Introduction: Student Experiences of COVID-19 Around the Globe: Insights from the Pandemic Journaling Project.

The COVID-19 crisis has taken a significant toll on the mental health of many students around the globe. In addition to the traumatic effects of loss of life and livelihood within students' families, students have faced other challenges, including disruptions to learning and work; decreased access to health care services; emotional struggles associated with loneliness and social isolation; and difficulties exercising essential rights, such as rights to civic engagement, housing, and protection from violence. Such disruptions negatively impact students' developmental, emotional, and behavioral health and wellbeing and also become overlaid upon existing inequities to generate intersectional effects. With these findings in mind, this special issue investigates how COVID-19 has affected the mental health and wellbeing of high school and college students in diverse locations around the world, including the United States, Mexico, Brazil, China, and South Africa. The contributions collected here analyze data collected through the Pandemic Journaling Project, a combined research study and online journaling platform that ran on a weekly basis from May 2020 through May 2022, along with complementary projects and using additional research methods, such as semi-structured interviews and autobiographical writing by students. The collection offers a nuanced, comparative window onto the diverse struggles that students and educators experienced at the height of the pandemic and considers potential solutions for addressing the long-term impacts of COVID-19. It also suggests a potential role for journaling in promoting mental wellbeing among youth, particularly in the Global South.

Cultivating Voice and Solidarity in Times of Crisis: Ethnographic Online Journaling as a Pedagogical Tool.

Ethnographic journaling can provide students with powerful opportunities to recognize and value their individual and collective perspectives as both observers and analysts of the world around them, especially in times of crisis. In this Perspectives essay, we share our experiences of using the Pandemic Journaling Project platform as a teaching resource in the first years of the COVID-19 pandemic and beyond. We consider various aspects of online ethnographic journaling, including creative teaching strategies, journaling's therapeutic potential, and student perspectives on the opportunity to document their own experiences as a forward-looking form of "archival activism." We also discuss how journaling can create robust ethnographic learning opportunities while at the same time providing a valuable space for connection and social support, especially when classroom dynamics are constrained by crisis conditions. Ethnographic journaling can help students appreciate what it means for ethnographers to bring their whole selves into their qualitative work in ways that can challenge mainstream misconceptions and contribute concrete forms of data and ethnographic insight. Overall, the essay explores how ethnographic journaling can create meaningful and creative opportunities for curricular innovation; generate durable forms of ethnographic insight; and also bring student experiences into the classroom in ways that can help them cultivate their voice, build a sense of solidarity, and potentially ease student distress.

Learning to See Racism: Perspective Transformation Among Stakeholders in a Regional Health and Equity Initiative.

CONTEXT: Achieving a meaningful reduction in health inequities will require not only policy and programmatic changes but also an increased understanding of structural racism and its deleterious impact on health and well-being. One way to enhance understanding is to actively promote "perspective transformation" (PT) around race among health equity stakeholders. Experiences of PT are defined as moments or events that bring about a deepened understanding of racism and that may result in new ways of thinking and acting. OBJECTIVE: To identify catalysts and effects of PT among health equity stakeholders. DESIGN: Semistructured, in-person interviews were conducted with stakeholders (n = 50) as part of a 2-phase, mixed-methods study (n = 170). Interviews were audio-recorded, transcribed, and coded using a mixed-methods software platform. SETTING: Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga), a regional health and equity initiative in Greater Cleveland, Ohio. PARTICIPANTS: A purposive sample of participants in HIP-Cuyahoga spanning 5 groups: metro-wide decision makers, public health professionals, clinicians, community leaders, and community members. RESULTS: More than two-thirds of interviewees reported at least one discrete experience that catalyzed PT, as defined earlier. Three catalysts were especially common: witnessing, learning, and personally experiencing racism. A fourth, less common catalyst involved getting uncomfortable during discussions of race and racism. Experiences of PT resulted in common effects including acquiring new terms, concepts, and frameworks; carrying the conversation forward; finding fellow travelers; and feeling energized and motivated to confront structural racism and its consequences. People of color tended to experience PT, and its catalysts and effects, differently than White interviewees. CONCLUSIONS: Many health equity stakeholders have experienced PT around racism and its impact. Experiencing PT is associated with new skills, capacities, and motivations to confront racism and its impact on health and well-being. Understanding how different groups experience PT can help advance efforts to promote health equity.

Introduction: Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project.

In this article, we introduce the SSM-MH Special Issue "Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project," which presents findings from the Pandemic Journaling Project (PJP). PJP is an online journaling platform and mixed-methods research study created in May 2020 to provide ordinary people around the world an opportunity to chronicle the impact of the COVID-19 pandemic in their lives-for themselves and for posterity. The essays in this collection demonstrate how journaling via an online platform can help illuminate experiences of mental wellbeing and distress, with important implications for both research and clinical practice. We begin by introducing the Pandemic Journaling Project and describing our procedures for generating the data subsets analyzed in the papers collected here. We then outline the principal interventions of the special issue as a whole, introduce the papers, and identify a number of cross-cutting themes and broader contributions. Finally, we point toward key questions for future research and therapeutic practice by highlighting the three-fold value of online journaling as a research method, a therapeutic strategy, and a tool for advancing social justice. We focus in particular on how this innovative methodological approach holds promise as both a modality for psychotherapeutic intervention and a form of grassroots collaborative ethnography. We suggest that our methods create new opportunities for confronting the impact of pandemics and other large-scale events that generate radical social change and affect population-level mental health.

Rethinking flourishing: Critical insights and qualitative perspectives from the U.S. Midwest.

In recent years, human flourishing and its relationship to mental health have attracted significant attention in a wide range of fields. As an interdisciplinary, mixed-methods team with strong roots in critical medical anthropology and critical public health, we are intrigued by the possibility that a focus on flourishing may reinvigorate health research, policy, and clinical care in transformative ways. Yet current proposals to this effect, we contend, must be met with caution. In particular, we call attention to the troubling disconnect between current research on flourishing, on one hand, and the voluminous body of scholarship demonstrating the detrimental impact of structural inequities on health, on the other. We illuminate this blind spot in two ways. We begin with a critical assessment of leading conceptions to flourishing in positive psychology, which are compared to current approaches in the critical social sciences of health. In the second half of the paper, we support our argument by presenting original findings from a mixed-methods study with a diverse sample of interviewees in the Midwestern U.S. city of Cleveland, Ohio (n=167). Our interviewees' rich narrative accounts, which we analyze both quantitatively and qualitatively, highlight important ways in which everyday understandings of flourishing diverge from prevailing scholarly accounts. Given these gaps and blind spots, now is an opportune time for robust interdisciplinary discussion about the implicit values and presumptions underpinning leading approaches to flourishing and their wide-ranging implications for research, policy, and clinical care in mental health fields and beyond.

Deservingness: migration and health in social context.

This article brings the social science concept of 'deservingness' to bear on clinical cases of transnational migrant patients. Based on the authors' medical social science research, health delivery practice and clinical work from multiple locations in Africa. Europe and the Americas, the article describes three clinical cases in which assumptions of deservingness have significant implications for the morbidity and mortality of migrant patients. The concept of deservingness allows us to maintain a critical awareness of the often unspoken presumptions of which categories of patients are more or less deserving of access to and quality of care, regardless of their formal legal eligibility. Many transnational migrants with ambiguous legal status who rely on public healthcare experience exclusion from care or poor treatment based on notions of deservingness held by health clinic staff, clinicians and health system planners. The article proposes several implications for clinicians, health professional education, policymaking and advocacy. A critical lens on deservingness can help global health professionals, systems and policymakers confront and change entrenched patterns of unequal access to and differential quality of care for migrant patients. In this way, health professionals can work more effectively for global health equity.

Flourishing: migration and health in social context.

Health and the capacity to flourish are deeply intertwined. For members of vulnerable migrant groups, systemic inequalities and structural forms of marginalisation and exclusion create health risks, impede access to needed care and interfere with the ability to achieve one's full potential. Migrants often have limited access to healthcare, and they frequently are portrayed as less deserving than others of the resources needed to lead a healthy and flourishing life. Under these circumstances, clinicians, healthcare institutions and global health organisations have a moral and ethical obligation to consider the role they can-and do-play in either advancing or impeding migrants' health and their capacity to flourish. Drawing on case studies from three world regions, we propose concrete steps clinicians and health institutions can take in order to better serve migrant patients. These include recommendations that can help improve understanding of the complex circumstances of migrants' lives, strengthen collaboration between care providers and non-medical partners and transform the social, economic and structural circumstances that impede flourishing and harm health. Developing new strategies to promote the flourishing of precarious migrants can strengthen our collective ability to re-envision and redesign health systems and structures to value the health, dignity and bodily integrity of all patients-especially the most vulnerable-and to promote flourishing for all.

Visualizing Health Equity: Qualitative Perspectives on the Value and Limits of Equity Images.

BACKGROUND: Health educators and advocacy groups often use side-by-side visual images to communicate about equity and to distinguish it from equality. Despite the near-ubiquity of these images, little is known about how they are understood by different audiences. AIMS: To assess the effectiveness of an image commonly used to communicate about health equity. METHOD: In 167 interviews with health stakeholders in Greater Cleveland, Ohio, in 2018 to 2019, a commonly used health equity image was shown to participants, who were asked to interpret its meaning. Interviewees included 21 health professionals, 21 clinicians, 22 metro-wide decision makers, 24 community leaders, and 79 community members. RESULTS: About two thirds of our socioeconomically, racial/ethnically, educationally, and professionally diverse sample said the equity image helped clarify the distinction between "equality" and "equity." Yet less than one third offered an interpretation consistent with the image's goals of foregrounding not only injustice but also a need for systemic change. Patterns of misinterpretation were especially common among two groups: ideological conservatives and those of lower socioeconomic status. Conservatives were most likely to object to the image's message. CONCLUSIONS: Equity images are widely used by public health educators and advocates, yet they do not consistently communicate the message that achieving equity requires systemic change. In this moment of both public health crisis and urgent concern about systemic racism, new visual tools for communicating this crucial message are needed.

How Do You Build a "Culture of Health"? A Critical Analysis of Challenges and Opportunities from Medical Anthropology.

The Robert Wood Johnson Foundation's Culture of Health Action Framework aims to "make health a shared value" and improve population health equity through widespread culture change. The authors draw upon their expertise as anthropologists to identify 3 challenges that they believe must be addressed in order to effectively achieve the health equity and population health improvement goals of the Culture of Health initiative: clarifying and demystifying the concept of "culture," contextualizing "community" within networks of power and inequality, and confronting the crises of trust and solidarity in the contemporary United States. The authors suggest that those who seek to build a "Culture of Health" refine their understanding of how "culture" is experienced, advocate for policies and practices that break down unhealthy consolidations of power, and innovate solutions to building consensus in a divided nation.

Health Is a Human Right-at CDC?

In 2013-14, the Smithsonian-affiliated David J. Sencer Museum at the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, hosted an original exhibition with an eye-catching title: "Health Is a Human Right: Race and Place in America." Given the American government's entrenched resistance to health-related human rights claims, the staging of an exhibition with this title at a museum described as the public face of CDC was striking. Taking this apparent disjuncture as point of departure, this article examines the origins, aims, and content of the "Health Is A Human Right" exhibition, which attracted nearly 50,000 visitors. Drawing on qualitative research findings, the article engages three interrelated questions: First, how can this exhibition, in this particular locale, be reconciled-if at all-with the absence of any firm right to health commitment in the United States? Second, what does the exhibition reveal about the "social life" of health-related human rights claims? Finally, what might we learn from the exhibition about the potential role of museums and museology in sparking public engagement with health and human rights issues, especially in settings where human rights have some rhetorical power but lack legal or political traction?

Syndemic vulnerability and the right to health.

Investigators working both in syndemics, a field of applied health research with roots in medical anthropology, and in the field of health and human rights recognise that upstream social, political, and structural determinants contribute more to health inequities than do biological factors or personal choices. Syndemics investigates synergistic, often deleterious interactions among comorbid health conditions, especially under circumstances of structural and political adversity. Health and human rights research draws on international law to argue that all people deserve access not only to health care, but also to the underlying determinants of good health. Taking the urgent matter of migrant health as an empirical focus, we juxtapose the fields of syndemics and health and human rights, identify their complementarities, and advocate for a combined approach. By melding insights from these fields, the combined syndemics/health and human rights approach advanced here can provide clinicians and other key stakeholders with concrete insights, tools, and strategies to tackle the health inequities that affect migrants and other vulnerable groups by: (1) mapping the effect of social, political, and structural determinants on health; (2) identifying opportunities for upstream intervention; and (3) working collaboratively to tackle the structures, institutions, and processes that cause and exacerbate health inequities. Undergirding this approach is an egalitarian interpretation of the right to health that differs from narrow legalistic and individual interpretations by insisting that all people are equal in worth and, as a result, equally deserving of protection from syndemic vulnerability.

Migration as a social determinant of health for irregular migrants: Israel as case study.

More than 150,000 irregular migrants reside in Israel, yet data regarding their utilization of and perceived barriers to health care services are limited. Drawing on semi-structured interviews conducted with 35 irregular migrant adults between January and September 2012, this article analyzes the role of migration as a social determinant of health for irregular migrants, and especially asylum seekers. We analyze two kinds of barriers faced by migrants when they attempt to access health care services: barriers resulting directly from their migration status, and barriers that are common among low-income communities but exacerbated by this status. Migration-related barriers included a lack of clear or consistent legislation; the threat of deportation; the inability to obtain work permits and resulting poverty and harsh living and working conditions; and discrimination. Barriers exacerbated by migrant status included prohibitive cost; poor and confusing organization of services; language barriers; perceived low quality of care; and social isolation. These findings support recent arguments that migrant status itself constitutes a social determinant of health that can intersect with other determinants to adversely affect health care access and health outcomes. Findings suggest that any meaningful effort to improve migrants' health will depend on the willingness of clinicians, public health officials, and policymakers to address the complex array of upstream political and socio-economic factors that affect migrants' health rather than focusing on narrower questions of access to health care.

Confronting a "big huge gaping wound": emotion and anxiety in a cultural sensitivity course for psychiatry residents.

In his seminal volume From anxiety to method in the behavioral sciences, George Devereux suggests that any therapeutic or scientific engagement with another human being inevitably will be shaped by one's own expectations, assumptions, and reactions. If left unacknowledged, such unspoken and unconscious influences have the capacity to torpedo the interaction; if subjected to critical reflection, however, they can yield insights of great interpretive value and practical significance. Taking these reflections on counter-transference as point of departure, this article explores how a range of unacknowledged assumptions can torpedo good faith efforts to engender "cultural sensitivity" in a required course for American psychiatry residents. The course examined in this paper has been taught for seven successive years by a pair of attending psychiatrists at a longstanding New England residency training program. Despite the instructors' good intentions and ongoing experimentation with content and format, the course has failed repeatedly to meet either residents' expectations or, as the instructors bravely acknowledged, their own. The paper draws upon a year-long ethnographic study, conducted in the late 2000s during the most recent iteration of the course, which involved observation of course sessions, a series of interviews with course instructors, and pre- and post-course interviews with the majority of participating residents. By examining the dynamics of the course from the perspectives of both clinician-instructors and resident-students, the paper illuminates how classroom-based engagement with the clinical implications of culture and difference can run awry when the emotional potency of these issues is not adequately taken into account.

How is health-related "deservingness" reckoned? Perspectives from unauthorized im/migrants in Tel Aviv.

Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care "make sense"? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related "deservingness." In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, this article further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to--and, furthermore, from the perspectives of-- unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must consider the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other. The paper analyzes findings from a 29-month mixed-methods study conducted in Tel Aviv, Israel, that approached unauthorized im/migrants as subjects, rather than simply objects, of ethical deliberation. Participants' conceptions of health-related deservingness are investigated using two sources of data: (1) quantitative findings from a self-administered, closed-ended survey conducted with 170 im/migrant patients at an NGO-run Open Clinic (2002-2003), and (2) qualitative findings from the larger ethnographic study of which the survey was part (2000-2010). The study findings both (1) contradict commonly circulating assumptions that unauthorized im/migrants are "freeloaders," and (2) highlight the need for rigorous investigation of how unauthorized im/migrants, among other marginalized and vulnerable groups, conceptualize their own relative deservingness of health-related concern and investment.

Do "illegal" im/migrants have a right to health? Engaging ethical theory as social practice at a Tel Aviv open clinic.

As the notion of a "right to health" gains influence, it is increasingly deployed in ways that are diverse, contextually variable, and at times logically inconsistent. Drawing on extended fieldwork at an Israeli human rights organization that advocates for "illegal" migrants and other vulnerable groups, this article contends that medical anthropologists cannot simply rally behind this right. Instead, we must take it as an object of ethnographic analysis and explore bow it is invoked, debated, and resisted in specific contexts. Critical ethnographies of right to health discourse and practice can enlighten us, and help us enlighten scholars in other fields, to the complexity, messiness, and "mushiness" (Sen 2009) of this right, especially in the context of advocacy on unauthorized im/migrants' behalf. It can also deepen understanding of the complicated and sometimes tense relationships among human rights, humanitarianism, and other contemporary idioms of social justice mobilization, especially in the health domain.

Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health?

Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or "illegal," basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants' exclusion intuitively "makes sense." As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice.