Narrative/interpretive perspective and Critical Medical (Health) Anthropology perspective of Malaria in Bangladesh. ( 5 pages )

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Narrative/interpretive perspective and Critical Medical (Health) Anthropology perspective of Malaria in Bangladesh. ( 5 pages )

Narrative/interpretive perspective and Critical Medical (Health) Anthropology perspective of Malaria in Bangladesh. ( 5 pages )
ROWMAN & LITTLEFIELD Lanham • Boulder • New York • London Introducing Medical Anthropology A Discipline in Action Third Edition Merrill Singer University of Connecticut Hans A. Baer University of Melbourne Debbi Long RMIT University Alex Pavlotski Aukland University Executive Editor: Nancy Roberts Editorial Assistant: Megan Manzano Executive Channel Manager—Higher Education: Amy Whitaker Interior Designer: Ilze Lemesis Credits and acknowledgments for material borrowed from other sources, an d reproduced with permission, appear on the appropriate page within the text. Published by Rowman & Littlefield An imprint of The Rowman & Littlefield Publishing Group, Inc. 4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706 www.rowman.com 6 Tinworth Street, London SE11 5AL, United Kingdom Copyright © 2020 by The Rowman & Littlefield Publishing Group, Inc. First edition 2007. Second edition 2012. All rights reserved. No part of this book may be reproduced in any form or by any electroni c or mechanical means, including information storage and retrieval systems, w ithout written permission from the publisher, except by a reviewer who may quote passages in a rev iew. British Library Cataloguing in Publication Information Available Library of Congress Cataloging-in-Publication Data Names: Singer, Merrill, author. Title: Introducing medical anthropology : a discipline in action / Merri ll Singer, University of Connecticut, Hans A. Baer, University of Melbourne, Debbi Long, RMIT Uni versity, Alex Pavlotski, Aukland University. Description: Third Edition. | Lanham : ROWMAN & LITTLEFIELD, [2019] | “Second edition 2012”—T.p. verso. | Includes bibliographical re ferences and index. | Identifiers: LCCN 2018048811 (print) | LCCN 2018051819 (ebook) | I SBN 9781538106471 (electronic) | ISBN 9781538106457 (cloth : alk. paper) | ISBN 978153 8106464 (paper : alk. paper) Subjects: LCSH: Medical anthropology. Classification: LCC GN296 (ebook) | LCC GN296 .S57 2019 (print) | DDC 306.4/61—dc23 LC record available at https://lccn.loc.gov/2018048811 ™ The paper used in this publication meets the minimum requirements of Ame rican National Standard for Information Sciences—Permanence of Paper for Printed Lib rary Materials, ANSI/ NISO Z39.48-1992. Printed in the United States of America Preface ix About the Authors xi 1 Introduction to the Anthropology of Health 1 Introduction and Overview 1 Encountering Health Anthropology 1 Three Case Studies in Applied Health Anthropology 2 Coping with Cystic Fibrosis 2 The Bone Crusher 3 Pesticide Poisoning 5 Practical and Theoretical Contributions of Health Anthropology 8 Clarifying the Culture of Health and Illness 8 Health Inequality 9 Defining Health Anthropology 10 Culture and Biology 10 History of Health Anthropology 12 The Straits Expedition 12 W. H. R. Rivers and Beyond 14 Rudolf Virchow 15 Er win Ackerknecht and William Caudill 15 The Postwar Period 15 Health Anthropology and National Development 16 The Discipline Is Born 16 The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines 17 Health Research and the Subfields of Anthropology 17 Health Anthropology and Epidemiology 20 Illness and Help-Seeking Behavior 24 Health Anthropology and Public Health 24 Health Anthropology and Bioethics 31 Health Anthropology Theories 32 Medical Ecology 32 Meaning-Centered Health Anthropology 33 Critical Health Anthropology 34 2 What Health Anthropologists Do 37 Introduction and Overview 37 Contents iii iv Contents Three Settings, Three Case Studies, Three Health Anthropologists 37 Life and Death in Tanala 37 Studying Surgeons 39 Folk Illness in Haiti 41 A Case Study 43 Having Impact 43 What Health Anthropologists Study 44 A Diverse Discipline 44 Studying the Life Course 46 Conducting Research: A Peculiarly Anthropological Approach 49 Holistic, Field-Based Understanding 49 Ethnography 49 Complex Sociocultural Tapestries 52 Research Methods 54 Multimethod Research 54 Examining Lives 55 Focus Group Inter views 56 Considering Consensus 57 Doing Diaries 57 Quantitative Methods 58 Broader Collaboration 59 Health Anthropology in Use 59 Mobilizing Research Findings 59 The Health Anthropology Crystal Ball 61 3 Understanding Health, Illness, and Disease 65 Introduction and Overview 65 Conceptions of Health and Illness 65 Defining Terms 65 Differentiating Disease and Illness 66 Reconceptualizing Disease and Illness 69 Understanding Cure 69 Folk Understandings 70 Understandings of Disease Causation 71 Humanizing Biomedicine 73 Sufferer Experience 73 Experience and Cultural Symbols 73 Cultural Emotions 74 Social Suffering 76 Beyond Social Suffering 77 Disability and Chronic Illness 78 The Patient in the Body 78 The Cultural Construction of Disability 79 Contents v Stigmatization 82 Human Rights and Health 83 Illness Narratives 85 The Social Uses of Narration 86 Analyzing Narrative 86 Embodied Health Experience 88 Why Bodies? 88 Body Theor y 89 Bodies in the Age of Immunology 90 Cyborg Bodies 91 Mindful Bodies 92 Engendered Bodies 95 Understanding Medicalization 95 Healer versus Sufferer Conception of Disease 96 The Two Sides of Compliance 96 Insider and Outsider Assessments of Health Status 98 One Word, Two Meanings 98 Diseased but Not Ill 99 Mismessaging 99 Analyzing Health Discourse 100 4 Health Disparity, Health Inequality 102 Introduction and Overview 102 What Is Health Disparity? 102 Health Disparity in the United States 103 Gasping for Breath 104 Causes of Health Disparity: Lifestyle versus Social Inequality 106 Living Right 106 Structural Explanation 106 Biology of Poverty 108 Insuring Disease 109 Culturally Competent Care 110 Health and Social Disparities Cross-Culturally 113 Child and Maternal Health Disparities 116 Addressing Health Disparities 121 Addressing Health Disparities in the Community 121 Upstream Analyses of Health Disparities 122 Gender and Global Health 124 Focusing on Disparity in Diseases 125 Multidisciplinar y Approaches 126 Studying Local Mediation of Global Health 126 vi Contents Pushing Back on Health Disparities 128 “Race” and Health Disparity 128 Race and Racism 129 5 Health and the Environment: Toward a Healthier World 131 Introduction and Overview 131 Medical Ecology and Critical Health Anthropology on the Environment 132 Health and the Environment in the Past 134 Health and the Environment Today 136 Depletion of Natural Resources and Environmental Degradation 137 Capitalism and Climate Change 139 Infectious Diseases in a Globalizing World 140 The Impact of Climate Change on Health 141 Other Environmental Impacts on Health 145 Water and Globalization 146 The Political Ecology of Cancer 148 Cancer in the Community 149 Cancer and Industr y 150 China’s Cancer Villages 151 Anthropological Examinations of Cancer Treatment 152 Nuclear Reactors and Health 152 Unconventional Natural Gas Extraction and Health 153 The Impact of Private Motor Vehicles on Health 154 The Political Ecology of AIDS: Assessing a Contemporary Syndemic 155 6 Ethnomedicine: The Worlds of Treatment and Healing 159 Introduction and Overview 159 Approaching Ethnomedicine 159 Indigenous and Folk Medicine Systems 162 Ways of Healing 162 Typologies of Healing Systems 163 An Evolutionary Model of Disease Theories and Healing Systems 165 Health, Illness, and Medicine in Family-Level Foraging Societies 166 Health, Illness, and Medicine in Village-Level Societies 169 Health, Illness, and Medicine in Pastoralist Societies 170 Health, Illness, and Medicine in Chiefdom Societies 171 Contents vii Folk Healers in Modern Societies 171 Case Study: Are the Therapeutic Aspects of Religion Something That Partially Address Refugee Health Problems? 173 Biomedicine as the Predominant Ethnomedicine in Modern Societies 175 Hospitals 176 Health Anthropology and the Pharmaceutical Industr y 178 7 Plural Medical Systems: Complexity, Complementarity, and Conflict 182 Introduction and Overview 182 A Case Study of Medical Pluralism in a Rural Area in a Developing Society: The Altiplano of Bolivia 183 Themes 183 Medical Subsystems 184 Status of Health Care in Bolivia in the Pre-Revolutionar y Era 184 Social and Health Conditions in Bolivia after the Election of Indigenous President Evo Morales 185 A Case Study of Medical Pluralism in an Urban Setting of a Developing Society: A View from Central Java 188 Medical Subsystems 188 A Case Study of Medical Pluralism in a Developed Society: The Australian Dominative Medical System 190 Medical Subsystems 190 Typologies of Plural Medical Systems 195 Healing and Histor y 196 Patients of CAM 199 CAM and Class 201 New Directions in the Study of Medical Pluralism 207 Medical Syncretism 208 Medical Diversity 209 Medicoscapes 210 The Globalization of Traditional Medicine and CAM 210 8 The Biopolitics of Life: Biotechnology, Biocapital, and Bioethics 212 Introduction and Overview 212 Critical Health Anthropology and Biotechnology 212 Science, Nature, and Culture 213 Biocapital: Bodies of Profit 215 viii Contents Reproductive Technologies 216 Divisible Bodies 220 Bringing the Lab into the Field: Anthropology and the Neurosciences 222 Molecular Biotechnologies: Tiny Pieces, Giant Infrastructures 224 The Story of hGH—Growing up Growth Hormone 227 The Culture of PCR 228 Visualization Technologies 229 When Technologies Combine 230 Ancestry, Families, and Genetics: Biotechnology and Belonging 233 9 Strategies and Visions for a Healthier World 240 Introduction and Overview 240 Global Capitalism 240 Democratic Eco-Socialism as a Pathway for a Healthier World 242 Health Anthropology as an Action-Oriented Endeavor 247 Source Material for Students 251 Glossary 255 References 260 Index 300 Students often do not bother with the prefaces to assigned textbooks, an d for understandable reasons. The comments of authors about their book are not going to be on any test and it is the contents of the book, its ideas, c oncepts, theory, and examples, not the book as a product of author labor or the g oals and intentions of authors, that is of most immediate concern to the student reader. We hope, in this instance, that these remarks capture some student attention because they deal with an important conceptual issue and provide a glimp se behind the curtain of book publishing. When the first (2007) and sec ond (2012) editions of this book were published, the authors recognized that while medical anthropology was not the most fitting name for the field our book wa s introduc- ing to students, it was the established and widely accepted term. Indeed , medical anthropology was a label that smuggled in a lot of problematic baggage. Since the last edition, however, our discomfort grew to the point that in 2016 , along with our colleagues Debbi Long and Pamela Erickson, we published a paper in a leading anthropology journal entitled “Rebranding Our Field: Tow ards an Articulation of Health Anthropology.” We feel strongly that the time has come to retitle medical anthropology using a more appropriate label that bett er reflects conceptual developments in the field. Our subfield, as shown clearly in the chap- ters of this book, has a wide range of concerns that includes a keen foc us on biomedicine and other ethnomedical and health-care traditions. But the w ork of those we have come to call “medical anthropologists” addresses mul tiple other issues that are not specific to medicine or healing, including underst anding health and illness within society and within the complex social and political-e conomic systems created by globalization. Consequently, we proposed the name “ health anthropology”; this better describes the core issue that unites the s ubfield. We called for dropping the term medical anthropology because, as has lon g been recognized by many in the field, it is limiting and misleading, and re flects the hegemony of biomedicine at various levels. This renaming does not preclu de health anthropologists working on or within biomedical, complementary, and alternative medical or indigenous medical settings, as reflected in th e fieldwork of all of the coauthors of this book. It was our intention, however, that i n its third edition this book be renamed Introducing Health Anthropology: A Discipline in Action to reflect the true breadth of the field. This is where good intentions ran into marketing realities. Our book, and its title, were known, and Introducing Medical Anthropology was widely used as a textbook, the second-best-selling core text on the market in our topical niche. In our publisher’s reasonable approach to their business it was not s een as a good idea to change the title of an established text. The book was seen as having instant name recognition for professors who might assign it in a class. Changing the title, the publisher felt, could cause confusion to teachers and to bookstores looking to order books for classes. As one reviewer of our proposed name change commented, “Why not continue to use it as a marketing tool to appeal to the Preface ix x Preface widest number of folks?” For these reasons, the title has not changed in the third edition, but the text has been updated to reflect our concerns on this matter. Throughout this text, if not on the cover, we use the terms “health a nthropol- ogy,” “health-oriented anthropology,” and “health anthropolo gists.” One thing that has changed is the addition of Debbi Long and Alex Pavlotski as coauthors, which, based on their areas of expertise and fi eldwork experience, allow us to further examine the wide range of issues investi gated in a health-oriented anthropology. One of the goals of the third edition of this book is to affirm that health-oriented anthropologists are very involved in the process of help ing, to varying degrees, to change the world around them through their work in a pplied projects, policy initiatives, and advocacy. Not all anthropologists teac h in a col- lege or university—many are involved full time in directly applied wo rk—and most who do teach medical anthropology courses are involved in applicati on. Moreover, as the landscape of academia endures major transformations, wi th underpaid adjunct labor now increasingly replacing stable faculty positi ons, anthropologists must find creative ways to bring their skill-sets out of the ivory tower and into the world. Our subdiscipline both addresses specific he alth issues and analyzes them in their broader context. In other words, we seek to u nder- stand health-related issues and to use this knowledge in improving human health and social well-being. A second goal of this book is a presentation of the fundamental importan ce of culture and social relationships in health and illness. Through a rev iew of the key ideas, concepts, methods, and theoretical frameworks that guide rese arch and application in health-oriented anthropology, the book makes the case that illness and disease involve complex biosocial processes and that resolvi ng them requires attention to a range of factors beyond biology, including local systems of belief, structures of (often unequal) social relationship, the deve lopment and globalization of new technologies, and environmental and climatic condit ions. Finally, through an examination of the issue of health inequality, such as exposure to pesticides among farmworkers, unequal access to health care, the role of poverty in the spread of disease, or environmental degradation a nd envi- ronment-related illness, this book underlines the need for an analysis t hat moves beyond cultural or even ecological models of health toward a comprehensi ve biosocial approach. Such an approach integrates biological, cultural, and social factors in building unified theoretical understandings of the origin o f ill health, while contributing to the building of effective and equitable national h ealth-care systems. In this manner, health anthropologists have a broad vision of p lanetary health and seek to be part of a collective process aimed at creating a healthier world for both humanity and the biosphere. The ultimate goal is prevaili ng over the social causes of disease, the structures of social injustice th at diminish well-being, and the social forces driving environmental destruction, inc luding human-created or anthropogenic climate change. For us, ultimately, bring ing these issues into the classroom, especially in a time when health has be come a daily issue of deep concern, is of far greater importance than the speci fic way the field is labeled. Merrill Singer is professor in the Departments of Anthropology and Com- munity Medicine at the University of Connecticut. Dr. Singer has publish ed 290 scholarly articles in peer-reviewed journals and book chapters, and has authored, co-authored or edited thirty-three books. His research and writing have addressed syndemics, HIV/AIDS and STDs in highly vulnerable and dis ad- vantaged populations, illicit drug use and drinking behavior, infectious disease, community and structural violence, and the political ecology of health, including the health consequences of climate change. Dr. Singer has been awarded t he Rudolph Virchow Professional Prize, the George Foster Memorial Award for Practicing Anthropology, both the AIDS and Anthropology Research Group’ s Distinguished Service Award and its Clark Taylor Professional Paper Priz e, the Prize for Distinguished Achievement in the Critical Study of North Ameri ca, and the Solon T. Kimball Award for Public and Applied Anthropology from the American Anthropological Association. Hans A. Baer is Principal Honorary Research Fellow in the School of Social Political Sciences at the University of Melbourne. He has published twen ty-one books and some 190 book chapters and articles on a diversity of research top- ics, including Mormonism, African American religion, sociopolitical life in East Germany, critical health anthropology, medical pluralism in the United S tates, United Kingdom, and Australia, the critical anthropology of climate chan ge, and Australian climate politics. His most recent books are Democratic Eco-Socialism as a Real Utopia (2018), and Urban Eco-Communities in Australia: Real Utopias or Market Niches? (with Liam Cooper, 2018). Debbi Long is senior lecturer in global studies at RMIT University (Melbourne, Australia). She is a critical health anthropologist and a pioneer of ho spital eth- nography in Australia. She is an experienced health ethnographer, having under- taken fieldwork in Turkey, Swaziland (eSwatini), and in a variety of contexts in Australian public hospitals, including maternity, spinal, intensive care , and dialy- sis units. She has worked as a consultant in clinical organization and m anagement on projects including quality improvement, patient safety, behavior change, and in industrial relations contexts. Recent research has included family vi olence education and compensation industry analysis. She has taught at undergra duate and postgraduate levels in anthropology departments; international development programs; medical, nursing, and allied health programs; and in indigenou s foun- dation and support programs. Alex Pavlotski is teaching fellow at Auckland University, New Zealand, and an honorary research fellow at Latrobe University in Australia. He is an anthro- pologist and graphic artist. Alex has conducted fieldwork with comic a rtists in About the Authors xi xii About the Authors Japan, and in Australia with an urban LGBTQI+ community; with CEOs and accountants across the country; and with recipients of government disabi lity payments. His PhD thesis was on the global movement subculture of parkou r, a multisited ethnography undertaken across twenty-four cities in eight n ations. His research interests are psychological and neuroanthropology, visual r epresen- tation in ethnography, cross-cultural communication, masculinity in lead ership research, organizational ethnography, systems design, mind-body connecti vity, and reactionary identities. 1 1 Healing requires a legitimated, credible and culturally appropriate syst em. —Mildred Blaxter (2004:43) Introduction and Overview I n this chapter, we begin the process of defining and differentiating hea lth an- thropology in light of the range of disciplines concerned with health. W e initi- ate this introduction to health anthropology by presenting three case st udies. We then address both the practical and theoretical work and contributions o f health anthropology, differentiate health and illness as technical terms in the discipline, engage the issue of health inequality, review the history of health anthropology, and compare and contrast health anthropology with other health-related fields including discussion of multidisciplinary collaboration. Encountering Health Anthropology People who encounter the term medical anthropology, or, as explained in the preface, “health anthropology,” for the first time often are puz zled by what it means. Is it the study of how medicine is practiced, what doctors, nurse s, or traditional healers from other health-care systems actually do? Or is it the study of what it means and feels like to be sick? Perhaps it is the study of f olk illnesses in different societies? Might it be the application of cultural knowledg e to the actual treatment of diseases? All these questions, in fact, can be answe red in the affirmative. Health anthropology addresses each of these issues—and far more. A starting premise of health anthropology is that health-related issues, including disease and treatment, how and why one gets sick, and the nature of reco very, are far more than narrow biological phenomena. These processes are all heavi ly influ- enced by environmental, political-economic, social-structural, and socio cultural factors as well. Consequently, health anthropology has developed a bio-sociocul- tural approach in its effort to address health as an aspect of the human condition. To take one example, health anthropologists ask questions such as the following: Could we really understand the AIDS pandemic and respond to i t effectively simply by studying the human immunodeficiency virus, its i mpact on cells of the body, and medical interventions designed to stop the vir us from destroying the immune system? Would we not also need to know how to reac h and effectively engage those who are at greatest risk for infection, to figure out the structural and situational factors that contribute to their involvem ent in risky behaviors, to know how much they know and what they feel about AIDS and how these factors influence their behaviors, and to determine whether the ways Introduction to the Anthropology of Health 1 CHAPTER 1 INTRODUCTION TO THE ANTHROPOLOGY OF HEALTH 2 Chapter 1 we go about interacting with them in the community and in the clinic dra w them closer or push them away from our treatment programs? In other words, be yond biology clearly there are critically important areas of knowledge in the ongoing fight against the now about forty-year-old AIDS epidemic. Now, if we t hink about the AIDS epidemic as a global problem, a global pandemic, with dif ferent routes of infection, different populations at risk, different beliefs an d behaviors associated with HIV/AIDS in diverse settings, and different health-care systems in different parts of the world or even different parts of a single coun try, we begin to get an initial sense of why a social science like anthropology might—as it certainly has—have a significant role to play in addressing the AIDS epidemic. This is of no small importance; we know from available research that HIV / AIDS is destined to take a greater toll on our species, proportionately and in terms of absolute numbers, than the bubonic plague, smallpox, and tuberc ulosis combined. Consider the epidemic in South Africa, the country with the hi ghest burden of HIV/AIDS in the world. As Didier Fassin (2007a:261) points out, “In one decade, the rate of HIV infection went from less than 1 perce nt to over 25 percent of the adult population and AIDS became the main cause of dea th for men and women between 15 and 49 years of age,” with an expected d rop in average life expectancy in the country of as much as twenty years. Mo reover, the global pandemic has helped to shape the social, cultural, and health worlds of people all over the planet, whether or not they are always aware of i t. Within the broader story of the devastating impact of HIV/AIDS, however, there are many differing local narratives that together comprise the complex mosai c of the pandemic. The work of health anthropologists has been part of that s tory in many places and the same is true for a vast array of other health issues . Moreover, health anthropology, while sometimes contributing to cultural explanatio ns of HIV/AIDS risk behavior, has struggled in recent years to counter explana tions that fail to address the fact that the global economy or capitalism and social inequality are the primary driving forces in the epidemic (Hlabangane 2 014).      Three Case Studies in Applied Health Anthropology Coping with Cystic Fibrosis The Reynolds family has two children. Carl is five and Stuart is seven. The younger of the two boys has cystic fibrosis (CF), the most common fatal genetic disease in the United States. Cystic fibrosis causes the body to produce a thick- ened form of mucus that clogs the lungs, leading to repeated bacterial infec – tions and increasing lung damage. While the median age of survival among CF sufferers has been rising, most people with the disease do not live very far i nto adulthood before they succumb. Day-to-day care of a child with CF commonly falls on family members who must learn to cope with both a painful prognosis and the demands of responding to the patient’s menacing symptoms, including pounding on the sufferer’s chest and back for at least thirty-five to forty minutes Introduction to the Anthropology of Health 3 at a time, two to four times a day, to dislodge mucus. Some burdens fall partic- ularly hard on the siblings of children with CF. Deana Reynold, Stuart’s mother, notes one of these burdens that he must endure: “When Carl’s sick, all the phone calls are, ‘How’s Carl?’ Everybody who sees Stuart [says], ‘How’s your brother doing?’ And all the presents. Carl gets all the presents. It has to have some kind of effect on him [Stuart].” How (and how well) do families with a child with CF cope? What toll does the disease take on family relations and on the emotional well-being of family members? How are siblings affected by growing up with a chronically ill brother or sister? How can health-care providers most effectively communicate with families at various stages in the natural history of CF progres- sion? Having previously studied children with cancer, health anthropologist Myra Bluebond-Langner (1996) set out to answer these critically important q uestions. For nineteen months, in the clinic and in their homes, she repeatedly interviewed and observed families that were recruited from the patient rolls of the Cystic Fibrosis Center of St. Christopher’s Hospital for Children in Philadelphia. She also interviewed attending physicians and reviewed patients’ medical charts. Like most anthropologists, she immersed herself in the lifeworlds of the people she was studying. Her field notes and taped interviews filled thousands of pages and numerous three-ring binders. In the end, after many months of data collec- tion and careful analysis, she was able to answer the key questions that moti- vated the study. Additionally—and tellingly—she was able to use her findings to develop a set of useful guidelines for physicians to use in clinical intervention with families with a CF sufferer. As a result, physicians now have a clearer idea of how best to communicate with families and to assist them in coping wi th the difficult challenges they face and the weighty burdens they must bear. Like the work of many other health anthropologists, this work by Bluebond-Langner has helped to make a positive impact in the tangled and often confusing worl d of health and illness. Addressing conflicts, miscommunications, and other prob- lems in doctor-patient relationships as well as patient access to high-quality, culturally appropriate health care are central issues in health anthropology. But there are many other concerns as well. The Bone Crusher Dengue, the most prevalent mosquito-borne viral disease on earth, is found in more than one hundred countries and territories around the world, primarily in tropical and subtropical environments of Latin America, the Caribbean, and Southeast Asia, although a U.S. outbreak occurred in Hawaii in 2001. Since then, however, locally acquired cases of dengue have begun to appear in sev- eral geographic areas in the United States and researchers fear that the disease could be gaining a significant foothold on the U.S. mainland. Current estimates are that each year fifty million to one hundred million peo- ple are infected with dengue when they are bitten by either the Aedes aegypti, the mosquito that also transmits yellow fever, or Aedes albopictus mosquitoes. 4 Chapter 1 Mosquitoes become infected when they bite people who are infected, and, in turn, they subsequently transmit the infection to other people that they bite. In Southeast Asia and in most of Latin America and the Caribbean, the disease is pandemic, meaning that it is now firmly entrenched in the population and spreading. Malaysia has been particularly hard hit; thousands of people fall vic- tim each year to this disease colloquially known—because of the fears ome joint pain it causes—as the “bone crusher.” Other symptoms include stomach pain, headaches, nausea and vomiting, pain behind the eyes, and body flushes. In a more intense and even more frightening form, known as hemorrhagic fever, the sufferer’s gums, nose, and internal organs bleed. A number of health anthropologists have worked on preventing the spread of dengue. Karl Kendall (1998), for example, developed a strategy that involves studying and utilizing local health beliefs and practices in the develop ment of community health campaigns about dengue in El Progreso, Honduras. In Kendall’s approach, the first step in raising community awareness of effective prevention involved conducting in-depth interviews and surveys with commun ity members to assess what they think and believe about dengue, its routes of infection, and the strategies they use to prevent becoming sick with the dreaded disease. This information was used to frame a locally meaningful educati on campaign designed to raise community awareness of the insects that transmit dengue, including effective pest control measures. This culturally sensitive proj- ect proved to be effective in reducing the populations of dengue-carrying mos- quitoes, lowering rates of infection. Sara Crabtree and colleagues (2001) built on this approach in the prevention of dengue in two communities in Malaysia. Like Kendall, Crabtree and coworkers began their work with a study of community knowledge, attitudes, and beh aviors related to the disease. They also conducted focus groups with four different sub- groups—women, youth, men who were heads of families, and village leaders—in an area that had not yet been hard hit by dengue. Through this research, it was found that the communities lacked much awareness of mosquito-borne disease transmission; they did not associate getting sick with being bitten by m osquitoes. Consequently, while they were available, people did not make much use of mos- quito nets or spray repellents. The team then organized a set of three-day work- shops designed to train volunteers to conduct a needs assessment on how to prevent dengue in their local communities. Under the guidance of the researchers, these individuals then carried out a door-to-door survey in their local communi- ties. Researchers then worked with the needs assessment staff in translating find- ings into a strategic set of recommendations for practical, achievable activities to reduce mosquito populations. With the support of local leaders, actions based on these recommendations, such as burning accumulated rubbish, cleaning water containers, and identifying and eliminating breeding sites, were implemented to lower mosquito populations, a goal that was achieved in both participati ng com- munities. The health anthropologists involved in this project believed that this Introduction to the Anthropology of Health 5 success was due in large part to the initial assessment to ascertain com munity concerns, mobilize locally generated prevention ideas, and involve community members in all phases of the prevention initiative. Despite the efforts described here, dengue continues to spread in the world, as do a range of old, new, and renewed diseases that were once controlled but are again spreading out of control (see chapter 6). From the fight against AIDS to the reduction of sexually transmitted diseases, health anthropologists, with their unique approach to understanding health and disease in terms of the interaction of human biology with social and cultural factors, are often on the front lines of infectious and other disease prevention as well as of the development of cul- turally and structurally appropriate and hence often more effective approaches to care. Although not all health anthropology projects are effective and success might be achieved at a much lower level of effect than would be desired, health anthropologists can point to a strong track record of making useful contributions to improving health, usually at the local level but sometimes even more broadly. In no small part, this is because a core realization of health anthropology is that disease vulnerability, including vulnerability to dengue, “is a relationship. It is always dependent upon cultural, social, and economic factors” (Nadin g 2017). Pesticide Poisoning The World Health Organization, a technical agency of the United Nations, esti – mates that there are more than a billion agricultural workers in the world, most in developing countries. Ethnographic research on the health of agricultural workers—specifically workers who work the fields by hands—are subject to “segregation . . . into a hierarchy of perceived ethnicity and citizenship” that pro- duces significant social and economic inequality and leads to “displa cement, migration, sickness, and suffering” (Holmes 2013:182). In the world inhabited by agricultural workers, their immediate supervisors, land owners, policy makers, and the wider society, the social and health inequalities suffered by agricultural workers are “considered normal, natural, and justified” (Holmes 2013:182) by ideologies of racialized biology. Rather than the consequences of unjust govern- ment policies that allow very low wages and limited occupational health protec- tions, exploitation by employers who are dependent on very cheap labor for their profits, and a health-care system that, by blaming workers’ culture and behavior rather than structural factors for their health problems, becomes inadvertently complicit in the functioning of a harmful social order. Various studies have shown that one of the health problems commonly faced by agricultural workers is poisoning due to exposure to dangerous pesticides; indeed, they are the sector of society most likely to suffer health consequences from the powerful commercial poisons sprayed on food and ornamental crops to limit plant pests. Not only are those who work in agriculture at risk, but so are their spouses and children. Poisoning occurs because pesticide sprays are caught in the wind and drift into adjacent fields where people are working or into areas where 6 Chapter 1 they and their families live, because workers are sent to work in fields in which pes- ticide has recently been applied, and because workers pick up pesticides on their clothing and other possessions, including their food containers, and bri ng them home unaware of potential risk. Even if exposures are limited, pesticides accu- mulate in the body, so that repeated contact increases risk for health-threatening outcomes. One of the most commonly used groups of pesticides, organophos- phates (OPs), can be taken into the body through breathing, through ingestion, and through skin exposure. Organophosphates are known to damage nerves by reducing the availability of acetylcholinesterase, a necessary enzyme fou nd at nerve endings. Organophosphate poisoning can produce rashes, nausea and vomiting, body fatigue, loss of consciousness, shock, and even death. One OP pesticide, chlorpyrifos, has the distinction of being a neurotoxin that has been shown to be particularly dangerous to infants and young children. Approximately five to ten million pounds of the chemical, most of it produced by Dow AgroSciences, are applied to agricultural crops in the United States annu- ally. A review of the pesticide by Environmental Protection Agency researchers during the Obama administration led to a recommendation that, given the threat it posed to children, chlorpyrifos be banned. The review found that residues of chlorpyrifos on food crops exceed existing safety standards and that drinking water exposure to the pesticide also exceeds safe levels. With the election of the Trump administration in 2016 and the subsequent appointment of an unabash – edly probusiness and antiregulatory advocate, Scott Pruitt, to head the agency, the decision was made not to ban the pesticide. Opponents of the decisio n, health anthropologists among them, assert that the job of the agency, which increasingly has adopted a position of regulatory laxity, is to protect the health and safety of people, not the profits of corporations (Kolbert 2017). Existing protections for farmworker health are limited. In 2002, for exam – ple, the Pesticide Action Network North America and a group of collaborating organizations issued a report called Fields of Poison based on data on pesti- cide poisoning collected by the California Department of Pesticide Regulation. The report found that farmworkers face a two-sided threat from pesticides: first, the existing set of regulations designed to protect them from harmful exposure to toxic chemicals is woefully inadequate to really provide safeguards against acute pesticide exposure, and, second, even the existing laws are weakly enforced. To address this issue, Thomas Arcury, Sara Quandt, and a team of colleagues (2005) recruited a group of nine farmworker households in North Carolina and Virginia for participation in an intervention study called ¡La Familia ! Reducing Farmworker Pesticide Exposure, funded by the National Institute of Environmental Health Sciences. The research team conducted in-depth interviews with agricultural landowners and agricultural extension worke rs, com- pleted interviews on beliefs about pesticide exposure and safety among primar – ily Latino farmworkers, collected samples in the homes of farmworkers to detect the presence of OP pesticides on household furnishings, and carried out urine Introduction to the Anthropology of Health 7 tests of farmworker adults and their children to assess body metabolite levels, which reveal whether OPs are present in the bodies of study participants. These researchers found high levels of OP metabolites, which are the by-products of OP exposure, in the members of all of the households they stud- ied, and all households had at least one member with especially high lev els. Moreover, families that had carpeted homes but lacked a vacuum cleaner had higher-than-average OP metabolite levels. Bathing patterns also were linked to OP metabolite levels. As a result of their findings, this research team was able to iden- tify specific policy changes that were needed to reduce farmworker exposure to OPs, including ensuring that all rented farmworker dwellings have shower facilities and working vacuum cleaners, that all farmworker dwellings are built at a safe dis- tance from agricultural fields, and that all farmworkers receive training in pesticide risks and handling. Reflecting on the ultimate goals of their study, they conclude, Providing farmworker families (as well as all Americans) with safe and a ffordable housing will reduce their exposure to pesticides. This is not an instance of “blaming the victim” for exposure to pesticides, and attempting to address a systematic health disparity by educating those exposed to pesticides. Rather, it is an effort to build the capacity of farmworkers to defend themselves and to demand safe housing for their children. (Arcury et al. 2005:50) Notably, most farmworkers live in countries with far fewer resources and weaker laws to protect workers than is the case in the United States. Pesticides produced in the United States, however, are shipped around the world, and anthropologists have observed them being applied by hand by workers who had received little or no information about how deadly they can be if not han dled properly. For health anthropologists who work with agricultural populations, there is much work to do to help them protect themselves from occupational threats to their lives and well-being. In this instance, part of the problem is social inequality and the prevailing structure of power relations in society, such as the making and enforcing of laws that favor one social class, ethnic group, or gender over another. Indeed, health anthropologists have found that social relationships, such as those between ethnic groups, and social structures that determine access to resources and other things of value are a fundamental factor in health generally. Although pesticide poisoning is a significant threat to the health of farmwork- ers, it is neither the only one nor the only one that has been effectively studied by health anthropologists. For example, Sarah Horton and Judith Barker (2010) have examined the issue of severe dental caries among the children of farm- workers in the Central Valley of California. They report that poor early oral health can have enduring effects both on children’s physical development, including malformation of oral arches and crooked adult teeth, and on their emotional development, as a result of social stigmatization as young adults. This research examined the role played by inadequate diet as well as other anthropogenic environmental factors in the development of what they refer to as stigmatized 8 Chapter 1 biologies. For example, these researchers present the case of Jorge, a young man who has “borne the marks of his lack of insurance as a child all his life. A star athlete and popular high school senior, Jorge feels his one social vulnerabil- ity is his stained and crooked smile” (Horton and Barker 2010:213). Moreover, they reveal how market-based dental health insurance sys- tems—and lack of access to insurance coverage among many farmworkers— contribute to enduring negative health effects. For this analysis, they use Margaret Lock’s concept of local biology and recognition of the plasticity of biol- ogy to show how biology, rather than being a static or uniform phenomenon, in fact differs across groups as a result of factors like culture, diet, and the impress of a human-made environment and as consequence of differential social access to prevention care and treatment. Thus, they argue that market-based health- care systems create embodied differences between groups of people in society that both reflect and reproduce a structure of social inequality. Investigations of this sort affirm the value of a bio-sociocultural model in health anthropology.      Practical and Theoretical Contributions of Health Anthropology The cases described here suggest an answer to the question, “why have a health anthropology?” The answer is this: because health anthropologists, us ing anthro- pology’s traditional immersion methods for studying human life up clo se and in context, as well as the discipline’s holistic picture of the human si tuation, a tradi- tional disciplinary concern with understanding things from the insider’ s point of view and flow of experience, and an applied orientation to human probl ems, can make an important difference in the world. Revealing the nature of this difference is, as noted in this chapter, one of the main goals of this book. While a primary emphasis of this book is on the practical contributions of health anthropology, the theoretical contributions of the discipline are equally important and guide the application of health anthropology in addressing par- ticular health-related issues. Theory in health anthropology addresses q uestions such as the following: What determines health and illness? How and why d o societies vary in their health-ca