Medical Humanities Blog

On Disease Causality

I have the great honor of having a guest-post up at Felice Aull's marvelous Literature, and Medicine Blog.  The subject of the post is disease causality, and discusses stigma, fatness, the SDOH, and public health ethics/policy.  Mosey on over if the mood strikes you.

On the WHO, the CSDH, and "Closing the Gap"

It has been one year since the World Health Organization's ("WHO") Commission on the Social Determinants of Health released its Final Report, entitled Closing the Gap in a Generation.  To mark the occasion, the current issue of the outstanding open-text electronic journal Social Medicine has several pieces devoted to the Report.  I am still reading through them, but have finished Anne-Emmanuelle Birn's provocative piece entitled Making it Politic(al): closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (PDF).  Here is the Abstract, after which I'll offer some comments:

The anniversary of the publication of Closing the Gap in a Generation (CGG) offers a moment to reflect on the report’s contributions and shortcomings, as well as to consider the political waters ahead. The issuance of CGG was not the first time the World Health Organization (WHO) raised the problem of global inequalities in health. Numerous analysts and advocates have compared CGG to the 1978 Declaration of Alma-Ata. Some see CGG as a continuation of Alma-Ata; others malign it for paying insufficient attention to the principles, background documents, and lines of action proposed in the Alma-Ata declaration. 

We might understand the two reports as bookends to 30 years of brutal global capitalism, punctuated by the “lost decade” of the 1980s, the end of the Cold War, and, more recently, the implosion of global finance. This period saw the publication of two seminal neoliberal health manifestos –the World Bank’s 1993 World Development Report and the WHO’s 2002 Commission on Macroeconomics and Health report. Both feature the term “investing in health” in their title, conveying “a double meaning—investing [through “cost-effective,” narrow, technical interventions] to improve health, economic productivity, and poverty; and investing capital, especially private capital, as a route to private profit in the health sector.”

For anyone interested in the social determinants of health -- which, frankly, should be everyone with an interest in health and illness in society -- Birn's essay is a must-read.  Birn, of course, is a preeminent SDOH scholar, and details a number of strengths and weaknesses in CGG.  

(An aside on terminology: She argues that the term "societal determinants of health" is more accurate than "social determinants of health" because the former refers to the "broader array of historical, political, and other structural influences" in comparison to the latter, which refers "to those factors related to interactions among people and communities."  (Birn, at 167).  I have heard this argument before, and remain frankly unconvinced.  Social is social.  Sociopolitical structures are in no ways I can tell less "social" than community level interactions).

Substantively, Birn tracks a recent and equally provocative piece (PDF) on the SDOH by Vicente Navarro, in arguing that assigning causation for the preventable deaths and suffering to inequities is not equivalent to assigning culpability to moral agents who benefit from inequities.  This is, to the best of my knowledge, an overtly Marxist argument, an interpretation buttressed by Birn's discussion of Engels's concept of social murder.

This leads into what I take to be Birn's central point; that CGG is "profoundly apolitical" (Birn, 172, quoting Navarro, at 15).  "The report says almost nothing about the causes of the "'causes of the causes," viz., what creates inequity in the first place" (Birn, 172) (footnote omitted).  Essentially, CGG fails to document how the distribution of raw political power is the primary determinant of inequitable social, political, and economic structures.  Hence, CGG is relatively silent on how political action is needed to ameliorate these structures.  Birn observes 

This criticism seems to imply that radicalization is needed to address the SDOH, and Birn confirms this, arguing that what is needed to ameliorate the SDOH is the disempowerment of moneyed "private-sector" interests who wield that power "block the passage or enforcement of laws and regulations aimed at protecting the public good" (Birn, 174).

As I said, provocative.  I personally have neo-Marxist tendencies, so I am somewhat disposed to agree with her, but I am also a pragmatist and a public health policy scholar, and at least in the U.S., am quite confident that the state of the political culture is exceedingly unlikely to support radical redistribution of wealth, which I agree could only proceed by upsetting dominant power structures.  I think such action is similarly unlikely to occur on the global scale as well.

Of course, what can happen and what ought to happen are not equivalent.  This is what I have referred to as the ethics of health policy paradox: what we can do may not be what we ought to do, and what we ought to do may not be what we can do.  At one point in her article, Birn acknowledges that the practical realties of global health politics may impede the activity Birn is recommending: "Surely CGG cannot be as incendiary as Engels!" (Birn, 174).  Indeed, they cannot.  CGG would never have gotten off the ground had it advocated radicalization, which (again), does not mean that it ought not have done so, but does present a practical policy problem.

Once again, the Aristotelian concept of phronesis matters here; we are looking for practical wisdom, what some have referred to as the least worst solution.  Note also that parallel processing is tenable; there is no rule which says one cannot attend to some of the intermediate "causes" CGG identifies while at the same time pushing for more radical alteration of power structures.

Thoughts?

On Interdisciplinarity & "Academic Gangs"

In the course of a fascinating discussion on the Interdisciplinary Studies listserv, sponsored by the Association for Integrative Studies (the closest thing to a professional association for interdisciplinarians that exists), Thomas Scheff, Professor Emeritus of Sociology at UCSB, directed the list to a provocative article he had published in 1995.  The title of the article is "Academic Gangs," and he has posted the text on his website.  Here is an excerpt:

Criminologists have proposed that patterns of behavior in youthful gangs can be understood in terms of what they call "the code of the streets," as in Anderson (1994). The code is a set of understandings between gang members which help them meet both their material and emotional needs. In this essay I describe the codes of academe, the understandings between professors in gang-like groups that function to fulfill their needs.

Most academics belong to one or another group called "a school of thought" or a specialty. For example, a large group of academic psychologists consider themselves to be behaviorists. These academics are loyal to the strict code of behaviorism which bands them together in thought, feeling and behavior. In addition to membership in a specialty, all academics are also members of a super-gang or clan, the discipline.

[ . . . ]

Just as members of street gangs earn most of their livelihood from theft, academics gain most of theirs from careers. Being a member in good standing of a gang and a supergang is crucially important for advancement of one's career. There is little chance of advancement in the academy without hard work, but flaunting membership in gang and clan can certainly supplement or even substitute for talent and intelligence.

[ . . . ]

The emotional function of the gang and clan is to remove the crushing burden of isolation created by esoteric knowledge . . .  In essence, academic gangs and clans create an artificial but highly involving round of problems and practices that provide a sense of unity among members . . . 

Given the emotional and material needs of professors, much of what goes on in teaching and research becomes a ritual whose main focus is on maintaining gang and clan identity. Given this mesmerizing focus, gang and discipline rather than real world issues take pride of place.  This idea explains most of the more obvious scandals in the academy, and some that are not so obvious. It completely explains the shocking distance that most professors maintain from their students, especially undergraduates. The center of the lecturer's interest is in problems of his or her specialty and clan, which mean nothing to undergraduates.

I have already excerpted more of the article than I should, so I am going to stop here.  I don't necessarily endorse all of Scheff's perspectives, but there is enough of a ring of accuracy to pay serious attention to what he is suggesting, not least because it may go some way to explaining the liminality of the interdisciplinary scholar.  This is not simply my opinion, although it is that, but there is excellent evidence that the overt pursuit of truly interdisciplinary work, as opposed to cross-disciplinary work, is not a likely path to professional success.  As another commentator in the listserv discussion put it, the political economy of American universities is not constructed to encourage interdisciplinary studies.

I was also drawn to Scheff's essay because of a series of articles that appeared in a recent issue of Academic Medicine.  The lead article was a plea to have more non-physician medical educators ("NPMEs") involved in medical education (full-text access).  As a NPME myself, I was intrigued by both the article, and by a commentary prepared by Frederic Hafferty and Janet Hefler (full-text access).  Hafferty is the principal figure responsible for bringing the concept of the hidden curriculum into medical education (Good lord -- there's the topic for the next Lexicon entry), which is simply critical, and one I address at some length in my dissertation.

Hafferty, who is a sociologist, and Hefler, who is an educationist, near as I can tell, applaud the effort to include more NPMEs in medical education, but express concern for a variety of reasons.  Moreover, they include a warning in terms that I have been unable to forget for some weeks now:

As we look toward the horizon, one major problem we continue to face is medicine's own tribal nature. We are a culture dominated by specialists, a culture in which generalists are devalued and in which outsiders (including educationalists) are routinely (if invisibly to insiders) treated as second-class citizens.

Indeed.  One of the most basic tenets of socialization is that key aspects of our beliefs, attitudes, and practices are often invisible to group insiders.  Thus, in response to the perspective, one I frequently encounter, that suggests something akin to 'You don't know, because you have not practiced X yourself,' where X can be any one of a number of things health care providers do, I often want to say something akin to 'You don't know, because you have practiced X yourself.'  The idea is not that practical experience is irrelevant or unimportant, but simply that there are important aspects of our own practices which are best seen and interpreted by learned outsiders by virtue of their outsider status.

My own perspective is that the legitimacy of this viewpoint is very poorly recognized in medical culture, but perhaps I am mistaken.

Thoughts?

On Ghostwriting

PLoS Medicine has generally impressed me with the amount of attention, as well as the validity of its substantive ethical positions, on the disgraceful prevalence of ghostwriting in biomedical scholarship. 

Today they publish an editorial (forthcoming in the September 2009 issue, available now on the PLoS Medicine Blog) announcing the creation of a public database of over 1500 documents acquired through the discovery process in various lawsuits filed against pharmaceutical companies that detail the nature and extent of ghostwriting.  Some choice excerpts from the editorial:

If you are an editor, author, reviewer, or reader of medical journals, or if you depend on your doctor or health care provider getting unbiased information from medical journals, then the 1,500 documents now hosted  on the PLoS Medicine Web site should make you very concerned and angry. Because, quite simply, the story told in these documents amounts to one of the most compelling expositions ever seen of the systematic manipulation and abuse of scholarly publishing by the pharmaceutical industry and its commercial partners in their attempt to influence the health care decisions of physicians and the general public.

[ . . . ]

What’s clear is that ghostwriting can no longer be considered one of the “dirty little secrets” of medical publishing that nothing can be done about. While editors, medical schools, and universities have turned a blind eye to, or at the least failed to tackle head-on the pervasive presence of ghostwriting, drug companies and medical education and communication companies have built a vast and profitable ghostwriting industry.

And consider the authors almost plaintive query, "How did we get to the point that falsifying the medical literature is acceptable?"

How indeed.

There is too much I want to say to really begin the task of blogging about it, although the inimitable Margaret Soltan is, as usual, worth reading.  I hope to wade through the database if I can stomach it, and may post further thoughts subsequent to the review.

On Fatness & Health

Perhaps because I read Gary Schwitzer's blog and quality assessment project so avidly, I am somewhat down on the quality of much health journalism, in the West, at least.  But every now and then, I read a terrific article that renews my faith.  One such article, authored by Margaret Wente, appeared in the Globe and Mail, a Toronto-based publication.  The article takes an unusually (for media, I think) critical look at the epistemology of the fatness-health connections.  It is quite well-written, and while I do not endorse the entire article, I absolutely appreciate the critical tone of the writing and the arguments adduced therein.  The article models, in many ways, some of the best and most persuasive academic writings in the critical obesity scholarship.

Some excerpts:

Thin was always in. But now, the social and public-health message is that fat is not simply a sign of sloth. It kills. The obesity epidemic is the greatest health crisis of the age. According to various health statistics (which are never consistent), between 17 per cent and 25 per cent of Canadian adults are obese. Thirty-six per cent of the adult population is overweight, or maybe two-thirds. Whatever. It's a catastrophe.

But is it? A new study based on Statistics Canada population data reaches an exceedingly awkward conclusion: People who are overweight live longer than people who are classified as “normal” weight. Not only that, people who are classified as significantly overweight also live longer.

(For the record, thin was most assuredly not always "in."  Quite the contrary, in fact.  But it has been so for much of the 20th century, at least in the U.S.)

[ . . . ]

“Overweight may not be the problem we thought it was,” said David Feeny, a senior investigator at Kaiser Permanente Center for Health Research in Oregon, almost apologetically. “Overweight was protective.” He added that agencies such as Health Canada might want to rethink the way they classify people's weight.

It is remarkable to see an academic investigator working on obesity research publicly allow as such.  Perhaps there is hope.  Indeed, as Wente notes,

Is this study just a fluke? On the contrary. It confirms the findings of dozens of other large population studies that rarely get publicity. They all conclude that being overweight is not a problem, except at the extreme. In fact, a little extra padding is good for you.

Many of these studies are documented in Gard and Wright's fine book on the subject.  Last excerpt:

In 2005, another researcher, Katherine Flegel, of the U.S. Centers for Disease Control and Prevention, published another large study with similar findings. Prominent health experts were outraged, calling the research flawed. “There's not a lot of money in trying to debunk obesity, but a huge amount in making sure it stays a big problem,” Patrick Basham, a professor of health-care policy at Johns Hopkins University, told The Associated Press.

Indeed.  

Go read the whole thing.  Thoughts?

(h/t SDOH Listserv) 

On Renaissance Networks

Ann Moyer (History -- Univ. of Pennsylvania) has a wonderful review up on H-Net of Paul McLean's recent book, The Art of the Network: Strategic Interaction and Patronage in Renaissance Florence.  Many aspects of this review should be of interest to a medical humanities audience.

Moyer notes:

To get things done, then, required knowing whom to ask; it also required that the petitioner have something to offer, whether now or later, tangible or intangible, to repay the favor. And of course these urban citizens lived their lives embedded in a number of relationships of different sorts: family, profession, neighborhood, political party, and so on, to a very long list of social groupings and obligations, any or all of whose members might hope to make claims on one another over the course of a career or a lifetime.

These matters are exactly what the studia humanitatis were targeted towards: a practical engagement with the world.  But not simply any practical engagement will suffice; virtuous engagement is needed, and the studia humanitatis was intended to facilitate.  This is in part why the apparent belief that the humanities are impractical vexes me no end.  If this belief is actually accurate -- if the humanities as currently practiced are in fact disengaged and impractical, then those of us responsible for such practices are abandoning the hopes, lessons, and programs of our forefathers.

Thus, Moyer notes that

McLean’s specific focus on Florentine letters of recommendation and request then leads him to look at the role of the humanist educators who set a high standard for quality of writing and dispensed rules about the specifics. These men helped establish formal norms for such letters, and the literary skills they imparted aided Florentines in both composing and reading such letters strategically.

It is no accident that so many humanists and humanistically-educated personages were active participants in social and political life as diplomats, jurists, couriers, advisors, officials, attorneys, professors, etc.

More from Moyer:

[McLean] argues that good letter writers were able to give a shape in their letters to the ongoing relationship between author and recipient, such that the request and its granting would, it was hoped, ring true with the recipient and inspire him to undertake the desired action. The rhetorical tools of the humanists, along with their goals of shaping people’s understanding of their world and bringing them to appropriate action within it, thus had a major role to play in the lives of scholars and of middle-class Florentines. As McLean notes, in Florence these tools served not only social ends, but political ones as well; indeed, political and social goals often overlapped.

These considerations are why I continue to believe that those of us interested in the medical humanities should ground our work in an historically and philologically informed understanding of those who mediated antiquity into the educational program we continue to call the humanities.  There is, if not an essence to the humanities, at least a set of family resemblances that can shed a great deal of specific light on the nature and potential goals of the interdiscipline.  And those resemblances emerge in important part from examination of the humanists, the studia humanitatis, and the local social worlds in which these conversations took place.

Thoughts?

(H/T H-SCI-MED-TECH) 

On Eugenics and History (II)

I have the privilege of corresponding, from time to time, with historian of eugenics Gie van den Berghe, a professor at the University of Ghent.  I reprint below his comments on my recent post on eugenics and history:

You call Oliver Wendell Holmes' line 'Three generations of imbeciles are enough' "infamous", but that is how we judge it here and now. In fact it was, seen in its time, a courageous and logical standpoint (and of course not only the decision of Holmes but of the almost unanimous Supreme Court). So his/their decision shouldn't, in my opinion, so much be admired ('Holmes was nevertheless ready, willing, and able to utter the infamous line') then understood.

"We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concer­ned, in order to prevent our being swamped with incompetence. It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are mani­festly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11. Three generations of imbeciles are enough".

 Generally one cites only this part of 'The Supreme Court Opinion in Buck v. Bell' (or some extract of it), but the Opinion continues and ends by the following line:

 "But, it is said, however it might be if this reasoning were applied generally, it fails when it is confined to the small number who are in the institutions named and is not applied to the ultitudes outside. It is the usual last resort of constitutional arguments to point out shortcomings of this sort. But the answer is that the law does all that is needed when it does all that it can, indicates a policy, applies it to all within the lines, and seeks to bring within the lines all similarly situated so far and so fast as its means allow. Of course so far as the operations enable those who otherwise must be kept confined to be returned to the world, and thus open the asylum to others, the equality aimed at will be more nearly reached."

This kind of argumentation had been employed in the 1920s by several eminent American and European men, frequently with a reference to the many thousands young, vigorous men who had died or ho were mutilated during the devastating Great War. In 1920, in Weimar Germany, the reknowned jurist Karl Binding and doctor Alfred Hoch pleaded wit this and other arguments for the 'euthanasia' for so-called lifes unworthy of life (Die Freigabe der Vernichtung lebensunwerten Lebens), and Adolf Hitler did the same in 1924 in the first part of his Mein Kampf.

his is not to claim that Nazism was founded on Darwinism. There is no direct link, but indirectly one can trace a kind of reasoning about asocial, marginal 'elements' in one's community, a community that was seen as of much greater importance than the individual. The people (Volk), the nation, the body of the nation (Volkskörper in German) had to be saved of the contaminated, rotten cells/individuals it contained. This kind of thinking generated in Great-Britain, shortly before Darwin wrote his 'On the origin of species' (1859) - think for instance of Herbert Spencer. And after the publication of Darwins masterpiece, more and more thinkers, such as Francis Galton, adopted it. Now that the motor of evolution, natural selection, was discovered, one was afraid that the biological evolution, this progress of the human species, was countered or even stopped by Civilisation. A civilisation who not only kept in live marginals that Nature normally would have eleminated (poor laws, medicine, hospitals, asiles), but even made possible that these unfit breed and multiply themselves at a faster rate then the fittest specimens of the nation.

On Eugenics & History (I)

H-Law published a review by Lynne Curry of two recent books on eugenics, including Paul Lombardo's account of Carrie Buck, and her experiences before, during, and after the notorious case of Buck v. Bell. 

Here is an excerpt from the Review:

Eugenicists, many of whom were associated with the Eugenics Record Office in Cold Springs Harbor, New York, exercised a profound and disturbing influence on law and social policy, including drafting a model compulsory sterilization law and then vigorously campaigning to have it replicated in the states.  While much of this material will not be new to historians, Carrie Buck’s story becomes even more compelling steeped in the rich detail that Lombardo provides.  Buck was an extremely poor, barely educated, seventeen-year-old rape victim, who in 1920s Virginia became a pawn of a blatantly self-serving cast of incredibly shady characters.  Mandatory sterilization laws had met with mixed success in state courts, and therefore in Virginia a small circle of eugenicist lawmakers, doctors, and institutional directors conspired to write and enact a statute and then manufacture a test case to gain a judicial stamp of approval for their own project.  Lombardo vividly presents the patently absurd case concocted purporting to show that Buck was both “feeble-minded” herself and the daughter and mother of feeble-minded females, rendering her a genetic threat to the population and a fit subject for the operation. (Her younger sister was also sterilized.)  Buck’s lawyer, himself a major crusader in Virginia’s sterilization campaign, “violated every norm of legal ethics” in deliberately failing his client at each step in the case, leaving Buck quite literally defenseless (p. 155).

I had the opportunity to meet Dr. Lombardo at the AAHM Meeting in April, and it was wonderful to get the chance to chat with him a bit about the history of eugenics.

Dr. Lombardo has compiled a wonderful web site in support of his book and his work, which features a rich digital supplement chock-a-block with downloadable primary sources from the public domain.  I cannot recommend either the book or the website enough.

As notorious as Buck v. Bell is, I think it is actually underemphasized in terms of its importance, mostly because the case aptly demonstrates how powerful was the hold eugenics exercised on American society during the 1920s.  Lombardo's book, which I am currently in the middle of, does an excellent job of separating the scholarly and religious debate over eugenics from the widespread acceptance it enjoyed among wide swaths of the lay public.  This last point is an important methodological aspect of any social history, which both Fairburn and Jenner warn against (presuming that the attitudes, beliefs, and practices of an elite subsume those of various less privileged communities and subgroups).

Having legal training as to Buck v. Bell helps, not so much because the case is difficult to interpret, but more because knowing anything at all about American legal history suggests just how visionary and singular a mind was Oliver Wendell Holmes.  Arguably the most important jurist in that history, and one of the most influential in Anglo-American jurisprudence itself over the last 100 years, Holmes was nevertheless ready, willing, and able to utter the infamous line: Three generations of imbeciles are enough.  This is a critical example of the reach and power of eugenics ideas, and it is absurd, as so many do, to see this history as a curio, an artifact. 

Roughly 90% of pregnant women informed that their fetus has trisomy 21 (Down Syndrome) choose to terminate the pregnancy.  I do not judge this decision, but do want to note that there is no way to interpret this as anything other than an example of the persistence of eugenics tropes.  Disability studies scholars have repeatedly pointed out that prenatal testing itself is founded on eugenics, whether we endorse or reject the practice.

The history of eugenics demonstrates the importance of understanding history dialectically, as events, ideas, and conditions continue to shape the world we inhabit in profound ways.  There are, in my view, fewer short-sighted approaches to the study of history then to perceive it as a linear "that-was-then-this-is-now" phenomenon.  History has much more to offer than that.  Despite the frequency with which people bandy about Santayana's quote, my suspicion is that a much lower percentage of those who quote him approvingly actually understand why it is that history repeats itself.  It does so, in short, because it never really leaves us.

Thoughts?

On Clinical Anthropologists

As most readers of MH Blog know, while I am no social scientist, I am, shall we say, an exceedingly friendly outsider when it comes to (medical) anthropology.  I read widely in the field, attempt to understand the implications of anthropological research for all manner of topics (e.g., pain, stigma, ethics, religion and medicine, etc.), and count it a great fortune that I have ongoing dialogue with several medical anthropologists.

Why so? After all, it is hardly as if, say, health psychology or medical sociology has nothing to offer the medical humanist.  Why am I particularly attracted to anthropology? The short answer is 'who knows;' why is any one person attracted to one field over another? There are many interesting answers to this question, but the majority of these, in my view, will vary widely depending on the context and the persons involved.

The longer, pedantic answer is that if nothing else, I think a medical humanist is or ought to aspire to be a social and cultural scholar as to medicine and medical practice.  If indeed the study of culture is central to the MH, then how, pray tell, can one pretense to get at that inquiry without guidance and insight from the very discipline which arguably centers the study of culture? 

In any case, in my travails at a medical school and an academic medical center, I have often wondered why it is that I have encountered so few "clinical" anthropologists, or medical anthropologists working in clinical settings, at the bedside, so to speak, and on staff at hospitals.  I do not mean to suggest that such practice is unheard of, but it certainly is not de rigeur the way clinical ethicists have become in clinical setting.  I do not have much of an answer to this question, but I have felt for some time that the relative lack of a continuing presence for anthropologists in the clinical setting -- not just doing time-limited field research -- is something of a loss, if not for the anthropologists, then for the rest of us, who could, IMO, benefit greatly from the insights and approaches regarding that most complicated of creatures -- humans, and human culture.

Just for example, I have often wondered how different my local world would be if it were anthropologists in charge of designing, implementing, and teaching cultural humility, instead of the relatively thin but conventionally dominant and poorly named "cultural competence."  How much richer would the learning opportunities be?

On the H-MED-ANTHRO listserv, a participant queried whether any of the members had any experience in clinical settings, and one of the answers struck me as so important, I requested and received permission to repost it here.  The question was posed by Nick Jefferson-Lenskyj from the University of Queensland (which serves large numbers of indigenous Australians), and the reposted answer is authored by Lissie Wahl:

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).