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Marcia C. lnhorn Department of Anthropology, University of California, Berkeley, California 94720 Peter J. Brown

Department of Anthropology, Emory University, Atlanta, Georgia30322
KEYWORDS: evolution, disease ecology, behavioral research, disease control ethnomedicine, infectious

INTRODUCTION Diseases caused by infectious agents have profoundly affected both human history and biology. In demographicterms, infectious diseases--including both great epidemics, such as plague and smallpox, which have devastated humanpopulations from ancient to modem times, and less dramatic, unnamedviral and bacterial infections causing high infant mortality--have likely claimed morelives than all wars, noninfectious diseases, and natural disasters taken together. In the face of such attack by microscopicinvaders, human populations have been forced to adapt to infectious agents on the levels of both genes and culture. As agents of natural selection, infectious diseases have played a major role in the evolution of the human species. Infectious diseases have also been a prime moverin cultural transformation, as societies have respondedto the social, economic,political, and psychological disruption engendered by acute epidemics (e.g. measles, influenza) and chronic, debilitating infectious diseases (e.g. malaria, schistosomiasis). Today, the global epidemic of acquired immune deficiency syndrome(AIDS)provides salient example of the processes underlyinginfectious-disease-related cultural transformations. As manyof the examplescited in this review illustrate, humangroups have often unwittingly facilitated the spread of infectious 89 0084-6570/90/1015-0089 $02.00

Annual Reviews 90 INHORN & BROWN

diseases through culturally coded pattems of behavior or through changes in the crucial relationships among infectious disease agents, their human and animal hosts, and the environmentsin which the host-agent interaction takes place. Thus, infectious diseases provide a rich area for anthropological research, with contributions to be made from all of anthropology’s subdisciplines. Indeed, because the study of infectious disease is an intrinsically biocultural endeavor, the "anthropology of infectious disease" described here must be a holistic one, in which traditional subdisciplinary boundaries are irrelevant. Infectious disease problemsare both biological and cultural, historical and contemporary, theoretical and practical. Because the relevant research requires the synthesizing theoretical frameworkof general anthropology, it cannot be subsumed by medical anthropology. Note the range of anthropological and public health literature cited in this review. Simplydefined, infectious diseases are those caused by biological agents ranging from microscopic, intracellular viruses to large, structurally complex helminthicparasites (see 33 for a classification of infectious disease agents, including viruses, bacteria, fungi, parasites, and several classes of intermediate forms, as well as their routes of transmission). The variety and complexityof infectious agents--in terms of their biological characteristics, their reproductive strategies, and their modes of transmission--are impressive (35). The classification of this tremendous diversity forms part of the subject of the World Health Organization’s (WHO’s) International Classification of Diseases, nowin its ninth revision (224). Thesedisease categories provide standard modeof scientific discourse in biomedicine, where "diseases" are consideredas clinical entities with pathological urlderpinnings, while "illnesses" are moreclosely linked to a patient’s perceptions and behaviors. As is generally recognized by medical anthropologists, however, biomedicine is only one type of culturally constructed medical system (100, 101). It is importantto note that infection with a specific agent does not necessarily result in disease. This progression dependsupon a numberof intervening variables, including the pathogenicity of the agent, the route of transmission of the agent to the host, and the nature and strength of the host’s response(23, 193). All of these factors, in turn, are affected by the natural and social environmentsin which the agent and host are juxtaposed; in somecases, the environmentmaypromote the transmission of the agent to the host, while in other cases it maylimit or even prevent such transmission. Critical characteristics of the environment result largely from sociopolitical influences; thus, many infectious diseases, such as tuberculosis, are rightly considered "social diseases" (57, 217). The American Anthropological Association’s Working Group on Anthropology and Infectious Disease defined the anthropological field of in-

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fectious disease as the "broad area which emphasizes the interactions between sociocultural, biological, and ecological variables relating to the etiology and prevalenceof infectious disease" (26:7). This reviewuses the samedefinition, examininganthropological works on infectious disease (including those by scholars in related disciplines whosemethodsor theoretical frameworksare anthropologicalin nature) and classifying themfor heuristic purposes according to their primarily biological, ecological, or sociocultural orientation.

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Microevolutionary Studies
Froman evolutionary perspective, infectious diseases have probably been the primary agent of natural selection over the past 5000 years, eliminating humanhosts who were more susceptible to disease and sparing those who were moreresistant. Individual biological factors that conferred protection from a specific disease could eventually be selected for in the humanpopulations living where the disease was endemic. Thus, as first suggested by Haldane(102), humans adapted to infectious disease at a most basic level-the level of the gene (5, 6). Over the past 40 years, anthropologists and human geneticists have been testing the hypothesis that specific genotypes mayconfer immunityor resistance to infection. Such hypotheses have also been suggested to help explain relatively common genetic conditions that maybe adaptive in one context and maladaptive in another. Allison (4) was the first to suggest that the heterozygous condition known as sickle-cell trait (i.e. inheritance of the gene for the common form of hemoglobin from one parent and the sickling hemoglobinS from the other) appeared with greater frequency in regions of Africa where life-threatening Plasmodiurnfalciparum malaria was present. This association led Allison to hypothesize that hemoglobin S, whenpresent in the heterozygous state, conferred resistance to death from malaria. Although this hypothesis has been a prominent textbook example for two decades, the statistical correlation betweenmalaria prevalences and sicklecell gene frequencies in West Africa has only recently been systematically confirmed(70). Moreover,while there is significantly higher malaria mortality amongchildren who are heterozygous sicklers than amonghomozygous normals, differences in parasite densities among individuals of the two genotype groups have not been determined (159). In a classic anthropological work that followed Allison’s, Livingstone (158) related the widespread distribution of the sickle-cell trait in WestAfrica to specific factors of cultural evolution: namely,the introduction of iron tools and subsequent swiddenagriculture. He argued that the diffusion of the new technology led to increased sedentism, horticultural production, and de-

Annu. Conversely. the major mosquito by WIB6013 . in combination. and Hb Similarly. Anthropol. West Africanagricultural societies and as a selective agent for the sickle-cell allele (158. provides a high level of protection from Plasmodium vivax.FU BERLIN on 04/14/09. through participant observation of family life in NewHebrides (51. including glucose-6-phosphateE. Rev. Thesediscoveries played a role in the successful development of a hepatitis B vaccine. Downloaded from arjournals. it has been argued that the Duffy blood group negative genotype. and hemoglobins c. Katz &Schall (136) have suggested that the combination of nonexpressed gene and consumption of lava beans (the "gene-beaninteraction") mayprotect heterozygousfemales from malaria death. other hemoglobinabnormalities have been identified (161) that appear to confer resistance to malaria. this would lead to greater selective advantage for heterozygous individuals. thalassemia. effectively increasing the available breeding grounds for Anopheles gambiae. In a different context. Morerecently. the P2 allele of the P blood group system (which is hypothesized to confer resistance to these zoonoses). G6PDdeficient males maysuffer potentially fatal hemolyticcrises of favism (32). These changes allowed falciparummalaria to becomeestablished as an endemicdisease among settled.e. This may be viewed as an excellent example of the "coevolution" of genes and cultural traits. although in this case. a more benign strain of malaria (164). part. .annualreviews. anthropologists helped to demonstrate that the hepatitis B surface antigen (HBsAg) was not part of the genetic endowment transmitted from parents to offspring. 52). carriers of the recessive genefor cystic fibrosis mayhave increased resistance to tuberculosis. characteristic of most African and USblacks.annualreviews. Wiesenfeld (221) demonstratedthat populations most reliant on root and tree crops (the Malaysian agricultural complex) created the most malarious environments. Other studies tentatively linking infectious diseases to genetic traits and cultural factors have recently emerged. circum-Mediterranean area. dehydrogenase (G6PD)deficiency. Throughanalysis of data from 60 African communities. for European populations with long history of pulmonary tuberculosis and high frequencies of cystic fibrosis. For personal use only. the clustering of the antigen observed in families was due to both horizontal (i. person to person) and vertical (i. whoenjoy protection from malaria death yet are not at risk of death from sickle-cell anemia(the condition of homozygous sicklers). and subsistence practices involving animal husbandry. In an examinationof fava bean consumption and its relation to malaria in the G6PD-deficiency-endemic. mother to infant) infectious transmission (20-22)---a finding made. Hb F. Rather.e. 160).org/aronline 92 INHORN & BROWN forestation. offer substantial protection from disease (135). Meindl (174) has hypothesized that. Blangero (18) studied the relationship amonghelminthic zoonoses. He has shownthat high frequencies of the P2 allele occur in populations manifesting heavy dependenceon and contact with domesticated livestock.Annual Reviews www. 1990. For example.19:89-117.

and (b) to contextualize these findings to the physical and cultural circumstances of the human populations involved.FU BERLIN on 04/14/09. This conclusion is based on abundant evidence of syphlitic skeletal material from pre-Columbian remains discovered in the NewWorld (43. Simply defined. as Crosby (45. In addition. 119-122). these have been well summarized by McNeill (172) and Wood(223). Anthropol. 94. 99. 179. First suggested by Dunn(58) and Polunin (196). Rev. 1990.Annual Reviews www. 206). soft-tissue evidence. 201. coprolites. paleopathology is the study of disease in prehistoric populations through examination of skeletal and tissue remains. utilizing dried fecal remains found in near prehistoric campsand shelters. Downloaded from arjournals. 46) has argued. and when available. and American(203) and African trypanosomiasis (151). examination of disease patterns in contemporaryisolated hunter-gatherer populations followed by extrapolation of these findings into the past. For personal use only. Usingosteological evidence. 222) and the distinct absence of pre-Columbian. The broad aims of this research are two-fold: (a) to establish the antiquity and evolution of various infectious diseases in human populations through examination of prehistoric osteological and.Old Worldskeletal material with any of the treponemalstigmata (223). . Paleopathologyhas had a particularly decisive role in the debate over the antiquity and origin of syphilis in the Old and New Worlds.19:89-117. in some cases. and coprolite by WIB6013 . have provided valuable insights on the epidemiologyof intestinal helminthiases in prehistoric populations (40. leprosy (179). examination of these remains has allowed researchers to describe the disease patterns of prehistoric populations and to establish relative chronologies. 191. 181.annualreviews. 181). paleoepidemiological reconstruction of infectious disease patterns in prehistoric and early historic human populations has been undertaken through ethnographic analogy--that is. Paleopathologicalreconstructions utilizing skeletal and tissue remains have been attempted for infectious diseases including tuberculosis (34. 205.200. Nevertheless. this approachhas been advocated subsequently by a number of scholars Annu. including. 69. other reconstructions of the history of syphilis based on contemporaryand historical knowledgeof the treponemal diseases have been put forward (39. Christopher Columbus’s crew. 93. paleopathologists have argued that humanvenereal syphilis originated in the Americasand was transported to Europeand then to other humanhabitats by Europeancolonists and explorers. worksof art (1. Studies of the kidneys of Egyptian mummies have yielded evidence of schistosomiasis (191). Paleopathologyhas contributed significantly to the understanding of the prevalence and spread of infectious diseases in INFECTIOUS DISEASE 93 Macroevolutionary Studies Macroevolutionary studies of infectious disease attempt to reconstruct epidemiological patterns of disease transmission amongprehistoric and historic human populations. 130).annualreviews. Because someinfectious diseases leave their marks on the humanskeleton and flesh.

and relative isolation from other by WIB6013 . Fromthe standpoint of natural selection. Thus. which spreads rapidly and immunizesa majority of the population in one epidemic. 40. if introduced. the agent of schistosomiasis) wouldhave been 94 INHORN & BROWN (16. marked by aggregates of people living in close proximity. Research from both the Old and New Worldsshowsa repeated pattern of decreased stature. 55. the contagious epidemic diseases. ancient hunter-gatherers were relatively free from the acute. 56. Rev. epidemic infectious diseases that later took their toll on moreadvanced agrarian societies. 171.g. amoebicdysentery. populations of no more than 200-300persons wouldnot have been large enoughto sustain such a chain of transmission.19:89-117. the domesticationof animals. . 195) have gone beyond this original proposition to describe the coevolution of humanculture and infectious disease. 1990. Anthropol. The health consequences of this transition from food foraging to food production have been topics of considerable attention. This cultural transition profoundlyaffected the nature of infectious disease patterns by (a) changing the degree of contact between humansand ani~nals. 17. Basing their theses largely on serological evidence collected from contemporaryhunter-gatherer groups. because of their small numbers. 95. Likewise. trachoma)and those that persist for periods of time outside the final host or vector (e. A numberof scholars (5. scattered villages of farmers. higher infant mortality.Annual Reviews www. 40. all of whichoccurred during the agricultural revolution of the Neolithic and Mesolithic periods.FU BERLIN on 04/14/09. 82.the clearing of land for cultivation. 185). as seen in the important collection Paleopathology at the Origins of Agriculture (42). pathogens that live in a long-term commensal relationship with the host (e.’~. provided ideal conditions for manyof the helminthic and protozoal parasites (5). these acute infections wouldhave run their courses and then died out. whichare characterized by brief and rapid stages of infection. would eventually decimatepopulations in urban center.mobility.annualreviews. basing their arguments largely on knowledge of population size and density and their impact on infection. they hypothesize that. Manyacute infectious diseases require large numbersof susceptible individuals to support their chains of transmission. and the concomitant problemsof human and animal waste removal. and (b) altering the size of human aggregations and the communications and movementwithin and between them. For personal use only. to large. Downloaded from arjournals. would have been rare or absent. the agents of typhoid.g. In early food-foraging groups. isolated groups of hunter-gatherers to small.annualreviews. preindustrial and then industrial cities. and infections like measles. Twelveof the eighteen case studies in this collection report substantial increases in infection rates fromthe time of early hunter-gatherers to early farmers (41). either directly or via arthropod vectors. the increase in sedentism. which would not have had a large enough population base to affect hunter-gatherers or even small farming villages. Humans madea rapid cultural transition from small. Annu.

we nowlive in a single epidemiological world system--despite striking differences in the distribution of disease and death between the poor societies of the Third Worldand affluent nations. cholera (202). 149. an important theme in a numberof recent analyses (14. Sucha pattern indicates the strong synergistic relation betweenchronic malnutrition and infectious disease morbidity and mortality (207). for better and for worse. 112). The depopulation of North and South AmericanIndian societies by epidemic infections brought from Europeby colonizers and from Africa by slaves (8. For personal use only. typhus (226). dis- . that the intensification of agricultural systems. however.who in his classic volume The Ecology of Human Disease (167) formalized the role of the environment--both physical and sociocultural--in the study of infectious disease problems. INFECTIOUS DISEASE 95 Annu. McNeill’smodelrequires the recognition that a universal aspect of history has been the "confluence of disease by WIB6013 . Disease ecology. whetherin the past or present. primarily medical historians. have examined the effect of infectious diseases on civilizations during historical periods (for numerous examplesof these works. malaria (105). and acculturation of tribes and chiefdoms. as state-level societies introduce endemicchildhood diseases into smaller and simpler societies. characteristic of populations during the Neolithic revolution. they have chronicled the impact of such infectious diseases as the plague (53). Utilizing texts and other primary and secondarysources. 186. a numberof scholars. Downloaded from arjournals. shows no direct linkage with increased infectious disease rates (41. ECOLOGICAL APPROACHES Theoretical Models Most anthropological research on infectious disease has been ecological. focusing on the interaction betweenagent and host within a given ecosystem. as the discipline is often called (33). causing massive population losses and subsequent socioeconomicdisorganization. Kunitz (150) and McKeown (170) have also concluded that socioeconomicchange has had a greater impact on improvement of health and diminution of infectious diseases than has the introduction of (and innovation in) clinical medicine. and smallpox(115). owes muchto the pioneering work of the medical geographer May. 1990. Mayconstructed a modelthat treated physical environment. 91. McNeill (172) argues that epidemics have played an active role in the expansion empires throughout history." Owing to rapid transportation.annualreviews.Annual Reviews www.FU BERLIN on 04/14/09. In the most comprehensive treatment of this theme. Rev. see 24). It should be noted.138. 171). subjugation. and increased physiological stresses indicative of malnutrition. 187) provides a salient example of McNeill’s point: Infectious diseases accelerated the conquest.annualreviews. uponstate-level societies and populations. In addition.19:89-117.

For personal use only. community mobility) significantly affected rates of parasitic infection. he showedhowlowland housing types. 66). Rev. Using examples from his ownresearch in Asia. which were transplanted without modification to the highlands. . Following May’s lead. Dunn(59. in China. Mayshowed how rates of hookworm infection depended upon the environments within which individuals worked: While rice growers whoworked in fields of mudmixed with nightsoil (raw humanfeces) were usually and often seriously infected.~ease.FU BERLIN on 04/14/09.g. altitude. silkwormfarmers whospent their days on ladders tending to mulberry leaves were not. chemical. 62-64. was never a constant. presence of scavenging animals) and human behavioral factors (e. on the other hand. and host-behavioral factors that must be considered whenstudying disease etiology or attempting to control disease spread. host-biological.exposure to a pathogen was a necessary but not sufficient cause of disease. disease expresses a temporary maladjustmentbetween human hosts and their environment. and the cultural practices employedby these hosts as separate factors in an interactive process. Moreover. which. Anthropol. broadened his approach to disease etiology by incorporating the notion of "insults" into his model. In this view. Audyviewed both health and disease as states in an individual’s dynamicrelations with the environment: Measuring either one depended upon identifying the multiple positive and negative insults and their cumulative effects. the progression from exposure to disease dependedin part on the health of the exposed person.Annual Reviews www. temperature. Audy (10.19:89-117. given an individual’s vtdnerability to a complexof insults. Downloaded from arjournals. and the environment.annualreviews. or social stimuli that adversely affected an individual’s or population’s adjustment to the environment. In his early work with Malaysian aboriginal groups. 1990. human hosts. infectious. soil by WIB6013 . He later demonstratedthe important implications of this modelin the design of effective disease control programs(60.g. Maydemonstrated how transmission of malaria in North Vietnam and hookwormin China were affected by specific environmentaland cultural patterns. a number of scholars delineated models of the interactions among infectious disease agents. In the North Vietnamesecase. Audyintroduced the concept of insults in an attempt to overcome the limitations of a pathogen-specific approach to di~. Insults were defined as physical. 61) showed how both environmentalfactors (e. had adjusted to the malaria threat by constructing stilted houses with living quarters above the mosquito’s 10-foot flight ceiling. Native hill peoples. psychological. humanhosts. whose ground-level dwellings exposedthem to low-flying mosquitovectors.annualreviews. Likewise. were responsible for the higher rates of malaria among lowland-to-highland migrant populations. housing 96 INHORN & BROWN ease pathogens. 11) whose major work focused on the roles of human behavioral and environmentalfactors in the transmission of scrub typhus (9). Annu. subsistence strategies. Dunn(68) developed the even broader concept of "causal assemblages"--complexes of environmental.

developmentprojects of dam construction.annualreviews. Anthropol. in that it focuses on the untoward consequences of ecologically ill-advised development schemes. few of the projects initiated on that continent over the past two centuries have been undertaken within a preconceived ecological framework. are little morethan accretions to the basic epidemiological triad of agent. the consequence of environmentaldisruptions caused by large-scale. all undertaken in the nameof progress. agricultural. whether industrial. Downloaded from arjournals. host. internationally sponsoredprojects (123). This approachhas also been influential in medical geography(131). in and resettlement in Third World countries have probably done more to spread infectious diseases such as trypanosomiasis. schistosomiasis. which focuses on modesand factors of production and changing social relations seen from the perspective of colonialist and neocolonialist history. and political.FU BERLIN on 04/14/09. Rev. Unfortunately. and environment--a modelthat is inadequate because it fails to consider the ultimate causes of disease. As they note. the sensible goal was thus not to maintainthe balance of nature but to change it to the benefit of as manyplant and animal species (including humans)as possible.19:89-117.annualreviews." Turshen (217) has argued that "bourgeois empiricist" models of disease causality. manyof the developmentschemes of the past and present have been neither balanced nor beneficial. Dubos(54. 1990.Annual Reviews www. 55) was among the first to note that technological innovation. It concerns the so-called "developo-genic" diseases. Research Examples in Disease Ecology Muchof the recent empirical work in disease ecology has been. For personal use only. In a radical departurethat she has labeled the "political ecologyof disease. as well as in the development "critical medical anthropology"(211).org by WIB6013 . land reclamation. Turshen argues that the continuedfocus on the former triad is the ultimate cause of scholarly failures to elucidate why epidemics occur at certain historical momentsor why eradication of a specific infection does not ensure prevention of illness. if not explicitly Marxistin orientation. In her ownstudy of infectious disease and related health problems in Tanzania. or medical. which she holds are INFECTIOUS DISEASE 97 Annu. As Hughes&Hunter (123) point out in their comprehensive review of developmentprojects and disease in Africa. The life-threatening blood fluke infection schistosomiasis (bilharziasis) provides a trenchant example of the unforeseen health consequences of ecological disruption caused by development schemes. political-economic. . As Heyneman (110. such as those described above. industrial. and malaria than any other single factor. road construction. upset the balance of nature. as well as resulting population relocations. She favors a Marxist construction of the causes of poor health. and infrastructural change. They include in their survey programsof agricultural.

researchers predicted.Annual Reviews by WIB6013 . South America. which was also responsible for an increased prevalence of malaria in this region (98). For example.The rapid spread of this disease is almost entirely due to programsof water resource developmentinvolving the construction of high dams. 147) have described the expanding distribution of schistosome-transmitting snail populations and escalating rates of human infection following government-sponsored creation of large. 208). Kloosand coworkers (140. 111. whichare acquired whenlarval parasites. 200-300 million people worldwide are estimated to be infected (134). released in the water from snail vectors. Rev. so have schistosomiasis infections. Subtler ecological changes mayalso be associated with increases in infectious disease. 141. and irrigation canals (50. given governmentplans to build more damsin the area (198). Asia. Downloaded from arjournals. 147). any anthropological study that hopes to shed light on the etiology and transmission of infectious disease must ultimately adopt both a macrosociological per- . Annu.annualreviews.Similarly. 144. and new "epidemics" of the disease occur following the expansion of waterways in areas of the world wherethe parasite and vector live. the disease cycle was established within a few years of the start of the Gezira scheme.annualreviews.19:89-117. 110. In neighboring Sudan. and the Caribbean. SOCIOCULTURAL APPROACHES HumanBehavior and Infectious Disease Transmission THEORETICAL MODELS As we have argued elsewhere (33).FU BERLIN on 04/14/09. a large-scale. Anthropol. the severe epidemic of typhoid fever in Mexicoin 1972-73 was the result of overuse of the powerfulantibiotic chloramphenicol for ailments such as the common cold. 98. 145. this change in disease ecology brought about rapid selection for chloramphenicol-resistantstrains of the typhoid fever bacterium (218). penetrate immersed 98 INHORN & BROWN 111) notes. Today. For example. the prevalence of schistosomiasis soared following construction of a low-earth damproviding perennial access to a large body of infective water--an increase that was likely to continue. These waterways have provided an ecological "free zone" for the snails that are the intermediate host of the schistosomal parasites. As the snail population has spread throughout Africa and parts of the Middle East. man-made lakes and reservoirs. In Nigeria. schistosomiasis is probably the fastest spreading and most dangerous parasitic infection nowknown. 1990. irrigated cotton project south of Khartoum (83. For personal use only. irrigated farming estates in the Awash Valley of Ethiopia. Chapin & Wasserstrom (37) have shownhow increased pesticide use in the intensive production of cotton in both Central Americaand India resulted in a serious resurgence of malaria because of the rapid evolution of insecticide-resistant strains of Anophelesmosquitoes.

184. He conceptualizes four major categories of individual or group health-related behaviors: (a) deliberate. 64) model of health-promoting and health-demoting behaviors is perhaps moreuseful on a methodological level. (b) deliberate behaviorthat contributes to ill health or mortality. (b) shedding of the disease agent from infected human host. differential rates of infection were linked by early epidemiologicalinvestigators to varying drinking patterns of factory workers (212). consciously health-related behavior that promotes or maintains health. in somecases. 62. and (d) behavior not perceived to be health related that contributes to ill health or mortality. For personal use only. and (d) diffusion of the transmission system from one place to another. Wehave defined the latter as the study of the individual manifestations of culturally prescribed behavioral patterns. Alland used the term "minimax"to refer to cultural practices that minimize the risk of disease and maximize the health and welfare of the group. . Downloaded from arjournals. Anthropol. 64-67. 210) have noted the importance of understandingculturally prescribed and proscribed behavioral practices and their effect on the transmission of infectious disease agents. 64) have suggested. Rev. Since then.annualreviews. 1990. 109. The impetus for this orientation in anthropologyowesmuch to the pioneering workof Alland (3). all human behavior is adaptive in the evolutionary sense. Roundy (204) has called such disease-promoting patterns of behavior " both Roundy(204) and Dunn(60. The critical links betweenhuman behavior and infectious disease transmission have been recognized for more than a century. (c) behavior not perceived to be health related that nevertheless enhances or maintains health." In his INFECTIOUS DISEASE 99 spective---of the kind advocated by Turshen(217) and exemplified in much the work on disease ecology and development--and a microsociological perspective. during an epidemic of cholera in by WIB6013 . Dunn classifies all health-related behaviors along two axes: deliberate vs nondeliberate and health-promoting or maintaining vs health-demoting. (c) creation of man-made habitats in whichthe transmission cycle can be completed. 176. He notes that each of these categories of behavior may be further divided along a third axis: the perspectives of "insiders" (the populations at risk) as opposedto "outsiders" (members of health-care community). 62. whichare seen as risk factors (or. when. since many culturally prescribed patterns of behavior actually promoteinfectious disease spread. whoused evolutionary theory to examinehowcultural behaviors could enhance humanhygiene and health. numerous anthropologists and other behavioral scientists (3. 62. Annu.19:89-117.FU BERLIN on 04/14/09. Utilizing concepts from mathematical modeling. 60. However. human behavior can affect disease transmission in four areas: (a) exposureto the agent. Dunn’s (60.Annual Reviews www. limiting factors) for the contraction of infection (33).204.annualreviews. 195.

Kuru and cannibalism Perhaps the best-known example of anthropological involvement in an infectious disease problem involves the case of kuru. he has outlined theoretical and methodologicalconsiderations in the study of behavioral risk factors for trachoma(66). permitting transmission of the deadly virus via cuts and sores on the hands of the women preparing dead bodies for burial. human arboviral infections (67). A multidisciplinary team anthropologists. migration pattems.19:89-117. and traditional medical treatments. However. have questioned the association between kuru and cannibalism.Annual Reviews www. These authors suggest that Fore mortuary practices were more likely the crucial behavioral variable. disease incidence plummeted. American and African trypanosomiasis. As Lindenbaum(157) notes. Malaria and cultural adaptation Anthropologists interested in cultural adaptations to disease have focused their attention uponmalaria. Nations (184) has recently summarized someof the behavioral factors that affect infectious disease transmission. observational studies of disease-related by WIB6013 . Anthropol. for one. and four of five parasitic infections (schistosomiasis. a parasitic . neurologists. and WHO for 20-year research and control programs (62.annualreviews. anthropological studies that "makesense" of these behaviors in a broader cultural context--are few. Rev. thus indirectly supporting the etiological role of cannibalism in kuru’s transmission. agricultural techniques. religious practices.ry infectious disease. since it was their responsibility to prepare corpses for consumption.annualreviews. considering the tremendouspotential for this type of research. Dunn (60). For personal use only. and malaria) targeted by the United Nations (UN).org/aronline 100 INHORN & BROWN Annu. more important. as Nations notes. Steadman & Merbs (215).FU BERLIN on 04/14/09. child care patterns. 1990. Downloaded from arjournals. a neurological degenerative condition found in the remote eastern highlands region of NewGuinea amongthe Fore (157). filariasis. 64). RESEARCH EXAMPLES The role of humanbehavior in increasing or limiting transmission can be demonstratedfor virtually ew. Adult women suffered the highest kuru infection rates. World Bank. including dietary customs. and epidemiologists eventually discerned that this lethal condition was due to an infectious agent--a "slow virus" acquired through behavioral practices associated with cannibalism (124). kinship relations. has applied his classificatory schemeto the study of behavioral factors in filariasis transmission. Anthropologists provided clinicians detailed information regarding subjects’ reports of the preparation and consumption of the flesh and organs of deceased relatives (157). noting that researchers in the NewGuinea highlands never actually witnessed an act of cannibalism. following the imposition of Western law and subsequent government-monitored ban on cannibalism. however. In more recent works. pathologists.

and malariologists have recognized the important role of humanbehavior in malaria control (see the bibliography in 213). clothing styles that serve as mechanical barriers to biting insects. and livestock (primarily sheep) live in close association. The Turkana Kenyaand the neighboring tribes of southwestern Ethiopia are highly infected. or the hydatid cysts they observein their livestock (92). dog feces. Unfortunately. traditional medicines in Nigeria (75. the Turkana and other highly infected tribes in this region do not associate their often lethal disease with dogs.annualreviews. infection thought to have killed more people than any other nameddisease (159). it occurs in areas of the world where humans. Anthropol. and seasonal migrations away from mosquitovectors. 90. 76). Hence." whichare specially trained to lick and clean children whohave just defecated. These include the use of alkaline laundry soaps that destroy mosquitobreeding sites. this situation makespreventive cultural adaptations to the disease less likely. that may limit transmission in areas where malaria is endemic.Annual Reviews www. 1990.wardoff evil spirits. and protect women’s skin from the damaging effects of their heavy layered necklaces (90). Rev. the use of malodorous traditional pesticides and insect repellents.Brown (27) has also argued that the combination of nucleated settlement pattern and inverse transhumance(flock movement to high elevations in summer) served to reduce exposure to malaria in Sardinia and to explain its social epidemiological distribution. Downloaded from arjournals. Schistosomiasis and water contact Schistosomiasis is a water-based parasitic disease in that water plays a major role in the developmental life cycle of . in so doing.19:89-117. these nurse dogs disseminate infective parasitic eggs throughout the domestic environmentand to their youngcharges. whichis used to dress wounds. For personal use only. dogs. potentially infective dogfeces are highly valued among the Turkanaas a traditional medicinal and cosmetic substance. Empirical evidence for the efficacy of such practices is generally lacking. 136). by WIB6013 . Behavioraladaptations to malaria in other cultural contexts include fava bean consumptionin the Mediterranean (135. Wood (223) summarizes of the studies of cultural practices. In addition.FU BERLIN on 04/14/09. most of themnondeliberate. Medicalanthropologists and geographers( INFECTIOUS DISEASE 101 Annu.annualreviews. 92) workingin this region have provided rich reports of the interactions between humansand their dogs. and the use of thick blankets and netting Africa (163). Of particular interest from the standpoint of echinococcosis transmission are the women’s "nurse dogs. Echinococcosis and companiondogs Echinococcosis (hydatid disease) is life-threatening parasitic infection transmitted from domesticatedlivestock to dogs to humans. These and other traditional behaviors based on the folk theory of miasma probably had preventive effects. Geneticadaptations to this disease havemerited particular interest.

197. and highly mobile. 176). 97. a small number of prostitutes have sexual relations . 146. 81. served to diminish the chances of schistosomiasis transmission. constitute the major reservoir of sexually transmitted infection. 1990. and the uneven distribution of economicopportunities--migrate to cities. Namely.annualreviews. a numberof other investigators in Africa have studied howindividuals became infected through water-contact activities (47. Sexually transmitted diseases (STDs) and labor migration The crucial role of humanbehavioral factors in the dissemination of sexually transmitted diseases (STDs) has been knownfor hundreds of years and is a reason why these conditions were dubbed"social diseases. Since by WIB6013 . brothels. Downloaded from arjournals. rapid modernization. Rev. Much less attention has been paid to ways individuals infect water through urination and defecation into waterways. presumably owing to the frequent Islamic practice of wudu. The typical pattern of transmission included the following components:Young menfrom rural tribal areas--areas plagued by political upheaval. 72. Cheesmond & Fenwick (38) showed that excretory behaviors in an area of the Gezira. characteristically. wherethey makeup the clientele of prostitutes operating from bars. and the street. primarily gonorrhea. 173. a number of behaviorally oriented researchers workingin that region (7.19:89-117. dance-halls. Anthropol.219) noted the roles of rural-to-urban migration and prostitution in the transmission of STDs. The risk of STDtransmission is even further increased when menmigrate to isolated labor camps and mines where. uneducated. Prior the recognition of AIDSas a widespread problem in sub-Saharan Africa. privacy being a more important consideration than proximity to water for purposes of ablution. 102 INHORN & BROWN Annu. For personal use only. They noted that schistosomiasis was more prevalent amongMuslims than amongChristians.annualreviews. 142. 49. 143. This need has been mademore urgent by the appearance of AIDS during the past decade (13. These prostitutes. The most extensive single investigation of water-contact behavior was carried out in Egypt. whoface the same economicpressures as the males and are mostly young (aged 15-30).FU BERLIN on 04/14/09. 84.Annual Reviews www. 192). occupational. they observed that excretory episodes occurred in sites far removed from bodies of water. 127. where Farooq and associates (77-80) performed elaborate observational studies of the daily social." However. the need for social scientific studies of the behaviors placing individuals at risk from STDs--and of the sociocultural determinants and consequencesof those behaviors has only been recognized recently.and religious uses of water in a Nile Delta village. WHO (225) has advocated and supported numerous water-contact studies throughout the world. ruralborn. 15. the parasite and in its transmission to humans.Becauseof the importanceof water contact in schistosomiasis transmission. or ritual ablution before prayer. unemployment. unmarried (often as the result of abandonment by nonreturning migrant husbands).

It is impossible to overemphasize the impact of this cycle of STDtransmission on the serious sociomedical problemof infertility in these populations (169).19:89-117. 199). on the other hand.. initial reaction to the epidemicin the gay community was denial.FU BERLIN on 04/14/09. For personal use only. In Africa (a) the infected populationcomprisesprimarily heterosexuals. the severity of the AIDSepidemic was deemphasized in the interest of preserving the sexual values and institutions that represented the successful political struggles of gay liberation (97. including HIV. these menreturn to their natal towns and villages. they are nevertheless limited in their utility if they do not proceedbeyond the observational level. Downloaded from arjournals. Ethnomedical and Cure Beliefs Regarding Etiology. 97. however. wherethey infect their regular sex partners. Annu. (b) prostitution plays a dominant role in the transmission of the human immunodeficiencyvirus (HIV). 183. usually their wives. and (c) the epidemiology of the disease largely explained by economicinfluences on male labor migration patterns (155). 209). AIDS and sexual behavior The above-described pattern of STDtransmission is also responsible in large part for the rapid spread of AIDS in subSaharan Africa and is a primary reason whythe epidemiological profile of AIDS in Africa is radically different from that in the United States (81. these urban epicenters had already had a high prevalence of STDsamong gay and bisexual populations. especially amongthe more sexually active menin the so-called "fast lane" (97. In the United States. prostitution. Any effort to change human behavior must rest on such studies. Since the early 1970s. By the mid-1980s. Anthropol.annualreviews. "A further series of studies. 148). 175. Uponaccumulating sufficient wealth." Dunn’scall for by WIB6013 . Diagnosis. 133. especially by reducing the number of casual partners (36). will be needed in each situation to specify whypeople behave as they do. and STDhas been recognized in other areas of the nonindustrialized world as well (106. This triad of migration. manygay and bisexual menbegan to modifytheir sexual behavior.Annual Reviews www. Among these institutions. in urban gay centers (209). early cases of the disease were reported almost exclusively amonggay and bisexual menin NewYork City and San Francisco (48). where and INFECTIOUS DISEASE 103 with a large number of men (155). 155). 1990. When AIDSappeared in the United States in the early 1980s. As Dunn(62:503) has cautioned in his discussion of schistosomiasis and water contact. whomaybe rendered infertile as a result of STD-induced reproductive pathology. RESEARCH NEEDS Although behavioral studies of the kind cited above can provide useful information on infectious disease transmission. the extent of this behavioral change toward "safe sex" is remarkable. Rev.annualreviews. bathhouses (and the sexual behaviorsthey encouraged) particularly facilitated the transmission of STDs...

Nation’s (184) recent survey of the literature revealed that ethnomedical studies of lay recognition. Nations (184) argues that traditional "folk beliefs. (b) detection morbidity and establishment of accurate attack rates. the intermediate host of the parasite. of whymore children with severe diarrhea and dehydration are not brought to physicians sooner. cultural.FU BERLIN on 04/14/09. For personal use by WIB6013 . including indigenousbeliefs about etiology. a numberof examplesof which are included here. Rev. anthropological studies that answer the . such as (a) underreporting of infant mortality. Nations concludes that the beliefs of poor Brazilian mothers regarding the recognition. 109. (c) identification high-risk populations.Annual Reviews www. and treatment of infectious diseases are evenrarer than behavioral studies.annualreviews. When infected individuals step into waterways. Yet.annualreviews. 104 INHORN & BROWN Annu. (d) identification of behavioral risk factors. Downloaded from arjournals. Theseissues are apart from that raised by frustrated physicians. the female worms vomit their eggs into the water via small ulcerations on the infected individual’s skin (114). Anotherexampleof the importanceof ethnomedicalbeliefs for the successful treatment of an infectious disease is provided by the work of Kendall and coworkers(137) in Honduras. information of this sort is of the utmost importancein ensuring the success of public health efforts.19:89-117. Anthropol. They showedthat diarrhea thought to be caused by the folk illness empacho was consistently not treated with oral rehydration therapy. in part becauseof the entrenchedbelief in the biomedicalcommunity that indigenous beliefs and practices are irrelevant to the problem at hand. 184)." disdained by the epidemiologists and biomedicalpractitioners working in this area. etiology. 1990. and cure--has been reiterated by a number of other anthropologists (33. If water fleas. she demonstrates. and treatment of childhood diarrheal illnesses are the key to this problem. and (e) generation of testable analytical epidemiologicalhypotheses. are present they becomeparasitized and . Dracunculiasis and contaminated water Dracunculiasis (guinea wormdisease) is a parasitic disease characterized by the presence of long adult worms in subcutaneous tissues. Diarrhea and folk beliefs In her study of indigenous beliefs surrounding infant diarrhea in northeastern Brazil. could not be morerelevant to controlling this widespread problem. and psychological correlates of human behavior relating to infectious disease. since empachowas thought to warrant a purgative cure. usually of the leg. etiology. RESEARCH EXAMPLES The need for such information becomes clear in the literature on ethnomedicineand infectious disease. diagnosis. when the chances of saving them are greater.Thesebeliefs. are intimately tied to epidemiological issues.all-important "why"question--by identifying the social.

the biomedicalconnection among brush. and the necessity of controlling it by slashing brush near streams to eliminate fly breeding areas. Furthermore. the British colonial government attemptedto rid the tribal Hausapeoples of northern Nigeria of the often fatal disease through efforts by biomedical personnel to explain the nature of the disease. whichthey attributed to spirit possession. its transport by by WIB6013 . studies (74. 188). In short. and sleeping sickness never successfully replaced the Hausa’sindigenous beliefs about the etiology of the illness. Some of these medicinal plants have been shownto change the oxidation-reduction status of red blood cells. transmit disease to humans. African trypanosomiasis and brush removal Another example of the need for ethnomedicalstudies revolves aroundAfrican trypanosomiasis. 76) have identified 31 antimalarial plant medicinesused by either herbal specialists or the general population. few individuals thought the disease was preventable or were aware of the modeof transmission of the parasite through contaminateddrinking water. Rather. efforts to prevent secondary infections in dracunculiasis ulcers.FU BERLIN on 04/14/09. whoingest them while drinking. dracunculiasis has been targeted by a number of international agencies. and the Hausawere convincedto slash the brush once a year. 74).annualreviews. as Miner (178) explains. including the UN. the disease was attributed to heredity. parasitological tests of ex- . thereby virtually eliminating the disease. Rev. or even the god of smallpox (2). in fact. Malaria and traditional medicines and foods Other researchers working amongthe Hausa have examinedtraditional means by which they have coped with malaria. Anthropol. WHO. However.19:89-117. Dracunculiasis is. Becauseof the importance of water in the transmission cycle.Annual Reviews www. For personal use only. But. the Hausareplied that they were forced to do so. Downloaded from arjournals. some of which exacerbated the dracunculiasis woundsor prevented healing (73. the Hausarefused to believe that brush was related to the illness. a significant cause of absenteeism in schools and agricultural settings throughout West Africa (126. 1990. and the World Bank. as the primary focus of their International Drinking Water Supply and Sanitation Decade(1981-90)(152). a physiological condition known to impededevelopmentof the malaria parasite (71). The control programwas eventually carried out by force. flies. the only infectious disease that could be completelyeliminated if all populations living where the parasite is endemicwere provided with---and used---safe drinking water (113). Etkin & Ross ( INFECTIOUS DISEASE 105 Annu. But. and many people wantedto discontinue the practice. despite eradication efforts. or "sleeping sickness. person-to-personcontact.annualreviews. transmission throughsoil or blood.220) carried out in villages Ghanaand Nigeria--wherethe disease has been called the "annual festival of agony"--showed that. were hampered by local methods of treatment. whenasked later why they cut the brush. In addition." In the 1930s and 1940s.

in China. 166). Such biochemical evaluation native ethnopharmacopoeias for the effectiveness of antimalarial treatments." whowere brought into programs following negative community responses. using a mousemodelof malaria. in dietary studies from Liberia. and blood-letting from the temples to let the "bad blood" out of the inflamed 106 INHORN & BROWN Annu. has gained added significance with the evolution of chloroquine-resistant strains of the disease.Annual Reviews www. Medical anthropologists workingin rural Egypt where the disease is endemic have examinedthe behaviors that place individuals at risk of trachoma(153) and described the traditional beliefs and practices surrounding eye disease in general and trachomain particular (177). 1990. whohas examined Liberian mothers’ folk classification of malaria symptoms (128). Local Responses to Infectious Disease Control Programs Giventhe small size of the discipline of anthropology.artemisinin.FU BERLIN on 04/14/09. whichhas its historical roots in the discovery of quinine.annualreviews. Downloaded from arjournals. extracted by chemists from a traditional antimalarial treatment (quing hao. dating back in somecases to Pharaonic times. Millar &Lane(177) showed that Egyptian villagers had a complex repertoire of "ethnoophthalmological" practices to treat trachoma. or "green herb. Rev. This was .19:89-117. because of the minute amounts of lethal cyanide contained in traditional cassava foods (unpublished manuscript). tracts of these traditional medicines. In addition. has hypothesized that regular cassava consumption may curtail parasite growth and development in humans. Lane & Millar argued that decisions to use traditional or biomedical treatment dependedmore on the individual’s status in the family or community than on belief in traditional-vs-biomedicaletiologies of the disease (154). Asa result. Trachoma and ethno-ophthalmological practices Trachoma. including mineral substances applied to the eyelids. showed that three of the substanceswere highly effective cures. Thesepractices can all be traced to earlier literate medical systems in Egypt. Similarly. particularly adult women and by WIB6013 . For personal use only. Anthropol. anthropologistsservedas cultural interpreters and "troubleshooters. is a bacterial eye disease whose transmission is highly dependent on individual and community hygiene (for comprehensive review of social factors relating to trachomatransmission. the leading cause of preventable blindness in the world. surgical curettage of the inner surfaces of the eyelids with a razor blade. has recently been identified (139). its contributions to international health and disease control programshave been significant (216). Jackson. were more likely to receive less highly valued traditional remedies~espite their elevated risk of trachoma and (amongwomen)blindness." related to Artemisia annua). In their early role in such efforts. see 165. a promising compound. Anthropologists demonstrated that public health interventions succeeded first by being acceptable to the public. individuals with less social status.annualreviews.

Of particular interest is the "checklist" of reasons for low immunizationcoverage developed by Brown (25). This remarkable accomplishmentof international public health involved minimal anthropological expertise--namely. Foster & Deria (88) veloped a culturally acceptable method of case isolation amongSomalian pastoralists by adapting a traditional technique used for sick camels. (c) the fallacy of the single pyramid. Thus. following epidemics in the 1940s (117.where recognition of differences in community organization. was hindered by the fact that villagers had their own ideas. Towardthe end of the eradication effort. Theoretically. Downloaded from arjournals. for mostvillagers.annualreviews. Heggenhougen & Clements (107) have summarizedmore recent applied anthropological work on the effective delivery of immunizations. provided important case studies of communityreactions to health programs." The tradition of ethnographyapplied to the critical analysis of international health programsis best exemplified by the recent work of Justice in Nepal (132). This recognition was basedin part on Polgar’s (194) insightful analysis of "four fallacies" afflicting international public health endeavors: (a) the fallacy of empty vessels. 1990. Foster.19:89-117.Annual Reviews www.annualreviews. For example. Culture. in BangChan. Thailand.and (d) the fallacy of interchangeable faces. cultural values. and preexisting health beliefs was critical. Health." about the cause of the outbreak. and Community (189). Similarly. . INFECTIOUSDISEASE 107 especially important in international programs. Rev. only a handful of villagers availed themselves of diphtheria immunization. whohad muchexperience in such work (85-87). Such an outcome has been achieved for only one disease--smallpox--through a coordinated. part of the early anthropological contribution to infectious disease control programsinvolvedidentifying social and cultural "barriers" to locallevel acceptance of innovations. both "scientific" and "magicoreligious. it includes behavioralattributes of both the participating populationand health providers. most of which involved infectious disease prevention or control. warned of the danger of inappropriately blaming"culture" for failures caused instead by the attitudes and behaviors of health care planners and providers (85). Suchcritical questioning of the intellectual premisesunderlying both biomedicine and the organization of health care probably played a role in the developmentof "critical medical anthropology. the ultimate goal of infectious disease control programsis the reduction of disease transmission to the point wherethe disease organism becomeseradicated. (b) the fallacy of the separate capsule. Paul’s edited by WIB6013 . Morinis’s assessment of the flow of smallpox case-detection information in rural markets in India (180). Annu. global effort completed in 1978 (116). 118).FU BERLIN on 04/14/09. For personal use only. because the channels of communication used by public health workers never reached the majority of the rural populace (103). Following initial anthropologicalactivity in international health programs. a cholera vaccination program in China. prevention did not involve acceptance of an injection.

tea pickers actively opposedthe programbecause of its dull routine and focus on what they deemed an unimportant problem (190). has encouraged the treatment of traditional sleeping nets with residual insecticides. a malaria control program using insecticide spraying in Surinam met resistance from local populations. Widespreadmedical anthropological interest in primary health care (PHC) (19)--including such key strategies as oral rehydration therapy (44)---is. 125) and malaria (105) appeared.Annual Reviews www. Various programs to eliminate hookworm (63. 87. Gordon’s survey demonstrated significant changes in people’s explanatory models of dengue. fact. by WIB6013 .FU BERLIN on 04/14/09. Downloaded from arjournals. this is an area where anthropological research contributions will be especially critical. An exampleof the latter approach is provided by the work of Gordon (96).19:89-117.annualreviews. who examined the causes and local perceptions of the vector-borne disease denguefever in an urban area of the Dominican Republic. the people’s point of view. Brown (28) has described approachas the anthropologyof disease control. Annu. Sudan(98). vertically oriented disease control strategies. CONCLUSION: THE IMPORTANCE AND LEGITIMACY OF INFECTIOUS DISEASE RESEARCHIN MEDICAL ANTHROPOLOGY Anthropologicalstudies of infectious diseases comprise an impressive literature characterized by a broad range of theoretical paradigms and research . More recently. economic. Because PHCrequires more community participation and adaptation of culturally acceptable and affordable health technologies than did the older.annualreviews. MacCormack (163). Far frombeing grateful to public health workers. control programsaimedat reduction of a single disease identified by outsiders can meet with resistance from local populations. In the tea plantations of Ceylon. Likewise. For personal use only. the Rockefeller Foundation’s 6-year programto eliminate hookworm through treatment and installation of pit latrines wasa failure. reasons for the reluctance ranged fromfear of the insecticide and its effects on animals and local gods to disbelief about the relationship between mosquitoes and malaria (12).org/aronline 108 INHORN & BROWN Yet. and Sri Lanka(31). Sardinia (29). since these researchers view health improvements as the result of outside influences on social and cultural change. too concentrated on a seemingly minor health problem. and cultural effects of successful malaria control in such locations as Mexico(108). As part of a mixed-strategy intervention program. although such changes were not accompaniedby a reduction of sources for the mosquito vector. In addition to direct participation in malaria control programs. 85. This approach contrasts with the application of anthropological knowledge in disease control programs. 1990. aimed primarily at the reduction of infectious disease morbidity and mortality. Anthropol. someanthropologists have focused on the demographic. Aedes aegypti. whohas workedin malaria control activities in Africa.

however.that they should be limited to that paradigm. biomedicine is predicated upon culturally limited assumptions about fundamental categories like "causation" and "disease". are receiving less than adequate attention from researchers. ecological. As such. culturally codedbehaviors provide critical clues for understandingthe social epidemiology and potential control of such diseases. Wehave examinedthis rich body of research. Second. Note that research related to the interaction of humans and infectious disease agents is not limited to medical anthropology. 2. For personal use only.annualreviews. And. anthropological research in infectious disease reemphasizes the Annu. Anthropol. that because all reality-including the processes of sickness and health--is socially constructed.FU BERLIN on 04/14/09. applied medical anthropologists must be equipped to workwithin the biomedical paradigmif they hope to be effective in improving infectious disease control programsor health care by WIB6013 . ethnomedicine. but they do not contradict the basic findings of the literature described here.the distribution of infectious diseases is significantly influenced by human actions that affect ecology. and 3. Rev.finally. Nevertheless. the diseases described above or epidemiological concepts) have been "coopted" by the intellectual hegemony of Westernbiomedicine. The origins of this suffering must be analyzed from both micro. . Third. First. In recent years. while still prominent in teaching texts (168). In fact. Conceptssuch as adaptation to disease. including the political-economicone. and sociocultural. since infectious agents makeup an important part of that ecology. Indeed. A focus on infectious disease requires us to bridge the gap betweenthe cultural and biological subfields and to return to a holistic perspective. which are not altogether new. that diseases are only the proximatecauses of human suffering. since the ultimate etiologies involve political and economic inequality (the so-called "political economyof health").and macrosociological INFECTIOUS DISEASE 109 methodologies. many medical anthropologists have abandoned the research directions described in this review. These criticisms. the charge has been made that medical anthropologists whoutilize biomedical categories (e. this subject requires discussion of classic research questions in biological anthropology. Even worse. Downloaded from arjournals.Annual Reviews www. cultural ecology. which does not advocate an unquestioning acceptance of biomedicine. archaeology. there are four reasons whymedical anthropologists in particular should pay increased attention to infectious disease research.19:89-117. and applied anthropology in international health. that the institution of biomedicine itself functions to maintain social inequalities. have merit. This accusation by critical medical anthropologists has three basic elements: 1. infectious diseases have acted throughout human history as important agents of selection for both biological and behavioral characteristics of the species. infectious diseases represent the most important cause of suffering and death in societies traditionally studied by anthropologists. 1990. categorizing it accordingto three basic orientations---biological.g. This does not imply.

BioScience 157:6386..FU BERLIN on 04/14/09. 1975. Red Mites and Typhus. Basch. New York: Columbia Univ. 1947. Changingpersonal and social behaviour: experiences of health workersin a tribal society. N. J. R. J. S. London: Athlone Press 10. Press 15. and applied issues in the anthropologicalstudy of infectious disease have been an inspiration. Evolutionary response to human infectious diseases. ed. Guinea worm control: testing the efficacy of health education in primarycare. Y. H. R. Anthropol. Blangero. J. by WIB6013 . Akpovi. 1990. The P blood group system: genetic adaptation to helminthic zoonoses. Reid. O. 6:57-69 110 INHORN& BROWN long-standing claim of medical anthropology that culture "manufactures" disease in two ways. 1970.. 1971. C. Ackerknecht. Protection afforded by sickle-cell trait against subtertian malarial infection. Press 4. InrernationalHealth.Annual Reviews www. 71-84 7. Vener. A. Measurementand diagnosis of health. Dewey. pp. P. Arya. Dada. D. In Anthropology Today: An Encyclopedic Inventory. Taber. J. Introduction (Anthropology and primary health care . Br. Johnson. M. A. Boston: Houghton-Mifflin 11. L. Black. First. I. Infectious diseases in primitive societies. Dunn. W. J. J. L. Audy. As students and interpreters of societies and cultures. 1953. Miller.. See Ref. C. Dis. A. Jacobs. S. 1973. The Ranks of Death: A Medical History of the Conquest of America. R. McKinley. C.. R.. S. H. A. Annu. F. 1980. Br. Elegba. 59:202-5 16. See Ref. ed. Anthropol. P. Med.annualreviews. Black. Rev. J. R. Alland Jr. C. J. Adaptation in Cultural Evolution: An Approach to Medical Anthropology. C.. Grabumand James Andersonfor reviewing an early draft of the manuscript.ed. In AIDSin Africa: The Social and Policy Impact.19:89-117. WHO 49:587-95 8. R. F. C. Downloaded from arjournals. pp.A. L. Clinical. ACKNOWLEDGMENTS Weexpress appreciation to Frederick L. B. Bull.culture provides a theoretical system for understanding--and attempting to manipulate through medicine--the diseases that cause humansuffering and death. For personal use only. J. Jenkins. H. Rockwell.. In Human Ecology. and P. methodological.. M. Barton. U. NewYork: CowardMcCann 9. 1981. NY: Edwin Mellen Press 14. ed. D. pp. Literature Cited 1. 1:29094 5. 1954. Shepard. S. thanks Eric Johnsonfor bibliographic assistance. O. who reviewed and revised earlier drafts of this manuscript and whoseinterests in theoretical. 1988. D. P. Paleopathology. J. S. P. 24:229-37 3. 214. Bloom. Goodman. Kroeber. Health Ed. Nsanzumuhire. thanks Nelson H.. Bello. Sexually-related illness in Eastemand Central Africa: a selected bibliography. 1978. L. T. Chicago: Univ.annualreviews. pp. societies actively change their ecology so as to increase or decrease the risk of particular diseases. Second. 1978. Brieger. G. J.. Science 187:515-18 17. 1982. because coping with themis a universal aspect of the humanexperience. cultural. Audy.. 1968. Sci. 120-26. In Environ~mental: Essays on the Planet as a Home. and demographic aspects of gonorrhoea in a rural communityin Uganda. F. NewYork: Oxford Univ. E. Allison. 1972. pp. R. anthropologists cannot afford to ignore the infectious diseases. Sargent. 1983. T. 26%91. G. Dunn. 325-43. Audy. Health and disease. Int. Med. D. Chicago Press 2. H. Med. Lewiston. Armelagos. R. 1974. 140-62. 37-54 18... J. 1970. Sexually transmitted diseases in northern Nigeria: five years’ experience in a university teaching hospital clinic. F. pp. Soc. NewYork: North Holland 12. 6:1-15 13. Ashbum. 162. Armelagos. K. Barnes. 1984.

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