Month: April 2023

An anthropological writing (March 10th, 2023) by Tongtong (Petra) Yang for the course Anthro 216GH: Case Studies in Global Health with Professor Felicity Aulino

What is Structural Violence?

Kleinman et al. (1997) created the concept of social suffering. Farmer (2004) wrote about structural violence that pain and suffering is caused by the institutions, policies, and systems’ constraint of choices of certain groups.

Structural violence is important because we can use it to analyze how violence in global health issues was created by race, gender, class, ideologies, and other systems of oppression and institutions in action. While sufferings of individuals are important, seeing the pain geographically broad and historically deep can offer insight into the engine of the suffering. Analyzing the policies and systems limiting the agency of LGBTQIA+ people can help us understand where their suffering from psychological disorders come from: bashing, stigma about HIV/AIDS, criminalization, no marriage allowed, discrimination at workplace, daily stress to hide identity, and more.

Structural violence can be applied in global health interventions by analyzing the health concerns and suffering with regard to how individuals’ choices are limited and relevant policies and systems, then designing, running, reviewing, and evaluating the interventions addressing these mechanisms. In DOT treatment for TB in rural Bangladesh, this means that:
– to address poverty, paying the shasthya shebikas for their work, offer food to meet nutritional needs, and refine water and sanitation;
– to address lack of health literacy, providing households with basic health education;
– to meet basic health needs, analyze the current health system and collaborate with the government to run health insurance;
– to understand other contributors to the suffering caused by systems, analyze how race and ethnicity, political ideologies, gender and patriarchy, and other types of oppression created the TB situation.

(ideas in italics are those I did not find in the BRAC’s TB Program report and might have been investigated)

What is Social Construction of reality/knowledge?

Berger and Luckmann (1996) created social construction of reality/knowledge. It is that all we know, despite perceived as objective, is socially constructed, specifically through habituation, institutionalization, and legitimation. Habituation is the process of learning through practicing routines to the point that the routine/action becomes a habit. Institutionalization is the process of establishing ways in which things are done and thus the way to do things, and maintaining “authority over the individual.” Legitimation is the process by which the institutions are justified through telling the new generations the institutional history while they are socialized.

This concept is important because it reminds us to examine our knowledge by thinking how it is embedded in the society, habituated, and institutionalized, and who defined and are defining the knowledge. When pharmaceutical companies developed the medicines and the clinics sell the medicines at certain prices, our knowledge of “we can access the medicines and health only by purchasing this medicine at this price” is habituated by seeing people around us buy medicines at a price and us buying more and more medicines; and institutionalized by pharmaceutical companies and clinics setting the needing-meds and being-healthy way as “buying meds at this fixed price and keeping yourself healthy,” also by limiting other ways to access meds and health.

This concept can be applied in global health interventions by analyzing what constitutes habituation, institutionalization, and legitimization within the region and health situation; designing the program addressing these constituents; and refining and evaluating the intervention with these constituents as part of the criteria. For HIV Care in Rwanda, this application means first analyzing the history of Rwanda politics, economics, and healthcare, how HIV and other health problems have been treated and the pros and cons of these interventions, the governmental and NGO relationships in the interventions, and the daily routines of local people of different generations and what they know and are used to about HIV care (by observation and interviewing). Second, designing the program responding to these analyses. Third, keep analyzing and refining in the intervention process by maintaining a good communication network. Fourth, assess the results of care and present the new knowledge formed (personal and institutional) after the intervention and new reality’s implications about healthcare, economics, politics, and the local life.

(ideas in italics are those I did not find in the Partners in Health: HIV Care in Rwanda 2010 report and might have been investigated)

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What is multi-drug resistant (MDR)-TB? What characteristics of tuberculosis transmission and treatment lead to drug resistance? Why is a biosocial lens particularly useful for understanding this disease and designing interventions?

Multi-drug resistant (MDR)-TB is the tuberculosis (caused by Mycobacterium tuberculosis) strain resistant to at least INH and RIF in the multiple drug chemotherapy treatment. MDR-TB occurs when naturally occurring mutants become favored during the course of inadequate therapy or being transmitted the drug resistant strain TB directly. It spreads by breathing in the air which TB bacteria is put into by coughing, sneezing, speaking, and singing. A biosocial lens is useful for understanding MDR-TB by looking into the biological, social, political, economic, historical, and environmental processes which led to the emergence and transmission of MDR-TB, which is more likely to happen in certain communities.

In 1990s Tomsk, Russia, TB and MDR-TB drug resistance emerged and stayed most in communities where social forces – of political changes, breakdown of health services, alcohol addiction, overcrowded and underfunded hospitals, overcrowded prisons and detention centers, poverty (unemployment and homelessness), and socioeconomic unequal access to care – were prominent. People facing these challenges were unable to complete 6 months of treatment for regular TB. More transmissions of TB and the drug-resistant strain happened in overcrowded areas. Homeless people were also vulnerable to MDR-TB after social services offering food and shelter disappeared. Before the ambulatory treatment program, people were unable to complete 18-24 months of inpatient treatment with second-and third-line medications given under direct observation and management of side effects for MDR-TB. Interventions including DOTS, DOTS-Plus, and Sputnik addressed these challenges. Social processes in the midst of a global health problem are important and a biosocial lens including the social theories can help stakeholders and others understand the problem and design interventions.

An anthropological writing (April 14th, 2023) by Tongtong (Petra) Yang for the course, Anthro 216GH: Case Studies in Global Health

Caregiving in community-based systems has been practiced in global health for its effect in transforming local systems of disconnected community and healthcare. This paper will compare the caregiving and community health in Boston, MA, USA and Okayama city, Japan, and use these comparisons to discuss the implications and actionable insights. 

Individual caregiving responsibilities and Organization operational structure

In Okayama city, Japan, Hiroko and Toshio Kashiwagi have multiple responsibilities as community care workers. They utilize their professional experience and knowledge about caretaking to serve their clients, the elderly and the disabled, train new care workers, and together run an NGO that offers community in-home help and affordable transportation services. The NGO sends home helpers to the clients to help with their daily routines, keeps an eye on their health condition, and contacts medical professionals if needed. The clients always have health concerns due to aging or disabilities. Toshio, using his knowledge as a retired special school principal, offers taxi transportation in a four-wheel welfare vehicle for clients to travel from their homes to nursing homes, hospitals, parks, stores, welfare facilities, and conveyor belt sushi restaurant. He also accompanies the clients throughout shopping and medical checks. Hiroko, as a professional caretaker, cooks for the clients, sweeps the home floor, does laundry, asks how the recent medical check went and whether the client took the medicine that day, and sometimes promotes the client to stop smoking because it is bad for their health. Although this NGO offers community in-home help, not community healthcare for the “indigent HIV-positive” patients like that of the Prevention and Access to Care and Treatment project (PACT) in Boston, MA, USA; individual caregivers’ responsibilities are similar and both act as the bridge between clients and doctors, except for the domestic housekeeping and welfare transportation parts. Working as either health promoter (HP) or directly observed therapy (DOT) specialist, community health workers (CHWs) in PACT visit patients’ homes regularly to talk about health, specifically on topics of HIV, the patients’ “health behaviors,” and social services available to them; they also help the patients learn about their medications and make sure they take the meds. CHWs do not help with housekeeping or transportation.

On the organizational level, PACT has a more role-specific operational framework. With PACT, CHWs practice community health caregiving and receive continuous training in medical science by the training and technical assistance team. The HIV program manager monitors CHWs and contacts patients on formal inquiries. The clinical supervisor makes sure CHWs are well, takes in patients, and outreaches the doctors locally. The accounts manager and administrative coordinator takes care of PACT’s financial situation and administrative work. The executive director and the director of operations supervise all. In Okayama city, however, Hiroko and Toshio perform multiple roles. Apart from caregiving and home helping, Hiroko works on the finance and administrative arm, also contacts local agencies and manages the NGO. Toshio offers more than welfare transportation. He connects with new welfare taxi drivers and trains them. 

Both the NGO and PACT function well. Although the roles are mixed or more concentrated, the caregivers offer actionable insights for community caregiving:

– going into clients’ homes

– performing their responsibilities fluently and understanding the group they serve (knowledge in HIV, aging, and disability)

– build relationships with clients, doctors, and more.

What is community?

In PACT, community is a metaphor of belonging; it is beyond physical space. Community takes the forms of understanding between CHWs and patients through shared experiences, as space and place of the clients, and as the relationships between CHWs and the patients. In Okayama city, the community takes similar shapes. It happens in the relationships between doctors, caregivers of the NGO (which literally translates as support group having tea together, 共助团体吃茶去), clients, and their families. It happens in clients’ homes, the NGO office, the hospital, and other places the clients and Toshio reach and explore together using the NGO’s welfare taxi. Both PACT and the NGO address the clinic-community gap by regularly visiting the clients’ homes and accompanying them, and the NGO goes further to offer convenient transportation for the clients.

Insights for community caregiving: 

• Share experiences with clients
• Respect and encourage clients’ space
• Accompany the clients and regularly visit them at home

Social and political economies

How has the community health workers and caregivers understand the impact of social and political economic forces on clients’ health and living? The Kashiwaga couple understand that these forces set roadblocks and created many rules for welfare transportation and in-home helping services because the government cut the budget and support. What the clients pay barely covers the cost like parking and gas. Toshio becomes a volunteer driver for the welfare not-free transportation. Hiroko says the NGO faces a financial crisis. Before 2006, the elderly and disabled could travel using the free extra service of home services companies. The normal taxi drivers claimed that these services influenced their business and campaigned against these free services, thus came the slightly-paid, almost-volunteer welfare taxi drivers. The drivers need to make sure they do not conflict with the taxi industry to become volunteers. Toshio had to purchase this welfare vehicle using his pension. Before PACT, the primary and rural community health field has a long history of various policies in different times and needs. PACT bases its framework on Partners in Health (PIH)’s Haiti work and has been training and supporting new health workers with its model.

Insights for community caregiving:

• Research and understand the impacts of previous practices and current local and national policies about community health and caregiving
• Communicate with other organizations offering care, provide training
• Be prepared for advocating for more support and taking risks as caregivers

Through what lens did the observation happen?

In his project on PACT, Mei acted as an “inquisitive observer,” observing different situations and listening carefully to understand “what it means for CHWs to work in the community and give care” and the local moral worlds (Kleimann 2006) through the interactions between stakeholders. Soda is also an observer. His documentary style is innovative observational. Using his camera, he observed the Kashiwagi couple and their clients’ work and life moments with least assumptions, has no scripts, previous planning, or theme, and uses least music, subtitles, and prologue, to encourage the audience to actively observe. Soda self-funded his films to stay independent of bias the funders would bring to the table. 

Bibliography

Soda, K. (Producer & Director). (2010). Peace [Motion picture]. Japan: Laboratory X, Inc.

Soda, K. (2023). Why I Make Documentaries. On Observational Filmmaking (S. Grasselli, Ed., M. Schley, Trans.). Viaindustriae publishing. (Original work published 2011)

John (Yuynag) Mei, 2012. “Caregiving Among Community Health Workers in Boston: The PACT Model.” Undergraduate thesis, Anthropology, Harvard College.

A Femme Shark + Eco-dystopian Sci-fi piece by Tongtong (Petra) Yang

⛰️🌗

“We have no categories. No gender, no mentally normal or ill, no official language, no government, no marriage, no money as currency, no race or ethnicity, no class. We make our own blades and our own moon.”

– Blade of HalfMoon Manifesto

How long can you stay mad/furious/enraged/irritated/indignant before losing it? I’ve been asking myself that question for a few weeks. People back in 2020 might use the pumping balloon and explosion metaphor. Plastic balloons, essentially fossil fuel, are extinct. Why do I know they exist? My generation’s kids grew up learning that history with balloons of all shapes and colors standing at the front of parking lots greeting customers to fast food places, clustering like grapes in birthday parties and graduation ceremonies, and carrying handwriting in oil black pen flying in the hallway of a gallery. They said the forests here avenged after going bald. The revenge lasted for a whole month when it was snowing and deadly quiet. A perfect time to bury bodies. Do you know pre-Blade people paid a lot to maintain their relevances’ graveyards? They could have gone into the ocean or flushed themselves down the K-toilet. During the revenge, people were silent like chickens and the recreation industry gradually died out. Bladers got to canoe (extravagant stupid tomato red like someone’s choked) from time to time, with wildflowers in our hair. Green is Bladers’ color. 

⛰️🌕

[Ebral singing]

Renovate

Add a B to your name

Study all Blader 

languages

And make a 

new one

新生

Walk barefoot in the Paper Excellence 

Remain

Iced lake

Gulp the now stream

Previous steam

Men hand logging 

Timber. Lean on

One and visit often

Visit The Shade

Stare at the newcomers

Through

Their waxing Gibbous Phase

Carve a Glittering Cave

Dry

A linen cloth

Put it on your Blade

Try

Double moon

Hunt a rabbit

Pick rosemary

Harvest a lemon

Cook in The Jut

Sit with solar panels

Charge a camera

Direct 

Film

Dance. Music. Art.

Mud

おやすみ

[Tonkba strolling in The Bmain]

Tonkba: Zeb will send me to North America Arm #4 next week to start my first-ever mission. I will then fly to #70 in Sept and #41 next year. I hope there’s coffee and Levofloxacin and moxifloxacin and all on that list. Ebral will take care of my eagles. Bladers prepared artworks, bows and arrows, some climbing stuff, and  Šebfika the healer. We will depart at dawn.

Nabomi: Oh, you got Zeb. Who were my first mission tutor again? Can’t remember. I see you got your double moon.

Tonkba: They’re all tight and sharp. Still practicing the Loi move. Can you show me?

Nabomi: Like this.

Tonkba: Can you do it again, please please please?

Nabomi: It’s deep in the night. I can’t hear my eagles.

[Tonkba blinking their starry eyes]

Nabomi: I’m hungry, sneak to The Jut and cook me proper ramen. I don’t get bribed by your beautiful face.

Tonkba: !!!I’ll be back in 20, before you fall asleep.

[Nabomi waving their hands, turning to their side]

⛰️🌑

“A group of sustainability advocates flooded the beautiful BC forests and set up another cult. Many young boys lost their lives there. These people do not use money. You can find photos of their exotic farms taken by our journalist Paul Bristle. They don’t get married. Naked dirty bodies run in those forests. They eat whatever they want. They are against human civilization. Do not go.”

An anthropological writing (Feb. 3rd, 2023) by Tongtong (Petra) Yang for the course Anthro 216GH: Case Studies in Global Health

Local Biologies sees biology and culture as contingent changing bidirectional influencers of each other, and, in turn, lead to biological differences in certain space and time (Situated Biologies) (Lock, 2017). These interactions are biosocial differentiation (Lock

& Nguyen 2010). Symptoms of certain conditions and both the social and cultural aspects of people differ from one society to another (Lock & Kaufert, 2001).

While Lock (2017) suggested that epigenetic adversity resulting from exposures to toxins are intergenerationally transmitted, neuroscience research by Marlin Lab showed that trauma can be inherited. Offspring can inherit, via germline DNA, the way a parent body responds to trauma. This phenomenon is transgenerational epigenetic inheritance. Furthermore, the concept of mismatch pathway is evident in offspring of Jamaica malnutrition (Forrester et al. 2012) and those of the Dutch Hunger Winter famine of 1944-1945 who had higher rates of physical illnesses and mental disorders.

Lock would respond to Marlin Lab that research on transgenerational epigenetic inheritance needs to go beyond the protocols and standardized lab environments, just like bell hook’s critique on the co-existing reality of imperialist white supremacist capitalist patriarchy. Lock (2017), “owing to space limitations,” did not write about how experiencing trauma influences development throughout lifespan; I will discuss, based on research by The TRUST Lab at UCLA led by Dr. Ng, local and situated biologies in Ethiopian and Botswanan people with Bipolar Disorder, Post-traumatic stress disorder (PTSD), and several mental illness (SMI).

Dr. Ng’s research showed one-directional correlational relationships between biology and environment, but not culture. Both study groups at Mass General Hospital in the US and rural Ethiopia suggested positive correlations between traumatic experiences and social functioning, where traumatic experiences were the predictors. Based on epidemiologic data, rural Ethiopia showed lower awareness of mental health, and stigma and discrimination, compared to US mental health. However, lifetime prevalence of bipolar disorder in Ethiopia, physiological pain of people diagnosed, social concerns of them fulfilling their roles, and health burdens on hospitals do not tell the complete story of culture about bipolar disorder in Ethiopia. Nor did current research demonstrate how culture influences mental health in Ethiopia, let alone with how interactions between biology and culture create biological differences between people in Ethiopia and other places in the world.

Ametaj et al. (2021) concluded that the team had developed a culturally appropriate psychological intervention for people with bipolar disorder in rural Ethiopia. They followed several steps for this development: a systematic review, a qualitative study with people with bipolar disorder and their caregivers, and workshops engaging mental health “experts” and other stakeholders. The intervention was an adaptation to psychotherapy methods used in the US like psychoeducation and problem-solving and behavioral techniques. Although workshops and interviews gathered information about mental health conditions in rural Ethiopia and the intervention included “Working with the community and religious leaders, and HEWs,” understanding of local culture was limited. 

Molebatsi et al. (2021) developed another culturally adapted intervention for people diagnosed with PTSD and other mental disorders in Botswana. The team was concerned with the feasibility of carrying out psychological interventions like CBT since training in therapy was limited in Botswana. Feasibility due to lack of “training” and translations of intervention plans into local languages and incorporation of local norms and concepts were the “adaptation.” Again, the team ignored the interactions between biology and culture and the changing nature of biology and culture.

People might take biosocial differentiation and use it to reinforce biological determinism, the false belief that there are essential and immutable biological differences among humans. Examples include racial essentialism (Rhodes & Mandalaywala, 2017). We should be mindful of attempts using biosocial differentiation to create essential differences in favor of certain people. Instead, local and situated biologies should be used to a) explore the nuanced and changing interactions between biology and culture, b) promote that health has an effect on everybody.

How do biological and cultural changes match/mismatch to the time needed to analyze local biologies? We look forward to more implications of Local and Situated Biologies.

Bibliography

Carcea, I., Caraballo, N.L., Marlin, B.J. et al. Oxytocin neurons enable social transmission of maternal behaviour. Nature 596, 553–557 (2021). https://doi.org/10.1038/s41586-021-03814-7

Rhodes, M., & Mandalaywala, T. M. (2017). The development and developmental consequences of social essentialism. Wiley interdisciplinary reviews. Cognitive science, 8(4), 10.1002/wcs.1437. https://doi.org/10.1002/wcs.1437

Forrester TE, Badaloo AV, Boyne MS, Osmond C, Thompson D, et al. 2012. Prenatal factors contribute to the emergence of kwashiorkor or marasmus in severe undernutrition: evidence for the predictive adaptation model. PLOS ONE 7(4):e35907

Ametaj, A. A., Hook, K., Cheng, Y., Serba, E. G., Koenen, K. C., Fekadu, A., & Ng, L. C. (2021). Traumatic events and posttraumatic stress disorder in individuals with severe mental illness in a non-western setting: Data from rural Ethiopia. Psychological Trauma: Theory, Research, Practice, and Policy, 13(6), 684–693. https://doi.org/10.1037/tra0001006

Molebatsi, K., Ng, L. C., & Chiliza, B. (2021). A culturally adapted brief intervention for post-traumatic stress disorder in people with severe mental illness in Botswana: protocol for a randomised feasibility trial. Pilot and feasibility studies, 7(1), 170. https://doi.org/10.1186/s40814-021-00904-1

Tongtong (Petra) graduated from Mount Holyoke College (USA) in December 2023 as an undergraduate researcher in psychology and neuroscience. She is interested in the neurobiological computations of memory and learning; science education; and global healthcare delivery. Apart from research, Tongtong creates work in photography, writing, art, and performs music on stage. She is also a traveler, tarot reader and rock climber. As a Davis United World College Scholar, Petra is fascinated by engaging with people from diverse cultures and professions. Most of her creative work source from these conversations and explorations.