Category Archives: medical anthropology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BW = Bjorn Westgard

AG = Alma Gottlieb

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

·         Personalized, social distancing recommendations

·         Neighborhood-level COVID-19 risk map

·         Privacy assured – no account required, you remain anonymous

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

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

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

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

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

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

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

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

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

Birth as Ritual/Ritual as Birth

Cultural anthropologist, Robbie Davis-Floyd, is a leading anthropologist in the fields of childbirth, midwifery, and obstetrics.

 

A Senior Research Fellow in the Department of Anthropology at the University of Texas-Austin, she has studied childbirth practices firsthand in the U.S., Mexico, and elsewhere, and has promoted the work and legitimacy of midwives around the world.

Robbie Davis-Floyd (back row, right) honored by the North American Registry of Midwives (NARM) for helping create a nationally recognized certification process for professional midwives in the U.S., Mexico, and Canada

 

She has also lectured as a featured, keynote speaker at over 1,000 universities and health practitioners’ conferences in the US and internationally, always taking the opportunity to learn more about the maternity care systems of the countries she has visited.

Robbie Davis-Floyd speaking at the 2014 Symposium of the California Endowment

 

Davis-Floyd serves as a Board member of the International MotherBaby Childbirth Organization (IMBCO) and its new International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby Family Maternity Care. She is also Senior Advisor to the Council on Anthropology and Reproduction, and Associate Editor of Medical Anthropology Quarterly.

Considering the cumulative impact of her energetic and creative efforts on many fronts to promote healthy childbirth without unnecessary, high-tech interventions, it is probably no exaggeration to say that Robbie Davis-Floyd has long served as the “public face of anthropology” to the international childbirth movement. Her work has been instrumental in bringing anthropological insights into the global childbirth arena and in effecting humanistic changes in childbirth practices in many countries.  Indeed, given the impact of her work, she is considered a “living legend” among birth activists both within and beyond anthropology.

Despite the enormous impact of her research, writing, and speaking on childbirth practices in the U.S. and elsewhere, birth is by no means the only topic that Davis-Floyd has studied. She’s recently given birth to a delightfully readable, new book, The Power of Ritual, co-authored with neuroanthropologist, Charles Laughlin.

Cultural anthropologist, Claire Farrer, has called the new volume “an exquisite and informative book,” writing:

I wish that this book had been available during my long teaching career–I would have used it in all my relevant courses!

Beyond professors and students, because of its breezy writing style, combined with its captivating examples from common experiences in Westerners’ lives, the book will surely appeal to many “ordinary” readers. Birth educator, Debra Pascali-Bonaro, has written:

Before I read The Power of Ritual, I thought I knew what ritual was, yet now I know that it is so much more–it can be everything from a simple conversation-opener to a powerful healing process, from an individual’s daily habits to full-scale ceremony. I have learned much from this book that I can apply to my own life to enable me to more consciously perform my daily, family, and professional rituals.

Robbie and I recently chatted about the book online. You can read our conversation below.

Meanwhile, you can learn more about Robbie Davis-Floyd’s work on her website here, including her C.V.  You can also find a view of Davis-Floyd’s many published books here, and downloadable PDFs of most of her dozens of published journal articles and book chapters here.

 

RDF: Robbie Davis-Floyd

AG: Alma Gottlieb

*

AG: You’re well known for helping develop and promote the anthropologies of childbirth, midwifery, obstetrics, and reproduction. Your fans may be surprised at the focus of this book on ritual. Yet, your first book (developing from your dissertation), Birth as an American Rite of Passage, used ritual as an analytic frame.

 

In that sense, would you say that The Power of Ritual reprises the conversation about ritual that you began nearly 30 years ago?  Or, takes it in new directions?  Or both?

Put differently (and more broadly), why would an anthropologist of childbirth write a book about ritual?

 

RDF: I’ve come full circle, as I did not start out as a birth anthropologist! My original graduate training was in both Folklore and Anthropology, and my interest in ritual was sparked by one of my Folklore professors, Roger Abrahams, whose writings on ritual I found enticing.

I did my Master’s thesis on the folklore of a Texas madam, Edna Milton, who for many years ran the notorious Chicken Ranch in La Grange, Texas—featured, after its closing, in the movie, The Best Little Whorehouse in Texas. The article I wrote about how Edna’s masterful use of jokes and other forms of language manipulation kept her in total control of the Chicken Ranch, its customers, and its employees was published in the Journal of American Folkore and was widely used for teaching for many years, as it clearly shows how jokes and folktales can be used for manipulation, plus it is hysterically funny!

In the middle of my PhD studies, I took some time off to spend a year traveling around Mexico and learning Spanish. I returned to Mexico often and worked with two shamans—Don Lucio, a traditional shaman and “weather-worker” (trabajador del tiempo) from a small village in central Mexico, and Edgardo Vasquez Gomez, a wealthy businessman living in Cuernavaca who had traveled the country in his younger years studying sorcery (brujeria), magic, and traditional healing, and later combined that with the teachings and philosophy of the Russian philosopher, G. I Gurdjieff. Both had large followings, and both could actually manipulate energy and perform what I experienced as magic. If you combined them into one person, you would get someone very like Carlos Castaneda’s Don Juan.

I know that Castaneda’s work has been discredited, but the two shamans I worked with were real—as were the effects of the (very different types of) rituals they performed. We used to joke that Edgardo was Don Juan. In my doctoral program, I later wrote several long papers on myth, ritual, and shamanism in Mexico and expected to do my dissertation research with those two. (That was before computers, and those papers, sadly, were lost in a house fire.)

But then I had a baby, got “bitten by the birth bug,” and decided, instead, to research women’s childbirth narratives, as I was still in folklore mode. Yet the more women I interviewed, the more one question grabbed me:

Given the highly individual nature of each woman’s birth experience for that woman, why is birth treated in such a standardized way in American hospitals?

I began to research the scientific literature on birth. I soon realized that the vast majority of “standard obstetric procedures” did nothing to make birth safer. Instead, they made it more predictable and controllable—while unnecessarily harming women and babies in the process.

Davis-Floyd has chronicled how fetal heart rate monitors keep women attached to a bed and claim attention on a machine’s readouts, rather than on a laboring woman’s subjective experience

 

At first, I was confused. Like most people, I had assumed that obstetrics was based on science. When I realized it wasn’t, I had to ask the most basic anthropological question: Why? Why would doctors do things to women that didn’t make birth safer? The explanation hit me like a bombshell.

’”Standard obstetric procedures” do not come from the logic of science but, rather, from the logic of ritual. Like most rituals, they reflect the core values of their culture—in this case, the culture of technocratic societies.

They are designed, as so many rituals are, to try to control the uncontrollable forces of nature, to keep fear at bay–in this case, fear of both death and lawsuits. So, I switched from simply analyzing women’s birth narratives to a focus on analyzing obstetric procedures as rituals.

To fully explore this notion, I needed to understand ritual more, and its primary characteristic– the use of powerful symbols to convey meaning. I took a summer seminar at the University of Virginia with Christopher Crocker on what was then called “symbolic anthropology” (now “interpretive anthropology”). I also taught myself medical anthropology, which I had never formally studied.  But I had to become an expert in it, as pregnancy and childbirth had long ago become defined as medical events.

After reading almost everything that Victor Turner, Clifford GeertzArnold van Gennep, and many others had written about ritual, I saw that birth, which used to be a physical and social rite of passage replete with social rituals, had become a completely medicalized rite of passage.  The rituals that characterize birth everywhere had become medical rituals, officially disguised as “standard procedures.”

Dissatisfied with the many definitions of ritual I read, I created my own:

a ritual is a patterned, repetitive, symbolic (and often transformative) enactment of a cultural (or individual) belief or value.

Obstetric rituals enact the core values of what I called “the technocracy”—a term that came to me from Peter Reynolds, via his book, Stealing Fire: The Atomic Bomb as Symbolic Body, but that I redefined:

a technocracy is a hierarchical, bureaucratic, capitalist, and (still) patriarchal society organized around the supervaluation [a word I coined] of the progressive development of high technologies and the global flow of information via those technologies.

I generated a list of what we might perceive as characteristics of rituals: symbolism, rhythmic repetition, order, formality, framing, performance, acting, stylization, staging, and often, intensification toward a climax. In my dissertation (which became my first book, Birth as an American Rite of Passage), in a chapter called “Birth Messages,” I dissected each standard obstetric procedure—its official rationale, the scientific evidence against it, women’s highly varied responses to it—and explained how it acted as a ritual by enacting, displaying, and transmitting specific core technocratic values and beliefs to women, their partners, and their practitioners.

In Birth as an American Rite of Passage, Davis-Floyd analyzes the wheelchair as a powerful symbolic statement conveying the clear message that the woman in labor is “disabled”

 

At first, some ritual scholars like Ron Grimes argued that I was metaphorizing obstetric procedures as rituals, but that they were not really rituals—they were like rituals—because most scholars saw ritual as religion-based. But since the publication of my book in 1992, and its second edition in 2003, my analysis of hospital birthing practices as rituals has held, and its framework for understanding the characteristics of “secular ritual“ (using childbirth as an example) has been widely used.

AG: What a fascinating intellectual history! So, for this book on ritual, how did you decide to collaborate with a co-author who specializes in neurological approaches to human experience?

RDF: From analyzing birth narratives, I saw that women’s perceptions of themselves and their ability to give birth were profoundly affected by technological hospital rituals (such as IVs, electronic fetal monitoring, Pitocin induction or augmentation, episiotomies, immediate cord clamping, etc.). So I knew there was a missing piece in my growing understanding of ritual. It seemed clear that ritual can affect the human brain–but how?

Davis-Floyd’s research has helped document the much higher likelihood of a C-section once a woman’s labor is “induced,” or accelerated, with Pitocin

 

I searched the literature but found no answers until, one day, while browsing the book stalls at the annual American Anthropological Association conference, I saw a book way at the back of the Oxford exhibit booth. That particular book was literally glowing at me—in much the same way that I could often see the reins of energy that Edgardo held in his hands glowing during group meetings. I pulled the book out, and my life changed! It was called The Spectrum of Ritual, and it gave me the answers I was looking for. Here, finally, was the missing piece—the neurophysiology of ritual, the explanations for how ritual works on the brain and, thus, where it gets its power over us humans—starting with its multiple roles among animals.

A few years later, I met one of its authors, Charles Laughlin, at a conference. We both had read everything the other had written, so our meeting was intense and our ensuing friendship equally so. We eventually decided to co-author a book on The Power of Ritual–because I wanted to expand my study of ritual into other arenas besides birth, while Charlie wanted to put his highly esoteric work on ritual (characterized by what he termed ”neurognosis”) in more straightforward language, so he could make it accessible to people with IQs lower than 180.  I kept telling him, “Just dumb it down and tell stories”!

AG: Did you run up against differences in approach?

RDF: Not really. Charlie accepted my definition of ritual as the one we would use.  We also used most of my list of the characteristics of ritual. At some point, though, we realized that some factors on my original list, such as the fact that rituals generally work to preserve the status quo yet, paradoxically, can also be used to generate rapid social or religious change, were actually effects of ritual, not characteristics.

In this book, I finally was able to write about my long-ago work with the two Mexican shamans.  Unfortunately, it was all from memory, since, as I previously mentioned, the graduate school papers I had written about those experiences had all burned up in a house fire.

 

AG: This book begins with a theoretical discussion of how to define and analyze ritual, but it ends with a surprisingly down-to-earth section offering models for how contemporary readers might create their own rituals for important moments in their lives, whether for menarche, meditation, lucid dreaming, prayer, birth (as Melissa Cheyney has shown, homebirthers in particular create lots of rituals for honoring, de-medicalizing, and helping them through the labor process–see her article, “Reinscribing the Birthing Body: Homebirth as Ritual Performance”), death, or other significant events or experiences.

When we think about “engaged anthropology,” we usually have more economic or political transformations in mind.  Would you consider the “how-to” section of the book another variety of “engaged anthropology”?

RDF: Yes! And also of “applied anthropology.” Anthropological understandings gained from studying people and their lifeworlds should be expressed in ways that enable people to apply them to their own lives and use them for their own purposes. We need to come down out of our ivory towers and make our work relevant and useful in immediate ways. That is why Charlie and I put so many personal examples of ritual into our book—to engage readers with those experiences and help them directly apply them, should they wish to do so.

 

AG:  So, what’s next?

RDF: Our refinement of both of our life’s works in this book is now feeding back into the third edition of Birth as an American Rite of Passage, which I am working on now, and which will be a complete revision and update (this time with a co-author, the amazing Missy Cheyney). Another full circle!

But I‘ve never confined myself completely to birth and related subjects. In addition to ritual and symbol, I’ve also intensively studied cults (as described in The Power of Ritual), medical doctors who became holistic healers (as described in From Doctor to Healer: The Transformative Journey), futures planning via global scenarios, and aerospace engineers. But those are stories for another time. That’s one of the great values of anthropology. Once you have the tools, you can study any phenomenon that captures your interest!

AG: Any other future projects in the works?

RDF: Betty-Anne Daviss and I are in the process of finishing Childbirth Models on the Human Rights Frontier: Speaking Truth to Power—a sort of follow-up to our book, Birth Models That Work (2009), which has been called “seminal” (though we would have preferred “ovarial”) because it was the first book to describe truly functional birth practice models that are woman-centered and evidence-based—as opposed to the dysfunctional, non-evidence-based maternity care models that predominate almost everywhere.

 

This new follow-up volume describes models that are way more “out on the edge”—in high-poverty, disaster, and war zones, for example. It also discusses birth models that are more iconoclastic, while addressing professional bullying and competition among doctors, and the de-skilling of obstetricians in techniques for vaginal breech birth.

Our next project will be an edited volume called The Global Witch Hunt: The Ongoing Persecution of Woman-Centered Birth Practitioners. Its purpose is to call attention to the often-intense persecution of some of the most skilled midwives and obstetricians in the world, who will often go out on a limb to honor the wishes for a normal birth of women considered high-risk, by attending them at home or in hospital, but then get punished for putting the woman, not the protocols, first. The “witch-hunted” practitioners will tell their own stories in each chapter, while we co-editors (Betty Anne-Daviss, Hermine Hayes Klein, and myself) will contextualize those stories in the Introduction and Conclusion.

In another vein, for years I have been writing short stories, which I hope to publish some day in a book called Robbie’s Reader: Vignettes of My Magical Life—for my life has indeed felt magical, primarily because my anthropological research and international talks have taken me all over the world, filled my life with adventure, and given me great stories to tell!



Everything You Thought You Knew about Orphans in Africa Is Probably Wrong

Policy makers, development workers, orphanage voluntourists, missionaries, prospective adoptive parents: ignore this book at your peril.

Crying for Our Elders-Front Cover

 

“AIDS orphans” are commonly imagined as the most vulnerable of the world’s most vulnerable populations.  In a provocative new study, anthropologist Kristen Cheney  challenges just about everything we thought we knew about the children of Africa who have been labeled “orphans.”  Along the way, she decries what she terms the new “orphan industrial complex.”

Crying for Our Elders: African Orphanhood in the Age of HIV and AIDS was recently published by the University of Chicago Press (2017).

In a pre-publication assessment, distinguished anthropologist Didier Fassin has written:

“Through her cautious, insightful, and moving ethnography based on fieldwork in Uganda, Cheney provides a deep understanding of the complex and unexpected forms of life that emerge around orphans. An important contribution to the growing field of critical children’s studies, Crying for our Elders is also a remarkable expression of ethically engaged anthropology.”

And in an early review, Rachael Bonawitz has written:

This abundantly researched work is essential to the study of international development and of orphanhood, as well as an enriching contribution to the field of children’s studies.

You can find a Table of Contents here.

Read excerpts online here.

The publisher offers complementary desk/exam copies to instructors here.

From the website of the Institute of Social Sciences/Erasmus University-Rotterdam (where she is Associate Professor of Children & Youth Studies), you can find Kristen Cheney’s institutional home page here.

At the recent conference of the American Anthropological Association (held in Washington, DC in December 2017), Kristen Cheney and I recorded a conversation about her new book.  Here’s what Kristen had to say (AG = Alma Gottlieb; KC = Kristen Cheney):

Kristen Cheney, Headshot

Kristen Cheney

AG: What gave you the idea to write this book?
KC: I had done fieldwork with children for my dissertation, which became my first book (Pillars of the Nation: Child Citizens and Ugandan National Development, University of Chicago Press, 2007).  In the process, I came across a lot of kids who were orphaned.  I was working at schools, so I’d often come to a primary school and have kids approach me—at least once a week—and give me letters, because they were too shy to talk to me directly about their situation.  A lot of the letters described their circumstances and asked for assistance—primarily, educational sponsorship.

In one instance, a girl came up to me one Monday and said that she lived with her aunt and uncle, and over the weekend, her uncle—who was her blood relative—had died.  Her aunt-by-marriage said, “You can continue to live here, but with him gone, I don’t know how long I can keep you in school, because I have to prioritize my own children.”  So by Monday, the girl was already coming to school and saying, “I’ll find the mzungu”—white person or foreigner—“and ask them if they can help me.”  That kind of thing happened fairly frequently.

So I decided the next book would look into how children experienced and understood orphanhood—as well as the broader purview of humanitarian responses to orphanhood, and how they either help or hurt those situations.

 

AG: That raises methodological issues.  In the book, you talk about adapting participant action-style research methods with children.  That’s a kind of research that’s become very popular in other disciplines, though we don’t call it by that name in anthropology.  Can you talk about the difference that this research method makes to working with children in this kind of project?

KC:  For what I term “youth participatory research,” the benefits were several.  I wanted continuity with some of the kids I’d worked with before.  My youth research assistants for this project were the young people who I’d worked with and had done life histories on for the first book.  So there was some continuity, because part of the purview of the book was mapping generational experiences of the HIV/AIDS pandemic onto different developments in the fight against AIDS.  These kids were born around the time of the “prevention of mother-to-child transmission” initiative, which meant that a lot of the kids who might have died from having gotten infected by HIV survived.

But their parents still often died when the kids were quite young.  So they were one sub-generation, in their teens by that time.  I wanted them to work with some of the younger kids who were 5-10 years old—kids of the post-ARV generation, for whom anti-retroviral (ARV) drugs had become much more available.

 

The post-ARV generation

 

Some of the teens had experienced these kinds of issues surrounding orphanhood themselves.  Some of them weren’t full or double orphans—some had lost one parent, some had lost both, some hadn’t lost either parent but had still struggled a lot.  So they were in a better position to work with the younger kids, by being closer in age, and having grown up in the same kind of society, facing the same kinds of issues.

Youth Research Assistant Works w His Group

 

A youth research assistant (right) works with his focus group, 2007

(photo by Kristen Cheney)

 

There was also a pragmatic element.  Being based in the US at the time, I’d be in East Africa for a while, or for a summer, and then I’d have to leave.  With this method, the youth research assistants could be visiting these kids with whom we’d matched them–visiting them in their homes or schools once a month, and talking about how it was going–and we’d get a broader sense of their lives, without me having to visit 40 different homes.  We could cover more ground that way.

I don’t want to claim a representative sample, but we could get a broader picture of what kids were going through.  That worked fairly well.

The down side is that this method takes you out of the field.  You have to yield your expertise and your authority, and make space for that to happen.

You have to yield your expertise and your authority.

I became a bit of an administrator rather than a direct researcher.  But when we had workshops together and compared notes and we asked, “What do we make of that?” it was much more participatory, and formulative of some of the broader arguments.  We’d decide as a group, Where do we probe further, and where do we go deeper into certain kinds of issues?

The research itself becomes transformative.  If you’re really interested in these issues, and you want to study it to help change something, and fulfill a sense of social justice, you start to see change within the community.  The younger children saw the youth research assistants as older brothers and sisters.  They became very close.  The young children would tell the youth researchers things that they would not tell anyone in their own family, and voice some things they didn’t feel they could voice, especially about loss—saying, “No one’s telling me what’s going on.  They think they’re protecting me, but I want to know.”

We really had to think about how we handled that relationship very carefully—think together, How do we counsel these kids?  Because the youth research assistants became mentors to those kids.  It was also transformative of relationships in the community.

I’ve done a lot of other youth participatory research projects since, and we’ve seen the same things happening.  Right now, I’m doing a project to study adolescents’ understandings of healthy relationships, for the Oak Foundation.  The work is supposed to help in the Foundation’s advocacy in preventing child abuse.  We’re doing that project in Tanzania and Bulgaria.

Youth Peer Researchers-Oak Fdtn ProjectYouth peer researchers in the Oak Foundation project on Adolescent Perceptions of Healthy Relationships, 2017 (photo by Kristen Cheney)

Now we have youth peer researchers who are as young as 10 years old!  I had a conference call—what they call a “learning call”—with some of the Foundation team, and I was describing the progress of the project.  They were already on board with the participatory method, so there was no having to convince them of its value, which was nice—because sometimes, you have to do a lot of convincing.  They said, “We’re really anxious to hear how your results will help our advocacy.”

And I said, “We can talk about that—but I want to be clear that our approach is that research IS advocacy.  We’re already seeing transformation in these kids, and the way that they talk about how, under the aegis of the research, they’re able to talk to adults across generational divides about things that they otherwise aren’t able to talk with them about.  Those adults come to see them differently, because they become informed about certain ideas and start to possess certain knowledge such that people start to see them differently. It raises their status.

So we’ve already seen a lot of transformation happen—between the kids we’re working with and their peers, and also other interlocutors in the community.

So I said, “It’s not research then advocacy; research is, in itself, a kind of advocacy.”

And they said, “Oh, okay.”  They hadn’t thought of that.

We have youth peer researchers who are as young as 10 years old!

 

AG: That raises another question.  Can you talk about how you compensate the youth researchers—whether financially or in other ways?  Because that’s a mode of doing research that may be unfamiliar to some anthropologists.

KC: Even working at ISS, a development studies institute, we work a lot on “capacity building” with non-academic development partners, and we’ve also talked with them about this.

We agreed that it doesn’t work well to do cash compensation with young kids.  It creates a perverse incentive, in a way, and doesn’t lead to quality research.  But there are other, non-cash incentives.

In the case of Crying for Our Elders, I helped the youth research assistants with school fees.  But it wasn’t conditional.  I said, “It would be great if you would help with this research,” but it wasn’t either a carrot or a stick.  They were happy to help with it.  I met with them before I published the book, a few years later, and had them reflect on the experience.  It was interesting for them to talk about that.  That issue of compensation came up, the ways that they gained skills—whether they were directly applicable in their professions as they got through school and went on, or just interpersonal skills. It was really rewarding to see.  That’s the sort of incentive I wanted to create—I told them, “You’ll build your skills, and they’ll be marketable skills.”

When my colleagues and I were doing a project for Save the Children that also used youth participatory research methods a few years ago, we trained almost 100 peer researchers in Uganda and Ethiopia.  None of them dropped out, unless their family moved.  But none of them said, “I’m bored” or “I’m not earning anything” or “It’s not helping me.”  They all stayed with the project for three years.  The idea that kids will be flighty and just leave is not necessarily true.

We trained almost 100 peer researchers in Uganda and Ethiopia.  None of them dropped out.

In our last workshop, we asked them to reflect on how they experienced the study.  We had them draw pictures of their journeys within the research project.  Some drew mountains, and some drew rivers with bends in them; there was always some sort of apex or obstacle to overcome.

One young man drew a bus and said, ”I feel like the bus is coming out of the woods and into the city.”  Basically, he was talking about the process of participating in the research project as enlightening.  Then he said, “The forest is illiteracy and the city is literacy.”

Youth Peer Researcher-Save the Children Project

 

A youth peer researcher for a Save the Children project sharing his research journey, 2016

(photo by Kristen Cheney)

 

He also spoke really movingly about how the research group had become like a family to him by the end of the project.

 

AG: You had meetings for everyone?
KC: Yeah, we had workshops where we got together a lot.  But they would also go out and do data collection in pairs, or they’d do interviews or focus groups together.  And they had a lot of support at different levels.  All of them said, “We feel like it’s a family now.”  And they said, “We’ve learned how to talk to adults about things that had been taboo, or difficult to talk about—and even how to talk to adults, more generally.”  For me, that was rewarding in itself.

Youth Peer Researchers in Ethiopia, Save the Children Project

 

Youth peer researchers (left and right) for a Save the Children project in Ethiopia engage with their supervisor (center), 2016 (photo by Kristen Cheney)

 

For that project, we’d also brought a lot of swag and bling from my institution (the Institute of Social Studies in The Hague)—backpacks, pens, trinkets that said ISS on them, and so on.  Every time I came to a workshop, I’d always have a bag or hats or whatever.  But the one thing that was really special to the kids was getting a certificate.  Early on, they’d even asked, “Will we get a certificate for participating in the project?”  Because certificates really mean a lot to them as they’re building a professional portfolio.  Even if they were still figuring out what they wanted to do when they grew up, they knew they’d always have that certificate that said, “I participated in this project, and I did research.”  They were more eager about that than they were about the other stuff we’d bring them.  They thanked us for the backpacks, but when you gave them that certificate, they were so, so thrilled by it!  It became a career-building sort of thing.  That was the thing that was really important to them.

 

Youth Peer Researchers w Backpacks, Certificates

Youth peer researchers with their backpacks and certificates (Uganda, 2015)

(photo by Kristen Cheney)

 

I’ve also given certificates to some of the youth researchers who helped with Crying with Our Elders.  When I met them years later, they said they’d saved their certificates.  One of them even reached into his bag and pulled out his certificate that I’d give him almost ten years before.  He’d had it laminated.  Another one said, “Mine got wet and got destroyed, and I was going to ask you for another one.”

It’s not about, necessarily, financial incentives.

 

AG: In effect, the certificates, and what they represented, became a sort of intellectual capital.

KC: Yeah, it’s helping them see the long view of how the research project might help them with making connections with people, because we were working with local development organizations—ones that did the research and training.  So it’s connecting them.  They saw the value in the social connections and the skills building, and that was enough in a lot of cases.

 

AG: In choosing youth researchers, were you looking for students who seemed to have particular intellectual capacities?  Or was it the opposite—those who seemed to need the most help?  Or, something else?

Youth Peer Researcher, Jill

 

Youth research assistant, Jill, reporting at a project workshop, 2008

KC: In Crying for Our Elders, I returned to work with kids I’d worked with earlier, when they were younger.  Some of them were quite strong as students, but some of them weren’t.  That could become a bit of a challenge in this project.  For the workshop, some of them were keeping very detailed notes and journals.  But one of them just didn’t like to write, and just wouldn’t do it—he refused to write.  I would say, “If you go into the field and don’t write anything down, it’s like you didn’t do it.”  That didn’t compel him to write anything down.  But he was a talented musician who really liked to work with audio equipment.  So I said, “You have your voice recorder.  You’re turning it on to talk to the kids.  Just keep it on and take notes—do verbal notes.”  And he said, “Oh, okay, I can do that.  I can just speak into the thing.”
AG: I do that often myself, when I’m driving away from an interview.

KC: Right. So you work with where they’re at.  Others were very good about keeping notes.   But that’s obviously not the only way to do it, and we sometimes tape fieldnotes ourselves.

I had another youth researcher who was really enamored of the video camera.  I just said, “Take the video camera and run with it.”  And he’d do that.  He’d get all this nice footage of the kids and use it as documentary evidence.

In this more recent project, one of the examples I gave to the Oak Foundation of the advocacy issue is, when we had our first workshop after the kids were recruited in Tanzania, we had one kid who was no longer in school.  She was a 14-year-old girl and seemed very shy, almost mortified by everything that was happening.

Sometimes we’d say, “Everyone think of three things and write them down and we’ll go around and share them.”  And we’d come to her and sometimes she’d be physically hiding her face, as if she didn’t want to be called on.  At first, we started wondering if she really wanted to be there.  By the end of the day, it started to dawn on us that we were asking them to do a lot of reading and writing, and she couldn’t read or write.  She’d gone to two years of school and dropped out.

My local project leader said, “I don’t know how she’s going to do the survey if she doesn’t know how to read or write.”

But I said, “No, let’s not push her out.  There’s a reason she’s here.”

We discussed this with her, and she said, “Don’t make me leave.  I’ll come tomorrow with a friend who can help me.”

I said, “She can reach people we can’t reach.  So let’s not exclude her because she doesn’t have these skills.  We can find other ways around this.”

And she was saying, “I can find other ways around this.  I’m willing to improve in order to be involved.”

So I said to the local project leader, “Let her stay.  She could be the most transformed by this project.”

The next day, she came with a friend and was much happier to participate.  I think partly she had just been worried that the other school-going kids would tease her.  When they didn’t do that, she settled down and stopped excluding herself and started to join in.

We have these “circles of support,” and we said to the supervisor in the closest circle, “Can you help her find an adult education class nearby?”

Three months later, when I checked in, the local leaders said, “She’s already vastly improved in her reading and writing, because she wants to participate in the project.”

So we’re already seeing that transformation happening.

 

AG: That’s awesome.  You’ve talked about advocacy and social justice.  You’ve mentioned that research itself can be a form of advocacy.  Beyond that, can you talk about what would be your best-case scenario if policy wonks interested in the HIV and/or orphan crises in Africa were to read your book?  What would you want them to do differently?

KC: What we’re seeing now is people acknowledging that the traditional family system in Africa has largely weathered the storm of HIV/AIDS orphanhood and taken those kids in.  But what we’re also seeing is people picking up and running with this very broad definition that UNICEF has of orphans—that an “orphan” is any child who’s lost at least one parent.  That’s become a justification for a lot of private donations, particularly, to orphanages (along with some public investment in them).  We’re suddenly seeing a mushrooming of orphanages in Uganda and other places.  This is what I’ve been talking about in lectures I’ve been doing recently—what I call an “orphan industrial complex” that’s come out of this desire to help orphans, and thinking that orphanages are the best way to do that—but they’re not.  It also comes out of the growing popularity of what’s now called “voluntourism,” and working with children has particular purchase with people.  They see orphans as the most vulnerable children, so people say they really want to work with orphans.

 

Proliferation of Orphanages in Uganda

Proliferation of orphanages in Uganda since the height of the AIDS pandemic (bit.ly/orphanindustrialcomplex)

I’m really challenging that sort of “child rescue” discourse that’s actually jeopardizing children and breaking up families and causing unnecessary institutionalization, because they’re building orphanages and pulling kids into them.

In short, I would like to see an end to orphanages in my lifetime, and I think that’s quite possible to do.  Instead, we’re seeing a real increase in orphanages, because people who think they’re helping are setting up new orphanages without realizing this broader picture.

“I would like to see an end to orphanages in my lifetime.”

First of all, from 60 years of child development research—which a lot of the donors to orphanages haven’t read— we know that orphanages are not good places for children to grow up in.  A lot of this comes from faith-based communities.  They’re talking about the Biblical command to “visit orphans and widows in their distress.”  Somehow, the widow falls out of the picture very quickly, because there’s a much more emotional purchase in the orphan.  A lot of these people don’t have backgrounds such that they would investigate this history or this research in the child development literature.  “Child rights” isn’t in their vocabulary.  “Child protection” isn’t in their vocabulary.  So it can be very difficult to break through this idea of, “I’ve always wanted to go to Africa and start an orphanage.”

 

AG: Or maybe they perceive the “child rights” and “child protection” discourses in very different ways that make it look as if they’re actually doing everything they can and should do to help?

KC: Right.  But it comes from a very different register—either this spiritual idea, or from “voluntourism” and service learning, on which there’s been a lot of good critical literature coming out stating that that sort of transformation is much harder than something you can accomplish while backpacking.  The supporters of orphanages don’t often think through some of the issues I’m trying to raise.  This is not about the supply of orphans, this is about the demand for experiences with orphans.  We’re actually causing orphanhood, de facto.

“We’re actually causing orphanhood.”

Locally, what’s happening is—if you build an orphanage in a poor community, kids will come.  But they’re not coming because they’re orphans—they’re coming because they don’t have access to schooling, and recruiters are going into the community to entice families to institutionalize their children in order to access education.  That’s the #1 reason we’re seeing why families are being induced to put their kids in orphanages.  To the local community, it’s often presented as free schooling!

 

AG: So, to the policy wonks, maybe your big take-away point would be, “Don’t build orphanages; build schools”?

KC: Yes, in some ways.  The main goal should be: improve educational access.  Don’t support orphanages.  Don’t build them.  Don’t visit them.

I’ve actually been working with a group called Hope and Homes for Children that’s doing de-institutionalization of orphans in a number of places. They’re helping the Rwandan government to close all their orphanages by 2020, and they’re ahead of schedule to do that.  It doesn’t take a wealthy country to do this; it just requires political will.

By the way, we generally don’t have orphanages any more in North America and Europe.  There’s a reason for that: we know family-based care is better.  Why is it that we’ve decided orphanages are not appropriate in our home countries, yet we’re saying, “Let’s build them in Africa because there’s a lot of orphans there who need it”?  First of all, that’s not true.  A lot of people are even saying, “Let’s get rid of this word, ‘orphan,’ altogether.”  It’s stigmatizing.  Kids don’t want to be called that.  And it’s often a misnomer.  It’s not that a child without one parent has no family and needs to be in an orphanage.  All the kids I worked with for this book—some 40 kids—lived with extended family in their community.  So I didn’t really have any association with any child care institution until the end, when I heard there’s also these baby homes, so I thought maybe I should go visit them.  That’s what got me down this rabbit hole: the cultural politics and political economy of orphanages on a broader, global scale.

“All the kids I worked with for this book—some 40 kids—lived with extended family in their community.”

 

AG: Really, the concept of “orphans” is Eurocentric insofar as it privileges two opposite-sex, biological parents.  And, in effect, it implicitly claims that once you lose both of those, you’ve lost everything.  In so-called “extended family” communities—which we see all over Africa—the concept of “orphanhood” in a sense is superfluous.

KC: Right.  It doesn’t exist—not in that form.

 

AG: Because you’ve always got other people.  In the local language, many of those other people are called “little mother” or “little father,” or “big mother” or “big father.”

KC: Right.  Or they just don’t have a word that means “orphan.”  They say, “Well, we might say enfunzi”—and they would whisper the word.  Because they don’t want a kid to hear that.

 

AG: They know it’s stigmatizing.

KC: Yeah, they know the children would feel bad to be called that.  Because it doesn’t mean the same thing that “orphan” does; it means you’ve not only lost your mother and father, but you’ve lost your “little mothers” and “little fathers”—your aunties and uncles, and your grandparents—and have basically been cast out and abandoned and have nobody.  So it’s not the same concept.

At the same time, one of the things I noted is that, when you have humanitarian assistance coming, specifically, for orphans—essentially, targeting them—these same people who acknowledge, “I wouldn’t call a child an ‘orphan’ to his face, it would be insulting, and they’d feel very bad”—these same people will say, in English, “Here are my orphans.”  And they’ll push forward “their orphans” and say the word in English and continue, ”I hear you have resources that might help me educate and feed these kids.”

Elderly Guardian w Children in Her Care An elderly guardian (right) with some of the children in her care, 2017

(photo by Kristen Cheney)

 

The unintended implication of targeting orphans in the humanitarian response is one of the things I discuss in the book.  At first, they were targeting orphans, but then they would find quickly that the status of orphans would rise higher in an extended family when orphans were targeted by humanitarian agencies.  But there’s also resentment in the family, because some kids might be going to school because sponsorship was available for “orphans” in the house.  The biological children in the same household would say, “Mommy, Daddy, why can’t I go to school?”  The parents would respond, “Because you’re not an orphan.”

It got to the point where someone from UNICEF told me, “We’d have an event where we’d distribute books and pens to orphans, and we’d hear other children saying, ‘I wish my parents were dead so I could get schoolbooks.’”  The UNICEF staff thought, “What are we doing when we have kids saying, ‘If my parents were dead, I’d get to go to school’?”

Schoolchildren in Uganda

 

Schoolchildren in Uganda, 2013 (photo by Kristen Cheney)

 

AG: It pays to be an orphan.

KC: Literally.  Or in other instances, a child soldier.  These sorts of targeting and labeling actually make people take on a role and can actually inscribe trauma where it didn’t exist.  If you’re not traumatized, but you understand the Western assumption, “You must be traumatized by being an orphan, or a child soldier,” or what have you, you figure out that if that’s the way to entitlement, then you really need to adopt that role.

And it can end up that if you really adopt that role, you can actually internalize that trauma and become vulnerable.

 

AG: There are so many unintended consequences of labeling.  And this label that you’re applying so provocatively, the “orphan industrial complex”—I guess, borrowing it from Eisenhower’s “military-industrial complex,” and then the second-generation term of the “prison-industrial complex”—that’s a really powerful concept.  I don’t think it’s yet been over-used, despite being adopted by folks critical of the prison system.  Do you find that your version of the phrase arouses interest, or just offense?

KC:  I’ve gotten good feedback.  I’m talking to those who are potentially participating in “orphan tourism”—college students, even high school students, from the global North.  So far, I’ve had pretty good reception to the term.  It is provocative.  But I do get people listening.  The way I lay it out, they start to see the bigger picture of how it works.  At first, they may come into it skeptically, saying, “What’s wrong with wanting to help?”  It’s difficult to be the killjoy who says, “This is what’s wrong with helping in certain ways,” if those ways really are destructive.  But I do say, “Here are things you can do that would be really helpful.  For example, helping keep children in families, and lobbying governments not to send them to orphanages.”

As I was saying about Rwanda, and Hope and Homes for Children, we went to DFID—the Department for International Development in London, which is like their USAID.  They handle all the development funds for the UK government.  We talked to them about divesting from orphanages and other organizations that support the institutionalization of children.  We were talking to them about this as experts.

And they were interested.  Usually, these people flit in and out of meetings, but they stayed for a good hour-and-a-half.  What really helped is that I had a former student who grew up in an orphanage in Kenya and talked about things they’d never thought about—including his loss of identity, as a child who grew up in an orphanage.  He ended up in an orphanage because his mother died in an accident.  The orphanage never made any effort to find his family.  When he was older, he wanted to see his file and try to trace his family—but he found out the orphanage staff had changed his name.  From the time he was four or five, he was called something else.

 

AG: So many layers of emotional theft. . .

KC: And he talked about how, when volunteers came to visit, they’d only pay attention and play with the cute, little ones.  It caused resentment among the other kids.  But once you’re not cute or little, you don’t get much attention from these volunteers.  Sometimes the staff would hide away the other children and only parade the disabled children, because there was a donor who was particularly interested in helping disabled children.

 “Once you’re not cute or little, you don’t get much attention from the . . . volunteers. “

 

AG: So it also pays to be disabled.

KC: There were all these ways they hadn’t thought about these issues.  I think that really moved them to have someone talk about that personal experience, and how identity gets erased. Being labelled an “orphan” has these lifelong effects.  Now he’s in his 30s, but he’s still saying, “This is the long-lasting effect of having gone through this.”

 

AG: I think your book is going to forge such a different conversation among so many kinds of people who I hope will read it.

KC: That’s what I’m hoping.  And also by being provocative about the “orphan industrial complex”—which, drawing on the “military industrial complex,” which deals with the politics of fear—but this is the politics of hope and love—and this idea of the “need to help,” as Liisa Malkki talks about, and trying to unpack that idea and be self-critical about it, and show how that has unintended consequences.  I do think people are listening to this message, and I hope they will change that discourse.

Of Diapers, Potties and Split Pants

Understanding Toilet Training around the World May Help Parents Relax

I recently published a piece on The Conversation about toilet training in a global context.  You can read the piece here.

 

Screen Shot 2017-11-20 at 10.52.58 AM

What a Brown Recluse Spider Has Taught Me

After having recently received a venomous bite by a brown recluse spider in NYC, I’ve spent some time researching my arachnid aggressor and discovering how to recover from the poisonous attack. Along the way, I’ve learned some life lessons.

Brown Recluse on Cardboard

Brown recluse spider

Statistical odds provide unrealistic reassurance.

  • Brown recluse spiders normally live in South America and a few southern and midwestern states of the U.S. They’re also loners and rarely approach humans. Yet, somehow, one managed to find its way to Manhattan, and to me.

Twain-Lies, Damn Lies, & Statistics

Rational choice theory is alive and well, even in those who challenge it

  • When in NYC, if I worry at all about the risks to life and limb, I probably focus (unconsciously) on getting hit by a speeding taxi, or crushed by a collapsing construction site, or shot in a terrorist attack. What I have most certainly neglected to worry about is getting bit by a subtropical spider far from its home territory. In this, my calculations must implicitly revolve around a rational choice model of risk/benefit assessment.

     

     

    But, really, I should have known better. Back in 1975, my graduate fellowship had me assisting in (and once lecturing to) a course that highlighted Mary Douglas’ theory of risk–a far different perspective that emphasizes individual perception shaped by complex social and cultural factors well beyond “simple” (especially economic) costs and benefits. Mark Twain’s insight is an earlier (and pithier) way of saying: statistical odds, at best, provide likelihood rather than certainty.

     

     

    Still

    , to be honest, there aren’t enough hours in the day to worry about every catastrophe that could conceivably befall us. So, we pick and choose our worries based on statistical odds that turn out not to be all that rational.

Ir-rational

 

Globalization works for creatures beyond humans, too.

Invasive Species Fish Cartoon

We are hardier than we may fear.

  • After surviving a herniated disc/back surgery, 15 months of intestinal parasites, and two unmedicated childbirths (my choice) a couple of decades ago, my pain threshold apparently remains pretty high. Okay, the partly-necrotic tissue now disfiguring a big chunk of my leg might have reminded me of a Green Day song about taking Novacaine. Still, wincing from the throbbing wound on my leg, I’ve managed to keep up with e-mail and other work tasks while popping only a few ibuprofens.

Pain-is-Temporary

Despite the above-mentioned point: Our life plans are frailer than we may hope.

  • Scheduled errands, meetings, outings, and dinners with friends are all on hold. My doctor predicts that my bite may take anywhere from a few days to a few weeks to heal. The Internet warns me it could even be a few months. That’s a lot of iCal events to tentatively reschedule.

Keep It or Cancel it?

I now know what bit me while living in a small village in Ivory Coast.

  • Back in 1980, a mysterious wound showed up on my ankle that worsened alarmingly, nearly causing gangrene. The local Senegalese doctor prescribed nine antibiotic treatments a day (3 shots + 6 pills)   . . . and declared me lucky to avoid amputation of my foot.

     

     

    In Parallel Worlds, Philip Graham and I wrote that my wound’s origins stumped the doctor, although he thought it might be an allergic reaction to an insect bite. But the symptoms resembled those of my current spider bite so closely that I am now certain it must have been a spider, not an insect, that assaulted me. Perhaps it was a kind of violin spider–the Loxosceles lacroixi, which lives in Ivory Coast and belongs to the same Loxosceles family as my more recent nemesis, the brown recluse. Of the violin spider, one website notes: “Their venom destroys tissue, causing a specific kind of skin necrosis known as loxoscelism in 66% of cases. The danger of secondary infection is high if left untreated.” Yep.

Snakes loom larger in the popular imagination than do spiders.

Poisonous Snake About to Bite

 

I am now officially nervous around spiders.

  • In any case, arachnophobia is a thing (not just a horror movie), and it’s definitely gendered. Until now, I’ve never had much patience for girls who screamed at the sight of a (harmless) spider. Hmm–is it too late for a feminist to enthusiastically embrace demeaning gender stereotypes?

Girl Screams at Spider

 

Speaking of gender . . .  turns out my poison was probably deposited by a devoted spider mom looking out for her kids’ interests.

  • That’s what Nobel Prize-winning chemist, Kary Mullis, wrote in his 1998 memoir, Dancing Naked in the Mind Field: “It’s a mother spider that first gets you and she wants a hole in you that oozes and expands and doesn’t ever heal. The females have the most powerful venom . . . . She wants that hole because her babies need a place to feed. They can dip their ugly little heads into the pool of nutrients that you are exuding and suck your vital fluids through their sucking tubes, and they can live. . .  After making the hole, she moves away and lays her eggs. It’s elegant biotechnology from the point of view of the spider.”

     

     

    I find this alarming. As a devoted mother of two, myself, I should sympathize with any mom’s efforts to nourish her children and give them the best foundation she can for their health and well-being. I have certainly tried to do that for my kids. Somehow, though, there’s a cross-species sympathy chasm I’m simply unable to traverse. I guess that’s a second blow to my identity as a feminist.

Brown Recluse Spiderling on Egg Sac (Photo by Sturgis McKeever, Georgia Southern U), cropped

 

Brown recluse spiderling on an egg sac (photo by Sturgis McKeever)

Conclusion:  Maybe it’s time for a new approach to studying pain.

Campodesmus alobatus (Millipede in CI)Guinea Worm Reduction Statistics

Campodesmus alobatus (millipede in Côte d’Ivoire)

 

  • When you live with long-term, disabling pain from childhood, how does that shape your brain, your temperament, your world view? Your sense of self, and your sense of being subject to, and capable of overcoming, hardships? By contrast, when pain invades your life only rarely, and briefly, what sort of identity forms surrounding notions of (in)vulnerability?

Pain Chart Form

  • Anthropologists: We have explored how plenty of other somatic experiences are influenced by factors beyond biology. Pregnancy and childbirth, menstruation, diseases from cancer to mental illness, and sports from walking to basketball have all claimed our attention. Yet, we live in a world of many people who experience pain routinely or even chronically. And when we’re not actively suffering from pain, we may spend much time thinking back on past episodes with amazement that we survived . . . or anticipating future episodes with dread. fear-tension-painPuzzlingly, few anthropologists have put that fundamental human experience front and center. True, some scholars discuss pain in investigating particular topics such as childbirthendometriosis and acupuncture. But to date, the 48 sections and interest groups contained within the American Anthropological Association–which focus on topics ranging from visual anthropology, music, and museums to agriculture, corporations, and tourism–do not include a group dedicated to exploring the world of pain.

    In a rundown of selected global perspectives on pain, anthropologist Mary Free has crafted a superb opening for a new subdiscipline. The brown recluse spider that deposited its poison in my leg this past weekend has suggested to me: it may be time for a systematic and dedicated anthropology of pain.

     

Postscript (Oct. 5, 2017): I’ve now been in touch with two entomologists who specialize in spiders, one of whom is a leading expert on brown recluse spiders. Both are quite skeptical that a brown recluse could have found its way to a park bench in Manhattan. My doctor and I are revisiting the diagnosis. Stay posted.