Understanding Emerging Epidemics: Social and Political Approaches: Volume 11

The concept of the emerging epidemic can evoke many different responses, but it is a major topic of our time, garnering attention in scholarship across the sciences, social sciences, and humanities, in the mass media, and in popular fiction and films. There is a designated journal and multiple study centers devoted to understanding, monitoring, and ultimately defeating emerging epidemics. Regardless of the venue, however, emerging epidemics create a great deal of popular fear, and they symbolize the continuing (and new) vulnerabilities of our late modern age. The contributors to this volume attempt to put this significance in context, offering critical, historical, structural, social constructionist, ecological, and political economic perspectives on the concept altogether or on specific epidemics. These authors deeply consider the knowledge we make of emerging epidemics and the meaning that knowledge has in our lives. Throughout this volume, social and economic justice and the representation of the needs of politically marginalized groups are matters of particular concern.

Purpose – For much of the first half of 2003 world attention was captured by news of a mysterious but deadly virus that was claiming lives in places as distant as Toronto and Beijing. In a matter of months there were around 8,000 infections and over 689 deaths related to severe acute respiratory syndrome (SARS). In my hometown, Toronto, 43 people died of SARS during the outbreaks of 2003.

Approach – This chapter examines issues of class and poverty in emergence of SARS. The chapter begins with a discussion of the political economy of the emergence of SARS, and its relation to the spread of the virus. It then discusses issues of public policy, and particularly neo-liberal cuts to social services and public spending, that set the stage for the SARS outbreak, influenced its impact and contributed to the failures of response in Ontario.

Findings – Through analysis of the lack of social resources available to working people in the province and the prioritizing of corporate, particularly tourism industry, concerns, the chapter illustrates how issues of class underpinned public responses to SARS, exacerbating problems. The chapter concludes by giving attention to the need for social solidarity and community mutual aid.

Contributions to the field – The chapter shows the extent to which neo-liberal governments prioritize business security above the health and social security of workers and reveals some of the ways in which the pressures of capitalist social relations make people ill.

Purpose – This chapter aims to provide a cross-section of some social, political, cultural, and economic factors that contribute to the conditions of illness, specifically malaria, in an area of Tanzania where both land and population have been marginalized to varying degrees over time. It also suggests the relevance of such considerations in the planning and implementation of public health interventions in the region.

Methodology/approach – This chapter elaborates upon a case study conducted by the author in the Ngorongoro District in Tanzania in 2006. A political ecology framework is used to guide the discussion.

Findings – Malaria in the Ngorongoro Maasai community can be more fully understood by incorporating critical social science perspectives into health-related analyses, by allowing for a greater appreciation of the complex history behind current configurations of infrastructure and sociopolitical interactions in the region. Assuming that equity is of concern, this appreciation can contribute to ensuring that all populations in the country have the opportunity to benefit from the public health momentum in Tanzania.

Contribution to the field – Much attention is justifiably directed toward the social and economic consequences of infectious diseases in developing countries. Tanzania alone accounts for a large proportion of malaria cases and deaths worldwide. This chapter recognizes that malaria is one of the many elements in an ecological system continually integrating cues from nature and society, and uses that framework to demonstrate the importance of qualitative analysis in view of the copious international funding and assistance for control measures.

Purpose – In this chapter, we compare the cases of India and Russia as they address the spread of HIV-AIDS in their respective countries. The countries, former Cold War allies, have embarked upon a path toward economic liberalization in the past decade and a half. In Russia's case, this came with political upheaval. In India's case, liberalization started with tentative steps and reached more full-blown economic and social liberalization in recent times. Both have also had to deal with the rapid spread of HIV-AIDS within their societies which brings with it the threat of derailing recent economic progress.

Methodology – A comparative case-study method is used to make comparisons between these countries which are facing similar challenges but whose approaches to them differ.

Findings – The chapter looks at how the government and a tradition-bound society in both cases have addressed the crisis. While both governments are recently becoming more serious about sustainable responses to the spread of the disease, in India's case this response has been buttressed by social liberalization unleashed by recent economic success.

Contributions to the field – We argue that social liberalization, as in the case of India, has made an impact in terms of the spread and acceptance of prevention education. This has positive implications for those countries where liberalization has changed traditional societies and where these changes are being used to battle the HIV-AIDS crisis.

Purpose – To analyze the concept of emerging infectious diseases, departing from the accepted definitions adopted by the Centers for Disease Control and Prevention (CDC, USA) and the now classical definition suggested by Grmek (1993, 1995). The emphasis of this chapter is on the roles that socio-economic and cultural changes play on the emergence of diseases.

Methodology – Bibliographical research.

Findings – Current definitions fail to address all instances of the emergence of disease. In order to illustrate the concept of emergence, we discuss two case studies. The first describes the constitution of abdominal angiostrongyliasis in Costa Rica. The second concerns an outbreak of Chagas disease that took place in 2005 in the state of Santa Catarina, Brazil.

Contribution – As a result of our analyses we propose a new classification of instances of emergence and emphasize the importance of an interdisciplinary approach for the understanding of diseases.

Purpose – The purpose of this chapter is to illustrate that when produced through relations of power, West Nile virus (WNV), as it exists on the Public Health Agency of Canada's (PHAC) website, is an effect of the kinds of knowledge, techniques of power, and disciplinary apparatuses that operate on the website and in society.

Methodology/approach – The approach used in the in-depth research project which informs this chapter is an elaboration of Michel Foucault's work on relations of power which offers an effective way of studying the PHAC's website as a collection of authoritative knowledges and as a product of a set of systems, structures, and processes which have helped to assemble and distribute knowledge about WNV.

Findings – The findings discussed in this chapter offer a critical reading of the PHAC's overall production of WNV, focusing particularly on its initial emergence starting in 2001. Cumulatively, this chapter argues that myriad relations of power have produced WNV as a bio-socio-administrative construct.

Contribution to the field – This research illustrates one way that Foucault's theories of power can be used to conduct a critical analysis of both the discursive and material dimensions of the production of contemporary public health issues. Such an approach is useful to scholars who wish to place the emergence of a disease phenomenon within political, institutional, economic, cultural, and social relations of power; thereby drawing attention to how specific spaces, places, individuals, and institutions contribute to the production of contemporary health alarms.

Purpose – The purpose of this chapter is to use the particulars of a single case study (Vietnam) to underscore common pitfalls that several governments have made during the emerging and concentrated stages in their policy responses to the HIV/AIDS epidemic and to underscore much needed actions in the HIV/AIDS prevention realm.

Methods – Literature syntheses, policy reports, interviews with in-country stakeholders, and a case study approach are used to explore key issues regarding common government missteps at the concentrated epidemic phase.

Findings – These include coverage of the history of social ills in the country and how these intersect with – first, myths about the spread of HIV within a given region; second, inadequate intervention with high-risk groups and lack of consideration of the ways in which high-risk groups interact with the general population (neglect of bridge populations); and third, poor emphasis on women and young women, who are disproportionately affected by key epidemic transitions, particularly the transition from emerging to the concentrated epidemic phase.

Contribution to the field – Documenting policy lessons in emerging and concentrated epidemics is urgent and can assist within and across nations to help control the spread of HIV/AIDS.

Purpose – This chapter considers the social politics of H5N1 (“avian influenza”), the 2009 H1N1 pandemic, and the response to it within the context of the history of pandemic influenzas and the continuing need for robust preventative public health systems more generally. In particular, the author considers how the borders between nations, species, and individuals are thrown into relief and called into question by influenza outbreaks and their management.

Methodology/approach – This work relies on literature review, media research, and critical and interpretative sociological methods.

Findings – While panic surrounding new and potentially highly virulent influenza strains is reasonable, such panic is not sustainable and belies the fact that every year presents the danger of a pandemic. This chapter argues that, if public health systems only respond to immediate panic and fail to consider how quickly airborne diseases can cross all sorts of borders, they do not attend to the real need for far-seeing, long-term, internationally collaborative disease prevention and disaster preparedness.

Contribution to the field – The author offers a critical and wellness- and prevention-oriented perspective on what priorities should be emphasized in the rapidly growing fields of disaster studies and disaster preparedness, which, by their nature, tend to be crisis oriented and focused on the micro-term, with planning done on a case-by-case basis. Such a narrow focus can render preventative health systems inflexible and unable to rise to the challenge of a disease that can spread easily through casual contact.

Purpose – This chapter sketches the major historical shifts in American circumcision discourse and examines the sociopolitics of those shifts.

Methodology/approach – The chapter centers on a critical analysis of competing narratives and knowledge claims about circumcision. It re-examines these narratives and claims, most of which are packaged in a rhetoric of health, specifically for their political valence.

Findings – The medical necessity of circumcision in the United States cannot be ascertained without attending to the disciplinary systems designed to produce and maintain religious, sexual and other cultural norms.

Contribution to the field – The chapter provides a clear and focused synthesis of many different literatures and contentions about circumcision that have yet to be brought together into a single narrative accessible for students and scholars of the medical humanities and medical politics.

Purpose – To explore how home care social worker perceptions of their organizations' dominant goals and means affect direct service home care professionals' care delivery and meeting of patient needs for persons with Alzheimer's disease.

Methodology/approach – The study used a convenience sample of 34 home care social workers in the New York City metropolitan area and an extensive literature review.

Findings – The study found that literature indicates a dissonance between effective, evidence-based research psychosocial Alzheimer's disease interventions and Medicare home health policy which does not cover their use. Furthermore, interviews indicated home care social workers' different strategies to cope with organization demands, which affect their perceptions and care delivered to patients. The coping strategies are characterized using a modified version of Merton's (1957) adaptation model – conformist, innovator, and rebel.

Contribution to the field – The study is the first to use the voice of home care social workers to explore how perceptions of organizational dominant goals and means affect direct service home care professionals' care delivery and meeting of patient needs. The study asserts the need for a home care-based policy model drawing on the Hospice Medicare Benefit (HMB) to address Alzheimer's disease more cost-effectively with a more positive quality of life manner, thus limiting the adverse consequences of the evolving epidemic.

Purpose – The aims of this chapter are twofold – first, to develop an understanding of the ways in which primary historical data come to be transformed across generations of popular science histories of emerging epidemics; and second, to develop an understanding of the ways in which those transformations impact on our ability to know what really happened during those epidemics.

Approach – The chapter begins with a rhetorical analysis of one particularly influential account of the 2003 severe acute respiratory syndrome (SARS) outbreak. Therein, we learn that the race to discover the outbreak's aetiology was tainted by scientific malpractice; that an esteemed Chinese microbiologist, Dr. Hong, apparently promoted his own, patently false, aetiological discovery, stifled debate on the matter and, in doing so, held the international response to the outbreak back by a number of weeks. But how was this account rhetorically constructed? And how did it engage with Dr. Hong's own research work?

Findings – Does Hong deserve to be remembered as an inept scientist? Subsequent accounts have been quick to repeat this one, founding text's account, suggesting that ‘yes, he does’. This chapter, however, returns to the primary data, examines the ways in which the original account troped those data and moves to suggest that ‘no, he does not’.

Contributions to the field – Teasing out the more general implications of this particular case study, the chapter concludes with a discussion of the analytical gains that might accrue if other popular scientific histories of emerging epidemics were approached as ‘topics’ rather than ‘resources’.

Purpose – To examine the rhetorical use of scientific medical evidence and diagnoses statistics in claims of an epidemic of childhood autism spectrum disorder.

Methodology/approach – Qualitative analysis of the content and dissemination of claims in several venues for social problems construction, including popular media, peer-reviewed scientific literature, and the Internet.

Findings – Rhetorical use of etiological evidence, both scientific and experiential, positing a causal link between medical interventions (e.g., vaccines), environmental toxins, and autism is prominent across several arenas for social problems construction. Claims and counterclaims involve statements amiable to or critical of evidence and its relationship to the scientific method. Presentation of diagnoses statistics and covariation with vaccination regimens are integral as a rhetorical device in claims of a true change in prevalence.

Contribution to the field – Elucidates how the medicalization of childhood developmental disabilities and increased lay involvement (e.g., parents) in the social problems process were vital for the proliferation of attention and resources directed to autism presently. The fundamental scientific method and the lack of sufficient, valid scientific evidence are not integral to the continuation of the movement that posits vaccines cause autism. The content of these claims is unfettered on the Internet as an arena for claimsmaking, allowing a lay social movement to continue that often stands in opposition to recognized scientific authority and evidence.

Purpose – Over the last years, in the United States there has been significant increase in the consumption of pharmaceuticals for the treatment of mental disorders. More specifically, the number of clinical diagnosis of bipolar disorders in young people has increased by 40 times over the last 10 years. The purpose of this chapter is to analyse the growth of bipolar disorder diagnosis using a sociological frame.

Methodology/approach – The methodology is based on the concepts proposed by the ‘conflictualist’ perspective of medical sociology. Medicalization, that is, the extension of medical categories in everyday life, is the main concept on which the chapter is constructed. The ‘syndromization’ of the Diagnostic and Statistical Manual of Mental Disorders lowers the threshold above which someone may be diagnosed with bipolarism. Moreover, advertisements push people to seek for pharmaceutical treatment for conditions of ‘normal’ sadness.

Findings – This work shows the importance of the analysis of ‘medical’ phenomena by approaches taken from social sciences. Bipolar disorder can be a terrible and painful disease, but it seems that there is the possibility that it is over-diagnosed.

Contribution to the field – In this epidemics of diagnosis of bipolar disorder it is central to integrate the medical perspective with other dimensions: the classification of mental disease, the advertisement for drugs and the cultural aspects of a given society.

Purpose – This chapter explores the changing definition of bipolar disorder, examining how debates within psychiatry actually construct the definition of mental illness, thereby creating the appearance of an emerging epidemic with increasing prevalence.

Method – I review the recent psychiatric and epidemiological research to reveal that the intellectual and scientific debates that occur in the psychological laboratory and in survey research are in fact falsely increasing the figures that show that an epidemic of bipolar is emerging.

Findings – For centuries, bipolar disorder was equated with severe psychosis and had a prevalence rate between 0.4% and 1.6%. As spectrum and subthreshold conceptions of bipolar disorder become established in official psychiatric diagnostic manuals, however, estimates of the prevalence of bipolar spectrum disorders have risen to almost 25%. I demonstrate that nearly all of this increase is a result of changes in the scientific and intellectual definition of bipolar disorders among psychiatric professionals, and that rates of symptoms are not in fact increasing.

Contribution to field – The arbitrariness of diagnostic thresholds naturally leads researchers to argue for lower thresholds. This allows more individuals who were previously considered psychiatrically normal to be reclassified as psychiatrically disordered. Lowering diagnostic thresholds increases the risk of confusing normal elation or sadness with disordered states, increasing the potential of false-positive diagnoses and the false impression of rising rates of disorder.

Purpose – To examine the influence of changing diagnostic tools and the pharmaceutical and health insurance industries' practices on perceptions of depression prevalence in the late 20th and early 21st centuries.

Approach – This is a general review of the sociohistorical shifts in depression diagnosis and pharmaceutical and health insurance industry practices during this time period as they impact professional and lay perceptions of changes in depression prevalence.

Findings – Shifts in the definition of depression to an increasingly medically oriented, social context-free definition along with the interaction of the pharmaceutical industry, health care, and health insurance industries in the U.S. system of mental health care have become major organizers of professional and lay perceptions of the nature of depression, its treatment, and prevalence. These sociohistorical and economic influences need to be factored into debates on depression prevalence.

Contribution of paper to the field – This chapter provides an introductory-level synthesis of basic psychiatric epidemiology concepts and social science critiques of professional and lay perceptions of depression prevalence as “epidemic.”

Purpose – The DSM-III reflected American psychiatry's shift from a dynamic approach to a descriptive diagnostic approach. This chapter seeks to elucidate the implications of this shift for the diagnosis and treatment of mental illness.

Methodology/approach – To shed light on this issue I analyze the diagnosis and treatment implications of this shift for Attention Deficit Disorder (ADD).

Findings – The transition to the diagnostic approach has had three consequences for the handling of ADD, and later Attention Deficit/Hyperactivity Disorder (ADHD): first, it increased the number of children diagnosed with the disorder; second, it encouraged clinicians to treat the disorder with psychostimulants; and third, it expanded the pool of clinicians who could prescribe stimulants.

Contribution to the field – Beyond illuminating the specific cases of ADD and ADHD, this analysis contributes to the medicalization literature by demonstrating that there is more to be studied than merely the expansion or contraction of diagnostic categories. Researchers also have to analyze the implicit assumptions within the diagnostic definitions, which have implications for the prevalence and treatment of illness.

Purpose – The purpose of this chapter is to explore a particular conception of youth deviance and some of its practical implications. This conception is evident in the way that the media and human services construe phenomena like teen violence and “risky” sex in epidemiological terms: as contagious and spreading rapidly through a population.

Methodology/approach – This chapter broaches these questions through review and analysis of human services research and literature as well as their practical recommendations.

Findings – This chapter argues that the concern over transmission of deviant behaviors or characteristics is linked to anxiety over youth sociality and the spaces it occupies. While historically contingent in their manifestations, causal logics using sociality to explain youth deviance (peer pressure, e.g.) continue to resonate with a medicalized viewpoint of the very category of youth.

Contribution to the field – This chapter has contributed to the field through exploring changing conceptions of youth and the sociological question of the medicalization of social problems.

Purpose – Obesity has reached epidemic levels in the United States and many other affluent countries and is a growing problem in some developing countries. World Health Organization estimates that the global rate will reach 13 percent by 2015. Because obesity increases the risk of many diseases ranging from type 2 diabetes and asthma to cardiovascular disease and some cancers, it threatens to undermine twentieth-century gains in life expectancy. This chapter offers a theoretical model of obesity that postulates the epidemic is a latent dysfunction of macro-structural changes initiated by industrialization that have decreased the physical activity of everyday life and promoted a nutrition transition to a high-calorie diet.

Methodology/approach – Comparative and historical population data are presented that generally support the conceptual model, although some significant cultural differences are found in particular race/ethnic groups.

Findings – The finding that structural changes in society created and continue to support the obesity epidemic will make it difficult to control by focusing only on health education campaigns aimed at changing individual behaviors.

Contribution to the Field – This chapter offers data and analysis that can support policy making needed to change the structural influences.

Purpose – To understand why obesity came to be considered an American epidemic, or even a global pandemic, in the mid-to-late 1990s. Why not decades earlier, given that by 1960 over 40% of Americans had body mass indexes (BMIs) above 25? Alternately, why at all, given the myriad ways in which obesity challenges standard definitions of an epidemic?

Methodology/approach – Four decades of American medical journal articles and best-selling diet books are reviewed for definitions, measures, prevalence estimates, and presumed causes of excess weight.

Findings – Developments paving the way for the “epidemicization” of American obesity include: (1) diffusion of the BMI as a standard measure of weight-for-height, and acceptance of increasingly low BMI cutoffs to define excess weight; (2) use of nationally representative surveys to estimate obesity prevalence; and, (3) the decline of psychoanalysis-driven prejudices predicating a wide gulf between a deviant obese minority and a nonobese majority.

Contribution to the field – By showing how the obesity epidemic was able to transcend metaphor and become fact within the American medical community, this study demonstrates that health issues can come to the fore of public consciousness for a complex host of reasons. Better understanding of such reasons could help in evaluating, prioritizing, and ameliorating those health problems.

Purpose – In North America today, we are witnessing an unprecedented preoccupation with “excess” weight, with millions of people perceived to be part of the epidemic of obesity. While this chapter does not seek to contest medical evidence that average weights of North Americans have risen in recent years, nor deny the potential development of associated health problems, it offers a critique of the terminology invoked in these discussions and especially challenges the characterization of increased weight among the population as an “epidemic.” This chapter suggests that what we are witnessing is more appropriately understood as a moral regulation project premised on ideas of risk, contagion, and neoliberal discourses of health.

Methodology/approach – In arguing that the concern about obesity may be understood as an example of moral regulation, this chapter employs the work of Alan Hunt, as well as Deborah Lupton's insights on governmentality and health.

Findings – In reviewing the scholarly literature on obesity as well as Canadian public health initiatives, a discourse of risk and contagion is evident. The overweight and obese (and these are commonly conflated) are presented as dangerous to themselves and others.

Contribution to the field – In suggesting an alternative understanding of the obesity “epidemic” as a socially constructed and morally regulated phenomenon, this chapter aims to further discuss and reassess how those who are considered fat are understood and treated in North America.