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

THE FOLLOWING IS A LIST OF CORE ISSUES THAT DEMAND CRITICAL MEDICAL ANTHROPOLOGICAL RESEARCH

  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.

Conclusion

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.

Articles: 

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


Hoaxes, Physical Distancing and (Un)masking in Small Town America

Janneli F. Miller, PhD   April 18, 2020

I live in a remote rural section of southwestern Colorado, in the four corners region.  Our county has 30,000 people and it didn’t have a case of COVID-19 until Saturday March 28. 

On that day there were 112,000 confirmed cases of the novel coronavirus in the US- compared to 583,220 today- a fivefold increase in 2 weeks and a half weeks.  President Trump was seeing off the USNS Comfort as it left for New York City, where 728 people had died at that time. Now the number of fatalities in NYC is 10,058, and we know the ship didn’t help much.

That same day Trump announced he was considering an ‘enforceable’ quarantine for New York, only to change his mind a few hours later, tweeting that quarantine was ‘not necessary.’ Instead of a quarantine he decided to ask the CDC to implement a travel ban, with the CDC confirming the Domestic Travel Advisory for New York, New Jersey and Connecticut the next day.

Tom Hanks and his wife had just returned from their quarantine in Australia, and the first infant died from the virus in Cook County, Illinois- the youngest victim to succumb to COVID-19 at that time.   

Things are moving so fast these days that it is hard to remember what it was like just two weeks ago, when our county recorded its first case.  We were immersed in the news, but New York City is far away and no one we knew was sick or dying.  We heard about flat curves and our county health department was putting out precautionary notices with information that seemed to change daily, but it all seemed a bit surreal.

Even as the health department told us to act as if COVID-19 was already here, we were wondering if, or more likely when, the virus was going to show up.  It had been coming closer and closer all month.  It ran through the Navajo reservation after a Church of the Nazarene service in Chilchinbeto, AZ because one member of the gathering who didn’t know they had COVID-19 coughed, resulting in 27 cases spread all over the reservation as attendees returned home. The reservation now has 813 cases and completed a 57-hour curfew over Easter weekend. Many people don’t have running water, health services are few and far between and Navajo officials and residents are worried.  There are rumors about roadblocks on highways leading in and out of the reservation, and locals in my county are now organizing and delivering food to isolated Navajo communities, since there are only 13 grocery stores on the reservation.

On March 28, COVID-19 had already been confirmed in Farmington, New Mexico, and had just hit Durango, Colorado. The day before, San Juan County, Utah, home to Bears Ears, Comb Ridge, and Valley of the Gods registered its first case- immediately shutting down the entire county to camping and travel for non-residents.  Just 2 weeks earlier, leaders in that same county had asked their Utah governor to “return to normal” because they thought the precautions were an overreaction to the virus.   https://www.sltrib.com/news/politics/2020/03/20/rural-county-leaders-utah/?fbclid=IwAR0JfJLyJdYDktMP_5Nzj_Pk6B-E6Np8HSN8DeWln811yjJ0jcWQ9IAQEy8

We had only been ‘sheltering in place’ for 2 days when we received news of the first case in our county.  It was March 26 when our Democratic Governor Jared Polis made the “lockdown” order, but everything was pretty much closed already. Restaurants and brew pubs were doing take out and curbside pickup, the libraries, bike shop and thrift stores were closed, meetings were virtual, schools had extended their spring breaks in order to shift to online educational strategies, and live music concerts and festivals (a big deal here) had all been cancelled.  River guides were staying home because their trips were off.  The lucky ones were working at home, the unlucky ones held down front lines at grocery stores or quickie mart gas stations, and many more lost their jobs or were furloughed.  Every day brought news of something else being cancelled or closed, and words like “lockdown” and “quarantine,” a part of the national discourse for weeks, were now heard around our county.

“Essential” businesses and activities seemed to be doing well. Farmers and ranchers continued working their fields and pastures, as lambing season began and irrigation ditches started running. The hardware store was open, as were dental offices, auto mechanic shops and natural food stores.  One friend went to a garden center to pick up seeds and soil- as an agricultural supply provider it was considered essential.  A farmer friend I saw at the grocery store said her life hadn’t changed at all, and that actually the current situation was “kinda cool.”  But then, she continued, she wasn’t going to let her dogs socialize with anyone, because the virus “lives for 9 days” on surfaces, including dog fur. Neither of these ideas have yet been confirmed, although the 9 day figure originally came from a retrospective analysis of 22 studies of SARS and MERS published in the Journal of Hospital Infection in early February and hit many popular news outlets.  https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext

Walking trails and parks around town were now full at all times of day since people were free from their usual working hours and could perform this essential activity at any hour. Parents were both rejoicing about staying home and homeschooling, while complaining that being home with small children all day every day was a bit much.  It’s not that different today.

But by the end of that weekend at the end of March when I checked the data and maps, our county was suddenly in the “red zone,” meaning that it had shifted to “high risk” in a matter of hours. This is because by the time we had 3 cases, 1 person had died, making our case fatality rate 30%.  Yikes.  As I write we are at 12 cases and 2 deaths- a death rate still higher than most regions, even though the numbers are low. 

And just now the articles are coming out about how rural America will be hit hard. 

I provide this information as a background to what seems to be a disturbing reality here in the remote rural west.  While many people do indeed take it seriously there is a fair amount of talk about “hoaxes,” both on the radical left and right, and this is impacting the extent to which public health recommendations are being taken seriously, including physical distancing and mask wearing.

On one side are the conspiracy theory types who are certain the virus has to do with the “New World Order” or 5G or both.  This is exemplified by the video “We’re Living in 12 Monkeys” on YouTube’s Truthstream channel, https://youtu.be/1JLBXfKDbbI, which unpacks the article “We’re Not Going Back to Normal” by Gideon Lichfield, published in the MIT Technology Review on March 17.  The article is used as a basis for how the “government” is going to take over and control us all.  I heard about this in passing, while talking to a neighbor who was walking by.

Others, on FaceBook, Instagram and in person warn about 5G.  The idea, as far as I can tell, is that somehow electromagnetic waves poison us and the coronavirus is really a “toxin” that our bodies excrete in response to a change in the force of the waves.  Wuhan is cited as the first urban area to go 5G, and several doctors, including Thomas Cowan, explain how pandemics are related to changes in radio wave technology. Unfortunately, his video has been taken down by YouTube (evidence that he was correct according to some) but others are onto this topic as well. Sally Fallon Morell, author of the popular cookbook Nourishing Traditions, has a blog post asking if the coronavirus is contagious, and explains there the link between waves and pandemics.

Dr. Andrew Kaufman has put up a power point on YouTube, https://youtu.be/KGGd7-vvd9Y in which he explains how exosomes are “identical” to the corona virus, and that there is no “gold standard” in current COVID-19 testing, meaning that we are getting a lot of false positives, which in turn makes the pandemic seem more serious than it really is.  If you check out that link be sure to read the comments, in which Kaufman is thanked for providing “real” evidence and helping watchers feel safer. 

Over in the UK, people are destroying 5G cell towers, while more and more articles pop up explaining that 5G has nothing to do with COVID-19. https://www.bbc.com/future/article/20200406-why-smart-people-believe-coronavirus-myths?ocid=ww.social.link.email  Articles like this are being used by the “conspiracy theorists” as further evidence that “they” don’t want “us” to know the “truth.”

Meanwhile, those who follow our President’s every word are (still) comparing the coronavirus to the flu. I can’t tell you how many times I’ve had to explain the difference between “prevalence” and “virulence” to intelligent people (not my anthropology students) who still don’t get why this is all such a big deal.  “The flu kills more people and we’re not locked down for it,” is an all too common refrain.  The fact that we have a vaccination for flu, and not for COVID-19, seems to be irrelevant to these folks, who also don’t seem to get what case fatality rates mean or why we should care about them.

Others are wondering why we aren’t jumping on board with the “malaria medicine” promoted by Trump.  This, even as an Arizona man died on March 23 after taking it with his wife upon hearing President Trump’s recommendations. Most recently the NYT reported on April 12 that a small study in Brazil on chloroquine was halted due to deaths among those taking the medicine https://nyti.ms/2RyHKiL   

There really are people who do believe this is a “hoax” and wonder what all the fuss is about, and some of them live in my small town. These ways of thinking, sadly, run along political lines- as we’ve seen with the Democratic governors recommending earlier precautions, while Republican governors wait to see what the President recommends.

This cultural divide is especially disturbing when it comes to public health measures- as evidenced by the recent order to wear masks- and exemplified by my experiences shopping in my small town of 900.  While many of my friends are busy at home sewing masks for distribution to local hospitals, grocery store workers and other mutual aid groups, other residents are flagrant in their violation of the order. 

I went to a Family Dollar four days ago, a day after the order to wear masks went into effect, (although the President said he wouldn’t wear one.)  I had a bandanna covering my face and was shocked to see that I was the only one in the store with a mask.  The employees were not wearing masks, nor were any of the shoppers.  Nobody was staying 6 feet apart from each other, except me as I negotiated the aisles in order to keep away from people while also trying to find what I was looking for on the semi empty shelves.  Once in line, I stood back from the others in front of me, even as the person behind me stepped up within a foot of me.  I was shocked.

After this, I headed over to my local grocery store, where I found people with scarves on waiting outside and a sign on the door stating that only 5 people were allowed in at a time.  After watching several (masked) people leave, a masked check out worker told us we were welcome to come in.  Everyone in the place had on masks and all employees had on gloves.  Several customers wore gloves as well.  And it was “normal”!!!  Nobody seemed to be bothered to wear a face covering- some pulled scarves up over their faces, others had on home sewn masks and a few had the paper medical supply types.  Conversations went on, and people seemed relatively cheerful, while keeping their distance from each other.  

I use these examples as a way to illustrate how uneven and disturbing our country’s response has been, due to, in my opinion, a lack of leadership providing consistent messages in alignment with the latest scientific data and public health recommendations. It’s a travesty that our president has downplayed the risks and placed “the economy” above human life.  Without human and environmental health, there is no “economy”!

I live out in the boonies- it took the virus a while to arrive, and even now our numbers are low, while our risk is high. Yet half the people I see think it’s a hoax, the flu, or a conspiracy, while the other half (I hope it’s half) are taking the precautions seriously.  Our masks- or not- are clear indicators of where we stand in terms of political predilections and pandemic philosophy.

One of the twelve stricken individuals in our county is a (Trump supporting) friend’s brother.  “It’s no big deal,” my friend said about his brother’s illness, seeming kind of miffed that he himself had to self-quarantine, because our county is contact tracing and recommending all those close to the infected individuals self-isolate.  This Trump supporter followed the county health department recommendations, only because it was his brother who was sick.  But the fact that his brother is OK and that he himself didn’t get ill indicates to him not that the precautions work, but instead that the virus really isn’t too serious.

In this kind of situation one wonders how effective the precautions can be.  I will not go to Family Dollar again, but others will and do- the most cars I see in one place in my small town are in the parking lot at the Family Dollar, or in line at the liquor store take out window. People I know call each other up in order to meet at the local brew pub so they can sit in their cars and drink their take-out beers “together,” while the Mexican restaurant is making a good business selling large take out margaritas in Styrofoam cups.  Who cares if alcohol depresses the immune system or Styrofoam is environmentally unsound?

https://pubs.niaaa.nih.gov/publications/10report/chap04b.pdf  Even the Huffington Post is telling us that drinking right now is not good for our immune systems, but that doesn’t matter around here- only “liberals” read the Huff Post, or ‘believe’ in science, right? https://www.huffpost.com/entry/how-alcohol-affects-immune-system_l_5e8f84c5c5b6d641a6bbf838 

Given this context, I worry about our county.  We’re an at-risk community because of our demographics- 22% of our residents are over 65 and 22% under 18.  13% have no medical insurance, 13% have a disability, and the per capita income is $25K (2018).  There is one hospital for 30,000 people, which has 4 beds in the ICU unit.  To get to any other medical facility you have to fly out, or drive for an hour and a half, minimum.  The first victim of COVID-19 who tested positive here was flown to a regional medical center and died there.  Drive through testing became available at the hospital last week, but it costs $75. The medical center website indicates test results will be available in 2-7 days because they have to be sent out to labs in other areas of our state or even out of state. Yet both people I know who have been tested waited 9 days for their results, which means our case numbers lag behind reality by almost 2 weeks.  One person I know, age 32 with flu like symptoms, found out the cost and didn’t get tested because he couldn’t afford it.  Others think there is no need- it’s not contagious, or they don’t have symptoms, which right now is the only way you are eligible for a test here.

Besides this, as a rural community in a part of the country known for its natural beauty and National Parks, we’re a popular tourist destination.  Although officials have recently closed all State Parks and camping facilities in the National Forest, those who are more well off are taking advantage of their “free” time by visiting our neck of the woods.  The mountain bike trails are full, and hordes (yes hordes) of SUV’s w/ bicycles on the back drive through town on their way to popular mountain biking spots. Skiers and snowboarders are climbing up snowy mountainsides and getting caught in avalanches, receiving national publicity for their feats. https://www.outsideonline.com/2411094/backcountry-accidents-coronavirus-colorado

Second home owners are being told to “stay away,” in some small mountain towns, including Aspen and Telluride, https://www.msn.com/en-us/news/us/coronavirus-in-colorado-pitkin-county-tells-visitors-its-time-to-go-home/ar-BB11HNX4 , but two houses down from mine there is a house owned by people from Arizona who just showed up, “for a month,” said the owner. The house, usually empty, is now occupied by the owner’s (Chinese) wife, their 3-month-old baby, 2-year-old son and his wife’s elderly Chinese national father, who speaks no English.  How many others like them have decided to “wait it out” here in our small community, where the hospital has 4 ICU beds and individuals have to be flown out for further care?

In spite of the risk I am acutely aware of, I find that I have conversations around town daily with people who minimize the pandemic, due to the explanations above.  Either right or left, Republican or Democrat (or independent or non-voter) the assumptions these people hold dictate their behavior, and they hold their beliefs tightly. 

I don’t see any clear results of the public health messages.  Trump says one thing, Fauci and Birx say another, and people in rural Colorado carry on, without masks, or with them, in a manner as haphazard as our administration’s messages have become.  One restaurant is closed and offers take out on the weekends, where your pizza is handed to you by a masked employee and there are “no touch” payment options.  Down the street, the burger joint is open daily and no one there, employees or customers, wears masks or gloves.

I don’t go to any stores regularly and haven’t eaten out in over a month.  I’ve lost income, I live alone and sorely miss human companionship and camaraderie, but I’m not anxious and fearful and I do wash my hands regularly and stay 6 feet apart from anyone I might meet on my walks around town to the post office or the grocery store.  I sanitize my shopping bags, door handles, and wallet after I go out.  I do pet dogs, and I’m not sick- but what will I do if I do become ill?

I’m an educated medical anthropologist with a PhD and I take the pandemic seriously even as I’m fascinated by the multiple reactions that my friends and neighbors have to the crisis.  For some, it’s not even a crisis, for others it’s an inconvenience, and for others it’s a welcome respite from the stresses of their jobs, or a reason to “vacation” in their second home.  Many people sit home in front of their screens, zooming with friends and family, or watching wide eyed as the New World Order dictates their reality and confirms their worst fears.  “Didn’t you hear Trump refer to the “Deep State?’’ a neighbor asks me. https://www.westernjournal.com/watch-dr-faucis-face-trump-calls-deep-state-dept-best-thing-see-day/

As days go by and the restrictions continue, I take advantage of the low population density and wonderful outdoor opportunities in my community to stay both physically and mentally healthy.  I still have the freedom to walk my dog out in the woods or red rock canyons without a mask on.  I have a big yard and can spend time working in the garden, listening to bird songs and breezes in the trees, or sitting quietly at sunset to watch the sky change color.  My local library places our books out on a cart for us to pick up after we order them online.  A neighbor with a new puppy comes by to let her pup play with my dog. 

There is a lot to be thankful for.  I, along with many others, hope that the pandemic will show us how to be better humans who take care of each other and our precious earth; humans who design systems and institutions that serve all of us- because, as the pandemic has ever so intensely demonstrated, we are all connected, and the suffering of some does indeed impact us all- no matter what we may or may not believe.

Let’s work together to make a better world- for everyone. 

Dr. Janneli F. Miller is a Medical Anthropologist, freelance writer, retired midwife and health care practitioner living and working in SW Colorado.  She teaches anthropology (online) at Pueblo Community College. 

Call to Action: Influence of Medical Anthropology for COVID-19 Response

To:                  Wider Medical Anthropology Community

From:              Anthropological Responses to Health Emergencies SIG

Authors:          Mark Nichter, Kristin Hedges, Elizabeth Cartwright

Date:               April 12, 2020

  • 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/
  • 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

THE FOLLOWING IS A LIST OF CORE ISSUES THAT DEMAND ENGAGED ANTHROPOLOGICAL RESEARCH

  • 1. Lay perceptions and understanding of   COVID-19 
  • 2. Disease transmission, adherence to public health guidelines and ad hoc harm reduction 
  • 3. Health and treatment seeking (including health care worker experiences) 
  • 4. Care of the ill
  • 5. Social stigma
  • 6. Mental health and social solidarity
  • 7. Precarious populations
  • 8. Health service issues  
  • 9. Death rituals and burials

1. Lay perceptions and understanding of COVID-19, and sources of information accessed  

  • How is COVID-19 understood in different locales? 
  • Where are people getting information, what sources of information are trusted, who are different segments of the population listening to? 
  • Describe images and metaphors related to Covid-19.  
  • What sound bites and facts do people remember from core health messaging?
  • What COVID-19 related information is driving behavior change: consider the impact of information related to the international, state, city, local levels?
  • Points of confusion 
    • How do people evaluate inconsistent messages and conflicting information from different sources?
  • Biocommunicability –Who is invested in promoting different representations of COVID-19, their circulation: politicians, public health experts, industry, other stakeholders?
  • Comparisons to other diseases and past experience 
  • How do local understandings of COVID -19 influence health care seeking, illness experience, and the identity of those falling ill?
  • Dis/Mis-information
  • Sources –media, sale of bogus products, political groups
  • Partisan fighting and othering, ‘democratic hoax’
  • Epidemic fear and rumors –what do they index, larger conspiracy theories
  • Efforts to address and debunk –by whom and how 

2. Disease transmission, adherence to public health guidelines and ad hoc harm -reduction 

  • Physical distancing
  • Cultural factors making physical distancing difficult
    • Gender and generational  responsibilities, expectations, social conventions 
    • Care for elderly: home care and institution, cultural values and shifts in care and visitation routines during COVID-19
    • Shifts in grandparent – grandchildren interaction and emotional dimension of decisions related to visitation
  • Modification of rituals and ceremonies: church / Mosque/temple attendance, graduation, weddings, funerals [all life cycle rituals, which vary tremendously.]
    • Modified forms of rituals and ceremonies (ritual via Zoom, outside vs. inside) 
    • Barriers to modification of rituals and religious gatherings 
  • Local ‘compliance’ and adherence to order to shelter in place
  • Enforcement of government orders
  • Wearing of masks 
    • Where and when are different types of masks worn by the public: spaces and places, social  activities, personal interactions in terms of perceived  risk 
      • Masks worn to protect self while traveling, shopping and on the job 
      • Masks worn to protect at risk groups: elderly, those who have chronic illnesses or impaired immune systems, etc.
    • How does wearing masks change perceptions of safety and adherence to physical distance guidelines? 
    • Perception of protection afforded –how does mask wearing change physical distancing behavior?
    • Children’s response to seeing family members and the public wearing masks 
      • How are people disposing and cleaning /re-using masks`
    • Confusion in messages related to wearing masks – who is believed? 
    • Masks and social norms
      • social norms of mask wearing prior to COVID -19,  
      • meaning of mask wearing in public 
      • How have new norms been introduced and responded to  over the course of the pandemic? 
    • Production of homemade masks for self -use and health care workers – meaning of making, wearing and gifting masks 
  • Cleaning procedures and rituals 
  • Hand washing –adults and children – how and how often
  • Cleaning of homes, purchased goods etc. 
  • Use of recommended cleaning products, what used when they are not available
  • Access to water, 
    • What steps are taken to engage in harm reduction in water scarce environments and situations 
    • Anxiety related to water scarcity 
  • Testing
    • PCR and serological 
    • How are tests being used and explained to the population?
    • Who is being offered tests and under what circumstances?
      • what underlies decisions about when and who to test
    • How is “swab” and blood” testing understood? Do people know the difference between testing for the disease and for immunity? 
    • Who is administering tests and how: in person / mobile phones? 
    • How is testing being received in the community –for those with and without symptoms? 
    • How are test being manipulated? Forged? 
    • What does it mean to have proof of immunity? 
  • Contact tracing
    • Local understanding of reasons for contact tracing 
    • How was population prepared for contact tracing?
    • Past experience with contact tracing? 
    • Piggy backing on TB, STI, Polio etc. programs, 
    • Experience of digital and in person contact tracing- how received in community, fears associated with citizenship status etc.?
    • What does it mean to be identified as an asymptomatic carrier? As the person who infected a group of people? Shame, blame and guilt.

3. Health and treatment seeking (including health care worker experiences

  • Health care seeking decisions related to home care and going to hospital 
    • Sensorial – what symptoms are seen as signs of COVID-19 
    • When is COVID suspected given the wide range of symptoms 
    • When are clinics /doctors contacted, how –use of phone as well as visits
    • Perceptions of  illness severity and how this  influences health care seeking
    • Danger signs – what are  seen as signs one must immediately see a practitioner
    • Decisions to visit a clinic-what basis, who decides, disagreements in household 
    • Therapy management group –who consulted for advice within extended family and larger social networks etc. 
    • Use of the internet to inform decision making 
    • Self -medication 
    • Treatment and prophylaxis     
    • OTC, home remedies , CAM, pharmacy 
    • Dietary
      • foods consumed and in demand for health improvement / immune system strengthening
  • Health care workers (HCW) 
    • Concerns about working in surge conditions given hospital inability to supply necessary PPE resources
    • Duty to patients / profession vs duty of family –concerns about bringing this  disease home to family 
  • Testimonials –documenting the experiences of  HCW  and  their families
    • Both those who return home to families ach day  and those who choose/ are able to self –quarantine  
    • Documenting the experiences of HCW who are ill –at home, quarantined elsewhere,  and in hospital
    • Social and cultural dimensions 
      • Lessons learned that can inform HCW support efforts 
      • Teamwork, comradery, resilience, psychological impact when colleague gets sick or dies  
      • Rules of hospitals allowing HCW to speak to press or acquire own resources 

4. Care of the ill 

  • Care of individuals within the household who are/presumed to be Covid- 19,  
    • Who is responsible for caring for  sick individual(s) gender/generation
    • How are individuals isolated in household, what happens if living quarters are tight ?
      • How are households re-arranged to accommodate for the presence of an infected individual?
    • Forms of support to households with ill person by kin, friends and neighbors 
    • Expected support that is not forthcoming?
  • Care of those chronically  ill or needing immediate treatment due to other health conditions 
    • Suspending of  routine  health care due to unavailability of  ‘essential services’
    • Self-suspending  health care treatment due to fear of going to clinic as environment of risk
    • Care of individuals with disabilities
  • Social stigma and ‘othering’  associated with COVID-19
  • Who are considered “dangerous others” associated with COVID-19 spread?
    • Ethic groups 
    • Health care providers and their families 
    • Other occupations working in environments of risk
    • Age groups 
  • Use of “othering” for political agenda
  • Source of  stigma  related messages and rumors – associated with past  messages related to other diseases 
  • Forms stigma takes from shunning and eviction to violence 
  • Stigma of recovered individuals 
    • Long term effects of stigma 

6. Social solidarity and mental health 

  • Impact of COVID lock down on social relations within households /families 
    • Gender relations – shifts in responsibilities 
    • Generation – inter and intra generational
    • Domestic violence 
    • Family support in person and on line and by phone
    • Extended and nuclear family decision making about staying in place, 
  • Community support 
    • What kinds of crises and safety net  support existed before COVID-19 and how mobilized now during lock down
    • New forms of support that have emerged –private and public 
    • How is support accessed 
    • Neighbors helping neighbors, intergenerational 
    • Virtual community services offered  during lock down  (free art classes, operas, virtual tours)
    • News ways of engaging in virtual interactions  ethnography of zoom culture
    • School related  support for kids out of school 
    • Access to wifi for low income kids out of school
  • COVID-19 and  mental health
    • Impact of sustained stress levels  and uncertainty  
      • HCW, and community essential service providers  
      • Families of HCW  , service providers 
      • General public 
    • Impact of  social isolation during physical distancing 
    • Impact of 24/7 news on COVID-19
    • Fear of/Impact of losing job, health insurance, business 
    • Food insecurity and mental health 
    • Idioms of distress that are culturally meaningful
    • Resiliency and idioms of concern
      • factors and activities contributing to a sense of psychological, emotional, and spiritual well being 

7. Precarious Populations (in addition to all the aforementioned issues 1-6)

  • Food security and feeding the hungry
    • Food scarcity, where is food acquired  when no resources to purchase ?
    • Feeding and subsidized food programs -how implemented and received? 
    • Children out of school who depend of school vouchers
    • Migrants on the move 
    • Availability of essential foods and rise in prices 
    • Homeless populations
    • Shame associated with household lack of food 
  • Migrant and refugee populations and precarity
    • Refugees
      • How fear of the virus is affecting life in the camps as environments of risk 
      • Limited resource for ‘compliance’: hand washing, physical  distancing
      • Language issues – minority language issues – translating, etc.
      • Movement of refugee and migrant populations –from cities to rural areas, places with few resources to places with more resources – reasons for leaving
    • Undocumented migrant workers
      • Being undocumented and also an ‘essential’ worker
      • Access health care and fear of accessing health services
  • Prisoners
    • Inability to abide by physical distancing recommendation
    • Elderly prison population have increased risk, 
    • Using exposure to infection as a punishment 
  • Native populations 
    • How fear of the virus is affecting life on  reservations  
    • Access to health care 
    • Care of the ill using traditional ceremonies and/or treatments
    • Access to water, supplies and other necessities
    • How virus is conceptualized 

8. Health service research questions 

  • Availability of essential resources (PPE, ventilators etc.) and their distribution and use in various settings 
    • Who is privileged and sacrificed–regarding treatment decisions 
    • COVID-19 impact on essential health campaigns, vaccination programs etc.
      • Delay in use of clinics and hospitals for other serious health conditions 
    • Staffing and payment of HCW issues 

9. Death-Rituals and Burials in the time of physical distancing 

  • Alternative funeral arrangements during COVID-19,  changes in rituals which previously  involved social gatherings and contact with bodies
    • How are bodies disposed?
    • Burial patterns/cremation/marking the graves
    • Memorial services –virtual, planned in future

Current anthropological articles on COVID-19:

  • Alyanak, O. (2020). Faith, politics and the COVID-19 pandemic: The Turkish response. Medical Anthropology, 1.
  • Ali, I. (2020). The COVID-19 pandemic: Making sense of rumor and fear. Medical Anthropology, 1.
  • Ennis-McMillan, M & Hedges, K (2020). Pandemic Perspectives: Responding to COVID-19.  Open Anthropology. Vol 8: 1

 

  • Manderson, L., & Levine, S. (2020). COVID-19, risk, fear, and fall-out. Medical Anthropology, 1.
  • Raffaetà, R. (2020). Another day in dystopia. Italy in the time of COVID-19. Medical Anthropology, 1.

 

Covid-19 Updates: New information! New research issues!

by Mark Nichter, Phd

“Calm, everything will be okay” Image by Cristiana Basto, Lisboa, Portugal, April, 2020.

Thank you Cristiana for the image from the streets of Lisbon.

Cristiana Bastos
Institute of Social Sciences | University of Lisbon | Av Anibal Bettencourt, 9 | 1600-189 Lisboa, Portugal https://cristianabastos.org/

Covid-19 Overview by Mark Nichter, UPDATED 3/31/20

Dr. Mark Nichter is an experienced  medical anthropologist actively engaged in global health research and outreach. This slide show is intended for a general educated audience, university professors wanting to educate their students  and engaged social scientists. This presentation was originally created during  the week of  March 12-18th and will be updated weekly.

UPDATE MARCH 31, 2020

Information on Covid-19 is changing rapidly. Many thanks to Mark Nichter for his work on integrating new information into this resource.

Photo by Ylanite Koppens on Pexels.com

If you are interested in writing a blog for our community, please contact me, Liz Cartwright, carteliz@isu.edu. It would be great to hear from all of you out there. What is happening in your communities around the Covid-19 pandemic? What are your theoretical ideas on ways to better understand cultural interactions, treatments, forms of personal protection, and the larger issues of power abuses, biosocialities, vulnerable populations, etc.?

Elizabeth Cartwright, RN PhD, is a medical and visual anthropologist who works in Latin America–mostly. Her work is focuses on environmental health, social justice and anthropology with an applied focus; she is a professor at Idaho State University in the lovely Rocky Mountains.

Visualizing the Pandemic by Jerome Crowder, PhD

Crowder is a medical and visual anthropologist. His research focuses on the conceptualization of illness and help seeking behavior among urban migrants. Crowder’s books, articles and exhibits explore how migrants define and maintain community; he is currently the president of the Society for Visual Anthropology.

Visualizing Covid-19

As Covid-19 wreaks havoc across the globe and close to home, one of the virus’ features that makes its spread so disconcerting is our inability to SEE it. Knowing its molecular structure or viewing its image from an electron microscope doesn’t help us avoid contracting it. How can we visualize Covid-19 in a way that is meaningful? 

First, we can see it’s impact on our society by viewing our preparation for its arrival and our reaction to its infection. These are material manifestations of the virus, which are culturally informed and expressed. They are different everywhere.

Covid-19 offers us a unique opportunity to reflect on our cultural assumptions and expectations about infectious disease. I immediately conjure up images from The End of Polio by Sebastião Salgado (2003), dramatic black and white images documenting the final stages in the eradication of that virus… what new images will Covid-19 bring us?

Early in the outbreak I was mesmerized by television images from the Chinese response to Covid-19, images of building temporary hospitals, people walking down the streets wearing face masks, gloves and smocks, empty roads, packed clinics. I also thought about the images we don’t get to see, the faces of the health care workers skillfully attending to their patients, families huddled together worried about a relative in quarantine, or public health officials in heated conversations with politicians obsessed with keeping the status quo. Over time, images will emerge that tell the stories we have not heard, they will help shape new facets in our understanding of what Covid-19 means.

As Covid-19 spreads, the images we see show how cultures respond to it. Even though the virus was discovered in South Korea and the USA on the same day (January 20, 2020), reviewing images from the news reveals a decidedly different approach to the rapidly spreading infection. Images from S. Korea show lines of people waiting to be tested, health care workers wrapped head to foot in disposable gowns with masks assisting patients on hermetically sealed gurneys, and teams of white-coat clad individuals with pump-sprayers walking in single file spraying the nooks, crannies, and surfaces where Covid-19 may reside. 

Meanwhile images published in the US show a president rebuking Covid-19’s danger, streets, parks, and malls heavily congested with people, and sign-clad residents in San Antonio protesting the arrival of Americans from China evacuated to US bases for quarantine and observation. And of course, the cruise ships not allowed to dock so infected travelers and well persons could disembark and seek appropriate attention.

As the infection spread to Italy and Iran, images depicting their plight revealed mask-wearing clerics, empty street markets and quarantined families standing in windows singing across to each other. The images are as strikingly different. By reviewing these images we get a taste for how Covid-19 is being conceptualized and addressed. Granted popular images published in magazines and newspapers have political intentions, but check out images posted on social media to really understand what is important about Covid-19 for people to share with others.

While medical anthropology’s eye is trained on people’s understanding of the outbreak and its potential ramifications to community health, my visual anthropology eye searches for scenes that reflect that understanding (or lack thereof). 

Escaping Houston’s urban center a couple weeks ago for Galveston Island, I was astonished to see the beaches filled with friends and families enjoying themselves for spring break. The Gulf side parking along the seawall was as full as were the cantinas across the street.  That’s an image burned into my mind’s eye, as three days later the County asked all guests and visitors to leave the island, residents were asked to practice social distancing and restaurants became take-out portals. Immediately, signs appeared in the windows indicating new hours of operation, reminding patrons to keep 6’ between themselves, and stores listed items they no longer had in stock (mostly TP, water, eggs, milk and pasta). 

Walking through the grocery I noted which aisles and shelves were bare and which remained well-stocked. While I couldn’t find rice, there was plenty of quinoa and couscous. What do these bare shelves tell us about our dietary preferences and cuisine? Upon entering a restaurant, I note the hostess was replaced with signs indicating which bags were for takeout or Grubhub/Doordash pickup, the lighting was cut back and the chairs were stacked on tables. 

While we all endure the trajectory of Covid-19, keep in mind its visual manifestations in your own community; what’s a unique response and what’s more general to your region or state? Keeping our eyes open for subtle changes in visual expression to the virus help us peel back the layers to better understand what Covid-19 really looks like and how we visualize the experience that will forever affect our society.

Jerome Crowder, PhD is a medical and visual anthropologist who has conducted fieldwork in the Bolivian and Peruvian Andes, east Houston, and most recently in Galveston, Texas. His primary research interest focuses on the conceptualization of illness and help seeking behavior among urban migrants.Crowder’s books, articles and exhibits explore how migrants define and maintain community; he is currently the president of the Society for Visual Anthropology.

Recent Book: Anthropological Data in the Digital Age (Palgrave 2020)

Articles:

Optimizing Community Bioethics Dialogues (Narrative Inquiry in Bioethics)

A Journey through Chronic Illness (Medicine Anthropology Theory)

Visualizing Tensions in an Ethnographic Moment (Medical Anthropology)

Covid-19 Overview by Mark Nichter, PhD, MPH

Dr. Mark Nichter is an experienced  medical anthropologist actively engaged in global health research and outreach. This slide show is intended for a general educated audience, university professors wanting to educate their students  and engaged social scientists. It was created during  the week of  March 12-18th and will be updated weekly.

March 23, 2020 UPDATE

Thanks to Mark Nichter, PhD, Professor Emeritus, University of Arizona for this great resource powerpoint. The presentation covers Covid-19 disease etiology, anthropological insights and future directions for research. Please pay attention to dates and recognize that information is changing very rapidly.

Guest blogs and information are welcome! Email me at carteliz@isu.edu if your are interested in contributing information, research ideas or perspectives from your fieldsites in the US and in other countries.