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ANTC68: Deconstructing Epidemics Lecture 4: Deconstructing Cholera Common Behavioural Patterns of Social Responses to Epidemics (Fox 1989; McGrath 1991)--> societal responses to epidemics & different responses to infectious diseases over time 1. Fear and anxiety 2. Flight or migration from epicenters of epidemic 3. Development of therapeutic and preventive measures that are commonly not the norm (i.e., ceremonies, quarantine), e.g., business-civic coalitions controlling public health interventions 4. Blaming & scapegoating individuals or institutions 5. Denial (underestimation of severity of the problem), or resignation /acceptance of the disease 6. Ostracism of sick individuals and those at risk 7. Intragroup conflict / social disorder Surat, India after a plague outbreak in September 1994  Social response  Lead to chaotic response  People were in panic mode  doctors, nurses tries to treat people infected by the plague but flee from it just like everyone else Extent of Cultural and Social Reactions to New Disease Depends on: 1. Virulence and pathogenicity of the agent 2. Pathway of transmission 3. Disease manifestations 4. Repercussions on cultural and societal norms  Importantly, culturally-specific beliefs (representations) of the epidemic/disease can become epidemic and endemic themselves  Can propagate an epidemic and jeopardize public health measures  Note, however, that these representations are not static and can change over time  Severity of individual/societal response depends to a large extent on how the afflicted perceive their risks o can be a significant factor in how we respond  Risk perception (which can be influenced by ideological and class-related perspectives) changes with a person’s perceived amount of control over exposure Factors in the (poor) Success of Public Health Interventions in an Epidemic 1. Awareness of the epidemic and concern of a population is low and needs to be increased 2. Knowledge about the vector and its life cycle is limited 3. The disease is not considered life-threatening and the symptoms are not viewed as signs of severe sickness 4. Ignorance of culturally-specific beliefs about health and illness, and other cultural constraints, i.e., economics --> Determinant factor in how we perceive it Public Health Interventions, especially Health Education, need to consider: 1. Group priorities and risk perceptions 2. Local belief systems and practices in their social and cultural, as well as economic contexts (including how disease-related community beliefs may conflict with biomedical knowledge) 3. Health educational measures that inform populations at risk of how behaviour change is feasible within existing social, economic and cultural constraints o Practical and feasible within the society's context  Interdisciplinarity and methodological “triangulation” between epidemiologists, virologists and social scientists o When approaching the aspects of disease from different perspectives o What is common or different between different approaches in disease  Epidemics should be considered social processes that are socio-culturally and epidemiologically constructed “ o consider them an essence in cultural event o socially constructed, not purely biological phenomenon  Epidemiologists cause epidemics” (Lancet 1993) ‘Miasma’ and Cholera  London, England  4 major cholera outbreaks in mid-19th C.  Cholera: acute intestinal infection caused by bacterium Vibrio cholerae  600+ deaths in 1854  John Snow o Played a role in trying to figure out the cause of cholera beyond the society's perception o Thought it was caused by bad air, cold wet air known as 'miasma' --> not scientific o Tried to identify the source of the disease by walking specific areas, neighbourhoods, basically geographic distribution to understand where it was occurring ... known as shoe-leather epidemiology o Germ theory: o Discovered that the disease outbreak was due to water pumps Medical Geography -->interested in geographic distribution of disease  Field of medicine that incorporates concepts and techniques of geography into the study of health and the spread of disease: 1) Examines the relationships between people and their environments in holistic terms 2) Spatial analysis (where disease occurs, and at what rate, is important….for clues to causation) – thus distributional maps showing patterns of health-related phenomena  Also: impact of climate and location on an individual's health  Distribution of health services: Cholera  Acute intestinal bacterial disease of Vibrio cholerae 01 (classical and El Tor biotypes) & 0139  Bacteria sensitive to high temperatures, acidity, dry conditions  Incubation period of 1-2 days; transmission through contaminated food, water, utensils; importance of seasonality  Cholera bacteria adheres to small bowel and produces a toxin that inhibits the absorption of liquids by the body (stimulates over- secretion of water and electrolytes) - kills via dehydration  Note: most strains of Vibrio do not carry the genes to make toxin  Pathogen multiplies in the gut of the carrier and are excreted  Majority of cases - mild (90%); many infected have no symptoms (carriers); 5-8% get mild to moderate diarrhea; 2-5% get severe “cholera gravis”: severe diarrhea, vomiting, and dehydration; oral vaccine offers some protection (reduces risk of death by approx. 50% in first year); use of antibiotics  Malnourished people and those who are carrying many intestinal parasites may be more susceptible than healthy people: it takes 100 billion vibrios in the gut of a healthy person to cause disease, because large numbers are immobilized by acids in the stomach, but in someone whose gut is less acidic, because of heavy parasite burden, it takes only 1 million organisms  Risk Factors: hygiene, sanitation, health care resources, SES Water Insecurity and Cholera  ORIGINS? Interaction with humans probably began with agriculture, as populations grew and polluted their water sources with human and domesticated animal waste – which created nutrient-rich ecosystems that allowed pathogens to thrive  First recorded historical outbreak: 1817, India  Innumerable epidemics around the world; end of 20th century – some of most extensive epidemics in recent times, esp. during refugee crisis in Central Africa (Rwanda, Burundi, DR Congo) in 1994/5: 40,000 cases, case fatality rates exceeding 30% in some areas (limited med facilities); also – South Africa, 2001, 86,000 cases  7 successive pandemics; 7th one in 1960s, El Tor strain (which later led to 1991 epidemic in Peru)  May be 8th pandemic in future, with new strain 0139 Bengal causing high mortality in South Asia in 1992 Image o Recent outbreak in 2010-2011 o Reports of cholera o Haiti is a big concern for cholera outbreaks--> started because of the earthquake --> largest cholera ORT and RIT  Mortality resulting from severe dehydration may be >50% if left untreated (< 2% w/ORT)  Oral rehydration treatment (ORT) and rapid intravenous rehydration therapy (RIT) o Mixed with clean water in order to balance electrolytes in your body  Chemoprofilaxis and vaccination not always recommended: mass treatment with antibiotics may lead to drug resistance and vaccination effective in only 50% of cases  Being vaccinated may also give a false sense of protection  The key to effective control is environmental sanitation Cholera in Peru, 1991: Ecological and CMA Explanations Peru o Affected by cholera o Vibrio cholerae isolated from the Peru epidemic in 1992  400,000+ cases in Peru both during 1991-1992  4000+ deaths in Peru during 1991-1992 POSSIBLE ECOLOGICAL CAUSES OF THE 1991-2 EPIDEMIC:  Dumped bilge water from an Asian freighter  Sea current El Niño: is a hot current coming from the north to the south along the South American coast in Pacific Ocean (usually takes place at the end of December and beginning of January)  1991: this current produced higher temp. than usual in that part of Pacific  Zooplankton that inhabit cold waters can carry large number of cholera vibrio on their bodies (zooplankton feed by grazing on phytoplankton which bloom with sunshine and warm conditions; thus, a phytoplankton bloom leads to increase in pop. of zooplankton which carry the vibrio)  A warmer than usual El Niño may have created ideal conditions along the Peruvian coast for humans to become infected with cholera  Zooplankton also live in water of ponds and rivers that people drink  Fish and shellfish eat zooplankton  Shellfish consumption can also lead to cholera if contaminated with the bacteria (ceviche….though not clear connection…lime acid) Cholera: A Critical Medical Anthropological Analysis -->political and environmental  Question: Why were Peru’s water and sanitation systems in such a state at that point in the country’s history?  Need to consider: historical evidence of the relationship between economic systems, supporting political and social structures, and patterns of health and disease Globally (1970’s, 80’s)  Improvements in child survival, longer lifespans  Increased population, urbanization  Economic recession with oil crisis of 1970’s  Debt crisis of 1980’s  Resulted in depleted capital, which “Third World” countries needed to maintain and expand the public health infrastructure (esp. w / ↑ urbanization) Peru: 1970-1990  Public health infrastructure (water/sewage) overwhelmed by socio-economic factors: 1) Unprecedented growth in urban populations 2) Chronic inflation and associated losses of capital for investment 3) Unsustainable public sector employment and subsidies Effects on Peru: Resurgence of infectious diseases  Social and Economic Factors: 1. 1950: 35% of pop. lived in cities: by 1990 – 70%; 1991: more than 25% of country’s population lived in the capital, Lima (6.5 million), where 1/3 of the residents lived in squatter settlements 2. 1950-1965: low inflation of 8%, compared with 31% in Brazil, 25% in Argentina; by 1980: inflation increased steadily, reaching 10,000% by the end of the decade…..poverty rose: in Lima, rate went from 17% of city (1986) to 44% by 1990 3. Public employment (½ of all salaried workers) and subsidies for food, public transportation and water/electrical supplies depleted foreign exchange reserves and left insufficient funds for maintenance and expansion of basic public services, as well as adequate health care (budget cuts) and basic medical supplies Fujishock, SAPs and Peru’s Health Care post-1990  Elimination of government subsidies on necessary household items  Staple foods (bread: 9K to 25K), fuel (21K to 675K)  Dramatic cuts in public employment  Health sector cuts Cholera and … 1. Poverty 2. Economic Globalization 3. Environmental Change CMA: Cholera is a product of social, rather than “natural”, circumstances  ecological environment created during the 1991-92 epidemic Quiz 1: Most correctly, a critical medical anthropological perspective of the cholera epidemic in Peru (1991): a) De-emphasizes the role of climate change b) Accepts the consumption of raw seafood led to the spread of the disease c) Disputes the role of government cuts in health sector funding d) Emphasizes the role of increased rural population in the spread of the epidemic Epidemics, Scapegoats and Stigma Scapegoating: Nelkin & Gilman 1988  Poor understanding of disease (pathogen, causation, transmission, etc.)  Poor understanding ----> threat to power structures  “Patterns of blame that prevail in different periods reflect the social stereotypes, fears, and political biases that are associated with threats of social or political change” (376)  Blame: way to “create order, reassert control over perceived threats, or preserve existing social institutions”  Douglas (1992: 87): accusations of illness used strategically to perpetuate cultural regimes and control those who are threatening, problematic or hated/feared Scapegoating in Late 19th Century Gibraltar (Sawchuk and Burke 2008)  IMP of disease in defining power imbalances/weaknesses  British fortress colony with strategic imp.; military rule  After 1783: high pop. growth of 6% per year for 2 decades  Flourishing economy, foreign immigration; diverse pop.  Linked to Malta as British colonies; high immigration from 1860s to 1890s, especially single males  Numerous recurring epidemics: yellow fever, cholera  British efforts to limit population growth Scapegoating in Gibraltar  Common beliefs regarding disease: o Contagionists: Diseases were imported with diseased individuals or things (from diseased territories)  Foreigners bring the disease o Localists: Diseases derived from local sources, i.e., dirty, foul-smelling environments, tainted food, poor sanitation  Dirty foul environments  Similar to 'miasma' bad air, damp area, etc. Sun, Sea and Cholera  Significant factor: sea-based interconnection of Gibraltar with other ports, esp. those with endemic cholera (i.e., Spain)  Cholera in Gib: a disease of importation – first in 1834, then 1860, 1865, 1885  Public response with each epidemic?  **1885 deaths: 25, while 1865: 477 o Social difference o Epidemic in 1865; came from barefoot foreigners which spread the disease o 1885: serious disease as perceived from society  1885 epidemic: 4 months long (at same time in Spain, 60K died in summer and fall) o Policies created to limit the disease o 1885: perceived as serious due to immigration; it was minor Cholera Epidemic of 1885  Total mortality of 25 (while 1865: 477 deaths) over 4 months (at same time in Spain, 60K died in summer/fall)  First fatality established link to Maltese: death of soldier linked to unripe fruit and decomposed fish (Maltese street vendors)  Cholera led to slowed
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