Dr. Christine Hunter Oral History
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Christine Hunter, Ph.D., ABPP
Behind the Mask
May 18, 2022
Barr: Good afternoon. Today is May 18, 2022. My name is Gabrielle Barr, and I'm the archivist with the Office of NIH History and Stetten Museum. Today, I have the pleasure of speaking with Dr. Christine Hunter. Dr. Hunter is the acting associate director for Behavioral and Social Sciences Research, and the acting director of the Office of Behavioral and Social Sciences Research (OBSSR). She is also a captain in the Public Health Service (PHS). Today she’s going to be talking about her COVID-19 experiences. Thank you very much for being with me.
Hunter: Thank you for having me.
Barr: To begin with, will you please introduce what social and behavioral research encompasses and how that pertains to dealing with different aspects of COVID-19?
Hunter: Behavioral and social science research is a really broad area. It covers behavioral, social, and environmental influences on behavior and health, how those intersect with each other, and how they intersect with biological influences. Behavioral and social sciences also look at everything from observational research–understanding how those factors interplay across time in different populations—to also thinking about what behavioral and social interventions can mitigate risk, prevent disease, or reduce symptoms and improve overall health. When you think about COVID-19, we certainly and understandably put a lot of emphasis on vaccine development and therapeutics—but when you really think about the experience of COVID-19, behavioral and social factors played a huge role in risk and spread of the virus. The things that we had to do to protect ourselves and others are behavioral in nature. Think about social distancing. That has implications for mental health and well-being—same for mask wearing, handwashing, what we think and feel about taking vaccines, and the divisive information and misinformation and how that affects decision making. Behavioral and social science has a lot to contribute to inform the response to COVID-19. It really highlighted how medicine and devices, while critically important, may not be enough to solve the most important public health issues of our day.
Barr: Definitely. How has OBSSR worked with other NIH institutes and centers, as well as entities outside of NIH, on incorporating social and behavioral research into NIH’s COVID-19 response, and can you please provide some specific examples?
Hunter: Sure, I’d be happy to. We jumped right in along with everybody else. It was a busy time for everybody. There are some things we led and some things we participated in. One of the things that we led, in partnership with multiple institutes and centers (ICs), was the COVID-19 Survey Item Repository. That can be found on DR-2 in the PhenX platform. The idea was, if we were going to be doing a lot of research to assess aspects of COVID-19 and its consequences, we needed to have a place that researchers could go to find measures. This way everybody didn’t have to reinvent the wheel to measure the important factors. We also convened a panel of experts and put together a report that summarized the best of the evidence that we had that can inform how to communicate about COVID-19 vaccination. We rapidly developed this report and a tip sheet. The intention was to go beyond NIH business as usual—we pointed to research opportunities and needs—but also presented what current research says and tried to make practical recommendations for communicators to adopt and use. We were proud that the report was published on the same day the first vaccine was given emergency use authorization.
Then we participated in multiple other research activities in partnership with NIMH [National Institute of Mental Health], NIMHD [National Institute on Minority Health and Health Disparities], NIA [National Institute on Aging], and NINR [National Institute of Nursing Research], and a lot of other partnering institutes and centers. We launched the Social Behavioral and Economic COVID Initiative to look at the immediate and longer-term downstream consequences of COVID-19 to mental health and well-being, with the economic changes that the pandemic wrought on our nation and the globe and how that was affecting people. We also supported research on digital and community interventions. We've participated in RADx-UP [Rapid Acceleration of Diagnostics—Underserved Populations] and a number of the other NIH-wide activities to make sure that behavioral and social sciences has a seat at the table. I think our sciences have heard and very welcome at the table so that's been great.
Barr: That's wonderful. Can you please talk about the process of drafting the Notices of Special Interest (NOSI) regarding the availability of administrative supplements and urgent competitive revisions for research on the 2019 novel coronavirus and behavioral and social sciences, which you all really took the lead on? You had mentioned that earlier, but can you provide a little more detail on that?
Hunter: Sure. Dr. Erica Spotts in our office was really the lead on this. It was also an all-hands-on deck activity because we needed lots of participation for it to be useful. That meant getting lots of institute and center partners. It meant getting it out the door quickly, publicizing it, making sure that researchers knew it was out there, and making sure the institutes were publicizing it [as well]. We just wanted to highlight—and I think we effectively did—the urgent need for social behavioral and economic research. The idea was to add additional measure collection to really capitalize on our investments and on the research that’s already underway to learn things that were unique to COVID. That's pretty exciting, particularly because a lot of those studies would have pre-COVID data, and we'd really be able to look at trends over time.
Barr: Can you talk about what some of the observations from this funded research have been so far, and some things that you and others would still like to learn?
Hunter: That is a two-day question, but I’ll try to give a little bit of an answer. As Dr. Collins was leaving NIH, he was quoted a number of times as saying that maybe we under-invested on research in human behavior. The spotlight is on how behavioral and social science research needs to be better integrated across the research enterprise. Not that there’s not a lot of good behavioral and social science research going on already. We learned, and are continuing to learn, that the response to health decision making and health crises is very complex, but one size does not fit all. Having an efficacious intervention, and even having fact-based communication, is really necessary, but not sufficient. We have to think about how we build trust in science and our scientists and how we engage a variety of members of the community to respectfully understand their concerns and what accounts for their hesitation. There's just still so much to learn, but we're learning a lot about some of the differences and some of the things that maybe we thought would work. Like incentives, for example. Early on, people thought if we just incentivize vaccines [people would get them]. Well, the data is mixed on that. It can backfire. For example, it might have some downstream effects of people noting that if they need to be paid to do it, what does that say about its safety?
Barr: Yeah, definitely. Speaking of vaccines, will you talk about OBSSR’s work on encouraging behavior and social science research to address the SARS-CoV-2 vaccine communication and increase the uptake on vaccination? Can you talk about the NIH’s working group on this topic as well as the manual communication around the vaccine that you all contributed to and helped with the production of?
Hunter: I've talked a little bit about it, but I'll try to expand on that. It was a really exciting opportunity to talk about what research is needed and is important right now. But it's also really important to ask what the current research already tells us. How does it inform “the now”—how we're responding now and how we're communicating to people now? We tried to bring in a lot of diverse experts in not just health communication, but behavioral economists, journalists—diverse perspectives to share and discuss what we know and what the data is telling us. We listened to them and then tried to put that in a report that gave tangible recommendations about how people might go forward and communicate. Our audience was federal communicators, but it was so exciting—over time, we got requests and emails from public health departments from other countries to see if they could translate it. It was something I was really pleased to be a part of. The group was so wonderful. We produced a good report, but the ripple effect was broader than I expected and that was gratifying.
Barr: Definitely. Can you talk about what efforts have been done with other populations that are either hesitant or resistant to getting vaccinated?
Hunter: There's been a lot. Some of the things are listening and understanding what the concerns are. We know, very clearly, that shaming and blaming is not an effective approach—and that vaccination hesitancy means they're unsure but with the potential to be tipped towards willingness to get a vaccination. Addressing those concerns in a respectful way that preserves people's autonomy to make decisions about their health is important. Thinking about the social and systemic structural barriers that make it hard for people to get a vaccine—if it's hard to physically get there or if the other people in the community are against getting a vaccine—how did those influences make it harder for people to make that decision and move from hesitance to acceptance? Thinking about culturally appropriate ways to make sure that the ways we approach things are consistent with people's cultural processes and values. What we might recommend for a tribal nation might be different from something we'd recommend for an Appalachian community—so thinking very closely about the community needs and concerns in a respectful way and then addressing them.
Barr: Just to go deeper into this, you published some comments along with Dr. Monica Webb Hooper and Dr. Wen-Ying Sylvia Chou earlier in the pandemic, but what updates have happened since this piece was written? Has your understanding and mindset changed at all since some of your initial writings?
Hunter: I wish I could say that in a year we've just learned so much, but I'd say many of the things that were in that paper remain true. Some of the things that resonate with me—that I knew but have become clearer with the COVID-19 pandemic—include this idea of real and sustainable community engagement. It can't be a drop in, drop out activity in research. The things we've built for COVID-19 have the potential, if we think about that as a model, to help us address all kinds of things—not just pandemics, but diabetes, obesity, and other kinds of public health crises. That was something I knew but it has become more apparent as a high priority need. Misinformation and information silos were a problem and were making it harder to promote health and well-being. The rapid proliferation [of misinformation] and sort of tribalism that we have taken on in the nation—of it being “either you're with us or you're against us”—has created problems in thinking about how to have conversations about science and how to have conversations about health. We're in a potentially scary position where trust in scientists, and including understanding of the scientific process, is eroding. Struggling people wanted answers and we didn't have them. We need to be very humble about explaining what we know and what we don't know and that it might change as we learn more over time because that's the nature of science. Those are some of the takeaways for me. Five years ago, I could have articulated them, but they wouldn't have been quite so crystallized. Does that make sense?
Barr: Definitely. Can you talk a little bit about how OBSSR, with the assistance of the NIH Disaster Research Response Program (DR2), went about compiling all the lists of tools and instruments for assessing COVID-19 social and behavioral research? You mentioned it earlier, but if you would just talk about it a little more.
Hunter: A lot of it was getting the word out—getting people to be willing to submit the surveys and questions that they were using and getting the word out that it was there for other researchers to use. Dr. Mike Spittel in our office really took point on this and reviewed every survey before it went into the repository. It was one of those real-time, rapid, relevant research activities that was designed to be a resource for the community. Hopefully people view it that way. There's been a lot of views and a lot of use. That tells me that it's hopefully made a difference.
Barr: I have definitely looked at it. Can you talk a little bit about your role with RADx-UP and how you guys have been involved with some of those initiatives?
Hunter: Sure. The previous director, Dr. Bill Riley, was on the Governance Committee and very actively involved our office. Then obviously, when I took on the director role, I started doing that. But the truth is, our staff have been doing the yeoman's work. There were so many things that needed to be reviewed and scientific input made on just a rapid timescale. For almost everybody in my office, it was all done on top of regular work—just countless hours of just writing and reviewing all of the initiatives to make sure that there was well-rounded scientific input and that behavioral and social science factors were included. There are so many people that are involved in it across NIH but I am proud of how our office pitched in.
Barr: For a while, they were saying vaccines have solved our problems with COVID or the antivirals are on their way. It doesn't seem like that has been the case and behaviors still have quite a role in how we're going to have to deal with COVID-19. Can you talk a little bit about how your group has tried to promote that message? That seems to be the reality, especially now—some of the legislative situations have changed. How have you handled both the reality and some of the “popular discussion” suggestions?
Hunter: Hopefully even-handedly, by just continuing to try to talk about where the data stands. Like you said, these mitigation strategies may be a part of our life for quite some time if we really want to avoid COVID. There's a lot of competing demands. Certainly, getting kids back to school safely is important. As to whether they should be wearing masks or whether we should all be wearing masks, we stay focused on what the data tell us and how we can promote that. It’s tough—it's such a politicized issue. There are so many points of view, but at the end of the day, if you want to prevent getting COVID and getting really sick, then get a vaccine, continue to wear a mask, and think about who you're engaging with and when you have opportunities to be outside versus inside. It's trying to be compassionate that there's a lot of competing voices and a lot of competing demands so one answer isn’t a fit for all, but also the data is the data—those behaviors will make you safer. Does that make sense?
Barr: Definitely. Do you feel like your group really has had to try to convince others at NIH to deal with more of the hard science of that kind of compassionate perspective? Or remind them of that perspective and that there's so many different interests, because so many people are siloed in their own ways?
Hunter: Yeah, I think that's very true. This is where Dr. Collin’s reflections as he left his role as Director of NIH [come into play]. Early on, understandably, there was a view that if we can just develop an effective vaccine, it will all be okay. Knowing what we know about human behavior and decision making around health, we knew a vaccine was critical, but more would be needed. For the behavioral and social sciences, it shone the spotlight and gave us an opportunity to show that almost any health issue also requires careful thinking about how people engage and accept preventative or treatment measures over time. Our fields showed up and continue to show where we add value.
Barr: Definitely. Can you speak a little bit about other ways that OBSSR plans to become involved in responding to the COVID crisis?
Hunter: There's a few things. We will probably shift more to thinking about longer term consequences. We have a generation of youth who have experienced very different school and social experiences. Also, there are the mental health, social, and economic pressures where we need to think about longer term consequences. We need to understand the emotional, physical, behavioral, and social consequences of long COVID. Not that we'll stop doing what we're doing, but we’ll also try to think about some of those other longer term and downstream factors where more research is needed to understand and address the challenges people face.
Barr: Definitely. How has OBSSR balanced its COVID-19 work with a lot of the other initiatives that you do, such as your work on violence and opioid addiction and the many other problems that did not go away just because of COVID?
Hunter: Absolutely. I have been so proud of the response of our office. I feel like our staff just really rose to the occasion, and we have not slowed down on any of that. We have been active in leading the prevention of firearms injury and violence research portfolio. We just published a supplement, a special issue in AJPH [American Journal of Public Health] on the opioid epidemic and all the social and behavioral contributions. We are thinking about how behavioral and social sciences can inform and engage with the larger conversation about systemic and structural racism and we're thinking about new initiatives. I feel very proud of the office. We worked hard, and we accomplished lot on COVID, but nothing slowed us down, and we're still pushing ahead on many other important areas of research.
Barr: What was your experience like in assuming such a significant leadership role in the middle of a pandemic?
Hunter: It was interesting. I think it helps that I had been the deputy here for a long time. It was a secondary leadership, but a leadership role. I was familiar with all the players which helped. It was a mix of business as usual and a lot more work. My priority was to really minimize the transitions and the disruption for staff as much as possible. When a new director is named, that will be another transition. My goal was to keep progress rolling along and not make this even more disruptive for the staff. Scientifically, it's been such an exciting time. There are so many new things on the horizon. That helps with the workload—even though the workload is a little tough, the work is exciting helps remain excited about the job and happy to have taken on this role.
Barr: Were there any particular ways that you try to keep up morale amongst your staff during this kind of turbulent time?
Hunter: I've always been somebody that valued work-life balance—really encouraging people to think thoughtfully about what they need and how are they taking care of themselves and being as flexible as possible. For example, as people were getting back to business, daycares were opening and closing—so one day daycare would be open, and the next day daycare wouldn't. I encourage people to understand that these types of scheduling challenges are not something to apologize for, it’s something for us to work with or work around. Trying to think about how to be creative in virtual or hybrid environments and how to be intentionally engaged with one another. It takes a different way of interacting. You can't just assume that everyone knows what's happening. You have to be more intentional about checking in with people and making sure that they're doing all right. Some things that I tried to think about are questions like Am I meeting with everybody regularly? Do I feel like I have a handle on the workload across the office? Am I checking in with them? Do they understand that I am here to support them? Those were kind of questions I asked before, but it took on a new importance and much more intentionality in a stressful and changing virtual environment.
Barr: As a Public Health Service officer, were you put on any deployments?
Hunter: I was. The first deployment I was on, I was a site lead for a COVID-19 community testing site—which as a psychologist was a bit of a strange job for me.
Barr: Where was it? Locally or somewhere else in the United States?
Hunter: It was in Peoria, Illinois. It was an interesting experience because it was state public health, FEMA [Federal Emergency Management Agency], National Guard, and PHS. It was an alphabet soup of government, and I was trying to navigate that and still do the right thing to make sure the community was getting the testing it needed. That was my first deployment. My second deployment was behavioral health support to the Navajo Nation—so completely different than the other deployment—and this one really focused on providing behavioral health support for the health care workers there who were stressed and burned out. They had seen so much—the Navajo Nation was hit so hard. The deployments were very different but rewarding.
Barr: Beyond being in your position, you're also an individual who's been going through this pandemic like everyone else. What are some of the opportunities and challenges that COVID-19 has presented for you?
Hunter: It was difficult to not see family for so long. We don't have family in the area, so there are a lot of people that I hadn't seen for a year and a half. That's a long time to go without seeing family. That was one of the most challenging things. Personally, I love working from home. I hated the reason I was working from home, but it really suits my personality. I feel like I was more productive, and I had more work-life balance. That was a weird thing, because it was just an awful world situation, and yet I was reaping personal benefits. That was tricky. But I learned I really enjoy working from home. My husband was working from home too, and it turns out we get along just fine when we're together 24 hours a day. That was nice to learn.
Barr: That's really great. Is there anything else you would like to share about your COVID-19 work and experiences?
Hunter: No. I appreciate the opportunity to talk with you, but I feel like we've touched on a lot of topics. Thank you very much.
Barr: Thank you for all that you do, and I continue to wish you and everyone in OBSSR utmost success and health.
Hunter: Thank you very much, and you as well.
Barr: Thank you.