Being a part of our sociocultural history, stories and narratives help us make sense of our lifeworlds. Stories, rumors, and conspiracy theories offer deep meanings when analyzed in specific contexts, and prominently appear in the face of looming uncertainties, anxieties, and fears. Similarly, many narratives have surrounded the coronavirus disease 2019 (COVID-19) pandemic at the global and local levels as people try to make sense of this invisibly spreading virus and its multidimensional effects. Drawing on the media reports, I show and analyze global-level narratives that reveal geopolitics in play. To present the local level narratives in Pakistan, I build on my long-term ethnographic fieldwork, recent telephone interviews, and content analysis to discuss why these tales emerge and spread. As the pandemic unfolded, local people started drinking “miraculous” tea as a form of prevention, shaving their heads, and/or praying to God to undo His “punishment” and conceptualizing the pandemic as an invented “plot.” With my analyses, I compare the “viral rumors” with the virus and argue that these narratives are social phenomena, carrying multiple meanings that need the thorough attention of social scientists, for example, anthropologists, just as we need experts to study a virus. The rapidity of their spread reveals the intensity of the challenge faced. Natural disasters, wars, and contagious outbreaks, epidemics, and pandemics, such as coronavirus disease 2019 (COVID-19), have accumulated multiple narratives. As the number of COVID-19 cases swiftly escalated, so did the rumors and conspiracy theories2 that led the World Health Organization (WHO) to coin a new term, “infodemic,” to encapsulate the pandemic of “(mis)information” that rapidly spread by means of social media and word-of-mouth.4Stories and narratives are part of our human sociocultural history. From our early beginnings as foragers, we humans have created and told and retold myths, legends, folktales, and other types of stories, both to help us make sense of our lifeworlds and to encode knowledge and wisdom learned over generations, thereby passing it on. Before the invention of writing, tales were the best sources to preserve and share specific meanings.At the global level, politicians and governments started pointing their fingers at each other. For instance, the United States and China made competing narratives to blame each other that they are the creators of this virus. At local levels, people brainstorm probable causes of COVID-19 and circulate advice about preventions and “cures,” and at all levels, rumors have spread about the potential agents behind this virus. When these narratives take the form of rumors and conspiracy theories, it is indispensable to document them for a thorough understanding of how people make sense of a looming threat, and most crucial to question the underlying reasons for these speculations and their impacts on the preparedness programs: Why do these narratives start and what do they reveal? How do people culturally construct, generate meanings, and negotiate the outbreaks of disease, particularly COVID-19? What implications will these have on programs of preparedness at a local, national, and global level?Precisely, studying viral rumors and conspiracy theories is as crucial as researching the virus to lucidly comprehend the content, sources, modes of spread, and impacts of these narratives.I draw on my ethnographic fieldwork on cultural understandings of health and illness, especially negotiations of infectious diseases, including vaccination in Pakistan, which I commenced in 2008 and have continued to date. In addition, while living in Austria during the COVID-19 pandemic that broke out in my country in February 2020, I have been having phone conversations with my family, friends, and acquaintances in Pakistan to thoroughly understand how COVID-19 is perceived, negotiated, and dealt with at village, provincial, and national levels. These data are based on convenience sampling. The data I analyze herein also come from the content analysis of mainstream social media reports that I began to undertake in January 2020. For providing a historical outline of rumors and conspiracy theories, I borrow from the relevant and extensive body of literature, largely from psychology and anthropology. The study is part of a project by the National Bioethics Committee Pakistan (reference No.4-87/NBC-471-COVID-19-09/20/).2 Likewise, China and Russia are pointing fingers at the United States, for example, Chinese officials claimed that the US Army had introduced the virus to China.6 The Venezuelan President also argued that the United States used the virus as a “bioweapon” for targeting China.7 Turkmenistan and Tajikistan asked their citizens to continue working after calling the virus and its treatment “bogus.”7Globally, conspiracy theories are revealing geopolitics. A conspiracy theory emerged that, although there is no evidence that the United States has bioengineered the virus, the country has deep interests in affecting China’s economy.7 Likewise, the United States blamed China for the origin and early transmission of the virus: US Senator Tom Cotton suspects that perhaps China produced the virus in its weapons lab7—a rumor that went so far that it is currently being addressed on US National Public Radio. President Trump started calling the virus a “foreign virus” and “the China Virus,”5 warned the WHO against being so “China-centric” and he is cutting funding to the organization, although the WHO firmly rejected that criticism.8In contrast, Matteo Salvini, the leader of Italy’s anti-migrant League Party, contended that the outbreak of the virus is China’s doing, insisting that the Chinese have deliberately cultivated a “lung supervirus” from “bats and rats.”9 Clearly, predicting the occurrence of something can lead people to believe that you created that something, perhaps just to prove yourself right.Furthermore, on social media, especially on Facebook and Instagram, people shared speculations that Bill Gates, on behalf of Big Pharma, is behind the emergence of COVID-19. People refer to his TED-talk of 2015, in which he argued that the next viral outbreak might prove more deadly than war.These news reports, social media videos, and stories have accumulated a plethora of comments that discuss, argue, and counter-argue these stories. These comments demonstrate how people are negotiating the pandemic by finding a scapegoat. People often need somewhere to go with their anger and confusion; blaming and shaming serve that purpose and make the people doing it feel powerful.10 About COVID-19, comparable stories have surfaced to trace a “hidden” agent: the pandemic is “bioengineered” either by the United States or by Big Pharma. Speculations also contain home remedies, such as drinking garlic water , or “blowing hot air from a hairdryer through your nostrils”; the country’s health ministry suggests keeping your throat moist.11 Many people are following these (relatively harmless) suggestions.In this section, I draw on various competing narratives with unknown and untraceable sources that have emerged in Pakistan, especially in villages. These narratives are not exceptional, as rumors and conspiracy theories about infectious diseases’ outbreaks have long been prevailing there. Various rumors surround vaccination programs—these are a means of “depopulation” by means of the sterilization of Muslim women and that hidden stakeholders are behind these campaigns.2 (b) A comparable rumor surfaced in the small towns of Azad Jammu and Kashmir (AJK): The government shoots the infected persons to contain the virus.Particularly, I describe and analyze 6 specific narratives currently circulating in Pakistan: (a) In a small village of Sindh Province when the pandemic was still unfolding, a rumor spread that the government sets the infected people ablaze to eliminate and contain the virus.Moreover, extraordinary narratives emerged as the pandemic grew. (c) In Punjab province’s 1 town, the narrative started that COVID-19 is the punishment of God, which is a result of the opening of cinemas in Saudi Arabia and general disbelief in God in the Global North, where everything is “too open,” especially romance. God has shown us how powerful He is in that science is unable to deal with the pandemic. Because Pakistanis believe in and worship God, their number of cases is far less than in the “Godforsaken” countries of the United States and Europe.(d) Yet a different rumor surfaced in Sindh and Punjab provinces that questioned the existence of coronavirus: How is it possible that one gets infected by means of shaking hands or standing close to someone? The rumor continues that the government is only imposing lockdowns to receive global attention for potential foreign aid and that there is no danger.(e) A widespread rumor broke out in Sindh province that shaving one’s head protects against the virus. Following this rumor, innumerable men (the shaving of a woman’s head is considered shameful) immediately shaved their heads considering an economically affordable preventive measure that costs only US5-10 cents. In 1 village of Sindh, over 50 men shaved their heads.(f) The last rumor is concerning a miraculous birth—of an infant who started talking after his birth—that emerged in the northern Sindh, which rapidly spread in many districts. The following is the rumor: “I will not survive. I am here to tell you something important about the current coronavirus that the disease is deadly. I will die at noon and will bring the coronavirus with me,” said the child. It could kill everyone if a recommended measure was not taken. The measure was brewing green tea, and every person should drink 5 sips. The one who would drink these 5 sips would survive; the rest would die. “As long as my heart beats, I ask you to please drink tea.” After conveying this message, the child died.Showing their concern, local people promptly made efforts to reach their families and friends by means of mobile calls and messages and paying in-person visits.The global level narratives would significantly affect the preparedness programs, not only related to COVID-19 but also other similar futuristic programs. On the one hand, linking the virus with the geopolitics would affect the programs of preparedness in terms of (in)effective political policies and lack of economic resources not only at a country level but at the global level. On the other hand, these narratives that the virus is a conspiracy of any “super-power” would significantly affect the local level perceptions and practices toward the virus. These competing narratives would testify to not falsify the similar local level narratives—as mentioned earlier, that some people believe that there is no virus.The local level narratives have adverse and positive effects on behaviors that may considerably affect the preparedness programs. The first 2 (a and b) rumors—burning or shooting infected people—can compel local people to avoid getting the COVID-19 test. Yet both may lead people to adopt preventive measures not to contract the virus due to that fear of death by the government. As these rumors compelled family members, particularly (older) parents, to become highly concerned about the mobility of their younger generation and to ensure that they all stayed at home. In this specific case, we can see that rumors can have positive, instead of solely adverse effects.The rumor (c), that the virus is “an act of God,” illustrates religious beliefs and gives people hope that the COVID-19 may be successfully dealt with through worshiping God. The rumor (d), that there is no coronavirus, reveals the mistrustful relationship between people and the government. Both rumors can be seen against the historical backdrop of the country and region: colonization, poverty, and aid dependency.Panjtan Pak (lit. “the Holy Five”), who include Prophet Muhammad, his cousin Ali, daughter Fatima, and their sons Hassan, and Hussain. People believe in their supernatural powers to be advocates to God for seeking help and blessings in normal, and especially during extraordinary, events. In this way, “drinking 5 sips of tea” has physical and symbolic powers—the properties of tea and the symbolic power of 5—both can exert positive impacts on people’s physical and mental bodies. Precisely, both rumors are a good example of how a society can produce an easily accessible “cure” in the absence of an efficient health-care system.The rumor (d), “shaving one’s head,” is relatively harmless and seems to reveal people’s desire for disease prevention by any means suggested, as does the rumor (e) “drinking 5 sips of green tea.” This rumor has some basis in fact because studies have shown the positive effects of black or green tea (as well as garlic) on the human immune system, although solely 5 sips are unlikely to help much. Moreover, the number “5” has a special meaning within the local belief system. Many people across the country, specifically those who practice Sufism and Shia-Islam, regard numeral 5 as lucky and sacred. They link this number to All and all, these local level narratives might have severe implications for the preparedness programs: either people ignore the recommended measures, that is, physical distancing, avoiding handshakes and hugs, or not organizing public gatherings. One might assume that the last rumor about belief in the “Holy Five” would exert critical effects on the recommended measures as local people would easily participate in the religious activities that generally are performed during the first month of the Islamic calendar by the practitioners of Shia-Islam.12I argue that rumors and conspiracy theories constitute “normal social phenomena.”13 and can bring excitement to people’s lives. More complex answers involve specific motives that lie behind people’s desire to believe, which include epistemic factors that are required to sufficiently understand one’s environment; the existential need to feel safe and in control of one’s environment; and the social need to maintain a positive image of oneself and one’s in-group.14While devoting considerable attention to document rumors and conspiracy theories, it is crucial to ask a simple question: Why do these stories emerge and receive wide attention? The simple answer is because, as previously noted, these narratives provide meanings and empower people to feel some sense of control in the face of frightening situations. In addition, these narratives are mysterious and captivating10Before the presence of mass media and social media, word-of-mouth was the primary source of rumor transmission. This historical source of circulation still prevails in those societies where access to media is low.15 Some people deliberately craft specific conspiracy theories, and others produce counter-narratives; hence, in a way, both equally participate in their spread,14 as to generate a counter-narrative to a given conspiracy theory is to give attention to and to further spread that theory. Rumors index ambiguities,16 convey coalescences of meaning, and reveal interconnections and interplays between local and global contexts. The speculations grow successfully in specific contexts: social, cultural, economic, and political.14 Their circulation continues in waves of what I term “the provision of meaning.” Rumors tend to occur in multiple versions and can constitute what is referred to as “global mass hysteria.”17 They describe the relationships among (geo)political and economic low-power and high-power groups. The rumors can explicate and indicate the politics of inequality.16 Therefore, their meanings must be deciphered within their historical, socio-cultural, economic, and (geo)political contexts to be fully understood.18These narratives may make people feel special—that they possess some essential and rare information that enhances their self-esteem.19 To meet an important objective, such narratives assist people to “create an alternative public sphere and maneuver to speak in oppositional voices.”20 Conversely, rumors can be created and spread by people who enjoy a great deal of power and wish to use that power to promote their agendas.Rumors can illuminate a lack of power and can allow the less powerful to express their fears. When local people see themselves as powerless against the dominant institutions, for example, the government or international nongovernmental organizations (INGOs), they spin rumors.21 Although rumors can be true or false, or half-truth-and-half-lie,15 they are always a form of communication, and they can convey hidden and vital meanings, reflecting beliefs and perceptions regarding the workings of the world, and collective explanations and illustrations about complex circumstances.22In addition to giving power to the powerless and more power to those already enjoying it, rumors can help to negotiate a given phenomenon.23 They can function to mobilize crowds and to unite rebellious masses.25 Rumors differ from other types of communication because of their enunciative and performative functions.26 Due to their flexibility, rumors work as a practical mode to reflect upon hard economic and political situations.16 In rumors, words transform from a medium of communication to an apparatus of force.27 Rumors can disappear and reappear during similar circumstances but with prominent modifications—additions and subtractions—such as in Indonesia.28 For a rumor to have a powerful effect, it does not matter whether it is true or false. A rumor containing unofficial information can be false, and so can “official” information.12 For their believers, rumor always counts as accurate and meaningful. Perhaps their credibility is unrelated to the rumors themselves but rather to the credibility of the tellers. The authentication of anything can be challenged.Rumors often have their roots in social institutions.Although the coronavirus and the rumors and conspiracy theories circulating in response to it appear to lie at 2 different poles, they have significant similarities. As viruses are a reality, so are these competing narratives.4 It has affected people socially, culturally, economically, and in terms of their health—physical, emotional, psychological. It has challenged our leaders and global stakeholders, such as the WHO, to effectively deal with it.COVID-19 is a viral infection. Viruses always have an origin: they emerge, spread, and sometimes cause a major outbreak. Such is the case with COVID-19, which appears to have originated from the Huanan seafood wholesale market in Wuhan, China, then was rapidly transmitted from person to person and then countries to continents.For studying the behaviors and patterns of viruses, we have experts, such as virologists, microbiologists, and epidemiologists, who appropriately investigate them. They explore where exactly a virus broke out, why and how it emerged as well as spread so rapidly, what are its modes of transmission and patterns of spread. Under what circumstances can it breed further?Correspondingly, rumors and conspiracy theories also have specificities that need to be thoroughly studied, adequately understood, and amply illustrated. Rumors and conspiracy theories also emerge in specific situations and diverse places and travel at a pace that is almost as rapid as the virus itself. Like the outbreak of this disease, these narratives affect multiple aspects of life and have their own set of researchers—specialists such as social scientists, especially anthropologists—who can systematically study the patterns, modes, and effects of these narratives. Unlike a viral outbreak, it is usually not possible to trace the origins of these narratives. Yet, it is entirely possible to locate in which area they started, under what circumstances they broke out, what meanings they are pregnant with, and what are their short-term and long-term consequences.Another critical commonality shared by viruses and rumors is the near-impossibility of stopping their spread or of completely eradicating them, as indicated in the saying, “The rumor went viral.” Various viruses  re-emerge from time to time and place to place, and new viruses emerge . Viruses can be classified into categories in terms of their similarities, such as the severe acute respiratory syndrome-coronavirus (SARS-COV) family of viruses, of which the coronavirus is a part. Similarly, rumors can be categorized, such as those related to medical or economic arenas. Also, they affect each other—viruses generate rumors and conspiracy theories, and those narratives can affect how people deal with those viruses. During pandemics, rumors and conspiracy theories can adversely, or positively, affect preparedness programs.Two additional commonalities between viruses and rumors are that both are highly contagious and affect “at-risk” populations. A virus severely affects those who are “weak” in terms of their immune systems, and that “weakness” often stems from their socio-cultural, economic, and political situations. That same population is especially vulnerable to the effects of rumors and conspiracy theories. These factors are critically interdependent and intricately interrelated.Just as microbiologists and epidemiologists can help to deeply understand a virus to contain and deal with it, so social scientists can help to meticulously understand, contain, and deal with viral rumors, especially anthropologists who are highly equipped, well-positioned, and appropriately skilled to study micro-level phenomena  and link them to macro-level structures .This study also has certain limitations. Because it draws on convenience sampling, the results cannot be generalized to the rest of the country’s population, although the study provokes interesting debates to compare rumors and viruses. All the data is either obtained from the media content or the telephone interviews, which may again affect the results of this study.Studying viral rumors and conspiracy theories is as crucial as researching the virus to lucidly comprehend the content, sources, modes of spread, and impacts of these narratives. Focus can be on factors that lie underneath these stories: why do they spread, in which circumstances and in which parts of the world, and who are their beneficiaries? In this article, I have sought to provide answers to these questions.As an inadequate understanding of the coronavirus hinders effectively dealing with it at the medical level, so does lack of understanding of the rumors and conspiracy theories surrounding it hinder dealing with this pandemic, the preparedness programs at societal levels. These narratives beg the same paramount attention as making the scientific inquiries of the virus.It is indispensable to understand that constructing stories—weaving meanings and deciphering them—is a longstanding human social phenomenon. We cannot survive without narratives. Functioning as building blocks of society and as means of enculturation, these narratives help us to encode crucial information that is necessary for biological, sociocultural, emotional, psychological, economic, and—the most important—political survival. It is my hope that my presentation and analysis of the rumors and conspiracy theories surrounding COVID-19 will empower others to understand their sources and effects, both negative and positive, and to find better and more effective means of spreading truths that can also be encoded in narratives—our most popular and longstanding form of information dissemination.


M = 21, range = 6–43). The survivors’ accounts confirmedpresence and overall phenomenological characteristics of commonly studiedperitraumatic reactions such as dissociation, distress, mental defeat, andimmobility. In addition, novel and understudied reactions were identified:cognitive overload, hyperfocus, and emotion regulation, as well as positiveaffect. Finally, a number of cross-cutting phenomena were identified such as thesocial nature of many reactions and survivors evaluating their reactions asdifficult to put into words. These findings have implications for theconceptualization of peritraumatic reactions, for trauma-focusedpsychotherapeutic interventions, and for the wellbeing of disastersurvivors.Thoughts, feelings, and behaviors during traumatic events, that is, peritraumaticreactions, are key to post-trauma psychopathology development. Qualitativeresearch is required to investigate whether existing quantitative methodscapture the range and complexity of peritraumatic reactions as described bysurvivors. Semi-structured interviews were conducted with 104 earthquakesurvivors. Participants reported experiencing various peritraumatic reactions( While these are reasonable methods to determinethe presence of such reactions, inductive, systematic qualitative work is needed toprovide a naturalistic and scientifically accurate account of the lived experience ofperitraumatic reactions among trauma survivors .In addition, the current approach to studying peritraumatic reactions is largely based onthe use of standardized questionnaires such as the Peritraumatic DissociativeExperiences Questionnaire  and the In the largest qualitative study to use interviews to investigate spontaneously reportedreactions during traumatic events, 125 survivors of various disasters across differentEuropean countries were asked to recall in a free narrative their own reactions . Across However the study was limited by a considerable time lag between the events and theretrospective accounts, that is, an average of 4 years, by the lack of homogeneitybetween the different traumatic events among participants, and by most interviews beingconducted in focus groups, which are not ideal settings for openly discussing someperitraumatic reactions  due to social desirability bias.N = 20) during the 2011 Christchurch earthquake, manyengaged in various emotional regulation techniques such as self-talk and deep-breathing,and problem-focused coping to give an impression of calm while prioritizing thewellbeing of their students .Demographic information on the current sample is provided in Table A inSupplemental Materials.Participants identified various key distressing moments during thesemi-structured interviews. The most commonly reported events are presented inA total of 85 different peritraumatic reactions were identified in the interviewssee . EachcoCertain reactions did not belong to any specific group such as “appealing to God”or “religious coping” , “over-identification with otherpeople” (15%), “avoiding distressing scenes” (14%), “being in physical pain”(7%), “feeling a sense of injustice” (5%), and “smoking tobacco” (5%).Therefore, when these reactions are reported in a certain section , it does not imply theywere not also associated with other peritraumatic groups.I remember that I was there in the middle of all this debris and Ithought, now I will die, and my family will die in another place, and Iwill die here on my own, I thought of my nephews, I thought of thepeople in my family, the people that I love that maybe were dying faraway from me [cries]. The majority of participants mentioned fear as the predominant emotionexperienced during the earthquakes. However, fear for the safety of others wasreported by more participants  than fear for one’s ownsafety . Fear was conceptualized by participants as asocial emotion often held in relation to significant others, especially familymembers not physically present at the scene. The first actions and thoughts ofparticipants were often social in nature, with participants either calling byphone or actively going to search for significant others. Even when in extremedanger or distress, the thoughts of some participants were directed towardothers. One participant who had remained stuck under debris described how:4 form, absorbing all other cognitive and emotional resources by completelyoccupying one’s mental space. Participants described how their brains, used as asymbol for rationality, were emptied, zeroed, or blocked by fear. Participantsvariously described fear as clinging to them, taking control of them, orpossessing them.Following fear for others, fear for one’s own safety was the most commonlyreported emotion. Fear was often described as an overwhelming emotion,experienced in a “pure”My first emotion was fear, an incredibly strong fear, a terrible fear,maybe the worst fear that I have ever experienced in my life, so muchfear, terror, I was terrified, you know like when you go and watch anhorror movie that you are not used to watching and you are scared evenof small things like the sound of wind through the trees, it was pureterror, it was unbelievable. Fear was at times associated with participants holding catastrophic beliefs.These ranged from thinking that everyone they knew was dying or was going todie, that the earth was going to split under their feet and swallow them, orthat the apocalypse was taking place.I was terrified that the earth was going to split and open up, and thatwe were all going to be swallowed up by it, and I kept crying. I thought that now the ground will open up and I will go down, I wasresigned to death, I made the sign of the cross and I waited for death[. . . ]“for all my sins” I said “please help me”, God will welcome me.Fear was associated with thoughts of death. Thoughts of dying and the possibilityof experiencing a painful death were most fear-provoking and distressing toparticipants. When faced with the possibility of death, some participantsdescribed appealing to God or other religious figures. Religious figures wereevoked generally to plead for survival but, in some cases, also for comfort whengetting ready to die or when praying for a quick and painless death. An elderlywoman recalled how:Behaviorally, the emotion of fear was often associated with flight responses. Aconsiderable number of participants described experiencing an urge to fleeduring the earthquake shocks. This instinct was generally triggered by thefeeling of being trapped when inside built structures. It was described as asudden, rushed, and not necessarily reasoned reaction, such as participantstaking the stairs without checking they were intact. Houses and internalstructures were generally conceptualized as spaces of risk one had to fleerather than as safe and solid refuges inside which one felt protected. Somehouses were perceived as being so unsafe that a number of participants jumpedfrom windows to get out of them.Another commonly reported negative emotion was anxiety, often connected tofeeling in a state of uncertainty. In addition, some participants reportedhaving anxious thoughts concerning their future, such as what was going tohappen to their lives and how they were going to continue living without familymembers, houses, and jobs.Other emotions such as sadness, anger, guilt, and shame were also mentioned.Sadness, melancholy, crying, desperation, and emotional pain were feelings andbehaviors associated with loss, often following the realization of the death offriends, family members, and acquaintances. This emotional pain was described asdeep, excruciating, and insurmountable as well as being associated with feelingsof unbridgeable void. The loss of people, in particular children, created gapingholes within the close-knit pre-earthquake social fabric, which participantsfelt could not be mended.why sucha thing had happened to them and what they had done to deserve so much pain.A number of participants also reported reacting to the events with anger,irritability, and frustration. Anger was often fueled by a perceived sense ofinjustice concerning the event. Participants often mentioned that what hadhappened was unfair, alluding to a tacit universal moral structure that hadsuddenly shattered. People reported asking themselves Participants reported experiencing a considerable number of agency-drivenreactions indicating orientation toward action, focus, and attempts at managingone’s emotions while in distress. Some participants reported quickly gainingfull understanding of what was happening. Others described progressivelyinitiating a process of making sense of the event and “putting things intofocus” in the subsequent hours and days following a period of initialconfusion.The process of gaining awareness of what was happening was generally followed bya shift to actions oriented toward a goal. These actions were both directedtoward the external environment, for example when providing support to others,and also toward oneself, such as by regulating one’s reactions. Participantsreported “switching” to an operational mode by “unblocking” or “activating”oneself and “springing” into action. Some participants described this shift fromconfusion to action as that of resetting a frozen computer or phone.It was only a moment of confusion, one second, then I saw the stones onthe ground and I thought “shit, it’s the earthquake”, it was as if I hadre-set my brain, and I went along with mechanical memory, I mean I hadidentified priorities 1, 2 and 3 and until I hadn’t completed all ofthese priorities I didn’t stop. A large number of different actions oriented toward a goal were described by mostparticipants . The most commonly reported externalaction was that of providing both practical and emotional support to otherpeople in need . Practical support ranged from offeringfood and water, giving people clothes and bedcovers, to providing first aid andrescuing people from under the debris. At times, participants reported puttingtheir own safety at risk to help others. People often reported that what pushedthem to provide practical support to members of their community as well as tostrangers was the need to feel useful and take agency in relation to thesituation together with an identification with the suffering of others duringthe event.I put myself in the background in order to help others, I instinctivelyannihilated my ego, I considered the life of another person fromAmatrice just as important as my own life. Participants also reported providing emotional support to others. This includedcalming and comforting others as well as being strong for people around them.One participant recalled his attempts to try and protect his elderly mother fromthe awareness of the loss of her town by telling her they were starring asbackground actors in a disaster movie and that everything she was witnessing wassimply part of the movie set.The act of providing emotional support was often associated with an attempt toput one’s emotions on hold to concentrate on the suffering of others.Participants reported engaging in various kinds of emotional labor to regulate,postpone, and control their emotions. The function of this emotional labor wasoften that of projecting and constructing an exterior impression of calm forothers, sometimes actively “lying to oneself” due to internal turmoil.Participants conceptualized other survivors as open containers within which onecould inject calmness, rationality, and tranquility. Emotions were described ascommunicable entities. Participants reported having been able to maintain astate of calmness and detachment by “freezing” and “turning off” their feelings.This emotional blunting was at times identified as a “defense mechanism” tohandle particularly distressing scenes such as removing corpses from thedebris.I remember that every time that I heard of the death of someone I thoughtok, in two or three days I will cry about the death of these people butnow I have to try and help other people knowing that if I had letemotions take hold they might have stopped my action of helping others.Generally I am a bit of a chicken, I faint, I am afraid of driving thecar, I am afraid of everything, but when I was under there I felt such astrength, because you want to live and so you do everything in order tolive. Some participants also reported being strong, firm, and courageous, often totheir surprise. A process that entailed an active search and buildup of internalstrength and courage within oneself was at times described in terms of “workingup courage.” One participant who had remained stuck under debris described how:At the cognitive level, participants also described a particular state ofenhanced focus on action. This was a state characterized by heightened levels ofconcentration and problem-solving, enhanced awareness and perceived rationality,mental lucidity and clarity, concrete thinking, and narrowing of attention to aspecific aim. Participants recalled having few particular thoughts but ratherbeing completely immersed in an action. The actions that participants wereengaged in appeared to function as mental black holes, totally absorbing thecognitive capacities of the individual. Participants described this state ofhyperfocus as similar to being in a state of trance.My head was completely empty, I was only focused on acting [. . .], it’snot that while I was lifting the debris I was thinking about things, Ididn’t think about anything, it was similar as when I go running and Ifocus on the run itself, on my breathing. The overwhelming intensity of thoughts, feelings, and sensory stimuli experiencedduring the traumatic event led some participants to enter a state of cognitiveoverload, a reaction consisting of moderate to severe disruption in how theyprocessed information around them. This often led participants to feel confusedduring certain moments of the earthquakes. Participants described this reactionas feeling dazed or stunned and as not being able to fully take in, process, orunderstand what was happening. External and internal stimuli were described asbeing too intense and too fast-moving for cognitive capacities to keep up withthem and assimilate them. The detachment from cognitive resources was describedmetaphorically by participants as being out of one’s mind, feeling absent, likea zombie, struck by lightning or drunk, and acting “without cognition.” Thisstate was often heightened when participants reported being woken up by thestrong shaking and failing to understand what was happening.Cognitive capacities were conceptualized by participants as being a finitecontainer that was overflowing with powerful internal and external stimuli,leading to confusion. Participants often compared their brains and minds withcomputers or mobile phones that were struggling to process the informationreceived. Participants variously described their brain and minds as going intooverload, haywire, or standby; as having to be reset or shut down; or as notconnecting and stalling.I had this phase of momentary blackout [. . .] I was blocked, I reallycouldn’t understand what I needed to do. In that moment everything isannihilated, it is as if you are a computer that has been reset, in thatmoment all the data in your brain have been zeroed by fear. The two core underlying triggers for this state of cognitive overload wereidentified by participants as feeling overwhelmed by emotions and feelingflooded by sensory stimuli, as if both the quantity and intensity of internaland external stimuli exceeded their psychological resources to process them. Twoparticipants reported feeling as if this emotional load was making them“explode,” while others used the metaphors of being physically engulfed by anavalanche of emotions or “submerged” by emotions.At the beginning you have too many emotions to manage and so your brainsort of goes in overdrive. Participants also reported that the amount and the intensity of sights, sounds,and smells contributed to the feeling of cognitive overload. Virtually everyparticipant clearly recalled the darkness, the stench of gas, the taste of dustin one’s throat, the sound of people calling for help from under the debris, andthe deafening rumble of the earthquake and of houses collapsing, together withthe feeling of broken glass and sharp materials under one’s feet.I remember this infernal heat, this heat that was suffocating me, mixedwith the dust, and these deafening sounds of the ambulances, of thepolice cars, the sound of helicopters [. . .], this huge chaos, itdisoriented me, it stunned me. Participants reported that thoughts appeared disorganized, racing, anddisconnected one from another. Thoughts were described as possessing amateriality and a mass that caused them to “crowd,” “pile-up,” “cram,” and“condense” in one’s mind. In addition, thoughts acquired a “stickiness” thatmade them clump together and made it difficult for participants to distinguishone thought from the other. Interestingly, while some participants reported anoverabundance of thoughts during cognitive overload, others also described anopposite state of thought vacuum and cognitive void where they reportedexperiencing no thoughts.In the first moments I couldn’t divide different thoughts one fromanother, I couldn’t think rationally at only one thing at a time, inthat moment they were all clumped together and I couldn’t manage todivide them. Some participants reported that while their basic functions such as perceptionkept working, they would fail to be integrated at a higher cognitive level withthoughts and beliefs. One participant described this as “seeing withoutunderstanding” and another participant as “the mind being outside of what theeye sees.”I didn’t immediately gain awareness of the severity of the earthquake, Isaw the stones of the school in the middle of the road but even there Ididn’t really realize, I mean I saw them but it was as if I hadn’t seenthem, it was a sort of seeing them but not thinking about it. This state of cognitive overload also led to disruptions in carrying outgoal-oriented behaviors as participants reported not knowing what to do and howto react during and immediately after the events.As with emotional distress, the initial phase of cognitive overload was, in someparticipants, followed by the ability to gather one’s cognitive resources andenter a more reactive and focused state. Others reported fluctuating betweenmoments of cognitive overload and moments of rationality. Conversely, a minorityof participants reported exiting this state of confusion and overload only daysfollowing the event.Participants reported experiencing a variety of peritraumatic dissociativereactions. These reactions clustered around three key phenomena: distortions inone’s sense of reality , distortions in one’s sense of self, and emotional numbness. The most commonly reporteddissociative reaction was experiencing distortions in one’s sense of reality(51% of the entire sample). The disaster experience was permeated by a profoundperception of “un-reality.” Some of the most common adjectives participants usedto describe what they experienced were “surreal,” “absurd,” “impossible,” and“unbelievable” to indicate the disintegration of their perception of reality.The most widespread perception concerning derealization described byparticipants was the feeling of being in a dream during the earthquake events.This recurring comment concerning the dream-like quality of the experience mighthave also been partially due to most participant being woken from sleep by theearthquake. Participants also described feeling part of a movie, a fiction, aparallel reality, another dimension, or a videogame.It felt as if I was in a dream, a thing that you don’t think it’s real,[. . .] I mean you were aware that it was all real but I had such azeroing of emotions that I kept thinking “now I am going to wake up” Iknew that it was real but at the emotional level it was as if it wasn’treal, a really strange thing. People reported struggling internally to determine whether what they wereexperiencing was real or the fruit of their fantasy. Reality was described aspossessing a malleable and ambiguous quality as what they experienced deviatedfrom their concept of normality so dramatically. The veil between reality andfantasy as well as between wakefulness and sleep had acquired a porous qualityallowing one to blend into the other as participants described “losing touchwith reality.” One participant described the urge to open the coffin of one ofhis deceased friends to actually make sure he had died and that he was notimagining everything. Participants proposed that derealization could have been aform of “self-defense” that their “brain” had actively conjured as anunconscious attempt to “reject” what was happening to them.Together with a disintegration in the sense of reality, a smaller number ofparticipants also reported disintegration in their usual sense of self andpersonhood . Participants reported not feeling likethemselves or feeling outside of themselves. One participant described thissensation as being so acute that he started thinking he had disappeared orbecome invisible, a “ghost,” and touched himself to check he still existed. Afurther reaction associated with depersonalization was the feeling of being aspectator to what was happening or being “outside reality” rather than beingdirectly involved in the experience.It was as if I was outside of the world for a bit, it was me and only me,and the world was outside, as if there was no one else [. . .], I didn’tfeel like myself. In these moments there are no emotions, it’s as if everything hasstopped, inside of me,I felt it was useless to scream, it’s useless, I was a person of stone,blocked, inside you are blocked [. . .] I didn’t shed one tear, thefeelings came after, in that moment there was nothing, [. . .] it’sunexplainable. Participants who reported disruptions in sense of self and feeling “absent” oftenalso described how at the emotional level they felt numb, apathetic, and empty.Participants reported a perception of emotional void; of having their affectiveresources completely depleted; of “feeling nothing,” feeling “emotionallyblocked,” or unmoved. Participants described feeling their emotions beinghollowed out like an “emptied carcass, only bones.” A participant described how,while his two children and partner were being extracted dead from the debris:Helplessness was a prevalent  peritraumatic response.The earthquake was often conceptualized as an entity that exceeded any humanattempt to react to it. Indeed, while individuals reported losing their ownsense of agency, they simultaneously projected a sense of all-powerful agencyonto the earthquake itself. Many participants animated the earthquakeconstructing it as an active and intentional entity endowed with human-liketraits such as cruelty, evil, ferocity, violence, and rage while also alwaysremaining distinctly nonhuman in its omnipotent strength. Participants variouslydescribed the earthquake as a monster, a giant, a beast, and the devil andreported feeling chased by it or begging it to stop.It felt as if we were inside the hands of a giant that did like this[makes shaking motion with hands], it moved us like a dice. [. . .].This perceived loss of human agency was at times associated with a feeling ofdefeat, discouragement, and resignation as some participants reported losing allhope, feeling destroyed as a person, or “psychologically annihilated.” Someparticipants reported losing interest in whether they were going to live or dieand surrendering to the event. This feeling of defeat was also associated with aperception of exhaustion as emotional, physical, and cognitive resources hadbeen depleted, leaving participants feeling drained.I felt weak in these moments, I had a feeling of powerlessness, like whenyou want to do something and you don’t manage to, as if you wanted tomove a mountain, it’s impossible. Helplessness and the perceived loss of human agency also contributed to shifts inthe perception of self and personhood during the earthquakes. Some participantsreported feeling like a “pawn” or a “vegetable” at the mercy of nature. Thissense of objectification was at times exacerbated to the point of participantsperceiving themselves as being nothing or no one. Other participants describedhow the power of the earthquake made them feel like a “shit” or an “amoeba,”adding worthlessness to their sense of helplessness. Individuals felt hollowedout of their humanness as their life was perceived as becoming dependent onchance, miracles, luck, and nature rather than individual willpower. Thisperception was generally associated with feelings of being useless,insignificant, small, and defenseless as well as vulnerable, fragile, andlonely.In that moment you realize you are a nullity, you realize that your lifeis worth nothing, it doesn’t matter how many people you saved or whetheryou built hospitals in all the world, it counts nothing, in that momentyou are no-one, you are only something to get rid of, a pawn. Participants also experienced a diverse range of psychosomatic reactions. Themost commonly reported  psychosomatic reaction wasphysical immobility. Participants reported generally experiencing immobilityduring the moments corresponding to the earthquake shock, although someparticipants had also experienced the reaction when exposed to very distressingscenes. Physical immobility was often associated with feelings of loss ofcontrol over one’s own body. Participants generally described the sensation ofhaving their entire body or specific body parts, usually legs and feet, blocked,heavy, stiff, rigid, paralyzed, or immobilized. They described feeling as iftheir body was “not responding” to intentional commands. Two participantsdescribed themselves as a “mummy” and as a “doll” respectively, inanimateobjects unable to move autonomously.During the moments when the shock was at its strongest, practically Ifelt that my legs were blocked, and therefore if I tried to take onestep ahead I felt as if my legs were incredibly heavy, as if a legweighted 200kg, I really couldn’t move, completely blocked. Some participants reported automatically feeling paralyzed, despite wanting tomove. Among these participants, physical immobility was generally associatedwith feeling overwhelmed both emotionally and cognitively.I remained still in my bed, clinging to my bed sheets, I remember hearingthe sound of the walls crumbling and I understood that the house wasbreaking but I could not manage to comprehend the severity of thesituation [. . .] in that moment I couldn’t do anything, I couldn’tmanage to move, I didn’t manage to get up. Conversely, some participants reported a more deliberate instinct of trying tostay “still” due to feeling helpless. This appeared to be similar to a “playingdead” response. Indeed, as detailed in the mental defeat section, the earthquakewas at times perceived as a possible predator, such as a monster or a beast.Some participants reported engaging in physical immobility as a survivalstrategy that could have been used against a living creature.During the earthquake shock while me and my wife were hugging each otherunder the bed I kept telling her “be quiet be quiet be quiet” as if theearthquake went directly towards who screamed and instead the silencemade you go unnoticed, as if, if he [the earthquake] didn’t hear us hewould go somewhere else. People usually reported that they managed to exit this stage of immobility eitherduring or immediately after the earthquake shock often due to other peoplearound them encouraging them to “switch” to a reactive mode or because the acutephase of helplessness or emotional/cognitive overload had ended. Therefore,physical immobility was reported as being a transitory state usually lasting afew seconds or, less frequently, a few minutes. Some participants also reportedthat this moment of immobility was functional for them to orientate theirattention to rationalize and understand what was happening.Participants also reported psychosomatic reactions related to fear responses suchas fainting, shaking, or losing one’s sense of appetite and thirst. In addition,in a minority of participants, a variety of psychosomatic reactions linked toimmobility were reported such as not feeling pain , not beingable to scream or shout , and feeling cold.While I was inside the debris as my house was collapsing, I didn’t feelany physical pain, this is adrenaline right? It felt as if I was fallingin cotton-wool, but then when they brought me to the hospital I wascovered in blood. A number of more positive emotions were also reported by participants. As withmost other reactions, positive emotions were localized to specific moments ofthe traumatic events rather than generalized to the entire event. Hope was themost common positive emotion reported by participants .The earthquake events were conceptualized as spaces of intrinsic uncertainty andambiguity, and while some participants filled this lack of information withcatastrophic prospects and anxiety, others filled them with hope. Participantsoften reported hoping that people close to them had survived the earthquake,while some reported hoping that they were in a dream. Hope was generallydescribed as being weak with participants speaking of “glimmers” or “strings” ofhope that could be easily extinguished by the harshness of reality. Hope wasoften reported during moments when participants had not gained full awareness ofthe situation, although some participants reported “clinging” to hope despiteclear contrary evidence.A number of participants also reported transient feelings of joy and happiness incertain moments during the earthquake events. Seeing people being extractedalive from the debris or being reunified with family members were key momentswhen participants reported feeling joyful, happy, or relieved. These emotionswere often reported as being circumscribed in time and “mixed” with a diverserange of other feelings and thoughts which often changed rapidly. In the midstof terror, fear, and anxiety, some participants were still able to identifymoments of lightness. A participant who had lost her husband next to herdescribed how she had felt comforted by the kindness of the medical personnelwho had extracted her from the debris.One moment we cried, one moment we laughed, and one moment we comfortedeach other, it’s a mix of feelings, it’s difficult to explain, it’s ajumble of sentiments, of thoughts. I remember when we saw all of our family members, or people that up tothe day before you had never talked with and you would hug each other,there was this feeling of brotherhood, people that maybe before youdidn’t even like, but seeing them there it was such a joy. This is the first study to explore naturalistically the lived experience ofperitraumatic reactions in a large sample of individuals exposed to the sametraumatic event. Our findings provide empirical support for the identification ofperitraumatic dissociation, distress, immobility, and mental defeat in thequantitative literature. While some work has explored peritraumatic reactionsqualitatively during distressing events, it has generally done so tangentially or insmall samples . This highlightshow the notion of a traumatic event might be best understood as an umbrella termcontaining within it many subevents with different peritraumatic characteristics(Another novel contribution to the literature was the finding that participantsreported fluctuating between a considerable variety of different peritraumaticreactions during the event (eristics.Particieristics.FurtherThe current study has a number of limitations. These include the retrospective natureof the peritraumatic accounts, as the accuracy and consistency of traumatic memoriesis a subject of controversy . While aIn addition, the open and exploratory method used in the current study, whileallowing for narratives to arise organically and spontaneously, might have also ledto the omission of certain reactions as participants only reported those that weresalient and noteworthy for them. Future studies will be necessary to test whetherthe current reactions are generalizable to other survivors of other types oftraumatic events in other cultural contexts. Furthermore, certain participants mightdiffer in their ability to describe their own feelings and sensations, leading tovariance in the amount and detail of reactions provided. Future work might attemptto control for this effect by measuring emotional granularity and interoceptiveawareness among responders. In addition, although a number of precautions were takensuch as ensuring not to inject any technical content into the interviews and havinga second coder naïve to the field recode a subsection of the data, the awareness theauthors had of previous work on peritraumatic reactions could have inadvertentlybiased the interpretation of the data toward preexisting conceptualizations of thereactions. Finally, the accounts reported represent the participants’ own subjectiveappraisal and recollection of their experience and might not necessarily coincidewith data elicited through other types of measurement such as biologicalmarkers.Besides having implications for mental health research and practice, our findingscould also be useful for earthquake preparedness interventions because they providedetailed insight into how people may act, think, and feel during an earthquake.They fuClick here for additional data file.Supplemental material, sj-pdf-1-qhr-10.1177_1049732320968791 for Feelings,Thoughts, and Behaviors During Disaster by Alessandro Massazza, Chris R. Brewinand Helene Joffe in Qualitative Health Research


The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms.n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices.We generated questionnaire (A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.Currently, harm reduction equipment and resources for safe injecting are not meeting the needs of people who inject drugs who are street homeless or unstably housed. Preparation of injections with non-sterile water sources could precipitate bacterial and fungal infections, particularly when used without the application of heat. It is crucial that water for injection, also skin cleaning, is made available for the unstably housed and that harm reduction messaging is tailored to speak to the everyday realities of people who prepare and inject drugs in public spaces. Health harms are increasing among the estimated 200,000 people who inject drugs (PWID) in the United Kingdom (UK). Since 2012, there has been a steady increase in hospitalisations for serious bacterial infections . The recHomelessness and public injecting are interrelated and constitute part of the structural risk environment fostering health harms, such as bacterial and viral infections, among PWID . Skin anWater is required to prepare street drugs such as heroin and crack cocaine into a solution for injection. As a component of injection preparation, water is a concern due to its ability to carry micro-organisms, and as it might be shared when groups of people inject drugs together. In the UK, “water for injection” (WFI) is a sterile pharmaceutical product used to reconstitute medicinal injections. It has to meet a range of quality standards including limits on particulate contamination and bacterial endotoxins . Prior tA maximum 2 ml volume restriction was initially placed on ampoules of WFI supplied to PWID, in order to reduce potential for water sharing . This coThere is a need to interrogate current harm reduction messaging and injecting paraphernalia provision to ascertain whether it meets the needs of PWID who are rough sleeping or unstably housed. In the UK, this is a growing population, increasingly vulnerable to health harms. Relatively little research has focused on the use of water for illicit drug preparations, apart from assessing viral transmission risk. Current harm reduction advice advocates the use of WFI, with the “next best” alternative boiled and cooled potable (drinkable cold tap) water, and after this, cold tap water. Our research illustrates that while these hierarchies of best practice may be actionable by people living and injecting in homes, they are not necessarily feasible for people living or injecting on the streets. We present mixed-method data generated with PWID in London to highlight the environmental constraints faced by people living and injecting drugs on the streets, with a focus here on reports of liquids used for drug preparation purposes. In doing so, we aim to inform pragmatic interventions to reduce drug, and other related, health harms among the most marginalised PWID in the UK.n = 455) and qualitative interview (n = 32) data with PWID in London, UK, between October 2017 and March 2019. The aim of Care & Prevent is twofold: (1) to explore associations between SSTI and the renal disease, AA amyloidosis, including though risk screening and specialist referral and (2) to explore the risk factors and contexts related to SSTI among PWID. This paper will present findings pertaining to the latter aim, primarily drawing on qualitative accounts of injection preparation practices.This paper reports on data from the London-based, National Institute for Health Research funded, Care and Prevent Study. This mixed method study generated questionnaire with urinalysis  for normally distributed continuous variables and median (95% CI) for non-normally distributed continuous variables. No multivariate analyses were undertaken for this paper as the risk variable, water, was not measured. Qualitative analysis was informed by constructivist grounded theory methods  with datEthical approval was granted by the London School of Hygiene and Tropical Medicine Observational Research Ethics Committee [12021], the London Bridge Research Ethics Committee and Health Research Authority [17/LO/0872]. All participants provided written consent after receiving study information and assurance of confidentiality.n = 336) as white or white British. Participants’ mean age was 46 years (range 21 to 68). Most  were currently receiving opioid agonist therapy, with two thirds  reporting drug injecting in the past 12 months. Use of crack and heroin in combination, aka “snowball”, was favoured, with 49% (n = 255) reporting this as their primary drug injected, risng to 58% among those who had injected in the past year (n = 164/284). Of note, given the vulnerability to COVID-19 among those with respiratory problems, 61% (n = 278) of the sample reported current crack smoking, 47% (n = 214) current heroin smoking, and 91% (n = 414) current tobacco smoking, the latter for a median duration of 29 years. Sixty-four (14%) participants had received a diagnosis of COPD, with a number likely undiagnosed. Most participants  reported a lifetime history of street homelessness with a mean duration of four years (range < 1 to 30 years). Just over half  were unstably housed for all or most of the past 12 months, with 33% (n = 152) in hostels, 14% (n = 61) street homeless, 7% (n = 31) staying with friends or family and 3% (n = 15) in prison. Participants were asked about lifetime experience of abscesses, cellulitis, venous ulcers and venous disease. The majority  had experienced at least one of these conditions, of whom 46% (n = 137) reported consequential hospitalisation. Notably, of the 291 participants (64%) reporting a bacterial infection (abscess or cellulitis), 27% (n = 80) reported a diagnosis of septicaemia and 7% (n = 21) endocarditis.Three quarters of those participating the survey  identified as male and  had similar characteristics to the survey sample, with 69% (n = 22) male; 81% (n = 26) white or white British, average age of 43 years old and 94% (n = 30) had experienced homelessness. Qualitative accounts indicate how injecting preparation practices, and the environments in which they are situated, can facilitate risk for SSTI and serious sequelae. Below, we present data pertaining to the injection preparation process with a focus on water source as an environmental constraint to safe practice and the strategies employed by participants to navigate this constraint.Qualitative interview participants Yeah, put the gear in, burn it up, cook it up … put water in and then put citric in … and cook, burn the brown up, then put about 20mil cooler and then put the white in, and just crush the white up, and draw it up and bang it. (Tim)Participants were asked to describe in detail their process for preparing a “typical injection”. All participants followed a similar procedure for preparing heroin, with variation in relation to amount of acidifier used and the order in which acidifier, heroin and a solvent were combined in the spoon . This mI’d put a little bit of citric in the spoon, open the stuff [heroin], put it in, add the water, cook it, put it down, add the rest of the water, put the white [crack] in, crush it up properly, put the filter in, pull it up. (Lee)I would put in two bags of heroin, so maybe like .4 [unit of street drug deal] and I’d then put in .2 of crack. No, first I would put in .4 of heroin, maybe 1 citric [sachet] for £20 worth of heroin, I would cook that up, I’d then add a little bit of cold water and put £10 worth of crack in there, make sure I can’t see it anymore, although it’s hard because it’s quite shit and then I’d suck it up, usually using the 2 ml [syringe]. (Ross)While Ross and Lee do not specify the amount of cooler used, or refer to it in those terms, their method follows a similar process:Ross’ reference to “quite shit” is echoed by others interviewed, with a general perspective that the quality of the crack available through London street markets at the time of the study was poor. When the end-point of preparation was judged by clarity of the injection solution, this could result in the addition of excessive acidifier to break down cutting agents and manufacturing by-products in the crack . What thThe environments in which participants prepared injections posed multiple constraints to enacting “best practice” harm reduction advice. As noted above, nearly 80% of the survey sample reported a lifetime history of rough sleeping, rising to 94% of those providing qualitative accounts. Many interview participants spoke of their “typical injection” preparation processes occurring in public or semi-public settings such as public toilets, bin sheds, stairwells, car parks, parked cars and even moving buses. As detailed in other qualitative studies , 13–15, I wouldn’t care where I cooked up, I’d cook up on rain water off the cars, car bonnets. I’ve even cooked up on Coca-Cola. Coca-Cola, yeah, and when you inject it you can taste it more, you can feel the coke going down the back of your throat, you feel like you’ve had a sip of coke. (Jeff)When asking about injection preparation practices, the first author took care to elicit specific detail about type and amount of acidifier used, but did not think to lend the same scrutiny to water source and type. Unelicited accounts of solvents used in the preparation process unsettled this lack of attention. Jeff, for example, spoke at length about the embodied effects of using cola as a water alternative, of which this quote is an extract:I’ve used whisky, Tennent’s Super Lager, all sorts to do my hit … vodka, whisky, you name it, I’ve used alcohol to do my cooking, to do my [hit] (Neil)Dean spoke of injections that “sting like fuck” when using “neat lemon juice” in place of water, acknowledging that he was “destroying my veins” by doing so. The use of alcohol in place of water was also frequently mentioned, and given that many rough sleeping participants were also heavy drinkers, this was likely to be a readily accessible liquid for injection preparation on the street:These practices were not spoken of lightly. The need to source an alternative to water was a desperate constraint in the context of injection preparation. As Alex indicates: “I’ve used alcohol or fucking, yeah, man, you do things when you’re desperate, you know.”I was that desperate one time I was even trying to cook up with my own spit, that’s how desperate I was. [Did it work?] No, it was fucked, it wouldn’t cook, just frazzled … I was going to try it but when I seen it’s frazzled I said fuck it and I flung it away (Jeff)The expression of desperation was most acute when participants spoke of using saliva as an alternative to water. For those who did so, this was framed as a last resort:You said you’ve got a wicked scar on your groin, right?It’s infection, it got infected. What it was, there was no water actually and I had to use a bit of saliva. I had to use a bit of saliva, there was more gear, yeah.There was no water, so you used saliva?Yeah, thinking that could work and it didn’t work, man. It worked, I still got my hit, but I also got the worst infection of my life, I nearly died … Yeah, I was in hospital for nearly 3 months. Septicaemia.Where were you cooking up the hit?In the flats, bottom of the flats.[In a stairwell?]Yeah, I was homeless at this time, innit.Can you tell me about it in detail, like walk me through what happened?What I remember, I must have gone out, graft, scored, I didn’t have enough fucking [water] … I didn’t have no trouble getting my groin, I must have got it and then it, I had some sort of fever like fucking hell, fever come across me and it was bad so I had to go to hospital … after that I was knocked out then woke up in the hospital bed, I went for fucking surgery. And then a second surgery after that because they didn’t get all the infection out.What did they say it was? Like, how did it get that bad that quickly?It was an infection, an infection was found, a bug was found in the mouth … Yeah, in any mouth, in people’s mouths. Just that bug and it’s a nasty bug, a right nasty bug. And that’s why I remember when I tried to put a bit of saliva in, know what I mean, so, it makes sense.So, was there was nowhere else you could get water from, or …?No, no.Jeff was lucky. Although he lost the hit he had been hoping for, he did not experience the health harms recounted by Dev in conversation with the first author:We were on the streets, I can’t remember where I was, but there was no water about anywhere and it was a red-hot day as well, there was no water anywhere. And I was dehydrating, dehydrating, plus there’s no toilet, no taps anywhere around, no rain, no nothing. I was proper sick for a hit, in the end because I couldn’t find no water and my spit wouldn’t work and then I got another bag and I had to do it with a puddle of water and then like filter the water through the sterits [alcohol swab], filter it out that way.Through the alcohol swabs?Yeah, just to get the dirt of the water.The context of constraint for many was one where public access to water, for drinking, washing or other purposes was not guaranteed. This has implications not only for injecting related practices but also for the ability to stay hydrated, as Jeff mentions in passing below:Of note in this excerpt are the lengths that Jeff went to, not only to have a hit, but to navigate the constraints of his environment. Filtering puddle water through an alcohol swab (provided by NSP for wiping injecting sites) is a poignant example of self-care, also illustrating the short-sighted limitations of service provision where swabs are deemed essential but water ampoules are not. As Sara says “you don’t get water with the [injecting] kit.”A lot of the time people would use puddle water. That’s a thing, yeah. But I was always scared of that, so I always got scared in case there was like an animal and then you’d suck the animal in and then you’d put the animal inside yourself … I used to always get people to buy me bottles of Volvic water and then I’d pull up from the bottle. People would come and buy me drinks and food all the time. They always asked me, what do you want from the shop?Okay, so like people walking by on the street?Yeah.Yeah. So you’d specifically ask for bottled water so you could use it for having a hit?Yeah. Yeah-yeah-yeah. (Ben)For Sara, and some other unstably housed participants, the answer is to carry bottled water. As Troy says: “I usually have a bottle with me, a bottle of water, yeah” and Jade: “then I would just draw up some water, because I have a bottle of water or something”. Ben details his rationale for using bottled water and his strategy for obtaining it:Participants also spoke of carrying baby wipes and swabs with them, particularly useful to wipe hands and injecting sites in the absence of water to wash with. Neil, who had prepared injections with a variety of alcoholic beverages, spoke with pride of keeping his injecting sites clean on the streets, showing the first author his stash of alcohol swabs, always replenished in his coat pocket: “I always have alcohol swabs and wipes and all that, just wee things like that, I always keep one … I’m just a survivor, love”. Lee would also carry baby wipes and bottled water with him when possible. He prioritised finding toilets to inject in that were “clean” and where he could wash his hands; however, bottled water (or an empty bottle) was often necessary, given the difficulty of obtaining water with a syringe from a public access sink when preparing and administering an injection in a closed toilet cubicle.A well-established body of literature evidences health harms and health system burden associated with injecting drug use , 37. UK Clostridium species that cause tetanus and botulism [Pseudomonas species, associated with multidrug resistance and sepsis [The risks or health harms associated with use of alternative solvents for injection has not, to date, been elucidated in the literature, apart from reference to bacterial infections arising from saliva contaminated injections. While some harms are proven, many are theoretical and not easily measured. This is particularly the case in relation to use of alternatives to water. Alcohol for example, although an antibacterial and effective solvent for base drugs such as heroin, as an injection solvent may pose an overdose risk particularly in combination with heroin, methadone or other sedatives. Although the amount of alcohol injected is small, when used intravenously, it does not go through the liver before the brain, as it would with oral (drinking) administration; therefore, it reaches the brain faster and in a more concentrated form. Puddle water may contain a range of organisms found in the environment, including the heat resistant spores of anaerobic bacteria including botulism  and Pseud sepsis , as welln = 46) reported licking their needles prior to injection. On examination, 32% (n = 54) presented with abscesses and/or cellulitis. After controlling for skin-popping and years of injection drug use, participants who licked their needles were more likely to have an abscess or cellulitis than those who did not. A study of 40 hospitalised PWID in New York found that 33% (n = 13) reported licking their needles prior to injection with three also licking their skin prior to injection to clean the site and 12 afterwards [n = 27) had been admitted to hospital for treatment of bacterial infections although no statistically significant association was found between needle licking and bacterial infection. Several case series and reports have documented infections  attributed to oral bacterial  among PWID who report licking their needle and/or injection site prior to drug injection [Our study is the first to report, to our knowledge, purposeful use of saliva as an alternative to water in injection preparation. Bacterial infections attributed to saliva-contaminated injections have been documented in the literature, however, only in relation to the licking of needles and/or injection sites. Binswanger et al.  found thterwards . The majnjection .n = 47), crack cocaine (n = 8) and heroin and crack together (n = 10). In contrast to Ponton and Scott’s findings that crack is added to the heroin mixture after heating, our participants all describe using cold water  to cool down the prepared heroin solution before crack addition. This is undertaken to prevent the crack cocaine congealing in a high temperature solution but may also have implications for bacterial contamination and infection. Heating drug solutions has been indicated to inactivate HIV [Of note, is the consistency of detail provided by qualitative participants about preparation of heroin and crack cocaine in combination for injection and that this differs from the only other study found to illustrate the steps taken in this process. Ponton and Scott (2004) recreated typical injection preparation practices with 65 people recruited through three NSP sites in England. Injection preparation was demonstrated for the following: heroin  used tap water, with other sources including bottled water , boiled water  and sterile water from ampoules . The only group documented not to heat their solution were people preparing crack on its own, with three using tap water, one using “boiled and cooled” water from the kettle, one using bottled water and one using water obtained from a toilet. Despite the latter finding, no reflection is included on the bacterial or other health implications of this practice. Interventions may be feasible in reducing risk. Campbell [Ponton and Scott (2004), also recruiting PWID through NSP in England, include information on water source. Of the 57 participants demonstrating heroin preparation, with or without crack cocaine, 61% (Campbell  reports Concerns around the potential for HCV transmission through sharing of water among PWID led to the legal framework for UK supply described in the introduction. Given the reluctance to provide glass ampules by some local authorities, it is timely to revisit this evidence and associated guidance. Heimer and colleagues  report rThe use of unsafe alternatives to WFI potentiates high health risks and health system burden among an increasingly vulnerable population of unstably housed PWID. We call, therefore, not only for policy reform but also for a revolution in harm reduction messaging, whereby “best practice” is presented as just one option among many—with others offered tailored to different levels of environmental constraint. In a context whereby PWID report use of puddle water, alcohol and saliva to prepare drugs for injection, harm reduction messaging that enjoins people to “wash their hands” before injecting, alongside the provision of injecting kits without water, enacts a structural violence—shaming through a denial of the constraints faced by the most marginalised. Here, disconnect between drug treatment providers, policy makers and those who they are served to care for is profound. Messaging based on a hierarchy of safety provides an alternative to the alienating potential of “hyper sanitary”  best praIn the time this paper has been in review, we have developed, in collaboration with Exchange Supplies, a prototype street injecting kit Fig. . This reOur study highlights the role of unsafe liquids used to prepare drug injection solutions. Given the serious health harms associated with this practice, it is crucial that services engage with the everyday realities of people living on the streets and amend service provision accordingly. Current harm reduction messaging and injecting equipment provision in the UK is failing to meet the needs of the most marginalised. There is an urgent need to revisit the marketing and/or legal limits to the volume of WFI ampoules supplied to PWID, particularly given that concerns about sharing water increasing HCV transmission seem not to have been borne out in subsequent analysis.


One of the key conceptual challenges in advancing our understanding of how to more effectively sustain innovations in health care is the lack of clarity and agreement on what sustainability actually means. Several reviews have helped synthesize and clarify how researchers conceptualize and operationalize sustainability. In this study, we sought to identify how individuals who implement and/or sustain evidence-informed innovations in health care define sustainability.n = 27). An inductive approach, using constant comparative analysis, was used for analysis of interview transcripts and field notes.We conducted in-depth, semi-structured interviews with implementation leaders and relevant staff involved in the implementation of evidence-based innovations relevant to cancer survivorship care (Participants described sustainability as an ongoing and dynamic process that incorporates three key concepts and four important conditions. The key concepts were: (1) continued capacity to deliver the innovation, (2) continued delivery of the innovation, and (3) continued receipt of benefits. The key conditions related to (2) and (3), and included: (2a) innovations must continue in the absence of the champion or person/team who introduced it and (3a) adaptation is critical to ensuring relevancy and fit, and thus to delivering the intended benefits.Participants provided a nuanced view of sustainability, with both continued delivery and continued benefits only relevant under certain conditions. The findings reveal the interconnected elements of what sustainability means in practice, providing a unique and important perspective to the academic literature. Despite an increasing emphasis on designing and testing strategies to effectively move evidence-based innovations  into heTo date, the vast majority of research in this area has focused on the adoption  and earWhereas others have proposed definitions based on concepts related to sustainability identified within the existing literature –20, thisThis inquiry was part of a larger mixed-methods study to examine sustainability processes, influences, and measures in cancer survivorship care. Specifically, we conducted a concurrent mixed methods study  focusingParticipants were multi-level stakeholders  involved in the implementation and/or sustainment of evidence-based innovations relevant to cancer survivorship care. Prior to identifying individuals to approach, we first identified innovations in survivorship care that were implemented in Canada  and were past the initial funding period. Potentially eligible innovations were identified via: authors’  knowledge and networks, both researchers focusing on cancer survivorship care; a Web search of all provincial and territorial cancer agencies ; a search of citations and work/research activities of all members of the Canadian Cancer Survivorship Research Consortium; and a PubMed search for published papers of Canadian-based innovations in cancer survivorship care. Each innovation was then assessed in terms of its level of evidence. Specifically, an innovation was considered evidence-based if at least one published peer-reviewed study, using either an experimental or quasi-experimental study design, existed to demonstrate improved outcomes for the target population. This criterion was selected because it is the National Cancer Institute’s criterion for Research-Tested Intervention Programs specifically aimed at cancer control and cancer survivorship (versus for therapies or diagnostic tests/procedures) . MaximumWe conducted in-depth, semi-structured telephone interviews after obtaining informed consent from participants. Each interview lasted approximately 40–60 min and was conducted by a Master’s trained research associate with experience in qualitative methods [LLM]. The interviewer had no prior relationship with any of the participants. The interview guide was developed specifically for this study using practical guidance from Patton  , although some innovations were delivered Canada-wide. Broadly, the innovations pertained to four main categories: physical activity programs; psychological support/counselling; transitions programs; and return to life and lifestyle programs. Participants described sustainability as an ongoing and dynamic process that incorporates three key concepts and four important conditions . These are discussed below and presented in Table sustainability refers to resources and that includes personnel resources and space resources. Don’t underestimate that one, because space is very difficult … the personnel, space, and then financial resources” [P18]. Another participant put it this way:Putting in place systems that aren’t going to regress because we run out of money and we can’t do it anymore. So it’s really sort of a fiscal and resource sustainability. … So essentially that something is not dependent on something that could disappear, and that could be an individual, it could be money, it could be a skill set. So that’s what sustainability means to me. [P9].Participants continually described sustainability as a process that must encompass a continued capacity to deliver an innovation over time. In fact, continued capacity was the most prevalent theme throughout the dataset. Participants discussed capacity mainly in terms of human, financial, and physical resources. This view was reflected by one participant, who said, “sustainability, to me, means, like, of course continuing the program and opportunities for the development of the program” [P19]. One condition, however, that many participants noted was that (2a) sustainability means an innovation continues in the absence of the champion or person/team who introduced it. As one participant stated, “my broad definition has always been that the program would be able to be maintained and flourish outside of me” [P23]. Similarly, another participant said, “That the program would continue beyond me, beyond any one person” [P1]. A second condition participants discussed was that (2b) sustainability is only germane to innovations that are still relevant and needed. One participant emphasized this by saying, “it has to fit, always address the need, always has to be relevant. Once you get out of the business of being relevant, you’re at high risk. People either won’t pay or follow through” [P20]. Related, participants discussed their view that unnecessary or irrelevant innovations should be discontinued not sustained.Participants recognized that sustainability must entail continuation of the innovation: “to me it means that we’ve been able to identify how much improvement we’ve made and continue to hold that … over time. So that’s one aspect of sustainability, is sustaining the improvement levels” [P9]. One condition to this concept was that (3a) adaptation is critical to ensuring relevancy and fit, and thus to continuing to deliver intended benefits. This concept was described by one participant who said, “it’s an ongoing, dynamic process. It continues to grow and develop and evolve. And there needs to be feedback loops. Things have to work, that’s why the refinement and feedback loops are necessary.” [P20] Further, participants posited that only when an innovation continues to be delivered and a need for it still exists would the innovation be in position to deliver the intended benefits.Most participants noted the sustained use of any innovation is immaterial in the absence of experiencing the intended benefits. Therefore, from their perspectives, sustainability is not anchored on the continued delivery of a program or service, but rather must produce patient, provider, or health system benefits. One participant said, “The other part of the sustainability for me was that there was benefit shown in what we were doing. So combining qualitative and quantitative outcomes to show that that it is a needed service and that it was worthwhile to everyone involved. [P23].A second condition described by participants was that (3b) sustainability is contingent on being able to demonstrate these benefits. One participant expressed this by saying:in practice; thus, they extend our understanding of sustainability by providing a unique and important perspective to the academic literature.This study explored how multi-level stakeholders who implement and/or sustain evidence-informed innovations in health care perceive sustainability. We found they define sustainability in terms of three concepts: continued capacity to deliver the innovation, continued delivery of the innovation, and continued receipt of benefits. These concepts align well with the academic literature on this topic , 43–45. Moore et al.  recentlySeveral authors have recently shown the most common definition of sustainability is the continuation or maintenance of an innovation or its activities , 43. IntFinally, participants defined sustainability using both process and outcome concepts and language. In both conceptual and empirical work, sustainability is most often viewed as an outcome with innovation components/activities, benefits, and/or capacity maintained , 43, 44,There are limitations of this study. First, the small number of participants may limit generalizability. The aim of qualitative research, however, is not to achieve generalizable results but to gain a rich understanding of people’s views and experiences. In this study, participants came from six Canadian provinces  and were involved in the implementation of 25 different cancer survivorship innovations, maximizing the credibility and confirmability of findings through triangulation of data sources. Moreover, although this study focused on innovations implemented in the area of cancer survivorship, there is no apparent reason why those working in cancer survivorship care would view sustainability differently than those working in other clinical care settings. Thus, the findings should be applicable beyond this clinical setting wherein innovations are similar to those implemented in this study . However, they may not be transferrable to other types of innovations such as diagnostic or therapeutic innovations that have different purposes and evidence bases. Second, participants included a wide range of managers, administrators, program staff, clinicians, and researchers involved in the implementation and/or sustainment of innovations in cancer survivorship care. While it is possible that some may have had an understanding of the concept of sustainability influenced by the literature, the data did not indicate or suggest a familiarity with the field.This study identified how individuals who implement and/or sustain evidence-informed innovations consider and define sustainability. This knowledge should be incorporated into existing definitions of sustainability to encompass the perspectives and experiences of individuals working directly to implement and/or sustain innovations, and therefore guide research relevant to practitioners, managers, and other decision-makers in health care.Additional file 1. Draft interview guide for semi-structured interviews.