Abstract
This commentary asks anthropologists to work within communities to actively address the global mental health impact of COVID-19 and contribute to the pandemic response. Multiple social and physical losses, worsened by numerous factors, have produced syndemic traumatic stress and suffering across populations, highlighting persistent inequalities further amplified by the effects of COVID-19. Specifically, anthropologists can work to contribute to the development of mental health programs; confront the racialization of COVID-19 alongside marginalized communities; support real-time policy making with community responses; and innovate transparent collaborative research methods through open science. This pandemic can serve as an opportunity to prioritize research endeavors, public service, and teaching to better align with societal needs while providing new opportunities for synergy and collaborations between anthropologists in and outside the academy. Anthropologists collaborating directly with mental health clinicians and the public can contribute to knowledge specifically through direct program development and implementation of interventions designed to improve mental well-being. Innovating to find impactful solutions in response to the unprecedented mental health challenges exacerbated by the COVID-19 pandemic has the potential to promote more equitable recovery around the world.
INTRODUCTION
This commentary asks anthropologists to contribute to the COVID-19 pandemic response in novel ways. As anthropologists working within health-care systems, we see firsthand the deficits and areas where improvements are desperately needed. Moreover, many have experienced mental health impacts in their own lives, among their family and social networks, their students, and their research interlocutors, but are in a place of privilege with access to resources to navigate behavioral health care. Here we provide examples and evidence of how anthropologists can call upon our colleagues across diverse settings inside and outside the United States to bring our training and scholarship to bear in pandemic and recovery responses.
COVID-19 has had an unprecedented impact on mental health globally, with increasing rates of depression, substance use, anxiety, traumatic stress, complex grief, interpersonal violence, disordered eating, suicidality, burnout, etc., manifesting in all ages (Boden et al. 2021; Ehlman et al. 2022). While clinicians are trained to treat these conditions on an individual basis, the social determination of health (Spiegel, Breilh, and Yassi 2015) and the processes that contribute to the spread and exacerbation of these conditions demand higher-level local, state, national, and global responses.
Multiple social and physical losses, worsened by health-system failures, social unrest, racial injustice, economic hardship, disrupted education, forced migration, and political instability have emerged. These factors have produced syndemic (Singer and Rylko-Bauer 2021) traumatic stress across populations, where persistent inequalities are amplified, and the greatest impact is endured by the most structurally marginalized (Whitacre et al. 2021). Acknowledging the limitations of the concept of trauma in Western society (Fassin and Rechtman 2009), anthropologists are in a unique position to address the COVID-19 global mental health syndemic through culturally and politically contextual epistemologies of mental health (Fletcher et al. 2022) within the global sociocultural contexts where anthropologists are located (Briggs 2020; Closser and Finley 2016; Ennis-McMillan and Hedges 2020; Kim 2020; Palinkas et al. 2021). We call on anthropologists to align our professional capabilities and sensitivities to support the alleviation of mental health conditions incurred by the pandemic and to take direct action related to development and implementation of solutions. The authors of this call to action are medical anthropologists and physician-anthropologists working within the Veteran Affairs Health System (VA) and in academia, all of whom work to align the social determination of health research (Spiegel, Breilh, and Yassi 2015) to address policy change to improve mental health and mental health services.
When the world transitions from pandemic/endemic response to postpandemic recovery, anthropologists are needed at the forefront of rethinking mental health and wellness both at home and globally. Several have offered important critiques of psychological and psychiatric practices, processes, and systems (Hansen and Metzl 2019; Jenkins 2018; Kleinman 2012; Luhrmann 2011). Because the need is so great, our response necessitates interdisciplinary efforts with a focus beyond individual treatment. Anthropologists ought to contribute to the development of mental health programs sensitive to community and culture, confront the racialization of COVID-19, and support real-time policymaking, and do so by leveraging open science.
DEVELOP MENTAL HEALTH PROGRAMS
Given the urgency and global scope of mental health distress caused by the COVID-19 pandemic (Boden et al. 2021), anthropologists can engage in critical perspectives while also working collaboratively to develop programs that center responses within community and culture (Pigg 1993). For example, in rural Wisconsin, VA psychiatrists leverage anthropological techniques vis-à-vis narrative medicine (Charon 2008; Sweet 2021) to treat veterans with traumatic stress. Narrative medicine, which incorporates patient experiences during treatment, has the capability to improve clinical engagement and empathy, a nuanced understanding of how others are feeling, in settings where participants have experienced traumatic stress compounded by isolation (Remein et al. 2020). Another application of narrative medicine is in a form of “writing therapy” or expressive writing, where instead of talking, trauma-affected individuals are instructed on how to write about their thoughts and feelings about a given traumatic experience. Working in conjunction with clinicians, anthropologists have contributed to the development of this intervention (Groleau, Young, and Kirmayer 2006; Sweet 2021) that could be done individually, in a group setting, or via telehealth, enabling greater treatment reach.
Recovery from traumatic experiences often requires transformative sense-making (Lester 2013; Panter-Brick 2014) and intensive translation of events that have felt threatening (Pillen 2016). Supportive modes for healing from trauma ideally would build capacity for those experiencing trauma to reconnect to community and social worlds in ways that feel safe (Lester 2013). Anthropologists can provide critical support for healing spaces to explore meanings of experiences—not just those associated with suffering—and embrace therapies beyond the conventional individually focused modes (Broch-Due and Bertelsen 2016), including those outside of the medical setting. Indeed, Pinto (2020) urges us to recognize diverse therapeutic places or, as Davis (2018) calls them, “counter-clinics” where “alternative techniques of care have developed to address both novel and enduring forms of individual and collective pathology and precarity.” Specifically, anthropologists may facilitate postpandemic recovery through interdisciplinary collaborations that foster healing spaces in community settings to encourage a wider variety of people to seek care, decreasing persistent stigma surrounding formal mental health treatment. Whether it be mental wellness talks at a local library, a psychological first-aid series held at a senior center, or a school meeting addressing the rise in teen suicide, anthropologists can work with others to help organize, mobilize, and learn from these efforts for the common good. When appropriate, we can facilitate foundational ethnographic work informed by critical theory instead of relying on public health departments, which are often under-resourced, to conduct these initial assessments.
Community-level interventions may be particularly helpful in heavily COVID-impacted neighborhoods. For example, after the California fires, psychologists from the VA’s National Center for PTSD developed the free Sonoma Rises app, mobilized locals to develop free yoga classes, and spearheaded town halls (Heinz et al. 2021). These embodied forms of healing came after foundational qualitative research elucidated community preferences. Moreover, culturally tailored school-based dance programs (Azevedo and Robinson 2015) can give children a future orientation, instill cultural pride, and build communities. Virtual “massive open online interventions” (Muñoz, Pineda, and Llamas 2019), which are mental health treatments designed for diverse communities, developed with community input, made accessible in the appropriate language, and delivered by culturally competent staff, are another area ripe for anthropological collaboration. Anthropologists are working on teams developing interventions, treatments, and solutions for communities (Hansen and Metzl 2019). Anthropologists can facilitate the development of community-based peer-support groups among those impacted by COVID-related trauma, especially where we are already working with community health workers. Anthropologists can also reframe the importance of “physical distancing” while maintaining “social solidarity,” helping local and regional governments protect physical health while also buffering mental health (Holmes 2020). These ideas represent only a handful of tangible ways that anthropologists can engage with communities in mental health and wellness activities. We advocate bringing anthropological perspectives into settings unaccustomed to collaborating with us, specifically around mental health prevention and treatment. For example, substance use and overdose deaths have increased dramatically during the pandemic. While psychiatry has effective medications to treat and dramatically reduce cravings in those who use opioids, including fentanyl, many users find it difficult to quit since people in their social network may still be using as they confront social, political, and economic obstacles (Stonington and Coffa 2019). Anthropologists can examine the social networks and structural obstacles in these settings and work with users in co-designing community interventions that would support sober living and postpandemic recovery through a participatory research framework.
CONFRONT THE RACIALIZATION OF COVID-19
Current work addressing the impacts of COVID-19 on women and children (Castro 2021) has highlighted the role anthropologists play in identifying new areas of inquiry. For instance, initial studies on COVID-19’s impact on Latinx/e youth mental health in the United States indicate that while some might have experienced worsened mental health, sheltering of families in place and the reliance on community may be protective factors worth exploring further (Penner, Ortiz, and Sharp 2021). Mental health concerns for youth are amplified by increased migration of unaccompanied children across international borders, making them more susceptible to heightened mental distress related to loss of family, experiences of detention, and insecure futures. The Anthropologist Action Network for Immigrants and Refugees is addressing the recent influx of young migrants at the US-Mexico border by outlining salient, long-term postpandemic solutions at both the policy and practice levels.1
Moreover, since the emergence of the pandemic on US shores, the Social Interventions Research and Evaluation Network (SIREN) at the University of California, San Francisco, has been collecting and storing a repository of tools and resources produced by a variety of social and health scientists to assess the impact of the COVID-19 pandemic on structurally marginalized populations. These include instruments, such as interview rubrics, and surveys that have been disseminated to gather data on pandemic impact. However, this large repository still lacks specifically tailored culturally informed research instruments that could improve data collection from communities most affected by COVID-19. Anthropologists can contribute their methods to advance this interdisciplinary repository with particular focus on participatory research frameworks and instruments developed from our studies, monographs, and applied work.
COVID-19 has especially impacted children, recent immigrants, communities of color, the rural poor, and Indigenous peoples, highlighting how “interlocking systems of oppression” (Combahee River Collective 1977) undermine the vitality of historically disadvantaged communities. Black anthropologists have expanded upon the Combahee River Collective concept that the “personal is political” to emphasize that there is no longer a separation between what is inside and outside the academy when anthropologists are also personally impacted by racism (Carter 2018). Anthropologists can better confront the racialization of COVID-19 (Whitacre et al. 2021) by first understanding how historical and intergenerational trauma impacted communities before the pandemic and by highlighting the strength of local community knowledge as foundational to program development. Specifically, it seems important that we acknowledge community experiences of systemic inequities in COVID and in policing. Anthropologists can help provide nuanced analyses of inequities and promote health equity by working with clinicians, patients, and community groups in the development and dissemination of programs (Holmes et al. 2021; Whitacre et al. 2021) while pushing to make sure development and testing include diverse community members and stakeholders.
There is a substantial body of work across disciplines that highlights the structural conditions that contribute to extreme mental distress in various communities prior to and since pandemic outset (e.g., Farmer 2004; Metzl, Maybank, and Maio 2020; Metzl and Roberts 2014; Stellmach et al. 2018). This call to action asks us to go beyond this important literature to develop and test new solutions to address these structures. For example, the late Paul Farmer’s collaborative work addressed the structural lack of quality medical care in Haiti by spearheading construction of a state-of-the-art university teaching hospital in Mirebalais with local, national, and international partners. Scott Stonington (2020) and the late Sam Dubal (2018) offer other critiques and reflections on how health care can support people without playing into essentialisms and exclusions—including even in the concept of “humanity.” We should not be afraid to aim high and work in solidarity with racialized communities’ efforts to produce bold structural and symbolic solutions.
SUPPORT REAL-TIME POLICYMAKING AND COMMUNITY RESPONSES
Anthropological work has been used to propose solutions to improve care processes and policies and increase access to care for those impacted by COVID-19. Anthropologists have long analyzed downstream effects of health policies and programming implemented at global, state, and community levels (Shore and Wright 2003). While anthropological theorizing can help us to understand human and government responses, direct anthropological action in development and implementation of solutions is often less emphasized (Pigg 1993, 2002). We recognize that structural barriers may prevent such work (lack of time, institutional restrictions), and that anthropologists, in some settings, may be negatively perceived (Fletcher et al. 2022). But for so many, the unprecedented health, economic, and political impacts that have occurred because of COVID-19 will take years, perhaps decades, to undo. We encourage anthropologists to take calculated risks, leverage their expertise, and engage as public servants and intellectuals in solidarity with others working to be part of the conversations to solve the emerging realities of postpandemic life at home and abroad. Anthropologists can extend critical studies of health-policy processes and impact, such as highlighting the undervaluing of mental health care at home and globally (Dao and Nichter 2016), to actively shape new policy, broadly construed. These policy responses need to consider decreasing health and increasing health-care inequities, making mental health-care services more accessible and decreasing the social distance between services and patients (Madaras et al. 2019). Anthropologists can investigate the social, political, and economic structural factors that impact mental health and health care to help clinicians and health-care systems respond to these factors (Seymour et al. 2018). They can also inform policy to decrease structural iatrogenesis (Stonington and Coffa 2019) and its unintended consequences (Pigg 1993) and consider the social forces that directly impact diagnosis and treatment (Holmes et al. 2020). Moreover, anthropological involvement in policy can support a more realistic and nuanced understanding of racialization and racism (Amutah et al. 2021).
Anthropologists in VA settings have taken up calls for increasing participation in making policy (Bernstein and Razon 2019). For instance, from September 2019 through December 2019, an analysis of open-ended comments gathered to address veteran suicide directly contributed to a 2020 national strategy to reduce suicide in veterans and civilians. The PREVENTS campaign was launched as the COVID-19 pandemic was hitting the United States. A review of texts to a national emergency distress hotline run by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed an increase of 1,000 percent over prepandemic levels (US Department of Veteran Affairs 2020). Data collected through these rapid-assessment open-citizen-science methods, analyzed through anthropological etiological frameworks, informed national policy to reduce pandemic-enhanced rates of suicide on a national level. Similarly, anthropologists may be able to address the complexity of COVID-19 impacts, even those not directly relating to health but needed to support community well-being and recovery more actively when societies transition to an endemic phase (Metzl and Kirkland 2010). The key is to translate and communicate our expertise in a way that is more legible to public health officials, mental health clinicians, and the public at large.
APPLY OPEN SCIENCE AND COLLABORATIVE RESEARCH METHODS
Our research methods need to be adaptable, transparent, and readily available. Anthropological methods are well adapted to examining health systems, gathering data to prepare for or respond to crises, including pandemics (Sangaramoorthy and Kroeger 2020), building on clinical ethnography to capture data connecting events at multiple scales and intersecting interests (Davis 2018). Traditionally, qualitative methods have been employed to analyze data in response to health crises, such as infectious disease outbreaks like the Ebola outbreak in West Africa in 2014–2016, and more recently, COVID-19 (Vindrola-Padros et al. 2020). Applying open science methods can increase the capacity for impacted communities to feel they can connect safely to research, making science safer and building trust through the co-creation of data and its translation. We might also consider using novel approaches, such as open and citizen science coupled with rapid and culturally informed techniques, to more effectively leverage implementation science to promote responsive practices in mental health (Messac et al. 2013).
Open science strives to make scientific inquiry accessible at all levels by incorporating citizen science, in which people experiencing a phenomenon are both reporters of data related to the phenomenon and experiential interpreters of the events. These methods typically generate large bodies of qualitative data during crisis periods. One current crowdsourced data repository, hosted by the University College London Department of Anthropology, is collecting COVID-19 digital ethnographies with a summary of responses updated as data is added and integrated (UCL 2020).
Within the VA, anthropologists are advancing implementation science, using rapid ethnography and qualitative analyses of data (Hamilton and Finley 2019) to assess crises in real time. In 2019, a team assembled to analyze a large body of unstructured, open citizen-science data gathered to address the epidemic of veteran suicide (Exec. Order No. 13861, 2019). The team devised an interdisciplinary rapid qualitative analytic method grounded in a medical anthropological explanatory model (Kleinman and Benson 2006) to analyze more than nine thousand free-text responses providing unique perspectives and knowledge of veteran suicide within three months of the data collection (Kalvesmaki et al. 2021a). Additionally, anthropologists affiliated with the VA’s Elizabeth Dole Center of Excellence for Veteran and Caregiver Research Center have supported the development of a participatory youth research study to understand how the pandemic is affecting the youth and family members caregiving for US veterans (Kalvesmaki et al. 2021b).
SIGNIFICANCE
Collective losses that worsen global mental health—colonialism, war, childhood precarity, racism, sexual/gender-focused violence, disease, and injury-related experiences, etc.—are not new. But the ways in which anthropologists are connected via multiple technological platforms globally is new, and this allows us to address mental health on a much broader scale. This pandemic can serve as an opportunity to prioritize research endeavors, public service, and teaching to better align with societal needs while providing new opportunities for synergy and collaborations between anthropologists inside and outside the academy. Making more transparent the interrelation of theory and practice while working to make our methods more accessible to the public increases our accountability and relevance to society at large (Pigg 1993). Anthropologists collaborating directly with mental health clinicians and the public can contribute to applied knowledge specifically through direct program development and implementation of interventions designed to improve mental health and well-being. Innovating to find impactful solutions in response to the unprecedented mental health challenges exacerbated by the COVID-19 pandemic has the potential to promote more equitable recovery around the world.
NOTE
1 See http://www.anthropologistactionnetwork.org/.
Article From: AnthroSource
Author: Kathryn J. Azevedo,Andrea F. Kalvesmaki,Rachel P. Riendeau,Philip A. Sweet,Seth M. Holmes
