Classical Methods From Epidemiology to Culture

Ethnography is the close study of everyday life, the representations that are drawn upon in the conduct of social relations, and the practices through which these are reproduced. These qualitative insights can prove crucial to understanding how epidemics emerge. Ethnography and epidemiology have been most closely linked in forensic investigations, familiar to us from numerous accounts depicting public health sleuths hot on the trails of a new outbreak (see, e.g., McCormick & Fischer-Hoch, 1996). In approaching emerging infectious diseases, these methods have been widely used by clinicians, biologists, and astute public health practitioners, as well as by anthropologists. After all, ethnography is much like private detective work. Both require a keen sense of observation, familiarity with social worlds different from one's own, a certain street-wise character, and an intuition for both the mundane and the exceptional.

What is often regarded as medical anthropology's greatest triumph, the discovery of the cause of the slow degenerative disease called kuru among the Fore people of Highland New Guinea, was accomplished by biologist Carleton Gajdusek's painstaking marriage of biological and ethnographic research. Gajdusek was faced with a perplexing situation: the terrible disease followed a peculiar epidemiological pattern, affecting only young children and older women—a pattern that could not be explained if the disease was genetic or transmitted like known infectious agents. However, pathological evidence of similar brain lesions and cultural evidence concerning funereal practices involving endocannibalism led to the hypothesis that an infectious agent was being transmitted from the brains of deceased victims to the living through the preparation of bodies for funeral rites. Gajdusek's work ultimately demonstrated that kuru is caused by infectious protein particles called prions. Such funereal practices were not always practiced among the Fore, but were borrowed from neighboring tribes (Lindenbaum, 1979, p. 22), an example of how even in apparently isolated societies, diffusion of cultural practices can play a role in social change.

The case of kuru illustrates how an emergent epidemic can result from the juxtaposition of a random event (in this case, a genetic mutation generating a pathogenic, infectious protein) and a particular social practice. Cultural practices accounted for the epidemiology of the disease, explaining why certain individuals were affected while others were spared, and why the disease was confined to a specific cultural group.

Kuru in the New Guinea Highlands and sleeping sickness in colonial Africa highlight the biosocial nature of emerging epidemics. On one side, evolutionary mechanisms produce biological variation and, occasionally, a newly virulent pathogen. On the other, a key, culturally driven practice provides the crucial link between, or separation of, pathogen and host. However, in considering how these two processes come together, it is difficult to separate the biological from the social. Biological variation can be driven by social changes that shift local disease ecologies and the "fitness landscapes" within which evolution occurs. Novel biological phenomena can themselves drive social change, as countless historical examples of the reaction to epidemics can attest.

The critical potential of anthropology became most visible with the HIV epidemic, where a new, lethal pathogen has emerged over the last three decades to claim over 15 million lives, and infect upwards of 40 million more. The epidemic has resuscitated anthropological concern with biosocial processes. Biological and medical anthropologists had long been interested in processes of bio-cultural adaptation; the AIDS epidemic demonstrated that such processes could have acute relevance. Initially, however, anthropologists were slow to take up the biological dimension of this biosocial event, as it involved consideration of the epidemic's origins and, in the early years of the epidemic, the question of "causes" and "origins" was heavily freighted with blaming and victimization. At the time, critical anthropologists denounced lurid theories advanced by other anthropologists, journalists, and scientists alike as more indicative of a propensity to accuse the victims than as a constructive engagement with a serious public health issue (Farmer, 1992). In the response to the epidemic, realist positions have prevailed, largely because of the overwhelming toll of the epidemic. Social constructivist positions have been acknowledged in attempts to overcome stigma and in the activist goal to achieve empowerment through knowledge, with those that doubt that HIV causes AIDS relegated to a marginal fringe.

Thus, initial anthropological work on AIDS concentrated on representations of the disease and pitted culturalist accounts of disease spread against more political analyses. For the former, the spread of HIV was best understood in terms of specific cultural practices, ranging from sanguinary religious rites to sexual behaviors. A more political-economic view has argued that AIDS spreads along the "fault-lines" of society, striking the poor and socially excluded whose vulnerability makes them most likely to be afflicted. Epidemiological research has largely supported the latter view, while pointing to the need for an ethnographic thick description—and the engagement with diverse communities this requires— to give a more finely grained picture of an increasingly heterogeneous epidemic.

Significantly, this debate has revealed weaknesses in epidemiology as an analytic science of epidemics. Its power in detecting associations and temporal patterns makes it a clumsy tool for explaining the rare events that trigger epidemics. Epidemiology is not a predictive science of epidemics. This is not surprising, given that epidemiology is a quantitative, descriptive science that is able to generate hypotheses but is weak at validating or invalidating them outside the social laboratory of the clinical trial or the case-control study. In the "real world" outside of the laboratory, epidemiological methods are unable to manage the presence of myriad known—or unknown—confounding factors that can account for an epidemic having emerged in one place but not another.

The landmark case of kuru demonstrated the importance of cultural beliefs in accounting for the contingency of biological phenomena such as epidemics. A growing body of evidence on HIV/AIDS has reinforced this view, showing that epidemics are constrained by social forces and local configurations of culture, political economy, and power. In this sense, it can be advanced that the science of emerging epidemics will be a medical anthropology that includes a dialogue across biological and social disciplines, and is reflexive; that is, takes account of the politics inherent in the production of knowledge.

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