CULTURAL ANTHROPOLOGY, Vol. 35, Issue 2, pp. 211-217, ISSN 0886-7356. DOI: 10.14506/ca35.2.03

TRUST WITHOUT CONFIDENCE: Moving Medicine with Dirty Hands


Purdue University

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What kinds of pragmatic entanglements take place among those living amid armed struggles for geopolitical security? What does it mean to act as if one trusts strangers, enemies, and unreliable allies? Wartime collaboration borne of necessity complicates our understanding of security-making and the line between crisis and continuity, thereby opening a space for theorizing crisis as a route to survival. This account follows a small medication-smuggling network across ISIS-controlled northern Iraq to three hospitals in the besieged city of Mosul. The story echoes Ross Porter (2020), whose interlocutors work from below against the threat of the state, to create new levels of trust.

In September 2014, Mosul was overrun by battles between ISIS, al-Hashd (Shia militias temporarily hired by the Iraqi government), and the Iraqi military. Besieged residents relied on relatives and community networks outside the city, and often outside Iraq, to supply them with food, medication, and toilet paper. Delivery took the form of smuggling, because it required hiding goods from checkpoint operators.

In high demand from militia fighters and civilians alike, hospitals in Iraq’s medical capital, Mosul, became precarious pockets of safety-under-siege, surrounded by impassable chaos. Medication entering the area was consistently seized and distributed on the black market at high prices. Doctors, desperate to treat patients, found themselves going out on the streets and buying medication from the very people (often soldiers, police, or militias) preventing medicine from reaching hospitals in the first place. This was a medical economy in wartime, and just as in Emrah Yıldız’s (2020) piece on Iran’s sanctions economy, the goal was to minimize losses.

I was among a group of people attempting to send medications from a pharmacy in Amman to the pediatric wings of three hospitals calling for supplies in Mosul. The plan involved pooling money from friends and family, filling prescriptions, disguising medication in cereal boxes, and sending them on a fourteen-hour drive to Mosul in a car that would be stopped, searched, and possibly looted along the way by a number of different armed entities.

Too often “trust and social crises are presented as natural enemies” (Jiménez 2011, 177), when in fact ruptures in positive experience or systems of accountability may actually breed trust. By forcing unwilling and even unwitting encounters, crises like the siege of Mosul can in fact generate trust, though in unpredictable forms extraneous to social solidarity, exchange networks, or kinship. Rather, trust becomes enunciatory:1 articulated into being, rather than felt and then acted upon; made real through, rather than in spite of, unintelligibility; and functional because of, rather than despite, traversing divergent interests.

Enunciatory trust is a prevailing way in which insecurity makes material conditions for endurance possible: when trust is not a feeling or a structure, one acts and speaks as if one feels trust, simply because it is necessary. It is “at the margins [that] we face far more opportunities for cooperating . . . with a wider array of people” (Hardin 2006, 38). Indeed, the very friction between actors carrying out their different goals physically propels medication across northern Iraq. We can say that people live in ad hoc multi-motivational presence with others, and when continuity is ruptured (in this case by geopolitical security regimes), these multiplicities can either be shut down or activated. This is a story, then, of activation: enunciatory trust is how people survive security projects like the war on terror or the making of modern-day Iraq.

To move medication across the Jordanian border, then smuggle it past two or three military factions struggling for regional control, one relies heavily on a trust network composed of a disjointed, ephemeral collection of people who neither know nor will ever meet one another. Rather than referring to a group of people who form part of a single project, I mean the term trust network to include both opponents and allies, thereby challenging the traditional notion of trust as a precondition for collaboration. Our trust network shared no common goal, transactional reciprocity, or built-in incentive for promise fulfillment. Such networks are tenuous, dissipate quickly, and at times work to demonstrate life-affirming human connection amid chaotic violence. When trust networks do not rely on common ground or intelligibility to open possibilities,2 people count on both the redeeming and horrifying surprises of human behavior under stress.

Among those involved in this trust network were Dr. Mahmoud and three of his colleagues in Mosul, who reported dwindling supplies and desperate conditions; Dr. Nanoor, a Palestinian pharmacist in Amman, who was willing to use her pharmacy to gather and package medication; me, an American presumed to have the legitimacy to acquire prescriptions for bulk quantities of medication through a Jordanian doctor; an anonymous driver none of us had met; Jafar, a middleman reputed for knowing the right people; four wholesale providers in Jordan; nearly one hundred Americans who pooled money; and somewhere between five and fifty militia fighters who could either interfere with or facilitate the movement of goods. Many people in this trust network acted in good faith, others in desperation, for profit, or for altogether other reasons. If the driver survived and the medication arrived, pediatric surgeons and oncologists would dispense the one-month supply of various goods, which included basic supplies like saline and IV needles, as well as more expensive medications like chemotherapy drugs and anesthesia.

Dr. Nanoor described the nature of our work as “moving medicine with dirty hands,” because many people in the trust network were not only unknown to us but also not motivated by solidarity—some not even by bribes or transactional gain. Imagining synonymy between trust and confidence can obscure how things really work. Vigdis Broch-Due and Margit Ystanes (2016, 1) describe trust as “a social orientation towards the future nurtured by the gradual accumulation of positive experience and sometimes revealed in a leap of faith.” But what does trust look like when the future is neither a cumulative project nor a leap made in good faith? What does it mean to act on trust without confidence, a trust that neither contributes to, nor relies on, solidarity?

In Iraq, decades of military violence have strained relations among diverse communities. Under such circumstances, moving medication among a network of unknown others offers a bumpy terrain of clashing motives and moral rubrics. The militias, doctors, drivers, pharmacists, and anthropologists in this trust network were not seeking a moral reconciliation or an accumulation of confidence; we were not even seeking to end ongoing disruption. We were living in it, together, via diversity otherwise unimaginable.

Thus, what erodes trust networks is an enunciation of distrust. To ask too many questions about anyone’s motives means to fracture a necessary unintelligibility that makes things workable. I learned this lesson when I expressed discomfort to Dr. Nanoor about leaving cash with Jafar, the middleman who found us a driver and for whom there was no system of accountability to disincentivize him from simply running off with the cash. Her response articulated enunciatory trust: “But how will the driver get the money if Jafar doesn’t give it to him?” An unwillingness to leave cash with the mysterious Jafar (to hand off to the even more mysterious driver) would have foiled the “sticky materiality of practical encounters” (Tsing 2005, 1). While transactional, such dealings do not build into reciprocal exchange, an economy, or other systems of accountability.

Between the Amman pharmacy and the Mosul hospitals lay a terrain pocked with shifting security regimes we needed to evade. How could we find a driver willing to risk the route? How could we get medication past possible ISIS checkpoints? An elusive and shifting “we” answered these concerns. For medication to reach the hospital, it would have to pass through roughly twenty official and unofficial checkpoints. The driver had to gamble on whether or not checkpoint guards would let him pass with a bribe, seize the contents, or kill him.

Dr. Nanoor had a theory about checkpoints: “We are really counting on greed, here. The Americans were no different, taking bribes and stealing from people. They all did it. The people change, but the behavior doesn’t!” We laughed at how glad we were to count on bad human behavior. After all, our trust network relied just as much on predictably bad conduct as good.

Dr. Nanoor was developing a theory of moral pragmatism in which she argued that regardless of motive, each person in our trust network would “choose life.” About the banality of evil, Hannah Arendt (1963a, 1963b, 1963c, 1963d, 1963e) argues that good people do bad things for good reasons all the time. But just as often, supposedly bad people do good things for bad reasons. If Dr. Nanoor was right, then the maxim “bad people do good things for bad reasons” clarifies how trust may not only be “the final device for coping with the freedom of others” (Gambetta 2000, 219) but also a device for opening up new freedoms for others. When a checkpoint guard is offered trust, in whatever form of bribe or plea, he is presented with an opportunity to “choose life” by exceeding the boundaries of his given role in formal securitization. Dr. Nanoor was not alone in thinking in terms that exceeded respect for or understanding of the motives of others. Jafar, who stopped by while we packaged medication, mused about the motives of the imagined ISIS members in our trust network: “Some may feel lazy, or they want the cash, or they want to avoid killing. We are all in this for different reasons, but we are here.”

A few days after sending medication from Amman with the driver, it seemed we had trusted too much. Dr. Mahmoud in the pediatric surgery wing of a hospital in Mosul sent me a text message: “I got some boxes of food. Thank you for all you are doing. Is this the quantity you meant to send?” With ordinary Iraqi politeness, he was asking: “All you sent was food?!”

I immediately called Dr. Nanoor, the pharmacist: “Can you ask Jafar to ask the driver what happened?” It seemed confusing that the hospital had received something, but not what we had sent. She got no return calls and felt reluctant to investigate too much. It appeared that while children were dying, some anonymous driver had sold our medication on the black market. I reconsidered Dr. Nanoor’s theory about choosing life: perhaps Arendt’s theory of evil’s banality could not be inverted. Perhaps dirty hands could not do good work. I was horrified that in getting my hands “dirty,” I had contributed to the structural violence of war by supporting its shadow economy.

Then, in the middle of the night, I woke up to a call from Dr. Nanoor, who realized we had outsmarted ourselves. I sent a text message in the dark: “Dr. Mahmoud, open the boxes! It’s not food: it’s medicine!” We had worked so hard to secure the medication from imagined enemy others that we had tricked our primary ally, a doctor who did not know we had disguised it in the first place.

Dr. Mahmoud texted me in English four hours later: “Received message during surgery on 4-year-old female with gunshot to abdomen. No anesthesia left, performed raw surgery. Sent nurse to check boxes, finished surgery with anesthesia. Good timing, you touch patient with your own hands tonight.”

Dirty hands. I was elated by the possibilities for life in the midst of war. My hands had only touched the medication for a moment to mispackage it in cereal boxes, little cardboard shields against anticipated ill will. My fingerprints were joined with varying degrees of incrimination by those of roughly forty other people, some allies, some enemies, and some profiteers. It is the only way our fingertips could ever mingle in a strange, consonant intimacy.

This trust network dissolved long before the siege ended. None of us is sure how many people it included, or why they chose to form part of it. We were bound by no connection at all, except that we acted as if we trusted each other to behave predictably in a world that felt defined by fleeting turns in military strategy. Through enunciatory trust, people who have no confidence in one another’s motives collaborate all the time. As Jafar theorized, we are a we simply because we are here.


As participants in a small trust network smuggle medication across ISIS-controlled northern Iraq to hospitals in the besieged city of Mosul, they theorize their pragmatic entanglements with unknown others. Based on ethnographic fieldwork in 2014 and 2015, as well as the author’s participation in this network, the essay introduces enunciatory trust, or trust without confidence, as an analytical framework for surviving (in)security in Iraq. [Iraq, trust, medicine, ethics and collaboration, siege warfare, smuggling]


1. I borrow the term from Kim Fortun (2001) to describe a space where parties with divergent goals gather—without reconciling their interests—to share in a fleeting chorus, before quickly dissipating.

2. No one actively described “trust networks” as such in my fieldwork: to name something that works by remaining unmarked would have undermined its possibility.


Arendt, Hannah 1963a “Eichmann in Jerusalem: I.” New Yorker, February 16.

1963b “Eichmann in Jerusalem: II.” New Yorker, February 23.

1963c “Eichmann in Jerusalem: III.” New Yorker, March 2.

1963d “Eichmann in Jerusalem: IV.” New Yorker, March 9.

1963e “Eichmann in Jerusalem: V.” New Yorker, March 16.

Broch-Due, Vigdis, and Margit Ystanes, eds. 2016 Trusting and Its Tribulations: Interdisciplinary Engagements with Intimacy, Sociality and Trust. New York: Berghahn.

Fortun, Kim 2001 Advocacy after Bhopal: Environmentalism, Disaster, New Global Orders. Chicago: University of Chicago Press.

Gambetta, Diego 2000 “Can We Trust Trust?” In Trust: Making and Breaking Cooperative Relations, edited by Diego Gambetta, 213–37. Oxford, UK: Oxford University Press.

Hardin, Russell 2006 Trust. Cambridge, UK: Polity.

Jiménez, Alberto Corsín 2011 “Trust in Anthropology.” Anthropological Theory 11, no. 2: 177–96.

Porter, Ross 2020 “Security against the State in Revolutionary Yemen.” Cultural Anthropology 35, no. 2: 204–10.

Tsing, Anna Lowenhaupt 2005 Friction: An Ethnography of Global Connection. Princeton, N.J.: Princeton University Press.

Yıldız, Emrah 2020 “Nested In(securities): Commodity and Currency Circuits in an Iran under Sanctions.” Cultural Anthropology 35, no. 2: 218–24.

CULTURAL ANTHROPOLOGY, Vol. 35, Issue 2, pp. 211-217, ISSN 0886-7356, online ISSN 1548-1360. © American Anthropological Association 2019. Cultural Anthropology journal content published since 2014 is freely available to download, save, reproduce, and transmit for noncommercial, scholarly, and educational purposes. Reproduction and transmission of journal content for the above purposes should credit the author and original source. Use, reproduction, or distribution of journal content for commercial purposes requires additional permissions from the American Anthropological Association; please contact DOI: 10.14506/ca35.2.03