Denmark’s public health system is so comprehensive, so systematic, so thoughtful, and so FREE, that it’s hard to imagine them NOT having the highest vaccination rate of children age 12 and up. According to the Borgen Project, here are some of the laudable features of Denmark’s public health system:
“All citizens in Denmark enjoy universal, equal and free healthcare services. Citizens have equal access to treatment, diagnosis and choice of hospital . . . . Healthcare services include primary and preventive care, specialist care, hospital care, mental health care, long-term care and children’s dental services.
Denmark organizes child healthcare into primary, secondary and tertiary healthcare systems. The primary level is free for all Danish citizens.
Tax revenue funds healthcare in Denmark. The state government, regions and municipalities operate the healthcare system and each sector has its own role.
The healthcare system runs more effectively than other developed countries, such as the U.S. and other European countries. For instance, experts attribute low mortality in Denmark to its healthcare success. . . . Denmark spends relatively less money on healthcare in comparison to the USA. In 2016, the U.S. spent 17.21% of its GDP on healthcare, while Denmark only spent 10.37%. By contrast, in 2015, the life expectancy at birth in Denmark was 80.8 years, yet it was 78.8 years in the U.S.
The high-quality healthcare system increases life expectancy. Danish life expectancy [even] slightly exceeds the average of the E.U.
Healthcare in Denmark sets a good example for elderly care in other countries. . . Danish senior citizens have the right to enjoy home care services for free, including practical help and personal care, if they are unable to live independently. Similarly, preventive measures and home visits can help citizens above 80 years old to plan their lives and care.“
The U.S. doesn’t have anything like any of the above systems. Instead, we value individual choice and effort over any notion of either community health or collective rights. That sounds good — until a pandemic reminds us of how lethal that value can prove.
Is it any wonder that Denmark is doing such a better job than the U.S. in vaccinating its teens against Covid?
This past month, the swans have taken up residence in our local cove, for the first time in the six summers we’ve lived here.
What could be a more beautiful way to celebrate the birth minute of my husband’s milestone birthday than a sunrise with swans?
What smiles the swans have brought to all who pass by. Plus, they’ve provided a great opportunity for conversations with admiring strangers. (“We just counted 81! How many did you count?”)
They’ve also motivated me to do some quick online research.
Turns out those oddly-shaped black blobs that sometimes rest on their backs are a leg. One leg. What’s going on with that? Does one webbed foot suddenly get tired and need a rest? Does resting a leg on a back stretch out taut muscles tired from too much paddling? Does a wet foot on some overheated feathers add a cooling touch under the hot sun? And how do they manage to navigate, anyway, without going awry from having only one limb for paddling? (Yes, I’ve seen them locomoting with a webbed foot lying on their rump.)
The anthropologist in me is frustrated no end that I can’t ask them for a direct response to these growing questions. I’ll have to keep testing out my theories using that other classic ethnographic method (which I honed while studying babies in West Africa): observing behavior and ruling out unlikely hypotheses. I wonder how likely this experiment in inter-species ethnography is to succeed.
Meanwhile, never mind their human fan club. Oblivious of us, and despite their reputation for nastiness, the swans that have taken up residence in our local harbor have co-existed happily all month with geese, ducks, egrets, seagulls, and terns.
Dare I hope the waterfowl offer a model for us bickering humans to re-gain a sense of community spirit?
We needed to find a new plumber. I called around. The first business that seemed willing to clean our boiler and replace a problematic hose spigot had availability soon. Before settling on a date, I remembered to ask the woman answering the company’s phone–let’s call her, Mary–a non-plumbing question: Will the plumber who comes into our house to work on the boiler for a few hours be fully vaccinated?
That inquiry took us to a place I hadn’t prepared to enter while finding the right vocabulary to explain our garden issue. Indeed, Mary’s unwelcome answer brought us into one of those difficult conversations we all dread these days. Here’s my best memory of how it unfolded:
Mary: I can’t guarantee that the plumber would be fully vaccinated.
Me: Are SOME of your company’s plumbers fully vaccinated?
Mary: We don’t require our staff to be vaccinated. The owner can’t force them. We’re not legally allowed to do that.
Me: Absolutely. But, the owner doesn’t have to keep paying people’s salaries if they won’t get vaccinated. That’s not forcing, that’s just his legal right to hire whoever he wants to hire. He’s got that freedom.
Mary: He won’t require it.
Me: But, are ANY of the plumbers who work for you vaccinated?
Me: Hmm. In that case, I’ll probably wait to use your services until after the pandemic is over.
I sensed that Mary was struggling to refrain from going into a political tirade about how Democrats and scientists were lying to Americans, and the vaccine would make people magnetic or sterile or digitally trackable or . . .
A normal person would have ended the conversation there. But I’m not a normal person. Suddenly, this conversation offered new possibilities for engaging with someone outside my usual social circle. The anthropologist in me was activated. I forged on.
Me: My husband and I are both vaccinated, but this aggressive Delta variant is now causing some mild, breakthrough cases that people might pass on without knowing. Since we have young grandchildren who can’t yet get the vaccine, and we’ll soon see them, we’re being extra-cautious.
Now the citizen in me was activated. Reckless, I plunged ahead.
Me: Meanwhile, since only the unvaccinated are dying from Covid now, you might want to recommend that your plumbers get vaccinated–not only to protect themselves, but also your customers.
Mary: We won’t do that.
Re-enter the anthropologist.
Me: Ah. [Pause.] Out of curiosity, I’m wondering why you don’t urge them to get the vaccine.
Mary: All our plumbers are very healthy and have great immune systems. They won’t get sick.
Me: Oh, that’s wonderful that they’re so healthy. [Pause.] Still, I keep seeing videos of people in the hospital with Covid, on ventilators, who said exactly that. This Delta variant seems to be extra-contagious and is getting so many people sick who had strong immune systems. The vaccine is a great way to protect your plumbers.
Mary: My husband and I don’t believe in the vaccine. We’re not vaccinated, and we don’t want our employees to get the vaccine, either.
Me: Really? Why’s that?
Mary: [Hangs up.]
So much for my long-honed interviewing skills. I’d have to grade myself an “F.”
But I’m never one to take failure lightly. The anthropologist in me wanted to call back and see if I could gently persuade Mary to explain her opposition to a vaccine that has so much overwhelming scientific evidence supporting its efficacy. Exactly what unfounded fears had grabbed Mary’s imagination? Who, or what, was her source of information? Why did she trust that source?
Still, the plumbing issues beckoned. Rather than re-engaging with Mary–trying to conduct instant phone ethnography that was, undoubtedly, doomed–I sighed and returned to an inventory of plumbers recommended on a neighborhood list-serv.
Phone call #2 produced an outcome at once similar, and worlds apart.
The woman answering the phone of the second business I rung up–let’s call her, Carol–offered a complicated reply that invited a conversation. Here’s what I remember of the non-plumbing portion of our exchange.
Me: Will the plumber who comes into our house to work for a few hours be fully vaccinated?
Carol: Probably, yes.
Me: Ah, that’s great. My husband and I are, too. But since we have young grandchildren who can’t be vaccinated yet, we’re being extra-cautious. Are all your plumbers fully vaccinated, then?
Carol: All but one. But, I can make sure that the one who isn’t vaccinated isn’t the one who comes to work in your house.
Me: Thank you, I appreciate that. [Pause.] Out of curiosity, is your boss encouraging that plumber to get the vaccine, to protect himself and your customers?
Carol: Actually, he’s already gotten the first shot. He just hasn’t gotten the second one yet.
Me: Oh, great.
Carol: Yeah, our boss is very big on the vaccine. He’s encouraged everyone in the company to get it. I’m the only one who hasn’t!
Me: Oh. [Pause.] Well, since you won’t be coming to work in my house, that’s not a problem for me. [Pause.] But, would you mind me asking why you haven’t gotten it, if your boss is encouraging you?
Carol: I’ve heard there are a lot of bad sideeffects. Did you have any bad side effects after your shots?
Me: Well, after my second shot, I was tired for a few hours, and the spot on my arm where I got the shot hurt a lot for about a day. But, really, it was no big deal. I’d much rather have a sore arm than die from Covid!
Carol: Oh! [Giggles, pauses a few seconds.] But,I have underlying conditions, and that’s what makes me very nervous about the vaccine.
Me: Ah, I can see that would make you nervous. Have you discussed your situation with your doctor?
Carol: No, I haven’t. I’m just reading stuff on social media.
Me: Maybe your doctor might have more information about whether your condition would make you a good candidate for the vaccine — whether it would be safe for you.
Carol: I guess so. But, I had [pauses] cancer some years ago, and I wouldn’t want the vaccine to bring that back. That was a nightmare. The treatment was so awful. And, the vaccine’s so new, no one knows what it will do, years later.
Me: I hear you. My husband was actually in treatment for cancer the past year, and his oncologist urged him to get the shot as soon as possible. He got it very early. I was online every day for a few hours, starting in January, looking for an appointment for him.
Carol: Wow, really?
Me: Yes. My husband got the first shot as soon as he could. Even though he’s now completely recovered from his cancer, now that booster shots are available, he’s going to get that third shot as soon as he’s eligible. His doctor thinks that’s a good idea.
Me: Yes, there’s a list of underlying medical conditions that make you more vulnerable to catching Covid, and suffering more, if you do. Cancer is one of them. Diabetes and asthma and obesity are some others. That’s why people with those underlying conditions were being urged to get the vaccine early on, before other people.
Carol: Hmm. You sound very knowledgeable. [Pauses.] Maybe I should consider it.
Me: Just this morning, my husband was almost in tears when he read a profile of an ER doctor in Los Angeles who is so, so frustrated with her Covid patients. None of them was vaccinated, and now, many of them are dying. As a doctor, she wants to do everything she can to help people survive, and she can’t believe that people are refusing to get vaccinated, since the vaccine pretty much guarantees that, even if you come down with Covid, it’ll probably be mild, and you won’t end up in the hospital and won’t die from it. Just about everyone in the hospital with Covid now is unvaccinated.
Carol: Where did your husband read that story?
Me: I think he said it was in the Los Angeles Times. If you like, I can ask him and maybe send you the link.
Carol: Oh, yes, please, I’d like to read that.
Me: Sure, I’ll send that to you as soon as I can.
We scheduled our plumbing appointment and Carol dictated her e-mail address so I could send her that newspaper article link. A few minutes after ending the conversation, Carol called back to double-check our street address. But first, she said, “I haven’t gotten that link yet. Are you still going to send it?”
I reassured her I would, then told her some updated statistics about Covid’s ravages that I’d read in the past few minutes. Carol eagerly resumed our conversation.
Carol: You sound so knowledgeable. I’ve enjoyed talking with you.
Me: Thank you. Same here!I do spend a lot of time every day reading updates, since the pandemic has taken such a toll.
Carol: I think I need to stop looking at social media and stop listening to people telling me not to get the vaccine.
Me: I know there’s a lot of claims out there about how the vaccine is unproven or dangerous. But, there’s definitely a lot of scientific evidence now that shows that the vaccine is super-safe and super-effective to keep you from dying from Covid. So far, something like 200 million Americans have gotten the vaccine, and no one has died from it. But we’ve had over 600,000 deaths from Covid.
Carol: Wow, really? [Pauses.] I think I’ll get it soon.
Me: That sounds like a good decision for you.
Carol: Yeah, I’m sure I’ll get it, now.
On the surface, the two women I spoke with share a lot of demographic characteristics. They’re both white. They both sounded within about 10-15 years of each other (I’d say, in their 40s to 50s). They’re both part of the working class. From a variety of speech styles and other markers, I’d guess they both stopped their formal education after high school. They’re both native English speakers. They’re both American. And they’ve both resisted getting the vaccine to protect themselves, their families, and their communities against Covid-19.
But, that’s where the similarities end. Together, Mary and Carol occupy two distinct points on the non-vaccinated spectrum in the U.S.
To put the contrast at its starkest . . .
Mary opposes the vaccine for political reasons; Carol opposes it for personal reasons.
Mary is angry about the vaccine; Carol is afraid of it.
Mary is sure in her decision; Carol is uncertain about hers.
Mary refuses to listen to counter-evidence that would challenge her decision; Carol is willing, even eager to listen to counter-evidence that might impel her to rethink her decision.
What does this tale of two women tell us about the people who have yet to get a free vaccine in the U.S. against COVID-19, despite incredible effectiveness and widespread availability? True, they’re only a sample of two. I can hardly claim that’s a scientifically representative group. But between them, these two women cover a lot of fascinating territory that I think is important, and instructive.
I draw some admittedly big lessons from my conversations with those two plumbing company receptionists. At the ethnographic level:
The “vaccine-hesitant” are not a single, homogeneous block. They include a variety of people who have arrived at their caution–or refusal–from a variety of subject positions.
If Mary and Carol offer strikingly different reasons for rejecting the Covid vaccine, they still do not represent the full range of reasons. Notably . . .
Some undocumented immigrants remain nervous about deportation, in case they have to show an ID at a vaccine clinic (as with some in the Cape Verdean community I research in Rhode Island);
Some blue-collar laborers work such long hours that they don’t find time or energy to go get a shot (as with the Stanley Steemer employee who came to clean our carpet earlier this spring, pre-Delta);
Some young people find it impossible to imagine that they could die (who among us hasn’t been there?);
Some “gig economy” workers live so precariously, from paycheck to paycheck, that they can’t risk missing a single unpaid day or two of work (why can’t the federal government address this with direct compensation?);
Some people of color retain such deep distrustof a medical system steeped in racism that they see no reason to let down their guard now (happily, physicians and nurses of color are starting to effectively address these concerns).
At the pragmatic (or, should I write, methodological?) level: Because “vaccine hesitancy” has many, diverse foundations, addressing it requires a multi-pronged approach.
“Meeting people where they are” has recently become a catch phrase among some in the medical community. That pithy motto is really just a simple way of signaling that what’s needed is an army of anthropologists. Who better to plumb people’s hidden, implicit values?
If the Biden administration were on the ball, they’d be recruiting anthropologists left and right for their medical team.
At the truly big-picture level: Education matters. Without research skills training us to evaluate the clearly false from the potentially true from the absolutely true, we are at the mercy of anything passing for “fact” that crosses our screen. Whatever the grade level, whatever the class subject, whatever the instructor’s expertise, every teacher’s first task should be to teach basic skills to evaluate evidence. The story of Mary and Carol makes it clear: our lives depend on those skills.
Meanwhile, here’s a rash prediction. This Monday, the F.D.A. is said to announce full authorization of the Pfizer vaccine. For some of the under-informed and mis-led Carols of the world ruled by a troubling combination of fear, misinformation, and eagerness for reliable advice founded in facts that regularly evade them, that authorization should provide some assurance that may motivate them to roll up their sleeves for their first shot. In short, I anticipate an enormous wave of new vaccine doses in the coming week or two, as several dams of hesitation break.
And, a wish. Maybe, just maybe, as the Marys of the world watch more people they know and even love die needlessly of Covid, at least a few of them may find some face-saving cover in the F.D.A. move and finally decide to go for a shot. After all, joining the pro-life camp of the vaccinated will confer the ultimate freedom.
1. The moment that any transfer of power occurs from one individual or regime to another is fraught—ritually, sociologically, emotionally.
Why? This is a liminal period–“betwixt and between,” as the great anthropologist Victor Turner described it–neither fully in one political space, nor in another. Liminal moments offer options for creativity, inviting artistic license. They also represent spaces of danger.
Here’s what I’ve learned about the liminal times of interregnum–those intervals between political regimes–from West Africa.
For the better part of two years, I lived in small, rain-forest villages hosted by the Beng people of Côte d’Ivoire. Their practices for seating a new king are a study in (ritual) risk management.
Beng people rank a king’s inauguration as an extended moment of extreme spiritual danger. During the days and, especially, hours before the installation concludes, witches reportedly roam freely during the daylight hours, taking advantage of the temporary power vacuum. As the time approaches for the king to be ritually seated, the witches’ work increases to a fever pitch, culminating in maximal damage during the moments right before the climactic ritual. It is said that more people die during the interregnum period than at any other time. Babies and children never attend a king’s investiture: parents fear that their weakness and youthfulness would render them especially vulnerable to the power of witches. Likewise, a pregnant woman assiduously avoids the event, protecting her fragile fetus.
Some in the modern world might dismiss such accounts as anachronistic relics of an ancient era. I suggest otherwise.
At the broadest level, let’s take “witchcraft” as a metaphor for the unleashing of any illegitimate and mystical power aimed at causing harm in the lives of ordinary humans. (That’s how the Beng perceive witches.) It becomes clear how the ritual drama of Beng kingship illuminates the events of last week in the American capital. The insurgents attacking the U.S. Capitol building played the role of witches, spreading spiritual chaos.
The much-photographed costume of the fiercest-looking insurgent was worn by one Jacob Anthony Chansley–an Arizonan man who forsook his prosaic name in favor of “Jake Angeli,” with its obvious religious reference to “angel.” But his attempt to wield spiritual power was not only through reference to Christianity. In a second perverse act of cultural appropriation, the terrorist also drew on indigenous religious traditions, calling himself a “QAnon Shaman.”
That is not just a meaningless moniker. The now-notorious Arizonan claims spiritual powers equivalent to those of the classic shamans of the Mongolian steppes. Chansley has categorized himself as a “multi-dimensional or hyper dimensional being” and claims he can “see into these other higher dimensions that these entities – these pedophiles, these rapists, these really high up people … that they can almost hide in the shadows in.”
Beyond Chansley, QAnon–the amorphous collection of groups with which Chansley associates himself–itself displays many qualities of a religious cult. For one thing, its strangely spelt name hints at a secret identity: Anon[ymous]. The secrecy encoded in its very name implies mystical foundations.
Then, too, the conspiracy-oriented group promotes hyperbolic but vague claims drenched in sensationalist innuendo: Satanic kidnapping, pedophilia, child trafficking.
Moreover, according to NY Times reporter Kevin Roose, QAnon followers have also been “flooding social media with false information about Covid-19, the Black Lives Matter protests and the 2020 election.” Some have, additionally, embraced anti-vaccine and anti-child-trafficking movements; others make further “claims about the assassination of John F. Kennedy, the existence of U.F.O.s, and the 9/11 ‘truther’ movement.”
What’s more, its messages are sometimes penned in cryptic language.
All these features smack of religious cults.
Dare I point out that this shambolic collection of creative but unrealistic fears constitutes a veritable witches’ brew?
Chansley is now in custody. I’m guessing that the higher powers with which he claims to be in touch may not prove persuasive in a court of law.
But Chansley is just the side show. The main act, of course, is Donald Trump. These past four years. Trump has turned into a religious cult leader par excellence.
Trump may not drape himself flamboyantly in bearskins or sport buffalo horns, but his toxic narcissism produces just the sort of charismatic charlatanism in which certain types of religious cult leaders have long specialized. Allying himself with flashier devotees merely highlights the religious fervor he ignites on his own.
As I watch reruns of the mob scene that Trump incited, I imagine that the great French sociologist, Emil Durkheim, would have recognized the energy as effervescent, when large gatherings of people create great emotional intensity dedicated to serving ancestral spirits. Tragically, the religious fervor we witnessed in the U.S. capital produced tragedy rather than spiritual enlightenment.
Last week in Washington, D.C., the bureaucrats in charge of security failed our nation miserably. Eventually, a systematic inquiry will determine whether this failure originated in inattentive incompetence or coordinated sedition. (All signs are currently pointing toward the latter.)
For now, I humbly point out what those in charge might have learned from Beng villagers (assuming they actually wanted to protect the nation): moments of political transition represent the most dangerous times of civic life.
During periods of political interregnum, society cannot be too cautious. Leaders must take all conceivable steps to protect the vulnerable and safeguard the polity, lest the forces of chaos–modern-day witches–avail themselves of the power vacuum and take charge.
2. The institutionof democratic rule is strong, sturdy, and stable–until it’s not.
In the village, my Beng friend Yacouba once told me, “When the walls have holes, the cockroaches get in.”
Yacouba had in mind the ravages of his two co-wives. In his view, their endless bitter arguments were causing all their children to constantly fall sick; one had even died.
Yacouba’s cockroach lesson might be applied to the broader house of civil society. Once foes scratch cracks into the walls of an institution, elements of destruction expand those chips and find their way in.
In Côte d’Ivoire, the initial challenge to the modern nation’s first democratic elections occurred in 1994. The past 26 years have seen more failed coup attempts than I have counted, punctuated frequently by violent civil unrest and two periods of out-and-out civil war. Today, the nation remains as unstable as it was at the beginning of those early political challenges. Côte d’Ivoire’s recent history should serve America as a warning.
During the past week, we have heard many journalists and political experts write that America is on a precipice. But, if we want to be honest with ourselves, we must acknowledge that, from the nation’s earliest days, America began in violent efforts to either subjugate or annihilate people of color–first, native peoples; then, Africans kidnapped and brought to these shores while enslaved. To claim that we are on a precipice now implies that this is the first time we face stark choices concerning racism. In truth, we have been balancing uneasily on that precipice since the founding of the republic.
Nevertheless, each time we venture farther out on that cliff, we come closer to toppling over its edge.
The lessons of Côte d’Ivoire’s difficult modern history are still something from which it’s not too late to learn. There’s still time to conduct thorough inquiries into who organized last week’s insurrection and then prosecute them. All of them. Even if he neither resigns nor is removed from office via the 25th amendment nor is impeached, Donald Trump can, and should, ultimately be judged–ideally in court, but certainly by history.
Meanwhile, we have an interregnum to plow through.
Recently, I checked in with Dr. Bjørn Westgard, to see how he was doing.
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, aLevel 1 Trauma Center in Minneapolis thatsees 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.
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 Westgardhere and his LinkedIn pagehere.)
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 ahemoglobinopathy. 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 forcytokine 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 tosyndemic 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.
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 docase-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 inmobilizing 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, maybeAtmosphere, but not many others in the national mediasphere.
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 auser-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.
UPDATE, June 19, 2020: Bjorn has just published a co-authored article analyzing changes in the numbers and kinds of patients arriving at ERs in one large, public Minneapolis hospital. You can request a copy here: https://www.researchgate.net/publication/342111120_An_analysis_of_changes_in_emergency_department_visits_after_a_state_declaration_during_the_time_of_COVID-19
Early generations of anthropologists offered all sorts of definitions. No matter what their specifics, the various definitions inevitably shared one feature: “culture” is identifiable. Above all, it encompasses a set of beliefs and behaviors that, together, are premised on an enduring set of values.
Or something like that.
And, as such, culture (it was thought) offers a source of stability. It occupies broad swaths of time and space: associated with a delimited place, and occupying long patches of history. For these reasons, culture makes for a certain level of predictability in the lives of community members.
Or does it?
Starting in the 1960s, anthropologists started questioning those assumptions. Marxists pointed out that ever since, oh, the advent of capitalism, or feudalism, or agriculture (pick your favorite starting point), “culture” has been perpetuated by the ruling class. Once the poor get fed up enough, they protest; eventually, they revolt. Then, suddenly, what passed for an enduring model of “culture” turns into a set of values to be challenged, and “culture” — or, one particular version of it — doesn’t seem so reliable or inevitable.
Around the same time, feminists began pointing out that “culture” has been perpetuated by men-in-power. Once women get fed up enough, they protest; eventually, they revolt. See above.
One can repeat similar arguments focusing on many other oppressed groups: racialized minorities, religious minorities, ethnic minorities, citizenship minorities, language minorities . . .
Nor is oppression the only reason for change. “Culture” also mutates when people from different backgrounds meet up, live near each other, work with each other, eat each other’s foods, dance with each other at street fairs, marry each other, have children with each other.
You get the point. “Culture” turns out to be way less permanent, less bounded, less intractable than early anthropologists claimed.
Not that the idea of culture is worthless. Contra some serious critics (Lila Abu-Lughod famously urged anthropologists to “write against culture“), I still find plenty of value in the notion. That’s because I see a lot of space between worthless and intractable. Culture can be malleable, adaptable, dynamic, while still remaining rooted in something. And, although the values that buttress culturecan change, while they are active, they are powerful. They lie behind many (perhaps, for the privileged few, most) of our decisions.
Still, in pop culture, the current generation of anthropologists’ critiques of what culture is, and isn’t, hasn’t taken hold. Instead, in texts ranging from newspaper articles to corporations’ reports, we easily read disturbingly essentializing claims about “the Chinese” and “the French” and “the Muslims” as if all Chinese people, all French people, and all Muslims were easily interchangeable, eagerly sharing all values and forever speaking with one voice.
Or we read simplistic assertions about “corporate culture” in the halls of this or that company, as if all employees endorsed and enacted daily the corporation’s stated idealistic goals.
Along comes COVID-19.
Of course, the most poignant takeaway of COVID-19 is the tragic demise of its most vulnerable targets.
But alongside the wrenching announcement of the day’s latest mortality statistics, as a cultural anthropologist, I find myself fascinated to read “culture” changing before our eyes — weekly, daily, even hourly. What we took as immutable practices grounded in deep-seated values are turning out to be far more pliable than most of us imagined.
Take the case of exercise. For the first few days of their local “lockdown,” people who got their workout in gyms despaired. How could they stay fit with health clubs closed?
Enter human ingenuity. Gyms have figured out ways to run “live” classes online. The acronym du jour — WFH for work from home — is expanded by some clubs to WFHBT: work from home better together. Buttressing that conceptual adaption is a simple technical one. Don’t have weights at home? How about using any heavy-ish household item you have lying around that you can hold? Say, pasta sauce jars, six-packs . . . or suitcases.
In such cases, people substitute one space for another. The exercise formerly done in the gym is now done in one’s living room.
But for some urbanites, studios may prove way too tiny to offer space for exercise. City-dwelling coaches are undaunted. Some suggest finding new purpose in a balcony.
For fitness enthusiasts, daily habits of organizing one’s life around outings to the gym morph into organizing one’s life around coaches’ new online classes. That may entail switching work and sleep schedules to accommodate new class times. But the stable source, here, remains the commitment to “fitness,” no matter where, when, and how. That part of local culture and its underlying values remains stable.
But, for a stronger challenge to “culture,” let’s look at a different physical practice common to most of us: that of ordinary walking. For those who learn to walk competently some time in the second year of life, walking becomes a rote activity by the third year. As adults, we rarely contemplate our gait, pace, or stride. No matter where in the world we live, we have a sense of exactly how much distance we should put between us and the next person in order to avoid being judged creepy or reported as criminal. In a New York City subway, that space might be just an inch or two; in rural Sweden, it might be quite a few feet.
Whatever the interpersonal space bubble that feels “natural” to us while out in the world, we must all now confront our unconscious body awareness as we constantly re-calibrate distance. Keeping six feet from the nearest person may now require crossing the street to avoid being too close to the person approaching you on a narrow sidewalk.
Previously, such an action might have seemed, at best, rude; in some contexts, it could have been deemed racist. (As a short film by Cydney Cort called “Passing” once suggested, even speeding up while walking on the same side of the sidewalk can be motivated by racialized fear). Now, not crossing the street to avoid someone approaching you might be assessed as thoughtless, selfish, even potentially murderous.
Normally, producing such a 180-degree turn in what constitutes proper etiquette doesn’t happen overnight. Anthropologists and sociologists from Erving Goffman on have chronicled the deep-seated values that lie behind bodily practices as basic as walking styles. Those values tend to make somatic habits relatively resistant to quick or arbitrary changes.
French sociologist Pierre Bourdieu termed such practices, habitus. He spent much of his celebrated career studying how we experience and embody entrenched assumptions about the world and our place in it, and how these assumptions shape everything from architectural styles to taste in dinnerware.
But with COVID-19, much of what heretofore passed for habitus has suddenly become its evil twin. An attempt at a friendly hug might as well be a curse.
If maintaining a span of two meters from the nearest human may require doing a sort of dance down the sidewalk, suddenly, we are all turning into novice choreographers, performing an awkward solo tango across the street. What was heretofore a routine somatic movement becomes a basis for uncomfortable improvisation.
Perhaps the professional dancer, actor, and jazz musician can teach us a thing or two. All these artists learn the art of improvisation as part of their training. It may seem odd to think of improvisation as something to be learned. But improvisation is actually a discipline that students practice in dance, theater, and music classes. Ironically, it turns out that the art of improvisation is, indeed, a teachable skill, and the rest of us non-artists are suddenly being required to master it. If you’ve got an artist friend or relative, ask them for some tips.
Artists are now designing striking face masks, teaching us to find beauty in even this new health requirement while enjoining others to do the same.
Powerful new works of art, such as this one by performance artist, Miles Greenberg, may speak to how many people feel these days — alone, awkward, defenseless, shackled.
But artists no longer have a monopoly on improvising new ways to cope with unprecedented challenges. Many who never considered themselves especially creative are finding themselves inventing new ways to cope with challenges and celebrate what remains noteworthy.
Neighborhoods are now organizing weekly shout-outs to thank those who risk their own health daily to care for the sick.
Workers in plenty of private businesses are also digging deep to find new modalities.
Distilleries that otherwise produce vodka have found a new use for excess alcohol: they are re-purposing that newly-hyper-valued substance into one of the rarest commodities of the day, sanitizing wipes.
Inside supermarkets, managers are getting creative about indicating six-foot intervals delimiting where people should wait on the checkout line.
Meanwhile, gig-economy musicians position themselves outside those supermarkets, where they entertain customers awaiting their turn to enter at safely-spaced intervals.
With all this creativity occurring in the economy, I find all the more reason for us to take another look at the homeless.
And, no, I don’t mean because they are especially vulnerable. They are, but we already know that. We’ve known that for a long time. Too many books have been written about their vulnerability, with not nearly enough done to address it. Here, I’d like to point out something we rarely think about when we consider the situation of those who live on the streets.
By necessity, the homeless are masters of improvisation. From whatever tragedies led to their plight, they must scrounge anew for food and safe spaces daily. As if that weren’t enough, they must often manage these demanding tasks while being stigmatized, mocked, even arrested or assaulted. Although the homeless are more frequently the object of derision than admiration, their life skills in the face of almost unimaginable obstacles are extraordinary. Along with artists, they, too, could teach the rest of us some important life lessons.
As an anthropologist who researches the lives of homeless people in Leipzig, Germany, Luisa Schneider writes in a new poem:
Even as many in the middle class (and beyond) are now coming to appreciate for the first time the low-paid workers who (often, invisibly) make their privileged world work — producing payroll checks, bagging groceries, cooking restaurant meals, packing and delivering packages, cleaning houses, teaching children — the one group that remains invisible for their life skills is the homeless. When this COVID-19 state of emergency finally passes, might this moment of global reflection produce new policies of compassion for helping the homeless to find new living quarters, while also helping them adapt their formidable survival skills to new careers?
But that biomedical level has its counterpart in sociological factors — inevitably, given that humans are, above all, a social species.
The new catch-phrase guiding our lives is “social distancing.” For some, the required new habits of isolation are causing great loneliness and worse. For others, the phrase couldn’t be more of a misnomer, as people with access to advanced technology forge ingenious ways to stay in touch with those they hold near and dear. In the global North, Zoom is making geeks of technophobes.
I do not mean to underplay the suffering that the most vulnerable are enduring. Of course, that group includes not just the homeless but also the incarcerated and the medically compromised — the elderly, and those with the now-famous list of “underlying medical conditions” that, especially, stress the heart (diabetes, cancer, obesity, serious organ issues) as well as the lungs (asthma and respiratory conditions).
But it also includes the sociologically most vulnerable — the poor. And, in most parts of the world, that means, especially — for historical reasons having everything to do with the past half-millenium of European colonial expansion — people of color. Maps plotting those five groups — the homeless, the incarcerated, the medically vulnerable, the poor, and Black and Brown populations — are disturbingly close to isomorphic.
In a future post, I will explore these sorts of social vulnerabilities in this COVID-19 moment. Here, I want to end on a different note.
COVID-19 is forcing us to do no less than not only reinvent ourselves as individuals, but reinvent components of who we are as communities. For those who fear change but recognize the suddenly urgent need to embrace it, artists and the homeless alike offer powerful models of inspiration.
The transformations now occurring at every level of society will offer anthropologists research topics for years to come — starting with reëvaluating some unexpected benefits of what we might have formerly dismissed as fragility, and what we mean by “culture.”
In elementary school, the first “robin red-breast” of spring signaled warmer days, colorful flowers, and a promise that the school year wouldn’t last forever. I considered robins my friends.
Of late, I’ve come to perceive those same songbirds as my enemies.
This year, thanks to non-stop April rains, the blueberry bushes in our back yard have burst with fruits as they’ve never done before. My husband and I have inspected the branches daily with equal doses of anticipation and dismay as their output has transformed from tiny, hard, green things, to pinkish-purple promises, to blue balls of deliciousness.
Keeping vigilant over every move toward the berries’ sweet inevitability, we’ve had to do more vigorous battle with their other major, neighborhood fans, the robins.
As a delicate bird alights on a twig, I play schoolyard bully and drive her–or, is it him?–away. (I’m embarrassed to say, I don’t know my adversary’s gender.) The robin flits across my neighbor’s yard, only to return a few minutes later.
Philip wickedly points out that some wild chirping in a nearby tree might signal a nest filled with robin babies, and who’s to say I’m not depriving babies of needed nourishment?
Despite usually being a sucker for all things baby, I don’t buy this bid for maternal solidarity and return to my war of words.
“Shoo! Go find your meal elsewhere!” I holler, clapping my hands firmly for extra emphasis. The call of a future blueberry clafoutis dominates my decision.
My Biology 101 level of understanding of evolution assures me that humans sit comfortably atop something we easily term the “food chain.”
Merriam-Webster defines “food chain” as:
an arrangement of the organisms of an ecological community according to the order of predation in which each uses the next usually lower member.
When I picture the food chain, a very human-centric model readily comes to mind. (You can tell I’m not a vegetarian.)
How can my husband and I be competing as equals with a small-brained creature so much lower on the evolutionary scale?
Maybe my human arrogance is misplaced. Given that we seem to have the same taste in fruit, who’s to say birds and humans can’t be classified as equals, at least when it comes to dessert?
Then I remember an image from some fields in West Africa where I used to hang out. Come the growing season, birds showed up en masse, excited about the feast of tiny baby corn and rice kernels suddenly enticing them. But any success they enjoyed would come at the expense of the villagers–subsistence farmers, whose food supply they were stealing.
So, farmers enlisted children from the age of three on to serve as a young army. From dawn to dusk, groups of children occupied the fields. To entertain themselves during any intermittent periods of truce, the children brought along homemade flutes, drums, and dolls. Whenever some birds showed up, the kids took a break from their play time to shoot little pebbles at the flying invaders. Their aim was impressively accurate, thanks to homemade slingshots. Deployed over the course of a couple of weeks by those youthful armed forces, that simple technology–a Y-shaped piece of wood, with strips of red rubber tied to two ends and linked by a small piece of leather, to cup the pebble–saved the year’s crops.
The Beng knew what every farmer has known since the advent of agriculture. Never mind brain size or evolutionary scales. For that matter, never mind cute images of birds as characters in children’s books. (Think, Make Way for Ducklings). A food competitor is a food competitor.
It’s true that a more “live and let live” approach to the natural world might re-orient the food chain toward a more cooperative image–say, a non-hierarchical circle, rather than a tiered pyramid.
Still, like farmers everywhere, Beng villagers don’t romanticize the quest for food. Once humans figured out how to plant seeds, everything changed. We’re not just digging roots and killing animals wherever we may find them, we’re setting out clearly demarcated territories for what we consider our food sources–and defending those boundaries not only against our human neighbors, but against other species, as well. If that means chasing away cute robins from our blueberry bushes, so be it.
In the U.S. these days, it’s common for urbanites to dismiss rural residents as less sophisticated–at best, country bumpkins; at worst, ignorant racists. But knowledge comes in many forms. From their distant perch in the rain forest of West Africa, Beng farmers–as rural as they come–have, as usual, taught me a thing or two.
What can an anthropologist (who specializes in humans) learn from an unlikely species (like a goose)?
Plenty, it turns out.
My husband and I went goose-banding the other day, thanks to my husband adventurous spirit in discovering a creative, public-outreach program organized by our coastal state’s Department of Environmental Management (“DEM”).
Knowledgeable staff from that department’s Division of Fisheries and Wildlife instructed a small group of citizen-scientists how to herd geese scattered around a large pond, via a strategically managed caravel of kayaks.
At some time in the future, if a hunter shoots one of those geese (or anyone encounters one of these geese anywhere), s/he should contact that lab to share the goose’s banded number. Scientists will use the data to understand more about the lifespan, habits, and vulnerabilities of the geese. Perhaps global warming-induced change might be inferred. As the lab’s website explains:
So much for the day’s mechanics, and the long-term goals of this worthy scientific project.
As for me, here’s what I learned from thinking about our day’s outing as an anthropologist.
1. Geese are the subject of powerful human stereotypes.
“Mean,” “stupid,” and “herd-like” recurred as assumptions readily evoked by friends and neighbors who heard about my husband’s and my plan to go goose-banding.
2. Geese are widely reviled in urban and suburban America.
From my non-scientific sample of friends and neighbors, I conclude that geese are commonly condemned for their repulsive, slippery, and pervasive droppings on lawns, outdoor running tracks, and park greens alike. Nor did my friends express admiration for their loud honking.
In fact, my pals all expressed grave disappointment on learning that my husband and I declined to kill all the geese we encountered at close range.
Despite their image as dirty, loud, aggressive beasts, geese also enjoy a fleeting reputation for their graceful, “V”-shaped migrating flights. As long as they remain far overhead, humans seem willing to cut them some slack and enjoy their passing beauty.
4. Geese aren’t as dumb as they seem.
Inside our pens, some birds climbed on top of others, making thoughtful efforts to turn their mates into ladders and escape over the top of their pen.
Well, it’s true that they failed at these efforts. Perhaps their brains required just a few more synaptic connections to discern that they needed one more storey of goose floor to reach over the pen’s top edge.
Still, I admired some of their perseverance.
5. Geese don’t just represent factory-like replicas of their species.
The birds we banded actually displayed individual personalities.
When we herded them into the pens, a few squawked mightily. Some even stuck out their tongues and hissed. Others vaguely whined. Some complied with docility. Most remained quiescent, thinking their private goose thoughts.
6. Geese feel emotions.
As the kayakers approached the shore, the staffers instructed us to hide quietly behind the marsh grasses.
If the birds spotted or heard us, the staff warned us volunteers, the geese would become scared. That might stress them even more.
7. Age matters.
While the adults in our pens varied impressively in their behavior, the goslings collectively seemed far less variable. In fact, they all appeared vulnerable. They found themselves easily trapped under the weight of the larger, older geese. I’m sure I even noticed some of them sweating. The biologists in our group became nervous about the risk of the juveniles being crushed to death and instructed the wranglers to extract the babies first.
Thankfully, they were all rescued in time.
So what did I learn about humans from my day hanging out with these water fowl?
It’s true that Canada geese occupy a far lower point on the evolutionary scale than do humans.
Butthat’s precisely what struck me about the occupants of our temporary enclosures.
Even the (evolutionarily) lowly Canada geese are complicated, intentional, worthy of respect for individuals, and defy our essentializing stereotypes.
Shouldn’t the same apply in spades to our fellow humans?
To explain what “getting above themselves” might include, Knight enumerates an impressive list:
not providing enough to eat
threats of, or attempts at, violence
chasing another woman
not having sex often enough.
Why should we care about Mbendjele women’s complaints about their men’s bad behavior?
Given that all humans began (evolutionarily speaking) as gatherer-hunters in sub-Saharan Africa, anthropologists have long pointed out the special insights that contemporary hunter-gatherers of Central Africa hold for our species history. Expanding on writings by anthropologist Chris Boehm, Knight uses the example of laughing Mbendjele older women to develop a broad-ranging theory of how laughter may have evolved as a unique human pleasure.
Why not learn from your Mbendjele sisters and take up coordinated public laughter at out-of-control men as your next power move?
In fact, our newly-elected women Members of Congress have already gotten a brief but great head start.
I’m guessing that Mbendjele women would recognize their strategy.
Maybe the next group press conference held by our women MoCs critiquing unjust laws and unethical practices (patriarchal and otherwise) will be accompanied by a full-scale, Mbendjele-style laugh-in. Our species’ long evolutionary history might well support it.
You can learn more about Dan Smith’s work on his website here from Brown University, where he holds multiple positions—as the Charles C. Tillinghast, Jr. ’32 Professor of International Studies, the chair of the Department of Anthropology, and the director of the Africa Initiative for the Watson institute for International and Public Affairs. You can also find a list of many of Smith’s published journal articles and book chaptershere.
Recently, Smith published a fascinating study of masculinity among the Igbo people of southeastern Nigeria: To Be a Man Is Not a One-Day Job: Masculinity, Money, and Intimacy in Nigeria (University of Chicago Press, 2017). You can find the publisher’s web page for the book here.
Robert Morrell has praised the book:
“In this brilliant and highly readable exploration of masculinity, Smith bores down into the lives of his Nigerian friends and informants to find out what makes them tick. Through his interest in and involvement with a local tennis club for a period of over twenty-five years, he has developed a depth of understanding that even for anthropologists is unusual.”
And anthropologist James Ferguson has written:
“Brimming with insightful observations and telling details, this book makes an outstanding contribution to our understanding of a topic of enormous contemporary significance—in Africa and beyond.”
Dan and I recently had a chance to speak online about his new book. You can read our conversation below.
DJS: Daniel Jordan Smith
AG: Alma Gottlieb
AG: In the past, your work in West Africa has focused on a variety of medical issues, economic questions, and gender topics. If we consider mental health a component of medical anthropology, one might say that your new book combines some of the most important questions you’ve addressed across some 25 years of ethnographic inquiry. What made you decide to write a book drawing together (but also going well beyond) issues you’ve tackled from all these diverse writings?
DJS: In many respects, my decisions about what to study and write about in Nigeria are driven by what seems most salient in the lives of the people I live with and work with there—intersecting, of course, with what I find interesting and important as an anthropologist.
The focus of this book on masculinity in Nigeria–and, specifically, on the relationship between money and intimacy in men’s lives—is the product of having spent much of my time in Nigeria in the company of men. In the places where I work in southeastern Nigeria, social life is quite gender-segregated—not extremely so, but to the extent that, as a man, over the years, I have spent a disproportionate amount of time with men. This book is an attempt to draw all of that experience together and to try to understand men’s lives.
The author during a match with his Nigerian tennis partner, Osofia, in 1989
Beyond that, I wanted to use masculinity as a prism or a vehicle through which I could explore social life, and social change more broadly, in Nigeria. I never actually did a research project focused on masculinity, per se—though many of my projects focused on masculinity implicitly in one way or another. But at some point, I realized that I had a huge corpus of material about men and masculinity, and so I decided to write this book.
The author with his Nigerian tennis partner, Osofia, 15 years after their first match
AG: Feminist anthropologists have critiqued earlier generations of scholars for focusing exclusively on men’s lives, without acknowledging this gender bias as such. Your study, grounded in the new “masculinity studies,” strikes me as quite different from those early works that discussed men’s lives without really problematizing the gendered nature of their experiences. Can you talk about the premises of the new masculinity studies that underlie your approach?
DJS: As your question suggests, I think one of the key premises of new masculinity studies is that the generations of scholars focusing more or less exclusively on men’s lives almost never examined masculinity “as gender.” By that, I mean that, while men were the assumed objects of study when trying to understand economics, politics, social organization, and culture, masculinity itself was not really examined, problematized, and unpacked in and of itself. The idea that masculinity is socially constructed and performed–rather than simply given—is at the heart of new masculinity studies. So, too, is the idea that there are multiple masculinities, not just one.
Portrait of an elderly Igbo man in his village in southeastern Nigeria
Also central is the recognition that masculinities, like femininities, are relationally constructed—both broadly and specifically in relation to femininity.
Portrait of a vulcanizer (tire repairer) in southeastern Nigeria
My work has benefited from all the excellent recent scholarship on masculinities, including in Africa. But my goal in the book is broader than trying to understand masculinity in Nigeria. I try to show that by understanding masculinity and men’s lives, we can better understand wider aspects of social life and social change in contemporary Nigeria. The book’s focus on the complex geometry of money and intimacy in men’s lives is intended not only to understand Nigerian masculinities, but Nigerian society more generally.
Men enjoying a moment of relaxation at Umuahia Sports Club, southeastern Nigeria
AG: In the book, you make this connection quite explicit. For example, you document what you call the “changing landscape of intimacy” by providing so many life stories that exemplify how “money has become the essential means to prove one’s value as a man.” In insisting on the deep nexus between emotion and economy, are you trying to make a theoretical point about, say, the mutual braiding between the anthropology of emotion on the one hand, and economic anthropology on the other? And, if so, do you think southeastern Nigeria is an especially apt place in which to make such a claim?
DJS: In connecting money and intimacy (and economics and emotion more broadly), I am certainly building on what I think is an already well-established theoretical point in anthropology—and specifically in Africanist anthropology—about the inextricable intertwining of economics and emotion in social life. But I think my more central conceptual contribution focuses on the way that concerns about morality infuse the intersection of money and intimacy. For example, I argue that men are constantly engaged in projects of what I call “conspicuous redistribution,” whereby they are trying to put money into the service of sociality, even as they show it off. This occurs, I argue, in both large collective occasions, like weddings and funerals, but also in more everyday contexts in which a man shares his money in his intimate relationships—such as with kin, friends, or lovers. At stake for men in these performances of conspicuous redistribution is whether their money is socially productive and morally legitimate.
I think the stakes are particularly high in southeastern Nigeria because money often stands symbolically for social changes about which people are ambivalent at best, including the rise of individualism and the pursuit of wealth. Even more negatively, money symbolizes (and is seen as creating) the pervasiveness of greed and corruption. Men face a double bind. They need money to be good men, yet they often feel compelled to pursue it by socially and morally problematic means. In this context, how they spend it becomes all the more scrutinized.
Portrait of a shop owner in southeastern Nigeria
AG: Bringing up the problematic relationship linking money, morality, and men in southeastern Nigeria inevitably leads us to the present moment in the US, where gender relations are an especially fraught topic—with a president accused multiple times of sexual harassment and even sexual assault, and a powerful and growing “#MeToo” movement arising among women to resist intimate practices of patriarchy. (How) would you say your book speaks to this moment in the US? That is, what lessons might American men draw from your discussion of contemporary Nigerian men’s lives, challenges, and frustrations?
DJS: I wrote the book well before the revelations about Harvey Weinstein and the rise of the “#MeToo” movement, so I certainly never intended for it to speak to the US context directly. That said, I think there are always opportunities to reflect on social life in one’s own culture that come in the process of trying to understand another society. For me, one of the most powerful (and in many ways most appealing) aspects of masculine social life in Nigeria is the pervasiveness and importance of homosociality—that is, of men’s social relationships with other men. As I discuss at length in the book, I found this dimension of Nigerian masculinity very compelling. At the same time, it was clear that Nigerian men frequently reinforced and rewarded patriarchal privilege in male-dominated fraternal settings.
I think similar dynamics between fraternity and patriarchy are common in the US. But it seems to me that the masculine enjoyment of male fraternity need not depend on patriarchy to enable men’s social solidarity. I think American men would benefit from more male comraderie, but in both the US and Nigeria it would be preferable to de-couple fraternal solidarity from patriarchy. They are often intertwined, but I don’t think they have to be.
AG: What’s on the horizon for your next research and writing project?
DJS: In Nigeria, people have a saying that “every household is its own local government.” By this, they mean that because the state so woefully fails to provide basic infrastructure and services—water, electricity, security, transportation, etc.—every household must figure out how to address these needs and desires. My current research project (and next book) examines the informal economic and entrepreneurial means by which Nigerians cobble together basic infrastructure, and what all this reveals about the state, citizenship, and political culture.
AG: That sounds like such an important issue for so many places (not just Nigeria).
Finally, a more personal question. While remaining extraordinarily productive as an author, you’ve held many administrative positions, and you’ve even won a campus award for teaching. Do you have any time-management secrets you can share with colleagues who might assume that being excellent simultaneously in all arenas of the academy (research/writing/ administration/teaching) is beyond impossible?
DJS: It’s very generous of you to pose the question in this way. I am afraid I don’t have any magical time-management secrets, but I can share a couple of thoughts. Most important, I think, is loving what you do, which makes it easier to work hard and work effectively. It sounds cliché, but it makes such a difference to like what you are doing. At least, that’s my experience. So, whether it’s research and writing, teaching, or administration, I try to do work that I want to be doing. That’s obviously easier said than done, especially for junior faculty, but in academia, we have a remarkable amount of freedom to pick what to work on—in administration and teaching, as well as in research and scholarship.
More mundanely, I think the secret to time management in academia is being able to use both huge chunks of time (like summer and winter breaks) and short spans of time (like 45 minutes between a class and a committee meeting) efficiently. Our profession provides an unusually large number of both very long and very brief periods of time that can be managed well or squandered. I always tell my junior colleagues that if you have 45 minutes between things, you can use it to grade some papers, or update a lecture, or read an article (or whatever). Those little chunks add up to a huge amount of time over a year (not to mention, over a career). And they are relatively painless to utilize. Using the big chunks effectively takes more discipline, but if they are filled with work you like (at least mostly), then working is easier and more rewarding.