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Journal of Political Ecology: 
Case Studies in History and Society

 

 

VOLUME 6 (1999)

The Anthropology of Infectious Disease: International Health Perspectives, edited by Marcia C. Inhorn and Peter J. Brown. Amsterdam: Gordon and Breach Publishers, 1997. xv, 495 pp.

 

Reviewed by Barbara Herr Harthorn, Center for Global Studies/Institute for Social, Behavioral, and Economic Research, University of California at Santa Barbara.

The Anthropology of Infectious Disease represents the first systematic collection of work exploring anthropologists' unique contribution to the international study of infectious disease. It is an important and groundbreaking work that will prove a crucial resource and baseline for future work by anthropologists and others as well. The "springboard" for the book was a session of the American Anthropological Association meetings in 1992, but the book goes far beyond the limitations often posed by such collections. The text focuses particularly on the troublesome "new" infectious diseases of the late 20th century like AIDS and HIV, "old" infectious diseases with alarming rebounding incidence in the past two decades (like malaria and tuberculosis), infectious diseases formerly identified and treated as non-infectious chronic diseases (e.g., infertility), and the introduction of infectious diseases into populations with no previous exposures (see introductory Chapter 1 by Inhorn and Brown, pp. 3-5). The text is dedicated to the tasks of encouraging medical anthropologists to focus attention on the increasingly important topic of infectious diseases and of providing a text that will instigate cross-disciplinary dialogue and collaboration with other biomedical and public health researchers and practitioners. The contributors represent many of the leading anthropologists who have been working on infectious disease over the past decade and a half, and the international and implicitly ecological focus offers a perspective on morbidity and the politics of treatment and control that is simultaneously transnational and thoroughly grounded in the particular and the local. 

The book consists of two introductory chapters by co-editors Inhorn and Brown, followed by 13 articles on the history, methodology, ethnography, and political economy of such infectious diseases as valley fever (William Harrison), smallpox (Carol Shepherd McClain), malaria (Peter Brown), dengue fever (Jeannine Coreil, Linda Whiteford and Diego Salazar), infertility (Marcia Inhorn and Kimberly Buss), respiratory infections (Karabi Bhattacharyya), intestinal parasites (Norbert Vecchiato), tuberculosis (Mark Nichter), measles (Dorothy Mull), pneumonia (Sara Cody, Dennis Mull, and Dorothy Mull), AIDS (Karina Kielmann) and HIV (Paul Farmer), and cholera (Marilyn Nations and Cristina Monte). The globe is well covered in these studies, which range in spatial/regional analysis from the southwestern US, the Caribbean, North Africa, sub-Saharan Africa, South and Southeast Asia, and South America, to the entire globe. The inclusion of five chapters (of 15) that are reprinted from recently published work gives the collection more coherence and balance than one can often expect in such compilations. The result is a provocative work that includes important case studies and yet goes far beyond individual cases and raises significant issues in the theoretical and methodological realms as well as in substance. This text exemplifies the specific contribution that medical anthropology informed by and allied with ecological and political economic approaches can make to one of the most pressing health issues of our time.

In their Introduction, Chapter 1, and in Chapter 2, The Anthropology of Infectious Disease (reprinted from the Annual Review of Anthropology, 1990), editors Inhorn and Brown have provided an essential critical frame that lends both structure and texture to the individual case studies that follow. This is a book with a mission, an important aim admirably achieved; that mission is to lay out a foundation and framework for future anthropological research on infectious disease, by establishing the advances and present shortfalls in knowledge represented in this cutting edge collection. Thus, in their introduction, Inhorn and Brown lay out an ambitious project for future research, reflected in the organization of the volume into five sections of "epistemological" approaches that are also their stated priorities for future research: 1) anthropologies (necessarily plural) of infectious disease; 2) histories of infectious disease, particularly those that focus on the epidemiological shift from infectious disease mortality to chronic disease mortality in developed nations; 3) methodologies that emphasize triangulation, especially using the methods of both ethnographic and epidemiological data collection and analysis, in order to improve reliability and validity, but also to enhance cross-disciplinary dissemination and collaboration; 4) ethnographies, essential to contribute to the behavioral study of risk behaviors and treatment processes and the construction of cultural models about medicines and diseases; and 5) the political-economic context, to widen the scope of analysis far beyond the frame of biomedicine, and aimed always at linking macro-sociological pressures with (locally specific) micro-sociological processes. Chapter 2 provides an essential review of the history of anthropologists' diverse contributions to the study of infectious diseases up to the late 1980's (the piece was originally published in 1990). It provides a sense of depth to the more contemporary studies that follow and increases the value of the book as a comprehensive reference source.

A number of important themes permeate the studies offered in this text and their synthesis by Inhorn and Brown. One of these is the ecological approach to infectious disease that the co-editors have advocated elsewhere (Brown and Inhorn 1990). Thus, the problems surrounding infectious disease are seen as essentially connected to interactions among human and animal populations (as disease hosts), disease agents, and the environment (both the physical and the sociocultural environment) in which "host-agent interaction" (p. 32) takes place. Within this frame, human behavior and beliefs are seen to crucially affect infectious disease etiology and transmission, among other ways by changing the environment, producing often unforeseen ecological disruption with serious health consequences. This approach views infectious diseases as part of "a single epidemiological world system" (Inhorn and Brown, p.38), which can show astonishingly rapid shifts and changes that are as yet little understood, especially since research to date has focused on an extremely limited number of diseases. One example of the ecological approach, very usefully focused on the household as a critical unit of analysis in ecological studies, is Chapter 6 by Coreil, Whiteford and Salazar on "The Household Ecology of Disease Transmission: Dengue Fever in the Dominican Republic," in which they convincingly show how the "household ecological system" figures in disease transmission.

Directly connected to the ecological approach is the attention to political economic and social processes reflected in every case study in the volume, and explicitly addressed in the 3 chapters in the final section of the book. Infectious diseases are particularly powerful sites for the analysis of health inequalities, both between the developed nations and those of the Second and Third Worlds and, increasingly, those linked to accelerating economic and social inequality within developed nations (e.g., see Wilkinson 1996). Thus, the attention to differential distribution of risk or disease on population wide studies like those of Harrison (Chapter 3) in his fascinating study, "Dangerous Dirt, : Paleopathology of Valley Fever and the Biopolitics of Race," or the social processes of blame making, stigma and social control so ubiquitous in infectious disease control programs reflects this macro-sociological focus and its microsociological manifestations. These latter approaches are most evident in Kielmann's evocative study of AIDS prevention and women's identity in Kenya (Chapter 13), '"Prostitution," "Risk," and "Responsibility": Paradigms of AIDS Prevention and Women's Identities in Thika, Kenya,' Farmer's further development of the thesis from his powerful and influential book, AIDS and Accusation (1992) in Chapter 14, "Ethnography, Social Analysis, and the Prevention of Sexually Transmitted HIV Infections Among Poor Women in Haiti," and Nations and Monte's piercing analysis of biomedical systems and the blaming of the underclass for the cholera epidemic in Brazil in Chapter 15, "I'm Not Dog, No!": Cries of Resistance Against Cholera Control Campaigns in Brazil."

Another theme of great importance to Inhorn and Brown's approach is the importance of anthropological studies and methods for elucidating the ethnomedical beliefs and practices of both local people and those of local (and international) professionals and practitioners. This emphasis is absolutely essential in the study of infectious diseases, particularly because 'barriers' to effective treatment are often identifiable in local biomedical practitioner beliefs and behaviors as much or more than among the patient population. This has important implications for the potential applied uses of anthropological research on infectious disease. For example, in Brown's study of the resurgence of malaria in Chapter 5, "Culture and the Global Resurgence of Malaria," he provides an exemplary analysis of three cultural systems (those of local peoples, those of donor countries, and those of the international health organizations themselves) involved in rebounding malaria, and the conscious and unconscious levels on which each operates. This kind of nuanced analysis greatly enriches (and complicates) the study of infectious disease, in a way that highlights the potential contribution of anthropology while yet remaining accessible to biomedical and public health scholars and practitioners. Cody, Mull and Mull's article in Chapter 12 on "Knowing Pneumonia: Mothers, Doctors, and Sick Children in Pakistan" also provides an excellent example of the value of this multi-dimensional approach.

Finally, another important aspect of anthropological contributions to the study of infectious disease evidenced in these studies is the emphasis on discourse analysis to understand and construct cultural models (e.g., about medicines, or diseases). To give just a couple of the many examples in the book, Nichter's article reprinted in Chapter 10, "Illness Semantics and International Health: The Weak Lungs-Tuberculosis Complex in the Philipines," shows the incommensurability of Filipino and biomedical understandings of tuberculosis. McClain's study in Chapter 4, "A New Look at an Old Disease: Smallpox and Biotechnology," examines the discourse of biomedicine and science in the debate about destruction of the smallpox virus stock and that of peoples who have suffered from smallpox. This focus on discourse, evident in many of the studies, is crucial to the unique contribution anthropologists can make in bridging micro- and macro-level analyses, in both medical anthropology and political ecology.

Every article in this text merits a detailed critique, which is unfortunately beyond the scope of this article. However, I particularly like the attention to methodological issues in this text (e.g., in the three chapters in the third section of the book). The "integrative anthropological-epidemiological exploration of various behavioral risk factors" for infertility from infectious disease used by Inhorn and Buss in Chapter 7 (p.201) in their article, "Infertility, Infection, and Iatrogenesis in Egypt: The Anthropological Epidemiology of Blocked Tubes" exemplifies the potential for convergences in approaches often thought hopelessly incompatible. Similarly, Bhattacharayya's chapter on "Key Informants, Pile Sorts, or Surveys? Methods for the Study of Acute Respiratory Infections in West Bengal," offers a rigorous comparative assessment of different behavioral research methods and their potentials for integrating research in the international public health arena, a crucial topic for anthropologists working on infectious diseases. And all the contributors to this volume carefully delineate their methods and analytical techniques in a manner that will be most helpful to fellow researchers in the field

The Anthropology of Infectious Disease offers an usually rich and thorough approach to a pressing global health concern to which anthropologists have the potential to make a great contribution. This text will be an essential introductory text for new researchers, a valued resource for the experienced infectious disease researcher, and an effective tool for communicating across the often impenetrable bounds between the social sciences and the worlds of domestic and international biomedicine and public health personnel.

References Cited:

Brown, Peter J. and Marcia Inhorn.

1990. Disease, Ecology, and Human Behavior. In: Medical Anthropology: A Handbook of Theory and Method, eds., T.M. Johnson, & C.F. Sargent, pp. 187-214. New York:Greenwood Press.

Farmer, Paul.

1992. AIDS and Accusation: Haiti and the Geography of Blame. Los Angeles: University of California Press.

Wilkinson, Richard G.

1996. Unhealthy Societies: The Afflictions of Inequality. London: Routledge.