On ‘social diseases’

Using examples from contemporary social and medical anthropology, critically assess the following review of Briggs’ book: “Cholera has always been regarded as a social disease. It is vastly underreported. Countries do not like to report it because of its commercial impact – they prefer to blame it on their neighbors – and because of variations in the definition of a case. The authors recognize this problem but offer few helpful suggestions. Rather, they criticize administrators, health care deliverers, and epidemiologists, and they take a long time to do it.” (Finkelstein)

Early on in his ethnography, Charles Briggs (2003, p.17) outlines his motivation ‘to disrupt the circulation of stories and practices that kill, foster critical awareness of the politics of health and inequality, and support global cooperation and justice’ which sets itself up for critique through Finkelstein’s review that suggests Briggs and his co-authors ‘criticize administrators, health care deliverers, and epidemiologists’ without advocating any practical points. Unarguably, Finkelstein’s assessment could be levied at many industries and persons, for it is typical of human nature to criticise rather than prioritise coordinated action, yet his review is, overwhelmingly, comprehensive. When contrasted with the clear, almost overly simplistic action plan proposed by Paul Farmer (1999) in ‘Pathologies of Power’, Briggs’ ethnography reemerges in a far less positive light, offering extended discursive engagements with cholera and its narration from several viewpoints, but scarce retrospective policy suggestions. As a result, it is intriguing that Briggs’ frontispiece appropriates Cindy Patton (1996) in Fatal Advice for, in many ways, his own explorations of cholera similarly represent a hysteria and ‘individual blame’ culture. The crux of the considerations prompted by this question is that disease; experiences of it and its outcomes, are variously perceived across cultures, peoples, and power structures. Precisely because the variance in fields of reference can become politically and socially charged, it is important to acknowledge difference rather than to attempt to write it away or negate its existence. Indeed, through the school of ethnomedicine one can argue that the definition of ‘disease’ is not universal; its significance and representations vary, and the only way to ascertain these values is to interact with peoples across disciplines, so introducing a spatial and subjective nature to any verbal construct of ‘disease’. Therefore, it is appropriate to use leprosy as a counterpoint to cholera, both considered social diseases that see lexical difference writ large, and broader overwhelming complications of policy approaches and social management.[1]

Indeed, it is fitting to assess definitions because Finkelstein (2003) employs this exact term: ‘variations in the definition of a case’. In order to distil this argument’s assertion that lexical difference at the microcosmic level extrapolates to public health agendas, one can consider the World Health Organization’s (2000) published resource on leprosy which adopts sweeping and inclusive terminology: ‘generally leprosy should not be diagnosed without a definite loss of sensation’. Extending from the clinical basis, the industry of health is registered through terminology of the ‘commercial’, at once denoting a concern or engagement with commerce: making or intending to make profit. The commerce of health is deeply volatile but pervasive, capitalizing not only on a globalized world economy but also on race, by racializing social constructs. Cholera and leprosy are regarded as social diseases because they exhibit a high incidence among predisposed socioeconomic groups under adverse living or working conditions. An alternative definition as sexually transmitted diseases (pertinent given that leprosy was originally associated with syphilis) captures the social movement of words and experiences of health – or lack thereof (Munro, 1890). What readers of Stories in the Time of Cholera: racial profiling during a medical nightmare (Stories henceforth) are exposed to is a consideration of the different discourses that arise and perpetuate social disease, in particular that of the media – in itself a commercial industry (with interesting lexical punning on ‘an advertisement’ as well as fiscally grounded methodology) – and the injustices that facilitate them. Finkelstein cites a failure of pragmatism in Stories, while Farmer similarly narrates a historical dislocation of justice and public health in the twentieth century. Notwithstanding the judiciousness of Finkelstein’s assessment, it does raise the timeworn debate of nature versus nurture, in itself demanding consideration. The ethnographic nature of Stories does not fulfil the activities Finkelstein expects of it – there is discursive discussion, sometimes delineated through a Western lens, but limited guidance. Perhaps this is based on the nature, or the conflicts of interest of Briggs, with accounts of social disease subject to narratorial framing as suggested by: ‘cholera stories varied widely. Nevertheless, narrators tended to view the epidemic either in terms of its broad social, political, and historical factors or as a medical and epidemiological phenomenon’ (2003, p.8).

Like any experiment or model, Stories is subject to various means and ends as Briggs focuses on the moralizing nature of cholera akin to ongoing engagements with leprosy. Indeed, the modern world’s media and political community encounter great difficulty in reconciling Norway with the existence and persistence of leprosy during the nineteenth-century, because such a social disease remains much easier to narrate through the context of a socio-economically deprecated country such as Bangladesh. Its history in Norway is framed within these terms: ‘leprosy is pre-eminently a disease of poverty – and the hygienic conditions and the economic welfare in Norway have increased considerably in this century. […] There are at present only seven lepers alive in the whole country. Leprosy may therefore be regarded as practically stamped out in Norway today’ (Vogelsang, 1965, p.35). In many instances, it is in the interest of these parties to encourage a racialization of disease, but also a biomedicalization of it as an experiment subject to investigation rather than a public health crisis. Indeed, during decisive years of London-based cholera, Dr John Snow referred to ‘his studies of the South London water supply and cholera as a naturally occurring experiment’ (Paneth, 1998, p.1550). So too, coverage – or otherwise – of these disease trajectories is shaped by timeliness, racialization and veracity. Only a decade ago, in a letter written to the editor of The Times, the problematic terminology of ‘leper’ was raised: ‘leprosy is curable, treatment is free and social discrimination has no place. […] I urge your newspaper to refrain from using the ‘L-word’ (leper) forthwith’ (Sasakawa, 2006). Once again, the lexicon of ‘place’ carries agency, highlighting that writers, forms of publication and circulation all politicize and subjectivise social disease, deciding what to showcase or conceal. The aim of any authorial ethnography is surely to capture what Farmer (2004, p.78) recognises as Pierre Bourdieu’s genius in pulling together a “compendium of testimonies from those the French term ‘the excluded’ in order to bring into relief la misère du monde. […] ‘To subject to scrutiny the mechanisms which render life painful, even untenable, is not to neutralize them; to bring contradictions is not to resolve them’.” Finkelstein appears to appropriately question the extent to which Briggs succeeds in emulating this methodology.

Social diseases are at once something that can be passed around between bodies, cultures, and voices but in each new embodiment or expression they come to represent different things that are empirically, historically and socially constructed. Indeed, Finkelstein’s critique raises Michel Foucault’s (1990, p.140) notions of biopower assessing actors on, and enactments of, change and health on our own bodies and those of others via ‘an explosion of numerous and diverse techniques’. Under this field of thought, power does not solely belong to actors; discourse, institution and regimes of truth produce and reproduce conditions and practices that can be harmful to health. Foucault’s recommendation to look at history less as a linear process of improvement but as an oscillating movement of experience reveals how power is a productive force over society. Biopower acts through knowledge techniques of peoples and subjugates them through ignorance both of historical evidence and constructed disinformation. Indeed, it might be argued that social diseases are ‘plagues’ (Farmer, 1999) widely apprehended even at the lay-person level, but such understanding is inextricably historically bound, and manipulated by local and digital media. Demonstrably, ‘when newspapers and television news programs across the country reported that a massive cholera epidemic in the delta was decimating its indígena residents, the depth of social inequality became deathly apparent. The revelation threatened the racial equilibrium that helped regulate access to power and resources in the region’ (Briggs, 2003, p. 135). Stories tracks the reports and power circulating within the cholera endemic Orinoco Delta of Venezuela between 1992-93 and seeks to highlight variance, revisiting that ‘time’ rather than re-enacting it for the purposes of didactic policy-making. The focus is on explaining health inequalities in the modern, globalized world and so exposing how its peoples can be victimized ‘in the context of local social worlds’ (Janes and Corbett, 2009). Stories cannot be assessed unfavourably for not outlining policy because it occupies a state of representation, exposure and reflection, without extending into the present structure of advocacy. It is useful to here consider the language of nightmare – in itself a social construct and a state of disturbance or non-reality, with shifting connotations and motivations from a thirteenth-century understanding of ‘an evil female spirit afflicting sleepers with a feeling of suffocation’ to ‘very distressing experience’ by 1831 (OEDictionary, 2001).

The move from the space of the book into the populated environment of social disease is taxed, in part through the pervasive literary references which are potentially alienating. Finkelstein’s review identifies the time-dependent nature of reactions to social disease: acute versus chronic, latent versus finite, fear versus memory. Surely Stories’ title is a direct nod to Gabriel García Márquez’s Love in the Time of Cholera, so questioning the role ‘time’ plays for Briggs as author, global health participant or figure of power. Typically, leprosy is figured as an ancient disease – constructed of and about people, while cholera is identified as the quintessential premodern disease (de Sainte-More, 1978) with ‘people who labeled their neighbors as cholera-ridden unsanitary subjects […] often [… catching] cholera’s stigma themselves. Since denigrating images travel so well, medical profiling tends to return to haunt those who use it’ (Briggs, 2003, p.319). Here again, the space of the nightmare and the language of time are registered and recall Finkelstein’s criticism of the taking of a ‘long time’, suggesting an anachronistic methodology for a modern-day publication. But this is in itself problematic. Cholera and leprosy have social understandings that are entrenched in an era that outlined disease etiology without recourse to a biomedical model, often relying on religious and social justification. Indeed, in the case of leprosy it is easy to temporally distance oneself, as its narrative of the ‘unclean’ dates back to Christian ‘times’, but vexedly so, with narration open to bias and questions of veracity surrounding the conception of modern disease. So too, Guy de Maupassant argues for the ‘other’: ‘cholera is something else, it is invisible, it is the curse of the olden days, of times passed, a sort of evil spirit that comes back and that surprises us so much that it haunts us’ (Delaisement and Schmidt, 1959). Of course, such a dismembered approach to social diseases means actively proposing strategies for their management is restricted or willingly overlooked. Which demands a questioning of how these ancient (or, at least, premodern) diseases of cholera and leprosy fit into ‘modernity’ and globalization. It was only two centuries ago that cholera plagued London with the infamous 1854 Broad Street outbreak identified by Snow and that leprosy was endemic in Norway. According to statistics recorded in 1856, the date of the first reliable national census of lepers, the count of a ‘total of 2,858 lepers was reported. Norway had at that time a population of about one-and-a-half million, so that about two per thousand of the inhabitants were lepers indicates a level above the modern-day WHO measure of elimination’ (Vogelsang, 1965).[2]

This identifies a common thread to both Finkelstein’s review and Briggs’ narratives: that of shifting boundaries. The linguistic definition of a ‘case’ is particularly apt to leprosy, which was declared eliminated by the WHO in 2000. This has led to a rise in hidden cases, guilt and blame imposition. This structural power is resonant with Finkelstein’s commentary on Briggs’ criticism of authorities constituting a discourse of blame, highlighting the context that facilitates this vast underreporting of cases. Briggs (2003, p. 21) identifies cholera, leprosy and so-called social diseases as spatial burdens with an associated geography of blame: ‘from the start, the language used to describe cholera was spatial. Defining the epidemic in terms of its location within and capacity to “spread” beyond national borders provided a narrative structure that appeared over and over’. This spatialisation is nationalistic at best, colonialist at worst. Indeed, these diseases have systems of representation that establish blanket associations within the popular imagination such as: cholera is linked ‘with Asia, specifically India’ (Briggs, 2003, p. 26). Meanwhile, Victoria Hislop (2006) demarcates an equally charged spatialisation of leprosy and its interactions in the modern world amongst its citizens: ‘events seem to take place out of the blue that change the course of our lives, but what really determines what happens to us are the actions of those around us now and those who came before us’. Such criticism is a necessary precursor to policy and the forms it takes, which are not, nor should they be, the nature, nor subject, of Stories. Much of this discussion orientates around the nature and functions of identity or personhood and its preservation at local and national levels. At a government level this self-creation is about distancing oneself, for as Erving Goffman (1990) has indicated, leprosy is underreported partly due to its stigmatising potential while cholera creates a culture of fear through its aggressively infectious potential. Linguistically, leprosy is ‘neglected’[3] because of fear of its social and commercial impacts: it is racialized through purblind ignorance and risk. Briggs (2003) seeks to overwrite this via Patton’s assertion that: ‘it is easy to overwhelm what people know with what they fear’. More judicious from Finkelstein would be an assessment that Briggs’ absence of practical solutions attempts to re-frame racialization as denigrating without inadvertently promoting it.[4] Furthermore, the association between health and inequality lies beyond epidemiology in social capital, and the overlap between both biological and neomaterialist explanations. This mixed state is a return to an interim – an attempt to highlight facts in a cogent manner without muddying these with policy-based assessments, a nightmare state that resists a possibilist world to wake into. Indeed, Briggs (2003, pp.3-4) describes the moment at which ‘the unknown disease thrust them [the Riveras] into a nightmarish world of terror and dislocation’.

Prioritising the narration of nightmare in real time, in the lived words of local peoples with cholera and leprosy rather than through the narration of an elitist publication can propel practical, representative and sustainable change. For Finkelstein’s review to be rewritten, it will be necessary to adopt a theoretical orientation that emphasizes shared responsibility and the role of political-economic factors and macrosociological factors (including ethnic conflicts, racism and migration). As Farmer (1999, p.1493) articulates, while ‘it isn’t really possible to merely study the topic [health and human rights] without meaningful and pragmatic interventions; it is important to distinguish between our best analysis and our best strategies’ straddling discourses of biomedicine, public health and social justice. Such developments must be made, for cholera and leprosy continue to influence life even after their ‘power to cause death had dissipated’ and its deadly potential risks becoming little more than a terrible dream (Briggs, 2003, p.298).

 

Bibliography

Briggs, C., and Mantini-Briggs, C., 2003. Stories in the Time of Cholera: Racial Profiling during a medical nightmare. Berkeley: University of California Press.

Conrad, J., et al, 2007. Heart of Darkness. London: Penguin.

de Sainte-More, G.R.B., et al, 1978. The Story of Troilus. Toronto: University of Toronto Press.

Delaisement, G., and Schmidt, A.M. (eds.), 1959, Contes et nouvelles 1884, Guy de Maupassant. Paris: unregistered.

Farmer P., and Gastineau, N., 2004. ‘Rethinking Health and Human Rights: Time for a paradigm shift’, pp. 73-94, in Gruskin, S. (ed.), Perspectives on health and human rights. Abingdon: Routledge.

Farmer, P., 1999. Pathologies of Power: rethinking health and human rights. American Journal of Public Health, 89, pp.1486-1496. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 4 March 2016].

Finkelstein, R.A., 2003. Book Review of Stories in the Time of Cholera: racial profiling during a medical nightmare. New England Journal of Medicine, [e-journal] 349 pp. 1297-1298. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Foucault, M. (1990). The History of Sexuality, Vol.1. London: Penguin, p.140.

García Márquez, G., 2007. Love in the Time of Cholera. London: Penguin Books.

Goffman, E., 1990. Stigma: Notes on the management of spoiled identity. London: Penguin Books.

Han, X., Silva, F., and Baker, S., 2014. On the Age of Leprosy. [e-journal] 8 (2). Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Helman, C.G. (ed.), 2000. Culture, Health and Illness: An Introduction for Health Professionals. Oxford: Hodder Arnold.

Hislop, V., 2006. The Island. London: Headline Publishing.

Janes, C.R., and Corbett, K.K., 2009. Anthropology and Global Health. Annual Review of Anthropology, [e-journal] 38, pp.167-183. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 12 March 2016].

Jopling, W., and McDougall, A. C., 1988. Handbook of Leprosy. 4th ed. London: Heinemann Professional.

Kleinman, A., 1988. Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books.

Munro, W., 1890. Leprosy and Syphilis. The Lancet, [e-journal] 135 (3487), p. 1436. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 10 March 2016].

Paneth, N et al, 1998. A Rivalry of Foulness: Official and Unofficial Investigations of the London Cholera Epidemic of 1854. American Journal of Public Health, [e-journal] 88 (10), pp. 1545–1553. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 12 March 2016].

Patton, C., 1996. Fatal Advice: How safe-sex education went wrong. Durham: Duke University Press.

Pfeiffer J. and Chapman R., 2010. Anthropological perspectives on structural adjustment and public health. Annual Review of Anthropology. [e-journal] 39 pp. 149–65. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 4 March 2016].

Rabinow P., and Rose N., 2006. Biopower today. Biosocieties. [e-journal] 1, pp.195-217. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 10 March 2016].

Sasakawa, Y., 2006. Letter to the Editor. Leprosy Review, [e-journal] 77 (84). Available through: Lepra Organisation website: <https://www.lepra.org.uk/leprosy-review-index&gt; [Accessed 6 March 2016].

Vogelsang, T. M., 1965. Leprosy in Norway. Medical History, [e-journal] 9 (1), pp. 29–35. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 2 March 2016].

WHO, 2000. Leprosy Elimination. [online] Available at: <http://www.who.int/lep/strategy/faqs/en/&gt; [Accessed: 9 March 2016].

WHO, 2000. Guide to Eliminate Leprosy as a Public Health Problem. [pdf] Available at: <http://www.who.int/lep/resources/Guide_Int_E.pdf?ua=1&gt; [Accessed 6 March 2016].

Williams H. W., 1977. Leprosy – a social disease. Canadian Medical Association Journal. [e-journal] 116 (8), pp.834-835. Available through: University College London Library website <http://ucl-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do&gt; [Accessed 1 March 2016].

Works of reference:
‘nightmare‘ (n.) from Online Etymology Dictionary (2001-2016) available at <http://etymonline.com/index.php?term=nightmare&allowed_in_frame=0&gt; [Accessed 29 February 2016].

[1] Leprosy is often used interchangeably with Hansen’s disease, but the latter is largely archaic in clinical parlance as in Jopling and McDougall, 1988.

[2] Definable as a population prevalence of fewer than 1 in 10,000 people.

[3] Being classified as a Neglected Tropical Disease (Han, X. et al, 2003).

[4] Denigration being a criticism typically levelled at Joseph Conrad’s Heart of Darkness, for example.

Image Credit: CDC Global, Flickr

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