Conference: American Society for Bioethics and the Humanities, Oct 19-22, 2017

This week we are highlighting four sessions from the upcoming American Society for Bioethics and the Humanities Annual Conference in Kansas City, MO from October 19-22, 2017. The sessions are categorized under Religion/Culture/Social Sciences, and include topics interesting to scholars in multiple disciplines. For the full conference schedule, visit the ASBH 2017 meeting website here.


Panel Session: China’s Forced Organ Harvesting: A Central Test of Our Time

Thursday, Oct 19 – 1:30-2:30pm

With David Li, Yiyang Xia, and Grace Yin

A decade of research by international investigators has concluded that the Chinese party-state is systematically killing prisoners of conscience on demand to supply its vast organ transplant industry. In June 2016, the U.S. House of Representatives unanimously passed H.Res. 343, condemning the harvesting of organs from Falun Gong adherents and other prisoners of conscience in China.

Researchers examined hundreds of transplant hospitals in China and analyzed data about their capabilities, capacity, personnel strength, and potential patient groups from medical journals, media reports, official statements, web archives, and government policies and funds.

The research estimates that China now performs between 60,000 and 100,000 transplants per year–more than any other country in the world. Even based on government-imposed minimum requirements, China could have performed more than one million total transplants since 2000.

The official organ sources–death row prisoners and voluntary donors–account for only a small fraction of the total volume. The victims are primarily Falun Gong meditators killed through organ extraction outside of judicial process as part of the Communist Party’s campaign to eradicate the group.

The issue of forced organ harvesting presents an opportunity and an obligation to bring medical and academic institutions to the center of bioethics. Presenters will articulate with the audience concrete actions to prevent the complicity of American institutions and individuals, including providing training, equipment, recognition, collaboration, and organ tourism to Chinese institutions that are participating in this crime. Comprehension of the issue helps institutions and individuals make informed choices and uphold social responsibility.


Panel Session: Pathways to Convergence: Sharing a Process that Aimed to Examine the Diverse Perspectives of Catholics on Advance Care Planning and Palliative Care in the United States

Thursday, Oct 19 – 2:45-3:45pm

With Robert Barnet MA MD, John Carney MEd, Matthew Pjecha MSPP, and Carol Taylor MSN PhD RN

Pew Charitable Trusts recently funded a project to examine views among Catholics in the U.S. regarding end-of-life, palliative care and advance care planning. Center for Practical Bioethics (CPB) served as coordinator for the project. A six-member steering group representing ecclesial, Catholic Health, and ethical interests, along with CPB (a secular organization) invited three groups of eight Catholics from different disciplines and perspectives to capture conservative and progressive themes within American society and among practice settings. Roles and responsibilities within those realms were prominently featured in deliberations with goal of clarifying areas of divergence, convergence and possible paths forward. The groups examined: – Social responsibility derived from tradition (how the Church presents itself and speaks in the public square and what informs this presence) – Covenant and contract (roles of free and informed consent in advance care planning and decision-making between patients and providers) – Shared decision making (Church teaching that informs specific decisions faced in goals of care conversations and interdisciplinary care planning for palliative care patients)Identified as Pathways to Convergence the groups aspired to identify common values and principles and report on the results following a convening. Presenters will explore how ethicists can use the processes, methods and findings of this group when workings with patients for whom faith tradition may play an important role and among providers, and others who share different perspectives on end of life to facilitate optimal advance care planning and palliative care.


Paper Session: Religion, Culture, and Social Sciences Paper Session 1

Thursday, Oct 19 – 4:00-5:00pm

Creating Compliance: Using Games to Engage Patients in Medical Management 

by Kristel Clayville

This presentation offers a method for increasing compliance among transplant patients. The recommendations presented are from non-medical clinical observation from a chaplain who deals with the day-to-day coping skills of transplant patients. The case studied focuses on the emotional aspects of compliance, and the attendant interpretation and recommendations focus on the social, emotional, and spiritual aspects of dealing with the existential difficulties of undergoing a solid organ transplant. Ultimately, the recommendations are for presenting medical compliance as a game that patients play rather than as a set of medical practices that sustain life. Thinking in terms of games not only helps the patient’s motivation, but it also offers the family and support network a language with which to engage the patient and help with the practices of compliance.

The Ethics of Influence: Celebrity Physicians and Social Media 

by Patrick Herron

Growth of social media has not only changed how individuals interact socially, but in how we engage with professionals too. Recognition of a physician’s social media “influence” is based on her/his ability to affect other people’s thinking. The greater the influence, the more appeal that individual has to companies or other individuals who might want to promote an idea or sell a product. Celebrity actors/athletes are often seen as prime influencers with regards to advertising campaigns, (i.e. “Got milk?” and “Milk: it does a body good”) to increase sales.

Celebrity physicians such as Dr. Mehmet Oz have used influence to promote health products and interventions, which raised considerable debate as to whether there were lapses in ethical and professional judgment. Not all physicians will have the platform of a Dr. Oz, but social media has created ample opportunities for many lesser known physicians and trainees to leverage their own professional expertise and growing social media prominence to become influencers. Such financial partnerships raise questions about conflicts of interest, professionalism and potential violations of an ethical duty of care.

The impact of social media on consumer healthcare decision making along with the dependence by consumers on their friends and families for healthcare product reviews (often shared via social media) has dramatically changed marketing. Consumer confidence and increased reliance on the opinions of physicians they follow via social media accounts can have a detrimental affect on the patient-physician relationship that consumers have with their actual health care provider.

Make Aging Great Again: Imagining a YUGE Lifespan

by Leah Fowler

The new era of longevity research seeks extended healthy life, with hoped-for interventions that would slow the aging process so that one year of clock time is matched by less than one year of biological time. Infirmities of old age would compress into a short period at the end of life—thereby increasing the ‘health span’. The benefit: living long and living well. Embedded in longevity discourse is humanity’s oldest and most pervasive wish: defying death. Slowing the process of aging, it is hoped, will lead to treatments to reverse it.

Social arenas and actors at the center of longevity are grounded in big data, big investment, and a breathtaking sense that “the person who is born today will live to 200.” A prominent longevity researcher says, “It is ageist and morally repugnant to not treat aging as a disease that needs a cure.” These expectations, fueled by aging populations, are rooted in narratives that render the possible futures of long, healthy lives as inevitable and real today. Bringing the future into the present—conveying hope and fear as moral vectors— introduces an imperative to pursue the extension of the life- and health spans as a matter of course, and devalues alternatives as non-progressive or even immoral. This paper presents a qualitative analysis of longevity stakeholders discussing the moral imperative to extend human life and free of the ravages of aging. Their narratives illustrate future social imaginaries that are central to the movement and spur us to take action today.


Paper Session: Religion, Culture, and Social Sciences Paper Session 2

Sunday, Oct 22 – 9:15-10:45am

Religion Matters: A Critical Response to Daniel Weinstock’s Appraisal of Conscientious Refusal

by Nicholas Brown

Daniel Weinstock has recently argued that it is necessary to make a distinction between freedom of conscience and freedom of religion when evaluating questions of conscientious refusal. Weinstock holds a right to refusal to care on the grounds of conscience enjoys a more privileged status than refusals made on religious convictions inasmuch as he judges religious refusals to be non-essential to the flourishing of a robust democratic ethos, and because he finds religious objections to lack a sufficient epistemological and ethical rationality that is publicly “reasonable.” The purpose of this paper is to offer a response that is both critical and sympathetic. Toward that end my argument is as follows: First, I will critically evaluate the underlying epistemological assumptions undergirding Weinstock’s privileging of conscientious over religious refusals to care. More specifically I will draw upon the philosophical work of Nancey Murphy and Michael Polyani to show not only why Weinstock’s account of reasonability is inadequate, but also why a religious ratio is just as publicly accessible as a non-confessional one. Next, I will draw upon Romand Cole’s political theory to demonstrate why religious perspectives are not only vital to the flourishing of a democratic ethos, but are so precisely because they help inculcate the critical mode of conscience that Weinstock endorses. Finally, I conclude by suggesting that Lisa Sowle Cahill’s articulation of theology as a participatory mode of discourse offers a more compelling basis upon which to adjudicate the ethical tensions entailed in conscientious refusal that Weinstock rightly identifies.

The Church Amendment Reconsidered: Lost Assumptions of the First Federal Healthcare Conscience Clause

by Ronit Stahl

In the wake of Roe v. Wade (1973), Congress passed the Church Amendment, which allows doctors, nurses, and hospitals to refuse to perform abortions or sterilizations on the basis of religious or moral convictions. As the foundation of subsequent federal and state conscience clauses, the Church Amendment operates as a powerful tool that enables healthcare providers and institutions to opt out of providing—and thereby restrict access to—contested medical interventions, typically in reproductive, end-of-life, and LGBT healthcare. Yet the legislative history of the Church Amendment offers a more complicated and nuanced set of assumptions about the intended effects and implementation of the nation’s first healthcare conscience clause. This talk will discuss the presumptions about access, disclosure, scope, and impact embedded in the Church Amendment and consider the value of a countervailing narrative about conscience clauses in an era of expanding conscience legislation.

Hinduism and Bioethics: Some Basics and Some Applications

by Deepak Sarma

With an increasing number of patients with Hindu heritage and background, it is imperative that the bioethics community begins better versed in germane issues pertinent to Hindus. What, for example, is the Hindu position on brain death and organ transplantation? What sorts of neurogenomic treatments and interventions are possible given the Hindu view of the self? How do these perspectives agree, or conflict with prevailing discourses in bioethics? Since Hindus makeup only a small population of patients they are further from the ‘center’ and from most patients. Healthcare providers, in this connection, will need to expand their knowledge of those whose beliefs are not at the center.

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Interview with Incoming Social Media Editor: Monica Windholtz

This week on the blog we are featuring an interview with our newest addition to the Culture, Medicine, and Psychiatry editorial team, Monica Windholtz. Monica will be joining us as a Social Media Editor on the journal’s blog, Twitter, and Facebook accounts this month. Monica has already been featured on the blog in July with her article highlight of “Engaging with Dementia: Moral Experiments in Art and Friendship,” available here. In this post, we learn about Monica’s background, academic interests, and her ideas for expanding the Culture, Medicine, and Psychiatry blog. 


 

  1. What is your academic background? How did you become interested in medical anthropology, medical humanities, and interdisciplinary cross-society research?

Currently I am a student at Case Western Reserve University in the Integrated Graduate Studies (IGS) program, working on both a Bachelor of Arts in Medical Anthropology, and a Master of Arts in Bioethics with a special focus on the Medicine, Society, and Culture track. I also will graduate with a minor in Sociology and a certificate in Global Health. My interest in these fields began with a study of Dr. C.W. Lillehei, an American heart surgeon who helped break ground in American heart surgery and the invention of the pacemaker. As I explored the connections between health care and people, I became fascinated with the intersections of policy, procedure, and the individuals they affect. I hope to use my knowledge of these intersections to promote people-oriented policy after attending law school.

       2. What are your research interests?

My research interests include post-mortem uses of bones, cultural perceptions of death, health care policy and practice, the differences and inequalities in societal roles across the genders, and reproductive health. I am currently working on my senior capstone project: a literary review of the death rites of several cultures that considers the changes local rituals have undergone due to health problems, such as the effect of Ebola on Liberian burial.

 3. What is your favorite running feature on the blog?

My favorite running feature on the blog is the “From the Archive” series, which features article highlights and from previous CMP journal issues. It is an interesting way to highlight what types of articles have been published in the journal that are still relevant for current readers, and connects blog followers with articles they may not have previously seen.

4. What new features or ideas will you bring to the blog?

I am looking forward to expanding on Sonya’s work connecting the journal’s articles to current events. As health is an ever-changing field and its interactions with society are always shifting, it will be exciting to highlight these connections. I would also like to provide blog readers with more external content from our contributing journal authors, such as with the University of Washington Today: Q and A with Janelle Taylor post, available here, that featured a video interview with Janelle Taylor, the author of the article Engaging with Dementia: Moral Experiments in Art and Friendship.

 5. How does your unique perspective integrate with the goals of CMP?

People need to have access to relevant and validated knowledge, and a curious mind, before they can effectively implement positive and meaningful policy changes. CMP promotes the study and exploration of the types of knowledge vital to these goals. As a reader of the journal, I continue to learn a great deal about various cultures and their interaction with, and impacts on, health care. I am excited to help connect others with the articles and ideas published in CMP, and looking forward to working with the rest of the CMP editorial team!

SPA Interview with Dr. Rebecca Lester

This week on the blog we are featuring a partial summary of an interview with Dr. Rebecca Lester, conducted by Ellen Kozelka, as part of the Society for Psychological Anthropology “Voices of Experience” series. In this audio conversation, available in full here, Dr. Lester discusses her newest book project, Famished: Eating Disorders in the Era of Managed Care, focusing on the conditions and experience of eating disorders treatment in the United States. Also discussed in the interview is Dr. Lester’s research interests, reflections on her personal experience experience with an eating disorder, and the linking of anthropology to advocacy. Dr. Lester’s book is not yet for sale.

The SPA “Voices of Experience” series is a venue to showcase the range of work that psychological anthropologists engage in, and to give listeners, virtually attending the live events, the opportunity to ask prominent scholars in the field about their work.


The interview begins with a reading of the book’s preface by Dr. Lester herself. The recitation narrates the experience of an insertion of a nasogastric (NG) tube and subsequent first “feeding” of an 11-year-old girl with anorexia. Capturing the anxiety and fear of being forcibly held down for the insertion of the NG tube, and yet still being terrified of eating, Dr. Lester describes the instructions given by the doctor before inserting the NG tube. “We are going to put it in. You can either cooperate with me here, or we can take you to a seclusion room and put you in restrains and do it there. It’s your choice,” the doctor says to the girl.

The process of having an NG tube placed is extremely uncomfortable. Feeling disconnected from the world around her, exhausted from the painful NG tube ordeal, and distraught from watching “so many calories” being pumped into her body while she is unable to do anything about it, the young girl is then further mentally assaulted by another patient nearby asking her questions about her new feeding tube.

“Is [anorexia] the thing where you’re scared of getting fat so you starve yourself and you get real skinny? Hell, I wish I could have anorexia for a day,” the older patient states while laughing and grabbing at her own stomach fat. The young girl is then left to make sense of her situation while listening to the woman and another patient chatting about how much they wish they had the willpower to starve themselves as the holiday season approached.

This preface sets the tone for what it is like to be a patient in an eating disorders clinic. This reading then transitions the conversation into the interview between Dr. Lester and Ellen Kozelka.

Ellen Kozelka: What is the managed care system as it relates to eating disorders treatment, and why is it so important to understand its moral dimensions?

Dr. Lester: Managed care operates as a moral system in our society. So in terms of eating disorders, we are in a situation where our healthcare system is really predicated on a certain kind of understanding of what health is and what a person is. This is foundationally oriented to the splitting off of behavioral health and medical care.

Managed care plans have a pot of money that goes to medical care, and another pot of money is set aside for mental health, behavioral, or psychiatric care, depending on how insurance companies classify it. What’s challenging in terms of eating disorders is that they are conditions that bridge both of those domains. Certainly there are medical complications to other things, such as addictions, but we find in eating disorders this bridging of the medical and of mental health in terms of the symptomatology.

Trying to get an integrated treatment approach for eating disorders is really difficult. Clinicians are left to try and piece together care, but getting that care reimbursed is extremely difficult. Often times managed care companies will pay for the acute medical issues, such as an inpatient hospitalization because of a cardiac incident, but you then cannot also get mental health care at the same time. Or you can go to an outpatient clinic for the psychiatric concerns, but you then are not able to also be treated for the physical complication that might be going on too. Thus it is very difficult to provide a full spectrum of care to someone in a way that is actually going to treat the problem.

Kozelka: The foundation of the system in the US is that physical medical care and mental health care are two separate things, which based on this idea of what health is and what the person is. So would that make managed care in the US a type of cultural system?

Dr. Lester: Absolutely. One of the things I’ve been interested in is what kind of philosophies of the person are embedded in our healthcare system and how is that structuring or impacting the way that clinicians are perceiving what’s going on with clients, what the problem is, or how to best intervene with them. It’s a whole epistemological and world view about humans and what motivates humans, and what the appropriate end goal of that behavior should be.

Kozelka: In your book you provide an overarching definition of care. Care “orchestrates cognitive and sensory attunement, practical agency, and affective imagination into a disposition to the ‘other’ which comes to organize attention, doing, and feeling in locally meaningful ways.” This definition of care combines two previously separate conceptual definitions of care as practical or political action, and care as affective concern. How do you see this combination linking to your understanding of care in relation to power?

Dr. Lester: Something that many of us as psychological anthropologists struggle to do in our work is try to illuminate the ways that these are not different domains. When we talk about political or practical action, and we talk about affective experience or subjective experience, they are not separate domains. We can separate them ideologically, but in terms of the way people live their lives, the domains are intertwined.

Part of what I’ve been interested in is how these structures of power operate across multiple levels of analysis at once. Care in all of the senses of the definition above, is a way of constituting not only an object of concern, but who the subject of care is, and how that person is constituted as a moral agent, or not, in a given circumstance. We have to look at how political and practical components of care are connecting and interacting with the affective dimensions and the subjective experience of care. That is where you see psychological anthropology coming in and trying to theorize about what these connections are in a way that’s rigorous and ethnographically grounded.

Kozelka: How do these moral dimensions of care, in terms of whether the or not the individual is considered to be a “good patient,” relate to the actions that these managed care systems either take or don’t take?

Dr. Lester: There are different ways of thinking about a patient, such as framing the patient as a moral actor, or discussing the patient in relation to her own quest for health, whatever that is. In the case of eating disorders, it can become a situation where it almost does not matter what the patient does. It does matter, but the same action can be interpreted in a variety of ways depending on how you are thinking about that actor as a moral agent or not.

Compliance and non-compliance are big concerns in all of healthcare, certainly in behavioral health, but particularly in the field of eating disorders where patients are historically thought to be non-compliant, resistant, or really difficult to work with. Managed care companies have concerns about patient complying with the treatment recommendations. What I saw again and again is that it almost did not matter what the patient did. There would be times where they were complying, following the regulations and meal plans, and doing what they were supposed to do. But the insurance companies were skeptical of the motivations for this behavior, so that even when clients were complying with treatment, their compliance was sometimes read as manipulation. That’s just an example of how these moral dimensions, or how you constitute the recipient of care as a moral agent or not, affects the way that care is delivered, almost regardless of what the person is actually doing.

Kozelka: In this system were patients are constantly being scrutinized, how do you think these factors affect their experience of treatment?

Dr. Lester: It’s horrible. It would be miserable for any of us to be in that circumstance. This is particularly challenging for these patients because a lot of the dynamics experienced during the course of treatment itself are the exact same issues that they are already struggling with. These are questions like, “Are you worthy of care,” “Are you worthy of attention,” “Are you worthy of time,” and “Do you matter?” These questions are really at the core of eating disorders for a lot of people.

Dr. Rebecca Lester, via Washington University in St. Louis Dept of Anthropology website

Patients are being told they should not always be monitoring or surveying themselves, yet at the same time, because of the kinds of things that the insurance companies care about in order to make their decisions, patients are being constantly monitored and evaluated. There is a constant, pervasive insecurity that pervades that clinic where you do not know from one day to the next if someone is going to be deemed “sick enough” to still need care, “too sick” to remain there, “invested enough” in her recovery, or “invested too much in her recovery” and thus deemed as manipulative. It is this constant uncertainty and people trying to make themselves into appropriate patients just so that they can get care.

This does not address the underlying issues that are going on. So this scrutiny affects them a lot, especially when clients want treatment, doctors say they need treatment, but insurance companies say “No.” There are even discussions among the clinicians, expressing that “if only she were cutting, because then we could get her treatments.”

Further, the patients may not even be able to deal with some of the underlying things that possibly got them to the eating disorder because they are so busy dealing with the feelings around not being worthy of getting treatment. If the insurance companies deny them, they cannot get treatment. There is a case I discuss in the book of a 14 year-old teenager who was struggling with anorexia in the clinic. Her weight had gone up a bit during the two or three weeks she was admitted and making progress. But then her insurance ran out, and the family did not have the financial resources to afford the $1,200 a day price tag. Their only option was to get the teenager into a research study going on at a local university where a randomly assigned treatment group would get free therapy. The problem was that she had gained too much weight for the regulations of the study, forcing the clinic staff to put her on a diet at the treatment center in order to get her down in weight enough so that she could get free treatment. That was the only option besides merely discharging her with no support.

Kozelka: What do you think the study of self brings to anthropology as a whole?

Dr. Lester: It’s absolutely critical. The self as a general category is about why people do what they do. We cannot understand why, or effectively theorize about why, unless we are willing to engage with questions about parts of experience that we cannot directly observe. We have to be open and flexible enough to understand different ways that different groups of people comprehend the components of what makes up a person, how to understand motivation, or whatever we want to call why people do things. It is imperative if we, as a field, want to have something useful to say.


The interview with Dr. Lester continues, and concludes with a question and answer session with listeners who were virtually tuned in during the live recording of the interview. The full audio interview recording is available here.


Dr. Rebecca Lester is an Associate Professor of Sociocultural Anthropology at Washington University in St. Louis, and a practicing clinical social worker. Her interests include how individuals experience existential distress, and how this distress manifests as psychiatric symptoms, religious angst, somatic pain, and other culturally informed bodily conditions.  Specifically, she considers how bodily practices deemed “deviant,” “extreme,” or “pathological” – and local responses to such practices – make visible competing cultural logics of acceptable moral personhood. Along with her many publications and previous book, Jesus in our Wombs: Embodying Modernity in a Mexican Convent (2005) from the University of California Press, Dr. Lester is also the founder, Executive Director, and a psychotherapist of the non-profit Foundation for Applied Psychiatric Anthropology.

Ellen Kozelka is a graduate student at University of California, San Diego.

In the News: “Life After the Storm” and the Psychological Impacts of Hurricane Survivorship

In our In the News post this week, we are discussing the lasting psychological impacts people face after surviving a large natural disaster event, such as the string of recent hurricanes battering the United States and the Caribbean. Building from a recent New York Times article by Benedict Carey entitled Life After the Storm: Children Who Survived Katrina Offer Lessons, available here, this post discusses how lasting damage from natural disasters can be much more than physical and economic.


September 2017. Benedict begins his article by sharing the story of Craig Jones, now 22 years old, who was in fifth grade when Hurricane Katrina in 2005 devastated his neighborhood of Pigeon Town in New Orleans. After spending years on the move, living between hotel rooms, Jones returned to New Orleans in his late teens. He remembers that “home” was not the same place he had left, and his “homesickness” became troubling anxiety and seemingly random panic attacks.

Lacey Lawrence, 22, at work in New Orleans. She escaped the floods of Hurricane Katrina on an air mattress. Now she teaches children coping skills. Credit: Annie Flanagan for The New York Times

Another survivor, Lacey Lawrence, now 22, escaped the water of Hurricane Katrina on an air mattress. Lawrence recalls the experience of seeing police officers pushing away floating bodies with oars, missing and uncle who presumably drowned, and wondering where a young cousin disappeared to for several hours. Later, at a new school, Lawrence was ill-equipped to deal with her experience. “I was getting into fights; real fights, violent ones. That was something I never did before, ever. But you lose everything and you don’t know how to deal with it – no one prepares you for that” (Benedict 2017).

Studying the psychological impacts from previous hurricanes may offer hints of what may be to come for those who have survived Hurricane Harvey, Irma, and most recently, Maria. Mental health providers and social scientists are acutely aware of the unpredictable traumatic consequences which can emanate from surviving natural disasters. Yet the impacts of surviving a hurricane may be unique.

Benedict (2017) writes, “Unlike an earthquake or a fire, flooding from a storm like Katrina or Harvey leaves many houses and buildings still physically standing but uninhabitable, simultaneously familiar and strange, like a loved one sinking into dementia.”

In a series of publications from the Stress & Development Laboratory at the University of Washington, the research teams concluded that the prevalence of “serious emotional disturbance” (SED) in young adults after exposure to Hurricane Katrina remained significantly elevated several years after their experience of the storm (McLaughlin et al. 2010). The prevalence of SED among young adults who experienced Hurricane Katrina was considerably greater than the pre-hurricane prevalence. According to a 2010 study, approximately 8% of youths were estimated to have SED that is directly attributable to their experience of the hurricane. Further, the majority of adults who developed posttraumatic stress disorder (PTSD) after Katrina, including delayed onset PTSD, did not recover within 18-27 months (McLaughlin et al. 2011).

Prior to Hurricane Katrina, the majority of the literature focuses on the prevalence of and risk for the development of mental health problems following a storm or hurricane. For example, a study of the presence of PTSD symptoms after Hurricane Mitch in 1998 in a low-income area of Nicaragua found that the occurrence of PTSD in the areas with the least damage was 4.5%, while the most damaged areas was 9% (Davis, Tarcza, and Munson 2009). Variables such as low social support, prior exposure to traumas, and poor health status were found to be universally predictive of psychopathology symptoms (Davis, Tarcza, and Munson 2009).

A 2005 study by Fried, Domino, and Shadle looked at the use of mental health services after Hurricane Floyd in 1999 and found that visits to psychologists, licensed clinical social workers, and physicians for mental health reasons were higher in affected areas after the hurricane. However, inpatient admissions and the money spent on anti-anxiety medications decreased, indicating that there were likely problems with service delivery for those that did seek help (Davis, Tarcza, and Munson 2009).

Flooded homes are shown near Lake Houston on Aug. 30 after Hurricane Harvey hit the Houston area.
Photo from NPR: Win McNamee/Getty Images

In the aftermath of Hurricane Harvey, Texas officials were “scrambling to coordinate mental health support” and the state’s psychology board issued temporary practice licenses for out-of-state therapists (Benedict 2017).

In a recent CNN article, Jesse Cougle, an associate professor of psychology at Florida State University, said that the people who stared and witnessed the destruction of Hurricane Irma will likely experience worse mental health problems than those who evacuated (Scutti 2017).

Chief of emergency mental health and traumatic stress services branch at the Substance Abuse and Mental Health Services Administration, Capt. Maryann Robinson, stated that “when you go home and now you are actually faced with what has happened — the devastation that has occurred in your home — it really does re-traumatize the individual” (Scutti 2017).

Overall, anticipating the consequences for major hurricanes should encompass more than disaster preparedness schemes and evacuations routes. Multi-state collaborations

Katrina’s young survivors, now older and reflecting on their experiences, say that “overcoming the mental strain of displacement is like escaping the rising water itself – a matter of finding something to hold onto, one safe place or reliable person, each time you move” (Benedict 2017).


References Cited:

Davis T.E., Tarcza E.V., Munson M.S. (2009) The Psychological Impact of Hurricanes and Storms on Adults. In: Cherry K. (eds) Lifespan Perspectives on Natural Disasters. Springer, New York, NY. Pp. 97-112. (Available here: http://stressdevelopmentlab.org/publications)

McLaughlin, K. A., Berglund, P., Gruber, M. J., Kessler, R. C., Sampson, N. A., & Zaslavsky, A. M. (2011). Recovery from PTSD following Hurricane Katrina. Depression and anxiety, 28(6):439-446. (Available here: http://stressdevelopmentlab.org/publications)

McLaughlin, K. A., Fairbank, J. A., Gruber, M. J., Jones, R. T., Osofsky, J. D., Pfefferbaum, B., … & Kessler, R. C. (2010). Trends in serious emotional disturbance among youths exposed to Hurricane Katrina. Journal of the American Academy of Child & Adolescent Psychiatry, 49(10):990-1000. (Available here: http://stressdevelopmentlab.org/publications)

Carey, Benedict. (September 8, 2017) Life After the Storm: Children Who Survived Katrina Offer Lessons. The New York Times. Available here: https://www.nytimes.com/2017/09/08/health/katrina-harvey-children.html?rref=collection%2Fsectioncollection%2Fhealth&_r=0

Scutti, Susan. (September 20, 2017) Resilience, suffering and silver liniings after a disaster. CNN. Available here: http://www.cnn.com/2017/09/19/health/psychological-aftermath-hurricanes-harvey-irma/index.html


Further Reading:

Davis III, Thompson, Amie Grills-Taquechel, and Thomas Ollendick. (2010) The Psychological Impact From Hurricane Katrina: Effects of Displacement and Trauma Exposure on University Students. Behav Ther 41(3):340-349.

Domonoske, Camila. (September 26, 2017) Long After The Hurricanes Have Passes, Hard Work – And Hazards – Remain. NPR. Available here: http://www.npr.org/sections/thetwo-way/2017/09/26/552063244/long-after-the-hurricanes-have-passed-hard-work-and-hazards-remain

Fothergill, Alice, and Lori Peek (2015) Children of Katrina. Austin: University of Texas Press. Available here https://utpress.utexas.edu/books/fothergill-peek-children-of-katrina

McLaughlin, K.A., Fairbanks, J.A., Gruber, M., Jones, R.T., Pfefferbaum, B., Sampson, N., & Kessler, R.C. (2009). Serious emotional disturbance among youth exposed to Hurricane Katrina two years post-disaster. Journal of the American Academy of Child and Adolescent Psychiatry, 48:1069-1078. (Available here: http://stressdevelopmentlab.org/publications)

Shear, M. K., McLaughlin, K. A., Ghesquiere, A., Gruber, M. J., Sampson, N. A., & Kessler, R. C. (2011). Complicated grief associated with Hurricane Katrina. Depression and Anxiety, 28(8):648-657. (Available here: http://stressdevelopmentlab.org/publications)

Article Highlight: Vol. 41, Issue 3, “Shame, Blame, and Status Incongruity: Health and Stigma in Rural Brazil and the Urban United Arab Emirates”

This week on the blog we are highlighting a paper by Lesley Jo Weaver and Sarah Trainer entitled Shame, Blame, and Status Incongruity: Health and Stigma in Rural Brazil and the Urban United Arab Emirates. The authors build on sociologist Erving Goffman’s classic notion of stigma as a social phenomenon to investigate the stigma attached to two seemingly disparate conditions: food insecurity in rural Brazil, and obesity in the urban United Arab Emirates. The authors’ analyses emphasize that both circumstances are stigmatized because they represent a deviation from a deeply-held social norm. Additionally, in both cases, the stigma related with food insecurity and obesity is likely at least as damaging to personal wellbeing as are the biological effects of these conditions. To close, Weaver and Trainer suggest that these forms of stigma transcend individuals and are principally structural in their origins. Viewing stigma as a common element of the human condition refocuses the analytic lens toward structural-level factors that need to be addressed in order to improve human wellbeing.


Weaver and Trainer begin by discussing the theoretical grounding of stigma. Frequently defined as an indicator of disgrace signifying physical, moral, or social flaw, stigma is a powerful determinant of physical and mental health. Whether externally imposed by others or internalized and self-directed, stigma may come from or produce feelings of shame and embarrassment. Sociologist Erving Goffman described stigma as a “single social process uniting a dizzying range of conditions and behaviors… Stigma is stigma because it is ‘fundamentally discrediting’—that is, it is perceived to index something inherently negative about a person.”

Precisely because stigma draws on core beliefs held by mainstream society and has consequences for both physical and mental health, stigma should be a public health concern. Having a unitary conception of stigma can be operationalized as status incongruity—that is, the potentially measurable difference between culturally held attitudes of what people should be or achieve in a given realm, and what they are actually able to be or achieve.

Food insecurity is defined as a lack of secure access to safe and culturally appropriate foods at all times. Food security is often stigmatized since it may be a public symbol of poverty, or force one to have to obtain food in socially unacceptable ways. Even when not visible, food insecurity often generates self-directed stigma, often with damaging psychological impacts and experiences of status incongruity.

While clinically obese bodies are an epidemiological norm worldwide, they are rarely socially normalized in modern Western cultures. Further, evidence suggests that obesity stigma has increased along with increasing global obesity. Obesity cannot easily be hidden, and therefore stigma acts through both internal shame and external blame, which distinguishes it in profound ways from food insecurity. Stereotypically, obesity stigma stems from a combination of Western beauty ideals of aesthetic thinness and increased risk of ill health, along with moral beliefs that obesity signals lack of control. Further, obesity now can serve as a visible marker of poverty in many cultural settings, signaling status incongruity.

The authors discuss two different case studies—Brazil and the UAE—precisely because the severity of the differences between the settings exemplifies the powerful underlying similarities in the ways stigma influences health and well-being through feelings of shame, blame, status incongruity, and social isolation.

Weaver’s research in rural Northern Brazil focused largely around food insecurity and mental health. Ethnographic research conducted in urban Brazil establishes that bodies are read as high or low status, and weight and body shape are a key part of that. There is also an agreed-upon set of factors that signal the “good life.” These signals include things such as the ownership of a television and computer, participation in leisure activities, and the attainment of a desirable body shape. Some food items signal luxury and abundance while others carry stigma because they indicate humbleness, if not outright poverty.

Household food insecurity scores collected from pilot study phases were associated rather strongly with symptoms of depression among heads of household. The depression associated with food insecurity in this setting may be a result of the understandable stresses of having limited resources, but potentially also a result of the shame related to having to eat low-status foods or engage in non-normative food behaviors, such not being able to invite neighbors to eat or reciprocate sharing food.

Many people reported that they were unaware of food insecurity in the community, despite the authors’ documentation of its frequency. It appears in this setting that the harmful effects of food insecurity on mental health might stem more from self-stigmatization of one’s own food insecurity than from active stigmatization by others. The authors state they suspect that shame and self-stigma surrounding food insecurity motivates people to hide it.

In the United Arab Emirates, the authors’ discussion of stigma focuses on interwoven behavioral and aesthetic norms, and stigma related to perceptions of deviations from these norms. Food and eating patterns, as well as bodies and body norms, have seen particularly profound changes over the course of only twenty or thirty years of intense socioeconomic, structural, and cultural shifts. Despite the conspicuous consumption and wealth on display in the UAE, poverty and food insecurity are also present within the local population and foreign workers, but again the social pressure to hide such deprivation was intense.

Much more publicly considered in the UAE is the growing apprehension over obesity and associated chronic diseases. While “fatness” was once a desirable physical characteristic, especially in women who were expected to “fill out their skins” in order to display familial wealth, today young people reliably express physical female beauty ideals that aspire to an hour-glass shape, while stigmatizing bodies categorized as too fat or too skinny.

At issue here are “bodies that don’t conform.” The implications of lack of cultural consonance with body norms in this context are serious. In the UAE, the recipients of stigma are very thin or obese bodies, and in Brazil, the recipients are people experiencing food insecurity. The moral discourse around these issues, the ways in which this stigma is enacted, and the importance of specific types of stigma over others varies in important ways between research sites, however. The relative importance of internal versus external stigma in each case is likely related to the fact that one condition (food insecurity) can be hidden, while the other (obesity) cannot.

For the authors, a second common element linking these two cases of stigma is the fact that each signifies a departure from a social norm, accompanied by intense social isolation. Third, both food insecurity and obesity have well documented consequences for physical health, as well as important but poorly understood consequences for mental and social health. Weaver and Trainer states that these common features suggest stigma around food insecurity and obesity can be conceptualized as two “outlets” for the same social phenomenon: “health stigma.”

The authors conclude by asserting a useful implication of considering stigma as a single social phenomenon is that it refocuses away from the individual and toward structural causes of stigma. While the everyday issue of stigma is enacted on the individual level, stigma is only stigma because people concur at a larger population level that a position is stigma-worthy. Focusing on the commonalities between stigma experiences functions as an important reminder that stigma is not just personal but also collective. Policy implications of stigma-as-structure have largely been overlooked.

Book Review: “A Surgeon in the Village”

This week we are highlighting a book review written by Veronica Tomasic originally published in MedHum Daily Dose, a blog for the intersections of medicine and humanities, available here. The book is entitled A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa (2017) by Tony Bartelme, published by Beacon Press.


A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa (Beacon Press, 2017) is the story of American neurosurgeon Dr. Dilan Ellegala’s efforts to provide medical aid in Tanzania. It was written by Tony Bartelme, an American reporter for Charleston, South Carolina’s Post and Courier; Bartelme is a three time Pulitzer prize finalist, including for the series that formed the basis for this book. The Post and Courier’s executive editor relayed a story to Bartelme about a “crazy brain surgeon who opened a guy’s head with a wire saw in Africa”; Bartelme’s interest was piqued and thus began the story that he narrates here (269).

A Surgeon in the Village is a bildungsroman of sorts. It describes the beginning of Ellegala’s career as a neurosurgeon and his personal journey toward finding meaning in his work. It is also about his ideas for how foreign medical aid should be delivered, and the growth of an organization, Madaktari Africa (Madaktari means doctors in Swahili), that he formed as a result of his ideas.

We first meet Ellegala when he has just completed his neurosurgery training in the US. He is burned out after years of grueling residency and fellowship programs. He travels to Tanzania for six months, volunteering to perform brain surgery at a small, remote hospital. Ellegala is determined to spend as much time as possible vacationing while there. But his plan changes after he starts to attend daily morning meetings where the visiting foreign students and MDs, and local medical personnel gather to discuss their cases. Ellegala observes that the foreign students sit in a privileged position at the front of the room, while the local personnel — such as assistant medical officers (or “AMOs,” who have paramedic plus a few years’ level of training) — stand at the back of the room. This disturbs his sense of propriety — in the US, medical students typically stand or sit behind attendings and residents. He insists that the students and local personnel trade places, a shift that becomes a central organizing metaphor for the book. The change symbolizes the degree of responsibility Ellegala believes the local staff should have for the care they provide, and the respect he feels they should be shown by foreign visitors.

Galvanized, Ellegala starts to rethink traditional models for providing aid in Tanzania, a country with limited resources to train and keep its own MDs. Rather than encourage foreign MDs to travel to a hospital, perform surgeries for a brief period of time and then leave, Ellegala realizes that it makes more sense to train local AMOs to perform neurosurgical procedures. If they can take over, he reasons, a hospital will transition from being dependent on outside help to being self-sustaining. Ellegala notices an AMO who has a surgeon’s confidence about him, Emmanuel Mayyega, and he trains him to diagnose and perform operations for a number of conditions, such as intracranial tumors, head trauma, and hydrocephalus. Eventually, Mayyega trains others. And thus began the “train forward” movement in Tanzania.

Bartelme weaves through his account the challenges Ellegala faces in his career as he devotes time, money, and considerable energy to Madaktari Africa. He also describes some of the ethical issues that are raised by the “train forward” practice. For example, should we accept that people will die in countries where there are not enough traditionally-trained MD surgeons to perform surgeries? Or should surgeries in these countries be performed by people with limited training and supervision because they can save lives? And what about the liability exposure for people trained under such circumstances? One area where the book could have been strengthened would have been to devote a chapter to the history of aid organizations and their varied philosophies. While mention of organizations such as Smile Train, or Paul Farmer’s Partners in Health, among others, are interspersed throughout the book, it was never clear to me whether Ellegala was the first person to conceptualize “train forward,” or whether such a practice had already been established in other countries.

Altogether, A Surgeon in the Village is a warmly engaging account of one doctor’s efforts to make a difference in a part of the world that has limited medical resources, and the personal rewards his efforts afforded him. It would be useful for medical providers and students to read, as well as anyone interested in how best to provide aid to other countries.


Veronica Tomasic (PhD, JD) practices community law in the New Haven, CT, area. She is a scholar of literature, painting, psychoanalytic theory, and end-of-life issues.

For more information about the book, visit the Beacon Press website, here.

Article Highlight: Vol. 41, Issue 3, “Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya”

This week we are highlighting an article from our most recent journal issue, Vol. 41 Issue 3, entitled Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya, by Christine Musyimi, Victoria Mutiso, David Ndetei, David Henderson, and Joske Bunders. Their study aims to determine the outcomes of using the evidence-based mental health Global Action Programme Intervention Guide to provide psychosocial interventions among depressed patients seeking care from Traditional health Practitioners (THPs). Their work is the first documented interventional study to investigate the outcomes of psychosocial interventions among THPs’ patients in Kenya. The authors argue that it is crucial to engage THPs in the care of patients with depression and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers to promote evidence-based care among marginalized populations.


During this study, Traditional health Practitioners (THPs) were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck’s Depression Inventory (BDI). The authors emphasize that THPs are trusted by community members and appropriately understand the community cultural and social norms due to their interaction with different individuals in their routine practice and the nature of traditional systems of care. Additionally, THPs’ services are usually more easily accessible and cost effective.

According to the authors, task-shifting can be defined as the rational redistribution of tasks among health workforce teams with an aim of making efficient use of available human resources for health. This approach has proved to be a very strong potential strategy for reducing global mental health challenges through identification and appropriate management of mental disorders. In a task-shifting model, THPs classified as traditional and faith healers may be incorporated into existing mental health services by using their cultural acceptability to deliver treatment. They may also be used as a way to mitigate the shortage of mental health specialists. THPs are widespread in Africa and are consulted for psychosocial problems.

Previous studies have shown that THPs use prayer, holy water, morality-based guidance, dietary advice, massage, and herbs as common treatment modalities. THPs have furthermore demonstrated willingness to collaborate with “conventional” workers in mental health care. For the authors, this willingness offers an excellent opportunity since consulting THPs is considered a more popular choice of first help-seeking contact for patients. Often, THPs do home visits, which is more convenient and acceptable to patients and family members. In addition, the consultation fee for THPs’ patients is either waived, paid in kind, in installments, or on recovery. As a result, THPs are considered to be reliable source for care and can still be sought in a more difficult financial situation.

The mental health Global Action Programme Intervention guide (mhGAP-IG) is a model-guide and helps non-specialists to identify and manage priority mental health problems, such as depression, psychosis, bipolar disorder, epilepsy, developmental disorders, behavioral disorders, dementia, alcohol use disorders, drug use disorders, suicide, and self-harm. Its efficacy has also been tested among non-specialized health workers, including traditional and faith healers in Africa, and shows a statistically significant improvement in knowledge among participants after training. The authors maintain that this is promising evidence that non-specialized health-care providers can be successfully trained to deliver a basic package of interventions for providing care and treatment for people with mental, neurological and substance use disorders.

This study involved training THPs to identify and deliver evidence-based mhGAP-IG psychosocial interventions to their patients screening positive for depression. A total of 377 patients screened positive for mild to severe depression using BDI were recruited into the study. Psychosocial interventions, such as cognitive behavior therapy or problem solving, were then described in detail to THPs. This gave the THPs an understanding of what to do, as listed under mhGAP-IG, in the depression component at the initial contact and one or two subsequent visits, depending on the severity of the patient’s symptoms. The outcomes of the intervention among THPs’ patients were measured at 6 weeks and 12 weeks from the initial assessment by determining the change in their depressive scores using BDI. Overall, the BDI mean score was 26.52 before intervention, and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention.

Based on their research, the authors argue that patients seeking care from THPs are responsive to psychosocial interventions as delivered by the healers. Patients recovered symptomatically, showing significant improvements at all time points after treatment. The authors state that consistent with other studies, psychosocial interventions have been shown to reduce depressive symptoms in primary care settings.

The authors conclude that the overall improvement of the patients in their study at 3 months is higher than the response rates seen among depressed outpatients followed over a period of one year in public sector clinics in the United States. A systematic review on enhancing antidepressant therapy with non-pharmacological interventions directed at improving the treatment of depression by Oestergaard and Møldrup (2011), has demonstrated that psychosocial interventions such as psychotherapy produce superior results at follow-up in terms of preventing recurrence and yields effects that cannot be detected by antidepressants including the quality of interpersonal relationships and coping skills.


References Cited:

Oestergaard, S., and C. Møldrup

2011        Improving Outcomes for Patients with Depression by Enhancing Antidepressant Therapy with Non-pharmacological Interventions: A Systematic Review of Reviews. Public Health 125: 357–367.