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Refugee COVID-19 protocol adherence and NGO staff perceptions: paternalism and power in humanitarian assistance

Abstract

During the COVID-19 pandemic, humanitarian NGOs have instituted safety protocols intended to reduce the risk of spreading infection during services to refugees. But those protocols are not always followed, and how staff attribute refugee non-adherence reveals underlying power dynamics in humanitarian assistance which can shape how they approach improving adherence in order to enhance effective service provision to the refugees. Using the data from 1466 interviews conducted with 468 different NGO staff in Türkiye, Jordan, and Lebanon, this study exhibits how paternalistic rhetoric operated in humanitarianism during the initial stages of the pandemic. While staff attribute the non-adherence of refugees to essential refugee culture and sometimes “immoral” character, they attribute their own non-adherence to morally neutral situational factors. Some NGO staff even perceived the refugees as incapable of complying with the safety protocols without assistance. While the literature on paternalism focuses on North/South power dynamics between service providers and refugees, our data show that these dynamics also exist in South-South humanitarian interventions where both the service providers and the refugees are from the region and have similar cultural backgrounds.

Introduction

In regions with large numbers of refugees, non-governmental organizations (NGOs) frequently provide a range of humanitarian assistance that is critical for the well-being of refugees. To provide services safely during the COVID-19 pandemic, those NGOs established certain safety protocols designed to mitigate the risk of spreading the SARS-CoV-2 virus, to which refugees and NGO staff alike are required to adhere. But when those COVID-19 safety protocols are not followed, how the staff at NGOs attribute refugee non-adherence and explain their own and their staff colleagues’ non-adherence reveals much about the power differentials between the service providers and the service receivers in the humanitarian sector. Scholars such as Barnett (2017) argue that the rhetoric of paternalism is adopted more often by the humanitarian workers coming from the West to provide services in the so-called Third World, but we argue that paternalism is enacted by humanitarian workers from the Global South as well. This reveals how power differentials are deeply embedded in humanitarian work and how “refugee-ness” is (re)constituted through humanitarian assistance.

This paper examines the attributions humanitarian staff make about refugees’ non-adherence to COVID-19 safety protocols in the Middle East where both the staff and the refugees are from the region and have similar cultural backgrounds. This paper is part of a larger study designed to assess the barriers to reducing the spread of COVID-19 during humanitarian assistance. We conducted a mixed-methods study with NGOs operating in Lebanon, Jordan, and Türkiye (three of the top refugee-hosting countries globally) between June and September 2020. In assessing barriers to better protocol adherence, we asked NGO staff what they saw as the most significant barriers, providing options for closed-ended and open-ended responses; in this paper, we analyze the open-ended responses. Many of the staff’s responses surprised us, while we expected staff to point to material limitations such as insufficient space or informational barriers like a lack of accurate knowledge, in the open-ended responses many staff attributed refugee non-adherence to aspects of refugees’ character or culture. Oftentimes, these attributions point out flaws in the characters or culture of the refugees that hindered their adherence to safety protocols.

Using the lens of attribution theory and a modified grounded theory method for analyzing the responses, we demonstrate how many humanitarian staff contributed to the construction of refugees as objects of humanitarian assistance, essentializing refugees as “bare life” (Agamben 1998) entities lacking the ability to follow safety protocols. By contrast, humanitarian staff position themselves as consistently able to follow safety protocols, or when unable to follow protocols, they attribute it to circumstances that were out of their control. In other words, humanitarian staff “other” the refugees by differentiating their character and culture from the refugees’ although the majority of the staff and the refugees came from a similar cultural background and were from the same region. In this way, humanitarian staff reconstruct paternalism in refugee assistance, reproducing unequal power dynamics even while providing services that arguably support refugees. The attributions they ascribe to refugees receiving services could hint at the larger structural forces shaping narratives of refugeehood, the paternalistic orientation of humanitarian assistance, and the macro-level stressors in the region impacting how assistance workers perceive and respond to refugees. This study illustrates how even when humanitarian workers are similar to refugees, paternalism infuses the discourse of humanitarian workers. In our conclusion, we suggest that paternalism may in fact be a default position (albeit not an essential one) in the ethos of humanitarian assistance.

To demonstrate our argument, we first discuss how essentialism and paternalism work in humanitarian assistance. We then introduce attribution theory and how it is connected to essentialism in the ways that “the other” is perceived. This section is followed by the barriers to keeping refugees safe during the COVID-19 pandemic in humanitarian assistance. We introduce our methodology before briefly presenting the quantitative results of the study and delving into qualitative findings. In the final section, we discuss the way in which these results reveal the embedded essentialism and paternalism in the Global South humanitarian assistance context which is mainly associated with the Global North humanitarianism providing services to the refugees from Global South.

Embedded essentialism and paternalism in humanitarian assistance

Harrell-Bond (1986) called for humanitarian actors to facilitate the agency of refugees rather than acting in the interests of refugees on their behalf. However, research on the humanitarian sector reveals the way that humanitarian NGOs enact power over refugees in paternalistic ways (Verdirame and Harrell-Bond 2005). Humanitarian assistance often de-emphasizes the agency of refugees, treating refugees as if they are detached from political belonging because they are not treated as political beings that have the capacity to belong to a polity. In this way, paternalism can lead to what Agamben (1998) called “bare life” and what Malkki (2002) later modified as “bare humanity.” Agamben described bare life as “the state of living dead; a life stripped of every social protection rendering life subject to exercises of all kinds of violence and whose inclusion within the political order is limited to their exclusion from the political order” (p. 71). Humanitarian assistance that strips refugees of agency also excludes them from the political order socially, even if they resided physically in a geopolitical space that would otherwise give them access to political rights. Whether in camps or urban settlements, the care (and the control) of mass displacement operates in many ways which are part and parcel of well-established international technologies of power for the control of space and movement (Malkki 2002). They reflect other familiar features of the modern socio-political landscape where the populations are transformed into the subjects of bare life by today’s “democratico-capitalist projects” (Agamben 1998: 180), such as prisons, reception centers, and/or the ghettos located on the edges and oftentimes hearts of urban centers. In most cases, no extra physical structure is needed to limit the control and mobility. Through the policies and regulations of central and local state authorities (Darling 2017) and the everyday interactions with the locals (Irgil 2022), the refugees are surveilled, policed, and externalized from daily life. In other words, refugees find themselves as people who have now become a problematic social category of “bare humanity” (Malkki 2002: 356).

The root of this connection between humanitarian refugee assistance and the construction of refugees as bare life may in large part be due to the paternalistic nature of humanitarianism itself. Dworkin (1972: 65) defines paternalism as “the interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced.” In a paternalistic relationship where power inequality is manifested in the rules of reciprocity, the dominant party makes sure that they are the provider while the beneficiary is the receiver (Aycan 2006) lacking the ability of helping themselves and reciprocating (Goodell et al. 1985). The provider/receiver divide can emerge from white supremacy and equating successful development with whiteness (Benton 2016). Power differentials can also emerge between international and national humanitarian staff, with national staff feeling that their training and experience are not respected while international staff’s education on local context further develops their own professional trajectory (Roth 2012). International staff’s discomfort with these power inequalities itself led to paternalistic relationships, such as financially supporting national staff or suspecting national colleagues were stealing from them but dismissing their suspicions (Roth 2015).

Barnett (2012: 485) links paternalism and humanitarian governance and argues that “paternalism is an organizing principle of the international humanitarian order.” Paternalism is institutionalized in humanitarian governance, which presumes that the objects of humanitarian governance are incompetent or inferior with low autonomy and high dependency on more powerful individuals who have the right to intervene for a greater good (Barnett 2012; Cohen 1985). Using Barnett and Duvall’s (2005) conceptualization of power within international relations to understand the agency of refugees, those providing assistance are able to influence the behavior of refugees through the act of assisting. They can influence refugees’ behavior through direct (making compulsory some actions in order to receive assistance) and diffuse (institutionalizing normative actions as part of service provision) relations.

Outside observers (humanitarian workers or others) can understand all refugees as consisting of bare life only if they attribute a lack of political being-ness as an essential part of their character. Essentialism relies on the immutability and fixedness of human nature (Rothbart and Taylor 1992). As Demoulin et al. (2006) argue, although people are prone to essentialize others in a wide range of social categories, the content of that essentialization varies with the type of group and the degree of control that the group members have. When an observer perceives that group members as having little or no control over membership in the group, they are more likely to essentialize the characteristics of that group (Demoulin et al. 2006). As refugees have very little control over their membership in that group, they are very likely to be perceived by others as having an essential “refugeeness” to their character. Thus, an observer making attributions to explain refugees’ behavior is likely to essentialize refugees.

Barnett (2017) argued that the rhetoric of paternalism is adopted more often by the humanitarian workers coming from the West to provide services in the so-called Third World. His research revealed the racialized hierarchies and inequalities between humanitarian staff from international NGOs and staff working in local NGOs. Roth (2012) argued that the skills, knowledge, and capacity of national humanitarian staff from the Global South are found less valuable and professional compared to their international counterparts from the Global North. Similarly, drawing on a 2-year work experience in Sierra Leone, Benton (2016) asserts that the expertise and local knowledge of African expatriate staff were undervalued, and they mostly were placed in translational or intermediary roles.

Given that our data come from NGO staff from the Global South, we can analyze the attributions of Global South/local NGO staff about the behaviors of Global South refugees. We argue that paternalistic humanitarianism is not limited to the Global North/Global South and/or International/Local context, but rather is embedded in the ways that Global South/Local humanitarian staff explain refugees’ public health behavior. Drawing on attribution theory, we explore how certain kinds of attributions essentialize refugees and indicate within-Global South paternalism operating in humanitarian assistance.

Attributions and perceptions of “the other”

Attribution theory (Heider 1944; Jones and Nisbett 1987) describes how individuals attribute the underlying causes of their own and other people’s behavior, and whether there are external (situational) or internal (dispositional) causes. Heider (1944) theorized how people make attributions to explain events, writing, “when we have a disagreeable experience or an unpleasant one, we may locate its origin in another person, in ourselves, or in fate” (p. 358). Heider (1944) proposed that attributions for the behaviors of others are most likely to be dispositional when the person belongs to a category of “other” (e.g., out-group member). In self-evaluations, a person is more likely to make a situational attribution with behaviors that have negative outcomes and dispositional attributions for behaviors that have positive outcomes. Heider (1944) called this the fundamental attribution error.

Jones and Nisbett (1987) built on Heider’s work by making the distinction between attributions of other’s behavior compared to attributions for one’s own behavior: “There is a pervasive tendency for actors to attribute their actions to situational requirements, whereas observers tend to attribute the same actions to stable dispositions” (p. 80). People are more likely to attribute stable dispositions to others’ behavior when the others being observed are perceived by the observer as an outgroup member. Outgroup members are more likely to be seen as people with an “essential” character that causes their behavior. Thus, when a person perceives someone else as an outgroup member or “the other”, that person is more likely to essentialize the outgroup member and attribute their behavior to essential characteristics (often characteristics considered to be flawed).

As Rothbart and Taylor (1992) assert, the core idea of psychological essentialism is that “people act as if things (e.g., objects) have essences or underlying natures that make them the thing they are. Yzerbyt et al. (1998: 1092) describe essentialism as lay people’s belief that, although group members may differ from one another at the surface level, group members very much resemble one another “deep inside.” In this sense, essentialism corresponds to the deepest, genotypic, level of group perception (Yzerbyt et al. 1998). When people essentialize a particular group of refugees, the refugees’ characteristics are constructed as both immutable and problematic, which justifies denying those refugees’ rights (including the right to enter a safe territory; Hanson-Easey et al. 2014).

Attribution theory is a useful tool for understanding the process of “othering” between different groups. The attributions that humanitarian staff make about refugees’ behaviors can indicate an understanding of the difficult situation refugees are in (i.e., attributing non-adherence to crowded conditions or a lack of resources), but attributions can indicate NGO staff’s feelings of paternalism towards refugees (i.e., attributing non-adherence to an inability to follow protocols) or their essentializing of refugees (i.e., attributing non-adherence to refugees’ culture). When staff essentialize refugees, it indicates that they perceive refugees to be a separate group from themselves. Moreover, it reveals how much essentialism and paternalism are embedded in humanitarian assistance when staff from a similar culture as the refugees use the refugees’ culture to explain undesirable behavior. In our data analysis, we discovered this pattern and found that attribution theory was well-suited to explain why the NGO staff ascribed dispositional factors to refugees’ behavior. Therefore, we use the lens of attribution theory to analyze how staff explain the barriers to public health protocol adherence during the COVID-19 pandemic.

Barriers to keeping refugees safe during the COVID-19 pandemic

Displaced populations globally have been disproportionately affected by the COVID-19 pandemic (World Health Organization 2020). The study countries, Jordan, Lebanon, and Türkiye, are among the top refugee-hosting countries in the world, hosting approximately 8 million refugees (Amnesty International 2019). Humanitarian NGOs in these countries provide various types of assistance in refugee camps (both newer temporary camps and long-settled camps with permanent infrastructure) and cities. The refugees they serve are mostly Syrian or Palestinian refugees, with smaller numbers of Iraqis, Afghans, and refugees from other countries of origin in the region. During the COVID-19 pandemic, humanitarian NGOs responded to the crisis by instituting new protocols to mitigate the spread of COVID, obtaining personal protection equipment (PPE) such as face masks and shields for their staff and masks for the refugee beneficiaries, additional hand hygiene supplies, and modified services to keep a 1.5 to 2.0-m distance between people whenever possible.

The data indicated that NGO staff observed refugees sometimes not complying with all COVID safety protocols, and while not the focus of our study, some of the attributions that they made for refugee non-adherence surprised us. Most of the staff came from similar cultural backgrounds as the refugees, and yet, they attributed many negative dispositional causes of refugee’s non-adherence. We argue that the attributions humanitarian staff made about refugees’ health behaviors reflected the larger structural forces shaping narratives of refugeehood, the paternalistic orientation of humanitarian assistance, and the macro-level stressors in the region impacting how assistance workers perceive and respond to refugees in micro-level humanitarian assistance relations.

Previous research has demonstrated that the discursive construction of refugee vulnerability shapes what kinds of assistance NGOs perceive that different refugee groups need and deserve (Sozer 2021; Witcher 2021) and that a focus on vulnerability can contribute to neglecting to develop a rights frame that provides greater long-term protection (Mencütek et al. 2021). Thus, it is important to understand how humanitarian staff understand and explain refugee health behaviors during the COVID-19 pandemic, as that could have material consequences for how staff support refugees’ public health behaviors and for viewing refugees as deserving of broader rights to protection, livelihoods, and permanent settlement.

In this paper, we analyze the way that humanitarian NGO staff describe refugees’ adherence and non-adherence to COVID safety protocols implemented by the NGOs. This paper is part of a larger study designed to assess the barriers to COVID safety protocols in these settings. Our study team included humanitarian NGOs working in Türkiye, Jordan, and Lebanon. Representatives of the NGOs were full partners in designing and implementing the study, and some representatives have also contributed to analyzing the data and publishing the results. Here, we focus on the attributions that staff make to explain why they think refugees do not always follow COVID safety protocols and compare that to how staff describe the reasons why they themselves do not always follow those same protocols. By making the connection between attributions and the discursive construction of refugeehood within humanitarian assistance, we hope to shed light on power dynamics in the humanitarian sector that might inhibit better support to refugees, including efforts to support their health against infectious disease.

Methods

This paper uses data collected from the staff at four humanitarian NGOs serving refugees in Lebanon, Türkiye, and Jordan. Our study team included representatives from each of the humanitarian NGOs working in these countries; representatives of the NGOs were full partners in designing and implementing the study, and some representatives also contributed to analyzing the data and publishing the results. The humanitarian NGOs were major contributors to the humanitarian apparatus in the region and were eager to have data that they could use to inform their work.

The authors are researchers with extensive experience working in and with refugee humanitarian organizations. Several authors are from and live in the research region and consult with or have been employed by the participating NGOs. The authors’ positionality informed our methodology, including data collection, analysis, and interpretation. At every stage of the research, we convened as a core team (researchers and NGO representatives) and extended team including the data collectors, on a biweekly basis, or more frequently when needed. These meetings served as a platform for us to reflect on the research process, revise our methodology and data collection materials, and improve our data analysis and interpretation. Additionally, these gatherings provided an opportunity to discuss the psychological and emotional well-being of team members, which could be influenced by significant events in the region, such as the Beirut explosion that happened in August 2020. With these efforts, we prioritized transparency and accountability within our team and sought to address and minimize any assumptions and limitations due to our individual positionality as research team/authors.

Each NGO had multiple service centers which were used to sample staff for interviews. The location of service centers in Türkiye was in Konya (central Türkiye) and Reyhanli (southeastern Türkiye). The service centers in Jordan were three locations in the governorate of Irbid (northeastern Jordan). The service centers in Lebanon were dispersed throughout the country, with four locations in Beirut. All NGOs instituted safety protocols of mask-wearing, maintaining social distancing, and hand hygiene to mitigate the risk of infection spread during service provision to refugees. The majority of services sampled were medical services, one-on-one and group training, and psychological counseling but also included a wide variety of services such as education for children, food distribution, language instruction, and vocational activities such as sewing and embroidering products for sale. The interviews were conducted between July 20 and September 15, 2020, with NGO staff who provided direct services to refugees, with the questions focusing on how well they, other staff, and the refugees receiving services practiced social distancing (keeping 2 m distance between each other), wore face masks, and washed or sanitized hands and surfaces before, during, and after services provided to refugees. Fifteen data collectors conducted interviews, asking a series of closed-ended and open-ended questions to staff either in person, over the phone, or in a few cases through video conferencing. We selected staff for interviews based on the services they led (with an attempt to sample a range of services) and availability. Because we were interested in changes over time, some staff we interviewed more than once.

The data collectors asked questions about how frequently safety protocols were followed based on a Likert-type scale: all of the time, most of the time, some of the time, or very little of the time. The questions referred to the services that the staff provided either earlier that day or the previous day (depending upon what time the interview was conducted). Staff were asked to reflect on how frequently refugees maintained social distancing, wore masks, washed their hands, and used hand sanitizer, how frequently staff followed these protocols around refugees and around other staff, and how frequently the interviewee personally followed these protocols. Table 1 illustrates the number and percentage of the interviews conducted in each service location.

Table 1 Number and percentage of interviews conducted in each service location

Staff were asked what they perceived to be the barriers to better protocol adherence with forced choice options and one “other—please specify” option that allowed staff to provide an open-ended response. In this paper, we focus on the open-ended responses to the questions about barriers to better protocol adherence.

Data collectors entered the interview responses into a Qualtrics database so that data monitoring could occur in real time throughout the data collection period. They conducted 1466 interviews with 468 unique staff members. All the data collectors were native Arabic speakers and conducted interviews in Arabic, which were translated into English by professional translators, with Arabic/English bilingual team members verifying the quality of the translation. It is important to note that the staff included in this study were primarily Arabic speakers; even in the NGO service centers in Türkiye, the staff was 70% Syrian and 30% Turkish. In Lebanon and Jordan, the NGO staff were almost entirely from those respective countries or were of Palestinian nationality and born in their current country of residence (and in some cases were born and raised in the refugee camp in which their NGO operated). Hence, almost all of the staff came from the same linguistic background as the refugees, and in many cases were of the same nationality, and most had very similar cultural backgrounds to the refugees.

We analyzed the data by employing a modified grounded theory approach, in which we started coding based on an existing framework but looked for other codes that emerged from the structured coding. The first round of coding was completed by three student research assistants (two undergraduate and one graduate), with a second round of coding completed by two faculty team members (one of whom is also an NGO representative). As we began to identify attributions in the data that surprised us, we focused on coding these attributions, coding attributions as either dispositional (describing essential characteristics of certain groups or individual shortcomings) vs. situational (describing factors external to the individual). We also coded for statements that were paternalistic (describing people as unable to independently act or make good choices without assistance) or statements that implied a moral judgment (such as “carelessness,” “recklessness,” or other terminology that attributed non-adherence to a lack of concern or consideration for others) which were often embedded in the attributions. Some of these are described in Table 2.

Table 2 Dispositional and situational factors extracted from the data

Results

Quantitative data: a snapshot of non-adherence to safety protocols

When NGO staff were asked about their adherence to the safety protocols, staff reported that they were better than refugees at following safety protocols of maintaining physical distancing and mask-wearing (see Fig. 1) and hand hygiene (see Fig. 2).

Fig. 1
figure 1

Percentage of adherence to safety protocols perceived by the staff

Fig. 2
figure 2

Percentage of the adherence to safety protocols “all the time” as perceived by the staff

When NGO staff were asked about the reasons for refugees’ non-adherence to all three types of protocols with closed-ended options, the most common attribution was lack of knowledge (which we categorized as a dispositional factor). The lack of knowledge responses are significantly higher among the refugees compared to the NGO workers (see Fig. 3). Conversely, when asked to identify barriers to other staff following protocols, they were more likely to cite the situational factors such as the need for proximity during services for social distancing violations (38%), and the weather/workspace being too hot (32%) for mask wearing.

Fig. 3
figure 3

Percentage of the “lack of knowledge” response as the barrier to non-adherence

If staff selected the “other” response for why COVID protocols were not followed, they had the option to reply with an open-ended answer. We analyzed 4359 units of responses given to the open-ended questions. Those responses provide additional insights into how they understand their own and refugees’ non-adherence. Therefore, this following section is dedicated to the analysis of the open-ended responses to why COVID protocols were not followed (either by refugees, other staff, or themselves), how these attributions can be categorized as either dispositional and situational, and how manifest in the hinted paternalism in the humanitarian organization that is rooted in the idea of bare life. Ignorance, carelessness, and recklessness of the refugees that are essentially associated with the culture of refugees by the NGO staff are the main concepts on which we focus.

Qualitative data: dissecting dispositional and situational factors

The interplay between bare life and cultural essentialism

The concept of refugeehood is built on the erasure of the agency of the refugees (Agamben 1998; Agier 2002) where refugees are primarily seen as the objects of the humanitarian apparatus that need to be processed (Malkki 2002). When asked to explain refugees’ non-adherence to the safety protocols, staff most often used dispositional factors, many of which included moral judgments. We defined “moral judgments” as statements that explicitly or implicitly attributed non-adherence to a failure to consider the well-being of oneself or others. The moral judgments made by NGO staff about refugees often refer to refugee’s culture, especially by putting emphasis on the way the refugees live, their customs, and habits (i.e., hand hygiene, gestures, how they behave to the elderly people and children, community gatherings). According to some NGO staff, the culture of the refugees (such as the way they greeted each other which violated social distancing) was the underlying causes of their non-adherence, and often staff used the term “culture” to explain refugees’ lack of knowledge, making it clear that the attribution was dispositional. Table 2 illustrates the dispositional and situational factors derived inductively from the research based on Heider’s (1944) conceptualization. We categorized factors associated with individuals’ or groups’ characteristics as dispositional and factors associated with external factors as situational.

We like to describe our decision-making process when determining whether a factor is situational or dispositional. Making these decisions are particularly challenging when assessing reasoning such as “forgetting,” “being preoccupied with work,” and “discomfort in wearing masks.” Initially, these factors seem dispositional, as they appear to stem from internal causes. However, the way the staff presents these reasons leads us to think that they are situational. For instance, when staff claim that their non-adherence to safety protocols was due to forgetting, they emphasized how preoccupied they are with work. In these cases, they describe their non-adherence as a result of external factors heavily influencing their internal decision-making ability. In other words, they believe that they forget because they have to remember a lot of work-related things, which is different from being inherently forgetful/forgetful person. The staff’s claims lack an internal locus of control regarding their non-adherence.

On the other hand, when the staff state that refugees do not adhere to the safety protocols because of forgetting (to wear a mask, keep a physical distance, and maintain hand hygiene), they mostly attribute it to the refugees’ personalities implying that these decisions are entirely the refugees’ responsibility. Additionally, they are often accompanied by other dispositional factors, such as carelessness, recklessness, and ignorance. Basically, when we look at the context of the quotes, we see that the staff sees refugees as they have shortcomings either as individuals or as a group.

Some explanations that NGO workers used expressed a perception of refugees as a uniform group who live in bare life existence, and at times were quite harsh in their assessments of refugees’ behavior. For example, one NGO worker in Lebanon said, “barbarian life in the camp is the important part of why they don’t follow the rules. They don't even wash their hands before eating.” Frequently NGO staff cited culture and customs as the reasons for non-adherence to safety protocols. For instance, NGO staff in Lebanon attributed the non-adherence of the refugees to “the Eastern style of life with being together in groups and visiting relatives. Despite their interaction in awareness sessions, they don’t believe in the existence of COVID-19.” Another said, “beneficiaries do not wash their hands or use disinfectants in normal life and won’t use them during the corona crisis.”

Similar references to the lifestyle of the refugees are shared many times by the NGO staff as reasons for non-adherence to safety protocols. An NGO staff in Lebanon links the lack of knowledge with the lifestyle of the refugees: Likewise, another NGO staff working in Türkiye links the culture of refugees to non-adherence: “In our work, it is very hard to deal with refugees, there is a lack of awareness and education among refugees in Konya and this is related to the area that they came from. Overcrowding occurs during distribution, so we distribute relief supplies to the refugees’ homes.” Others described individual lack of concern, such as this NGO worker in Lebanon who simply said, “they do not care about personal hygiene.”

Staff did not always use negative descriptions when they attributed refugees’ non-adherence to their culture. They sometimes described cultural norms as generally positive but admitted that those norms made adherence difficult. For example, an NGO worker in Jordan said: “social customs make maintaining physical distance hard, especially with the elderly. They do not realize the importance of physical distance and they feel that you do not like them if you ask them to keep their distance from you.” Another worker in Türkiye told us, “it is hard to accept not being touched, no handshakes and no exchanging kisses for refugees [because they are] loving people.”

The NGO staff frequently attach moral judgments to their explanations of why refugees do not adhere to safety protocols. Their moral judgments assign value (oftentimes negative and sometimes positive that causes negative adherence outcomes) to refugees’ culture, frequently blaming that culture for refugees’ unwillingness to follow protocols. In contradiction, situational factors that are mostly stripped from moral judgments such as forgetting, being preoccupied with work, limitations of the space, the nature of the work, and work fatigue are cited by the NGO staff for explaining their own non-adherence.

NGO staff frequently attributed their non-adherence to situational factors related to the conditions of their work, as this NGO worker in Lebanon did: “as a service provider with work pressure, no distance can be left due to the space limitation and large numbers of beneficiaries.” The most frequent conditions were fatigue from working for long hours in stressful settings, limitations of the physical space in which they worked, the requirement to be close to refugees in order to provide services, and removing their masks during services when refugees did not understand what the staff were saying. For maintaining hand hygiene, staff cited situational factors such as the lack of nearby hand hygiene facilities as the reasons why they did not always wash their hands consistently, using hand sanitizer instead. The lack of time for washing hands between the consequent activities made maintaining hand hygiene difficult, as illustrated by an NGO staff in Lebanon: “work pressure and preoccupation with providing services may create an obstacle to frequent use of washing facilities, but this is replaced by the use of sterilizers.” We found no staff who attributed their own or other staff’s non-adherence to dispositional factors.

Manifestation of institutional paternalism: “I must help them, otherwise they fail”

Among the attributions that included dispositional factors, some staff expressed feelings of paternalism towards refugees. Most of the NGO staff responses noted that the refugees do not adhere to the protocols on their own and that they needed supervision or monitoring in the waiting areas of the organizations’ service provision units/offices/camps and during the service provision. As one example, an NGO staff in Lebanon said, “we ask refugees, during the awareness sessions, to keep maintaining distances, but by the way of their lives, they tolerate the issue of maintaining a physical distance.” Another staff person said, “some people have masks, but they do not wear them until we ask them to wear them.” Other similar statements of NGO workers were, “I force them to always wear masks,” “[we] force them to wash their hands,” and “we required beneficiaries to disinfect their hands before entering the center.”

Additionally, numerous staff described refugees as being particularly susceptible to virus skepticism and misinformation that are interrelated with perceived lack of knowledge, as in the following statements of NGO workers in Jordan and Lebanon respectively: “For visitors and some beneficiaries, they don’t commit to wearing masks unless you ask them to, and I think it’s because they don’t understand the importance of wearing masks, and some of them are not convinced that the Coronavirus exists, and if it exists, it’s not dangerous for them.” “They think they are immune, they do not think the virus exists. They have been through wars so this will not kill them. They are running away from reality.”

These statements illustrate how refugees were perceived as non-agentic beings who are not able to make protective decisions by themselves. In the humanitarian assistance structure, they were positioned as bare life objects that need to be protected by the humanitarian assistance staff that perpetuate the essentialization of refugees. These rhetoric captures how humanitarian assistance staff essentialize the non-adherence to the culture and being of the refugees and generalize the behaviors. Refugees were seen as static and homogeneous groups who were in need to be protected, taught, and dictated by the humanitarian staff as the agents of inherently paternalistic humanitarian governance system. In that way, the ethos of humanitarian assistance put barriers between the staff and the refugees and hindered the effective service provision. These examples exhibit how macro-level paternalism that shapes the humanitarian governance globally manifests in the micro examples from the South-South forced migration context in the initial phase of the pandemic.

Conclusion

Barnett (2017) argued that the rhetoric of paternalism is adopted more often by the humanitarian workers coming from the West to provide services in the so-called Third World. However, this study sheds light on how the paternalistic rhetoric in humanitarian governance can manifest even when both the NGO staff and refugees originate in the same region. All of the staff working at the NGOs in our study were from the Middle East region and share similar geographical, cultural, and linguistic backgrounds and characteristics with the refugees. Although many of the NGO staff were not culturally distant from the refugees, their rhetoric about refugee non-adherence still implies an “othering” of refugees. Staff positioned their non-adherence as being due to external circumstances that are out of their control, while the refugees’ non-adherence as essential to their culture and the uniform idea of refugeehood that portrays the refugees as having insufficient agencies to make public health decisions. This reproduction of paternalistic rhetoric reconstructs the unequal power between the humanitarian aid provider and the refugees as humanitarian aid receivers.

Humanitarianism incorporates within it an idea of “refugeeness” in which refugees are positioned as helpless bodies in need who live on the edges of bare humanity (Malkki 2002) either with no agency or limited capacity of using their agency when making choices. Humanitarian intervention perpetuates the idea of those in need and those who have the resources to provide support through paternalistic relationships (Barnett 2012). This current study demonstrates that the way NGO staff explain refugee’s non-adherence to the safety protocols reproduces paternalism in humanitarian interventions via three significant sets of findings. First, NGO staff created clear in- and out-group distinctions in how they explained refugee’s and their own non-adherence to safety protocols. Second, in those in- and out-group distinctions, NGO staff essentialize refugees’ culture and make attributions about refugee behaviors that are imbued with moral judgments. Third, portraying themselves as the caregivers of the refugees, NGO workers describe refugees in paternalistic terms, at times suggesting that the refugees need staff assistance to make good decisions about their health during a pandemic. Paternalism does not operate solely in humanitarian assistance relationships between international staff and refugees, or between international and local actors. Rather, the condition of “refugeeness” turns the individual into an essentialized affected population and object of humanitarian assistance even if the staff and refugees share similar cultural backgrounds and histories.

The NGO workers described the non-adherence of refugees to safety protocols with essentialized dispositional (internal) factors loaded with moral judgments and references to the essence of the refugees as if they were a uniform group while describing their and the other NGO workers’ non-adherence with situational (external) factors. The former includes references to ignorance, lack of understanding/knowledge, carelessness, and recklessness of the refugees that staff often associated with the culture of the refugees. Staff attribute their own non-adherence, on the other hand, to forgetting, being preoccupied with work, work stress, lack of organizational safety protocols, the nature of the certain services that prevent adherence to the safety protocols, and lack of hygiene facilities and sufficient space in the service locations for establishing hand hygiene and practicing social distancing.

The quantitative results demonstrate that staff are more inclined to wear masks and maintain social distancing around refugees and are less likely to follow these when around staff colleagues. The better adherence to safety protocols for humanitarian staff when around refugees might be the considered as paternalistic too, as the institutional safety protocols should be implied for everyone, including the cases when staff is around another staff. Being more inclined to adhere to safety protocols when around refugees rather than when around other staff might be the consequence of institutionalized paternalism.

It is important to note that we do not aim to place blame on individual NGO staff for the paternalism embedded in their language around protocol adherence, nor do we intend to make organizational-level inferences from these data. Instead, through the perceptions of the NGO staff, we aim to demonstrate the broader culture in humanitarian assistance in which power operates. Hor (2022) argues that humanitarian work itself leads to a desire “to distance oneself from the anxiety of being an outsider oneself” (p.22). Hor (2022) identifies this anxiety as a struggle for international aid workers, but it might also describe the experience of local humanitarian workers who are in many ways similar to the beneficiaries they serve, except that they themselves are not in need of services. But being so similar in nationality, language, or culture to people who are refugees and are struggling to meet basic needs, the humanitarian NGO staff in our study may have eased their anxieties about their own vulnerability by seeing refugees and very different people with cultures that were inconsistent with sound public health behavior.

Additionally, this study does not claim to capture the degree to which refugees actually behave in response to COVID safety protocols. Rather, it describes how NGO staff’s perceptions of refugees’ behavior are embedded in a larger system of power and paternalism in humanitarian assistance, which limits the staff’s understanding of barriers that refugees face in following protocols. This is important not just for determining better ways to implement safety protocols during humanitarian assistance, it can also help humanitarian actors and leaders in refugee communities to ensure better compliance with vaccinations. As vaccines become more widely available in refugee-hosting countries, ensuring that refugees have not just access but willingness to take vaccines will be critical for protecting their health and the health of their host communities. As part of the larger study, we intend to examine COVID skepticism and resistance to protocol adherence among refugees with the intention of informing interventions to ameliorate vaccine hesitancy.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to privacy concerns of the non-governmental organizations that participated to the study but are available from the corresponding author on a reasonable request.

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Acknowledgements

As this current study is a collaborative effort of NGO coordinators in the participating countries, and Global Health Research, Management and Solutions, the authors are grateful to the contribution of Dr. Rania Mansour, Dr. Ali Ghassani, Dr. Adnan Hammad, and Mahmoud Durid and the data collection teams in the research countries.

Funding

The study and mainly the data collection step of the study were funded by Enhancing Learning and Research or Humanitarian Assistance (ELHRA).

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Contributions

EK analyzed and interpreted the data, conceptualize the theoretical grounding (attribution theory, bare life, paternalism) for drafting the initial version of the manuscript, drafted the first draft of the manuscript, and took part in multiple revision processes. SJN conceptualized and designed the study, analyzed and interpreted the data, substantively revised the drafted manuscript, substantively contributed to set the theoretical structure (application of attribution theory, bare life, paternalism), substantively revised the manuscript in terms of grammar check, and took part in multiple revision processes. Natalynn Q analyzed and interpreted the qualitative data, revised, and made minor edits to the manuscript. Natalie Q analyzed and interpreted the qualitative data, revised, and made minor edits to the manuscript. AJN contributed to the design of the study, interpreted the data, and made minor edits to the manuscript, especially the sections on Jordan. SG contributed to the conceptualization and design of the study, contributed to the analyze and interpretation of the data, and made minor edits to the manuscripts.

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Correspondence to Ezgi Karaoglu.

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Karaoglu, E., Nawyn, S.J., Qaji, N. et al. Refugee COVID-19 protocol adherence and NGO staff perceptions: paternalism and power in humanitarian assistance. Int J Humanitarian Action 8, 10 (2023). https://doi.org/10.1186/s41018-023-00141-6

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