Theoretical Heritage

Anthropological engagements with non-Western and Western medical systems has left a rich theoretical heritage that is drawn on studies of emerging epidemics. Three theoretical frameworks for analyzing health and illness phenomena in a cross-cultural perspective have emerged from these engagements. A realist framework explains local variations in disease phenomena as culturally driven deviations from a biological universal; this use of biology as the ontological ground of disease phenomena is a resolutely modernist position. In contrast, a relativist framework examines how scientific discourses, practices, and institutions "construct" the biological world as objective and manipulable phenomena; the use of such social constructivist explanations for local variations has a postmodernist sensibility. Finally, a radical constructivist framework focuses on how biological and social processes are historically and geographically contingent and intertwined; these processes are understood to co-produce disease phenomena in variable ways. This is an a-modernist position that grants ontological privilege neither to the biological nor the social world. The significance of these three frameworks for consideration of emerging infectious diseases will now be explored in order.

Although anthropology was not overtly concerned with health issues in the tropical climates where it cut its ethnographic teeth, the engagement with "primitive culture" left a theoretical legacy that shapes anthropological approaches to emerging infections to this day. Anthropologists examining indigenous medical systems sought to understand how these achieved healing outside of a Western, biomedical framework. To do this, two options were available to anthropologists. The first was to assume that non-Western medical traditions had biological efficacy because of their ability to manipulate physiological states through the use of biologically active substances or the psychological manipulation of body states; in short, herbs and trances. This modernist approach was also realist, in that it was committed to a universal biology as the yardstick for measuring therapeutic outcome. It remains germane to contemporary attempts to reinforce the role of traditional medical practitioners in the response to infectious diseases such as AIDS and sexually transmitted infections, as well as with medical anthropologists sympathetic to a biomedical basis for understanding, and responding to, epidemics.

As historians have pointed out, epidemics are social events that require understanding not only how disease is produced in bodies, but also how it is reproduced in social relations (Ranger & Slack, 1992). Similarly, anthropological examinations of emerging infections seek to extend our understanding of them beyond the biology and epidemiology of these diseases in order to demonstrate how epidemics are embedded in economic relations and anchored by social systems of meaning. This social dimension furnishes the conditions of emergence of epidemics in space and time. Social relations configure exposure to risk, transmission, and susceptibility, as the 19th-century pathologist and father of social medicine, Rudolph Virchow, first taught us. Epidemics are caused by pathogenic social relations, whether in the case of tuberculosis amongst South African mineworkers, cholera outbreaks in refugee camps, or epidemics due to hamburger meat or water being contaminated by Escherichia coli O:157.

Within this realist framework, several approaches to elucidate the social pathways of disease causation have been drawn by anthropologists, archeologists, medical geographers, and epidemiologists. Political-economic approaches have stressed how economic structures perpetuate social inequalities that increase the risk of disease amongst the disadvantaged, while culturalist approaches have emphasized the role of local beliefs and practices in modifying risk of exposure, impacting transmission, and shaping susceptibility to pathogens. Both draw attention to the nature of power and how it is exercised in society, leading anthropologists to focus on how individuals are enacted through, negotiate, and resist power relations to modify their own health.

The second explanatory framework, which can be glossed as relativist, sought to situate the therapeutic effect of non-Western medicine in operations that constructed medical objects and therapeutic effects within a self-vindicating, cultural system. Sociologists of science applied the skeptical stance of anthropological approaches to non-Western medical systems to biomedi-cine. Not to do so, they argued, was to succumb to an a-symmetrical and a-sociological program. Biological claims of efficacy could no longer be privileged over social explanations in a symmetrical program of investigation. These critical scholars of science, often referred to as "social constructivists," inspired anthropologists' attempts to examine biomedicine—and the question of therapeutic efficacy—in social and cultural terms. If bio-medicine works, then, a broad corpus of anthropological studies of biomedicine argue, it is because biomedicine is able to harness the symbolic and material means necessary to achieve healing. Therapeutic efficacy is neither a matter of just herbs and trances, nor drugs and surgeries, but requires power, access to economic resources, and the ability to fashion meaning.

Drawing on this framework, these studies emphasize that pathogens themselves are socially constructed. Sociologists of science have argued convincingly that pathogens are invisible outside of the plethora of laboratory techniques that visualize and represent them in scientific documents, making them into social actors that "act" through social practices and "speak" through scientific discourses. In addition, scientific knowledge is driven by political, economic, and institutional concerns that frame the questions that get asked, researched, and published. This is not to say that pathogens are to be dismissed as figments of a fertile social imagination. Pathogens are real precisely because the effects they engender in bodies and societies are mediated through scientific practices. Without epidemiology and molecular virology, for example, the HIV epidemic would be less "real" precisely because we would not have the scientific instruments that allow us to see it and to understand it as the common denominator across multiple registers, whether embodied or social.

More recently, a third theoretical framework has emerged from critical consideration of the knowledge garnered from advances in biotechnology, namely the increasingly detailed epidemiological maps afforded by global surveillance programs, and cross-cultural research on disease entities (Diamond, 1997; Ruffie & Sournia, 1984). This view, which I call the radical constructivist view, argues that social relations can change pathogens themselves, as well as the representations we have of them. In short, biology is local rather than universal (Lock, 1993). The notion of genetically engineered pathogens so feared by bioterrorism experts is a dramatic example; a far more mundane one is the creation of drug-resistant organisms through irrational prescribing practices. Drug-resistant bacteria and viruses such as HIV are different organisms from their drug-sensitive ancestors, not only in genetic make-up but also, in some cases, in terms of their biological behavior. Social relations can change pathogens by impacting the environments within which these evolve—the "fitness" landscapes that drive evolution one way or another.

The radical constructivist view is most strongly supported by molecular biological studies of emerging epidemics. Many emerging infections are caused by pathogens derived from a-virulent organisms that did not cause epidemics previously. Biologists concerned with the conditions of emergence focus on how such organisms become pathogenic. The organisms most likely to trigger epidemics are those with the most plastic—changeable—genomes. The simplest, and most mutable, pathogens are RNA viruses;—indeed, almost all new epidemics have been caused by RNA viruses, from AIDS to West Nile Virus (Burke, 1998). The biggest reservoir of potential new pathogens is not humans, but animals. Almost all the major infectious diseases of humans came from zoonotic, or animal, reservoirs (with the notable exceptions of polio and smallpox). Culture and social relations are powerful determinants of the relationship between humans and domesticated animals. Trypanosomiasis—African sleeping sickness— emerged as a major public health problem in colonial Africa largely because the colonial economy disrupted existing agricultural and animal husbandry practices. Cultural beliefs acted as a public health system by dictating the separation of herds from human settlements, which prevented transmission of the parasite from the tsetse fly to human populations (Ford, 1971). The zoonotic origins of emerging epidemics identifies a constellation of human practices that have the potential to condition exposure to new pathogens. These may impact exposure directly, as in the case of animal husbandry, hunting, or pet-keeping, or indirectly, as in the case of shifting agricultural and economic practices that transform the habitats of these zoonotic reservoirs (Hardin, 2001).

All three frameworks agree that the material effects of epidemics far surpass our ability to grasp them through epidemiological surveys and laboratory investigations. These material effects include the production of disease in bodies, certainly, but also a diverse range of representations, practices, and technologies deployed to understand, prevent, and treat disease. Mass vaccinations, public health campaigns, media stories, rumours, and gossip are powerful social mechanisms through which pathogens act on society. The rubric of culture allows these phenomena to be grouped together as an object of anthropological analysis. In this view, pathogens are like onions, and anthropologists have sought to peel back the cultural skins that envelop the biological pathogen and charge it with its social valence.

In summary, anthropological approaches allow a broader consideration of how epidemics, and pathogens themselves, are deeply socialized. This tells us that emerging infectious diseases cannot be taken for granted as "natural" phenomena—they are part of larger biosocial processes that play out both at the "micro" and "macro" levels. The potential of these theoretical approaches to deepen our insight into the emergence of infectious diseases has been underutilized, as anthropologists have largely served as "cultural interpreters and 'troubleshooters' ... brought into projects to anticipate, or to provide post-hoc explanations of, negative community responses" (Inhorn & Brown, 1997, p. 12).

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