Before thinking about the new issues facing anthropologists and epidemiologists at the beginning of the twenty-first century, it is important to recall the contemporary themes that already have received decades of attention. For example, the interdisciplinary exchanges between these fields four and five decades ago were based partly on the movement of epidemiologists from home to foreign terrain. Anthropology became more relevant and necessary when epidemiologists started working more often in cultural contexts they did not understand. This theme is still relevant today, although the uncharted terrain now includes a mixture of foreign territories and domestic communities. As epidemiologists have become increasingly involved in the design and implementation of intervention trials attempting to change human behaviors such as unsafe sex, smoking, and high alcohol consumption, their need and desire to understand communities and human behaviors has grown correspondingly (Smedley and Syme 2000).
The growth of an integrated approach joining anthropology and epidemiology also rests on disciplinary responses to social and cultural change. Increased migration and urbanization make it important to define and measure the health effects of these social and cultural processes; a mixture of epidemiological and other social science theory and method is required for this purpose. We human beings are modifying our ecological context through the rapid transport systems we invent, the forests we cut down, and the new medicines and poisons we produce. Familiar diseases such as hypertension and diabetes are spreading more generally across the planet, helped along by changing dietary preferences and levels of physical activity. War, violence, political repression, and inadequate services shift people into new areas, bringing new customs, new diseases, and new epidemiologic patterns. Good fieldwork continues to be important to understanding this changing context because it puts researchers in direct contact with what they otherwise have to imagine (Agar 1996).
Studies of how the changing social and cultural environment affects human health will continue to be of critical importance for the foreseeable future. No single discipline can develop the complex models needed to account for the interplay between the individual and the environment and the rise of diseases such as AIDS, SARS, E. coli O157-H7, and antibiotic-resistant tuberculosis. As we will see in Chapter 6, interdisciplinary collaboration to treat and prevent these diseases is just as critical as the collaborative work undertaken to understand their burden and their causes.
Some of the forces that will continue to facilitate exchanges between anthropologists and epidemiologists in the twenty-first century are related to the growth of disciplinary research tools and knowledge not all that dissimilar from that of a century ago. For example, innovative administrative procedures in the nineteenth century helped create health insurance schemes, national health care, and systems of vital statistics. Administrative processes today help enroll or trace study participants or maintain consistent procedures across multiple study sites; these make it easier to use complex research designs and to increase the volume of research containing both biological and sociocultural variables. These procedures also facilitate looking at patient enrollment or nonparticipation in research studies as sociocultural processes relevant to epidemiologic research.
New technologies that facilitate the processing of large amounts of data will obviously continue to push interdisciplinary or integrated research studies. Statistical procedures such as path analysis and nonlinear regression make analyses of multivariate relationships more feasible. This allows researchers to examine multicausal models of disease causation that include social as well as biological factors. Ever-faster computers, cheaper massive data storage, and more complex computer-based statistical packages support the new analytic techniques critical to today's social and cultural epidemiologic research. Combining geographic information systems and statistical procedures for modeling and graphing social networks makes new studies of human interaction and disease transmission possible.
Technologies make information easier to process, but they also help make things visible. As stated earlier in this chapter, techniques of imaging such as stethoscopes, microscopes, and tissue staining helped to create new disease categories and scientific disciplines in the nineteenth century.
Twenty-first-century technologies for seeing inside human bodies, testing for genetic anomalies, and decoding the human genome are creating similar opportunities for joint anthropological and epidemiological research. These technologies help change definitions of disease and disorder even as they also modify how humans are grouped into "healthy," "diseased," and "at risk" categories.
Increased recognition of mutual interests between anthropologists and epidemiologists will continue to promote more frequent collaboration and more closely integrated studies and programs. Both disciplines actively debate critical issues such as the sources of their theories, validity of their methods, and utility of their findings. Medical anthropology has come to use a broad range of qualitative and quantitative research techniques to describe illness in biological and cultural contexts (Dunn and Janes 1986). Cultural anthropologists have assessed the use of statistics in anthropology and have written about the differences between ethnographic and statistical representation (Asad 1994). In similar fashion, epidemiology has subfields open to collaboration with anthropologists, and epidemiologists have expressed interest in qualitative methods and interpretive modes of inquiry (e.g., Almeida Filho 1992, Behague et al. 2002, Black 1994, Breilh 1994, Donovan et al. 2002).
Some new big questions prompt discipline-based critiques within and across anthropology and epidemiology. In Chapter 1, I presented a description of cultural epidemiology as a field of study concerned with how diseases are defined and measured as well as patterned. The type of intense reflexivity seen in anthropology also has been articulated by some epidemiologists in the past decade. They have started to ask explicit questions about whether their paradigms of disease causation might best be labeled as "causal webs" (Krieger 1994), "blackboxes" of unknown complexity, or "Chinese boxes" of nested levels of organization (Schwartz et al. 1999, Susser and Susser 1996).
Anthropologists are asking questions about the epidemiological vocabulary and method that mark some departures from the past. For example, only in the past few decades have they asked what the meaning of "race" is when used as an explanatory variable in studies of human health and through what causal pathways it might influence human health. They are giving similar critical attention to words such as "stress," "lifestyle," "risk," "socioeconomic status," and "community." They are asking how best to measure the mental health problems of diverse groups in the United States (Guarnaccia and Rogler 1999) and internationally (Weiss 2001), and how feminist perspectives can inform epidemiology (Inhorn and Whittle 2001). The following chapter takes a more detailed look at these kinds of questions.
Understanding how human bodies react to the presence, status, and power of others is another theme now receiving integrated attention. Studies of the influence of social support on human health have been joined by studies of the effects of social networks on human physiology and health. One critical question is how the environment and disease burden of the surrounding population influence individual disease risk. Strong evidence that poverty is a cause of sickness and mortality is being buttressed by evidence that the widening gap between rich and poor is itself a major cause of poor health and death (Farmer 2003, Kawachi et al. 1999, Nguyen and Peschard 2003). This is of particular interest to anthropologists because both pathogens and ideas about pathogens are transmitted through populations. The tools and theories to understand these phenomena must be able to move between the intracellular and the interpersonal, tracing causal relationships among pathogens, behavior, power, and disease.
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