Call to Action

To:              Wider Medical Anthropology Community

From:          Anthropological Responses to Health Emergencies SIG

Authors:      MedAnth Collective

Date:           May 15, 2020 (Updated July, 6, 2020)

Call to Action: Critical Medical Anthropology of COVID-19 

This is a follow up to the first Call to Action, which focused on core issues for engaged anthropological research. This second working list highlights themes and issues related to COVID-19 that demand critical medical anthropology consideration. The list will be posted at: http://arhe.medanthro.net/call-to-action/

As with the first Call to Action, we would like this to be a working list, we envision this as a crowd sourced document. You may contribute to updating these working lists by adding suggestions on this google docs file: https://docs.google.com/document/d/1kWucuLxtxPDVOsjZews2KASFurhlwiZ7smKV3L3vp54/edit?usp=sharing

As a special interest group, we would also like to collect briefs from different settings on the issues listed under thematic topics below enabling intra and intercountry comparisons. If you would like to submit a brief please to our blog page: http://arhe.medanthro.net/ please email your submission to Kristin Hedges (ARHE co-chair at hedgeskr@gvsu.edu)

THE FOLLOWING IS A LIST OF CORE ISSUES THAT DEMAND CRITICAL MEDICAL ANTHROPOLOGICAL RESEARCH

  1. Bio communicability and Disinformation
  2. Social Determinants of Health
  3. Agricultural Workers
  4. Health Service Research
  5. Food Security & Food Processing
  6. Mitigation activities
  7. Gender issues
  8. Prevention measures
  • 1. Bio communicability and Disinformation
    • What competing discourse and evocative images are being circulated in the media/social media/ related to COVID-19; who is invested in circulating these different ways of thinking about COVID-19
  • Metaphors used to describe the disease and efforts to contain it
  • Military metaphors – how do military metaphors frame both models of and models for containing the disease, (who is the real carer of the sick? what

 is the role of women?)

  •  what do they enable (eg. chain of command) 
  • what do the suppress (critique of the government etc.)  
  • Other metaphors such as ecology or natural disaster metaphors
  • Comparisons to other diseases  
  • 1918 influenza
  • No more dangerous than the seasonal flu
  •  Like SARS, MERS…
  • Messages that place responsibility
    • Origin messages  
    • “Chinese virus”
    • Messages employed to deflect attention away from ineptitude of government policy 
    • Immuno-politics – messages that favor the shutting down of borders, and blaming non-nationals, etc.
      •  Messages that employ COVID-19 to support ethnonationalism, populism, authoritarianism and push back against human rights
  • Conspiracy theories and how they are being used for political purposes and constitute metacommentary 
    • To places: China, United States,
    • To things:  cell phone towers  
    • Labs unintentional, intentional: bioterrorism 
  • Messages driven by product advertising and forms of profiteering 
    • Cleaning products, Masks, Medications, Testing, Other technology  
  • Messages that are driven by “Othering”, and victim blaming as political strategy
    • Dehumanizing memes  
  • Messages using religion to further political agenda related to COVID-19 policy 
    • such as right to assemble in groups 
  • What do anti-quarantine protests index: what other issues are represented along -side anti quarantine: anti vax, climate change denial etc
  • Defiance messages in support (for example) of ending quarantine and lock down – anti public health advice and government policy
    • What values are invoked (ex. freedom, liberty, my body my rights etc.)  and who is targeted 
    • Who is supporting and bank rolling protests, who is being enrolled, and to what end? 
    • Confrontations between HCW:  protestors and public reaction 
  • Sources of intentional misinformation and disinformation; need for critical analysis as well as info epidemiology 
    • Politics of numbers. What numbers released -both their accuracy and critical assessment of what story they are telling and what story they are deflecting attention away form, misleading comparisons 
    • Weaponizing Covid-19 through strategic reporting of numbers 
  • Information suppression, controlling the narrative  
  • What is and is not being counted, attempts to suppress reporting of numbers for political reasons
  • Muzzling of HCW from talking to press by hospital admin –critique of working conditions and safety in hospital and quality of care 
  • Political response to disease modeling and public health recommendations related to relaxing restrictions 
  • Funding and the politicization of science —follow the funding and funding cuts 
  • 2. Social Determinants of Health: Health disparity and COVID-19, factors influencing maldistribution of hospitalizations and mortality 
    • Factors behind racial disparities
      • What does race have to do with it, and how much is race a marker of other risk factors
    • Economic and gender Inequalities 
      • Essential workers in low income bracket (how men and women are affected and infected ?)
        • Higher risk exposure on job and daily commute with less resources to respond
          • Janitors, housekeeping, gas station, agriculture workers
      • Employment insecurity (who is most likely to be affected?
        • Enduring risk exposure due to limited options
      • Density in housing
        • Higher population density in neighborhoods increases transmission rates
        • Higher population density within households increases transmission rates
    •   Lack of health insurance
      • Uninsured/underinsured for health care exacerbates chronic conditions that put people at risk of COVID complications
        • Differential access to Obamacare based on territorial status
      • Exacerbated COVID infections due to 
        • Difficulty in accessing telemedicine advice
      • Loss of health insurance related to loss of work
      • Difficulty in accessing test without primary provider to order
    • Environmental risk
      •  Environmental pollution impacting lung health and COVID infection 
    • Comorbidity
      • Racial and ethnic disparities in health conditions exacerbating COVID infection
      • Gender aspects
      • High Blood Pressure, asthma, diabetes, obesity, taxed immune system 
  • 3. Agricultural Workers
    • Ability to work
      • Availability of work in sufficient hours, job losses
      • Working sick? Protection of self and others
      • Need to return to work vs social distancing
      • Pressure from companies to return to unsafe work conditions
      • How companies define who is ‘safe’ to work? Testing? Certificates?
      • Ability to get testing tied to immigration status?
      • Blaming the victim in occupational sites where outbreaks occur  as a means of deflecting attention away from working conditions 
    • Family living conditions-
      • Isolation of sick members
      • Multi-generational families
      • Living conditions when travelling for harvests-cars, camping, company houses
    • Packing plants
      • Close working quarters
      • Availability of masks, handwashing, social distance
    • Education-
      • Ability to access classes for K-12 that have moved online, WiFi available?
      • Bilingual education availability online?
      • Linking into education programs that have been moved online as they follow crops
    • Health Conditions of agricultural camps 
      • Covid-19 infections in individuals with asthma, allergies, high dust exposure, respiratory exposure to pesticides
      • Washing facilities for people, clothes, dishes
      • Availability of reliable health information
      • Distance/access to medical care in breathing emergencies
      • Fear of seeking treatment if undocumented
    • Virus fugitives
      • migrants trying to escape the virus, 
      • migrants return home and escape environments of risk and food insecurity  
  • 4. Health Service Research
    • Overarching themes
      • Access to/distribution of health services and limited health care resources (links to disparities)
      • Expertise (competing expert knowledges; local knowledges; politicization of science)
      • Magnification of broken health care system (in U.S.), and potential of COVID-19-produced changes to permanently change system
    • COVID-19 diagnosis and treatment 
      • Testing – individual patient concerns and health system epidemiology
  • Access to testing
    • Shifting screening qualifications
  • Inadequacies (volume, quality, time to process)
  • Shifting case definitions
  • Molecular vs. serological
  • Treatment decision-making
  • Acute: respiratory
    • Distribution of limited resources, e.g. ventilators
  • Immediate post-acute: secondary concerns (e.g. kidney) some lethal (e.g. strokes) 
  • Long-term: unknown
  • Politics of numbers –
    • How is data being presented and misrepresented 
    • Politicized response to disease modeling 
    • Suppression of data on disease prevalence and mortality
    • Misleading comparisons 
  • COVID-19 spillover effects on other health service
    • Service limitations and their impacts on non-COVID-19 health conditions
  • Essential health services such as routine childhood vaccinations
  • Patients delaying care of serious health condition, for example out of fear
  • Negative long-term effects of limited management of chronic conditions that can cause unnecessary suffering to patients and may overwhelm primary care when services open back up
  • Medications
  • Shortages produced, e.g. hydroxychloroquine for management of lupus
  • Management of unfounded treatments, e.g. poisoning by household cleaners
  • Relaxation of standards of care reported in hospitals
  • Opposite effects: Social distancing causing declines in typical E.D. volume e.g. trauma
  • Health care worker safety and wellbeing
    • PPE (volume, quality, distribution decisions)
    • Care of colleagues who become ill
    • Mental health 
    • Censorship of health care workers
    • Debates over what is deemed essential services 
  • HSR Concerns related to death (maps to disparities)
    • End-of-life care, for both COVID-19 and non-COVID-19 patients
    • Physical distance from loved ones during death
    • Management of bodies
    • Safety of chaplain staff and PPE
  • Health policy and practice
    • Health insurance and financing
  • Private insurance declines amidst layoffs/closures across sectors
  • Federal policy change to guarantee coverage of COVID-19 testing but not treatment
  • Health system revenue concerns amidst limitations on non-essential care 
  • Opportunity to drive permanent health insurance reform
  • Health care delivery modalities
  • Drive-through COVID-19 testing
  • Pharmacist expansion of duties
  • Contact tracing
  • Rapid expansion of telehealth
    • Telehealth disparities
      • By population (e.g. rural)
      • By health care setting type (e.g. large, integrated system vs. small practices; academic medical centers versus non-) 
    • Expansion = accompanying opportunity to drive permanent telehealth reform
  • Professional shifts
    • Expedited licensure among final-year clinical students
    • Liberalization of out-of-state license restrictions for telehealth expansion and medical humanitarian volunteerism
    • Reskilling/transition of clinicians from specialization that is undeliverable under COVID-19 to essential/overburdened specializations
    • Furloughs/layoffs of clinicians in “low revenue” fields due to service restrictions
    • Mandated schedule shifts
  • Research fast-tracking
  • Some, extra-legal e.g. testing at UW pre-FDA approval
    • Public relations and image management
  • Health systems infrastructure and operations not covered above
    • Institutional health care considerations
  • Nursing homes
  • Prison health
  • Military health
  • Safety net settings
  • Community health centers
  • Home care (formal and informal)
  • Emergency Operations Centers (EOCs)
  • Coordination (or non-coordination) with other sectors
  • Public health
  • Emergency management
  • National guard
  • Crafters, “innovators” and others organizing novel PPE
    • Mask-sewing, 3-D printing shields, Manufacturing gowns, Refiguring other pumping devices into ventilators
  • Clinical trial recruitment and enrollment
  • How systems respond to shifts in demands at different sites of care (e.g. emergency department, primary care, specialty care) at different points in local/regional COVID-19 spread
  • Health services that occur outside of health systems
  • CAM
  • Oral health and dentistry
  • Health systems in sociopolitical contexts
    • Supply chains
    • Relationships with local businesses
  • Restaurants
  • Childcare coverage for HCW and other essential workers
  • Public responses
  • 7pm nightly public “thank a HCW”
  • HCW confrontations of “reopen” protestors
  • Intensification of single payer debate due to timing w/ U.S. presidential election
  • Policies that exacerbate covid-19 spread
  • Politicization of science —follow the funding and the funding cuts 
  • The impact of local medical culture and record-keeping apparatuses
    •  how/when people seek help, are diagnosed
    •  who “counts” in the numbers as “recovered,” “treated,” and “died due to COVID-19.”
  • 5. Food security and food processing
    • Food scarcity
      • Where is food acquired when no resources to purchase?
      • Feeding and subsidized food programs -how implemented and received? 
      • Children out of school who depend of school vouchers 
      • Homeless populations 
      • Shame associated with household lack of food
      • Food insecurity and other chronic treatment adherence
    • Availability of essential foods and rise in prices 
      • Defense act for meat processing plants
      • Risk of infection for workers at meat processing plants
      • Prioritizing meat production over other production
      • Guidelines for safety in meat processing plants
  • 6. Mitigation measures
    • Increase or lack of increase in wide-spread testing
      • Mixed messages on testing as a tool for mitigation
      • Continued lack of testing kits and materials for widespread testing
    • Guidelines for reopening cities and states
      • Are guidelines enforced
      • Which guidelines are being used?  CDC? State? Local? 
      • Legislative push back on governor orders
      • Local protests to guidelines
  • 7. Gender issues
  • What is the impact on men and women and how it intersects with other markers of identities and vulnerabilities?
  • How gender issues contribute to the higher mortality in men?
  • mortality, morbidity
  • Analyse the higher mortality in men and how it relates  to sex and to gender 
  • Which gender norms put men at higher risks?
  • How men and women are impacted by the economic and social crisis
  • 8. Prevention measures
    • How masculinities and femininities facilitate or hamper adoption of prevention measures?
      • Are guidelines gender sensitives?
      • How information about impact on man and women inform the prevention messages and policies