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It was after our Kenyan research colleague Juliet recounted her first interview with Evelyn, who is from Mathare, one of the most densely populated informal settlements in Nairobi, Kenya, that one of our project’s key learnings emerged. Evelyn never left her home for fear of catching COVID-19, and yet Juliet told us she had been extended an invitation to Evelyn’s son’s first birthday party and might attend. When we, two researchers based in the United Kingdom and Canada, asked Juliet if she planned on attending, her answer was “most likely yes” because “I don’t know anyone with Corona.” Amidst the first wave of COVID-19, Kenya introduced a series of measures to limit movement and implement lockdowns, and we had anticipated some reluctance in response to government messaging about the dangers of the virus, but not to the extent internalized by members of our own research team. Our team had aligned on the project’s goal—to uncover communities’ perceptions of the pandemic’s impact across Kenya—but had missed the reality that individual perceptions and experiences of COVID-19 among our study participants, and even local researchers, varied greatly with our own.
Our conversation with Juliet was the beginning of a shift in how we attended to our positioning and to the data emerging in our research to reframe the largely biomedical and clinical angle taken in global health conversations. Our new way of working became a means of striving towards equity through research outputs as well as through the research process itself.
Pathways and the context of global health
COVID Pathways is an offshoot of a larger global health endeavor, called Pathways, which is aimed at identifying the social, cultural, and environmental factors that amplify dimensions of maternal and infant vulnerability among highly marginalized families across low-resource settings in Kenya and India. This larger effort is an interdisciplinary project, funded by the Bill & Melinda Gates Foundation, to develop targeted solutions that have lasting positive impact on reproductive, maternal, neonatal, and child health outcomes. The work was designed from the assumption that to achieve the Sustainable Development Goals and significantly improve the health and well-being of women and their young children, the field of global health and development must do more to consider and address risk to poor health outcomes through the lens of social, cultural, and environmental vulnerability.
From 2018, our Pathways team of anthropologists, designers, behavioral and data scientists, and global health experts were immersed in the lives of women and their families, both through secondary research and in-person ethnographically informed design research, across diverse regions of Kenya and Uttar Pradesh and Bihar states in India. Extensive field research in Kenya allowed us to create intimacy with research participants and their families, but it also offered the opportunity to establish more sustained relationships with local researchers who joined us as members of the Kenyan Pathways team.
This viscerally brought to life what population-based data was only just beginning to hint at: the pandemic was driving up rates of domestic violence.
With the onset of COVID-19, we re-engaged with the same families who had welcomed us into their homes during the early stages of the project in an effort to humanize what COVID-19 looked like for them and ultimately drive more context-specific global health interventions. National directives and data about the virus were changing almost daily, so we planned to remain exploratory and fluid, allowing the evolving day-to-day field reality to steer the process.
Lockdowns and limits to mobility prompted us to explore new ways of facilitating our work. We restructured our processes so that they became remotely managed and locally driven. In practice, this meant that the local team—four women, each born and raised in one of our research geographies—who had been instrumental in connecting us with families, navigating communal dynamics, and providing live translation during field conversations, now shifted to conducting the research themselves. Their familiarity with the project goals made them well-positioned to adopt new roles as researchers, despite a lack of formal training and facilitation experience.
While the global health community, reliant on primarily quantitative and biomedical data, was rapidly trying to design and implement solutions aimed at alleviating the adverse health consequences of the virus, exploratory and real-time engagement with participants taught us that COVID-19 was not being experienced as a biomedical illness, but rather as a social and economic one. The project became not only about identifying what is critical to know and relevant to hear, but also how to articulate a message of humanity and actionability—how people were experiencing the pandemic needed to be taken into account when developing responses.
Evolving practices
Applying anthropology in the arena of global health and development leads to shorter timeframes for research and raises the question of whether we are gaining a full picture of life as it is experienced. Local researchers provide a critical corrective: they can return to a participant and their daily lives in real time to go deeper into certain stories or trace their thread as the effects of a crisis unfold. For example, one of the Kenyan women who we spent time with had an aunt who ended up in the hospital in the early days of the pandemic and subsequently died. We were only able to piece this story together because of the multiple touch points our researcher had with this participant. Our local researcher’s ability to see the value in following up on this story over the course of a month provided rich insights into the long-lasting effects on families of the government-enforced COVID-19 restrictions. At the same time, this process required us to rethink our own positioning and adapt to listening and following our local researchers when it came to identifying which on-the-ground experiences needed more focus.
The local researchers had access to community gossip and history, and this more emic approach provided us with context and understanding that we would not have otherwise been able to develop. For example, one woman we wanted to follow up with was repeatedly unable to meet with us. We couldn’t understand why her initial enthusiasm to be a part of the research had dissipated so quickly. Eventually, we learned she was often too drunk to be interviewed, and that finally, unable to pay her rent, she had relocated to a more rural village. Where we might have simply moved on from this participant, a lack of data became information on the extent to which COVID-19 was taking a toll on women’s social and emotional lives. Working with local