On Swine Flu

It is fascinating to observe the current American discourse on swine flu.  Keller reminds that scientific discourse is a praxis, which indicates that the phenomena of the reaction to swine flu plays out in a space between public, lay, media, and professional stakeholders.  Public reactions, impressions, and language shape scientific, epidemiological, and political responses and actions, and vice-versa, in a constant feedback loop.

One of the most prevalent themes in the social construction of disease in general, but especially as to infectious disease, is the tight connection between illness and culpability.  This is a topic I am currently working on, though it has consistently enjoyed ample attention in the medical humanities literature.  But no sooner does news break of a potential influenza pandemic then the finger-pointing and responsibility-assessing begin.  As countless historians of medicine & public health, and other medical humanities scholars have painstakingly demonstrated, these assessments frequently stratify along social fault lines, typically coming to rest at the feet of already marginalized and disadvantaged social groups.  Thus, it should be entirely unsurprising that the "patient zero" trope identifies impoverished, rural Mexican pig farmers, and, predictably, the nascent anti-immigrant predilections in the U.S. have also been activated.

Perhaps, then, this is a good time to revisit Wendy Parmet's recent article on the ethical inadvisability of the "dangerous patient perspective," which traces causal roots of infectious disease outbreaks to individual actors.  This makes absolutely no sense epidemiologically, of course, because epidemic disease are primarily the result of social, economic, and political conditions.  Mary Mallon did not cause any epidemics of typhoid fever (<50 people were infected as a result of contact with her -- this is not trivial, but is nevertheless a tiny fraction of the numbers of persons infected with typhoid fever at the time); as Leavitt demonstrates, and Parmet notes, thousands of persons became infected with typhoid fever in NYC at the fin-de-siecle, persons who had no contact with Mallon.  Once again, I suggest, thinking deeply about our attributions of disease causality is a powerful window into the social and cultural meanings of illness.

Thoughts?

UPDATE: Erin Koch, over at Somatosphere, has a fine post where she explains in a bit more detail some of the social and economic factors that are prime determinants of the spread of this particular influenza outbreak:

  . . . industrial livestock production is the main culprit here . . .

[I]ndustrial livestock production is a powerful driver of viral (and bacterial) evolution. Davis emphasizes that the transition "from old-fashioned pig pens to vast excremental hell, unprecedented in nature, containing tens, even hundreds of thousands of animals with weakened immune systems, suffocating in heat and manure, while exchanging pathogens at blinding velocity with their fellow inmates and pathetic progenies" creates a perfect storm for evolving pathogens likely to establish resistance to antivirals and antibiotics. This is not just the case in China (everyone's favorite target for allocating bird flu blame) or Mexico (everyone's new favorite target for allocating swine flu blame). 

Quite.

UPDATE II (5.3.09): Friend of MH Blog Dan Bustillos points me to an article discussing the predictable linking of swine flu with concerns over immigration.  From the article:

The North Carolina-based Americans for Legal Immigration called for the border to be shut down and asked for the resignation of Homeland Security chief Janet Napolitano because she did not order agents on the border to wear masks . . .

Swine flu is a mix of pig, bird and human genes, and some radio hosts are calling it the Fajita flu – including Neal Boortz, an Atlanta-based radio talk show host.

In Texas, especially, the humorous ignorance of this appellation is perfectly clear.  (Pork is never, ever served with fajitas).

Comments

[François]

Hi Daniel,

Thanks for a great post. From a very naive perspective, I'm just still shocked (but not surprised, unfortunately) at a) lack of public knowledge, in developed countries, regarding basic facts of health/disease prevention, which directly play into the easy xenophobic tendencies you've noted and b) the obtuseness of "professional" journalists to do their jobs when it comes to science (yes, there can be facts, and yes, they are likely discovered by a technical process "owned" by experts, with all the problems coming with that) -frequently seen with climate change issues (e.g. http://tinyurl.com/defmsv )- and their willingness to invite anybody but calm and current epidemiologists/public health specialists (granted we're lacking in that latter department) to share facts about the epidemic.
This just emphasises for me the desperate need for orders of magnitude more public education (including in schools!) regarding science, so that there is a possibility for the general public to at least evaluate the authority of sweeping statements made in public forums.
(Apologies for making this sound like an opinion piece.)

[Daniel S. Goldberg]

Francois,

Nothing you say strikes me as either naive or anything to apologize for. Much of it sounds about right to me. Thanks for reading and commenting.

In my more cynical moments, however, I wonder if public education is enough to dislodge some of the deep social and cultural reasons why we stigmatize the sick as culpable. That doesn't obviate the importance of such education, of course, but suggests that, as I frequently find myself musing, culture is the hardest thing in the world to change.

[Erin Koch]

Hi Daniel,

Great post (and thanks for mentioning mine). I think that, no matter how much attention ties between illness and culpability receive in medical humanities and anthropological literature, the topic cannot be over-studied. The dynamics of the 2009 H1N1/swine flu outbreak and its responses underscore your points!

In thinking about the particular nuances of infectious disease, I think it is also really interesting to scrutinize the ways in which individuals are rendered culpable in their susceptibility to an infectious agent. I think the ties that are established--and naturalized--between diseased populations and causal viruses and bacteria are also a compelling lens for, in your words, "thinking deeply about our attributions of disease causality...[to understand] the social and cultural meanings of illness." Among other things, I'm thinking about rhetorics of both "behavior" and "compliance."

Love your blog!

[Daniel S. Goldberg]

Hey Erin,

Thanks for the kind words on the post and the blog. And I whole-heartedly agree that the ties between illness and culpability cannot be overstudied. (Sidebar: While infectious disease outbreaks provide a particularly powerful window for the analysis, I admit to perturbation that the links in context of chronic illness experiences enjoy less scholarly attention).

The individual susceptibility theme is crucial, and as, as I'm sure you know, quite old, as it harkens back to humoral medical cosmologies. This, among other phenomena (e.g. the prevalence of the chemical imbalance theory of the causality of depression/mental illness) feeds my belief that Noga Arikha may be correct in suggesting that understandings of health and illness in Western and/or American culture remain deeply humoral in many important ways.

I loathe the word "compliance." Kleinman is right on when he points out how the geography of the term vitiates any sense of a colloquy between illness sufferer and healer. It also, as you point out, assigns culpability.

[Bears are Fat]

For commentary on patient culpability in chronic contexts see Greenhalgh's Under the Medical Gaze. For cinematic commentary on the same dynamic, see Todd Haynes's Safe.

I'm really enjoying this discussion. Koch's post at Somatosphere brought me here.

One thing to note: while I think unmasking the ways in which the domain-jumping 'hype' and 'hysteria' around "swine flu" cover over (a) industrial or iatrogenic nature of the problem and (b) seem to be linked in uncanny ways to anxieties about 'Mexicans' in the US immigration debate, I wonder if a bit more interpretive generosity toward those who indulge in 'patient zero' blaming might be called for. That is: blaming industrial agriculture has a morality built into it *as well*: it is a political statement (M Douglas taught us about this) as much as is the phantasmogoric evocation of infectious hordes from elsewhere threatening the USA (and the world)...

[Daniel S. Goldberg]

Bears,

Funny to see you mention Greenhalgh, as my dissertation is on the undertreatment of pain. The work is valuable, but from an ethnographic perspective, I prefer Jean Jackson's works on chronic pain, esp. her 2005 essay.

As for your point on interpretive generosity, you may be right, but I'm not sure I understand how that is connected to the fact that tracing causal responsibility for the H1N1 outbreak to agribusiness is itself normative. Of course the latter is; causal attributions themselves are irreducibly value-laden. This does not by itself say much about the merits of the substantive normative claim, nor do I entirely see how, by itself, it suggests greater interpretive generosity is due those who frame the meaning of the outbreak in terms of the "patient zero" narrative.

That said, if there is one thing Parmet's essay, along with some of my favorite history of medicine analyses of ID and stigma (esp. Rosenberg) make clear, it is the social, cultural, and psychological reasons why the dangerous patient perspective is so prevalent. It is both wholly understandable and quite perilous, in my view. It is also normatively undesirable, I think, and I am quite happy to note the value-laden nature of my claim here.

Can you say more about how and why you might think more charity is due the moral agents who conceptualize the outbreak in such ways, and also how that charity justifies a normative claim on behalf of the frame?

[Eric]

There is actually substantial evidence that factory farmed meat has been responsible for this recent outbreak as well as earlier pandemics (such as avian flu). See this post at the Nature Network for more info, and a substantial list of primary sources confirming the link.

[François]

Bears & Eric: I'm vastly suspicious of the "Smithfield hypothesis" as far as origin/source of swine flu epidemic is concerned. I originally saw it in the MSM (I think reported by AP) and, if I recall correctly, it seems that the people of the city were 100% certain the origin of the epidemic was there, although Mexican health officials determined that there had been only one case of swine flu in the city, the others being 'regular' human flu. E.g.: "And in Mexico reports in at least two newspapers focused on a factory farm run by a subsidiary of global food giant Smithfield Foods. Some of the rumors mentioned noxious fumes from pig manure and flies -- neither a known vector for flu viruses." http://www.reuters.com/article/scienceNews/idUSTRE53T3ZK20090430

My main concern with this argument is that it's attacking indirectly the Mexican health authorities in a conspiracy-theory-like way, and that it's playing to the vastly discredited arguments that the Mexicans have been doing a bad job containing the flu, etc. -when in fact it's clear that through the sacrifices they made and excellent containment they've spared the rest of the world a much faster initial spread. (Be happy to provide reference for that claim if required, but it's 3 am so I'm going to be a bit lazy and not look it up right now.)

Also, I think that conspiracy-theory-like arguments aimed at shitty agricultural/farming practices discredit much stronger arguments against them -we don't need them to be at the origin of a global pandemic to refute them.

Disclaimer: I'm by no means a supporter of shitty agricultural practices, buy local & organic as much as I can, and subscribe to a CSA service.

[François]

Actually I'm re-reading Snow's "Two Cultures" for a completely different project, but I'm just realizing that this narrative (i.e. the factory is responsible for the epidemic) doesn't just feed into the anti-underdeveloped country trope but might more generally be a nice case of a classic anti-modernist trope, assuming that the town's inhabitants' impressions of the origin of the disease have been at least amplified and deformed by the media (which I think, perhaps naively, is not a far-reaching assumption). Reading Snow in the Canto edition, I'm looking in particular at p. 27.