When the trial ends: moral experiences of caregiving in a randomized controlled trial in Goa, India.

This is an ethnographic study that examines the experiences of peer counsellors in the Thinking Healthy Programme Peer-delivered (THPP), a randomized controlled trial of a psychological intervention for perinatal depression in Goa, India. Based on nine months of fieldwork from 2015 to 2017 and through caregiving theories posited by one of us, we examine how caregiving is experienced by peer counsellors in a randomized controlled trial, a context in which care is given for a finite period and is removed at the study's end. Analysis of our data generated three themes: caregiving as a reciprocated process that impacts peer counsellor and participant; memories of care, with attention to the space that caregiving occupies in the memories and subjectivities of peer counsellors; and the end of the trial as experienced as a removal of care in the community of the counsellors. We posit that the moral aspects of caregiving are particularly important for peer counsellors, and that the context of randomized controlled trials is central to these moral experiences, particularly at the trial's end, when peer counsellors are asked to end care that, in many cases, remains expressed as needed.

Siamit: A Novel Academic-Tribal Health Partnership in Northwest Alaska.

PROBLEM: American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. APPROACH: Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. OUTCOMES: Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. NEXT STEPS: During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.

Complementing standard western measures of depression with locally co-developed instruments: A cross-cultural study on the experience of depression among the Luo in Kenya.

Our present understanding of depression relies on a Western nosology that might not be generalizable across diverse cultures around the world. As a consequence, current clinical research and practice may not capture culturally salient features of depression. Expanded cross-cultural research that uses ethnographic methods and local instruments may yield information of clinical utility to enhance culturally sensitive research and practice. In this mixed methods study, we used ethno-semantic interview procedures based on the DSM-5's cultural formulation process to elicit a broad range of depression features reported by the Luo people of western Kenya. We identified how the Luo conceptualize depression, including idioms of depressive distress, moods associated with persistent negative affect, and other features including context, stressors and support systems. This information informed the co-development of a Luo Depression Questionnaire (LDQ-17). We used the LDQ-17 in a cross-sectional community survey (N = 116) to investigate its association with a standard Western instrument (Patient Health Questionnaire-9; PHQ-9). Factor analysis revealed a one-factor model for the PHQ-9 but not the LDQ-17 for which exploratory factor analysis suggested a three-factor model including cognitive, affective, and physical symptoms. Psychological, environmental/social, and even supernatural causes (i.e., ancestors, God and devil) of these symptoms were identified, as were support systems. Finally, visualizations through multidimensional scaling approaches showed some overlap between the LDQ-17 and the PHQ-9, but the local LDQ-17 identified salient features the Luo associated with depression that the PHQ-9 missed. Our findings illustrate how simple ethnographic procedures may guide the development of local instruments to complement current standardized instruments, potentially enhancing cultural relevance.

Social Technology: An Interdisciplinary Approach to Improving Care for Older Adults.

Population aging is a defining demographic reality of our era. It is associated with an increase in the societal burden of delivering care to older adults with chronic conditions or frailty. How to integrate global population aging and technology development to help address the growing demands for care facing many aging societies is both a challenge and an opportunity for innovation. We propose a social technology approach that promotes use of technologies to assist individuals, families, and communities to cope more effectively with the disabilities of older adults who can no longer live independently due to dementia, serious mental illness, and multiple chronic health problems. The main contributions of the social technology approach include: (1) fostering multidisciplinary collaboration among social scientists, engineers, and healthcare experts; (2) including ethical and humanistic standards in creating and evaluating innovations; (3) improving social systems through working with those who deliver, manage, and design older adult care services; (4) promoting social justice through social policy research and innovation, particularly for disadvantaged groups; (5) fostering social integration by creating age-friendly and intergenerational programs; and (6) seeking global benefit by identifying and generalizing best practices. As an emergent, experimental approach, social technology requires systematic evaluation in an iterative process to refine its relevance and uses in different local settings. By linking technological interventions to the social and cultural systems of older people, we aim to help technological advances become an organic part of the complex social world that supports and sustains care delivery to older adults in need.

Covid-19 Requires a Social Medicine Response.

Covid-19 is an inherently social disease, with exposure, illness, care, and outcomes stratified along familiar social, economic, and racial lines. However, interventions from public health and clinical medicine have focused primarily on the scale-up of technical and biomedical solutions that fail to address the social contexts driving its distribution and burden. Fused with a moment of reckoning with racial injustice and economic inequality in the U.S. and across the world, these disparities charge policy leaders to develop, study, and share a response grounded in social medicine. As a yardstick for formulating, evaluating, and implementing health policy and care delivery, social medicine recommends at least three things: integrating health, social, and economic responses; bringing care to the points of greatest need; and focusing on broad equity-driven reforms in the pandemic's wake. With these tools, Covid-19 presents us with an opportunity to address the inequities that the disease highlights, exploits, and may otherwise entrench.

Varieties of Experiences of Care.

The human sciences have witnessed a decades-long transition from an emphasis on theories centered on hermeneutics and the interpretation of meaning to a preoccupation with theories that privilege performance, action, and being/becoming. This essay develops out of the conceptual orientation of William James, which holds that all knowledge comes from experience, as well as the author's writings on what matters most to participants in local worlds. The essay shows how meaning and being/becoming are unified in moral life and understood as embodied and lived experiences of care and caregiving, and it draws upon the author's experience of being the primary family carer for his late wife, who died of early onset Alzheimer's disease, as well as his experience of self-isolation in the COVID-19 pandemic. The essay's intention is to advance theoretical questions raised in the author's 2019 book The Soul of Care: The Moral Education of a Husband and a Doctor.

A partnership for transforming mental health globally.

The large and increasing burden of mental and substance use disorders, its association with social disadvantage and decreased economic output, and the substantial treatment gaps across country-income levels, are propelling mental health into the global spotlight. The inclusion of targets related to mental health and wellbeing in the UN's Sustainable Development Goals, as well as several national and global initiatives that formed during the past 5 years, signal an increasing momentum toward providing appropriate financing for global mental health. Drawing on the organisational and financial architecture of two successful global health scale-up efforts (the fight against HIV/AIDS and the improvement of maternal and child health) and the organisational models that have emerged to finance these and other global health initiatives, we propose a multi-sectoral and multi-organisational Partnership for Global Mental Health to serve two main functions. First is the mobilisation of funds, including raising, pooling, disbursing, and allocating. Second is stewardship, including supporting countries to use funds effectively, evaluate results, and hold stakeholders accountable. Such a partnership would necessarily involve stakeholders from the mental health field, civil society, donors, development agencies, and country-level stakeholders, organised into hubs responsible for financing, scale-up, and accountability.

The vicious circle of patient-physician mistrust in China: health professionals' perspectives, institutional conflict of interest, and building trust through medical professionalism.

To investigate the phenomenon of patient-physician mistrust in China, a qualitative study involving 107 physicians, nurses and health officials in Guangdong Province, southern China, was conducted through semi-structured interviews and focus groups. In this paper we report the key findings of the empirical study and argue for the essential role of medical professionalism in rebuilding patient-physician trust. Health professionals are trapped in a vicious circle of mistrust. Mistrust (particularly physicians' distrust of patients and their relatives) leads to increased levels of fear and self-protection by doctors which exacerbate difficulties in communication; in turn, this increases physician workloads, adding to a strong sense of injustice and victimization. These factors produce poorer healthcare outcomes and increasingly discontented and angry patients, escalate conflicts and disputes, and result in negative media coverage, all these ultimately contributing to even greater levels of mistrust. The vicious circle indicates not only the crisis of patient-physician relationship but the crisis of medicine as a profession and institution. Underlying the circle is the inherent conflict of interest in the healthcare system by which health professionals and hospitals have become profit-driven. This institutional conflict of interest seriously compromises the fundamental principle of medical professionalism-the primacy of patient welfare-as well as the traditional Chinese ideal of "medicine as the art of humanity". Patient trust can be restored through rectifying this institutional conflict of interest and promoting medical professionalism via a series of recommended practical measures.

The crisis of patient-physician trust and bioethics: lessons and inspirations from China.

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient-physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust - a crucial matter in healthcare especially because there are numerous ethical implications - has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework.