Category Archives: Community education

What Anthropology Teaches Us about COVID-19, Part 4: A Conversation with Physician-Anthropologist, Dr. Bjørn Westgard

Recently, I checked in with Dr. Bjørn Westgard, to see how he was doing.

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Back in the ‘90s, Bjørn was enrolled in a wildly demanding, combined M.D./Ph.D. program at the University of Illinois, where I had the pleasure of serving as his academic advisor.  After completing his medical school coursework, Bjørn conducted doctoral research in cultural anthropology in a small town in northern Senegal, studying the complexities of intersecting local and global medical systems as they sometimes complemented one another and sometimes competed.  He intentionally combined “bottom-up” and “top-down” perspectives, interviewing everyone from village-based farmers and healers to biomedically trained nurses and doctors.  (From that research, Bjorn is fluent in French and Wolof, the most widely spoken language in Senegal; he also speaks Serer and Mandinka, two linguistically unrelated languages spoken in the region of his research.)

When it came time to choosing a medical specialty in which to pursue his residency, Bjørn surprised me: he decided against his early interest in pediatrics or family medicine and opted instead for emergency medicine.

Initially, I was disappointed: I thought that working in ER rooms would waste Bjørn’s formidable scholarly skills.  How could he get to know transient patients and put his extensive training in biomedical cultural sensitivity to work?  Of course, Bjørn had already thought through that concern.  “There are more return patients than you’d think,” he explained.  Bjørn understood what few others in the U.S. yet knew: that many, many uninsured Americans used emergency rooms for routine medical services.  That included the poor and the undocumented—for all of whom, Bjørn (with his ample wading into the deep waters of culturally sensitive issues) would have special insights.

Bjørn had an additional reason for selecting emergency medicine that made equally compelling sense.  “There’s so much wrong with the American medical system, and a lot of it is encapsulated in ERs,” I remember him explaining.  “As an anthropologist, I can start addressing the systemic problems if I have a position working in the belly of the beast.”  At the time, no one was talking about this problem in such clear ways–at least, not in public conversations about healthcare policy.  I remember being instantly both impressed and persuaded: Bjørn was making the right decision.

Besides, if I thought about everyone I had ever known, Bjørn would have been my first pick for an ER doctor.  He has the sort of calm temperament and clear, logical mind that would make him the obvious choice for captaining any sinking ship.

Fast-forward fifteen years, and Bjørn now finds himself working as Research Director and Senior Staff Physician at Regions Hospital, a Level 1 Trauma Center in Minneapolis that sees over 90,000 Emergency Center visits every year.  A Fellow of the American College of Emergency Physicians, Bjørn holds secondary medical appointments in emergency departments of four other hospitals in Minnesota and Wisconsin.

Over the years, Bjørn has researched heart disease among Somalis in Minneapolis (with support from the National Institute for Health); has specialized in hyperbaric oxygen therapy for certain medical conditions; and has helped create an innovative program finding housing and lifestyle amelioration for homeless people in Minneapolis.

Clearly, Bjørn has harnessed the wisdom he gained from studying pluralistic health practices in a small town in Senegal to the technical skills he gained in studying medicine.  With his incredible combination of scientific and humanistic talents, I was unsurprised to learn that Bjørn is now leading a medical team that is fashioning policy responses to COVID-19 for the state of Minneapolis.

On his home page, Bjørn describes his approach to medicine this way:

My teaching and research have focused on Emergency Department use for preventable conditions among priority populations, “food deserts” and diet-related Emergency Department visits, longitudinal changes in Emergency Department use among the homeless, supportive housing, and reducing health disparities in emergency care.

Who could be more qualified than an ER physician-anthropologist such as Bjørn Westgard to understand the COVID-19 crisis in both scientific and human terms?

(You can read a brief bio of Bjørn Westgard here and his LinkedIn page here.)

Recently I had a conversation with Dr. Bjorn Westgard about this long COVID-19 moment—about what he has learned, and what he can teach the rest of us.

BW = Bjorn Westgard

AG = Alma Gottlieb

AG: An ER doctor in New York, Dr. Cameron Kyle-Sidell, recently claimed that ER doctors around the world may have drastically misjudged the nature of the COVID-19 beast when it enters the lungs, and may have unintentionally harmed patients by keeping them attached to respirators administering too much pressure on fragile lungs.  His claims are quite striking and disturbing!  If this ER doctor is right, it’s tragic to think of what damage might have already been done by mis-calibrating those respirators.  What do you think of his claims, medically?  And, why do you suppose he posted this video on YouTube for general consumption?

BW: This has gotten a lot of play.  Unfortunately, his understanding of high-altitude pulmonary edema is a little off, and no one has put anything together about his critique that is systematic or peer-reviewed.  However, multiple physicians from China, Italy, and New York in particular (on some emergency medicine podcasts and the like) have raised the possibility that treating COVID using ventilator parameters for ARDS [acute respiratory distress syndrome] may be incorrect, at least initially. 

The ventilator management of these patients doesn’t sound incompatible with early ARDS, but it is still very controversial.  I just got into a heated argument with an intensivist earlier today for even bringing up the above.  There is fear among all sorts of health professionals right now, especially among those who tend to “know what they know” with the most certainty.  So the idea of managing critical pathophysiology that might be different from what is expected–requiring a veritable, Kuhnian paradigm shift–can be very anxiety- and anger-provoking. 

To add further fuel to that fire, there has also been discussion of a possible hemoglobin issue (oxygen carrier in the blood), but there has been nothing other than a pre-press 3D computer modeling paper out of China in the rapid-fire literature to support that idea.  However, a group from NYU did use machine learning to predict severe disease, with results that could support the idea of a hemoglobinopathy.  I even have colleagues in my other Board specialty, hyperbaric medicine, who are working on a trial to use hyperbaric oxygen to get around the possible hemoglobin issue.  I think there’s probably more to the receptor for COVID, which is present in all of the body’s vasculature, which could potentially trigger inflammation and coagulation that way, and that inflammation and small clots, which we’re finding everywhere in coronavirus patients, could be causing diffuse injury.

It’s fascinating to watch the accretions of science and knowledge in the age of the Internet and social media.  Already, cranks are hawking conspiracy theories and supplements in response to the “censored” knowledge above.

As an emergency physician and an anthropologist, I’m a bricoleur of the contingent and the emergent, by trade.  I’ll consider new ideas if they make pathophysiologic sense, and I have no doubt that someone will examine these ideas further and more systematically, so I’ll keep watching for more evidence.  For now, I’ll care for the patient in front of me and adjust their vent settings as needed.

AG: That sounds like a good strategy both for an ethnographer and a doctor.  But then, I always thought that all doctors ought to have training in anthropology.

BW: I hope I didn’t give you the impression in my last email that I was resistant to the ideas presented, just that I’m looking for more information, whether from personal, clinical experience or other data.  I’m just not generally inclined to change my clinical practice in response to social media.  I’m in the middle of our Thursday morning residency conference right now, and we’re discussing initial and ICU ventilator settings, given developing information, and it’s fascinating to hear an intensivist colleague suggest that “we’re all in the same boat here, the attendings [fully credentialed, attending physicians], the fellows, the residents, and the med student . . . we’re all learning together as we go.”

AG: Speaking of combining social and technical approaches, we’ve been reading about efforts to systematically calculate social contacts for COVID-19 patients, to help track the socio-geographic spread of the disease.  What do you think of those?

BW: Very cool.  I’m trying to get our state to do something similar using an app I’ve worked with a team to develop.  I’m arguing with our Department of Health, who have difficulty appreciating how technology might help.  But they’re also feeling less pressure to consider novel options, since our state is doing relatively well.

AG: Here’s something else I thought you might have a lot to say about . . . the whole “herd immunity” question strikes me as so interesting for anthropologists.  I’ve been reading a lot about this recently.  This piece in the Boston Globe really caught my attention.

First, there are the epidemiological questions.  How accurate is the concept of “herd immunity” to begin with?  As a doctor and scientist, I assume you’ll have much to say about that.

Second, there are the sociological implications.  How can your perspective as an anthropologist speak to the epidemiological factors?  If the US (and/or other nations) adopts a “herd immunity” approach at some point (before a vaccine is widely available), what sorts of people will be allowed—or even encouraged–to be exposed to the virus?  What sorts of people should be allowed, or even encouraged, to be exposed to the virus?  Are those two groups of people the same?  Or, will socioeconomic disparities intervene, and might large numbers of the wrong people (the most vulnerable) end up being exposed to the virus?  I’m thinking about this because, over the past two weeks, many mainstream journalists in the U.S. have begun noting racial disparities in COVID-19 mortality.  Of course, that’s no surprise to anthropologists (and some other social scientists), though it seems to be surprising plenty of politicians.  Thinking about these social factors, are there new risks to perpetuating racial disparities with a “herd immunity” strategy?

Third, there are the symbolic/conceptual/philosophical implications.  As a scholar steeped in sensitivity to discursive implications, what are the ramifications of using a metaphor of (non-human) animal behavior for human behavior, in evoking “herd” immunity?

The maddening “organism at the edge of life” (as virologist E. P. Rybicki describes viruses) that is far too dangerous to appear this beautiful

BW: I haven’t had time until after my shift this evening to get to your questions, but I like them.  It prompts me to reflect and consider with a wider lens.

I’m not an expert in infectious disease or epidemiology, but my understanding is that “herd immunity” is primarily a statistically useful concept that expresses the aggregate balance between immune systems and infectious vectors such that there’s enough immunity to prevent ongoing transmission.  But when you get into the immune system, things become very complex very quickly.  Talking about vaccines and immune medications (like those being discussed as treatments for cytokine storm, for example), the questions pertain not just to the dose of a drug in the volume of an aqueous human, but also to what the most productive triggers are for the bodily machinery churning out the immunity widgets of antibodies.  The questions become: What is needed to trigger the production of immunity?  How effective is the immunity that is produced?  Does it wane, and if so, when?

And all that is without discussing the social patterns of intermixing that we all experience, and which have become the main means by which we are currently intervening upon the spread of this pandemic.  I think that’s where the concept of “herd” becomes interesting.  Anthropologists and many others are comfortable with the idea of the population as a biopolitical concept generated by a certain kind of governmentality.  But how do we, the multitude, deploy that in an effective, self-governing manner? 

It seems to me that the concept of the “herd” could allow us to conceive of our collective biology, our animality, in a way that is positive and potentially collectively empowering, rather than biostatistically disempowering.  That said, it seems clear that a “herd immunity” strategy that treats the lot of us like chattel (the flip side of the “herd”), positing that we should all “put on our big boy and big girls pants” and accept that a lot of people must die, will undoubtedly do more harm.  We’re seeing this in those areas of the country where few or late actions have been taken to mitigate the spread of coronavirus. 

It’s my hope that we’ll use available information from around the world to develop better methods that capitalize upon our current collective engagement.  It seems like “flatten the curve” has brought the collective back to the biostatistical.  Hopefully, well-thought-out approaches to “reopening” and easing social/policy measures could do the same.  But the evidence for these measures is thin, and we are all learning about one of my favorite areas or research, complex population models of disease. This is another area where science is being built daily, as the pandemic provides some of the first empirical test cases for these tools.

But it is disheartening that in areas both with and without aggressive measures, we see the impact of racial and socioeconomic disparities.  Those disparities are at play in health inequities and inequitable care in the best of times.  Now, resources are strained, so it would be almost unthinkable that those factors would not be significantly at play in the pandemic.  In areas with less, or late, social and political measures to isolate people, the historic clustering of populations through systemic segregation, with associated increases in population density and decreases in access to resources, lead to syndemic conditions.  In areas with more social and political measures to isolate people, many who work low-end jobs become unemployed, with all the accompanying fears and hardships, while those who keep their low-end jobs–clerks, janitors, service workers, etc.–are left out in public in positions that put them in contact with large numbers of potentially infectious people.  So, between the two groups, disparities in rates of infection and adverse outcomes should come as no surprise.

I’ll get back to you with more, as this is the next bit of thinking required.  In Minneapolis, the group I’ve assembled between HealthPartners and the University of Minnesota are going to consider how to model this process to provide guidance for the long term of the pandemic.

AG: Yes, racial disparities are emerging with disturbing alacrity and intensity in the US.  But, as you say, that’s hardly a surprise, for all the reasons concerning systematic, structural disempowerment that have characterized US society since Europeans set foot on these shores.  Those sorts of disparities have begun to be part of a growing national conversation since the Civil Rights movement of the ’60s, and they took on new force more recently with the Black Lives Matter movement.  One of the components of the current horrible moment that I’m actually finding most heartening is the extent to which social conditions ARE finding their way to being front and center of many conversations.  It strikes me that this moment of national (and global) crisis offers America new opportunities to expand that conversation and really take its lessons seriously in a new way for the first time in US history.  And, medical researchers and doctors will be at the forefront of that conversation.  Someone like you, with your dual training, is especially well positioned to think systematically about just how to operationalize those lessons in ways that work with public health protocols.  That’s why I’m excited about our continuing conversation!

BW: I think it’s very clear that this virus is hitting communities in both indiscriminate ways (with some reportedly healthy individuals going on ventilators or even ECMO life-support machines) and in VERY discriminating ways, hitting poorer communities and those of color.  What I haven’t heard exactly is any discussion about ways to focus resources on those communities that are hardest hit, which is disappointing but not unexpected, given the current national leadership. 

I actually think race and structural inequalities and violence have very much come to the fore within medical practice.  It’s just that our sphere of influence is limited.  For example, in Minnesota, our healthcare system has an Equitable Care Committee that has done a lot of great work, although it has vacillated between focusing on equitable care and health equity, depending upon what we think we can actually achieve.  Residents and med students, particularly the med students, are very aware of disempowerment, and it’s one of the things I teach about when I’m on shift [teaching residents].  In fact, next week, I’ll be drawing directly from anthropology in giving a talk as part of a panel at our Society for Academic Emergency Medicine national meetings (now online!) about teaching residents to be “structurally competent”—meaning, thinking about larger, structural issues that shape the experiences they see in particular patients. 

What’s most difficult is to figure out how to get beyond the clinical domain and affect pathologies upstream, closer to their source.  It helps one understand why Paul Farmer long ago advocated for large-scale wealth transfers between north and south, and why we need to do the same in the U.S.  That’s actually some of what was achieved by the Affordable Care Act but then was largely undone or undercut by recent tax cuts for the wealthy.  So it’s good that these issues are front and center, but I think they could be even more so.  And it’s good that we’re thinking communally, as I said before, but the idea that we might differentially focus collective resources upon communities that are hardest hit seems to meet resistance with predictable frequency. 

AG: In Rhode Island, where I now live, there’s actually a vigorous initiative (Beat COVID-19) with just that emphasis.  Beyond the capital, the two cities hardest hit in Rhode Island are Central Falls and Pawtucket, both of which have large, immigrant communities of color (mostly from Latin America and Cape Verde).  The current rate of infection in both those cities currently surpassess that of New York City.  Nationally, these two small cities are invisible in news reports, but locally, a multidisciplinary coalition has formed that is forging creative approaches to reach these communities. The coalition includes a normally unlikely set of folks, including a local doctor, representatives from the state’s Department of Health and the two cities’ police departments, marketing specialists, local community organizers and advocates, translators, and even yours truly, as an academic critic.  I’ve been heartened to see a far more open-minded approach to reaching these communities than I would have imagined.  For example, since many residents of these neighborhoods feel more comfortable speaking either Spanish, Portuguese, or Care Verdean Kriolu, a new COVID-19 hotline in these three languages now welcomes callers, and there are now public service announcements in those three languages that are being promoted online in all sorts of social media spaces where people from these communities are likely to read them.  I’m so impressed by what I’m seeing that I’m starting to consider this local initiative a model for communities elsewhere.

Once COVID-19 starts hitting the white heartland–as now seems inevitable–because of resistance both by Republican governors and local residents to maintain social isolation procedures, and insistence to “re-open” the economy prematurely and indiscriminately–it will be interesting to see how those communities respond to the crisis suddenly invading their families.  As a physician, I imagine you must feel quite frustrated by those conditions.

BW: Just look at the largely white nationalist forces that have hijacked what began as small-business protests about state efforts to enact social-distancing policies, in an effort to minimize the impact of the COVID surge. 

Photo by MEGAN JELINGER via Getty Images
A local militia group is seen at a rally to protest the stay-at-home order amid the Coronavirus pandemic in Columbus, Ohio, on April 20. For the third time that week, hundreds of protesters gathered at the Ohio State House to protest the stay home order that was in effect until May 1.
Source here.

Those folks are having trouble getting on board with just the baseline collective actions needed for public health.  Currently, so many folks in the rural parts of the country see this crisis as an urban thing.  But if we look back at the influenza pandemic of (supposedly) 1918-19–which actually lasted three years (my grandfather nearly died of it in 1921)–the initial wave hit densely populated areas, but the next waves were largely rural.  And today, if you look at rural areas, they’re as disproportionately disadvantaged as are many of the low-income, urban communities from which we’ve divested as a society.  In fact, rural America overall is actually less insured, has less access to services, and is more dependent upon government transfers of resources than is most of urban America.  So, I’d really like us to be able to see both of those kinds of communities with one gaze.

AG: That makes a lot of sense both politically and intellectually.  It will be interesting to see if white conservatives come around to that position, once they are affected.

Since you’re enjoying thinking about epistemological issues raised by COVID, I wonder what you might think of an e-mail I recently received.

A prominent medical school has decided to confer MD degrees a little early, for med students who had completed all their training and were scheduled to receive their degrees within a few months.  (The e-mail subject line read: “Emergency Powers Exercised: Approved Early Degree Conferral of 4th Year Medical School Students.”)

That will allow these brand-new medical residents to start practicing in COVID-19 hotspots and help alleviate the hospital crisis in those areas.  Seems like a great idea–this is a good time to challenge bureaucracy, right?

But I also saw an online petition on a related question that made me more nervous–to grant “registered nurse” (RN) licenses to “licensed practical nurses” (LPNs), who have quite a bit less training than registered nurses do.  That struck me as way riskier.  But perhaps I’m being too conservative.  Maybe LPNs are actually being asked to do the work of RNs in this crisis, and so they should be credentialed and salaried accordingly.  What do you think?

BW: I definitely agree with deploying fourth-year medical students early.  It strikes me as a safe move at this time in their training.

However, in areas that are not already seeing surge conditions, I think the country would be best served by deploying medical students to do case-contact tracing.

And I agree with you that granting RN licenses to LPNs is riskier.  Credentials are indicators of different kinds of training, and their significance should be maintained, though that’s the professional in me coming out and maintaining boundaries.

As with many things at the moment, one could simply and temporarily alter practice parameters for surge or crisis standards of care.

AG:  I recently read another, especially thoughtful piece in the New York Times, about when to “re-open America”—with the intentionally provocative title, “Restarting America Means People Will Die. So When Do We Do It?”  A staff writer for The New York Times Magazine moderated a panel discussion with five people with varying backgrounds (a minister, an economist, a global health specialist, a civil rights specialist, and a bioethicist).  They raised sociological issues related to those raised in the Boston Globe piece about “herd immunity”–but from broader perspectives, and more critically, I think.  Lots of food for anthropological thought here.  As a physician-anthropologist, you can, I imagine, bring special perspectives to this emerging national conversation about how we think about risk in “re-opening society.”

BW: There definitely needs to be attention to those who are at higher risk for contracting and dying from COVID-19, and to those communities whose residents don’t have a choice about going back to work.  It’s really a matter of whether people are forced to be at risk, or are allowed to be agents of their own risk and that of their loved ones.  Are we going to make re-opening businesses opt-in?  

Unfortunately, the baseline state of affairs in America is far from a level playing field.  Some people will, essentially, be forced to work so that states don’t have to pay them unemployment benefits, and small business owners will be forced to run risk so they can qualify to get loans and other state-funded stimulus funds.  Yet, somehow, there’s no national conversation questioning whether oil, airlines, and other large industries should be bailed out. 

I think we could consider restarting by focusing on the social and the scientific.  I think most of us would be doing better with all of this isolation, quarantine, and lockdown if we had a few more people to connect to.  If you look at places that are opening up, or even how we started this all, we could start clustering in smaller groups, 10 people or fewer.  Just folks who you would know were sick.  And we could get the kids back together.  Given the low likelihood of adverse effects in children, the fact that they have been much less symptomatic, but that they are also very good at transmitting disease to each other (just ask any parent of a daycare child), getting them back together would get us started with herd immunity.  Bioethicist and oncologist, Zeke (Ezekiel) Emanuel was one of the first to say that we should probably get summer camps up and running.  To me, that makes sense.  But, again, it’d have to be opt-in, both for those who run the place and those who go to camp. 

AG: Scholars and doctors aren’t the only ones talking about how to protect ourselves from this virus.  I just discovered a pretty awesome rap video about COVID-19 from Y’en a Marre, a group from Senegal (here).  Any thoughts?

BW: Y’en a Marre are a great group.  They were instrumental in mobilizing the youth vote to get Wade out of power in Senegal, so I feel like they’re always “au service du peuple et de la nation” [in the service of the people and the nation].  It’s so interesting how hip-hop and other forms of art in a smaller country, fending for its own identity and economy with a smaller media space due to the constraints of language, can be called on–if not officially (like this probably was), then culturally–to serve the body of the nation.  In this new video of theirs, I love how they’re all doing scientific activities–looking at charts, microscopes, and blood specimens–instead of just striking stereotypical poses in hazmat suits.  It’s a solid video.  I can’t imagine many hip-hip artists in the States pulling something similar off with the same tone–in Minnesota, maybe Atmosphere, but not many others in the national mediasphere.

Senegalese group, Y’en a Marre, in a new music video (singing in Wolof) advocating safety measures to protect against COVID-19
Source here

AG: You mentioned that you’ve just co-authored a short piece about COVID-19 that you’ve submitted to a medical journal.  Can you talk a bit about the orientation of that article?  Were you able to insert an anthropological perspective into an article for a medical journal?

BW: In Minnesota, we’ve just had a huge decline in visits to the emergency department and to the hospital for just about everything.  Most of the news outlets have covered it, but no one has published any numbers or more detailed reports of what’s not coming in.  I’m fine with a slowish day in the ER, but across the country, particularly in those places not seeing the surge, the changes in patient volume have had devastating effects on clinics, hospitals, and health systems that have to operate at near full capacity and with razor thin margins in normal times just to stay afloat.  So, at the same time as we have surge, we’re also seeing mass furloughing and pay cuts for nurses, doctors, and even (gasp) administrators. 

So we just pulled the numbers for before and after our great Governor Walz’s announcement of a statewide “peacetime emergency,” comparing volumes and visits to a year ago, and we found a 70% drop off in strokes, and a 50% drop off in heart attacks, but also declines in really painful things like kidney stones, too.  And, who’s not coming in?  Well, it’s the elderly, children, and those who have insurance through Medicare.  Much of this drop is likely prudence on the part of high-risk individuals, but we know there’s also some desire to not burden the health systems with non-COVID related care, as well as some fear of actually contracting coronavirus in healthcare settings. 

Similar trends have been seen in China, Taiwan, South Korea, and Europe, as well as in chronic care.  In Minnesota, the HealthPartners Institute has a chronic care surveillance group, and they saw visits drop off by 90% in three days after the statewide announcement. 

We’re interested in doing follow-up studies, monitoring for the effects of delayed or deferred care, both acute and chronic, and seeing who comes back first, and with what.

AG: That sounds like an important set of considerations I haven’t yet seen anyone talking about in the press.  Everyone is so focused on the now of the emergency, and how to extricate ourselves from it, that few I’ve seen are allowing themselves the luxury of imagining ancillary questions such as those you’ve just raised.  Again, I imagine your training in anthropology makes it easier for you to keep your eyes focused not only on the big picture, but on seemingly unrelated factors that, in the end, turn out to be deeply related.  That’s what we do in anthropology, right? 

Well, let’s end on a positive and practical note.  Last week, the team you’re leading produced a new app, “SafeDistance,” to provide up-to-date information about COVID-19 incidence in micro-neighborhoods. 

Online, the website for the new app describes it this way:

SafeDistance is a free, non-profit app and website that crowdsources symptom data to help detect, predict, and prevent the spread of COVID-19, while assuring your privacy.

·         Personalized, social distancing recommendations

·         Neighborhood-level COVID-19 risk map

·         Privacy assured – no account required, you remain anonymous

Can you talk about what sorts of social knowledge about Minnesotans factored into how you designed the app for ordinary people?

BW: The basics are maintaining privacy while collecting data of actionable utility.  So we’re focusing on anonymity–both to allay privacy concerns, and also to make it an easy tool to begin using.  Instead of identifying individuals, we’re mapping and doing analytics by neighborhood.  This approach allows both individual users, and anyone else who is interested in the data from a more sociogeographic perspective, to have some granularity to what they’re seeing. 

If you look at most of the data that’s out there, even the Johns Hopkins and Unacast or SafeGraph data, it’s mostly out there in county form, which is fine if you’re interested in the temperature of the pandemic locally, but it doesn’t tell you the weather and how much caution you should be exercising.  Right now, that’s not a huge deal, because we’re all being very cautious with our efforts to self-isolate, mask and the like.  But as we open up, and we find that our prior efforts burn out and COVID-19 flares up in different spots, we’ll probably have to dial up and dial down and differentiate our self-protective and collective efforts to deal with the virus.  As I said, the “1918” influenza pandemic actually lasted until 1921, so it’s like [epidemiologist] Mike Osterholm has said, we need tools to figure out how we’re going to live WITH this virus, since it’s unlikely that we’ll just out and out defeat it–at least, until an effective vaccine is available globally.

AG: You initially launched the app in and for Minnesota, but it’s now available for anyone across the U.S. via a user-friendly website.  Do you imagine it could have equal relevance anywhere in the country?

BW: If all the app does is give users good information and maps that convey the details of the pandemic in their neck of the woods, I’ll be satisfied. 

But the detailed neighborhood maps that will be produced in the app from new user data will soon be available nationwide.  If the data that are generated can be combined with other datasets to get us to a geospatial SEIR model that would allow us to predict more accurately when and where future outbreaks might occur, that would be a real contribution to fighting this pandemic–as well as to science more generally.  

Well, it’ll likely only be the former, but hope springs eternal.

N.B. Another version of this post appears on the website of the anthropology journal, Public Anthropologist. You can find it here.

Doing Development the Right Way: A Conversation with Charles Piot

Anthropologist Charlie Piot has been conducting research on the political economy and history of rural West Africa for over thirty years. His first book, Remotely Global: Village Modernity in West Africa (1999), has gained wide attention for re-theorizing a classic, out-of-the-way place as existing within the modern and the global.

 

His next book, Nostalgia for the Future: West Africa after the Cold War (2010), explored shifts in Togolese political culture during the 1990s, when NGOs and charismatic churches reorganized social and political life in the absence of the state.

His current project focuses on Togolese who apply for, and attempt to game, the US Diversity Visa Lottery.

You can find out more about Charles Piot’s work on his Duke University website here.

While pursuing his own research in Togo, Piot now brings undergraduate students from his U.S. campus (Duke University) for short stays in the West African villages of the Kabre people where he has made a second home.  While there over summer and winter breaks, the students have developed and pursued their own, small-scale development projects.  In developing these projects, the students aim to tap into both their own skills and the needs of the villagers.

Neophytes are notoriously doomed to fail in such culturally and politically sensitive work. But these students are lucky to have Professor Piot to guide them in the exceptionally thoughtful and informed way that anthropologists do best.  Many of the projects have already proven transformative, while the failures have proven instructive.

Piot has worked with the students to publish a striking collection of essays chronicling their efforts.  The result: Doing Development in West Africa: A Reader by and for Undergraduates (Duke University Press, 2016).

Anthropologist Brad Weiss calls the book “an innovative . . . eminently readable and teachable text valuable to courses in international relations, political science, and anthropology.”

The book was “Highly recommended” for libraries by Choice.

Recently, Charlie and I had a conversation online about the book.  During part of our conversation, Charlie was actually back in the villages, checking up on recent projects and tweaking them to make improvements.  I think you’ll find the conversation fascinating.

CP: Charles Piot

AG: Alma Gottlieb

 

AG:  This book features projects that your undergraduate students at Duke have undertaken in a rural area of Togo where you’ve conducted research among the Kabre people for a few decades.  What inspired you to compile a book of essays by and about research in West Africa done by American undergrads?

CP: The idea for the book was entirely student-driven!  One year’s group of students with academic leanings – all three went on to graduate study, with one now pursuing a PhD in medical anthropology – asked if they might write up the results of their summer projects in an Independent Study class.

I agreed and put them through the paces – first week, produce an abstract; second week, an Introduction; and so on.  Before you knew it, they each had short articles, which were surprisingly strong.  One of the students asked if we couldn’t try to publish them, and of course I said, “Sure”–while secretly imagining that we’d end up publishing them on a website of our own design.

But one thing led to another.  We added more essays the following year.  We found some money to fly in to Duke an anthropologist (John Hawkins) who had published a similar book of student essays, and he gave us outstanding editorial advice.  We had lunch with a Duke University Press editor who was super-supportive of the idea – for him, it was a novelty, a book by undergraduates for undergraduates about development – and said he’d send the essays out for review.  But then, of course, the real work of producing a book – of editing and fitting all the pieces together – began.

Then, too, the projects themselves have always drawn me in.  These projects – all, student-designed – are interesting and doing important work in the villages.  And they tell interesting cultural stories.

Recipient of the Writer’s Collective Award for Best Poem (with a Duke Student), in a Kabre Village (Togo)

 

Finally, the problems and challenges of development in West Africa are vexing and fascinating.  I didn’t used to think so.  In fact, in years past, I would run the other way when I saw a development worker.  But now I find issues of development not only urgent but also (as Lévi-Strauss might have said) “good to think with.”

2017 Group of Duke University Students in a Kabre Village (Togo) 

 

AG:  Let’s start with that last comment.  As an Africanist, I spent three decades lecturing to students about the failures of large-scale “development” programs across Africa.  I suspect you did, too.  Yet we both find ourselves now working with small-scale “development” projects in our fieldsites.  Or maybe, it’s because we found so much wrong with those large-scale programs that we’ve both now embraced much more local, small-scale projects, in spaces we know well.  (Your work with these projects in Togo is exactly why Philip Graham and I invited you to join the Advisory Board of the Beng Community Fund that we founded, to create small-scale projects with Beng villagers in Côte d’Ivoire.)

In helping your students design their micro-projects, do you find yourself thinking explicitly about the failures of so many past IMF (etc.)-funded projects in Africa, and working with these students to design projects that will avoid those well-documented problems?

 

CP: Everything we do in Togo is tied to the spectre of development’s many failures that you reference.  My own feeling is that many of those failures, whether large-scale or small, are due to the failure to understand or engage with local culture.  How can you introduce new systems of debt (that come in with a microfinance project) if you don’t understand local notions of debt?  How can you design farming or health projects if you don’t understand local labor and cultivation practices, the way gender and labor intersect, and even local conceptions of the body?  But, astonishingly, most development projects never get down in the weeds of the local like this.  They assume the benefits of their projects will be obvious to all.  So they hire technicians and economists and agronomists, who are all well-versed in the Western sciences—but, rarely, anthropologists!

All of our projects in Togo – a microfinance opportunity for teens, a village health insurance system, computer classes, a writers’ collective – attempt to draw on local knowledge from the get-go, from design to implementation.  If we’ve had any success at all–and I believe we have– it’s because of our attention to local culture and history.

But there are no guarantees!  Indeed, as a provocation, I tell the students they shouldn’t get their hopes up too much, they should remain humble (and assume that locals know much more than they do – about farming, their bodies, local institutions), and even expect failure.  But such failure can be instructive in informing future efforts.

Another blind spot of many development projects is sustainability and follow-up.  Do they ever think about the time, five or ten years down the road, when the outside director or project manager will no longer be there?  Usually not.  This is a topic I’m preoccupied with right now.  What will happen to these projects after I stop taking students to Togo?  And what happens each year after we leave?  Do the computer classes live on, does the microfinance project continue to function?  I’m actually in Togo right now for a few weeks for that very reason, to follow up on all of the projects and continue to brainstorm the question of sustainability.

Charlie Piot Drinking Sorghum Beer with a Local Chief in a Togolese Village

 

AG: That’s fantastic that you’re writing about this from the village–using Internet supplied by one of your students’ projects.  That would certainly be one of the success stories.   Can you talk about the projects that have been the most–and least–sustainable?  In the case of the projects that are faltering, are the obstacles more technical, or sociological, or economic, or emotional . . .or a combination of some or all the above?  Are there things you now realize you could do in the future to make new student projects more sustainable?

Wireless Relay Station outside a Kabre Village (Togo) Demonstrated by Duke Student

 

CP: A nice question!  I’ll respond by discussing two examples of projects of ours that have had mixed success.

First, the health insurance system we’ve set up in a village clinic.  With this project, member families get free consultation and pay 25% the normal cost of medications, all for $4 a year per family.  The project has had fluctuating membership since it began 10 years ago, with only 25 families out of 200 currently enrolled.  And this, despite the fact that all insurees are unanimous in their praise of the benefits of the system.  Every year, we interview members and non-members to try to get to the bottom of why more families aren’t signing up.

Some of their responses: the health insurance scheme requires payment on a schedule, while the local system of payment and debt is more accommodating to unforeseen contingencies; the indigenous system of medicines is also efficacious and cheaper (you never “thank” a healer until after you are cured, with payment in kind – some beer, a chicken); some worry that paying for a cure before you fall sick might (through mystical means) bring on the sickness; others want to know if they can get their money back at the end of the year if they never attend the clinic.  All these responses make us realize how culturally shaped the idea of “health insurance” is!

The second example involves the cyber café.

                Muddy Flip-flops Left outside the Entrance to the Kudwe Cyber Café                          in a Kabre Village (Togo)

 

The computer classes we’ve offered while we’re there have been wildly successful.

Schoolroom Chalkboard Demonstrating the French Keyboard in a Kabre Village (Togo)

And we’ve found a high school student, a real wiz, who took our classes, to teach them to others after we left.  That could make the project sustainable beyond our presence.

Students inside Classroom in a Kabre Village (Togo)

But last month, when I was visiting the villages, I discovered that the cyber café has been closed to classes since we left last August, because the person responsible was transferred to a town fifty miles away,  and the person taking over hasn’t yet done what they call a “transfer of power” (passation de service), because no one has yet compiled an inventory of the materials in the cyber café.

So, as you can see, these are not technical problems–they’re social and cultural.  And while both projects are “successful” – the health plan works well for some families, and we’ve taught computer and Internet skills to several hundred youth in the villages – they’ve nevertheless fallen short of realizing their full potential.

 

AG: You’re unusually honest in assessing the weak spots of promising projects. I’m guessing this is because your training as an anthropologist compels you to see the social fissures that are invisible to the directors of so many large-scale development projects, who often focus on the technical components alone.  Our propensity as anthropologists to see the invisible but powerful lines of the social universe may make it easy for us to spot problems that elude the gaze of others.

But, does that skill also enable us to fix the problems?  For example, once you discovered the personnel problem with the cyber café, did you perceive any viable way to tackle it?

The insurance situation strikes me as even more challenging, because there, you’re dealing with a clash of values, and that’s almost always far trickier to address than other challenges.

Thinking about both these projects–with their encouraging yet mixed successes–I wonder if you have thoughts about how the next group of Duke students you bring to Togo might brainstorm solutions that could further address this thorny but critical question of sustainability.

CP: I do think our training as anthropologists aims our attention to the social life of communities, with all its messiness and conflict and fissure.  Do these insights also enable us to find solutions to the problems of development in small-scale contexts like this?  In principle, yes.

To stay with the example of the cyber café we’ve installed: despite the frustrating loss of time – eight months of inactivity – my students and I have familiarity with the lines of authority at the cyber café and in the larger community, and we know what jealousies might be in play—so we are able to brainstorm solutions with local allies.

In this case, a promising outcome is in progress – and one that may vault the cyber-café into a whole new orbit of activity, with a private entrepreneur from a different ethnic group managing it, while adding a photo-copier and printer, and installing a money transfer kiosk. (Local wisdom is to go outside the community to look for a manager, as locals might attempt to poach on the goodwill of a family member or close acquaintance, quickly bankrupting the enterprise.)  So – perhaps!  Only time will tell if this will be a failure-into-success story.  If it does, even a success will surely generate its own new round of challenges and setbacks.

But, development in such a context is always like this.  If we’re lucky, we might take three steps forward for every two steps back.  And, in any case, staying with the challenges has its own rewards.

2017 Teen Microfinance Awardees (and Family Member Guarantors) in a Kabre Village (Togo)

 

Fabulous Art from Abandoned Flip-flops

Cleaning up beach waste in the form of abandoned rubber flip-flops . . . recycling landfill-able castoffs . . . training low-income men and women in job skills and providing them with living wages in Nairobi . . . creating beautiful art . . . saving fish, dolphins and baby turtles from choking on rubber detritus . . . educating local residents in recycling options . . . so much goodness in one small company!Dolphin Sculpture from FlipflopsThis small effort may not solve the world’s pollution and poverty problems, but it does highlight one local success story.

The Ocean Sole Company that makes sculptures from flip-flops funnels 5% of its profits into its educational foundation.  That’s not a huge percent, but it’s something.  Its website says: “The Ocean Sole Foundation works with communities, scientists, conservationists, artists, governments, industries and other not-for-profit organisations that are raising awareness and actively involved in marine conservation. We support actions that recycle, reduce and reuse marine and waterway debris.”

Contrast this encouraging account of garbage-to-art with the typical gloom-and-doom story about sub-Saharan Africa that lands in the Western press.  If more journalists published reports like this, instead of yet another lament about ebola, civil war, corruption, or AIDS, what might white people’s images be of the land from which their long-ago ancestors came?

I’m not advocating that Africa’s considerable challenges be ignored.  But how about a bit more journalistic balance?

Otherwise, there’s always the stereotype-reinforcing strategy that Kenyan author Binyavanga Wainana offers, instructing would-be authors how (not) to write about Africa:

Binyavanga Wainaina

“Always use the word ‘Africa’ or ‘Darkness’ or ‘Safari’ in your title. Subtitles may include the words ‘Zanzibar’, ‘Masai’, ‘Zulu’, ‘Zambezi’, ‘Congo’, ‘Nile’, ‘Big’, ‘Sky’, ‘Shadow’, ‘Drum’, ‘Sun’ or ‘Bygone’. Also useful are words such as ‘Guerrillas’, ‘Timeless’, ‘Primordial’ and ‘Tribal’. Note that ‘People’ means Africans who are not black, while ‘The People’ means black Africans.

Never have a picture of a well-adjusted African on the cover of your book, or in it, unless that African has won the Nobel Prize. An AK-47, prominent ribs, naked breasts: use these. If you must include an African, make sure you get one in Masai or Zulu or Dogon dress.”

 

P.S.  Check out the awesome “open letter” recently addressed to the producer of the popular CBS news show, “60 Minutes,” about the unacceptable biases in the show’s (rare) coverage of Africa.  Dare we hope this passionately and intelligently argued plea, signed by dozens of prominent scholars and other thoughtful people, might produce some positive changes in the show?