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.
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
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.