Episode 10: Emily Mendenhall on COVID-19, Syndemics, and Community

In this episode of the Global Health Politics Podcast, I sit down with Georgetown University anthropologist Emily Mendenhall to discuss her book, Unmasked: COVID, Community, and the Case of Okoboji. We talk about her past work on non-communicable diseases, particularly diabetes and mental health, and her concept of syndemics, which examines how multiple health and social conditions intersect.

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Global Health Politics Podcast
Episode 10: A Conversation with Emily Mendenhall on COVID-19, Syndemics, and Community

Joseph Harris  00:00

Welcome to the Global Health Politics Podcast, where we go beyond the articles and books and have real intimate conversations with people working in the field of global health today. I'm your host, Joseph Harris

Emily Mendenhall  00:20

That's such a good question. I grew up in rural Iowa, and the two paths for careers were to be a doctor or a farmer. So I thought I would be a doctor. And so I started taking, you know, really loved science; I was almost a chemistry minor. But then I started taking bioethics and other feminist theory, and I realized I wanted to do something more interdisciplinary. And one thing led to another, and I wrote an honors thesis where I had spent a couple of months in different indigenous communities. So I spent six weeks with a Mapuche cultural broker; she was a midwife and cultural broker, basically at a hospital in Chile. And then I spent a month in western Zambia with this Lozi midwife, learning about how she cared for women and really worked between medicine and belief, and just changed how I thought about everything. So I paused the idea of medicine and wanted to explore public health: it felt more natural. But then, when I went to study public health, I met Peter Brown at Emory, a medical anthropologist, and Sarah Willen and this whole community of people, and I realized that the way that I was thinking was a little bit deeper than behavioral interventions or kind of the ways in which medicine stopped at the body or, you know, the ways in which public health answered questions without digging deeper to the root causes. So I wanted to do more work in explore anthropology after I'd been working in Zambia again; I'd gone back and worked for two years on this project in Zambia while I was at Emory and public health, and it opened some doors to just think deeper. So I ended up returning to anthropology after that.

Joseph Harris  00:30

So today, I'm really pleased to be here with Dr. Emily Mendenhall, a leading medical anthropologist of global health and professor at the Edmund A. Walsh School of Foreign Service at Georgetown University. Dr. Mendenhall has written four books that include Syndemic, Suffering, Global mental health, Rethinking Diabetes and her latest, Unmasked: COVID community and the case of Okoboji, which she will talk about today at The Global Health politics workshop. In 2017, she led a series in the Lancet on syndemics, a theory of how and why social and health conditions travel together. Dr Mendenhall is co- editor in chief of Social Science and Medicine: Mental Health and was recently named a Guggenheim Fellow. Congratulations on that most recent honor, and thanks for coming to speak today at the Global Health Politics Workshop and joining the Global Health Politics Podcast! 

Emily Mendenhall  01:25

Well, it's great to be here. 

Joseph Harris  01:27

So you've made some really important contributions to the field of global health. What drew you to work on global health issues, and why did you choose to become an anthropologist?  Interesting, thanks. Now, while your most recent book explores COVID 19, a number of your books have explored noncommunicable diseases, including depression, diabetes, mental health. Why noncommunicable disease and why there's issues in particular?

Emily Mendenhall  03:57

 Well, we all fall into certain things, so I actually had been working on basically HIV and therapy for couples with discordancy in Zambia, and I went to work on this HIV project in Guatemala after I finished my public health program. After a year, I realized it wasn't working out. I had a great time, but I moved to Chicago and got a job at Cook County Hospital. And, you know, it's hard to get a job with an MPH in the US to do community therapy, and I wanted to do more community therapy work, but I didn't have an MSW, so I couldn't get this job. But I found this incredible scholar, a health services researcher, Elizabeth Jacobs, working at Cook County; she hired me. During that time, I ended up just throwing in a couple of applications for PhD programs in anthropology at the University of Chicago and Northwestern. I ended up getting into Northwestern, so I worked at Cook County Hospital for those five years in the study with this woman, Elizabeth Jacobs, who was on diabetes, immigration, and healthcare. I got really into it; I was still speaking Spanish and working with the Central American community, mostly Mexican immigrants in the county, but it was all on diabetes. When I was working on this project on diabetes, I realized that everyone wanted to talk about trauma, and that it kept coming to the surface. I realized that I could study the same questions that I had, which were about structural liminality, trauma, embodiment, and well-being through the prism of diabetes. That's kind of how I got into studying diabetes. I ended up continuing that work for my dissertation, and I worked at Cook County actually the whole time I was working on my PhD, because it felt really grounding. I was kind of in the field the whole time, working on projects on the side with this incredibly inspirational team at the Collaborative Research Unit at Cook County.And then, I ended up getting a postdoc because I ended up writing on trauma and diabetes for my dissertation through a syndemic lens. I actually wrote three chapters of my dissertation on embodiment and the relationship between trauma and diabetes. I sent it to this anthropologist, a friend of mine, Kenny Mays, to read it, and he wrote back, saying, 'You know, you're writing about syndemics,' and I was like, 'What is that?' No one at Northwestern had ever introduced me to the idea or the term. I spent a month reading everything I could, thinking and figuring out what this meant, and it resonated so strongly with the different kinds of literature I was reading. It felt like a way to communicate this work in a clear way that could be transdisciplinary. I rewrote everything. So that's how I got into syndemics. I ended up being a Fogarty fellow, which brought me to India, and then I went to South Africa and Kenya and did this comparative work, partly because the epidemiological trends were emerging in the early 2010s, looking at how diabetes was affecting low-income populations. So I was just really curious about it.

Joseph Harris  07:09

That's interesting. Well, you mentioned this idea of syndemics, and this is a term that you've helped to popularize quite a lot in your work. And this is an idea that points to the way some health and social conditions travel together. Could you say a bit more for our listeners about what you mean by syndemics and why it's such a powerful and important idea?

Emily Mendenhall  07:31

Syndemics is, in some ways, very strategic, but also a simple idea. Syndemics, in a way, forces us to rethink the idea of epidemics. I have interviewed people around the world and never met anyone with one problem. Often, those problems aren't just physical or medical. They're social, they're psychological, they're emotional; they're multiple conditions. They might be metabolic and infectious that are interacting and affect lived experience at the individual level. We know people do not experience one disease alone, but we know that's also true for populations. Syndemics push us to think about how certain conditions can be intervened upon upstream to mitigate the impacts or interactions of more than one condition within a population. A great example is TB and HIV, or HIV and Hep C, and how these infections cluster together. But I think it's particularly pernicious when we think about less visible conditions, from heart disease to hypertension to cardio metabolic diseases that then interact and undermine the immune system's response to infections. Also, of course, mental health, which is always kind of a secret burden people carry, especially when living with chronic illness. Syndemics require us to think about these social and medical conditions that travel together and become hidden in the ways we think about policy and the way we organize care. Still, we have loads of evidence from decades and centuries about how social and economic interventions upstream can be radically impactful, especially for lower-income people in the world. Social uplift can elevate health better than anything. We know that there have been debates in public health since the 17th, 18th, and 19th centuries about how to do this. We also have so much evidence that integrative primary health care really matters. These debates continue despite the fact that we know it really works. That's one of the ways in which thinking syndemically pushes us to think about radically caring for people.

Joseph Harris  09:51

That's wonderful!  And you recently encouraged us in a 2020, Lancet piece, to think of COVID 19. But not as an epidemic, but as a syndemic that differs based on context. The point here being that syndemics themselves cannot be global as pandemics can. Could you say a bit more about that?

Emily Mendenhall  10:11

Well, if you followed this, Richard Horton and I have been having this little debate in the last bit. I led the series in 2017 about what syndemics are, and then a couple of years later, he hosted a commission on global syndemics, and I was pretty outraged. I wrote a response, which they published along with the series on global syndemics, basically saying that global syndemics cannot happen and that saying that syndemics are global undermines the histories of inequality and oppression that undemines  syndemic clustering. Why do some communities, why are they disproportionately affected by social inequality, or, you know, segregation, housing, food policies, enslavement, genocide? All of these have deep histories, colonialism, and how they become embedded and embodied in present-day health conditions. How do we recognize and think about reparations? How do we think about certain communities that have been disenfranchised or dislocated from loci of power? Taking seriously local histories and local epidemiology matters for important political reasons, but also epidemiological reasons. So it was interesting. Meryl Singer and I responded to this global syndemics commission, and it was great. Richard's always been really open to our kind of response. He has this offline blog where he wrote, you know, "COVID is not a pandemic; it's syndemic." I was like, "Oh my God, he's doing it again." So I sat down, all fired up, and wrote 300 words off, you know, and sent it. I said it is not global because it erases these really important histories. But also, it can't be global. If we look at New Zealand at that moment, New Zealand was closed, and it has histories of inequality and oppression, especially racial disenfranchisement, specifically of the minority. We see a lot of similar trends among indigenous groups of the Māori, specifically in New Zealand, and white settlers in New Zealand too, as we do in the US. There are some similarities there, obviously completely different contexts, histories, and populations, but it would be easy to see the kind of fault lines of society being affected by COVID-19 and underlying conditions in New Zealand if the politics were the same, but the politics weren't the same. Inherently, the politics are part of this endemic, and that was the argument that I was making there.

Joseph Harris  12:41

I want to go back to this point earlier that we discussed about non communicable diseases. And obviously you mentioned that a little bit in the way we think about syndemics. But do you think, in your view,  that noncommunicable diseases remain a sort of neglected area, both in the field of global health, you know, as it's done in practice, but also within Global Health scholarship?

Speaker 1  13:10

Emily Mendenhall  13:13

Well, I think it's shifted. I think there's been a lot more attention to non-communicable diseases in the last 10 years. But I think all of this comes down to money. If we think about where all of the money goes in global health, continually, it's through PEPFAR, it's the Global Fund, it's Gavi; it's really prioritizing infectious diseases. And I think until we change the ways in which we think about the financial arrangements in development, the scholarship will follow the funding structure. I think that what we even do as scholars reflects those funding priorities and financial preservations of historic inequalities of what medicine prioritizes. So I think, yeah, NCDs, neglected tropical diseases, mental health—all of these injuries and conditions continue to be marginalized partly because of these financial prioritizations. I think people are talking about it more than they used to be. There is more integrated care, but just like we were talking about earlier, that's still marginalized in part because it's perceived to be more expensive, even though, probably in the long term, it's not. If we think about how much money has been put into PEPFAR and how that could be reorganized to uplift clinics themselves. This is a bigger debate, but I really think it comes down to that.

Joseph Harris  14:46

Now you occupying an really interesting position as a medical anthropologist who's published books with top university presses and articles at leading journals within the discipline of anthropology, and at the same time, you've made major marketing field of public health, publishing multiple times in the Lancet and other leading public health and medical journals. Could you share a bit for our listeners about what it's like to walk in those two worlds? Do you see them as two different worlds, and is there a world you prefer? What does your conference circuit look like? I'll share with us a little bit about what it's like to straddle the different rules that you occupy.

Emily Mendenhall  15:27

Yeah, this is one of the questions I thought was really interesting. How do we answer that? I don't—I feel like I'm an outsider in both. I think that is very common when you try to occupy different spaces and make interventions in different spaces. I think anthropologists might say I'm not anthropological enough or adapt too much in public health. Then, you know, people in public health would consider me to be too critical to be in public health, which is fine. I think you can make space to do your own thing. I've always just kind of walked my own walk, done my own thing, which is fine. I actually see some of the work in clinical settings; I've been publishing a little bit in Nature lately, the Nature journals. I see that as intellectual interventions. I see it almost just—not as service—but how do you, because syndemics itself is a way to challenge medicine and public health to think more critically? Colleagues in anthropology have said, 'Well, syndemics is, you know, overly simplistic or excludes other, kind of more critical theories,' which they're right about, you know. But what syndemics does is it works within these three, three kind of—I call them three guiding rules—which I don't think other theories do as well. It brings together even, you know, Nancy Krieger and eco, you know, eco-social theory, or Margaret Lacks' local biologies. Intersectionality has been and is critical to thinking about syndemics. But, you know, these theories don't necessarily take this idea of clusters and the biological interactions between certain conditions, like when I think about diabetes and depression. I think about cortisol and insulin that become interactive. When you have heightened, untreated depression, partly because of access to healthcare over time, the elevation of cortisol in your body actually functionally affects your cells to become insulin resistant. The kind of social structural factors have a biological production that then becomes diabetes as well, especially if you're dealing with other infections—maybe it's recurrent COVID-19 or HIV or recurrent flu—because you're a working parent whose kid is in childcare, and you're always, you know what I'm talking about, you're always getting these recurring infections. This kind of weathering, again, a different theory, right, comes together to create a different illness experience than one of those conditions ever would on their own. It's not just the infections or the non-communicable diseases or mental health, but it's these social conditions that are embedded and entwined in our lived experience. These interactions can be measured at the population level, and syndemics is inherently a measure of populations, even though—I mean, I wrote Syndemic Suffering, and it was about the embodied lived experience of syndemics. My book Rethinking Diabetes is also thinking about syndemic portraits, right? How we think about these lived experiences and how they differ and why from place to place. I just finished a project; we published in Nature Human Behavior called Soweto Syndemics. We used ethnographic work that we've done on living with diabetes and living with breast cancer in Soweto and built some locally designed scales to look at stress and coping and how people live well with or live with chronic illness and multiple conditions. Our outcome was not a disease; it was quality of life. So what does quality of life look like? We found that social stress conditions, or the number of stresses that people described in their lives, were a more powerful indicator of quality of life than actually living with multiple conditions and which conditions. It didn't matter which conditions you had; if you had fewer stresses in your life, you were more likely to define a higher quality of life, which really puts the onus on social interventions and how sometimes wellness really needs to be out of the hospital, right? A lot of the people we spoke to would talk about—because we also did this in-depth, kind of ethnographic interviews—that ethnography was cut short somewhat because of COVID, but we had five waves of the study. We kept going back and really connecting with people. We found that, you know, prayer groups were incredibly important ways of healing and doing well and just feeling heard, you know, and well-being. Most of the studies I've found around the world indicate that if you just have one person who can lend you money when you're in a pinch, you do better. It's not just having one person to listen to you and be there, but actually having the material means to help you put food on the table when you need it. Those kinds of elements come out from more ethnographic work, just listening to people and spending more time learning about lived experience and who you rely on and who your people are really matters. We did some really neat work on flourishing as well, in relation to the study and how people define flourishing. In Soweto, people don't necessarily define these in individual terms, which can also be troubling when we're doing epidemiological studies of individuals because people are so relational in how they think about health and well-being, which was really fun to work on.

Joseph Harris  21:03

What I'm hearing from you is that you've been able to take some critical ideas from anthropology, like syndemics, and enrich sort of the way that we think and operate within public health, and also take some of the methods like ethnography and to learn about important new mechanisms that people are using, like these prey roofs and sources of lending money to improve human flourishing.

Emily Mendenhall  21:30

Yeah. And, you know, I think that anthropologists can learn from public health too. Sometimes anthropologists are so critical they can't see beyond their nose, which is not useful. They write this work that no one reads, and they don't translate it to the public. I'm the co-chair of the Critical Anthropology of Global Health interest group right now for the SMA Society for Medical Anthropology. One of the things we're trying to do is just provide—we just, I have to email us too—but we had like nine ways in which you can engage more broadly with your work. You know, writing white papers, engaging with policymakers, writing op-eds, making your trade book open access, or just publishing in The Conversation. Every time you publish an article, write a small piece for The Conversation. It's not a lot of work; it's 800 words, and they'll help you write it. It's a way to have a piece that people can access of your work, so really sharing in a deeper way. Most public health colleagues I have don't read books, so they're not going to read your 500-, 200-, or 300-word in-depth critical analysis of this problem, unfortunately. It's not just conveying to the larger public, but also to people really doing intervention or implementation science, who really need this work, who need to understand this. In that way, I think anthropologists can really benefit from working across disciplines too.

Joseph Harris  22:59

So it sounds like you found this position in between the two worlds, rather rewarding. And seeing, yeah, some benefits from from both.

Emily Mendenhall  23:08

Oh, absolutely. And, you know, having the privilege of being in a School of International Affairs enables me to kind of not take sides. I'm not in school Public Health. I'm not in a department anthropology, so I have stayed awayfrom.

Joseph Harris  23:25

 And you managed to make the contributions you want to make, ones that are important.

Emily Mendenhall  23:29

Yeah, it's an extraordinary privilege to do that, so I feel lucky. 

Joseph Harris  23:33

That's great. I want to ask you, well, what are some of the places you'd like to go in terms of conferences, you know, where have you found yourself most nourished during the year?

Emily Mendenhall  23:49

Well, I have to say, as a mother of two young children, I don't travel as much. I mean, I can't go to half the things I'm invited to. I don't go to a lot of things unless they're in DC, and if they are on the weekends, I don't, you know—I go up until the weekend because that's my time for my kids. So we all make choices. There are a lot of things, like, there's a meeting at the end of this week I couldn't go to, partly because I have a family commitment, but also I'd committed to this. That's our Society for Psychological Anthropology. You have to make choices. I try to go to the American Anthropological Association meetings every year. I don't go to APHA because I feel it's so big, it's hard to find your people, and it's really expensive. I went to the Consortium of Universities of Global Health last week because someone paid for me to go. We had a big reunion of Fogarty fellows. I was a Fogarty Fellow at NIH, yeah, and that was lovely. We celebrated Roger Glass, who just stepped down from the Fogarty Center, which was a really nice event. So I just have the extraordinary privilege of living in DC, and everyone comes to us. I go to everything that's in DC if I can. But also, budgets are limited. I run out of money, and I can't go to anything for the year, you know?  So, yeah, that's kind of, I go to health systems global, which I couldn't go to the last one because of funds. But also childcare, my husband goes to that meeting, and we didn't have childcare, so he got to go to that because he's in public health. So you know, you give and take and make these decisions, but you know, for me, that the meetings are not only intellectual, but they're really about my family situation.  

Joseph Harris  25:30

Yeah, definitely understand that, who are some Junior Scholars who are doing really exciting work in global health today that you've been following, and you could give us your thoughts, both inside and outside anthropology,  if you have?

Emily Mendenhall  25:49

Well, there, I mean, it's such a big question. I think that there are—I mean, I could—I'm thinking of like 10 junior scholars who I am actively interacting with and mentoring. Younger junior scholars often reach out to me for advice. I was just reading this amazing woman, Annika, field notes. She's at Wash U on long COVID, and she was doing this intellectual thing, and she wanted some advice. So I edited it and gave her feedback. There's some really great work on kinship and diabetes I've been reading from Senegal by Emma Bunkley, who's doing this. Actually, I'm a discussant on our panel at AAA on inner embodiment, so how we think about illness and disease and the physicality of chronic illness, but how this is so social and dimensioned and bound in our communities. I really think that stuff's interesting. One of the things I'm doing with my journal Social Science, Medicine, Mental Health is leading these series. I'm really excited about it. Just like The Lancet had these series, we're trying to do series that are just focused on mental health. We have a series on South Africa, one on India, and one on China, and they're focused on the histories, legacies, inequalities, and epidemiology and culture of mental health in those contexts. We're going to have these comparative case studies that are going to be really, truly enriching, I think, to think with and do. Oh, and actually, for your class on comparative health systems, they're all about the health systems and mental health specifically, which is really exciting. I review so many people's work all the time, and, yeah, also something that really gets me excited. I think people are really thinking critically with health systems. I think anthropologists—it's an area that we need to really think critically about. Anthropologists specifically are starting to engage more deeply with health politics and health systems, and it's an area that we need to continue focusing on and engaging with that's been pretty neglected, I think. I think both anthropologists could benefit from doing this critical work and actually thinking about elites, but also I think the field itself could really benefit from this work. Yeah.

Joseph Harris  28:10

So I'd love to hear you say more about that, because I also feel in sociology that this has been a enormous neglected area, and we had some really early pioneers, people like David Mechanic, Donald Light, who made a real mark, and I think obviously about really important people in anthropology, from Judith Justice to Adia Benton. But it just feels like there could be so much more. Where do you see some of the exciting sort of frontiers, contributions to be made in this area of health politics, health systems? 

Emily Mendenhall  28:47

 Well, some of the pieces. There's this really great book that I think does a good job On Love and Liberation, by Lauren Carruth, that's about how, so...Life in Crisis, by Peter Redfield, was about MSF a few years ago. What she discusses is basically the foreign nationals who work in MSF and come in, but really, when we think about humanitarianism and health systems in emergencies—especially as we start framing everything as an emergency these days—she works in the Somali Region of Ethiopia. Her work is really about how these humanitarian emergencies that are elongated, you know, 30-40 years, are really the humanitarian work not by foreign nationals, but by locals. Ninety percent of the people who are actually working for these organizations are local. It's really about how people think about reciprocity and care in their own communities through these ideas of consistent emergencies. I think that book is really powerful and a really good way to think about framing and how we think about this work. I think, I mean, obviously we talked about last night, about Debbie Shulman's work, and, you know, really taking a critical look. She's not an anthropologist, but really taking stock of finance, seeing where money comes from and how governance is determined. I mean, just even at the Consortium of Universities for Global Health meeting, you see all these elite meetings in global health; a lot of people making the decisions are really disconnected from the people they're making decisions about. We have a lot to say on that, but anthropologists and sociologists less so often, but get sidelined into these very local communities where they can't make these bigger critiques because they are just so localized. I think work like Svea Closser's Chasing Polio in Pakistan, which is a critical study of the Global Polio Eradication Campaign, you know, from studying the who the CDC to even a campaign in Pakistan, that kind of approach is what we need to do more of.You know, I'd love to see something on guinea worm like that. No one's really working on guinea worm, which I think is fascinating. My husband worked on the campaign in South Sudan, and it's just so fascinating to see how such a charismatic individual like Jimmy Carter can, almost like smallpox, move around these global fiery dialogues and do the work through national organizations. Each government really was leading the way. They had international technical advisors, but it was a more nationally driven organization on way fewer funds than, like, polio, for example. I just think that model needs to be promoted—or, I mean, although there were plenty of problems with it, it's just interesting to think about what is written about and what's not, what's marginalized, what's promoted, and what's not. There's a lot of really interesting stuff I've been reviewing. I have a book series with Vanderbilt University Press, with Judith Justice, Peter Brown, and Svea Closser, that we're starting to wrap up, but we've published a number of pieces on basically health systems and policy and how, you know, in anthropology—so really thinking about policy from an anthropological perspective, which has been fun, but more is needed. We actually wrote a review article for Social Science and Medicine on anthropological contributions to health policy and systems, which I should share with you, actually. Yeah, it came out last year. It was kind of fun. It's always fun writing with Judith and Peter and Span; there's just such a wealth of information and history in the field. You know, she wrote one of the first books, and it's just really, really important. It's also really interesting to be critical and think about where health anthropology has done things wrong in the field and kind of reproduced development projects that were, you know, colonial and problematic and harmful. So it's important to be reflective, yeah.     

Joseph Harris  33:01

Oh, you bring up so many issues, you know, I think about, obviously, James Ferguson's Anti-Politics Machine in that respect. But also, you're talking about, you know, books that connect, I think the micro, well, to the macro, you know, Salman Keshavjee's Blindspot, one of my favorites. I teach it all the time, and Nora Kenworthy's great book Mistreated and JT Crane's Scrambling for Africa just amazing, amazing works. Let me ask if you would say a few words about this wonderful book that I'm holding in my hand right now, Unmasked: COVID, Community and the Case of Okoboji.  What led to this book? How did it come about?

Emily Mendenhall  33:46

Well, we were in March of 2020 when we all hunkered down. I had a four- and six-year-old, and my husband and I were both teaching. He's a professor at Hopkins in public health, and I'm at Georgetown, and we were both, you know, handing off and trying to get through the days. After three months, we were like, "Okay, let's just go to the lake." My sister moved back about ten years ago to our hometown, where we've lived for five generations, and her husband’s a family doc. He's from Connecticut. They met on the East Coast and moved back to Iowa. She’s an organic farmer and does all this organic farming policy. She wanted to be the resistance, you know, to corporate agriculture. We grew up during the middle of the farming collapse; when I started school, 30% of my friends lived on farms, and by the time I graduated, 3% did. The radical dislocation and loss of land, and even farmer suicide, were things we knew about as children. I mean, we see this all around the world now. I don't know if you've read Stuffed and Starved by Raj Patel; the book kind of deconstructs. Alicia Galvez’s book, Eating NAFTA, is the best example, I think, of critical analysis of policy using what that anthropologist should embody, and sociologist. She locates the space between, you know, smart ethnographer thinking about her, you know, wealth and years of ethnographic knowledge and experience in Mexico, but also access to elite actors and critical reviews of newspapers, documents, policies, and laws, really reflecting on what NAFTA did on these multiple latitudes of meaning. It is brilliant. I think she did such a great job. I love that book. I just taught it, and it went over so well, which was fun. I got distracted by what we were talking about. Anyway, so, yeah. We packed up the car with our dog, and we drove west. As we drove west, there were fewer masks. In the week before we left, we had gone into a supermarket coming back from a hike, and they actually had police outside of the supermarket in rural Maryland, making sure we masked. It was militant. In D.C., we were going farther west, and no one was masking. By the time we got to Iowa in the middle of the night, we drove 20 hours in one day because we were going to leave at five, but I woke up at four, and I was like, you know, scooped up the children, put them in the car. Just get in the car. Let’s go. I just wanted to go, and so we ended up getting there. One morning, I went and got groceries, picked them up, I ordered them online, and no one was masking. It just felt like an alternate reality. My brother-in-law was actually leading that; he’s head of public health in this community, and he was leading the public health effort, and he was having a really hard time. Every week he did this Facebook message for the community, and people were really following him. He was already getting pushback. In three weeks, there was the Fourth of July, and Minnesota was closed down, so everyone was coming down to holiday on this lake because, as Trump said, he was going to open the economy in April. So did Governor Kim Reynolds, and so did the local representative writing in the newspaper his GOP kind of local narrative of, let’s open the economy. Be safe about it, but let’s get back to work. This was April of 2020. Some people never left their offices in this area. The alternate reality of the COVID pandemic in this community was very different than, for example, in D.C., and that was shocking to me, having a foot in the global health security and kind of global health D.C. community, where it's so urgent, so serious. My students are suffering, you know, themselves from being online, and we're taking everything so seriously. My kids are home from school. It was so fascinating to see that. Then I just started interviewing everyone I grew up with, all the political leaders; everyone. I mean, it was just easy to talk to people because I was really trying to figure out a way to help the community, to help Zach. Then I just continued because I was so curious. It was fascinating to hear how people were thinking about local politics and to really see the gray areas. Everything was red and blue, and everyone talked about it as like this way or this way, this, you know, red state or blue state. It all felt that people were really grappling with things in different ways. Right before, right before, the only policy that Kim Reynolds actually made was to keep the schools open for the year. It was like the only COVID policy she implemented until she did have a masking policy in November of 2020, a little bit later, for a few weeks, but when there were a lot of cases. Every school board had to come together and deliberate what public health measures they put together. My brother-in-law felt really dismissed by the board of supervisors and the superintendent, so we went to the school board. It’s legal to record any school board meeting if you ask someone. So I asked Zach, "May I record this meeting?" I said it publicly, and he said yes, so I recorded it. It was fascinating to hear the deliberations around masking. It just so happens that I had been working on this Vox piece about the complexities, cultural complexities of masking and what I'd seen that summer, and it was about to be published. I had one moment after the meeting to make some edits, so I just put something about the superintendent and the school board in that meeting. The actual final vote was on Monday, the first week of August or so, and they had the meeting. I recorded it, quickly transcribed it, and wrote it up in this Vox piece, you know, just a paragraph or two, saying that they were not going to mask and they were not taking it seriously. This was, you know, because of politics. It came out on Saturday morning, and actually, my brother-in-law was meant to meet with the superintendent that morning. He called someone who texted him and said he can’t meet with you; he’s dealing with media fallout. This article went viral. I work on trauma and chronic illness and marginalized people; my work doesn’t go viral. It’s interesting to see what people want to read. There were all these pictures of half-dressed people on boats drinking in the middle of a pandemic, so those photos were very powerful. It was interesting to think, to see what happened, because then, on Monday, my sister was like, "I am not sitting by you." My sister spoke at the open meeting of the working group and the voting of the school board, and they ended up voting to actually implement masking. What I take away from that, to be honest with you, is that the one powerful thing when there’s no regulation is shame. I think a really great public health book is Amber Wutich and Alex Brewiss' book on shame, or on shame, blame, and dirty. I forgot the name of it [Lazy, Crazy, and Disgusting]. Anyways, their book, I can get it for you, and we can write it in lazy. I can’t remember what it’s called, but it’s a brilliant title. I reviewed it after having COVID; I have all these recall issues, all this COVID brain, but "Lazy, Dirty, and Disgusting" or something like that. It’s such a good book, but it’s really about shame as a big part of it in public health, and that’s an element we undersell as these social dynamics that affect how we think. That’s what "Unmasked" does; it really brings us through the idea that many people— I have this one woman who had a "Fuck Your Feelings" flag on her house, which was a Trump 2020 flag, you know. She also didn’t want anyone to know, but she was really scared about leaving her house because she didn’t want to mask and be judged for masking, but her kid had pneumonia and a respiratory condition and had been in and out of the hospital, and she didn’t want her to get COVID. So she didn’t leave her house because she didn’t want to get shamed for masking, which I thought was fascinating. On the other hand, after I got back to D.C., I went for a run in the middle of the day, and someone shamed me for not masking on the trail where no one was in sight. Plenty of studies had said that outside, you were fine, and I didn’t run again without a mask for a year. It was so fascinating to be shamed for masking in one town and shamed for not masking in another place. I’ll talk about this in my talk, but one of the most fascinating places for ethnographic observation was Walmart. Oh, really? It was the only place where there was a national masking mandate, so the only place in town you had to mask, which I found fascinating.  

Joseph Harris  43:33

Yeah, a whole book could be written about that. 

Emily Mendenhall  43:35

Oh, I'm sure people will, but I have a whole section on Walmart, which was one of the most interesting kind of places to do ethnography! 

Joseph Harris  43:42

Well, I can't wait to read the book, and particularly the sections that you mentioned. This issue of shame is a really interesting one. And what  I've thought about a lot, and also talked with other people on the podcast about thinking about, you know, AIDS activists, for example, and the ability to bring the cost of pharmaceuticals down after naming and shaming both the Clinton administration, but also pharmaceutical companies. And the way in which there seems to be applications for that for a lot of things, certainly been efforts to go after pharmaceutical companies for insulin costs, which are well capped for some groups. You know, how much do you feel like that is, you know, mechanism that you know will continue to have currency in public health and activism in the future?

Emily Mendenhall  44:37

Yeah. I mean, without strong political leadership and strong political leaders to advocate for more just regulation of pharmaceuticals, we need social dynamics to make social change, right? I think shame is a powerful tool; yeah, um, it’s a powerful tool to change policy. It’s a powerful tool, you know, especially for elites who link everything to their reputation and their identity in that way. So, yeah, as a political movement, shame has always been used to make that kind of social change, and that’s why I thought it was so interesting to, you know, use shame and moral arguments for this community, for masking for children, when everything had been so political and had been about parroting these larger messages. When we think about the politics around COVID and how, you know, obviously both sides were extreme and not listening to each other, the right and the left, the kind of performative politics around COVID were just so shameful. Really being able to open the lid on that, I think, was an important moment to remind us. COVID reminded us how political and social all of these conditions are. I still remember, and you probably remember this, when Francis Collins was stepping down from the NIH, he said, “One of my greatest regrets is not funding more social behavioral research.” My Twitter feed exploded with people just naming the title and the year that they had their social behavioral research rejected from the NIH. You know, it’s not that it’s not there; it’s not the priority. They’re not prioritizing this work. So, yeah, I think shame is really, really powerful. I think shame can be a powerful political tool. But at the end of the day, we need a stronger political public health workforce. We need a more structured and regulated public health workforce that has some legitimacy. If you think about the great influenza pandemic of 1918, in this town where I’m from, the county supervisors listened to public health and shut down the town. A hundred years later, they didn’t listen to public health and didn’t shut down the town. So it’s interesting to see these cultural and social dynamics shifting on what knowledge is trusted.  

Joseph Harris  47:19

Yeah, it's fascinating. And, you know, you bring up political leadership, the importance of it in the case of COVID, and also the public health workforce. And I think about one point that I think it's made again and again by knowledgeable public health people, is that we've under invested in public health for decades. And I've wondered often, you know, is there a role for shame in trying to correct that lack of investment? What do you think?

Emily Mendenhall  47:46

I think there are different elements that are kind of embedded and bound into this, and I think it's the culture of service in America. You know, lots of countries have compulsory or recommended sources of service. We have the Peace Corps and AmeriCorps. But, you know, whether it be military or rural projects, farming, or health promotion in public health, I am not against. I think this came up with the Clinton campaign, actually—the idea of a year of compulsory service for all Americans at 18. I mean, I doubt that would ever work because of the compulsory idea, but the idea of having a benefit for doing that service and reorienting our culture of community and collectivity as a nation is really needed in how we think of ourselves as Americans. We're so individualistic and obsessed with our own success or the needs of our communities. I mean, we are one nation of 100 nations, right? So many different communities and cultures and people, but really thinking about the collective in a compulsory or in a way that benefits you or others would be a welcome shift. So, yeah, I think that would be a way to promote public health because it would be embedded in this notion of the collective, and that's what public health is about. 

Joseph Harris  49:29

Yes, to have broader ripples of outreach that go well beyond the sort of your service that's fascinating,yeah. One sort of thing that's been neglected to me in this COVID pandemic is, it seems we've been given this opportunity to teach about social justice and solidarity and responsibility, and yet in many cases, I've seen we've missed that opportunity. And I think that your ideas about service is another interesting thread on that. 

Emily Mendenhall  50:02

But you know we don't talk about public health link to this. A lot is this notion of  public health and authority and really listening. I mean, still, most people, including my brother-in-law, who lead public health, are physicians, you know, who still have a biomedical framework. Even within, I mean, at the beginning of the Constitution of the WHO, the U.S. demanded that anyone who serves as a representative of the United States be a physician. The power of the American Medical Association in weakening public health and elevating the role of physicians in America has been a fundamental deterrent to our public health, right? We know we could talk for another two hours about that, but I think what's interesting is that public health has gotten such a bad rap from the COVID pandemic. What I learned in "Unmasked" is that public health had no authority. If we relegated authority from the President at the federal level to the state level, and then when it was relegated to the local level, it was all county supervisors. There was no reason why they needed to listen to public health authorities. So really thinking about who makes these decisions, especially at the local level, when you have, like, you know, people with very little public health or medical or nursing training. Mayors have quite a bit of authority in large cities. Mayors do not have authority in small towns. County supervisors did. Most of the work that I am inspired by is local because you see people really working and doing the work, like Ayuda, which is a law firm in D.C. that does a lot of immigration law and is also working with people to get them access to mental health care as they're enduring these pretty intense asylum cases. Also, my colleague, Sharon Brooks, does a lot of asylum work, linking scholars to defending people who are looking for immigration rights, which are often embedded and bound in health rights. Locally, like La Casa del Pueblo, these community federally qualified health centers are really doing this health justice work in the community that I admire and engage with, specifically through my Unitarian Church. A lot of the work that I do, kind of thinking globally, is training. I have a colleague, Edna Bosire, who just finished her PhD with me at the University of Pittsburgh and is now leading this work in medical anthropology in Kenya. She just got a job as a medical oncologist at Aga Khan University. A lot of my personal health justice work is through this training—training PhD students and medical anthropologists to do this more critical work at the University of West Lauderdale. I admire so many of my colleagues who can really do this political work; it’s a little bit hard to engage in a deeper way when you have young children and a busy career, but it's exciting to watch.

Joseph Harris  53:34

What do you feel are the most pressing issues that we need to tackle today in global health?

Emily Mendenhall  53:40

I think they're largely political. I think we need to rethink how we finance global health. We need to rethink whose voices matter, which is really happening and we're seeing. I think we need to stop thinking about—we've actually moved beyond this paradigm of, you know, we had colonial medicine, we moved to international health, and now we are in global health. But really, it's impossible to think about health and health systems without considering climate. I really think Renzo Guinto, from the Philippines, who's, I think, just gotten a job in Singapore, is doing all of this work around planetary health, and he's become kind of a figurehead for it. I think he's really right on with thinking about how we even conceive of what we're doing, and everything that we do needs to be more inclusive of thinking about the environment. At my own university, I've pushed this, and people are so territorial that they're like, "Well, we don't want to combine and work on environment and health because we all want our own identities," but we can't do one without the other. They're not separate challenges. We're all on the earth here. We're all on the earth, right? When I think about activism, I think about health justice as bound in environmental justice. Some of the most important work is about where the money goes and how it's organized. But this is not a new question. How we in international development engage and think about working as a global community is still highly held in the hands of elites, and agendas are always benefiting the wealthy, and that is something that we're going to have to reconcile before change is really made. 

Joseph Harris  55:27

Follow the money, as you say. So could you share with us a little bit about you know, how you intend to use your time on this wonderful Guggenheim Fellowship about to embark on?

Emily Mendenhall  55:40

Yeah, it feels so privileged to have a year to take a breath. I'm exhausted. It's been a lot being a scholar of global health and having in children during COVID And so I I'm going to do some pottery. I'm going to do a lot of yoga, I'm going to spend a lot of time with my kids, and I'm writing a book on long COVID, which I've started to kind of unpack, but the book is on long COVID, but it's kind of using long COVID to open Pandora's box of contested illness. And really think a lot about why people are so mistrustful of American medicine and and some of this really stems from the fact that American medicine is so bad at looking beyond the nose. You know, it's anything that isn't systems based or a symptom is hard to conceive of, and care is so truncated and so short and so just junk, you know, just juncture that. You know, we don't care for people with complex illness very well. And this is something that you know, I've been working with this one person with long COVID For a year, a student of mine year and a half now, and he's felt dismissed continually and and devalued and not believed about his symptoms and his condition, and it's been extraordinarily severe. And, you know, I follow all of these blogs of how people symptoms are occurring and have massively transformed their lives, and that their clinicians don't believe them, and so often with long COVID and other contested conditions, clinicians are treating symptoms, but not people, not illnesses, which is a symptom of American medicine in general, but with these contested and complex illnesses, it becomes even more serious. But I think this has actually played a huge role in Americans public dismissal of public health in the COVID pandemic, but also the disbelief in medicine, in mistrust of medicine in general. And it's a really big problem American medicine, how you know we have this, you know, paternalism, where you know the idea that you know doctor is God, or that you know, this form of healing is prioritized, is a huge problem. So this is, see there. These are some of the things I'm working through. And you know, some of it comes back to some of the ways in which I kind of unpack the politics of disbelief and unmask in unmasked itself, and it is playing into this book. But I also, I'll just mention, because we talked about it last night, that I wrote a book about my great grandmother who was a spy during the Irish revolution. And it's my first book of historical fiction, and I really enjoyed it, so I might do some other creative work as well.

Joseph Harris  58:33

That's wonderful. Well, you certainly deserve to have a break as well as some good time for for new work. It's I look forward to all of that. Let me ask you a few questions about the research process. What would you say are the most meaningful parts of that process to you?

Emily Mendenhall  58:53

Well, it's always about the team who you're working with, so if you're doing so, if I'm working on my own, like for Unmasked part of it, I mean, my favorite part, is just listening and learning and being with people, so opening space to not define the question or what you're working on from the early onset. And if I'm working with a team like my work in South Africa, my most recent work on the Soweto syndemics project, it's really learning from how your team members are really thinking about the process and letting them lead and being a part of a collaborative idea generation process. And this amazing colleague, Lindy Lesele [sic], who was leading the ethnographic she's our lead ethnographer for our sweater cenomics project. And she was like, you know, I really want to do this work on good health and like how people are defining a good life in the midst of illness. And I said, That's awesome. Let's do a project on flourishing and what that means. And so she led a piece, and she actually ended up doing all of the interviews, following up with these people we'd already interviewed multiple times, and then leading the paper. And she's first author on her paper in Social Science and Medicine Mental Health, which is on flourishing, as part of this series on flourishing, led by Sarah Willen. And we actually had used adapted Sarah Willen's interview guide, who's a medical anthropologist and professor at University of Connecticut. So we wrote these comparative pieces to how people define flourishing in Cleveland based on the study that they'd done, and then how they defined, in Soweto, how these communities, two communities, define flourishing, and there were pretty different ways in which people thought about flourishing and defined flourishing, and what, how people define a good life. But, you know, really providing the space to listen to my team and learn as a collective is really meaningful to me, which is pretty different from most anthropologists who work as lone wolf ethnographers or in isolation, and I've done both, but I really like both processes for different reasons.

Joseph Harris  1:00:52

Are there any neglected parts the research process that you feel we don't talk about enough?

Emily Mendenhall  1:00:58

Analysis - absolutely! I think that. I think that qualitative work can be so iterative, but nothing is. I think nothing is actually replicable. Because how you think about data and how you write things up is based on what you know. You don't know what you don't know, and you only know what you know. So the interpretive process, you might see something because you've done 20 other studies related to it that someone else who is just learning may never see. So that's why I think it's important to work as teams in defining a codebook, for example, and defining the terms of the codebook, and then reviewing through my colleague and my longtime mentee, Edna Bosire, who's now a professor at Aga Khan, who I mentioned earlier, and I have worked on collaborative projects for years. And you know how we do data analysis together, I really see ourselves in our work together as partnership, where, you know, we always see different things and we, you know, teach each other. We're missing this. I'm missing that. You know, what are you missing? What am I missing? And how do we do this together? So it's really hard to teach, especially in public health, because people do, I get submissions all the time. They're completely atheoretical descriptive studies in public health, which is common in public health, because they teach very little theory in general. And so I just don't think you can do the work without the theory, because knowledge is generative. And so that's a tricky thing to teach. Yeah,

Joseph Harris  1:02:37

Yeah, absolutely. What are some of the biggest influences you would say, in terms of your own writing and research? What are some of the biggest influences in terms of your writing and research? 

Emily Mendenhall  1:02:51

Um, parenting,

Joseph Harris  1:02:53

Parenting? Say more about that.

Emily Mendenhall  1:02:54

Um, well, ever since I've had kids, I've had such little time, so I've gotten really fast. So I have 30 minutes here, I have an hour there, or, like, I wake up early for an hour, and have writing time or reading time, you know, or you know, you can only do so much in a day. Yeah. So what I do? And I mean, I do way less work internationally than I used to, what is possible. I do a lot more mentoring, and a lot of zoom, mentoring, you know, and collaborative work, especially with COVID, I wasn't able to kind of wrap up my the Soweto endemic study. Had to do it virtually, which felt bad, and I don't want to continue doing that kind of work. So I'm trying to reassess how I want to do things. But also my, I mean, I my kids in my house for 10 more years, and I want to be present, yeah. Really love having them and being a parent. So balancing time and priorities also like leadership positions. It's really hard as a parent to take on the director of a center or to, you know, to do these other things, because there's so many events. So what I do and how I spend my time right now is, is what works with with being a mom, and, you know, it's, it's tough. There's a lot of things I don't do because of that. And so to be honest, that's what, yeah, that's how I kind of assess what I can do.

Joseph Harris  1:04:17

Yeah, no, I love that. You bring up parenting, because it does shape so much of what's possible right now and what I can do as a father of twin 7-year old boys, let me ask, are there any practices or habits that you found indispensable in helping you in the process of conducting research and writing? 

Emily Mendenhall  1:04:39

Sure! Before I had kids, I used to wake up every morning and write from seven to 10. So I wake up and have a cup of coffee, and I would write for three hours every day, not the weekends, but and I would go for a run, you know, or whatever. And usually then, I mean, it's when you're a student or a postdoc or working on a research team, or you'd have to leave by nine or something. But I would work. I would write every. Day, and it's because I have most clarity in the morning some people do in the evening. Everyone's different. But just like everyday, writing is really helpful. And I I edited these three books on global health for youth during graduate school is kind of just a side project. And I think the amount of editing that I've done, and I've edited lots of books, and I've edited series and just for friends, continuously doing collaborative work or editing for each other, I think the more you edit, and the more you think, and the more that you read, I mean, the more you edit, the more you're reading anyway, because you're reading for other people constantly, but it really deepens your ability to also write. So I think, I think that's just been a huge asset.

Joseph Harris  1:05:49

That's great. Well, my last question for you, if you could give first year PhD students doing work on global health, one piece of advice, what would it be?

Emily Mendenhall  1:06:00

Just get into the field as soon as you can, and listen and take notes, and don't make any decisions about what you're doing yet. Just go spend the whole summer as much as you can, three or four months. And just unless you've already spent time there, then maybe, you know, bring your books, do a bunch of reading, but also just be present. I think, you know, really, having your field work entwined in your earliest days is important.

Joseph Harris  1:06:24

And why is that so important?

Emily Mendenhall  1:06:27

Because everything's iterative, right? You learn, we don't want to come with these a priori expectations or like ideas about what are the problems, because that reproduces these kind of Western centered questions that we ask, you know, just as your work, you know, is really language based, and, you know, being able to speak the language, being able to be present and really, you know, deconstruct the problems in a deeper way matters. 

Joseph Harris  1:06:52

Yeah! I love that so much. So today, we've been talking with Emily Mendenhall, Professor, Medical Anthropologist at Georgetown University. Go get if you have not already her new wonderful book, award winning, wonderful book, Unmasked: COVID, Community, and the case of Okoboji. Emily, thanks so much for joining us today. Thank you so much. All right. That concludes the Global Health Politics Podcast. We'll see you next time. This episode of The Global Health Politics Podcast was produced by Joshua Emokpae. Thanks for listening.

This transcription was produced with the assistance of Kaussar Karymsak.