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Tropical Medicine and International Health

volume 3 no 12 pp 1020–1027 december 1998

Applying medical anthropology in the control of infectious

disease
Lenore Manderson

Australian Centre for International and Tropical Health and Nutrition, The University of Queensland, Australia

Summary This paper focuses on two roles of anthropology in the control of infectious disease. The first is in
identifying and describing concerns and understandings of disease, including local knowledge of cause and
treatment relevant to disease control. The second is in translating these local concerns into appropriate
health interventions, for example, by providing information to be incorporated in education and
communication strategies for disease control. Problems arise in control programmes with competing
knowledge and value systems. Anthropology’s role conventionally has been in the translation of local
concepts of illness and treatment, and the adaptation of biomedical knowledge to fit local aetiologies.
Medical anthropology plays an important role in examining the local context of disease diagnosis, treatment
and prevention, and the structural as well as conceptual barriers to improved health status. National (and
international) public health goals which respect local priorities are uncommon, and generic health goals
rarely coincide with specific country and community needs. The success of interventions and control
programmes is moderated by local priorities and conditions, and sustainable interventions need to
acknowledge and address country-specific social, economic and political circumstances.

keywords anthropology, public health, infectious disease, sustainable intervention

correspondence Professor Lenore Manderson, Tropical Health Program, Australian Centre for
International and Tropical Health and Nutrition, University of Queensland Medical School, Herston Road,
Herston QLD 4006, Australia. E-mail: l.manderson@mailbox.uq.edu.au

public health scholars in anthropological methods and

Introduction
Historically, anthropologists have always been interested in
health and illness, diagnosis and healing and death and dying.
This has been both as a consequence of the discipline’s wider
concerns with the management of crises and the search for
causality in everyday life, and due to the role of science,
religion, magic and ritual in protecting community welfare
and ensuring continuity through generations. While medical
anthropology as a discrete subdiscipline has a briefer history,
its genesis is tied to anthropology’s most fundamental
questions of social and cultural life.
Anthropological interest in infectious disease control is, by
contrast, relatively recent. The expanding range of specializ-
ations within medical anthropology has occurred partly due
to continuing anthropological curiosity about the natural,
biological and cultural worlds and their intersections. The
focus on particular illnesses, including infectious diseases, has
led to the exploration of various theoretical interests. The
interest in infectious disease follows from anthropology’s
professionalization as an applied science, the interest of other
theories, and the involvement of anthropologists in inter-
national health programmes of multilateral organizations
and bilateral aid programmes. The increasing presence of
anthropology within WHO programmes is an example here
(Gove & Pelto 1994; Vlassoff & Manderson 1994).
Practically, the failure to contain various infections bio-
logically or environmentally, and the continued lack of
comprehensive and enduring technical programmes leave us
with health education and related behavioural interventions
as the primary means to limit disease and reduce mortality.
This emphasizes the need to understand better the roles of
human behaviour and social structure in the transmission of
infections, and to analyse the difficulties in introducing and
sustaining interventions for prevention or treatment.
Belief, anthropology and public health
In his critique of developments in medical anthropology,
Byron Good (1994) problematized the role of medical
anthropology in public health. In most intervention-driven

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L. Manderson Anthropology in infectious disease control
medical and public health programmes, he argued, scientific
medical knowledge is positioned as superordinate to folk
beliefs, constructing in the medical as in other domains a
hierarchical relationship between cosmopolitan and indigen-
ous knowledges, right and wrong, science and magic, myth
and truth. This juxtaposition of knowledge/belief, truth/myth
underpins various models of health behaviour and
behavioural change. This includes the Health Belief Model,
which remains the predominant conceptual framework
determining health education and promotion and which takes
as axiomatic the linear relationship of knowledge to
behaviour. Accordingly, public health programmes aim to
replace ‘false’ beliefs with ‘accurate’ knowledge, and by
changing community knowledge, it is assumed, behaviour
will also be changed. Consistent with this assumption, a
major social science component of disease control has been
to document knowledge, attitudes and beliefs, either through
ethnographic interviews or surveys, with the aim to adapt
national or multinational interventions to suit local settings.
Good acknowledges the tensions that exist for
anthropologists. Institutions that are responsible for policies,
resources and programmes to improve people’s health enjoy
the power and authority that privileges their knowledge over
those of their subjects. Public health institutions determine
the means by which good health might be attained, and
anthropological knowledge feeds into this process. For many
anthropologists, however, there is considerable unease in
documenting behaviour and beliefs assumed to contribute to
disease and ill health, in isolation from the social, economic
and political contexts. But pragmatic, humanistic and ethical
considerations confuse the case. The applied anthropological
involvement in public health and other public interest
programmes is also motivated by a commitment to minimize
suffering, and although various local remedies may be
effective in preventing infection or reducing distress, the
pragmatic position which most anthropologists adopt is to
facilitate access to known, effective interventions – antibiotics
for bacterial infection, multidrug therapy to treat leprosy,
early diagnosis and appropriate treatment of malaria, and so
on. As Wall (1995) argues, shamans’ songs cannot treat
obstructed labour; neither, in the context of this paper, do
they prevent pneumonia, malaria or dengue fever.
Rapid anthropological asessments
Anthropologists conventionally conduct extensive field
research to contextualize human behaviour and specific
beliefs and values. This has been modified over the past
decade, as a result of changes in the careers and employment
of anthropologists as consultants, in such areas as policy and
programme development, monitoring and evaluation, health
communications, and so on, where there are typically explicit
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volume 3 no 12 pp 1020–1027 december 1998
demands for ‘deliverables’ and ‘products.’ Consultancy work
– for private organizations, government contractors and
nongovernment organizations working in development – in
particular demand that anthropologists take short-cuts in
their research, temporally and methodologically, while
maintaining the methodological mix that has characterized
conventional ethnography to allow maximum internal
validity through triangulation (Brewer & Hunter 1989;
Brannen 1992; Breitmayer et al. 1993).
The adaption of anthropological techniques to fit
contractual and logistic constraints (Manderson & Aaby
1992a, 1992b; Beebe 1995; Bennett 1995) is somewhat
problematic. Anthropologists working in infectious disease
control have been particularly exercised to clarify and adapt
the methods and techniques of anthropology to allow ‘rel-
evant’ data, however defined, to be collected, which might
then provide the informational basis for the development of
policy, programmes or specific interventions. Often,
particularly in poor country settings and with respect to
infectious disease control, this collection of data takes place
in localities and under circumstances without trained
anthropological or other social science expertise, hence the
need for a simplified approach to collecting social
information. The cost of this approach is the loss of
contextual information, and the probable oversimplification
of behaviour due to the brevity of fieldwork and the lack of
participant observation which enhances, and indeed is the
one means to ensure, validity of data.
Other public health researchers within epidemiology,
health education and communication, demography, health
economics and so on, however, have incorporated
anthropological techniques such as in-depth interviews and
focus groups, placing anthropologists in competition with
other professionals and demanding that they exercise
efficiency in their work. This has made it important for
anthropologists to be explicit about their methods and
techniques.
Over the past 15 years, manuals, handbooks and field
research protocols have been developed to facilitate the
application of anthropological techniques, interests and
concepts to applied research. This paper draws substantially
on my own experience in designing rapid assessment manuals
and approaches in infectious disease and other health-related
areas, including with respect to malaria (Agyepong et al.
1995), hygiene and sanitation (Almedom et al. 1996a), food
safety (unpublished, in collaboration with P. Desmarchelier),
reproductive health (Manderson 1997a, b), STDs and
HIV/AIDS (Aboagye-Kwarteng et al. 1997; Larson &
Manderson 1997), and mental health (Larson et al. 1997).
Many of these have been concerned with infectious disease,
where the impetus has been to provide road maps to the
collection of data that can be quickly fed into control
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programmes or related interventions. The work undertaken
in water and sanitation programmes, diarrhoeal disease
control and respiratory infections, malaria and other vector
borne diseases, as well as especially HIV/AIDS, are cases in
point (Scrimshaw and Gleason 1992; Manderson et al. 1996)
For manuals and articles pertaining to these fields, see inter
alia Scrimshaw and Hurtado (1987, 1988), Bentley et al.
(1988), Manderson and Aaby (1992a, b), Gove and Pelto
(1994), Helitzer-Allen and Allen (1994) and Nichter (1994).
To date, there has been neither evaluation of rapid
assessment sampling procedures and the manuals, nor of
their role in collecting information for applied health
interventions or by control programmes. The exception is
Kate McIntyre’s study of fertility control and contraceptive
behaviour, which compares data collection by rapid
assessment sampling with hand-held computers, with
conventional sample survey procedures (Manderson 1997a;
McIntyre 1998).
The manuals often make explicit the need to describe and
analyse the broader social, economic and cultural context in
disease-based research, but there is no way that
anthropological sensibility – theories and concepts, analytic
approaches and anthropological imagination (Dimen-Schein
1977) – can be collapsed into this same format. Hence more
conventional anthropology remains important to generate
baseline information and to monitor changes in the
transmission, prevention and treatment of disease.
Ethnographic research within the context of rapid assessment
procedures is a valuable means to understand behaviour and
action.
Local taxonomies and aetiology
For a number of infectious diseases including diarrhoea, ARI
(acute respiratory infections) and malaria, early diagnosis
and treatment is critical in reducing mortality, and social
science as well as applied clinical research has concentrated
on this (Gove & Pelto 1994). This research has had two
purposes: identifying the factors that influence people’s
ability to diagnose illness and/or to distinguish minor
ailments from life threatening disease, and the factors that
affect people’s preparedness to use biomedical services and
adhere to prescribed treatment. In this context,
anthropological research has documented different
modalities, therapies and folk aetiologies of illness,
recognition of signs and symptoms and their congruence
with biomedical categories and patterns of use of healers and
health services, as well as compliance with treatment and
disease prevention interventions (Helitzer-Allen et al. 1993).
Ethnographic research to reduce pneumonia deaths
provides a useful example. Cough is the entry point for WHO
treatment algorithms (Gove & Pelto 1994). The caretaker’s
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knowledge of cough is her own starting point for response
which, to reduce severe morbidity and mortality, requires a
mother to calibrate information about the cough with other
signs – particularly fast breathing and chest indrawing – to
ensure timely treatment of the sick child. Several studies have
now drawn attention to the importance of local
categorization of cough and the role that this plays in
determining treatment strategies by caretakers. In the
Philippines Nichter (1994) and others (McNee et al. 1994;
Simon et al. 1996; Tallo 1996) have described the particular
importance of folk categories in delaying biomedical
treatment. A child’s cough may be a sprain (i.e. piang) and
this demands that the mother take the child to a local healer
for confirmed diagnosis and treatment (by massage) before
alternative paths are pursued. This occurs although people
differentiate between numerous types of coughs and degrees
of severity on the basis of cough type and/or additional
symptoms, allow for a wide range of aetiological agents
(natural and supernatural), and follow highly individualistic
patterns of resort to care (McNee et al. 1994; Tallo 1996).
Circumstantial factors such as access to cash and transport
complicate timing of care-seeking (Simon et al. 1996), but
still piang is one of the major reasons explaining why women
with sick children present to clinics relatively late.
Prevention of infectious disease and change of behaviour
The prevention of infectious disease is complex, and for only
a few diseases, such as smallpox and polio, is an effective
vaccine available and easily delivered. The complexity derives
from the mix of circumstances that affect transmission:
environmental, financial, structural, infrastructural, and
behavioural. For example, the prevention of water-borne and
water-wash diseases can be achieved with the introduction of
water safety, sanitation and hygiene procedures (Boot &
Cairncross 1993). Successfully introducing and sustaining
behavioural change is not so simple, however: the
interventions require substantial financial investment for
water and sanitation infrastructure, and major health
education campaigns to encourage people to use latrines at
all times, to wash hands after the use of latrines, before
preparation of food and eating, and after handling material
that might be contaminated. Yet this is still too simple. In
poor communities, individual household latrines may not be
affordable, and communal latrines may cease to be used
because they are poorly maintained, smell and are
surrounded by flies; insufficient taps may be provided, taps
may be placed in inconvenient locations, or people may
maintain a strong preference for flowing river water over tap
water; notions of hand washing vary and the action is not
always sufficient to reduce bacteria; household animals and
children may continue to pollute the environment and
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themselves; fuel may not be available in sufficient quantity for
cooking or cleaning utensils and the safe preparation of
foods; there may not be appropriate ways to store food to
avoid contamination after preparation; householders may
lack sufficient time to adhere to the wide range of actions
required to ensure hygiene; and so on (see Almedom et al.
1996a, b). Cultural values related to pollution, hygiene and
domestic duties shape these behaviours that are associated
with infection.
A specific example of the difficulties in prevention is from
the public health work to prevent opisthorciasis, a liver fluke
(Opisthorcis viverrini) infection of approximately 7 million
people in north-east Thailand and Laos. The life cycle in-
volves snail and fish intermediate hosts with the adult liver
fluke inhabiting the biliary system of the final host (human or
other fish-eating mammal). People acquire the infection
through the consumption of encysted metacercariae within
the muscle tissue of raw or undercooked fish, which is eaten
frequently in the form of fermented fish sauce (pla-ra) and
raw fish (koi-pla) (Sornmani et al. 1986; Preuksaraj 1984;
Harinasuta & Harinasuta 1984). Public health education
programmes commenced in 1953 to discourage the
consumption of raw or undercooked fish by drawing
attention to the association between fish consumption and
associated illnesses. These education programmes raised
public awareness but have not greatly affected consumption
of raw fish and fish sauces, and 40 years on, levels of infection
and associated morbidity rates remain high. No systematic
anthropological research with respect to the infection, but
epidemiological and nutritional evidence suggest the
importance of social and cultural factors (Doherty & Posanai
1990). Seasonal availability of foodstuffs and limited cash to
purchase food, for example, influence the consumption of
raw fish within the village. The production and distribution
of pla-ra for home and commercial use increases particularly
during the dry season when villagers are subject to food
shortages and diet is often limited to sticky rice and pla-ra,
insects and other gathered foods. Class differences in
morbidity suggest also that poor people are more likely to
consume local fish-sauce before fermentation is complete, i.e.
when there are still viable encysted metacercariae in the
sauce. The disproportionate number of infected adult men
highlights the importance of the ritual and social
consumption of raw fish (and other raw foods), in particular
at drinking parties. Health education campaigns aimed at
reducing the consumption of pla-ra ignore the poverty of
people’s diets, and underestimate people’s resistance to what
is seen to be the imposition of central Thai values over local
traditions. In the short term, delayed diagnosis and treatment
increases the risk of transmission of disease and its severity
for the individual; in the long term, failure to follow the
protocol of early diagnosis and treatment leads to continued
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transmission of infectious disease and increasing possibility
of drug resistance. Malaria provides another illustration.
Research in The Gambia and subsequent work elsewhere in
Africa indicates the potential of insecticide-impregnated
bednets in reducing infection, morbidity and mortality from
malaria, especially in infants and young children (Greenwood
& Baker 1993). The task of encouraging people to sleep
under bednets to avoid mosquitoes is not unproblematic,
however, since people do not necessarily accept that malaria
is transmitted by mosquitoes, nor that mosquitoes are the
sole cause of disease. People may not be able to afford nets,
and may find sleeping under the nets too stuffy, smelly,
claustrophobic or too hot. Variability in local understandings
of disease and preventive practices, and variance in vector
habitat and behaviour, endemicity, and so on, further make
dependence on a particular intervention problematic.
To elaborate: research in eastern Ghana indicates that
people vary net use inter- and intra-seasonally and among
households (Gyapong et al. 1992). My collaborative research
conducted in urban Accra and the Greater Accra district in
Ghana highlights different uses of bednets according to
perception of mosquitoes as a nuisance, unrelated to
perceptions of their role in transmission of malaria, and
according to householders’ need for cash flow on an everyday
basis (Agyepong & Manderson 1998). In Tanzania, again,
people’s use of nets varies according to season, temperature,
and number of mosquitoes (Minja, personal
communication).
Yet even where communities do not accept the association
between mosquitoes and malaria, nor bed net use and
prevention of disease, nets have been introduced for their
other perceived advantages such as the reduction of bed bugs
and nuisance mosquitoes (Aikins et al. 1993; Klein et al. 1995;
Cham et al. 1996). This reinforces the often tenuous links
between knowledge and practice, and the need instead for
interventions to be easy to adopt, suitable to the local
environment and affordable. The development of effective
IEC (information, education and communication) material to
support these behavioural interventions, in turn, requires
good community-based data, as illustrated in Kenya where
the community education programme was developed on the
basis of extensive anthropological information and
community surveys of knowledge and perceptions of the
disease, ownership and use of nets, and sleeping patterns
within households (Mwenesi et al. 1995a,b).
Compliance with treatment
The difficulty in reducing transmission of infectious diseases
through behavioural interventions has reinforced the need to
continue to reduce severity of infection and risk of trans-
mission through early diagnosis and treatment. Poor
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adherence to medical advice has complicated this issue,
affecting the effectiveness of treatment at an individual level
and, both in the short and long term, the public health
benefits of the strategy. In the short term, delayed diagnosis
and treatment increases the risk of transmission of disease
and its severity for the individual; in the long term, failure to
follow the protocol of early diagnosis and treatment leads to
continued transmission of infectious disease and increasing
possibility of drug resistance.
Compliance has been a long-standing concern in clinical
research, and the need for anthropological input in different
cultural settings has to a degree been predicated on the
assumption that if people have adequate knowledge and
understanding of the rationale for a particular treatment,
consistent with the Health Belief Model (see above), then
they will adhere to the prescribed regime. In this respect,
there has been considerable ethnographic research on the
appropriate use of medication for illness treatment and/or
prophylaxis. Helitzer’s work in Malawi (Helitzer-Allen et al.
1993) is one practical example: women’s reluctance to take
malaria chemoprophylaxis during pregnancy derived from
their association of chloroquine, on the basis of its bitterness,
with abortifacients, thus suggesting to women that
compliance was to risk miscarriage. In this case the practical
outcome was to sugar-coat the pills. Work on women’s poor
adherence to treatment for leprosy, conducted in
Maharashtra, India (Vlassoff et al. 1998) revealed that the
blister packaging for multidrug therapy was sufficiently
similar to contraceptive pill packages that the drugs were
confiscated by unbelieving mothers-in-law.
Compliance appears particularly problematic where
regimes are drawn out, where doses for medication are
intermittent with long delays between administration (e.g.
ivermectin for the treatment of onchocerciasis), where there
are severe side-effects of the drugs causing confusion of their
efficacy (e.g. with leprosy, Srirak 1997), and where there is
rapid subsidence of symptoms well before the completion of
a course of treatment, as is often the case with antiobiotics
and antimalarials. Caretakers in Bohol, The Philippines, for
instance, tend to foreshorten courses of cotrimoxazole when
illness signs subside (Simon et al. 1996; Tallo 1996). Cultural
perceptions of medications may further influence compliance.
For example, people may classify medications as ‘hot’ or
‘cold’ in accordance with humoral theory, whereby their
acceptance of drugs is contingent on an appropriate fit of
disease and drug classification (e.g. Logan & Morril 1979;
Manderson 1987; Craig 1997). While people may recognize
the value of some western pharmaceuticals, this is not
equivalent to rejecting alternative medications and other
treatment regimes, and it is not unusual for people to
combine various therapies to maximize their chances of
healing. Medical pluralist practices are normal not
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exceptional regardless of culture, country, or social and
economic context.
The political economy of disease control
The foregoing discussion suggests that anthropological input
may clarify the cultural, social, cognitive and individual
factors which influence people’s willingness to accept inter-
ventions to reduce transmission of illness and adhere to
treatment regimes. But these factors alone are not sufficient,
and research conducted in association with the development
and assessment of interventions highlights the difficulty of
introducing behavioural and household changes in contexts
which lack the infrastructural, structural and political
support to sustain them.
First, health care involves more than the immediate costs of
a clinic fee and medication. The costs of drugs are a factor:
for praziquantel for schistosomiasis treatment (Huang 1997),
for antiobiotics for pneumonia (Simon et al. 1996), for
antimalarials (e.g. in Ghana (Agyepong & Manderson 1994)
the Philippines (Miguel et al. 1998a). But the indirect costs of
seeking treatment (transport, time lost in wages, care of
children, and so on) are all also mentioned frequently (e.g.
Asenso-Okyere & Dzator 1997; Miguel et al. 1998b). The
immediate costs of health care are inevitably weighed against
other indirect, recurrent and capital costs. As is well
documented, drug distribution is conducted internationally
not nationally, and companies continue to operate to promote
the use of brand-name prescriptions and to encourage over-
medication despite official commitment to rational use of
drugs and the promotion of generic drugs (Silverman 1976;
Tomson & Sterky 1986; Kanji et al. 1992; Carpenter et al.
1996; Craig 1997). The distribution of health services
continues to disadvantage poor people and is a major factor
confounding accessibility of services. Allied to this are issues
affecting the quality of services. Delays encountered in
relation to diagnosis and prescription discourage people’s use
of clinical services (Espino, personal communication; Miguel
et al. 1998a). The logistic issues implicated in this also affect
the implementation of control programmes, where, for
instance, supplies are unreliable (the delivery of insecticide
for impregnation of bednets is a case in point).
A far wider range of factors affect the potential impact of
interventions to control disease. Development policies within
countries are one example, whereby government, private local
companies or international consortia are responsible for
environmental changes that create new conditions for the
spread of disease. This includes the disruption of the local
environment and changing the local ecology of vectors, by
encouraging immigration of workers from endemic areas
who introduce infectious disease into the area and/or by
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exposing immunologically naive immigrants to areas of
disease, and by providing workers with housing which due to
crowding and poor construction exacerbates disease
(Briceño-León 1990).
As a result, sustainable interventions necessarily need to
deal with systemic, structural, institutional and behavioural
issues associated with disease transmission and control. The
Agusan del Sur-Malaria Control and Prevention Programme
(ADS-MCP), southern Philippines, provides one practical
example of the way in which anthropological, parasitological
and entomological research have been brought together in the
context of community development, government malaria
control activities and community interventions. Baseline
social and cultural information, collected through the
application of rapid anthropological assessment procedures,
identified the potential and focus for a two-pronged strategy:
the delivery of health education and active case detection
through training barangay health workers, and community-
wide health education interventions. Subsequently,
anthropological data was used to develop a mass media
approach built on community knowledge of malaria and its
prevention, in order to increase awareness of the disease,
increase the use of preventive strategies at a personal and
household level, and increase prompt diagnosis and
treatment.
The mass media campaign is one component of the
project, however, and the overall aim is the development and
implementation of a self-sustaining, community-based
malaria control programme emphasising prompt diagnosis
and treatment of malaria. A community health intervention
programme will use strategies of community participation to
motivate members of the community to become actively
involved in installing, patronizing and sustaining malaria
control mechanisms, and in ensuring accessible, locally
organized and locally delivered services. A precondition to
the success of the project has been institutional strengthening
through capability-building exercises for local government
and service units. This presentation focuses on the activities
of community organizers in mobilizing the government and
the community in the project districts.
A further arm of the project is the development of
multimedia approaches to interventions for malaria control.
There has been increasing appreciation of the importance of
communication strategies in health interventions, and of the
utility of strong links between health communication, public
health approach, social marketing and diffusion theory. On-
going research aims to develop a health education strategy to
maximize community involvement. In particular, interpersonal
approaches of barangay health workers to villages, advocating
early diagnosis and treatment for malaria, have been
supplemented by mass media and print, with radio
programmes focusing on local personnel and health issues.
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Here, the primary goal, informed by anthropological enquiry
at the outset of the study, is to encourage community
ownership by delivering messages of local interest, in a form
that enables frequent access to the target population in order
to create and maintain motivation, inform, and induce
behaviour change.
Conclusion
Anthropological research in infectious disease has often
focused on the specifics of illness: cultural perceptions of
disease entities, understandings of aetiology, diagnostic
categories and treatment-seeking. The ethnographic details of
this work, rather than its use in interventions, are most widely
published. In contrast, there is relatively little which
demonstrates this use, partly because the interventions are
frequently government or NGO initiatives, where programme
reports are internal documents and accountability is to
funding agencies rather than a scientific public (Manderson &
Mark 1997). While anthropological input in terms of
community perceptions of illness, including local taxonomies
and aetiology, have value in developing health educational
material to support interventions, a more sophisticated
understanding of cultural and social dimensions of illness and
disease draws attention to the structural barriers to change and
to the difficulties of introducing and sustaining interventions.
Anthropological involvement ensures that some account is
taken of local knowledge, cultural influence on the patterns of
disease, and structural barriers to good health. Although the
social, cultural and political contexts in which people
experience illness and seek to recover is a small section of a
more complicated puzzle, interventions that overlook these
components risk failure as the structures around it crumble.
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