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The Anthropology of Infectious Disease

Anth 606, Spring 2009 Wednesday 1:30-4, Saunders 345 Office Hours: Monday 12-2, or by appointment Professor Nina L. Etkin Saunders 321: 956-7726 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 as tuberculosis, malaria, and polio. The problem is compounded by infectious disease traffic introducing infections to new species and previously not affected populations. This growing disease burden can be linked to human activities such as deforestation and other environmental transformations, contact with exotic animals, over- and other inappropriate use of antibiotics, limited knowledge of disease transmission, and lack of resources for vaccination and other preventions. The anthropological study of infectious disease explores the interrelations among pathogenic microbes in human populations by focusing on the intersection of cultural, ecological, and political factors related to the transmission and experience of infectious disease. Given the role of human action in infectious disease traffic, anthropologists who observe and interpret human behavior have insights and other resources that can improve 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, and cultural contexts in which they occur. These contexts are defined by a constellation of variables in nature (e.g., parasites, environment) and in society (e.g., subsistence, gender relations, differential access to resources) that shape how a particular community will experience infectious 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 and parasite/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 commodification of health and in preventive and therapeutic measures?

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 other students are assigned presentations. The full class will participate in the general discussion that follows. Everyone is expected to comprehend the material at the theoretical and conceptual level, informed by an anthropological perspective, and to master (i.e., commit to memory) sufficient detail to illustrate discussion points. It is not expected that students will memorize all the characteristics of each infectious agent, chronologies of disease epidemics, and the like. Rather, the intent is to know how/when to draw in such factual summaries specific data and research findings to engage discussion on a more abstract level. One goal is the comprehension of the co-evolution of people 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 compares and contrasts the authors, and pose two questions (about the readings collectively) that will engage group discussion. Hand in these weekly summaries at the end of each class. This is not meant to be an exhaustive treatment of the readings only an overview plus discussion topics. The student leading the discussion can turn in 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 infectious disease 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 of malaria: ! 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, which encourages 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 of your presentation, with references listed. If you request, I will provide you with suggestions including readings for preparation of specific and general discussions. Appropriate sources include recently published texts, books, and journals. General discussion will include all seminar participants, and will focus on the interrelations among the biomedical facts of the disease in question and features of culture and society. Our primary objective is to contextualize the bioepidemiological parameters by drawing attention to the cultural construction and social negotiation 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

Uh Oh If I become dissatisfied with the level of participation, I will assign additional written work or examinations. In other words, it is in your collective best interest that all students be prepared to discuss each week's readings. An appropriate strategy would be to prepare summaries of sub-themes that you find especially compelling for each article/chapter, and raise specific questions to clarify some aspect of those readings. Please keep in mind the primary objective of learning in this course: bioepidemiological parameters are the backdrop, cultural constructions and 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 individual professional objectives and intersects with the objectives and content of this course. This product can take the form of 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 a complete bibliographic citation for each work cited/referred to in the text of the paper. Reference materials should be drawn from academic/professional works published in recent journals and books (last 10 years or so)** at least 35 references should be consulted and cited. Direct quotes must be kept to an absolute minimum. It is best to avoid quotes altogether. The paper must have a problem orientation (be linked to concepts and theory), and not be merely a description of some phenomenon. An appropriate format would include a literature review of the selected topic, and an introduction and conclusion that discuss the particular and general significance of the topic, including 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 about its significance to Anthropology, and annotate at least 60 recent (last 10 years or so)** journal articles or books about that topic. The annotation for each item will consist of a summary of the article (one or two paragraphs, about 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 particular geocultural location, reveals the interplay of culture and biology in the expression of phenomenon X, offers a crosscultural perspective on phenomenon X, provides a theoretical basis for the study of phenomenon X). The goal is to understand 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 a 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 grade Weekly writing assignments 25% Seminars 25% Discussion 25% Papers/Bibliographies 25%

Seminar Outline and Reading Assignments


14 January: Seminar Overview What is a uniquely anthropological perspective on infectious disease? Review of syllabus and seminar organization Biomedical terminology Who speaks for the microbes?

21 January: Introduction A. Anthropological contributions to the study of infectious disease and international health research B. Theoretical perspectives 1. Biological approaches micro- and macro-evolutionary studies 2. Ecological approaches 3. Sociocultural approaches: human behavior, ethnomedicine, indigenous peoples and the formal medical sector 4. Political economy/political ecology 5. 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 P.J. 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 Infectious Disease. 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 California Press. 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: an introduction. 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

11 February: Paper/project topics due 11 February: Ethnographies of Illness A. Biomedicine and the germ theory of disease B. Worms, winds, evil eye, birth in nose, and other explanatory models C. Perceptions of the immune system metaphors of prevention and healing 1. Media view: body at war 2. Alternative practitioners view: fix my head 3. 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 Immune System 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. In 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 local responses 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 Infectious Diseases 9(10):1242-1248. Wallis, Patrick and Brigitte Nerlich. 2005. Disease metaphors in new epidemics: the UK media framing of the 2003 SARS epidemic. Social Science and Medicine 60:2629-2639. Stivers, Tanya. 2005. Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance. Social Science and Medicine 60:949-964. Poltorak, Mike, Melissa Leach, James Fairhead, and Jackie Cassell. 2005. MMR talk and vaccination choices: an ethnographic 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 of western Kenya. Anthropology and Medicine 5:63-79

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. Hahn, ed. Pp. 165-181. Oxford University Press. Oxford. Nichter, Mark. 1996. Vaccination in the Third World: a consideration of community demand. In Anthropology and International 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 Medicine 63:1857-1869. Blume, Stuart. 2006. Anti-vaccination movements and their interpretations. Social Science and Medicine 62:628642.

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

11 March: More Theoretical Considerations: Co-evolutionary and Historical Perspectives A. Infection and the evolution of sex: 1. The significance of self and non-self 2. 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 Epidemics and Ideas: Essays on the Historical Perception of Pestilence. T. Ranger and P. Slack, eds. Pp. 77-99. Cambridge University Press. Cambridge. Louria, Donald B. 1998. Emerging and reemerging infections: the critical societal determinants, their mitigation, and our responsibilities. In Emerging Infections. W.M. Scheld, D. Armstrong, and J.M. Hughes, eds. Pp. 247-259. American Society for Microbiology. Washington DC. Ewald, Paul W. 1994. Vectors, vertical transmission, and the evolution of virulence. Chapter 3 In Evolution of Infectious Disease. Pp. 35-55. Oxford University Press. Oxford. Armelagos, George J., Peter J. Brown, and Bethany Turner. 2005. Evolutionary, historical and political economic perspectives on health and disease. Social Science and Medicine 61: 755-765. Brown, Peter and Elizabeth Whitaker. 1994. Health implications of modern agricultural transformations: malaria and pellagra in Italy. Human Organization 53:346-351. Etkin, Nina L. 2003. The co-evolution of people, plants, and parasites: biological and cultural adaptations to malaria. Proceedings of the Nutrition Society (UK) 62:1-7.

25 March: Research Methods in The Anthropological Study of Infectious disease A. Household production of illness and health 1. developmental niche framework B. The paradox of iatrogenic infection C. Collecting ethnomedical data in the field Reading: Coreil, J., L. Whiteford, and D. Salazar. 1997. The household ecology of disease transmission: dengue fever in the Dominican Republic. In The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 145-171. Gordon and Breach. Amsterdam. Inhorn, M.C. and K.A. Buss. 1997. Infertility, infection, and iatrogenesis in Egypt: the anthropological epidemiology of 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 the study of acute respiratory infections in West Bengal. In The Anthropology of Infectious Disease. M.C. Inhorn and P.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 infection 1. 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 the Philippines. In The Anthropology of Infectious Disease. M.C. Inhorn and P.J. Brown, eds. Pp. 267-297. Gordon and 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 and agro-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.

8 April: Political Economies of Tuberculosis Reading Farmer, 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 of California Press. Farmer, Paul. 1999. Immodest claims of causality... In Infections and Inequalities. Pp. 228-261. University of California Press.

15 April: Zoonoses A. Where have you been, how did you get that? B. Three dog night and similar contexts that foster transspecific contagion C. Eosinophilic meningitis, hookworm, rabies D. The dangers of domestication Reading: Murray, Keith, Bryan Eaton, Peter Hooper, Linfa Wang, Mark Williamson, and Peter Young. 1998. Flying foxes, horses, and humans: a zoonosis caused by a new member of the Paramyxoviridae. In Emerging Infections. W.M. Scheld, 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.M. 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 livestock 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 pathogens. Environmental 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 of anthropological, public health, microbiological, biomedical, etc. perspectives on infectious disease.