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The Anthropology of Infectious Disease

Anth 606, Spring 2009 Professor Nina L. EtkinWednesday 1:30-4, Saunders 345 Saunders 321: 956-7726Office Hours: Monday 12-2, or by appointment etkin@hawaii.edu

Scope:There are troubles ahead: early in this millennium infectious diseases remain the major

cause of death worldwide. We live in a time of emerging (new) infectious diseases (e.g.,HIV/AIDS, Ebola Fever, Hantavirus, Legionnaires Disease) and resurgent old ones such astuberculosis, malaria, and polio. The problem is compounded by infectious disease traffic introducing infections to new species and previously not affected populations. This growingdisease burden can be linked to human activities such as deforestation and otherenvironmental transformations, contact with exotic animals, over- and other inappropriate useof antibiotics, limited knowledge of disease transmission, and lack of resources for vaccinationand other preventions. The anthropological study of infectious disease explores theinterrelations among pathogenic microbes in human populations by focusing on the intersectionof cultural, ecological, and political factors related to the transmission and experience ofinfectious disease. Given the role of human action in infectious disease traffic, anthropologists who observe and interpret human behavior have insights and other resources that canimprove understanding infectious diseases.

Course Description and Objectives:This seminar advances an integrated biocultural perspective, emphasizing the importance

of human actions, to comprehend infectious diseases in the specific political, ecological, andcultural contexts in which they occur. These contexts are defined by a constellation of variablesin nature (e.g., parasites, environment) and in society (e.g., subsistence, gender relations,differential access to resources) that shape how a particular community will experienceinfectious diseases. A uniquely anthropological perspective interprets the prevalence and

experience of illness in view of local knowledge of disease causation, patterns of transmission,indigenous preventions and treatments, and formal-sector programs for vaccination andparasite/vector control. We will consider questions such as these:

, Did Neanderthals get / receive / catch chicken pox?, How is the risk of infectious disease influenced by subsistence strategies (e.g., hunting and

foraging, fishing, agriculture) and by residence patterns (e.g., dispersed vs clustered)?, What are the cultural and political-economic bases of concepts such as risk and

prostitution as these terms are used by AIDS prevention programs in SE Asia?, Are traditional plant medicines effective against infectious diseases?

, Why do 20,000 people die each year from influenza, a vaccine-preventable infection?, European contact led to high mortality among Native Hawaiians. Why did Europeans not

experience a reciprocal transfer of infections from indigenous peoples?, How is susceptibility to infectious disease influenced by rapid social and cultural

change e.g,. migration, globalization, technological development?, What are the epidemic politics of infectious diseases in poor communities?, Drug-resistant infections are being treated with polypharmacy (more than one

antibiotic). Has the magic bullet become the magic machine gun?,Are emergent infections really new?

, What power asymmetries are reflected in the commodificationof health and in preventive and therapeutic measures?

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Organization:The course is organized in a structured seminar format which includes each week my short introduction on a

theme related to the weeks readings. Every week one student will lead discussion of the readings, two otherstudents are assigned presentations. The full class will participate in the general discussion that follows. Everyo

is expected to comprehend the material at the theoretical and conceptual level, informed by an anthropologicalperspective, and to master (i.e., commit to memory) sufficient detail to illustrate discussion points. It is not expecthat students will memorize all the characteristics of each infectious agent, chronologies of disease epidemics, athe like. Rather, the intent is to know how/when to draw in such factual summaries specific data and researchfindings to engage discussion on a more abstract level. One goal is the comprehension of the co-evolution ofpeople and parasites from an anthropological perspective that is incremental over the course of the semester:discussion of readings and presentations in one week should reflect earlier discussions.

Each week all students will write a two-page (double-spaced) integrated overview of the readings that compaand contrasts the authors, and pose two questions (about the readings collectively) that will engage groupdiscussion. Hand in these weekly summaries at the end of each class. This is not meant to be an exhaustivetreatment of the readings only an overview plus discussion topics. The student leading the discussion can turn

his or her notes, rather than a summary.

PowerPoint presentations are recommended for seminar presentations and-end of-semester presentations.

Individual seminar presentations must briefly address the bio-epidemiological dimensions of an infectiousdisease treated in that weeks readings. Such information can be drawn from the assigned, and additional,readings and should outline these parameters as understood by bio (western) science below is the example omalaria:! infectious agent: 4 species of the protozoan genus Plasmodium! symptoms: fever, anemia, enlarged spleen! prognosis: recovery likely unless the parasite is drug resistant! mode of transmission: Anopheles mosquito vector

! ecological risk factors: poor soil drainage and irrigation schemes that allow water to accumulate, whichencourages mosquito breeding

! social/cultural risk factors: residence or activity adjacent to water, high population density! ecological protective factors: cold temperatures do not support mosquito breeding! social/cultural protective factors: medicine, migration, architecture, smoke! prevention: water control, mosquito netting, pharmaceutical antimalarials! treatment: chloroquine, mefloquine, indigenous medicines such as Artemisia annua

On the day of your seminar presentation, distribute to all seminar participants a one-page abstract/outline ofyour presentation, with references listed. If you request, I will provide you with suggestions including readingsfor preparation of specific and general discussions. Appropriate sources include recently published texts, booksand journals.

General discussion will include all seminar participants, and will focus on the interrelations among thebiomedical facts of the disease in question and features of culture and society.Our primary objective is tocontextualize the bioepidemiological parameters by drawing attention to the cultural construction and socialnegotiation of health and illness:! disease explanatory models! social mediation of knowledge and health resources! patterns of access to resources! the meaning of health, illness, and medicines

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Uh Oh

If I become dissatisfied with the level of participation, I will assign additional written work or examinations. Inother words, it is in your collective best interest that all students be prepared to discuss each week's readings. A

appropriate strategy would be to prepare summaries of sub-themes that you find especially compelling for eacharticle/chapter, and raise specific questions to clarify some aspect of those readings. Please keep in mind theprimary objective of learning in this course: bioepidemiological parameters are the backdrop, cultural constructioand social representations of illness are the frontpiece.

Individual Projects:

On consultation with me, each student will identify a goal/product/activity that meets his or her individualprofessional objectives and intersects with the objectives and content of this course. This product can take the fof an annotated bibliography, MA or other research paper, a research proposal, or something else.

The student who elects the Research Paper option will write a research paper on a subject of his/her choice

The minimum length is 40 pages double-spaced, using standard font and margins. Papers must include acomplete bibliographic citation for each work cited/referred to in the text of the paper. Reference materials shoube drawn from academic/professional works published in recent journals and books (last 10 years or so)** atleast 35 references should be consulted and cited. Direct quotes must be kept to an absolute minimum. It is beto avoid quotes altogether. The paper must have a problem orientation (be linked to concepts and theory), and nbe merely a description of some phenomenon. An appropriate format would include a literature review of theselected topic, and an introduction and conclusion that discuss the particular and general significance of the topincluding how it relates to the concepts, theory, and substance of subjects addressed in this course.

The student who elects the Annotated Bibliography option will select a topic, write a one-page introduction aits significance to Anthropology, and annotate at least 60 recent (last 10 years or so)** journal articles or booksabout that topic. The annotation for each item will consist of a summary of the article (one or two paragraphs, ab

1/3 page) and a statement (two or three sentences) about how this particular article informs your specific topic e.g., outlines methods appropriate for the study of phenomenon X, explores phenomenon X in a particulargeocultural location, reveals the interplay of culture and biology in the expression of phenomenon X, offers a crocultural perspective on phenomenon X, provides a theoretical basis for the study of phenomenon X). The goal isunderstand how contemporary Anthropologists study this phenomenon.** If you elect an historical treatment, some older references are appropriate.

Writing Assignment for the Last Day of Classes, 6 May

All students review the semesters readings, presentations, discussions, and conceptual summaries to write five-page (double-spaced) summary (or series of summary statements/observations). Everyone presents,followed/punctuated by general discussion.

Readings are available for photocopying in the Department of Anthropology Office.

Evaluation: % of final course gradeWeekly writing assignments 25%

Seminars 25%Discussion 25%Papers/Bibliographies 25%

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Seminar Outline and Reading Assignments

14 January: Seminar OverviewWhat is a uniquely anthropological perspective on infectious disease?Review of syllabus and seminar organizationBiomedical terminologyWho speaks for the microbes?

21 January: Introduction

A. Anthropological contributions to the study of infectious disease and international health researchB. Theoretical perspectives

1. Biological approaches micro- and macro-evolutionary studies2. Ecological approaches3. Sociocultural approaches: human behavior, ethnomedicine, indigenous peoples and the formal medic

sector4. Political economy/political ecology5. Biocultural approaches

Reading:Farmer, Paul. 1999. Introduction. In Infections and Inequalities. University of California Press. Pp. 1-17.

Inhorn, M.C. and P.J. Brown. 1997. Introduction. In The Anthropology of Infectious Disease. M.C. Inhorn and Brown, eds. Pp. 3-29. Gordon and Breach. Amsterdam.

Inhorn, M.C. and P.J. Brown. 1997. Anthropology of infectious disease. In The Anthropology of InfectiousDisease. M.C. Inhorn and P.J. Brown, eds. Pp. 31-67. Gordon and Breach. Amsterdam.

28 January: Conceptual and Theoretical Perspectives

Reading:Farmer, Paul. 1999. The vitality of practice. In Infections and Inequalities. Pp. 18-36. University of CaliforniaPress.

Farmer, Paul. 1999. Rethinking emerging infectious diseases. In Infections and Inequalities. Pp. 37-58.University of California Press.

Goodman, Alan H. and Thomas L. Leatherman. 1998. Traversing the chasm between biology and culture: anintroduction. In Building a New Biocultural Synthesis: Political Economic Perspectives on Human Biology. A.H.Goodman and T.L. Leatherman, eds. Pp. 3-41. University of Michigan Press. Ann Arbor, MI.

4 February: No regular class meeting, finalize topics for papers/projects

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11 February: Paper/project topics due

11 February: Ethnographies of IllnessA. Biomedicine and the germ theory of disease

B. Worms, winds, evil eye, birth in nose, and other explanatory modelsC. Perceptions of the immune system metaphors of prevention and healing

1. Media view: body at war2. Alternative practitioners view: fix my head3. Bioscientists view: -cells, lymphocytes, T-cell activation, immunoglobulin, antibodies

Reading:Martin, E. 1994. The body at war: media views of the immune system. Flexible Bodies: The Role of the ImmuneSystem in American Culture from the Days of Polio to the Age of AIDS. Pp. 49-81. Beacon Press. Boston.

Vecchiato, N.L. 1997. Digestive worms: ethnomedical approaches to intestinal parasitism in southern Ethiopia.The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 241-266. Gordon and Breach.

Amsterdam.

Liu, Tik-Sang. 2008. Custom, taste, and science: raising chickens in the Pearl River Delta Region, South China.Anthropology and Medicine 15:7-18.

Zhang, Letian and Tianshu Pan. 2008. Surviving the crisis: adaptive wisdom, coping mechanisms and localresponses to avian influenza threats in Haining, China. Anthropology and Medicine 15: 19-30.

18 February: Ethnographies of Illness - continued

Reading:Hewlett, Barry S. And Richard P. Amola. 2003. Cultural contexts of Ebola in northern Uganda. Emerging InfectDiseases 9(10):1242-1248.

Wallis, Patrick and Brigitte Nerlich. 2005. Disease metaphors in new epidemics: the UK media framing of the 2SARS epidemic. Social Science and Medicine 60:2629-2639.

Stivers, Tanya. 2005. Non-antibiotic treatment recommendations: delivery formats and implications for parentresistance. Social Science and Medicine 60:949-964.

Poltorak, Mike, Melissa Leach, James Fairhead, and Jackie Cassell. 2005. MMR talk and vaccination choicesethnographic study in Brighton. Social Science and Medicine 61:709-719.

Farmer, Paul. 1999. Sending sickness: sorcery, politics ... AIDS in Haiti. In Infections and Inequalities. Pp. 158183. University of California Press.

Geissler, P. Wenzel. 1998. Worms are our life, part I: understandings of worms and the body among the Luo western Kenya. Anthropology and Medicine 5:63-79

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25 February:(Re)emergent Infections and the Diminished Biomedical Arsenal

Reading:Etkin, Nina L., Paul J. Ross, and Ibrahim Muazzamu. 1999. The rational basis of irrational drug use:

pharmaceuticals in the context of development. In Anthropology in Public and International Health. R.A. Hahned. Pp. 165-181. Oxford University Press. Oxford.

Nichter, Mark. 1996. Vaccination in the Third World: a consideration of community demand. In Anthropology anInternational Health: Asian Case Studies. M. Nichter and M. Nichter, eds. Pp. 329-365. Gordon and Breach.Amsterdam.

Renne, Elisha. 2006. Perspectives on polio and immunization in northern Nigeria. Social Science and Medicin63:1857-1869.

Blume, Stuart. 2006. Anti-vaccination movements and their interpretations. Social Science and Medicine 62:62642.

4 March: No regular class meeting, work on papers/projects

11 March: More Theoretical Considerations: Co-evolutionary and Historical PerspectivesA. Infection and the evolution of sex:

1. The significance of self and non-self2. Safety in diversity

B. People, plants, herbivores, and all their respective pathogens

Reading:Conrad, Lawrence I. 1992. Epidemic disease in formal and popular thought in early Islamic society. In Epidemiand Ideas: Essays on the Historical Perception of Pestilence. T. Ranger and P. Slack, eds. Pp. 77-99. CambriUniversity Press. Cambridge.

Louria, Donald B. 1998. Emerging and reemerging infections: the critical societal determinants, their mitigationand our responsibilities. In Emerging Infections. W.M. Scheld, D. Armstrong, and J.M. Hughes, eds. Pp. 247-2American Society for Microbiology. Washington DC.

Ewald, Paul W. 1994. Vectors, vertical transmission, and the evolution of virulence. Chapter 3 In Evolution ofInfectious Disease. Pp. 35-55. Oxford University Press. Oxford.

Armelagos, George J., Peter J. Brown, and Bethany Turner. 2005. Evolutionary, historical and political economperspectives on health and disease. Social Science and Medicine 61: 755-765.

Brown, Peter and Elizabeth Whitaker. 1994. Health implications of modern agricultural transformations: malaria pellagra in Italy. Human Organization 53:346-351.

Etkin, Nina L. 2003. The co-evolution of people, plants, and parasites: biological and cultural adaptations tomalaria. Proceedings of the Nutrition Society (UK) 62:1-7.

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25 March: Research Methods in The Anthropological Study of Infectious disease

A. Household production of illness and health

1. developmental niche frameworkB. The paradox of iatrogenic infectionC. Collecting ethnomedical data in the field

Reading:Coreil, J., L. Whiteford, and D. Salazar. 1997. The household ecology of disease transmission: dengue fever inDominican Republic. In The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 145-17Gordon and Breach. Amsterdam.

Inhorn, M.C. and K.A. Buss. 1997. Infertility, infection, and iatrogenesis in Egypt: the anthropological epidemioof blocked tubes. In The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 173-210.Gordon and Breach. Amsterdam.

Bhattacharyya, K. 1997. Key informants, pile Sorts, or surveys? Comparing behavioral research methods for tstudy of acute respiratory infections in West Bengal. In The Anthropology of Infectious Disease. M.C. Inhorn anP.J. Brown, eds. Pp. 211-238. Gordon and Breach. Amsterdam.

25 March: Spring Holiday - no class

1 April: More Ethnographies of Infectious Disease

A. Weak lungs and the social stigma of tuberculosis

B. Count your children only after the measles pass epidemics of a preventable infection1. Spiritual dimensions of a viral infection

C. Pneumonia bacterium, virus, or cold air?

Reading:Nichter, M. 1997. Illness semantics and international health: the weak lungs-tuberculosis complex in thePhilippines. In The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 267-297. Gordonand Breach. Amsterdam.

Padmawati, Siwi and Mark Nichter. 2008. Community response to avian flue in Central Java, Indonesia.Anthropology and Medicine 15:3151.

Cheungsatiansup, Komatra. 2008. Ethnography of epidemiologic transition: avian flu, global health politics andagro-industrial capitalism in Thailand. Anthropology and Medicine 15:53-59.

Washer, Peter. 2006. Representations of mad cow disease. Social Science and Medicine 62:457-466.

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8 April: Political Economies of Tuberculosis

ReadingFarmer, Paul. 1999. The consumption of the poor... In Infections and Inequalities. Pp. 184-210. University of

California Press.

Farmer, Paul. 1999. Optimism and pessimism... In Infections and Inequalities. Pp. 211-227. University ofCalifornia Press.

Farmer, Paul. 1999. Immodest claims of causality... In Infections and Inequalities. Pp. 228-261. University ofCalifornia Press.

15 April: ZoonosesA. Where have you been, how did you get that?B. Three dog night and similar contexts that foster transspecific contagion

C. Eosinophilic meningitis, hookworm, rabiesD. The dangers of domestication

Reading:Murray, Keith, Bryan Eaton, Peter Hooper, Linfa Wang, Mark Williamson, and Peter Young. 1998. Flying foxeshorses, and humans: a zoonosis caused by a new member of the Paramyxoviridae. In Emerging Infections. WScheld, D. Armstrong, and J.M. Hughes, eds. Pp. 43-58.

Hanlon, Cathleen A. And Charles E. Rupprecht. 1998. The reemergence of rabies. In Emerging Infections. W.Scheld, D. Armstrong, and J.M. Hughes, eds. Pp. 59-80.

Nyamanga, Peter A., Collette Suda, and Jens Aagaard-Hansen. 2006. Similarities between human and livesto

illnesses among the Luo in western Kenya. Anthropology and Medicine 13(1):13-24.

Wilcox, Bruce A. And Duane J. Gubler. 2005. Disease ecology and the global emergence of zoonotic pathogenEnvironmental Health and Preventive Medicine 10:263-272.

22 April: Individual Appointments to Discuss Semester Projects/Papers

29 April: Presentations of Individual Projects/Papers

6 May: Concluding Session

Presentations of Individual Projects/Papers continued

Semester Summary is due described on syllabus page 3:Reflections on a semester of spots, sputum, contagion, corporality, microbes, and the co-evolution ofanthropological, public health, microbiological, biomedical, etc. perspectives on infectious disease.