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Lecture 3

ANTC68 Lecture 3.doc

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University of Toronto St. George
Bianca Dahl

ANTC68 Lecture 3: Jan 24, 2013 Epidemiological Transitions, Syndemics, Disease Transfer at Contact Anthropological Approaches (Manderson 1998) • Health Belief Model: says that educating patients will lead to a change in behaviour by replacing ‘false’ beliefs with ‘accurate’ knowledge • Doesn’t always work in practice. • WHY? • Ex: bed nets, water, drug packaging • > Water: washing your hands with clean water, but if you don’t have clean water, you can’t do that. • Drug packaging: people who had TB , and prescribed medications (blister package) and parents thought it was birth control; they couldn’t have it so the parents threw it out • Rapid Anthropological Assessments: anthropologists familiar with a particular population may be asked to quickly ascertain human behaviour and specific local beliefs and knowledge. • May be rapid because of time or money constraints or in locations without trained personnel • During an epidemic it is especially important to come up with quick interventions • Anthropological methods include in-depth interviews and focus groups. • Anthropologists also contribute to the study of infectious disease by discovering LOCAL taxonomy (how a disease is defined) and etiology (how a disease is caused)  Identifying the factors that influence people’s decisions to diagnose illness or differentiate between threatening and life- threatening diseases  Identifying factors that affect people’s preparedness to use biomedical services and adhere to prescribed treatment • Anthropologists help minimize suffering • Anthropologists facilitate ACCESS to biomedical resources and SUSTAINABLE interventions • Anthropologists help translate information between biomedical practitioners and local populations to result in more effective health interventions Syndemics Syndemic refers to the synergistic interaction of two or more co- existing diseases AND the resultant excess burden of disease > Could be a short answer or MCQ Making each other worse than it would’ve been (the whole is greater than the sum of the its part) • Medical Anthropology contributes to the study of illness by exploring alternate concepts of sickness in a socio-cultural context • As the way we think about sickness changes our response to it changes as well (ie. Biomedicine sees all diseases as discrete and bounded; treatment is based on symptoms of individual maladies) • In a syndemic, the whole is greater than the sum of the parts • ex: HIV AND TB: patients with both have decreased survival compared to those with either separately (burden of disease is worse) • HIV+ patients develop symptoms of TB earlier than HIV- patients • Biomedicine: Symptoms don’t overlap (????) • The interaction between two diseases can occur at a biological level, for example genes of two viruses mixing in the body • A syndemic doesn’t have to just be two sicknesses, it could also be the interaction of a disease with something else, such as poverty or stress. > Ex: asthma sufferers have higher rate of influenza infection than non-asthma sufferers. • Hospitalization rates are higher in inner cities (poor) and for racial minorities • Asthma rates are also higher in children surrounded by neighbourhood violence > Syndemics could also be a disease + something else that’s creating a bad health in an individual (ex. Poverty) Syndemics: Poverty • Rates of impoverishment increase every year, as does the gap between the rich and the poor • Poverty impacts nutrition, shelter, access to health care, sanitation, water, political power, psychological stability, … • Overall: increased poverty leads to increase susceptibility to infectious diseases and limited means to change/adapt • It is one of the greatest determinants of human health today Structural Violence: “violence of poverty, social and political marginalization, racism, sexism, and other forms of structured inequalities and their effects on people’s lives, health, and agency” (Leatherman & Thomas 2009: 197) Agency: “the capacity of human beings to affect their own life chances and those of others and to play a role in the formation of the social realities in which they participate” (Barfield 1997: 4) • A common component of syndemics is MALNUTRITION, which lowers the body’s ability to fight infection • Ex. Malnourished patients have longer duration of influenza infection than well-nourished patients • Poverty and poor childhood nutrition are associated with heart disease in adulthood. • Patients experiencing stress and stigma have quicker progression of HIV • SAVA: a syndemic between Substance Abuse, Violence, and AIDS. Unfortunately, a very common combination • Anthropological application: since we know certain populations (poor, homeless, malnourished, stigmatized, etc.) are at high risk of AIDS, target interventions at similar populations not currently experiencing AIDS epidemic Epidemiological Transitions • First proposed by Omran (1971) • Epidemiological Transition Theory focuses on the complex change in patterns of health and disease & on their demographic, economic and sociological determinants and consequences. • Omran says MORTALITY is the key to understanding population dynamics • Before you can understand Epidemiological Transition, first need to talk about Demographic Transition • Omran’s three disease stages correspond with first three demographic transition stages • Demographic Transition describes the change from high fertility and mortality to low fertility and mortality (and accompanying changes in population size) • STAGE 1: birth rates and death rates are both high with occasional fluctuations (war, disease, famine) • Population size at constant low level OMRAN STAGE 1: Age of Pestilence and Famine > Life expectancy low (20-40 years), children and women most affected by poor conditions Lots of kids are being born, but they’re not living long This graph is pre 1760.. High rates of infectious diseases killing everyone off High infant mortality • STAGE 2: Mortality experiences rapid decline while birth rate still high and stable • Population size increases rapidly • WHY does mortality decline? Improvements in sanitation, hygiene, nutrition (Note time period: this is before effective medical interventions) OMRAN STAGE 2: Age of Receding Pandemics > Life expectancy improving (30-50 years), few crisis events > Smallpox vaccinations made a big impact on life; in general mortality rates decline • STAGE 3: Mortality stabilizes at lower level, birth rate falls • Population size increases less rapidly (this graph doesn’t do good job of showing that) > Why a falling birth rate? Higher infant survival, transition to industry, fewer children needed > Overall fertlitiy is going down OMRAN STAGE 3: Age of Degenerative and Man-Made Diseases > Life expectancy still improving (50+ years) > Fertility now critical factor in population growth (mortality stable) Demographic Transition/ Omran • Note that the reason for transitions is NOT medical science. (Medicine does help with later transitions) • Infectious disease mortality was already declining long before Germ Theory (recall 1860-ish) • Better standards of living, hygiene, health habits, nutrition (all by-products of social change) • The most profound improvements in health were seen in children and young women. • Omran did have variations on his models: (i) Classical (western) – what you just saw (ii) Accelerated (Japan) – took longer to reach stage 3 but quick catch-up (iii) Delayed (Latin America, Africa, Asia) – slower changes to health infrastructure, sanitation. Fertility still quite high. > Infant mortality dropped STAGE 4: mortality and birth rates at new, lower level • Population size remains constant at high level (or slow increase) Incremental increase Family planning (contraceptives)  People are having kids later in life Demographic Transition • STAGE 4: better health care, nutrition, family planning, later marriages • STAGE 5: (?) Fertility drops below replacement levels, population size slowly decreases Examples: China (one-child policy), Italy Criticisms of Epidemiological Transition Theory • Teleological (goal-directed): it suggests that there is an end goal of being “developed” (at which point change may stop) • Actually: we are always changing and there is no end point • Hierarchical: societies are expected to pass through each stage in order. Those in an earlier stage are less advanced. • Actually: The Epidemiological Stages occurred in a specific historical context with circumstances that may/may not be replicated • Stages are fixed, with no overlap. No going back and forth between stages. • Actually: many societies have elements of more than one stage at the same time (ex. Obesity and ‘old’ infectious diseases such as cholera) > In Canada, people are usually in stage 5 Subpopulations: having a lot of children at earlier stage • Does not address quality of life • Actually: as life expectancy increases, the changing burden of disease may make people unhappy even though they’re living longer • Uses whole nations • Actually: within a particular country, some populations may have elements of Stage 1 (the poor) while others have elements of Stage 3 (the rich). Overall disease load increases with both. • Says disease profile changed completely • Actually: many diseases have been with us the whole time and never went away (such as Tuberculosis), it’s just that the people who have the disease are invisible. Our
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