volunteers (i.e. through money or training) were typically those who had many dependents to care for, who could not afford to work overtime, and who were unable to spend their own money on objects such as medical gloves.Just as staff members often found it unfair or unjust when patients developed strong affective ties with missionaries, it was also resented when staff members who were already in a better economic position were offered additional opportunities for professional advancement.
Having described the ethnographic context in which positive attitudes toward visiting missionaries emerged among both patients and staff members, it is now possible to explore the relational dynamics and forms of division that resulted.

Relational harm
Within the hospital, many Zambian staff members were highly attuned to the dynamics that I have described above.These staff members knew that visiting missionaries were able to work from a position of extreme privilege -educational, racial, and economic.These staff members were also aware that many visiting missionaries were not always providing care of a high standard, due to their inefficiency and lack of local knowledge.In this context, the presence of positive attitudes was deeply frustrating for many staff members and shaped the way in which they related to their patients and colleagues.In this final section, I describe the perspectives of two health workers at the hospital whose experiences help to illuminate the nature of this relational harm.
Matthew was older than many other Zambian staff members.He was a clinical officer and one of the most highly trained health professionals at the hospital.In his work at the hospital, Matthew moved between different departments -from the OPD to the operating theater.He had therefore worked with a number of visiting missionaries over the course of his career.Matthew explained to me that he had good working relationships with many of these missionaries, but he complained about how their presence had altered his relationships with Zambian patients and some of his colleagues over time.I met Matthew shortly after I began my fieldwork, but it was much later on that I got to know him properly.I had been conducting interviews with different staff members who had begun to open up about some of their negative experiences with volunteers.When Matthew discovered that I was interested in learning about the perspectives of staff members who had difficult experiences with visiting missionaries he approached me and asked me to interview him.
As I have described above, one of the reasons why patients felt strong emotions toward visiting missionaries was due to the perception that they were able to offer a higher quality of care.This was something that frustrated Matthew: Most people will say that [the missionaries] will help with transport money and [the patients] get back home and then they share with their friends that they got transport money.But sometimes this is at the expense of local staff who then get called bad.We are not trusted ourselves . . . .so most of the people who work hard are not seen to work hard.So the patients will group us together and exclude us.
Matthew felt that the positive attitudes of patients toward missionaries who gave them transport money directly contributed to a negative assessment of Zambian staff members.Matthew raised the giving of gifts and transport money as a problem that led to unfair accusations that Zambian staff members were less caring.For Matthew, it was distressing that he and his colleagues were not being recognized -"most of the people who work hard are not seen to work hard."For Matthew, the presence of positive emotions being expressed toward visiting missionaries was therefore experienced as personally demotivating.
Matthew experienced a form of what Tanya Jakimow (2018) has called "affective injury" -the metaphorical "slap in the face" that is experienced as a rejection of one's efforts to help others.As Jakimow has described: "It is the lack of gratitude, the rejection of claims that she is 'doing good,' that has an affective force: a force all the greater as it questions her self-understanding" (Jakimow 2018:558).After working for so many years at the hospital, Matthew felt that his hard work and labor were being ignored and overlooked.Matthew experienced the presence of these emotions not as one-off events -the single metaphorical slap -but as an ongoing and enduring experience of estrangement.In one conversation, Matthew told me that it was important for him to be appreciated for the work he had done over the course of his life, but he felt that his retirement would not be noticed by anyone -a reflection that was especially poignant in light of the public recognition the missionaries received at a ceremony that was presided over by the district chief.
David was younger than Matthew and had been working for several years in the OPD.Like Matthew, he reflected on the relational dynamics at the hospital with some bitterness.David described his perceptions of material and racial inequality in the following terms: It affects us.Whether we are trained here or in the US, we learn the same things, but what creates a boundary is the delivery of service and you find out about the technologies that you people have . . . .But we don't have that equipment here and then . . .when somebody comes in and says they want to be treated by a white student, then you feel like a stranger in your own country.
David explained that when patients chose to see missionaries instead of Zambian staff, he felt estranged and rejected by these patients.I asked David about this idea of being a stranger and he explained that "when they [patients] see a Zambian doctor and they think, 'they won't be able to help me' . . .you feel neglected in your own country."This phrase was a striking way of describing these frustrations.David was articulating feeling estranged from his own professional identity and authority as well as feeling that his relationship to his patients -who were fellow Zambians -had been undermined.
When patients expressed positive attitudes toward visiting missionaries, this was experienced by David as a form of disloyalty to him as a fellow Zambian.The positive attitudes of patients were therefore regarded -in David's language -as a form of disharmony between Zambians who should recognize and appreciate one another.The whiteness and the foreignness of visiting Christian missionaries was a key part of this image.As David said, "when a patient makes a decision, then you respect that decision.But when they choose to see a white who is less qualified than you are, then it is frustrating, and I have felt it before." The positive attitudes expressed toward missionaries by patients had profound effects on the relational field -changing how staff members viewed and related to patients.In the ceremony described at the beginning of this article, the elderly chief of the district said that the event was "a challenge to all employees of this district."He was therefore directly comparing the work of missionaries and Zambian health workers, suggesting that Zambian health workers had something to learn from the example of white missionary volunteers.Even without this direct comparison, the presence of these positive attitudes and praise for missionaries was already experienced by many staff members as an implicit critique of their own performance.But the presence of positive attitudes toward these volunteers did not simply cause temporary forms of resentment and unhappiness -the relational harm was enduring.This can be seen in the different expectations that staff members, patients, and residents had about the future.

Divided futures
Toward the end of my fieldwork, a rumor began to circulate that the missionary couple at the center of the ceremony (described at the beginning of this article) might soon leave the hospital -something that might also discourage other missionary volunteers from visiting.After this rumor began to circulate, many staff members, patients, and residents began to discuss what the future might look like in the absence of missionary volunteers.When I asked people what they thought would happen, few were able to imagine a future in which the relations between health workers and patients would become harmonious or positive.David predicted that patients would face poor treatment from Zambian staff members.
You know, there is a normal human reaction.You will find that if a patient has always wanted to see a white person and then, when the whites are gone, they go and see a Zambian staff member.Then that staff member won't treat them well, saying, "You are only seeing me now that the whites have gone!"For staff members who were close to missionaries, similar anxieties were present.A Zambian health worker who worked closely with several visiting missionaries expressed his anxieties in the following terms: The fear that I have . . .just from my own observations ... [is that] the people who've been close to the missionaries and who have been retaining a lot of favours . . .they might suffer because people will say, "Your superiors are now gone, now see the way you will survive on your own!" The idea that those who were close to visiting missionaries -both patients and staff members -would face negative treatment in the future was common.One staff member told me that he thought one of his colleagues would leave the hospital because his relationships with other staff members would be too difficult to negotiate.
Patients and local residents expressed similar concerns.As Daniel -the community health worker described above -explained to me: "There will be very serious problems if there are no [missionary] volunteers to help . . .People in the villages will really not be happy."A stronger view was expressed by several women I spoke to outside of the maternity ward one evening toward the end of my fieldwork: "If the missionaries go then we will die, and children will die . . .this place will no longer be a hospital."Another woman added: "This hospital will crash to ashes."By contrast, many staff members were pleased.Those who resented the presence of missionaries imagined the prospect of their future absence with enthusiasm.As one staff member said to me: "I will be very happy . . .we need to have other Zambian doctors here instead."These different responses are evidence of the damage done to these relationships.The presence of missionary volunteers had altered these relationships and created new forms of anxiety, resentment, and division.
Finally, despite the presence of these strong attitudes, it is important to point out that the relational field of the hospital was not shaped entirely through binary attitudes -positive and negative -toward the presence of volunteers.Although these strong attitudes profoundly shaped relations at the hospital, there were staff members who did not articulate such strong attitudes or emotions.These staff members expressed something closer to resignation or disaffection with the dynamics that I have described here.There are different ways of understanding these forms of disaffection -the emotional withdrawal that clinicians experience through challenging medical work (Wendland 2010) or the cultivated form of detachment that is encouraged through medical training (Holmes 2023).However, against these portrayals of disaffection as a dulling of engagement or empathy, it is also possible to think about it in more positive ways.In her recent work, Xine Yao has explored how being "disaffected" can be understood as a political act in which "racialised and colonised peoples" refuse to exhibit "the reactive feelings attributed to [them]" (2021:52).Although it might seem obvious that disaffection or disengagement would be damaging to relations, it could also be that disaffection was a more or less conscious attempt on the part of some staff members to prevent further damage to relations by refusing to dwell in feelings of resentment, frustration, and bitterness.

Conclusion
In this article, I have tried to show how the presence of white medical volunteers at a hospital in rural Zambia disrupted relations between staff members and patients by creating division and resentment.The work of visiting medical volunteers was shaped by forms of material inequality and racial hierarchy that often produced the appearance of high quality care.As a result, many patients and residents expressed positive attitudes toward these visiting missionaries -something that was deeply resented by Zambian staff members who felt that their own hard work and efforts were being overlooked and undervalued.As I have shown, the presence of visiting missionaries -and the attitudes that their presence incited -was damaging to the relations within the hospital.
Understanding this kind of relational harm is important because the relationships that health workers have with one another and with their patients are central to the delivery of effective healthcare.And yet the fragility of these relationships is often overlooked.The challenges involved in maintaining these relationships involve "hidden" forms of emotional and physical labor that remain "socially invisible and economically undervalued" (Lee et al. 2022:4131).Returning to Lee et al.'s (2022) notion of "relational infrastructure" offers a way of thinking about their value and importance alongside the material infrastructure that is widely recognized as essential to healthcare.Adopting this approach makes it possible to think not only about how to support and maintain this relational infrastructure, but also about how it can be harmed, disrupted, and damaged.
One of the implications of the argument here is that anthropologists and other critical scholars should begin to examine the relational harm that can be produced through global health volunteering, as well as other global health interventions and programs.This means moving beyond the individual perspectives of those involved -whether patients or health workers -in order to situate these attitudes within a broader relational field.This approach has implications beyond the southern African context.Anthropologists have observed the frustrations of health workers in other parts of the world when foreign volunteers appear to get more of the "credit" than they deserve.As Pierre Minn has shown in his work in Haiti, health workers who felt that their work was devalued in relation to that of foreign volunteers highlighted these unfair dynamics by using the Haitian proverb Bourik travay, chwal galonnen: The donkey works, the horse gets the honors (Minn 2016:85).
When scholars and practitioners attempt to evaluate the costs and benefits of global health projects it is therefore important to consider the potential relational harms that might emerge.In settings that are under-resourced, healthcare involves a great deal of relational improvisation, repair work, and resourcefulness (Livingston 2012;Lee et al. 2022;Vernooij et al. 2022).This makes it even more important for medical volunteers and other global health actors to reflect on the ways in which their presence might cause relational harm.It can profoundly disrupt the lives of frontline health workers and their patients.

Notes
1.All names (including the name of the hospital) are pseudonyms.The biographical details of some of the people described have also been altered.2. This problem was highlighted in the case of Renee Bach, a missionary from the US who (without having any medical training) ran a clinic in Uganda where 105 children died.Bach is the subject of a 2023 HBO documentary series entitled Saviour Complex.See The Guardian (2019).3.As Adia Benton points out, many white anthropologists do not acknowledge how their work is shaped by the "structural benefits of whiteness in their field sites" (Benton 2016:10).I clearly benefitted in certain ways from an environment in which many people had positive attitudes to missionaries.At the same time, it was also more difficult to build rapport with staff members who were unhappy about the presence of white missionaries.4. It has the same connotations in other Zambian languages.Naomi Haynes (2017) has noted in her work on the Zambian Copperbelt, the term "to choose" (in Chibemba, ukusala) is used to convey "giving preferential treatment" and "favouritism" (2017: 88, 109). 5.As anthropologists have shown, care is not everywhere associated with qualities such as warmth, closeness, or affection.In other words, when patients praised visiting Christian missionaries, this was not because they necessarily shared the same ideas as Christian missionaries about what constituted care or effective treatment.6.Some missionaries were prepared to admit that their expertise was lacking.One missionary explained to me that, in her view, practicing medicine in the US was "entirely different" to practicing medicine in Zambia.She explained that it took her a long time to learn the skills required and what to expect in a different epidemiological landscape.At the same time, it was necessary to learn to make judgments and improvise without having access to the same diagnostic technologies that were available in the United States.In her view, there were therefore visiting missionaries whose presence was more valuable than others -for example, those who could perform specialist operations (such as visiting plastic surgeons), rather than those who were trained in family medicine.7. My thanks to the reviewer who suggested this.8.Even the basic take of translation itself presented challenges and required a great deal of skill and medical knowledge on the part of translators such as Ruth.This was sometimes not appreciated by visiting missionaries who simply assumed that Chitonga contained obvious corresponding equivalents to biomedical terms such as "lacerated cornea" or "transverse fracture"