A Primer on COVID-19:Placing the disease in context

by Mark Nichter, PhD, MPH and Collin Catalfamo, MPH

June 26, 2020. This week’s updates include new information on the rapidly changing distribution of Covid-19 within the US and the world, changing age demographics/spikes in disease numbers, more longitudinal data on the recovery phases and testing issues and more.

Download the pdf and/or powerpoint version of the update here:

Photo by E. Cartwright 2020 “SE Idaho”

Guest blogs and information are welcome. Email me at carteliz@isu.edu if you are interested in contributing information, research ideas or perspectives to the blog.

Reasoned use of face masks in the Covid-19 pandemic: a bio-socio-cultural approach.

by Jesús Armando Haro  Profesor investigador del Centro de Estudios en Salud y Sociedad, El Colegio de Sonora. Correo: aharo@colson.edu.mx

The current debate on the use of face masks in the Covid-19 pandemic contains several edges, which denote that the issue, far from narrowing down to the biological and epidemiological aspects of prevention, affects economic, social, political and cultural spheres. The range of their prescription has ranged from mandatory use, implemented early by China, Korea, Japan, and other Asian countries, then later in other countries, regions, or cities; to emphatic discouragement, with variable recommendations to use them, from the type, if permanent or selective and how to care, reuse or not. They were handled in an ambiguous and changing way, as happened in the United States, as well as with the World Health Organization, which initially advised against, to end up recommending them. In Mexico, attempts have been made to politicize the matter, blaming the health authorities for not making them compulsory, while the Government of Mexico City, as well as other Mexican cities, and even states, such as Coahuila and Yucatan, have implemented its compulsive use in public roads, along with other measures aimed at preventing the transmission of the virus, such as restricting the movement of people, limiting occupants by vehicle, suspending non-essential productive activities and disseminating information on the advantages of staying home, washing hands frequently, keep a healthy distance, isolate yourself and give warning in case of symptoms.

Understanding what is debated in the case of face masks and respirators, leads us to notice two aspects that, although complementary, are still different: prevention thought in individual terms, me and my family; and, from public health, consider that what is relevant is not to abolish but to delay contagion, “flatten the curve so as not to overload the health services”. From clinical prevention, it is convenient to distinguish the conditions in which each domestic group is found to design routines according to their vulnerable members. The use of facial protectors should be guided by a logic that reasons their use to reduce the risk of contagion, without forgetting that it is only a complementary measure that does not absolutely prevent viral transmission. 

Image by E. Cartwright

Understanding it leads us to analyze the biology of SARS-2, the causative agent of Covid-19 and its reception by the human body. This type of betacoronavirus measures between .05 and 0.2 um (microns) in diameter. It is a “vital” form that can only be expressed if it infects living cells, where it reproduces. It is transmitted through droplets and micro-droplets that are respectively sprayed (particles larger than 10 um) and aerosolized (smaller than 10 um), with oral and respiratory secretions, when speaking, sneezing or coughing, with the average incubation period being 5.1 days, although the vast majority of cases are asymptomatic, without knowing the exact time it is transmitted (Meselson 2020). Viral particles can evaporate or fall to the ground within two meters, but also survive up to seven hours in closed environments, where they spread farther away, although their concentration decreases, as happens on plastic and metal surfaces, where it persists between 3 hours and 9 days if there are favorable environmental conditions, as it appears to be inactive relatively early in the sun, in airy conditions, although its viability has not been sufficiently verified. This is why face masks are not enough. It is also pointed out that there is the possibility of acquiring it through the conjunctivae, although it is much more feasible that the main route is the nasopharyngeal, where there are abundant ACE2 proteins to which the virus binds. Although we do not know key factors in its transmission and immune brand, indirect data about other coronaviruses (SARS) suggest that infection by SARS-CoV-2 generates immunity after recovery, given that it is an RNA virus and not DNA, like HIV. But, it can be lethal for those who need to be hospitalized, mostly elderly and chronically ill, although young people, more or less healthy adults, pregnant women and children.

Regarding facial masks and other protectors, the capacity of a mouthpiece is very different from that of an N95 “respirator”, capable of filtering, as its name suggests, up to 95% of airborne particles, thanks to a polypropylene nanofiber filter, guaranteed not to let micro-droplets pass, although it is not suitable for gases or vapors, despite the hermetically sealing mouth and nose, making it uncomfortable for prolonged use. Although they are more expensive, they are considered reusable. In contrast, surgical masks and other face masks only protect against visible droplets. They are effective at hampering large particles, which may contain viruses, bacteria, or other germs, but not aerosolized ones. And they are disposable. On the other hand, artisan masks, even when they are not very effective – they are made of different materials – constitute a particularly useful barrier for not transmitting to others, being mostly reusable after disinfection.

Since the “Spanish” influenza of 1918, facial protectors began to be used as a preventive measure, but it was not until 1972, when the 3M company developed the first respirator capable of filtering microparticles, with a technology developed to manufacture bras. Since before the 2009 pandemic of influenza A (H1N1), the preventive usefulness of both mouthguards and N95 respirators began to be debated, especially in health workers, being in 2013 when the National Institute for Occupational Safety and Health (NIOSH) of the United States, implemented its mandatory use in hospitals with risk of respiratory infections.

Since then, various studies have been carried out that show favorable findings to recommend the use of both in specific circumstances. As several researchers point out, in any case, it is always better to carry some barrier than not to bring one, if one considers not only the possibility of contagion, but also the intensity or viral load of the exposure (Milton et al 2013). Our immune system has a better chance of getting away with a minimal, even repeated, load than a massive virus invasion. Other works point out the negative effects of prolonged use of both, arguing that the breath moistens them and favors reservoirs for various microorganisms- It is recommended to use them for a limited time or change them, in addition to taking care of other measures, such as not touching it from the front when removing it, not use it as a chin strap and proceed to store and disinfect it, with various methods, depending on the type. Research has been published that highlights the cultural impacts of protectors, their increase according to the incidence of cases and how they affect physical distancing, highlighting that they were rarely used in a unique way, but in conjunction with other preventive measures, such as handwashing, the closure, control and sanitation of surfaces in public spaces and courtesy sneeze, among others. Some conclude that facial protectors are perhaps the most cost-effective preventive measure, estimating a reduction in infections of 10% in the general population and up to 50% in those who wore them (Mniszewski et al 2013).

During the current pandemic the use of face shields has become politicized, especially from speculation subsequent to its high demand, with global scarcity, which has increased, for example, the price of the N95 from 0.65 cents to almost three per unit, in addition to causing international acts similar to piracy. The shortage contrasts with the contamination registered in various beaches of the world with waste, as well as the just claims of health personnel at the national and international levels for the shortage. Also, with the creativity to design various types of protectors, including those with full 3D masks, handcrafted prints or embroidery, even palm; or airtight-seal respirators made from industrial towels, copper mesh, and other polymer “non-woven fabrics.” Several systematic reviews (Stern et al 2020, Xiao et al 2020) indicate that the studies are not conclusive, but, in their methodology, they exclude the majority of works carried out, because they do not meet certain stipulated criteria, such as selection of the samples, the absence of adequate tests and other control strategies, to conclude, paradoxically, that the information is not conclusive, as it is not consistent or comparable. Relevant findings, such as community experiments in Japanese schools, where mask covers proved to be as effective as vaccines (Uchida et al 2017), or controlled clinical trials in health services, which in other reviews demonstrate the effectiveness of face mask and respirators to prevent acute respiratory infections, are discarded. (Offedu et al 2017). Others highlight the synergy of measures (Pan et al 2020), when combined, for example, with handwashing (Smith 2015).

Nor do critics of public use mention why specialists who have years of research on the subject, such as Robert Hecht, Nancy Leung, Raina MacIntyre and Shan Soe-Lin, among others, recommend any type of facial protection in risky situations, such as measure of personal and also collective prevention, because, finally, it is a matter of reducing the rate of incidence and not of abolishing the contagion, for which it would perhaps be necessary to spread the use of N95 at the community level, as well as to apply other measures already proven, including in addition to those described, temperature monitoring, follow-up of cases and contacts, tests on suspects and sentinel sampling, which should be added to a strict household restriction. But it would not be desirable for group immunity, just as it is not desirable to prolong the quarantine too long, due to its economic and social impacts.

Although the climatic effects on the biology of the virus are still unknown, the effectiveness of other practices remains to be verified, such as ventilation of public spaces (Gao et al 2016), humidification of dry environments (Reiman et al 2018) and selective use of ultraviolet light to disinfect objects (McDevitt et al 2012). The reasoned use of protectors is justified both clinically in vulnerable cases and at the collective level, as there are recent works that suggest that almost 80% of infections occur through contact with people who are not diagnosed, as was demonstrated in China (Li et al 2020). Other works (Backer 2020) suggest the influence of sunlight on transmission and a better clinical course of Covid-19 in those infected, although the information on the climatic effects is not yet conclusive (O´Really, KM Auzenbergs, Y. Jafari et al. 2020). In any case, exercise, which combines air and sunlight, is one of the few proven strategies to increase immunity (Shephard, et al 1991).

Christos Lynteris recently wrote in The New York Times, “Understanding epidemics not only as biological events, but also as social processes is key to successful containment. Members of a community wear masks not only to protect themselves from disease. They also use them to demonstrate that they want to be, and bear, together the scourge of contagion”. This signals one of the cultural changes of the present pandemic, where it is ceasing to be a cause of stigmatization to become a courtesy mark. Although it is alluded that wearing a mask can lead to avoiding the rest of the measures, such as disinfecting the items that are brought home or taking off shoes, in practice one observes that wearing it makes it easier to maintain attention on these and other preventive measures, acting as a reminder. However, its reasoned use depends on the person and the context. If a vulnerable person is cared for at a domestic level, the surgical mask or face mask is recommended only in the near moments. It is about going out, wearing it only in places where physical distance is not guaranteed or are closed, without natural ventilation, for which it is best to get a handmade mask, preferably made with synthetic nanofibers. If you have symptoms, do not go out except to go to the doctor, in which case, it is very important to carry protection all the time. Its use in people who are not under house restriction, such as merchants and other workers, should be guided by crowded circumstances, such as public transport. The N95 must be left for health personnel, since they are scarce and there are already more than 140 deaths attributable to the lack of personal protective equipment, among more than 13 thousand deaths recorded in the first week of June in Mexico. If we already have one, remember that it is not recommended to use more than 5 times, although with the relative and complementary principle that is recommended, its use can be extended by drying it in the sun. Currently, the evidence of the important role that asymptomatic carriers of the virus have in the transmission of the disease tends to consolidate, so the protector is emerging as a sensible measure to be incorporated collectively, which requires designing models and modes of use according to the that each situation deserves in particular, with bioecological, socioeconomic and cultural criteria. The issue denotes that common sense needs science, but that it must also benefit from good sense, referring to achieving more with few resources.


Bäcker, Alex (13 de abril, 2020) “Follow the sun: slower COVID-19 morbidity and mortality growth at higher irradiances”. SSRN.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3567587 [Consultado el 11 de junio, 2020].

Gao, Xiaolei, Jianjian Wei, Benjamin Cowling y Yuguo Li. 2016. Potential impact of a ventilation intervention for influenza in the context of a dense indoor contact network in Hong Kong. Sci Total Environ 569-570: 373–381.

Haro, Jesús Armando. 2020. Dossier cubre bocas y protectores faciales en la pandemia Covid-19. Recuperado dehttps://es.slideshare.net/JESUSARMANDOHARO/haro-2020-dossier-cubrebocas-y-mascarillas-protectoras-en-la-pandemia-covid-19  [Consultado el 11 de junio, 2020).

Li, Ruiyun, Sen Pei, Bin Chen et al. 2020. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 368 (6490): 489-493.

Lynteris, Christos (17 de febrero, 2020) “¿Cuál es la verdadera razón por la que la gente usa mascarillas durante una epidemia?” The New York Times .

McDevitt,  James., Stephen Rudnick y Lewis Radonovich.  2012. Aerosol susceptibility of influenza virus to UV-C light. Appl Environ Microbiol: 78: 1666–1669.

Meselson, Matthew. (15 de abril, 2020). Droplets and aerosols in the transmission of SARS-CoV-2. N Engl J Med. DOI: 10.1056/NEJMc2009324.

Milton, Donald et al. 2013. Influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks.PLoS Pathog.  9 (3): e1003205.

Mniszewski, Susan, Sara Del Valle, Reid Priedhorsky, James Hyman y Kyle Hickman. 2014. Understanding the impact of face mask usage through epidemic simulation of large social networks. En Theories and simulations of complex social systems, editado por V. Dabbaghian y V. Mago, pp 97-115. Intelligent Systems Reference Library, Springer.

Offedu, Victoria et al. 2017. Effectiveness of masks and respirators against respiratory infections in health care workers. Clin Infect Dis 65 (11): 1934-1942.

O´Really, Kathleen, Megan Auzenbergs, Yalda Jafari et al. (25 de marzo, 2020). Effective transmission across the globe: the role of climate in COVID-19 mitigation strategies. CMMID Repository. Recuperado de https://cmmid.github.io/topics/covid19/role-of-climate.html. [Consultado el 11 de junio, 2020].

Pan, An et al. (10 de abril, 2020). Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China. JAMA 323(19):1915-1923. doi:10.1001/jama.2020.6130. 

Smith, Sheree M. et al. 2015. Use of non-pharmaceutical interventions to reduce the transmission of influenza in adults: A systematic review. Respirology. 20 (6): 896–903. 48.   

Reiman,  Jenifer M. et al. 2018. Humidity as a non-pharmaceutical intervention for influenza A. PLoS One 3:e0204337.

Shephard, Roy, Tony  Verde, Scott Thomas y Pang Shek. 1991. Physical activity and the immune system. Canadian Journal of Sport Sciences 16 (3): 169–185.

Stern, Dalia, Nancy López, Carolina Pérez, Romina González, Francisco Canto y Tonatiuh Barrientos. 2020. Revisión rápida del uso de cubrebocas quirúrgicos en ámbito comunitario e infecciones respiratorias agudas. Salud Pública de Méxicohttps://doi.org/10.21149/11379.

Uchida, Mitsuo et al. 2017. Effectiveness of vaccination and wearing masks on seasonal influenza in Matsumoto City, Japan, in the 2014/2015 season: An observational study among all elementary schoolchildren. Prev Med Rep. 5: 86–91.

Xiao, Jingyi., Eunice Shiu, Huizhi Gao, Jessica Wong, Min Fong, Sukhyun Ryu y Benjamin Cowling. 2020. Nonpharmaceutical measures for pandemic influenza in nonhealthcare settings—personal protective and environmental measures. Emerging Infectious Diseases 26 (5): 967-975.

Commonly Used Epidemiology Statistics in the Time of COVID-19. What They Do and Do Not Mean

by Mark Nichter, Collin Catalfamo and the HCW-Hosted.org team, June 5, 2020

“•A lack of federal guidelines has created huge variation in how states are reporting their COVID-19 data and in what kind of data they provide to the public.”…

In this powerpoint presentation, the authors explore basic epidemiological terms and how they are used both correctly and incorrectly. The conclusions regarding the mis-use of statistical data and concepts are well worth taking a bit of time to consider as we continue along our path to understand the meanings of this pandemic.

Photo by Elizabeth Cartwright June 2020

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Presentación. “Sabemos que no somos prioridad” Comunidades indígenas de México ante la pandemia Covid19. (Spanish/English)

This is a very complete compendium of insights into how Covid-19 is impacting indigenous communities in Mexico.

See below for English translation

Jesús Armando Haro (Profesor-investigador del Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, México. Correo: aharo@colson.edu.mx. Agradezco los comentarios a versiones previas de este texto por parte de Rosa María Contreras, Ramón Martínez Coria, Ricardo Campos, Daniel Mato, Eduardo Menéndez, Florencia Peña, Patricia Alonso, Enrique Perdiguero, y Pastor Sánchez.)

Introducción en español:

Los pueblos originarios enfrentan en México la pandemia del Covid-19 en circunstancias extremas de viejo cuño, con un gobierno nacional que los reivindica en el discurso mientras que la actual crisis pone de relieve la insuficiencia de la respuesta gubernamental, por lo que se han activado numerosas estrategias comunitarias, algunas con acompañamiento universitario o de la sociedad civil, otras desde la autogestión, bajo su propio esfuerzo. En este trabajo repasamos los sucesos ocurridos de enero a mayo de 2020, cuando la curva de contagios y muertes continúa siendo ascendente y nos preguntamos cuáles van a ser los resultados y las consecuencias de esta pandemia para el país, sin valorar aun que en buena parte dependen de los impactos en la diversidad cultural y la biodiversidad biológica, pues seguimos considerando que los problemas indígenas son lejanos y ajenos, aunque en realidad sea todo lo contrario, pues el “México profundo” no solo siempre ha producido sus propias respuestas ante las crisis, sino que ha sido garante y custodio de las riquezas, el patrimonio y el bienestar del país, desde las remesas enviadas desde Estados Unidos por los trabajadores a las comunidades, como el cuidado de los territorios donde se alberga la mayor biodiversidad. La crisis del coronavirus amenaza con despojarlos de su memoria, su cultura y sus territorios, por circunstancias y factores que con mucho rebasan el rango de lo epidemiológico, aunque obtengan su legitimidad del manejo sanitario.

English Introduction:

“We know that we are not a priority” Indigenous communities of Mexico in the face of the Covid19 pandemic

The indigenous peoples of Mexico face the Covid-19 pandemic in extreme old-fashioned and also new circumstances, with a national government that claims them in the speech while the current crisis highlights their insufficiency in response, so they have been activated numerous community strategies, some with universitys or civil society support, others from self-management, under their own efforts. In this work we review the events that occurred from January to May 2020, when the contagion and death curve continues to rise and we ask ourselves what the results and consequences of this pandemic will be for our country, without evaluating even that in large part we depend on the impacts on cultural diversity and biological biodiversity, as we continue to consider that indigenous problems are distant and alien, although in reality it is quite the opposite, since “Mexico Profundo” (the deep country) has not only always produced its own responses to crises rather, it has been guarantor and custodian of the country’s wealth, heritage and well-being, from the remittances sent from the United States by the workers to the communities, such as the care of the territories where the greatest biodiversity is hosted. The coronavirus crisis threatens to strip them of their memory, their culture and their territories, due to circumstances and factors that far exceed the epidemiological range, even if they obtain their legitimacy from the health management of the virus.

“Three Possible Pandemic Curve Scenarios”, “Contact Tracing Process, “Guidelines for Opening up Society” and more.

Mark Nichter PhD, MPH School of Anthropology, University of Arizona. Updated 6/2/2020 University of Arizona

Here is the 6/2/2020 update we’ve all been waiting for! Tons of new information on Covid-19. Clear. Concise. What we need to know. 

Thank you Mark!

A Primer on COVID-19

The disease
Placing the disease in context
Information backing up present public health measures Practical tips on staying safe
And much

The disease
Placing the disease in context
Information backing up present public health measures Practical tips on staying safe
And much more

To be updated periodically

Mark Nichter PhD, MPH School of Anthropology, University of Arizona. Updated 5/13/2020 University of Arizona

Here is the 5/13/2020 update we’ve all been waiting for! Tons of new information on Covid-19. Clear. Concise. What we need to know.

Thank you Mark!

Critical Medical Anthropology Call to Action: Covid-19

by Mark Nichter (University of Arizona), Kristin Hedges (Grand Valley State University), Elizabeth Cartwright (Idaho State University), Sarah Raskin (Virginia Commonwealth University), Deon Claiborne (Michigan State University)

  • Medical anthropology has much to contribute to an understanding of the COVID-19 pandemic as it changes over time in different contexts. As medical anthropologists, our focus is broadly on how Covid-19 is experienced by the public, stakeholders facing different social and economic circumstances, and Covid-19 related policies introduced by those in power, for better or worse.
  • More specifically, we see our research as contributing in three ways. First, our research endeavors to inform those delivering health services as well as policy makers by enhancing their understanding of the social relations of COVID-19 and how social relations influence disease transmission, health care seeking, and support of those who are vulnerable or have fallen ill.  Our research provides information on adherence to the preventive and promotive COVID-19 guidelines recommended by experts, and the ad hoc harm -reduction and self-care activities undertaken by community members. We also track changing perceptions of the physical, social and economic risk of COVID-19.  And we document   information and disinformation circulating in mainstream and social media  as a means to identify what information is compelling as well as  points of confusion, mistrust and uncertainty fostering non –adherence to guidelines and epidemic fear . 
  • Second, as medical anthropologists we can contribute to an assessment of COVID-19 policies and the political and economic factors that have influenced them.  Attentive to health disparity and those who are structurally vulnerable, we investigate who is favored and who is overlooked if not sacrificed by COVID-19 related policies. Our purview takes into account the survival and livelihood of all segments of populations at home and abroad.  
  • Third, we also see our role as contributing to the generation of innovative ideas for better pandemic response now and in the future, in communities and health care settings.
  • Toward these three ends, we are generating working lists of high priority research issues in need of investigation by medical anthropologists. The first list highlights themes and issues in line with the objectives of action oriented engaged anthropology.  A second working list will highlight themes and issues related to COVID-19 that demand critical medical anthropology consideration. The list will be posted at: http://arhe.medanthro.net/
  • You may contribute to updating these working lists by adding suggestions on this google docs file: https://drive.google.com/file/d/1cq7-JrP29PYGS5clcpvX7EUD8LGmKk1x/view?usp=sharing
  • As a special interest group, we would also like to collect briefs from different settings on the issues listed under thematic topics below enabling intra and intercountry comparisons. If you would like to submit a brief please to our blog page: http://arhe.medanthro.net/ please email your submission to Kristin Hedges (ARHE co-chair at hedgeskr@gvsu.edu


  1. Bio communicability and Disinformation
  2. Social Determinants of Health
  3. Agricultural Workers
  4. Health Service Research
  5. Food Security & Food Processing—coming soon
  6. Mitigation activities—coming soon
  • 1. Bio communicability and Disinformation
    • What competing discourse and evocative images are being circulated in the media/social media/ related to COVID-19; who is invested in circulating these different ways of thinking about COVID-19
  • Metaphors used to describe the disease and efforts to contain it
    • Military metaphors – how do military metaphors frame both models of and models for containing the disease,
      •  what do they enable (eg. chain of command)
      • what do the suppress (critique of the government etc.) 
    • Other metaphors such as ecology or natural disaster metaphors
    • Comparisons to other diseases 
    • 1918 influenza
    • No more dangerous than the seasonal flu
    •  Like SARS, MERS…
    • Messages that place responsibility
      • Origin messages 
      • “Chinese virus”
      • Messages employed to deflect attention away from ineptitude of government policy
      • Immuno-politics – messages that favor the shutting down of borders, and blaming non-nationals, etc.
        •  Messages that employ COVID-19 to support ethnonationalism, populism, authoritarianism and push back against human rights
    • Conspiracy theories and how they are being used for political purposes and constitute metacommentary
      • To places: China, United States,
      • To things:  cell phone towers 
      • Labs unintentional, intentional: bioterrorism
    • Messages driven by product advertising and forms of profiteering
      • Cleaning products, Masks, Medications, Testing, Other technology 
    • Messages that are driven by “Othering”, and victim blaming as political strategy
      • Dehumanizing memes  
    • Messages using religion to further political agenda related to COVID-19 policy
      • such as right to assemble in groups
    • What do anti-quarantine protests index: what other issues are represented along -side anti quarantine: anti vax, climate change denial etc
    • Defiance messages in support (for example) of ending quarantine and lock down – anti public health advice and government policy
      • What values are invoked (ex. freedom, liberty, my body my rights etc.)  and who is targeted
      • Who is supporting and bank rolling protests, who is being enrolled, and to what end?
      • Confrontations between HCW:  protestors and public reaction
    • Sources of intentional misinformation and disinformation; need for critical analysis as well as info epidemiology
      • Politics of numbers. What numbers released -both their accuracy and critical assessment of what story they are telling and what story they are deflecting attention away form, misleading comparisons
      • Weaponizing Covid-19 through strategic reporting of numbers
    • Information suppression, controlling the narrative 
  • What is and is not being counted, attempts to suppress reporting of numbers for political reasons
  • Muzzling of HCW from talking to press by hospital admin –critique of working conditions and safety in hospital and quality of care
  • Political response to disease modeling and public health recommendations related to relaxing restrictions
    • Funding and the politicization of science —follow the funding and funding cuts
  • 2. Social Determinants of Health: Health disparity and COVID-19, factors influencing maldistribution of hospitalizations and mortality
    • Factors behind racial disparities
      • What does race have to do with it, and how much is race a marker of other risk factors
    • Economic Inequalities
      • Essential workers in low income bracket
        • Higher risk exposure on job and daily commute with less resources to respond
          • Janitors, housekeeping, gas station, agriculture workers
      • Employment insecurity
        • Enduring risk exposure due to limited options
      • Density in housing
        • Higher population density in neighborhoods increases transmission rates
        • Higher population density within households increases transmission rates
    •   Lack of health insurance
      • Uninsured/underinsured for health care exacerbates chronic conditions that put people at risk of COVID complications
      • Exacerbated COVID infections due to
        • Difficulty in accessing telemedicine advice
      • Loss of health insurance related to loss of work
      • Difficulty in accessing test without primary provider to order
    • Environmental risk
      •  Environmental pollution impacting lung health and COVID infection
    • Comorbidity
      • Racial and ethnic disparities in health conditions exacerbating COVID infection
      • High Blood Pressure, asthma, diabetes, obesity, taxed immune system
  • 3. Agricultural Workers
    • Ability to work
      • Availability of work in sufficient hours, job losses
      • Working sick? Protection of self and others
      • Need to return to work vs social distancing
      • Pressure from companies to return to unsafe work conditions
      • How companies define who is ‘safe’ to work? Testing? Certificates?
      • Ability to get testing tied to immigration status?
      • Blaming the victim in occupational sites where outbreaks occur  as a means of deflecting attention away from working conditions
    • Family living conditions-
      • Isolation of sick members
      • Multi-generational families
      • Living conditions when travelling for harvests-cars, camping, company houses
    • Packing plants
      • Close working quarters
      • Availability of masks, handwashing, social distance
    • Education-
      • Ability to access classes for K-12 that have moved online, WiFi available?
      • Bilingual education availability online?
      • Linking into education programs that have been moved online as they follow crops
    • Health Conditions of agricultural camps
      • Covid-19 infections in individuals with asthma, allergies, high dust exposure, respiratory exposure to pesticides
      • Washing facilities for people, clothes, dishes
      • Availability of reliable health information
      • Distance/access to medical care in breathing emergencies
      • Fear of seeking treatment if undocumented
    • Virus fugitives
      • migrants trying to escape the virus,
      • migrants return home and escape environments of risk and food insecurity 
  • 4. Health Service Research
    • Overarching themes
      • Access to/distribution of health services and limited health care resources (links to disparities)
      • Expertise (competing expert knowledges; local knowledges; politicization of science)
      • Magnification of broken health care system (in U.S.), and potential of COVID-19-produced changes to permanently change system
    • COVID-19 diagnosis and treatment
      • Testing – individual patient concerns and health system epidemiology
    • Access to testing
      • Shifting screening qualifications
    • Inadequacies (volume, quality, time to process)
    • Shifting case definitions
    • Molecular vs. serological
      • Treatment decision-making
    • Acute: respiratory
      • Distribution of limited resources, e.g. ventilators
    • Immediate post-acute: secondary concerns (e.g. kidney) some lethal (e.g. strokes)
    • Long-term: unknown
    • Politics of numbers –
      • How is data being presented and misrepresented
      • Politicized response to disease modeling
      • Suppression of data on disease prevalence and mortality
      • Misleading comparisons
      • Death deflation for political purposes
    • COVID-19 spillover effects on other health service
      • Service limitations and their impacts on non-COVID-19 health conditions
    • Essential health services such as routine childhood vaccinations
    • Patients delaying care of serious health condition, for example out of fear
    • Negative long-term effects of limited management of chronic conditions that can cause unnecessary suffering to patients and may overwhelm primary care when services open back up
    • Medications
    • Shortages produced, e.g. hydroxychloroquine for management of lupus
    • Management of unfounded treatments, e.g. poisoning by household cleaners
    • Relaxation of standards of care reported in hospitals
    • Opposite effects: Social distancing causing declines in typical E.D. volume e.g. trauma
    • Health care worker safety and wellbeing
      • PPE (volume, quality, distribution decisions)
      • Care of colleagues who become ill
      • Mental health
      • Censorship of health care workers
      • Debates over what is deemed essential services
    • HSR Concerns related to death (maps to disparities)
      • End-of-life care, for both COVID-19 and non-COVID-19 patients
      • Physical distance from loved ones during death
      • Management of bodies
      • Safety of chaplain staff and PPE
    • Health policy and practice
      • Health insurance and financing
    • Private insurance declines amidst layoffs/closures across sectors
    • Federal policy change to guarantee coverage of COVID-19 testing but not treatment
    • Health system revenue concerns amidst limitations on non-essential care
    • Opportunity to drive permanent health insurance reform
      • Health care delivery modalities
    • Drive-through COVID-19 testing
    • Pharmacist expansion of duties
    • Contact tracing
    • Rapid expansion of telehealth
      • Telehealth disparities
        • By population (e.g. rural)
        • By health care setting type (e.g. large, integrated system vs. small practices; academic medical centers versus non-)
      • Expansion = accompanying opportunity to drive permanent telehealth reform
    • Professional shifts
      • Expedited licensure among final-year clinical students
      • Liberalization of out-of-state license restrictions for telehealth expansion and medical humanitarian volunteerism
      • Reskilling/transition of clinicians from specialization that is undeliverable under COVID-19 to essential/overburdened specializations
      • Furloughs/layoffs of clinicians in “low revenue” fields due to service restrictions
      • Mandated schedule shifts
    • Research fast-tracking
    • Some, extra-legal e.g. testing at UW pre-FDA approval
      • Public relations and image management
    • Health systems infrastructure and operations not covered above
      • Institutional health care considerations
    • Nursing homes
    • Prison health
    • Military health
      • Safety net settings
    • Community health centers
      • Home care (formal and informal)
      • Emergency Operations Centers (EOCs)
      • Coordination (or non-coordination) with other sectors
    • Public health
    • Emergency management
    • National guard
    • Crafters, “innovators” and others organizing novel PPE
      • Mask-sewing, 3-D printing shields, manufacturing gowns, refiguring other pumping devices into ventilators
      • Clinical trial recruitment and enrollment
      • How systems respond to shifts in demands at different sites of care (e.g. emergency department, primary care, specialty care) at different points in local/regional COVID-19 spread
      • Health services that occur outside of health systems
    • CAM
    • Oral health and dentistry
    • Health systems in sociopolitical contexts
      • Supply chains
      • Relationships with local businesses
    • Restaurants
    • Childcare coverage for HCW and other essential workers
      • Public responses
    • 7pm nightly public “thank a HCW”
    • HCW confrontations of “reopen” protestors
      • Intensification of single payer debate due to timing w/ U.S. presidential election
      • Policies that exacerbate covid-19 spread
      • Politicization of science —follow the funding and the funding cuts
      • Politics of accountability as it is shunted between federal to state to county

Who’s responsible? Between discipline and politics in times of coronavirus*

By Davide Casciano, PhD.

Italy under lockdown

Since mid-February 2020, measures to contain the COVID-19 pandemic in Italy have involved domestic self-isolation, through increasingly restrictive measures. The movements have been limited to those considered ‘essential’: grocery shopping, or going to work in one of the few ‘crucial’ industries still open (without public debate on the matter), such as those linked to military production. It has been forbidden to move from home, even for a short time, to do outdoor activities, to meet in groups composed of strangers; for those who tested positive, it is completely forbidden to move from home. Tests are expensive, masks unavailable, and the public health system collapsing.

Reuters image

One of the first critics of these measures was Giorgio Agamben, with an article much criticized in the national debate. Agamben is notoriously skeptical about the initiatives of those sovereign states in which people, stripped of their legal status, are exposed to a state of exception, without rights. It is difficult to say, as some people seemed to read in Agamben, that the virus is an ‘invention’; but we should catch at least a provocation from him. We are living in extreme times. Indeed, the rhetoric of a state of exception has been spread through newspapers, with consequences that ethnography could grasp, in Italy and beyond.

War metaphors for extraordinary times

As I wrote elsewhere, among the metaphors and images most widely disseminated by the media were metaphors of war, the state of exception par excellence. While it is difficult to say that there is such a thing as ‘the State,’ against which Agamben directs much of his criticism, there are discursive practices (and social agents) that materialize it. These discourses remodeled people ethical dispositions in Italy, turning into abnormal, and to a public hunt what before was taken for granted – a run in the street, a hug. In trying to justify these epidemiological measures of containment, military discourses have depicted a united population, and also indicated transgressors. The war would have been non-existent without mentioning enemies, cowards, unwilling to discipline (and sacrifice themselves) for the homeland.

If it’s a war, who’s the enemy, and what would be after?

But there is another result, perhaps more dangerous, that emerges from the use of battle and discipline metaphors: the enemy is someone else than those who evoke it. After years of spending cuts towards public sectors not considered ‘strategic,’ including health, talking about war allows someone to get rid of public responsibilities concerning the gravity of the current situation, leaving someone else alone, apparently a victim of himself. And yet, no public intervention is really ‘neutral.’

Confronted with so many ‘hard science’ experts, anthropologists cannot fail to point out which health policies were wrong, and the possible errors in the management of this emergency in the time ahead. Besides providing knowledge instrumental to the guidelines for dealing with the crisis, anthropologists must have the courage to show the COVID-19 pandemic as a total social fact, and therefore also political. Now that the virus has proven humanity united in grief, we need the courage to imagine alternative futures.

“Davide Casciano, PhD Social Anthropology, worked on AIDS in Ibadan, armed groups and Pentecostalism in Port Harcourt and private security in Johannesburg. He is currently Teaching Assistant of Social Anthropology at the University of Bologna.”

*This contribution is an outline of a full article published in the Journal of Extreme Anthropology, titled “COVID-19, Discipline and Blame: From Italy with a Call for Alternative Futures”, available online.

Vulnerability, Isolation, and Access in the Time of COVID-19

by Kristy Buffington, MA, NIC, April 24, 2020

The Coronavirus pandemic has created worldwide disruption and left many of us searching the headlines for information and resources we can trust. Access to reliable COVID-19 information is vital, and lack of access for deaf people substantially increases their isolation and vulnerability during a time of heightened stress. 

Access through Interpreters/Captioning

[Image description: Blue and white computer-generated drawings of the various disability accommodation symbols. The drawings are arranged in a square with a large question mark in the middle.]

The National Registry of Interpreters for the Deaf recently issued a position statement calling for the use of Certified Deaf interpreters (CDIs) during Coronavirus press conferences. CDIs are interpreters who are native users of American Sign Language (ASL) and are themselves deaf. They provide interpretation with linguistic fluency that is understandable to large portions of the deaf population. While many city and state governments are doing an excellent job of providing CDIs for press briefings, others are providing unqualified interpreters or failing to provide interpreters at all, such as at the federal level during White House briefings (DPAN.TV has taken it upon itself at their own expense to provide interpreters and captioning for COVID-19 White House briefings). 

While the provision of interpreters increases access, it does not guarantee access for deaf people who rely on captioning or receive their information via social media. Much of the content on social media platforms is either uncaptioned or auto captioned. Auto-generated captions, used by Facebook, Instagram, YouTube, and some videoconferencing platforms such as Zoom and Google Hangouts, are notoriously inaccurate, often to the point of being non-sensical. Although captioning software is improving, technology has yet to equal the skill of a human real-time captioner.

The provision of press conference interpreters further does not guarantee access for those among the larger deaf population who are particularly vulnerable, such as those with language deprivation, deafblind people, deaf prison inmates, and deaf children. 

Language Deprivation and Health Literacy 

Language deprivation results from the chronic deprivation of an accessible language within the critical language window, the first few years of a child’s life. Language deprivation is rare among hearing children and generally only occurs in cases of extreme abuse or neglect. Since 90% of deaf children are born to hearing parents and do not acquire an accessible (visual) language through a natural first language acquisition process and because audiologists and other medical professionals frequently advise hearing parents avoid ASL and rely solely on technology such as cochlear implants and hearing aids, language deprivation is much more common among deaf children and adults (Hall 2017; Murray, Hall, and Snoddon 2020).

Deaf people with language deprivation exhibit common tendencies, including disorganized or incorrect syntax, limited vocabulary, a lack of incidental learning or limited fund-of-information deficits, difficulty expressing and understanding time, and difficulty with story structure and abstract thinking (Crump and Hamerdinger 2017; Hall, Levin and Anderson 2016). Deaf people with language deprivation tend to be concrete thinkers and may struggle to understand others with more fluent language. In turn, those with more fluent language may struggle to understand those with language deprivation.  

Deaf people as a whole have lower health literacy rates than hearing people and deaf people with language deprivation may have even lower health literacy, struggling to understand basic medical terminology or functions of the human body (Hedding and Kaufman 2012; Pollard and Barnett 2009; Smith and Samar 2016).  This raises the question of how are deaf people with language deprivation understanding COVID-19, including what they’re seeing on social media?

A deaf woman with language deprivation recently described to me something she’d seen on Facebook. She used the sign commonly glossed as MONSTER to describe virus transmission from one person to another through a vampire-like bite on the neck. As I explained the cough and fever that often accompany COVID-19, she shook her head in agreement and then added BITE on-the NECK, as if I’d forgotten that symptom or mode of transmission.

If she presented at a hospital or clinic with this belief would a medical professional have enough training to understand that this is most likely related to her language deprivation? Would that same professional have enough time, patience, and empathy to sensitively navigate the situation and explain, with the assistance of a qualified medical interpreter, virus transmission?  Finally, would she understand the professional’s explanation, or would it influence her thinking or change her belief or behavior? 

Other Vulnerable Groups

[Image description: Two women with their hair pulled back and wearing masks, gloves and eye protection stand in front of two commercial washing machines.]

 Pro-tactile ASL (PT-ASL) is a communication philosophy that allows deafblind people and their support service providers (SSPs) to relay linguistic information by signing into one another’s palms and to convey prosody and visual information on a person’s back, shoulders or thighs (see the link above for a video example). PT-ASL relies on touch and requires signers to be close to one another. With the advent of social distancing many agencies have limited or suspended SSP services leaving deafblind people extremely isolated and struggling with unmet accommodation needs. 

Prison inmates are at increased risk for COVID-19. This is especially true for deaf inmates as prisons, in direct violation of the Americans with Disabilities Act, frequently isolate deaf inmates and refuse to provide qualified interpreters. Deaf, deafblind or deafdisabled prisoners with no accommodations or access to information may not even be aware of the pandemic and their increased risk for COVID-19. Subsequently, they are unable to advocate for early release or other measures to protect themselves.   

The National Association of the Deaf maintains a list of care facilities across the U.S. that specialize in or are knowledgeable about the communication needs of deaf people. However, this list is small and many states have no such services, leaving deaf senior citizens or deaf people with developmental disabilities who live in care facilities isolated with staff who know little to no ASL. Like deaf prisoners, those within care facilities without adequate access to information are highly vulnerable and may be unaware of how best to protect themselves. 

Experts are concerned that rates of child abuse may rise among the general population due to COVID-19 stress. Deaf children are particularly vulnerable as family members may or may not sign and as they are isolated from their peers and support staff such as interpreters and teachers for the deaf. Prior to Coronavirus, researchers reported that deaf children suffer trauma more than hearing children and are twice as likely to be victims of sexual abuse. Given extended shelter in place orders and increased stress, these grim statistics will likely increase.

[Image description: A group of graduating high school students from the Idaho School for the Deaf and the Blind, dressed in black and white caps and gowns, pose for a photo celebrating their graduation.]

Deaf students have lower postsecondary graduation rates than their hearing peers. Research further shows that deaf people experience increased mental health risk factors and a lack of specialized mental health care compared to the general hearing public. Because of the rapid move to online education deaf students may be overwhelmed. I’ve recently had several students call me in tears. They are emotional and frustrated with a lack of accommodations, including no captions or inaccurate captions on instructor’s recorded lectures/ videos and long wait times for disability service offices to add recordings of interpreters to lectures. Many of them feel undervalued and overlooked by their colleges and universities. Some feel like failures and are grappling with the decision to drop-out.

The university where I teach has sent email announcements to all students reminding them of the availability of remote counseling services at no charge. While this is helpful for hearing students it may not adequately benefit deaf students as counselors are frequently untrained in the communication needs of deaf people and in the unique forms of oppression and trauma they experience.

The Role of Anthropology? 

[Image description: Two blind children with white canes walking down the sidewalk. Both children have posters celebrating White Cane Safety Day. A sighted teacher walks behind them.] 

  • Medical anthropologists can:
    • work to help inform and improve the understanding of healthcare and mental health professionals regarding the needs of special populations such as deaf people
    • undertake research that helps to direct and inform clear and accessible healthcare policy and advocate for inclusion and equitable access at all levels of healthcare 
    • further research how vulnerable groups within the larger deaf population, including deafblind, deafdisabled, deaf people with language deprivation, and deaf refugees, migrants and immigrants conceptualize health, illness, risk, and mental well-being 
    • present their research and lend their professional support to organizations that work on behalf of the underserved, such as The American Deafness and Rehabilitation Association (ADARA), the Association of Medical Professionals with Hearing Losses (AMPHL), and the National Center for Deaf Health Research (NCDHR
  • Educational anthropologists can:
    •  research transition pedagogy and help implement inclusive early transition programs for children with disabilities, increasing rates of postsecondary success
    • collaborate with colleagues in their university’s Department of Education and/or Special Education
    • present their research and lend their professional support to organizations that focus on student needs, such as The Association on Higher Education and Disability (AHEAD), the National Technical Assistance Center on Transition (NTACT), and the National Deaf Center on Postsecondary Outcomes (NDC).
  • Anthropologists who teach at the college or university level can:
    • be flexible during this time and check-in with their students with disabilities
    • educate themselves on common postsecondary accommodations, and if need be, seek advice from their campus disability service office or organizations such as their state commission for the blind or council for the deaf and hard of hearing 
  • Professional anthropologists, regardless of sub-field, can:
    • be welcoming and supportive of students with disabilities into higher education and as anthropology majors
    • be collegial and supportive of anthropologists with disabilities in the profession
    • establish a professional network and collaborate with professionals in disability-related fields such as vocational rehabilitation counselors, disability resource and transition coordinators and disability advocates

Author’s note: Following the lead of the NDC, I use the term deaf in an inclusive manner to include those who identify as deaf, deafblind, deafdisabled, hard of hearing, late-deafened and hearing impaired. 

Kristy Buffington, MA, NIC, is the Post-Secondary Transition Coordinator for the Idaho Educational Services for the Deaf and the Blind (IESDB), a licensed, certified Sign Language interpreter and an adjunct instructor for the Idaho State University Department of Anthropology. 

Weaponized Professionalism in the Time of COVID-19

Ye Kyung (Yekki) Song is a soon-to-be MD, PhD in Medical Humanities. 

I’m a fourth- year medical student, and since March 18, 2020, clinical rotations have been suspended and third- and fourth-year students have moved to completing coursework online. Ever since then, I’ve seen numerous posts on my class’s Facebook group and talked to other students who wanted to help out and volunteer. I felt immensely guilty for not wanting to be on the “front lines,” since this was “what I signed up for.” When I drove by campus recently, my institution had posted a large banner near their Emergency Department parking garage – “Heroes Work Wonders Here.” [YS1] [LC2] The institution even has a dedicated COVID-19 webpage which features video interviews of staff describing their experiences. 

/r/medicalschool, a community on Reddit, a major news aggregator/anonymous forum helped me relieve some of my guilt and I felt less alone, less ashamed of being thankful. /r/medicalschool’s mega-thread on COVID and popular image macros centered around student concerns about the pandemic, often using the rhetoric of war – being on the “front lines” and early graduation of medical students as getting ready to “deploy more workers.” being reticent to be used as a “human meat shield,” and pointing to their limited capability to contribute to the team. What is particularly egregious is the numerous reports from medical students being told that they are “unprofessional” when they voice these concerns, as evidenced in a popular image macro below (4.5k upvotes, #4 most popular post in the last 30 days).

Deployment of Soldier/Hero Rhetoric

What does the deployment of the Hero/Soldier rhetoric do for those working in healthcare? Who primarily uses it, and for what purpose? Anonymous online discourse on Reddit reveals opinions on these issues, and the in-real-life discourse which is suppressed due to real concerns of retaliation. Reddit’s various medical subreddits (subforums) allows for healthcare professionals to come together and share their experiences. Seeing the vast number of people who identify structural issues with how their institution is addressing COVID, and also reject the Hero/Soldier rhetoric personally provided me with comfort – I felt less guilty for being afraid. For example, the creation of the image macro below provides insights into what the hero rhetoric does and has received 1.0k upvotes, however, the comments only state how true this is, rather than providing solutions. 

Roger Stahl argues that the rhetoric surrounding war time, such as the contemporary call to “support the troops,” functions as means of deflection and dissociation: by focusing on the individuals at the front lines, the focus is then on saving individuals, rather than the policy and systemic factors at play. This rhetoric also dissociates the citizen from questions of healthcare policy, and dissent against how COVID-19 is being handled by the administration is seen as immoral.

As one friend told me, firefighters sign up to put out fires, but no one asks them to do it naked; healthcare workers are rationed personal protective equipment, with some institutions only allowing for one mask a week. In hotspots, providers are resorting to improvising their own PPE: wearing trash bags and homemade cotton face masks. In many places, the community is taking the initiative to take care of the failures of the medical system. For example, my mother leveraged her connections in the Korean-American community in Houston to gather materials and funding to make masks at the alteration shop she works at.

Difficulties in Creating Change

According to some users on Reddit, revealing problems with their workplace, even on social media, can lead to retaliation from the institution, such as suspension or even termination of employment. A Name and Shame Google Doc was posted, which goes in depth into the mistreatment present, particularly in hotspots. This crisis has led to the call for physician unionization, but some are doubtful that anything will happen. The author of the post writes, “However – I may be come to realize that this is place, much like other parts of Reddit, is an echo chamber that we’re all screaming into.

“It’s the same cycled post about needing to unionize. There’s a brief upswell with a few upvotes, and then it dies down. Someone will comment about PPE. Someone will mention that they already have unions in ____ place. There will be a comment about how nursing is doing it/that’s how they’re getting their agenda passed. Rinse, and repeat,” and a commenter replies, “Our profession is quite selfish tbh. Once everyone gets past that resident threshold, we quickly forget the struggles of those below us with a “cut the rope” mentality. It forces us to turn fiscally conservative reallll quick because we’re scrambling to make up for lost time from our prime earning years. . . . We can keep talking about our clinical training hours, patient outcomes and yrs of training to no avail. Nothing we do or say is going to stop encroachment and they have momentum on their side. Can’t we just break down the outdated hierarchical structure of this profession and have some significant reform?” I desperately want this to happen, but I don’t know how to even begin. I imagine others know that change needs to happen, but we don’t have the tools or know-how to get this movement off the ground.”

This brings us to a question about social media use in general: while Reddit is beneficial as it allows for people to freely express problems with their institution and the culture of medicine, some theorize that online engagement promotes “slacktivism,” while others state that online engagement has no correlation with in-real-life political action for younger people.

Systemic Vulnerabilities

What is more alarming is my particular institution, despite stating that “heroes work wonders here,” is asking for those same heroes to take a day off a week, using personal leave/vacation/sick days, to help alleviate the 40 million dollar deficit, and for faculty to contribute part of their salary toward the COVID relief fund. These measures are part of a plan to reduce the number of layoffs. Other institutions have already cut staff and physician salaries, furloughed workers, prior to cancelling the planned salary increase for resident physicians.

Residents and trainees are the most vulnerable, who have very little negotiating power as far as salary, hours worked, and where they are being asked to practice. As their training is tied to their employment contract, residents are afraid to voice their concerns because they fear being terminated from their training position. One bright spot in this sea of bleak news is that the American Medical Association recently acknowledged issues with residency, such as that resident salaries are low compared to those of other healthcare workers, and recommended that residents should be candidates for hazard pay, and granted forgiveness and/or forbearance for all or portions of their student loan debt. This acknowledgement is a small step in the right direction.


The heroes feel compelled to contribute – without a financially solvent hospital, they would also be unemployed, and their sacrifices would be even more in vain. The institution’s plea for its employees to help shoulder some of the financial burden is just another representation of the system level failures present in today’s healthcare system, such as how expensive medical care is, and how requests for federal and state funding were inadequately answered due to their own lack of funds. We need to look past the hero/soldier rhetoric which deflects from these larger issues, while still working to support individual healthcare workers during this crisis. So – how do we get this movement off the ground? 

Author Bio:

Ye Kyung (Yekki) Song is a soon-to-be MD, PhD in Medical Humanities. Her PhD dissertation analyzed expressions of medical student burnout online on Reddit, and her research interests include physician/trainee education, mental health, and netnography on social media sites. She will begin her Psychiatry residency at Duke University in July.


Memes in Medical Education (Medical Anthropology Theory)
The Medical Student Manifesto (Pedagogy and Theatre of the Oppressed Journal)