Week 2 is a philosophical one. More reflection on how this world operates.
Week 2 is much less eventful comparing to week 1. It is likely a more truthful depiction of a typical week in the coming 3 years.
Measure and Routine Practices
Why we do what we do the way we do it?
Several constellations lined up to trigger this train of thought. I recently finished listening to Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness by British Sociologist Andrew Scull, whilst starting James Vincent’s first book, Beyond Measure: The Hidden History of Measurement. A challenge faced by psychiatrists in the 1970s as they put together DSM III was not a new one. It is a problem of establishing a reliable measure. As the French tried to establish the metre, the Chinese Emperors defining the tunes, and the Egyptians keeping time – to be reliable in what they measure. A proper measurement often relied on a naturally occurring (hence valid) phenomenon to establish it’s reliability, which is relatively easy to do for some of the things, etc. how sundials and waterclocks were used to track time. Mother nature became their guarantor. For other constructs, like friendship, happiness, rights and responsibility, we are less capable to do so, or at least haven’t found a way to reliably doing so yet. How we measure things tell us a lot about our understanding (or the lack) of the phenomenon.
The same applies to the research in health equity. What is being recorded and how they were recorded matters. And these directly influence what is available in our routine administrative data. For example, indicating the poor uptake of psychological therapy in an ethnically diverse catchment area do not simply mean that there is a strong stigma, but perhaps more entrenched distrust in the system, lack of support for people to access services etc. Moreover, alternative support provided by community members, cultural practices and are merely not recorded, and discounted from routine records. From this snap shot understanding of the “evidence” for poor therapy uptake, what could be a proper policy in response? It is impossible to tell just by data, and this is because of how we decided to frame and measure access.
It begs the question, who decides what to measure and how? Under this veil of evidence-based policy making, which people groups are routinely under-represented? I reflected on some of these question in my blog earlier this week (Reflecting on Ethnicity in Research – Challenging the Default). These are the questions I will keep in mind and keep interrogating myself as I carry on with my PhD research.
Starting to experience once again the joy and frustration of learning a new program. Successfully installed relevant packages – celebrates! Failed to reliably call my virtual environment – felt defeated… I have been forking people’s repos on Github but struggling to understand the process… Would appreciate any tips on picking up Python!
Reflecting on how Ethnicity is researched in academia, challenging “defaults practices”
From the latest release of admin-based ethnicity statistics (ONS), it was shown that, across several administrative data source, there are a significant proportion of people having reported to belong to more than 1 ethnic group.
Similar evidence of changing ethnic identification was demonstrated in Understanding Society @usociety youth survey in young people aged between 10-15.
Ethnicity is a dynamic historic-cultural construct, and for most people from ethnic minorities groups, it changes overtime. In research/policy-based evidence making, ethnic groups are often lumped together (#BAME…), assumed to be constant, and you can only pick 1. It bears the question, how come the default practice in research is to treat ethnicity as time-invariant?
You might notice that – Changing ethnic identity is very uncommon among people reported to belong to White British groups.
And rightfully so! At the time when the population is predominantly white British (or that people from other groups are mostly slaves or seen as objects), research is predominantly initiated by white British, it is reasonable that ways of research are agreed for and within white British.
I am not saying it is a bad thing to have a consistent ethnic identification! But this lived-experience of an invariable ethnicity by white British groups has dominated the knowledge generation process and structure. And this assumption, rightfully based on white British experience was then assumed to be an universal experience.
It became The Default.
I did not recognise the issues with The Default.
I thought it was a consensus, as it was widely replicated and taught to next generations of researchers. I still do the same in my own research: treating ethnicity as lump sum categories, do not change over time.
And perhaps this IS the manifestation of systemic #oppression/#racism. Paraphrasing Dr. Celestin Okoroji: @CellyRanks shared at @kcsamh#PartneringforChange event yesterday (21/6), we need to recognise the hegemonic knowledge and evidence generation mechanisms in this society, and challenge them. (See my thread to capture part of the talk here)
The next question is: “how” – what can we do, if we think we should challenge the default – or at least suggest an alternative of how “reality” is conceived. I have 2 thoughts – (please share yours with me too!) 1) Community-Centric Research 2) Improving Methods
(1) Community-Centric Research means to put local communities – people – at the heart of research. It is about valuing relationship building, and demonstrate impact valued by local people. It is one form of Public Patient* Involvement I suppose, but more. This should be embedded in how funding is planned and commissioned.
(2) Improving Methods This is one goal of my PhD project (with @Klharron & @rob_aldridge), to improve research equity, to face the biases in “default practices”, more specifically in the practice of data linkage, interpretation and public health policy decision making.
This is new to me – and I am empowered to see so many pioneers on this path. Change can only come from a collective effort. Do share your thoughts and idea with me here or via email!
Originally tweeted by Joseph Lam (@Jo_Lam_) on 22nd June 2022 as a Twitter Thread.Minor edits and expanded on points without character limits.
First week of PhD, thoughts on Remote Start. Software Nightmare. and Academic Career Progression
“Welcome to UCL” – 10 online induction courses (no kidding!) but I doubt I’d remembered a lot from them. Possible true that it is to leave a gist, an impression of what the college values: fire safety, implicit bias, data security… All is well! Changing jobs are never simple, and doing this in a remote-working era makes it … a bit weird? But I presume it is something for all of us to get used to.
The plus side of everything going online is that, I get to attend A SWARM of online talks, seminars and groups. It does feel a bit overwhelming to start – my schedule is quickly populated with scheduled meetings and invitations, there are always this prominent speaker coming, that core training one cannot miss – can’t help but wonder – will I ever attain this wisdom to determine which talks are the truly good ones I should listen? Would be a thing to reflect perhaps a few weeks down the line..!
The excitement of starting at a new post was quickly overtaken by the frustration of – you guessed it – installing the relevant applications and softwares on my laptop! Numerous emails, calls and remote access sessions but still not able to get all I need. There must be more flexible ways for colleges to adapt to this fast-changing landscape of software development! Take Python as an example, the only version that is easily installable via college software centre is version 3.6.4, which failed to satisfy a lot of the dependencies of many recently developed softwares. Guess it is always this tug of war between data system safety & integrity vs freedom & flexibility…! Hope they all get sorted next week!
Imagining an Inclusive Academia
UCL provides a clear guidance on career progression – the Academic Career Framework (see below) – with a comprehensive list of things one is expected to achieve at UCL Grade 7 and above. This is something I have never heard of! It provides a substantive structure into what is needed to progress at UCL, in other words, things that are (currently) valued by the college.
It is said that contributions to all 4 categories is necessary to measure one’s achievement. I appreciate the attempt to provide clarity on progression, and I can see a wider potential of these frameworks to revolutionise academics’ roles in society – As Dr. Nadia Islam rightly put, a community-focused collaborative role needs to be more heavily emphasised in academic research. This would be a part of a change I would like to see, and contribute to in academia in near future!
I think this pretty much wraps up week 1 – excited to continue to embark on this journey, and hope that you will be adjourning with me 🙂
Gender, Race and power in Academia: Complexity of Intersectionality.
The tweet above is tweeted by an Asian American women professor in sociology, Prof X, who serves as the director for the Centre for Research on Social Inequality. My understanding of the original post (OP)’s intention is to invite discussion and reflection on the inequity and (micro) aggression directed towards women of racialized communities in academia; in this case, from a student.
However, Twitter reacted slightly different from what the OP expected. At first glance, a lot of people saw this as an act of oppression and public shaming of the student. I thought we Twitter user must have learned by now that 280 characters is just too little to paint the full picture, and to be kind before jumping to conclusions. Prof X very soon found herself at the receiving end of all sorts of criticisms and degrading comments on her character and professionalism. This is an unfortunate case study to look at how intersectionality plays out in real life, how the role of race is dismissed for minority groups in power, and the lack of solidarity within racialised communities.
I am summarising a few common comments (filtering out straight up insulting ones) under the original tweet:
Response 1: “It is a right question to ask!”
This response highlights that it is important to find out about potential supervisors’ skills, styles and whether it matches with them before a student decide to work with them. I think this is indubitably true. However, this comment missed the OP’s point. The problem is two folds. It was never about whether the student should ask the question, but the subjective experience of an Asian American women’s qualifications and capabilities being constantly questioned in academia. It is not about whether the question is appropriate, or even how that question was asked, it is about the cumulative experience of being treated as lesser because of their gender and race. In Ljeoma Oluo’s book, So You Want To Talk About Race (2018), she illustrated clearly the case of how racism cannot be reduced to isolated events. What is experienced and reported in this tweet is merely the tip of the ice-burg, the straw that broke the camel’s back. Many comments along this line went on to discuss “Whether or not” this question should be asked, such as:
“It’s that the student asked a professor if she was qualified (like an interviewer) instead of asking if they were a good fit (like an advisee). The tone and phrasing can feel insulting because it questions competence instead of appealing to the specificity of one’s expertise.”
But the OP is not really talking about the wordings. It is about TO WHOM this question is asked, and what this reflects. In case this was not clear, a fellow Asian American colleague of Prof X shared in the comments, but it did not turn the tides of toxic criticisms towards the OP.
Instead of recognizing the racial and gender inequity that lingered for far too long, instead of believing that the OP is, indeed, about race, instead of reading carefully what the OP is trying to get to, Prof X was torn into pieces. This blue bird is definitely a carnivore, beware.
Response 2: “Why would you shame your student in an open platform?”
This points to a different problem. Where is the proper place talk about racism? When is the proper time to talk about racism? Should this be discussed on a public domain where people can share their learnings, or should this be a private conversation between the affiliated parties? We may never have a good-enough answer for everyone for the questions above. However, the problem I see here is the need for people to police on how these issues should or can be discussed. This act of policing itself is part of the attitude that perpetuates structural and casual racism. This suppresses minorities groups to share their lived experiences on a day-to-day basis. Yes, the OP did not spell out word by word that the student is sexist/racist; yes, the OP tried to find excuses for such questions to be asked given it’s unpleasant manner; I see these are the result of similar policing on when can people from racialised or minority groups talk about their lived experience, such that we pitifully comply with conscious choice of self-censoring and humour to cover up our pain. This is not a problem of platform; this is a problem of power.
I think the presenting case here is a lively example of the complexity of intersectionality, when power and race coincide. A lot of the criticisms following the lines of Response 1 hold the notion that, the professor is in the position of power, it is hence an act of oppression. When the OP talked about her particular interaction with a student, they are automatically assumed to be the oppressor, wherever the platform may be, on whatever topic, in whatever context. The position dictates everything. Perhaps the OP would be much less controversial if the question did not come from a student, but from a colleague, or a member of the public, where public discourse favours OP’s position. Perhaps the OP would be much less controversial if the OP is a white male professor, where public discourse favours the criticisms. This reductionist way of thinking succeeds only in applauding a superficial understanding of “social justice”, but in reality often works against their intention, in worse case, a valorised, covert form of racism.
This is an example in how intersectionality plays out, in situations where systems of powers seem to operate in contradictory manners. When people from minority races are in a position of power, people assumed that their position of power would always overshadow their race, and that racism does not seem to, and should not affect how they interact with the world. The emergence of Critical Race Theory is a response to exactly these situations. Our case here exemplifies that we’ve still got a long way to go.
East Asian are the majority ethnic group in the world, but we are never the majority in these contexts. We are not white, not brown, not black. We are a distant majority group that was left out of the discussion. We are the ones that are stuck in the middle. We do not need to indulge in a competition of whom the most deprived group is, it is meaningless; however, we do need solidarity from other racialised communities to stand with us when we face racism, sexism, as other groups do. Please be kind.
Thinking of you Prof X, hope you are well.
“My dear brothers and sisters, take note of this: Everyone should be quick to listen, slow to speak and slow to become angry,”
Reflection on the Ownership of public space – physical or intangible
A procedural depiction of a futuristic world is characterised by a sophisticated metropolis, with a jungle of high-risers and floating cars. Cities are regarded as the pinnacles of civilisations – from Jericho to Manhattan – displaying the glory of our collective effort and wisdom. For some, however, cities are synonymous for crime and danger, where deceit and lies crouch; for some, cities are apathetic, every one looks after no more than themselves.
Moving from one overpopulated city to another, it wasn’t until awhile ago that I got the chance to visit Brick Lane. With no exception, I too was stunned by the vast display of creativity in the form of street graffiti. This kind of artistic expression is almost never seen in Hong Kong, where the art form is largely associated with outlaws and delinquents. My friendly tour guide explained that the graffiti at Brick Lane is tightly regulated – art pieces are regularly brushed off the walls and replaced by others’ work, popular ones might get a 2-year airtime. Perhaps this is how “Graffiti at Brick Lane” differentiated itself from “malicious defacement of public property” to one of the most popular tourist hotspots in London.
“Regulated graffiti”, I have to applaud the tenacity of the governing party’s attempt to “valorise” the art form. By putting order in disorder, graffiti at Brick Lane became a formal route of artistic expression; one can proudly sign one’s name next to their work, without having to worry about the legal consequences. Having one’s work displayed at Brick Lane became a sought-after honour. Your artwork’s intended audience expands from local bobs to tourists around the world. Comparing to unregulated graffiti, or just “normal graffiti”, rules and regulations freed one’s work from the laws of the jungle: your work won’t be vandalised or painted over just because you’ve painted on the wrong side of the road, or that you’ve taken a “better” spot. Popularity becomes a fair estimation of how long one’s work should stay up, reducing the risk of a horrible work occupying the public space.
However, it wouldn’t take one too long to smell the irony of such practice. One could go as far as saying “regulated graffiti” is an oxymoron. Graffiti emerged as an anti-establishment form of public art. With regulation, with no exception, comes censorship. This compromised version of graffiti sold their soul to buy airtime and public acceptance.
This short case study of Brick Lane graffiti invites deeper deliberation on the ownership of public spaces. In a framework that relies on rules and regulation, the responsibility of implementing and policing these rules fall onto the governing institute. It became no ones’ but the institute’s responsibility to delegate and manage the public space. With great power comes responsibility (No Way Home!), I’d think the reverse is equally true. The institute, by design, manifest the power of the many, with such power comes freedom to shape the rules in the forms they see fit – no swearing, no nudity, or, no disturbance of public order (…) or national security(…) (almost seems like I’m endorsing anarchy). The institute owns the public space. One might suggest that institute is the least of the evil, assuming the only alternative for an unregulated system leads to barbaric chaos where iron fists and crime rules. I would argue otherwise.
Graffiti is a public art form. The essence of graffiti lies in the public sphere – anyone with a can of paint could chip in. There is a natural selection mechanism – messages that the mass agreed with would be replicated; messages few agreed with would be ignored, and probably soon scratched; only messages most strongly disagreed with would be “cancelled”. There is no singular institute that decides what to censor, it is but a shared power, hence responsibility for all in the community. The public space is then, co-owned by the public. Correspondingly, this system of public space management requires members of the public to take an active role in co-creating, maintaining and cultivating the public ecosystem to ensure people’s artistic expressions could be sufficiently captured.
The elephant in the room is, perhaps regardless of how eye-catching the graffiti are, quite a number of us just don’t want paints on our properties. Similarly, not everyone wants to take part in the public sphere. This is a nature of the crowd, and coincidentally the downfall of a completely non-regulated community. The silent majority is how the mafia could take ownership of the streets by brute force. The opportunity to paint on walls would be stifled, when mutual dependency of the public is broken, and that the powerful abuse ones with less power, not respecting their stakes in the community.
Never an easy way to please everyone, ay? There is no one superior way to manage any public spaces, it largely depends on their compositions. I guess a lesson from this is, we should try to be appreciative of opinions shared in the public sphere, be it graffiti, podcasts, or blog posts. They may not occupy the BBC headlines, or shine amongst the Brick Lane graffiti, they nevertheless are part of our voices that deserves to be listened. Pray that the institute have the breadth of mind to reflect on the power imbalance and empower the public; and that the public would feel safe and ready to share and co-create our public space.
Following the majestic lead of Twitter, I stumbled upon this thread:
There are several interesting candidates for “Justifiable Deviances”: “Functional Nonconformity”, “adaptation”, “Workarounds” etc. Of all the suggestions, “Expertise” caught my attention. To compliment his suggestion, Steven Shorrock linked his page with lively examples to illustrate how reality often deviates from prescribed plans (fig 1), and that the specialism of medical staff gives them the authority to make decisions that might deviate from the standard. For example, nurses might change the time of insulin administration to meet the arrival times of meals on ward. Another Twitter user, however, questioned the notion that these medical judgement could at all be impartial, and therefore, leave space for incompetent and immoral practice. This brought my memory back to a conversation I had with my father.
My father is a respiratory medicine consultant. He takes pride in providing the best care to his patients, nights in and nights out. He has his fair share of “justifiable deviances”, most of which converted into Thank You Cards on the shelves, but there are occasions when things did not go as planned. There are occasions when the family of the deceased filed complaints to the medical council, and his medical judgements would be put under scrutiny, often against the “standard procedure”. These trials seldom bother him, rightfully so, as he is consistent and transparent in how he communicated and shared decision making with his patients. However, as we share the bottle over Zoom that night, there is this moral dilemma I felt imposed inadvertently by these complaints on my father, in the way he described the case of Pt. X .
A case study: Pt. X
Pt. X was late into their lung cancer when they came to my father. They presented with shortness of breathe and persisting lack of energy, and can barely take any stairs. After several courses of treatment, their lung function returned to pre-cancer level and Pt. X regained independence. After years of cancer management, Pt. X’s condition deteriorated, their lung function compromised, was wheelchair-bounded due to difficulty of breathing, and had to rely on carers for daily activities. There is nothing more to be done according to standard procedure. My father suggested a non-standard treatment that he believe could partially recover Pt. X’s lung function to allow them to regain a certain level of independence. Pt. X acknowledged the risks of the surgery, saying they would rather die then to be left as a burden to their family, and decided to go for it. Surgery was successful, however Pt. X passed away on operation theatre due to other surgical complications. Pt. X’s family filed a complaint to the medical council, which was dismissed after some investigation.
I could imagine the complex feelings my father must have been through: the grief of losing a patient he cared for such a long time, the stress of his professionalism being scrutinised, the sense of betrayal from the patient’s family, and ultimately, the moral dilemma – whether he should have made this option (the surgery) known to his patient in the first place. To answer the question, I would try to draw from different schools of philosophy in dealing with moral uncertainty – being Utilitarian, Deontological and Practical Rationality perspectives. This part is greatly inspired by Professor Trisha Greenhalgh’s article: Moral Uncertainty: A case study of Covid-19. My condolence and respect to Professor Greenhalgh and her family.
A Utilitarian Perspective
A Utilitarian moral theory suggests that whether actions are morally right or wrong depends on their effects (in our context, health). Actions that has the highest degree of moral rightness, or when uncertain, is most probable to maximise moral rightness, are more moral. In our case, we should then ask 2 questions:
Is advising the option of a non-standard surgery morally permissible? I’d say “Yes, but not absolute”.
If advice taken and successful, Pt. could regain some degree of independence
current condition was “worse than death” for Pt. – Reduces Negative Disability-Adjusted Life Years (DALY)
Not Permissible since:
Pt’s health could deteriorate: Risk of dying when Pt. currently not critically ill
Pt.’s death could have secondary effect on their family etc. emotional
Is NOT advising the option of a non-standard surgery morally permissible? Similarly, “Yes, but not absolute”.
Out of Standard Procedure means there is Nothing more we should do
Medical resource could be distributed to other patients in need
Not Permissible since:
Pt. would be distressed by the news
Pt.’s health would not improve from their current state
Based on the Utilitarian perspective, whether putting this option of surgery on the table is moral comes down to how likely the desired and undesired outcomes would occur. However, It occurs to me that there is a major conflict in what is deemed to be “good health” – what should be the endpoint of treatment? In the case of Pt. X, proposing the surgery would be deemed more morally permissible if health is evaluated under DALY, to treat such that Pt. could reach their maximum potential of life in their remaining years; whilst the opposite would be true if the endpoint was to manage deterioration of chronic lung cancer. I am in no position to claim to know the risks of the procedures, nor decide if Pt. X’s conditions should be maintained but not treated. Therefore, the Utilitarian approach is of limited use to me on the topic.
A Deontological Perspective
Deontological ethics concerns the morality of an action based on whether the action itself is right or wrong (under certain circumstances), rather than based on the consequences of the action. It concerns about the motivation by which action is driven. Let’s put together a list of potential motivations of advising and not advising the surgery to Pt. X.
From expertise, allow Pt. to regain independence
For Fame and Pleasure from saving a Pt
To push the boundaries of modern medicine
To personal development in surgical skills
To avoid not suggesting an option that could have improved Pt’s quality of life (thus prevent moral injury to self)
From guidelines, nothing more could be done
To avoid risk of receiving complaints by “following the standard procedure”
To avoid “unnecessary” risk of death of Pt, hence emotional burden on family
To vacant resource for other Pt
To avoid suggesting an option that could cost Pt’s life
A deontological moral theory examines the doctor’s motivation in sharing their advice with patients. It depends on whether the decision (of disclosing) is made based on the best interest of the patients.
The deontological model triggers another conflict that medical professionals might diverge on what the roles of “Standard Procedures” in healthcare setting would be. Some regard the “Standard Procedures” as “the gold standard evidence-based” practice, thus following the “Standard Procedure” serves as a safety net as medical professionals would be sufficiently protected from medico-legal responsibilities. Some perceive the “Standard Procedure” as general recommendations and references to guide, but not to dictate medical decision making. Taking necessary deviances from standards based on contextual factors is the value of expertise in a complex, noisy environment.
The former view, embodied as defensive practice, defined as solely following “Standard Procedures”, could be an unwarranted consequence of a medical system where clinicians are punished economically and socially by deviances that did not fare good outcomes; whilst good practice beyond medical standards are seldom rewarded or glorified. It is much easier to find news regarding medical malpractices or negligence than any positive news focusing on individual merits (Could this be partly due to how insurance and legal systems works? We can find numerous catalogues dedicated solely to medical malpractices, and I’d be surprised to find even 1 doing the opposite).
I am not claiming that medical professionals should be let loose to do whatever they see fit, but to state that defensive practice could camouflage itself within “Standard Procedure” and be iatrogenic. This predisposes medical professionals to “stay safe”, take no risk and continue enjoy their social status; while patients, mostly unknowingly, have their opportunities to get better – however we would define it – denied.
I think this defensive mentality feeds into the power dynamics between physicians and patients. The physician-patient power imbalance is ever persistent, which could be partly attributed to the 3 gaps (The Knowledge Gap, The Power Gap, The Arousal Gap) as illustrated by Dr Patricia Cantley in her blog. I would add, building upon the Knowledge Gap, optionality, or the choice of disclosure vs concealment is really what gives doctors their power. The choice of concealing a potentially beneficial treatment option is selectively protected by law, and the choice of disclosing a potentially beneficial treatment option punished. In a patient-centred shared decision making rhetoric, physicians’ roles include gatekeeping evidence-based treatment options, communicating risks and benefits of these options, and facilitating patients to navigate within the medical system. If the treatments options are locked within the “Standard Procedures”, there would be no true shared-decision making. The physicians always had the power of optionality. If “Standard Procedures” are the only thing that is of our concern, I’d say the days are numbered before AI completely takes over healthcare.
Enough side-tracking, back to the topic. It is inconvenient that we could not go back in time and read people’s mind to make an objective judgement on whether one’s action was stemmed from a morally-sound motivation, but this could well serve as a alarm bell for us in making future decisions.
Practical Rationality Perspective
Practice rationality concerns not only empirical facts, but also attempts to capture subjective emotions, narratives and contexts in which an action took place. The decision to provide the option of treatment would be moral in my portrait of Pt. X’s story. Being a strong provider of the family who’s pride and independence stripped away by chronic cancer, Pt. X is desperate to get better, or else they would rather die. It is difficult to argue against this account unless there is more context to Pt. X’s background, relationship with family etc. which we could not illustrate. Contingent on the adverse outcome (of death), we could argue that Pt. X’s family members would have to bear the emotional burden of losing a close relative pre-mature to their original course of life. This could have been what they felt, which drove the action of filing the complaint. Yet this line of reasoning reverts back to the naïve consequentialism, and is unhelpful for us to make future decisions morally.
But, does it really matter?
However, this highlights the crux of our discussion. Discussing what is morally right might be meaningless, when a right and moral decision (of disclosure) does not mean that you would not be punished, in a system where Punishment is solely determined by Consequences. Even all of the complaints were dismissed, the stress you’ve been put under, moral dilemma, reputation tarnished, professionalism questioned… None of these would be reimbursed or valorised. It’s simple operant conditioning, punishment of a moral action discourages future moral actions. It wouldn’t take long until “standard procedures” precedes morality in healthcare. May this be a naïve outcry for change.
You either die a hero, or live long enough to see yourself become the villain.
Harvey Dent, The Dark Knight.
Reflecting on my experience writing this blog, my main motivation is to reassure, comfort and encourage my father – to choose to be stubborn by doing what is morally right. And I hope the same message goes out to every one of you who’s doing the same.
“To be evenminded is the greatest virtue” – Heraclitus
This quote hit particularly strong as it came from Heraclitus, a.k.a “the weeping philosopher”, as later scholars speculate the great mind could be long troubled by depression. To be evenminded, calm, undisturbed is the virtue Heraclitus sought after all his lifetime. People now refer to Heraclitus’ school of thoughts as “early-stoicism”, which some regarded as the philosophical basis for modern cognitive (behavioural) therapy (CBT). CBT is built around the idea of dissecting and challenging the thoughts, belief and behaviours that maintained one’s mental illness. To develop insight (read my MSc Dissertation on the topic), or the awareness of the mental illness, is said to be the first step that is necessary for CBT. Lack of insight – at least the illness recognition components of insight – could not blissful within this framework.
For mood disorders such as bipolar disorders, this idea of mood monitoring is widely used in treatment and self-management. This follows the stream of thought that better awareness of one’s mood changes would prepare one better to account for potential relapses. Jasper Palmier-Claus and colleagues (2021) has recently published an article evaluating whether mood monitoring is Always helpful in people with a diagnosis of bipolar disorder.
The authors cited qualitative evidence that mood monitoring could induce counter-effective pre-occupying thoughts, such that people could not tell whether their day-to-day moods are an early sign of an extreme mood state, or are merely a “normal” fluctuation in mood. Authors also cited the MONARCA single-blind Randomised-control trial that mood-monitoring alone does not on itself reduce depressive or manic symptoms. It seems that mood monitoring alone might not deliver the proposed clinical benefits, and are certainly not without risks. As I quote from Jasper’s twitter thread,
We suggest that an individualised, collaborative and normalising approach to mood monitoring may be optimal and reduce potential limitations.
@JPalmierClaus on Twitter
Authors have identified several knowledge gaps in mood monitoring, I am summarising and adding my 5 cents on the topic.
a) Awareness itself isn’t enough, what we do with the new-found awareness is key.
Authors suggested clinicians to develop pre-agreed coping strategies to increase perceived control over foreseeable problems. This means that mood monitoring shouldn’t be used as a plug-and-play band aid for every one, but a tailored intervention plan that is closely followed-up by trained clinicians.
b) We do not know what is within the normal mood variations We have to understand how mood variation patterns and cycles differ in remission, recurrence and relapse, and how it differs inter and intra-individually.
Both of the trials cited above measured changes in mood once a day. In the same cited qualitative study, a common feedback described the limited flexibility of a daily mood measurement to represent the context and variability of mood within a day. But this could go on further, what really is the meaningful time lapse between each measurement? Or is there a meaningful time lapse for each person? Or, whether it depends on other ancillary factors such as – context?
Studies of bipolar disorder using Ecological Momentary Assessment (EMA) methods have explored a lot of different time lapses, from daily, twice-daily, to three times a day. Time-gap between each assessment varied across individuals within study, and between studies. It wasn’t always clear in the papers what the rationale, and the theory behind such decisions. A rational approach to the question would be first establishing a representative norm. The ERC-supported WARN-D project (led by Eiko Fried) is set to investigate what a “normal” biopsychosocial mood systems might look like. I am excited to hear more from the project in near future!
c) The fault may lie in the tools of the trades
Set aside the theoretical complexities, another factor that might hamper people from benefiting from the mood monitoring experience could be the poorly designed digital apps. From a recent review of bipolar disorder related apps, of the 98 included apps, 12 were rated as capable of causing harm to a user, by offering potentially triggering information that goes against the treatment guidelines. Only 1 app had supporting feasibility and efficacy studies, but no people with bipolar disorder was involved in those studies. These publicly accessible yet unregulated apps might undermine the efficacy of properly managed and delivered mood monitoring interventions. With the vast boom of self-help and mental health apps on the market in the last couple years, I feel there is an imminent need for relevant regulating bodies to rigorously assess the boundaries of these self-help apps.
“The only thing constant in life is change.” – Heraclitus
Change is only thing that remains to be always, Heraclitus surely helped us avoid all ceiling effects in psychometric surveys! May He enjoy his fair share of even-mindedness in peace.
On the 22nd Nov (2020), as Hong Kong was faced with yet another wave of Covid-19 outbreak with numerous cases with undetermined source, the government announced a $5,000 one-off incentive for all people who tested positive to Covid, aimed at encouraging people to take Covid-19 tests by relieving concerns on loss income in quarantine. The government faced immediate backlash against the proposal, as the public teased the non-means-tested subsidy meaningless. Non-selective, Non-targeted, Non-sufficient. Rather disheartening, but understandably, sarcastic comments about the proposal flooded the internet, with many saying they’re would purposefully get Covid-19 for the 5K “reward”. There is little discussion around whether the amount is sufficient for the unfortunate in desperate needs. Anger and disappointment, instead of empathy and compassion, was elicited by the announcement. However, as always, public discourse has to be viewed in the larger picture, as cross-sectional observations could only depict a snapshot of the undercurrents. The attitudes towards the persons in power in Hong Kong is massively polarised. It is hard to identify the root cause of distrust in the population, to disentangle poor governance, questionable response to Covid-19, and more. It could have been the case that no matter how well-planned the proposal would be, it would not be well-received in the public eye. Sparing myself from the politics (today), this blog will try to shed light on how conceiving the subsidy as a “reward” tells us about how collectivism remains defining a cultural feature of people of Hong Kong.
“Reward” – a potential reason of the disapproval may stem from the sense that the government is using a monetary reward to degrade what is a moral responsibility. That is, one should have the obligation to seek treatment if one might have gotten Covid-19, and that one should be doing so regardless of situation or social economic hardship. This is a defining feature of collectivism, where the cohesion and benefit of the community is placed before the individuals. This was also demonstrated in the 99% populational surgical mask (not whimsy cotton masks) usage in Hong Kong in the first 3 weeks of the pandemic. Whilst it is true mask wearing has been a socially acceptable behaviour, and it is also true that Hong Kong people still aches from the scars SARS left not long ago, both of these reasons are indications of the care for community weigh over individual inconvenience, that collectivism run in our veins.
If this notion of a degrading “reward” stands, we’d expect a similar level of dissatisfaction from the community if we were to say, an incentive was introduced to encourage mask-wearing. Perhaps another way of seeing it, would be the lack of compensation to the public comparing to the extent of economic activity loss in Hong Kong, but dissatisfaction did not reflect through poor adherence to guidelines. This could explain that strict social isolating measures were well-tolerated, such as 14-day mandatory quarantine for inbound overseas travelers, mandatory quarantine camps for people who had close contacts with confirmed cases, school closures etc. Hong Kong is one of the most densely populated city in the world, housing 7.4 million people, thus highly susceptible to mass outbreak. Yet compared to the England capital of 7.5 million people, London has 25 times the number of Covid-19 infections (30th Nov figure), whilst being 30% larger than Hong Kong (in km2), and Hong Kong’s infinite times closer to the first identified cases of Covid-19. Outbreak risks would have been considered negligible in the UK parliament were faced with measures no tier could match, and welcomed by its people. This is a price Hong Kong people willing to pay for the community.
Collectivism is a treasure in a contagious virus outbreak, but it does not come at no cost. The benefit of the community do not always align with the benefit of all individuals. Whilst this do not necessarily always translate into the deprivation of individual freedom, this is the case regarding Hong Kong Mental Health Ordinance (MHO). The MHO is the legislation in Hong Kong that gives medical practitioners power to assess and treat patients with mental incapacity, including intellectual disability (the legal terms were loosely defined). MHO resembles the Mental Health Act (MHA) in the UK. Conditional Discharge (CD) is part of the MHO, it refers to
A legal provision that mandates a person with mental illness who meets certain criteria to follow a course of treatment while living in the community, non-compliance of which may result in a recall to inpatient treatment (Cheung, 2017)
Without going too much in detail, CD is similar to Community Treatment Orders in the UK & Europe. CD could be issued based on a”disposition to commit violence”. In Hong Kong, approximately 2.5% of all patients with severe mental illness are put on CD. There is no limit to the length of CD, and their liberty could be stripped away when the patient was deemed to pose risk of harm to self or others. There is no strong international nor local evidence that CD achieved what it proposed. In a naturalistic cohort of 140 people under CD, only 5% had any forensic contacts after 12 months – meaning the vast majority of them has restricted freedom, and this would continue be so indefinitely. CD could be appealed via Mental Health Review Tribunal, yet there is no available data on the number of people applied or success rate whatsoever. Patients were often left stranded with no money, knowledge and power, when public stigma against mental illness disproportionately weighed in the legal system. I have only scratched the surface on the topic, pleasure to have been inspired by Prof. Daisy Cheung (Hong Kong University) in our chat. Please do follow her series on pragmatic suggestions on mental health law reform. (Twitter @daisytmcheung)
Countless challenges awaits Hong Kong people, as a collective. The search for post-colonial identity, diverse but discriminatory, greedy but generous, together but torn. The love for our community runs in our veins, it is a moral value we proudly upheld in times of crisis. The way forward is not naming, shaming, segregating and excluding, but appreciating unity in diversity, pushing for change without loosing respect for each another. As we share the love for the same community, we shall then share our honor, our pride, our misbehaves, our history, and only then, we can shape our future – collectively.
“We lived through the pandemic.” For some, this would become a badge of honour, how we individually and collectively guarded each another amidst of adversity. For some, this would signify the loss of precious ones, a time to weep and mourn. Albert Camus <The Plague> has tainted how the absurdness in people’s hearts, the degradation of humanity spread along with deadly illness. Gabriel García Márquez on the other hand sees <Love in the time of Cholera>, that love transcends amongst fear of death, and the comfort of solitude. What does the pandemic mean to you? What would the pandemic mean to you?
The first sign of humanity begins with a healed femur bone. We – humanity as a whole – would have certainly progressed a lot from the past, haven’t we? We long possessed the strongest weapon against the virus, and no, you know I am not talking about the vaccines. I am talking about the shared values that marked the progression of humanity (No, not the small steps on the moon). COVID-19 feels much closer to Camus than to Márquez.
I recently saw an interview of the (in)famous Prof. Slavoj Žižek. The bits and bops about international relationships have proven to be too puzzling for my feeble mind, but something did caught my attention.
“We are more bodily isolated, but socially connected. In a situation of social distancing, we are more socialised, open to society, more than ever. What I miss the most is being authentically alone. We are more connected than ever! The most annoying part of COVID is not being able to be alone.”
I guess when you are Slavoj Žižek, you’re bounded to be crowded by people seeking advice or wanting to share your wisdom at all times. Complaining to be not alone in a pandemic- this must be an ubiquitous experience for Žižek. As UK has re-entered the lockdown for the second time, one literally can not be much more isolated than it is now. But since it is from Žižek, I had to deliberate, are people really more lonely in the pandemic?
Loneliness is a major public health concern, associated with a heightened risk of mental and physical illness, cognitive decline, suicidal behaviour and all-cause mortality (Leigh-Hunt, et al. 2017). Loneliness is also associated with severity of depression (Lee et al., 2020 – Shout out to Lee Siu Long, Early Career Psychologist from Hong Kong, first first-author publication on Lancet Psychiatry!). As social distancing measures were widely implemented to put a halt to the raging COVID-19, this led to many worrying and scaremongering claims in the UK, such as “lockdown will trigger a spike in suicide”, some even from “experts” in the field (see open letter from 42 mental health practitioners). These claims often argue that (1) increased loneliness would be an inevitable result of lockdown, and consequently (2) lead to increase number of suicides. I’d like to dissect these claims, and see whether they are supported by evidence.
It is key to separate the constructs of social isolation from loneliness, but differentiate their impact on mental wellbeing could be challenging. Social isolation can simply mean living alone, while loneliness usually is described as the subjective feeling of feeling alone, regardless of the extent of social contact. Although these 2 constructs are correlated, logically, one could be living a life of solitude and never feel lonely (rang me up if you’ve met someone like this).
Researchers in the UK compared the level of loneliness in the UCL COVID-19 Social Study (N = 60,341, March 2020) and the UK Household longitudinal study (UKHLS) (N = 31,064, 2017-2019). They also investigated whether the risk factors of feeling lonely changed in the pandemic. Loneliness levels were higher in the UCL COVID-19 Social Study than in UKHLS, with 32.5% of people feeling lonely sometimes (28.6% in UKHLS) and 18.3% often (8.5% in UKHLS). Around 40% scored 6 or above in the UCLA-3 Loneliness Scale (Range from 3-9 = most lonely)* in UCL COVID-19 Social Study (around 25% in UKHLS).
Despite being more lonely during COVID-19, the risk factors for feeling more lonely are very similar in the 2 cohorts, some significant ones include: (1) aged 18–30 (vs aged 60+) (2) living alone (social isolation) (3) Having a low household income (4) being unemployed. Risk of feeling more lonely as a student was much higher during the pandemic. Other known risk factors including non-white ethnicity, being a woman, having low educational attainment and living in urban areas – these were relatively small risk factors.
The first part of the argument stands – people appear to be more lonely during the pandemic (we need more Žižek?). From existing literature, relationship between loneliness and suicide is not crystal clear. There was evidence that the relationship between self-harm and loneliness was strongest when the self-harm had no suicidal intent or was not considered a suicide attempt. The pathway in which loneliness lead to suicide is often through depression. Majority of the studies were conducted in cultures where individualism dominates (Europe). It appears that the second part of the argument demonstrate some face validity. At least, I feel Émile Durkheim would agree!
(This paragraph is heavily inspired by Prof Anthony David – Into the Abyss – 10/10 read!) Durkheim published “On Suicide” in 1897, where he shared his observations on social factors on rates of suicide. One of his key observations was that Protestant Christians has a consistently higher suicide rate than Roman Catholics. Durkheim did not think it was the difference in rituals or doctrines that had led to this difference. He argued that “intense collective life” of Catholics inhibited suicide. This sense of collectivism is vital –
“… not because we need to sustain the illusion of some impossible immortality; it is because it is implicit in our moral being and cannot be lost… [If lost] the slightest cause for depression can give rise to desperate acts”
Émile Durkheim – On Suicide
This need of being part of a group, to live a collective life appears to be an anecdote to why immigrants are at elevated risk of feeling lonely and dying by suicide. There are many reasons why immigrants failed to assimilate into local culture: racism, trauma, and becoming more and more relevant, nationalism etc… I’d love to give this another take.
We all belong to groups – we all share identities with others. We are members of the family, workplace, country. Some groups are mutually exclusive: some countries do not allow their citizens to own dual-nationalities; some could care less as long as you pay taxes. Some of these groups are inherited, some are results of your choice. Regardless, it is not difficult to differentiate group membership from belongingness. You could be a member of the local gym (where you might have yet to visit twice), but belong to the charity you volunteer down the road. Membership solely denotes status, belongingness is tied to your values, emotions and your emotionally modified experiences (or simply, memories). In my opinion, every group must share at least 1 of the 2 key elements: (1) values (2) mission. A study group share a clear mission, to complete the group project. A great study group shares also the values of scholarship and commitment. A marriage share the same mission, to support each another economically, to share a household, legal responsibility and social rapport. A great marriage shares also the values of fidelity and love. One group could achieve its mission rely on their members, but only those who share its values would belong.
Nationality is an interesting example. Benedict Anderson described nations as imaginary communities, and nationality as a means to gather #wethepeople (jks) to defy against hereditary monarchies. Yet we all seem to be happy to play along as members, or strongly relate to this imaginary construct that we “inherited” (Well I guess in some it could also be a choice – holding the ”green card“ is still a highly-valued asset or social status). Anderson’s theory offers a partial explanation of why nations arise – it’s mission. Ask any patriots you’ve met, I’d hardly imagine their love for their country is fuelled by their will against a monarchy (in some countries, the opposite might be more relevant…). It is the values that the patriots truly support (at least claims to support). In the Era of gods, wars between nations are figuratively fights between divine beings. Religions then were much more than moral teachings, but rules of law and order, and the core of the culture. National boundaries were then defined not by sticks and stones, but by their values. Segregation is a bottom-up phenomenon, not a top-down demand. Projecting our thoughts back to the notion of immigrants, these increased rates of suicides, loneliness and dissociation from society might stem from their non-adjustment to a different set of values. Mere physical membership would not translate to belongingness.
Back to the topic, what we’ve discussed seem to support the claim that lockdown measures are detrimental to public mental health, and suicide rates should rise in the pandemic. Early studies predicted suicide rates to increase from 1% to 145% in the pandemic, using different assumptions. There is no ways to verify or disprove these claims, as there is no real-time suicide surveillance systems. It is a technical and legal challenge to determine whether a death is classified as a suicide (see this post for more). Finally, a long awaited report by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) (UK) was published earlier this week, and a publication on the British Medical Journal describing suicide trends in several high-income countries. Paper suggested that suicide rates did not rise in Massachusetts, USA; Victoria, Australia; England, and fall in Japan and Norway in the early months of the pandemic. The claim that suicide would spike in lockdown is not supported by evidence.
Suicide rates did not increase in the pandemic. But this does not imply people do not need support on their mental wellbeing. People are feeling more lonely, and experiencing increasing number of mental health difficulties. Non-evidence based claims has achieved nothing but division, elicit our primal emotions of fear, and corrode our decision-making process. Ill-advised approaches, such as “herd immunity”, is killing off our comrades with the broken femur bones. Have we travelled backwards as a civilisation? Or progressively speaking, have we progressed beyond what humans should mean?
What has gone wrong in the argument? We’ve spend a big chunk of this article alluding the rise in suicide rates, but it did not convert. The answer has to be Slavoj Žižek. In the same interview. Žižek encourages his fellow philosophers that during COVID-19 is no better time to study philosophy. There is no better time to reflect and develop what it truly means to be a human in this trouble-found times.
We all belong to groups, we all support different values: Biden vs Trump, Science-first vs COVID-Deniers, no matter which group you are a member of or belong to, we all share a largest common factor – we are humans. We are, indeed. In the pandemic, we experienced collectively the brittleness of human lives. In this sense, along with Žižek, we were not alone. We were forced to accept “the new norm”. We had to resist our nature as social and communal animals. We are more exposed than ever from our concrete buildings, professional certificates and luxury, that we are – humans. Perhaps this sense of collective living/suffering protected us from the suicide spikes. Are we merely a member of the human class – our mission being sustaining the status quo? Or do we belong to this group, by uplifting our values in the ways we treat each another? This question warrants a rethink of the values of being human, and whether we’d share these values.
“We lived through the pandemic.” We can still right our wrongs. We can still win this war. We have to find our values, and uphold these values in every way forward. Because we all are rightful humans.
With the love of God.
*UCLA-3 is one of the widely evaluated loneliness measure, consist of the 3 following questions:
(1) how often do you feel a lack of companionship? (Never – 1, Some of the times – 2, Often – 3) (2) how often do you feel isolated from others? (3) how often do you feel left out?
TL:DR; – People have been claiming that lockdown will lead to a “suicide epidemic” due to loneliness, thus refuted against the lockdown decisions. This narrative in my opinion led to regrettable public health policy and decisions. Lives were lost – not to suicide. Recent figures from Australia, British Columbia, US, UK & Norway compares suicide rates prior to and during lockdown. NONE of the figures show that suicide rates increased compared to pre-COVID numbers. This does not imply people do not need support on their mental wellbeing. People are feeling more lonely, and experiencing increasing number of mental health difficulties. These claims of increased suicides were busted. These non-evidence based claims has achieved nothing but division, elicit our primal emotions of fear, and corrode our decision-making in protecting lives. We dropped our comrades with broken femur bones in our “herd immunity” approaches – evident in the US & Sweden. The way forward has to begin from reconstructing what it means to be human – what are the values that group us together, and we should uphold these values every way forward.
Saw this Tweet on Jul 31, 2020 by Twitter User: @ravenscimaven
I really don’t like being labeled “BIPOC*” y’all. I don’t know what it is, but I’ve had more people these past few months refer to me with an acronym than ever in my life and it doesn’t sit right with me. I wonder, how do LGBT+ folks feel about being identified with an acronym?
@ravenscimaven on Twitter
*Black, Indigenous and People of Colour
I’ve first encountered the term BAME (Black, Asian, and Minority Ethnic) when I first arrived in the UK. I never liked the term, as it was used and discussed as if the experience of ethnic minorities in the UK are similar/comparable. I appreciate the motivation to raise awareness and fight for the rights of the minorities. Yet I can’t help to feel elements of tokenistic labels in the imprecise languages around the topic. Why create this label BAME, when you can just describe – for example, Black Caucasian – and acknowledge the differences between this group and, say Black Caribbean?
The question then shifted from category of ethnicity to sexual orientation – whether the label of LGBT+ is identified by people of these orientations. In the current age, this comparison is appropriate in sense that, a person can identify their belongingness to their identities, based on their intuition, affection and resolution. Yet I think there is a slight difference between the two, as the latter is described as a spectrum is a varying index on a 2D scalar field; while the former is conceived as categories.
I think my question is, what qualifies the latter to be a spectrum, instead of groups in a wide array of categories? What are the 2 ends of the scale? Is a spectrum specifically used to encourage us to reject binary categories? Bunch of categories sprung up in my mind, I’d invite readers to help with this thought experiment and classify, which would be spectrums vs categories.
Ethnicity – Nationality – Mental Health – Political Philosophy
A Corresponding Tweet from Twitter User: @thecrobe caught my attention.
I do not mind being grouped into the queer community (usually). What I DO dislike is when it is used for performative action by someone doesn’t understand the nuances in the community (and does not educate themselves).
@thecrobe on Twitter
From this user’s experience, I am tempted to think: Rejecting existing binary categories doesn’t matter – discovering the new identity matters. Whether such category (within a spectrum) exist in the past doesn’t matter, but whether there is scope in the present to allow the development of character to this label matters. It is not the half-hearted belongingness to these labels that elicited negative feelings amongst the labelled, but the movements that attempted to create history, culture and character around that single ambiguous label/category – that failed to echo with these groups.
If this is the case, the central aim of the advocates – for whichever group – should shift away from proving that some people are different, and stop putting people into more complicated categories. We already know that. But to help create an enabling environments, such that these individuals can explore their individual identities to the fullest.
Voices from people with lived experience MUST stay at the centre of all advocative movements, research and policy-making. For the sake of the individuals, the community and humanity.