Therapeutic citizens or therapeutic refugees? An examination of triage, refugeehood, and referral health care in Tanzania.

Referral health care refers to the movement of populations between different levels of a health care system, often to seek specialized care at higher level centers. It requires mobility of populations. Critical questions on the shortcomings for accessing referral health care, especially for refugees in sub-Saharan Africa, remain unexplored. How do global guidelines on referral health care play out in the local context of a country like Tanzania, where refugees are not legally allowed to leave the refugee camp without permission? How do health care providers navigate this complex space, and how can we leverage anthropological theories of biopower and therapeutic citizenship to better understand this context? Based on six months of ethnographic fieldwork in Tanzania between 2011 and 2021, I trace how global refugee policy manifests itself locally. I argue that referral for refugees in Tanzania is as much a political and social process as it is medical. The bureaucratic process favors certain pathologies over others and creates significant delays in referral. Triage takes on nuanced forms whereby a certain aspect of a patient's case (i.e., prognosis, cost, age) is privileged in a context of strict refugee policy that restricts independent care-seeking. Most patients are approved for referral, but many are denied. A patient may not be sick enough to merit timely referral, or they may be deemed too sick to prevent referral altogether. Challenging other arguments of therapeutic citizenship where people living with certain health conditions acquire access to certain therapies and their right to health, I show how refugees with certain pathologies are actually excluded from care. These therapeutic exceptions produce consequences whereby bureaucracy and security have prevailed over the right to health and reinforced the power of state sovereignty in what may best be understood not as a therapeutic citizenship, but instead as a therapeutic refugeehood.