On September 15 of this year, I learned from my Program Officer at the National Science Foundation (NSF) that the House of Representatives Committee on Science, Space and Technology had requested the “jacket” for my NSF-funded project, “Oppression and Mental Health in Nepal.”
The jacket is an informal term that refers to all information related to a project, as specified in a Letter from Representative Lamar Smith, Chair of the Committee on Science, Space and Technology, to the NSF, including:
“every e-mail, memorandum, record, note, text message, all peer reviews considered for selection and recommendations made by the research panel to the National Science Foundation (NSF), or document of any kind that pertains to the NSF’s consideration and approval of the grants…including any approved amendments.”
Because of its broad relevance to theory and practice, I was surprised that the project was selected by the Committee. Research on mental health in Nepal matters because it can help us clarify how mental health interacts with culture in a wide variety of ways. For example, mental health appears to be positively correlated with a strong sense of spirituality. Understanding how the two are actually linked is crucial. By providing new ideas and information, the research in Nepal can help improve knowledge and treatment of psychiatric problems in ways that will improve the mental health of our own citizens.
I treated my Program Officer’s call to me as a heads up only; my project was scientifically sound, but I needed to be aware that the project might turn up in unexpected places and that I might be contacted by reporters. I was advised to inform the News and Communications Office of my university (Wake Forest) of the Committee’s request, so that they could advise me if need be.
Shortly thereafter, I started receiving communications from outside Wake. A smattering of friends and associates told me they had seen the news that I was one of the PIs (principal investigators) of NSF grants under the Committee’s scrutiny. I welcomed their support.
I also appreciated the American Psychological Association for writing to my co-PI, Dr. Lisa Kiang, a psychologist, to offer whatever assistance they could. My colleague and president of the Association for Nepal and Himalayan Studies, Dr. Mary Cameron, reached out in the same manner. I hope that other organizations of which I am a member, such as the American Anthropological Association and the Society for Applied Anthropology, will also express their support.
Reporter Jeffry Mervis of the Association for the Advancement of Science interviewed me for an article, Battle between NSF and House science committee escalates, which he published on October 2 in the News section of Science. I was given the opportunity to explain my reaction to being one of TheNSF50. My project was one of 30 jackets demanded at the time; 20 others were included in a previous request.
Mervis wrote about my project:
The 3-year, $160,000 award supported [Folmar] and two colleagues in a study of how social status affects the mental health of Nepalese adolescents. Folmar has worked on and off in Nepal since 1979, and he says the country’s economic and cultural divisions are so striking that it’s an ideal place to measure the impact of discrimination on those in the lowest caste.
Folmar says that his first reaction after hearing that his grant had been singled out was to hunker down and keep quiet. “I felt like somebody in a war movie, with bullets whizzing over my head.” But after further reflection, he thinks that speaking up may not be such a bad idea.
“I’d tell [Smith] that our work has a great deal of relevance to this country,” he says. Measuring how social inequality can cause depression and anxiety is valuable information for U.S. public health officials, too, he explains, noting that some Nepalese victims display symptoms akin to post-traumatic stress disorder.
The project was a bargain, he adds. The grant covered several months of field work by three senior researchers and their graduate students, he notes, “all for about $50,000 a year. That’s pretty cheap science.”
What This Research Tackles
Here I want to expand on why the Oppression and Mental Health (OMH) project matters. OMH-Nepal is a number of years in the making. I began doing research for my doctoral dissertation in anthropology at Case Western Reserve University on how fertility changed under conditions of “modernization” in caste-Hindu society in Nepal. In 1991 I updated that research, and returned again to Nepal in 2000, when I began to look at how oppression operated in Nepal.
Since then I have traveled to Nepal more than a dozen times and have increasingly focused on the people at the bottom of the caste system, who are called Dalits. The caste system is a complex social structure with castes ranked hierarchically and semi-bounded by ritual practice and rules that discourage marrying people of other castes. The most difficult aspect of the caste system for Dalits is that it is very difficult to move up, especially for those who are in the lowest positions.
In 2001 I visited the tourism village of Sirubari, which offered cultural programming from the Gurung ethnic group for tourists. The traditional style wedding music offered by members of one of the Dalit castes formed a significant part of the cultural offerings in Sirubarai. Here is one example of this type of music, much as a tourist might experience it.
I became interested in how the Dalit contributed to the local tourist economy and what they gained. Here is the oversimplified summary of what I learned over several trips to Nepal: the contribution was much and the benefit insignificant.
So I began to ask broader questions about Dalits in this area of Nepal: How do they and others perceive being Dalit? In what ways are Dalits talked about and treated? What are their living conditions like? Are things like family, opportunity and discrimination changing for Dalits?
The more I looked into the daily lives of the least privileged people in Nepal, the more apparent it became that the psychological burden of their social status must be great. That is why I began orienting my research more toward questions of the mind, especially psychological suffering. I asked them about dukkha, a term commonly translated as “suffering,” which the Dalit peoples experience and talk about rather freely.
Dukkha is quite a broad ranging concept. A person might apologize that he caused dukkha for someone who made tea for him. Or he could complain that his hardscrabble life was the cause of much dukkha (worry, sorrow, mental anguish, all wrapped up as one), which is the type I focus on.
In the NSF project, alongside the research on how social status affects mental health, we also examine how identity affects that relationship. I conceive of identity as a cognitive orientation toward status, a way of thinking about it. On the extremes this sense of status could be viewed as either an immutable, innate substance, an identity that is impossible to change, or alternatively as something constructed by society and mutable. There are similar dynamics with identity and status in the United States, where ideas about identity can impact rich and poor, racial and ethnic groups, immigrants, and even people with mental health diagnoses like autism, schizophrenia, or addiction.
This research is in the national interest, one of the concerns expressed by Congressman Lamar Smith, Chairman of the Committee on Science, Space and Technology in his communications with NSF (complete correspondence here).
Logically speaking, we would expect that people at the bottom of the social ladder would suffer more mental angst (dukkha) than those at the top. This point takes reality in government statistics in Nepal and in research conducted there and elsewhere. The relationship is not a perfect one, however, and is affected by such things as material circumstances, gender, and other factors. These factors help explain some but not all the variation.
What my colleagues and I seek to understand is how identification with a group alters what the other factors would predict mental anguish. We are especially interested in the extremes of how we identify with social status, where some people see their social status as innate and unchangeable (in many circles this is called, “essential”) and others as constructed and changeable. Do those different perspectives on identity and social status matter?
We have just started to analyze the results, but we can see that some of the basic relationships are holding. Our main hypothesis is that Dalits who believe in a constructed Dalit identity will fare better psychologically than those who feel locked in by an essential view of their identity. And we predict that the effect will work in the opposite way for high caste people – those who think their status is essential will have better mental health than those who think identity is constructed. This situation has a rough parallel with race in the United States, where some people believe it to be a biological essential and others think it is a social construction.
But one of the most important take-away messages is that context matters. While caste and race share some similarities in how they affect people, they are not the same thing. When we study questions like the effect of social status on mental health, it is helpful to conduct it in a place that is culturally different from our own surroundings. The fact that culture is different makes it more visible and helps us get to how culture affects mental health more clearly. Then, we can take these lessons, modify them appropriately, and see how they apply to our situation.
The project adheres to a mixed-method approach which is highly valued in anthropology because it emphasizes the strengths of two perspectives that are often at odds, the scientific and the humanistic, the quantitative and the qualitative.
The wedding of these two approaches is important for making future progress, and this is nowhere more evident than in the field of cross-cultural psychiatry. For example, the Diagnostic and Statistical Manual of Mental Orders (DSM), considered the bible for psychiatric diagnosis, now pays serious attention to culture. This awareness has come through the recognition that qualitative and quantitative data each contribute different strengths to understanding complex problems of the mind.
The research team spent nearly two years collecting data on the formation of identity and how it is related to mental health among adolescents in Lamjung District. We studied three samples of 100 adolescents, each divided evenly between girls and boys, living in urban and rural locations. The three samples we drew were from a high status group (high caste Hindus), a low status group (Dalits), and an intermediate status group (ethnic Gurungs). We gathered economic data, household censuses, ideas of identity, and mental health status. At the same time, we lived among these people in several locations, visited their schools and teashops, spoke to people frequently about caste and identity issues and attempted to firmly understand the relationships we sought to study.
The data collection for the project ended in the summer of 2014, and we are now in the process of conducting our analysis of the qualitative and quantitative data. And while we are not prepared to release statistical results yet, we have learned much. Perhaps most significantly, we understand better the relationship between culture and mental health: how mental health issues arise in specific local contexts, are detected through local means, discussed through local idioms of distress and treated, however imperfectly, through local healers.
Significantly, it is clear that a Western paradigm based on psychiatric assumptions of mental health and its causes and consequences is at best a misfit between measurement and phenomena. Western psychiatric methodology is designed to tap into concepts from Western medicine, so how well will it find cultural data that it is not looking for? This conundrum speaks directly to the relevance of the project for the US, where many people are working diligently to develop better, more culturally sensitive ways of diagnosing and treating mental health in America.
Thus, our overall research approach pertains directly to studying mental health in the US; if we narrow our focus only to medicine, how do we understand how family, world view, and spirituality intersect with our mental well-being? Only by using a more open, comprehensive methodology will we know.
All NSF applications require that we speak to the broader impacts our work will have on society, both in its application to science and to the public’s welfare. Our project alone will not solve the most difficult of questions about the intersection of psychological health with culture, but it will contribute to that effort.
Another positive effect is the cross-fertilization of scientific theory and practice among the three disciplines represented among the co-PIs, anthropology, psychology and psychiatry (Dr. Guy Palmes). The project, which cost $160,000, supports this scientific effort for three years. It includes salary support for the three investigators and one research assistant (full time at present), besides also supporting a native Nepali research assistant of Dalit background. The project promises to have meaningful scientific payoff and challenges the stereotype that qualitative data comes at a high price. In a previous academic life, I worked on many worthy projects, including clinical trials. As worthy as they were, data for dollar, they were significantly more costly than OMH-Nepal. And in terms of relevance to the US, OMH-Nepal has just as loud a bang for the buck.
As the House Committee on Science, Space and Technology argues, science should be transparent and serve important national interests. Inequality affects health, both physical and mental. Understanding how is crucial to better public health approaches and to improvements in medical care. The research in a small area of Nepal, where this relationship stands revealed in sharp contrast, joins a long line of case studies that address significant health issues. Imagine if the study of milkmaids hadn’t revealed so much about how to prevent smallpox. Or that penicillin can kill bacteria. We’ve addressed those problems, but for the epidemic of mental health, we need the best case studies possible to understand how we can help people who suffer.