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On January 8, 2020, Iran launched ballistic missile attacks on two bases housing U.S. troops in Iraq. Despite early reports of no casualties, it was later revealed that at least one dozen American service members had sustained concussions and been medically evacuated to be treated and evaluated for possible traumatic brain injury, or TBI (Lubold, 2020). At a press conference two weeks after the missile attacks, the U.S. President described the injuries as "not very serious," saying "I heard they had headaches and a couple of other things." He went on to characterize the service members' injuries as less severe than those of troops who lost limbs in roadside bomb attacks, "I don't consider them very serious injuries relative to other injuries that I've seenâ€¦. I've seen people with no legs and with no arms. I've seen people that were horribly, horribly injured in that area, that war" (Donnelly, 2020). The Brain Injury Association of America, a prominent advocacy and research organization focused on increasing awareness and understanding of brain injury, expressed concern that the President's remarks minimized the severity of TBI as "a major cause of death and disability in the United States" (Brain Injury Association of America, 2020). The co-chairs of the Congressional Brain Injury Task Force released a bi-partisan statement reiterating the nation's commitment to providing "unqualified support and respect" to persons impacted
by TBI, noting "brain injury should never be minimized. Unfortunately, too many people, including elected leaders, are not familiar with the terrible realities of traumatic brain injury." (Office of Congressman Bill Pascrell, 2020). [Excerpt from forthcoming paper in Journal of Community Engagement and Scholarship by True et al.]
Scientists encounter misinformation and misunderstanding frequently. In 2020, we are seeing examples of scientific illiteracy and public health illiteracy weekly. Lack of public understanding about science and our work as researchers can feel painful and personal. What will it take to get people to understand? To build trust between science and the public? To make leaders see what is at stake for individuals’ health, families, and quality of life?
This is where we bring this line of thinking back to our work as HSR&D researchers grounded in anthropological training, and where it gets personal for us. We share common questions that guide our work regardless of topic and strive to increase the usefulness of our work. Our VA HSR&D colleague, Dr. Erin Finley, sums up the root of these aims nicely: “Anthropological theory has a powerful grasp of the connection between broadscale social structures and intimate lived realities, and its methods are perhaps unequaled in capturing the nuances of context.”1
As technology has evolved and the use of information has changed as a result of technological developments such as the Internet, the public’s contact with research has increased. While we might hope this means our findings and insights get fast-tracked into meaningful policy, more often it leads to feelings of being misinterpreted or wondering, “but did they read what I wrote?”
Even before the Internet, subjects of anthropological research started reading what was said about them. As a result anthropologists increased their grappling with how we represent others, use the details of their lives as data, and sleep soundly at night. Anthropologists largely agree that our work requires attention to the dynamics of partnership and awareness of who defines the research question, who interprets the data, and who determines what to do with what one finds out. This does not make for easy, or particularly fast work, however, it may generate something different, something that Veterans see themselves in and connect to.2
What if we saw the people who participate in our research studies as partners rather than de-identified subjects? We know it would not work for every study and that it is not appropriate for all methods, but in studies where partnership is possible we find that the learning and the personal value of our work increases. As the number of anthropologists has increased in VA HSR&D research, so has the presence of studies and individuals on study teams that push on ideas of what research can do and seek to innovate.
In addition to training in anthropology, Dr. True is a folklorist. She chose folklore for its focus on vernacular culture and understanding how people build community and express multiple and intersecting identities through small, everyday expressions of language, dress, and the stories they tell about themselves. In a recent conference presentation, she commented: “I wanted to work with Veterans in a way that engaged them as equal partners in the research, did not pathologize or attempt to label their experiences, and enabled them to tell and share their own stories in private safety and in public venues.”
In an HSR&D-funded study “Communicating the Impact of TBI on Post-Deployment Reintegration using Photovoice” we used a photovoice method to assess and generate awareness of “invisible injuries,” in particular TBI, by inviting the voices of Veterans and their family caregivers into the research conversation. Photovoice is a qualitative method that pairs images and text to communicate on topics that are often hard to capture using conventional research instruments. This approach to research invites participants to become collaborators in data collection, product generation, and dissemination. In this research, we were guided by critical pedagogy and participatory action research’s recognition of researchers and participants as bringing different types of expertise to the research enterprise.
Anthropology’s immersive methods highlight the importance of establishing a social contract in this field, especially, in order to accurately and ethically represent community perspectives through a collaborative effort. It is an ongoing process to adapt the ideals and methods of anthropology to the VA setting and we believe it is worth the effort. The anthropological perspective contributes to work that seeks to make connections and orient the findings in a larger, complex context. We often talk about “the big picture.” The big picture is short-hand for an aim of anthropology: seeing the whole. Whether that whole is a culture, a village, or a healthcare system.
Researchers are trained to focus on a topic or questions that over time becomes more refined and targeted. The challenge with this approach is that it begs the question: at what point do we pull all the findings into conversation with each other and who does this work? This systematic and incremental approach is a mark of scientific rigor and the ideals of the laboratory.3 Science seeks to bring order from disorder. Anthropology says, the state of being messy tells us something about all the pieces and how they interact with each other. Anthropologists were champions of whole health before it became a branded approach to health care.
As scientists we most often strive to get clean and controlled results, i.e. evidence that is empirical. The challenge here is that the world and individuals do not exist in laboratories. We can make the world into labs, our sites of experimentation and data collection, but these are messy labs. A primary care physician working with Dr. Ono makes the case that research, in particular implementation efforts, targeting specific conditions (e.g. cardiovascular disease) with focus on related measures (e.g. hypertension) more often than not brings that laser focus to the task at hand and fails to see the rest of the person – the patient – in front of them. Generalists in medicine know that a risk of heart disease is important, but not more important than the poor sleep caused by anxiety and depression or the borderline A1C. These competing demands are the ones occurring in the body. Health care is in a moment when it is also asked to consider and address the fact that someone may have just lost their job or embody the impact of being Black in the United States. Hypertension may be a result of being Black in the United States and if this is acknowledged it may take more than a diuretic and a promise to make lifestyle changes to meet clinical guidelines.
Following talks with the Afghan president and anthropologist Ashraf Ghani in 2015, President Obama quoted anthropologist Ruth Benedict when he said, “the purpose of anthropology is to make the world safe for human differences.” Underlying the core tenets of anthropology is the belief that different people see the world differently. The anthropologist attempts to communicate, understand, and bridge those differences rather than try to erase them.4 In health services research, the work we do seeks to bring to the surface these variations in viewpoint to expand our thinking and increase the relevance of services that VA provides to Veterans and their families. We are constantly striving to marry the big picture and the individual story with the goal of strengthening the impact of research.
- Closser, Seva and Erin Finley. “A New Reflexivity: Why Anthropology Matters in Contemporary Health Research and Practice, and How to Make It Matter More,” American Anthropologist 2016: 118(2):385-90.
- True G,“‘Institutions Don’t Hug People:’” A Roadmap for Building Trust, Connectedness, and Shared Purpose through Photovoice Collaboration. Journal of Humanistic Psychology, Special Issue on Veteran Involvement in Research. First Published June 19, 2019.
- Latour, Bruno and Steve Laboratory Life: The Construction of Scientific Facts (1986). Princeton University Press, Princeton, New Jersey.
- Kuper, “Barack Obama: Anthropologist-in-chief,” Financial Times, September 21, 2016.