Inhorn-AnthropologyInfectiousDisease-1990

The Anthropology of Infectious Disease
Author(s): Marcia C. Inhorn and Peter J. Brown

Source: Annual Review of Anthropology , 1990, Vol. 19 (1990), pp. 89-117
Published by: Annual Reviews
Stable URL: https://www.jstor.org/stable/2155960
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Annu. Rev. Anthropol. 1990. 19:89-117
Copyright (? 1990 by Annual Reviews Inc. All rights reserved
THE ANTHROPOLOGY OF
INFECTIOUS DISEASE
Marcia C. Inhorn
Department of Anthropology, University of California, Berkeley, California 94720
Peter J. Brown
Department of Anthropology, Emory University, Atlanta, Georgia 30322
KEY WORDS: evolution, disease ecology, behavioral research, ethnomedicine, infectious

disease control
INTRODUCTION
Diseases caused by infectious agents have profoundly affected both human

history and biology. In demographic terms, infectious diseases-including
both great epidemics, such as plague and smallpox, which have devastated
human populations from ancient to modern times, and less dramatic, un-
named viral and bacterial infections causing high infant mortality have
likely claimed more lives than all wars, noninfectious diseases, and natural
disasters taken together. In the face of such attack by microscopic invaders,
human populations have been forced to adapt to infectious agents on the levels
of both genes and culture. As agents of natural selection, infectious diseases
have played a major role in the evolution of the human species. Infectious
diseases have also been a prime mover in cultural transformation, as societies
have responded to the social, economic, political, and psychological disrup-
tion engendered by acute epidemics (e.g. measles, influenza) and chronic,
debilitating infectious diseases (e.g. malaria, schistosomiasis). Today, the
global epidemic of acquired immune deficiency syndrome (AIDS) provides a
salient example of the processes underlying infectious-disease-related cultural
transformations. As many of the examples cited in this review illustrate,
human groups have often unwittingly facilitated the spread of infectious
89
0084-6570/90/10 15-0089$02.00

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90 INHORN & BROWN
diseases through culturally coded patterns of behavior or through changes in

the crucial relationships among infectious disease agents, their human and
animal hosts, and the environments in which the host-agent interaction takes
place.
Thus, infectious diseases provide a rich area for anthropological research,
with contributions to be made from all of anthropology's subdisciplines.
Indeed, because the study of infectious disease is an intrinsically biocultural
endeavor, the "anthropology of infectious disease" described here must be a
holistic one, in which traditional subdisciplinary boundaries are irrelevant.
Infectious disease problems are both biological and cultural, historical and
contemporary, theoretical and practical. Because the relevant research re-
quires the synthesizing theoretical framework of general anthropology, it
cannot be subsumed by medical anthropology. Note the range of an-
thropological and public health literature cited in this review.
Simply defined, infectious diseases are those caused by biological agents
ranging from microscopic, intracellular viruses to large, structurally complex
helminthic parasites (see 33 for a classification of infectious disease agents,
including viruses, bacteria, fungi, parasites, and several classes of in-
termediate forms, as well as their routes of transmission). The variety and
complexity of infectious agents-in terms of their biological characteristics,
their reproductive strategies, and their modes of transmission-are impressive
(35). The classification of this tremendous diversity forms part of the subject
of the World Health Organization's (WHO's) International Classification of
Diseases, now in its ninth revision (224). These disease categories provide a
standard mode of scientific discourse in biomedicine, where "diseases" are
considered as clinical entities with pathological underpinnings, while "illnes-
ses" are more closely linked to a patient's perceptions and behaviors. As is
generally recognized by medical anthropologists, however, biomedicine is
only one type of culturally constructed medical system (100, 101).
It is important to note that infection with a specific agent does not necessar-
ily result in disease. This progression depends upon a number of intervening
variables, including the pathogenicity of the agent, the route of transmission
of the agent to the host, and the nature and strength of the host's response (23,
193). All of these factors, in turn, are affected by the natural and social
environments in which the agent and host are juxtaposed; in some cases, the
environment may promote the transmission of the agent to the host, while in
other cases it may limit or even prevent such transmission. Critical character-
istics of the environment result largely from sociopolitical influences; thus,
many infectious diseases, such as tuberculosis, are rightly considered "social
diseases" (57, 217).
The American Anthropological Association's Working Group on An-
thropology and Infectious Disease defined the anthropological field of in-

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INFECTIOUS DISEASE 91
fectious disease as the "broad area which emphasizes the interactions between
sociocultural, biological, and ecological variables relating to the etiology and
prevalence of infectious disease" (26:7). This review uses the same definition,
examining anthropological works on infectious disease (including those by
scholars in related disciplines whose methods or theoretical frameworks are
anthropological in nature) and classifying them for heuristic purposes accord-
ing to their primarily biological, ecological, or sociocultural orientation.
BIOLOGICAL APPROACHES
Microevolutionary Studies
From an evolutionary perspective, infectious diseases have probably been the
primary agent of natural selection over the past 5000 years, eliminating
human hosts who were more susceptible to disease and sparing those who
were more resistant. Individual biological factors that conferred protection
from a specific disease could eventually be selected for in the human pop-
ulations living where the disease was endemic. Thus, as first suggested by
Haldane (102), humans adapted to infectious disease at a most basic level-
the level of the gene (5, 6).
Over the past 40 years, anthropologists and human geneticists have been
testing the hypothesis that specific genotypes may confer immunity or resis-
tance to infection. Such hypotheses have also been suggested to help explain
relatively common genetic conditions that may be adaptive in one context and
maladaptive in another. Allison (4) was the first to suggest that the
heterozygous condition known as sickle-cell trait (i.e. inheritance of the gene
for the common form of hemoglobin from one parent and the sickling
hemoglobin S from the other) appeared with greater frequency in regions of
Africa where life-threatening Plasmodium falciparum malaria was present.
This association led Allison to hypothesize that hemoglobin S, when present
in the heterozygous state, conferred resistance to death from malaria.
Although this hypothesis has been a prominent textbook example for two
decades, the statistical correlation between malaria prevalences and sickle-
cell gene frequencies in West Africa has only recently been systematically
confirmed (70). Moreover, while there is significantly higher malaria mortal-
ity among children who are heterozygous sicklers than among homozygous
normals, differences in parasite densities among individuals of the two geno-
type groups have not been determined (159).
In a classic anthropological work that followed Allison's, Livingstone
(158) related the widespread distribution of the sickle-cell trait in West Africa
to specific factors of cultural evolution: namely, the introduction of iron tools
and subsequent swidden agriculture. He argued that the diffusion of the new
technology led to increased sedentism, horticultural production, and de-

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92 INHORN & BROWN
forestation, effectively increasing the available breeding grounds for An-

opheles gambiae, the major mosquito vector. These changes allowed falcipar-
um malaria to become established as an endemic disease among settled, West
African agricultural societies and as a selective agent for the sickle-cell allele
(158, 160). Through analysis of data from 60 African communities, Wiesen-
feld (221) demonstrated that populations most reliant on root and tree crops
(the Malaysian agricultural complex) created the most malarious environ-
ments; this would lead to greater selective advantage for heterozygous in-
dividuals, who enjoy protection from malaria death yet are not at risk of death
from sickle-cell anemia (the condition of homozygous sicklers).
More recently, other hemoglobin abnormalities have been identified (161)
that appear to confer resistance to malaria, including glucose-6-phosphate-
dehydrogenase (G6PD) deficiency, thalassemia, and hemoglobins Hbc, HbE,
and HbF. Similarly, it has been argued that the Duffy blood group negative
genotype, characteristic of most African and US blacks, provides a high level
of protection from Plasmodium vivax, a more benign strain of malaria (164).
In an examination of fava bean consumption and its relation to malaria in the
G6PD-deficiency-endemic, circum-Mediterranean area, Katz & Schall (136)
have suggested that the combination of nonexpressed gene and consumption
of fava beans (the "gene-bean interaction") may protect heterozygous females
from malaria death. This may be viewed as an excellent example of the
"coevolution" of genes and cultural traits, which, in combination, offer
substantial protection from disease (135), although in this case, G6PD-
deficient males may suffer potentially fatal hemolytic crises of favism (32)
Other studies tentatively linking infectious diseases to genetic traits and
cultural factors have recently emerged. For example, Blangero (18) studied
the relationship among helminthic zoonoses, the P2 allele of the P blood
group system (which is hypothesized to confer resistance to these zoonoses),
and subsistence practices involving animal husbandry. He has shown that
high frequencies of the P2 allele occur in populations manifesting heavy
dependence on and contact with domesticated livestock. In a different con-
text, Meindl (174) has hypothesized that, for European populations with a
long history of pulmonary tuberculosis and high frequencies of cystic fibrosis,
carriers of the recessive gene for cystic fibrosis may have increased resistance
to tuberculosis.
Conversely, anthropologists helped to demonstrate that the hepatitis B
surface antigen (HBsAg) was not part of the genetic endowment transmitted
from parents to offspring. Rather, the clustering of the antigen observed in
families was due to both horizontal (i.e. person to person) and vertical (i.e.
mother to infant) infectious transmission (20-22) a finding made, in part,
through participant observation of family life in New Hebrides (51, 52).
These discoveries played a role in the successful development of a hepatitis B
vaccine.

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Macroevolutionary Studies
Macroevolutionary studies of infectious disease attempt to reconstruct
epidemiological patterns of disease transmission among prehistoric and
historic human populations. The broad aims of this research are two-fold: (a)
to establish the antiquity and evolution of various infectious diseases in
human populations through examination of prehistoric osteological and, in
some cases, soft-tissue evidence; and (b) to contextualize these findings to the
physical and cultural circumstances of the human populations involved.
Paleopathology has contributed significantly to the understanding of the
prevalence and spread of infectious diseases in human populations. Simply
defined, paleopathology is the study of disease in prehistoric populations
through examination of skeletal and tissue remains, coprolites, and when
available, works of art (1, 130). Because some infectious diseases leave their
marks on the human skeleton and flesh, examination of these remains has
allowed researchers to describe the disease patterns of prehistoric populations
and to establish relative chronologies.
Paleopathological reconstructions utilizing skeletal and tissue remains have
been attempted for infectious diseases including tuberculosis (34, 181), lep-
rosy (179), and American (203) and African trypanosomiasis (151). Studies
of the kidneys of Egyptian mummies have yielded evidence of schistoso-
miasis (191); and coprolite studies, utilizing dried fecal remains found in or
near prehistoric camps and shelters, have provided valuable insights on the
epidemiology of intestinal helminthiases in prehistoric populations (40, 69,
191, 201, 205, 206).
Paleopathology has had a particularly decisive role in the debate over the
antiquity and origin of syphilis in the Old and New Worlds. Using osteologi-
cal evidence, paleopathologists have argued that human venereal syphilis
originated in the Americas and was transported to Europe and then to other
human habitats by European colonists and explorers, including, as Crosby
(45, 46) has argued, Christopher Columbus's crew. This conclusion is based
on abundant evidence of syphlitic skeletal material from pre-Columbian
remains discovered in the New World (43, 93, 94, 179, 181, 200, 222) and
the distinct absence of pre-Columbian, Old World skeletal material with any
of the treponemal stigmata (223). Nevertheless, other reconstructions of the
history of syphilis based on contemporary and historical knowledge of the
treponemal diseases have been put forward (39, 99, 119-122); these have
been well summarized by McNeill (172) and Wood (223).
In addition, paleoepidemiological reconstruction of infectious disease pat-
terns in prehistoric and early historic human populations has been undertaken
through ethnographic analogy-that is, examination of disease patterns in
contemporary isolated hunter-gatherer populations followed by extrapolation
of these findings into the past. First suggested by Dunn (58) and Polunin
(196), this approach has been advocated subsequently by a number of scholars

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94 INHORN & BROWN
(16, 17, 40, 95, 185). Basing their theses largely on serological evidence
collected from contemporary hunter-gatherer groups, they hypothesize that,
because of their small numbers, mobility, and relative isolation from other
groups, ancient hunter-gatherers were relatively free from the acute, epidemic
infectious diseases that later took their toll on more advanced agrarian societ-
ies. Many acute infectious diseases require large numbers of susceptible
individuals to support their chains of transmission, which are characterized by
brief and rapid stages of infection. In early food-foraging groups, populations
of no more than 200-300 persons would not have been large enough to sustain
such a chain of transmission; if introduced, these acute infections would have
run their courses and then died out. From the standpoint of natural selection,
pathogens that live in a long-term commensal relationship with the host (e.g.
the agents of typhoid, amoebic dysentery, trachoma) and those that persist for
periods of time outside the final host or vector (e.g. the agent of schistoso-
miasis) would have been favored, and infections like measles, which spreads
rapidly and immunizes a majority of the population in one epidemic, would
have been rare or absent.
A number of scholars (5, 40, 55, 56, 82, 171, 195) have gone beyond this
original proposition to describe the coevolution of human culture and in-
fectious disease, basing their arguments largely on knowledge of population
size and density and their impact on infection. Humans made a rapid cultural
transition from small, isolated groups of hunter-gatherers to small, scattered
villages of farmers, to large, preindustrial and then industrial cities, marked
by aggregates of people living in close proximity. This cultural transition
profoundly affected the nature of infectious disease patterns by (a) changing
the degree of contact between humans and animals, either directly or via
arthropod vectors, and (b) altering the size of human aggregations and the
communications and movement within and between them. Thus, the con-
tagious epidemic diseases, which would not have had a large enough popula-
tion base to affect hunter-gatherers or even small farming villages, would
eventually decimate populations in urban centers.
Likewise, the clearing of land for cultivation, the domestication of animals,
the increase in sedentism, and the concomitant problems of human and animal
waste removal, all of which occurred during the agricultural revolution of the
Neolithic and Mesolithic periods, provided ideal conditions for many of the
helminthic and protozoal parasites (5). The health consequences of this
transition from food foraging to food production have been topics of consider-
able attention, as seen in the important collection Paleopathology at the
Origins of Agriculture (42). Twelve of the eighteen case studies in this
collection report substantial increases in infection rates from the time of early
hunter-gatherers to early farmers (41). Research from both the Old and New
Worlds shows a repeated pattern of decreased stature, higher infant mortality,

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and increased physiological stresses indicative of malnutrition, characteristic

of populations during the Neolithic revolution. Such a pattern indicates the
strong synergistic relation between chronic malnutrition and infectious dis-
ease morbidity and mortality (207). It should be noted, however, that the
intensification of agricultural systems, whether in the past or present, shows
no direct linkage with increased infectious disease rates (41, 112).
In addition, a number of scholars, primarily medical historians, have
examined the effect of infectious diseases on civilizations during historical
periods (for numerous examples of these works, see 24). Utilizing texts and
other primary and secondary sources, they have chronicled the impact of such
infectious diseases as the plague (53), typhus (226), cholera (202), malaria
(105), and smallpox (115), for better and for worse, upon state-level societies
and populations. In the most comprehensive treatment of this theme, McNeill
(172) argues that epidemics have played an active role in the expansion of
empires throughout history, as state-level societies introduce endemic child-
hood diseases into smaller and simpler societies, causing massive population
losses and subsequent socioeconomic disorganization. The depopulation of
North and South American Indian societies by epidemic infections brought
from Europe by colonizers and from Africa by slaves (8, 91, 138, 149, 186,
187) provides a salient example of McNeill's point: Infectious diseases
accelerated the conquest, subjugation, and acculturation of tribes and chief-
doms.
McNeill's model requires the recognition that a universal aspect of history
has been the "confluence of disease pools." Owing to rapid transportation, we
now live in a single epidemiological world system-despite striking differ-
ences in the distribution of disease and death between the poor societies of the
Third World and affluent nations, an important theme in a number of recent
analyses (14, 171). Kunitz (150) and McKeown (170) have also concluded
that socioeconomic change has had a greater impact on improvement of health
and diminution of infectious diseases than has the introduction of (and
innovation in) clinical medicine.
ECOLOGICAL APPROACHES
Theoretical Models
Most anthropological research on infectious disease has been ecological,
focusing on the interaction between agent and host within a given ecosystem.
Disease ecology, as the discipline is often called (33), owes much to the
pioneering work of the medical geographer May, who in his classic volume
The Ecology of Human Disease (167) formalized the role of the environ-
ment both physical and sociocultural in the study of infectious disease
problems. May constructed a model that treated physical environment, dis-

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96 INHORN & BROWN
ease pathogens, human hosts, and the cultural practices employed by these
hosts as separate factors in an interactive process. In this view, disease
expresses a temporary maladjustment between human hosts and their environ-
ment. Using examples from his own research in Asia, May demonstrated how
transmission of malaria in North Vietnam and hookworm in China were
affected by specific environmental and cultural patterns. In the North Viet-
namese case, he showed how lowland housing types, which were transplanted
without modification to the highlands, were responsible for the higher rates of
malaria among lowland-to-highland migrant populations, whose ground-level
dwellings exposed them to low-flying mosquito vectors. Native hill peoples,
on the other hand, had adjusted to the malaria threat by constructing stilted
houses with living quarters above the mosquito's 10-foot flight ceiling.
Likewise, in China, May showed how rates of hookworm infection depended
upon the environments within which individuals worked: While rice growers
who worked in fields of mud mixed with nightsoil (raw human feces) were
usually and often seriously infected, silkworm farmers who spent their days
on ladders tending to mulberry leaves were not.
Following May's lead, a number of scholars delineated models of the
interactions among infectious disease agents, human hosts, and the environ-
ment. Audy (10, 11) whose major work focused on the roles of human
behavioral and environmental factors in the transmission of scrub typhus (9),
broadened his approach to disease etiology by incorporating the notion of
"insults" into his model. Insults were defined as physical, chemical, in-
fectious, psychological, or social stimuli that adversely affected an in-
dividual's or population's adjustment to the environment. Audy viewed both
health and disease as states in an individual's dynamic relations with the
environment: Measuring either one depended upon identifying the multiple
positive and negative insults and their cumulative effects. Moreover, expo-
sure to a pathogen was a necessary but not sufficient cause of disease; the
progression from exposure to disease depended in part on the health of the
exposed person, which, given an individual's vulnerability to a complex of
insults, was never a constant.
Audy introduced the concept of insults in an attempt to overcome the
limitations of a pathogen-specific approach to disease. Dunn (68) developed
the even broader concept of "causal assemblages"-complexes of environ-
mental, host-biological, and host-behavioral factors that must be considered
when studying disease etiology or attempting to control disease spread. In his
early work with Malaysian aboriginal groups, Dunn (59, 61) showed how
both environmental factors (e.g. altitude, temperature, soil type, presence of
scavenging animals) and human behavioral factors (e.g. subsistence strat-
egies, housing types, community mobility) significantly affected rates of
parasitic infection. He later demonstrated the important implications of this
model in the design of effective disease control programs (60, 62-64, 66).

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In a radical departure that she has labeled the "political ecology of disease,"
Turshen (217) has argued that "bourgeois empiricist" models of disease
causality, such as those described above, are little more than accretions to the
basic epidemiological triad of agent, host, and environment-a model that is
inadequate because it fails to consider the ultimate causes of disease, which
she holds are economic, social, and political. In her own study of infectious
disease and related health problems in Tanzania, Turshen argues that the
continued focus on the former triad is the ultimate cause of scholarly failures
to elucidate why epidemics occur at certain historical moments or why
eradication of a specific infection does not ensure prevention of illness. She
favors a Marxist construction of the causes of poor health, which focuses on
modes and factors of production and changing social relations seen from the
perspective of colonialist and neocolonialist history. This approach has also
been influential in medical geography (131), as well as in the development of
"critical medical anthropology" (211).
Research Examples in Disease Ecology
Much of the recent empirical work in disease ecology has been, in fact,
political-economic, if not explicitly Marxist in orientation, in that it focuses
on the untoward consequences of ecologically ill-advised development
schemes. It concerns the so-called "developo-genic" diseases, the conse-
quence of environmental disruptions caused by large-scale, internationally
sponsored projects (123). Dubos (54, 55) was among the first to note that all
technological innovation, whether industrial, agricultural, or medical, upset
the balance of nature; the sensible goal was thus not to maintain the balance of
nature but to change it to the benefit of as many plant and animal species
(including humans) as possible.
Unfortunately, many of the development schemes of the past and present
have been neither balanced nor beneficial. As Hughes & Hunter (123) point
out in their comprehensive review of development projects and disease in
Africa, few of the projects initiated on that continent over the past two
centuries have been undertaken within a preconceived ecological framework.
They include in their survey programs of agricultural, industrial, and in-
frastructural change, as well as resulting population relocations, all un-
dertaken in the name of progress. As they note, development projects of dam
construction, land reclamation, road construction, and resettlement in Third
World countries have probably done more to spread infectious diseases
such as trypanosomiasis, schistosomiasis, and malaria than any other single
factor.
The life-threatening blood fluke infection schistosomiasis (bilharziasis)
provides a trenchant example of the unforeseen health consequences of
ecological disruption caused by development schemes. As Heyneman (110,

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98 INHORN & BROWN
111) notes, schistosomiasis is probably the fastest spreading and most danger-
ous parasitic infection now known. The rapid spread of this disease is almost
entirely due to programs of water resource development involving the con-
struction of high dams, man-made lakes and reservoirs, and irrigation canals
(50, 110, 111, 208). These waterways have provided an ecological "free
zone" for the snails that are the intermediate host of the schistosomal para-
sites. As the snail population has spread throughout Africa and parts of the
Middle East, Asia, South America, and the Caribbean, so have schistoso-
miasis infections, which are acquired when larval parasites, released in the
water from snail vectors, penetrate immersed human skin. Today, 200-300
million people worldwide are estimated to be infected (134), and new
"epidemics" of the disease occur following the expansion of waterways in
areas of the world where the parasite and vector live. For example, Kloos and
coworkers (140, 141, 144, 145, 147) have described the expanding distribu-
tion of schistosome-transmitting snail populations and escalating rates of
human infection following government-sponsored creation of large, irrigated
farming estates in the Awash Valley of Ethiopia. In neighboring Sudan, the
disease cycle was established within a few years of the start of the Gezira
scheme, a large-scale, irrigated cotton project south of Khartoum (83, 98,
147), which was also responsible for an increased prevalence of malaria in
this region (98). In Nigeria, the prevalence of schistosomiasis soared follow-
ing construction of a low-earth dam providing perennial access to a large body
of infective water an increase that was likely to continue, researchers pre-
dicted, given government plans to build more dams in the area (198).
Subtler ecological changes may also be associated with increases in in-
fectious disease. For example, Chapin & Wasserstrom (37) have shown how
increased pesticide use in the intensive production of cotton in both Central
America and India resulted in a serious resurgence of malaria because of the
rapid evolution of insecticide-resistant strains of Anopheles mosquitoes. Sim-
ilarly, the severe epidemic of typhoid fever in Mexico in 1972-73 was the
result of overuse of the powerful antibiotic chloramphenicol for ailments such
as the common cold; this change in disease ecology brought about rapid
selection for chloramphenicol-resistant strains of the typhoid fever bacterium
(218).
SOCIOCULTURAL APPROACHES
Human Behavior and Infectious Disease Transmission
THEORETICAL MODELS As we have argued elsewhere (33), any an-

thropological study that hopes to shed light on the etiology and transmission
of infectious disease must ultimately adopt both a macrosociological per-

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spective-of the kind advocated by Turshen (217) and exemplified in much of

the work on disease ecology and development-and a microsociological
perspective. We have defined the latter as the study of the individual man-
ifestations of culturally prescribed behavioral patterns, which are seen as risk
factors (or, in some cases, limiting factors) for the contraction of infection
(33).
The critical links between human behavior and infectious disease transmis-
sion have been recognized for more than a century, when, during an epidemic
of cholera in London, differential rates of infection were linked by early
epidemiological investigators to varying drinking patterns of factory workers
(212). Since then, numerous anthropologists and other behavioral scientists
(3, 60, 62, 64-67, 109, 176, 184, 195, 204, 210) have noted the importance
of understanding culturally prescribed and proscribed behavioral practices and
their effect on the transmission of infectious disease agents.
The impetus for this orientation in anthropology owes much to the pioneer-
ing work of Alland (3), who used evolutionary theory to examine how cultural
behaviors could enhance human hygiene and health. Utilizing concepts from
mathematical modeling, Alland used the term "minimax" to refer to cultural
practices that minimize the risk of disease and maximize the health and
welfare of the group.
However, as both Roundy (204) and Dunn (60, 62, 64) have suggested, not
all human behavior is adaptive in the evolutionary sense, since many cultural-
ly prescribed patterns of behavior actually promote infectious disease spread.
Roundy (204) has called such disease-promoting patterns of behavior
"hazards." In his model, human behavior can affect disease transmission in
four areas: (a) exposure to the agent, (b) shedding of the disease agent from an
infected human host, (c) creation of man-made habitats in which the transmis-
sion cycle can be completed, and (d) diffusion of the transmission system
from one place to another.
Dunn's (60, 62, 64) model of health-promoting and health-demoting be-
haviors is perhaps more useful on a methodological level. Dunn classifies all
health-related behaviors along two axes: deliberate vs nondeliberate and
health-promoting or maintaining vs health-demoting. He conceptualizes four
major categories of individual or group health-related behaviors: (a) de-
liberate, consciously health-related behavior that promotes or maintains
health; (b) deliberate behavior that contributes to ill health or mortality; (c)
behavior not perceived to be health related that nevertheless enhances or
maintains health; and (d) behavior not perceived to be health related that
contributes to ill health or mortality. He notes that each of these categories of
behavior may be further divided along a third axis: the perspectives of
"insiders" (the populations at risk) as opposed to "outsiders" (members of the
health-care community).

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100 INHORN & BROWN
RESEARCH EXAMPLES The role of human behavior in increasing or limiting

transmission can be demonstrated for virtually every infectious disease. Dunn
(60), for one, has applied his classificatory scheme to the study of behavioral
factors in filariasis transmission. In more recent works, he has outlined
theoretical and methodological considerations in the study of behavioral risk
factors for trachoma (66), human arboviral infections (67), and four of the
five parasitic infections (schistosomiasis, filariasis, American and African
trypanosomiasis, and malaria) targeted by the United Nations (UN), the
World Bank, and WHO for 20-year research and control programs (62, 64).
Nations (184) has recently summarized some of the behavioral factors that
affect infectious disease transmission, including dietary customs, child care
patterns, religious practices, migration patterns, agricultural techniques, kin-
ship relations, and traditional medical treatments. However, as Nations notes,
observational studies of disease-related behaviors-and, more important,
anthropological studies that "make sense" of these behaviors in a broader
cultural context-are few, considering the tremendous potential for this type
of research.
Kuru and cannibalism Perhaps the best-known example of anthropological

involvement in an infectious disease problem involves the case of kuru, a
neurological degenerative condition found in the remote eastern highlands
region of New Guinea among the Fore (157). A multidisciplinary team of
anthropologists, neurologists, pathologists, and epidemiologists eventually
discerned that this lethal condition was due to an infectious agent a "slow
virus" acquired through behavioral practices associated with cannibalism
(124). Anthropologists provided clinicians detailed information regarding
subjects' reports of the preparation and consumption of the flesh and organs of
deceased relatives (157). Adult women suffered the highest kuru infection
rates, since it was their responsibility to prepare corpses for consumption. As
Lindenbaum (157) notes, following the imposition of Western law and a
subsequent government-monitored ban on cannibalism, disease incidence
plummeted, thus indirectly supporting the etiological role of cannibalism in
kuru's transmission.
Steadman & Merbs (215), however, have questioned the association be-
tween kuru and cannibalism, noting that researchers in the New Guinea
highlands never actually witnessed an act of cannibalism. These authors
suggest that Fore mortuary practices were more likely the crucial behavioral
variable, permitting transmission of the deadly virus via cuts and sores on the
hands of the women preparing dead bodies for burial.
Malaria and cultural adaptation Anthropologists interested in cultural

adaptations to disease have focused their attention upon malaria, a parasitic

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infection thought to have killed more people than any other named disease
(159). Genetic adaptations to this disease have merited particular interest, and
malariologists have recognized the important role of human behavior in
malaria control (see the bibliography in 213). Wood (223) summarizes many
of the studies of cultural practices, most of them nondeliberate, that may limit
transmission in areas where malaria is endemic. These include the use of
alkaline laundry soaps that destroy mosquito breeding sites, clothing styles
that serve as mechanical barriers to biting insects, the use of malodorous
traditional pesticides and insect repellents, and seasonal migrations away
from mosquito vectors. Empirical evidence for the efficacy of such practices
is generally lacking, however. Brown (27) has also argued that the combina-
tion of nucleated settlement pattern and inverse transhumance (flock move-
ment to high elevations in summer) served to reduce exposure to malaria in
Sardinia and to explain its social epidemiological distribution. These and
other traditional behaviors based on the folk theory of miasma probably had
preventive effects. Behavioral adaptations to malaria in other cultural contexts
include fava bean consumption in the Mediterranean (135, 136), traditional
medicines in Nigeria (75, 76), and the use of thick blankets and netting in
Africa (163).
Echinococcosis and companion dogs Echinococcosis (hydatid disease) is a

life-threatening parasitic infection transmitted from domesticated livestock to
dogs to humans. Hence, it occurs in areas of the world where humans, dogs,
and livestock (primarily sheep) live in close association. The Turkana of
Kenya and the neighboring tribes of southwestern Ethiopia are highly in-
fected. Medical anthropologists and geographers (89, 90, 92) working in this
region have provided rich reports of the interactions between humans and
their dogs. Of particular interest from the standpoint of echinococcosis
transmission are the women's "nurse dogs," which are specially trained to lick
and clean children who have just defecated; in so doing, these nurse dogs
disseminate infective parasitic eggs throughout the domestic environment and
to their young charges. In addition, potentially infective dog feces are highly
valued among the Turkana as a traditional medicinal and cosmetic substance,
which is used to dress wounds, ward off evil spirits, and protect women's skin
from the damaging effects of their heavy layered necklaces (90). Un-
fortunately, the Turkana and other highly infected tribes in this region do
associate their often lethal disease with dogs, dog feces, or the hydatid cysts
they observe in their livestock (92); this situation makes preventive cultural
adaptations to the disease less likely.
Schistosomiasis and water contact Schistosomiasis is a water-based parasit-

ic disease in that water plays a major role in the developmental life cycle of

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102 INHORN & BROWN
the parasite and in its transmission to humans. Because of the importance of

water contact in schistosomiasis transmission, WHO (225) has advocated and
supported numerous water-contact studies throughout the world. The most
extensive single investigation of water-contact behavior was carried out in
Egypt, where Farooq and associates (77-80) performed elaborate observa-
tional studies of the daily social, occupational, and religious uses of water in a
Nile Delta village. They noted that schistosomiasis was more prevalent
among Muslims than among Christians, presumably owing to the frequent
Islamic practice of wudu, or ritual ablution before prayer. Since then, a
number of other investigators in Africa have studied how individuals became
infected through water-contact activities (47, 72, 84, 142, 143, 146, 192).
Much less attention has been paid to ways individuals infect water through
urination and defecation into waterways. Cheesmond & Fenwick (38) showed
that excretory behaviors in an area of the Gezira, Sudan, served to diminish
the chances of schistosomiasis transmission. Namely, they observed that
excretory episodes occurred in sites far removed from bodies of water,
privacy being a more important consideration than proximity to water for
purposes of ablution.
Sexually transmitted diseases (STDs) and labor migration The crucial role
of human behavioral factors in the dissemination of sexually transmitted
diseases (STDs) has been known for hundreds of years and is a reason why
these conditions were dubbed "social diseases." However, the need for social
scientific studies of the behaviors placing individuals at risk from STDs and
of the sociocultural determinants and consequences of those behaviors has
only been recognized recently. This need has been made more urgent by the
appearance of AIDS during the past decade (13, 81, 97, 127, 176). Prior to
the recognition of AIDS as a widespread problem in sub-Saharan Africa, a
number of behaviorally oriented researchers working in that region (7, 15, 49,
173, 197, 219) noted the roles of rural-to-urban migration and prostitution in
the transmission of STDs, primarily gonorrhea. The typical pattern of
transmission included the following components: Young men from rural tribal
areas areas plagued by political upheaval, unemployment, rapid moderniza-
tion, and the uneven distribution of economic opportunities migrate to
cities, where they make up the clientele of prostitutes operating from bars,
brothels, dance-halls, and the street. These prostitutes, who face the same
economic pressures as the males and are mostly young (aged 15-30), rural-
born, uneducated, unmarried (often as the result of abandonment by
nonreturning migrant husbands), and highly mobile, constitute the major
reservoir of sexually transmitted infection. The risk of STD transmission is
even further increased when men migrate to isolated labor camps and mines
where, characteristically, a small number of prostitutes have sexual relations

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with a large number of men (155). Upon accumulating sufficient wealth,

these men return to their natal towns and villages, where they infect their
regular sex partners, usually their wives, who may be rendered infertile as a
result of STD-induced reproductive pathology. This triad of migration, prosti-
tution, and STD has been recognized in other areas of the nonindustrialized
world as well (106, 133, 175, 183, 199). It is impossible to overemphasize
the impact of this cycle of STD transmission on the serious sociomedical
problem of infertility in these populations (169).
AIDS and sexual behavior The above-described pattern of STD transmis-

sion is also responsible in large part for the rapid spread of AIDS in sub-
Saharan Africa and is a primary reason why the epidemiological profile of
AIDS in Africa is radically different from that in the United States (81, 97,
155). In Africa (a) the infected population comprises primarily heterosexuals,
(b) prostitution plays a dominant role in the transmission of the human
immunodeficiency virus (HIV), and (c) the epidemiology of the disease is
largely explained by economic influences on male labor migration patterns
(155). In the United States, on the other hand, early cases of the disease were
reported almost exclusively among gay and bisexual men in New York City
and San Francisco (48). Since the early 1970s, these urban epicenters had
already had a high prevalence of STDs among gay and bisexual populations,
especially among the more sexually active men in the so-called "fast lane"
(97, 148). When AIDS appeared in the United States in the early 1980s, an
initial reaction to the epidemic in the gay community was denial; the severity
of the AIDS epidemic was deemphasized in the interest of preserving the
sexual values and institutions that represented the successful political strug-
gles of gay liberation (97, 209). Among these institutions, bathhouses (and
the sexual behaviors they encouraged) particularly facilitated the transmission
of STDs, including HIV, in urban gay centers (209). By the mid-1980s,
however, many gay and bisexual men began to modify their sexual behavior,
especially by reducing the number of casual partners (36); the extent of this
behavioral change toward "safe sex" is remarkable.
Ethnomedical Beliefs Regarding Etiology, Diagnosis,

and Cure
RESEARCH NEEDS Although behavioral studies of the kind cited above can
provide useful information on infectious disease transmission, they are never-
theless limited in their utility if they do not proceed beyond the observational
level. As Dunn (62:503) has cautioned in his discussion of schistosomiasis
and water contact, "A further series of studies . . . will be needed in each
situation to specify why people behave as they do, where and when . . . Any
effort to change human behavior must rest on such studies." Dunn's call for

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104 INHORN & BROWN
anthropological studies that answer the all-important "why" question by

identifying the social, cultural, and psychological correlates of human be-
havior relating to infectious disease, including indigenous beliefs about etiol-
ogy, diagnosis, and cure has been reiterated by a number of other an-
thropologists (33, 97, 109, 184).
Nation's (184) recent survey of the literature revealed that ethnomedical
studies of lay recognition, etiology, and treatment of infectious diseases are
even rarer than behavioral studies, in part because of the entrenched belief in
the biomedical community that indigenous beliefs and practices are irrelevant
to the problem at hand. Yet, information of this sort is of the utmost
importance in ensuring the success of public health efforts.
RESEARCH EXAMPLES The need for such information becomes clear in the
literature on ethnomedicine and infectious disease, a number of examples of
which are included here.
Diarrhea and folk beliefs In her study of indigenous beliefs surrounding

infant diarrhea in northeastern Brazil, Nations (184) argues that traditional
"folk beliefs," disdained by the epidemiologists and biomedical practitioners
working in this area, could not be more relevant to controlling this widespread
problem. These beliefs, she demonstrates, are intimately tied to epidemiologi-
cal issues, such as (a) underreporting of infant mortality, (b) detection of
morbidity and establishment of accurate attack rates, (c) identification of
high-risk populations, (d) identification of behavioral risk factors, and (e)
generation of testable analytical epidemiological hypotheses. These issues are
apart from that raised by frustrated physicians, of why more children with
severe diarrhea and dehydration are not brought to physicians sooner, when
the chances of saving them are greater. Nations concludes that the beliefs of
poor Brazilian mothers regarding the recognition, etiology, and treatment of
childhood diarrheal illnesses are the key to this problem.
Another example of the importance of ethnomedical beliefs for the success-
ful treatment of an infectious disease is provided by the work of Kendall and
coworkers ( 137) in Honduras. They showed that diarrhea thought to be caused
by the folk illness empacho was consistently not treated with oral rehydration
therapy, since empacho was thought to warrant a purgative cure.
Dracunculiasis and contaminated water Dracunculiasis (guinea worm dis-

ease) is a parasitic disease characterized by the presence of long adult worms
in subcutaneous tissues, usually of the leg. When infected individuals step
into waterways, the female worms vomit their eggs into the water via small
ulcerations on the infected individual's skin (114). If water fleas, the in-
termediate host of the parasite, are present they become parasitized and

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transmit disease to humans, who ingest them while drinking. Dracunculiasis

is, in fact, the only infectious disease that could be completely eliminated if
all populations living where the parasite is endemic were provided with and
used-safe drinking water (113). Because of the importance of water in the
transmission cycle, dracunculiasis has been targeted by a number of in-
ternational agencies, including the UN, WHO, and the World Bank, as the
primary focus of their International Drinking Water Supply and Sanitation
Decade (1981-90) (152). However, studies (74, 220) carried out in villages in
Ghana and Nigeria where the disease has been called the "annual festival of
agony" showed that, despite eradication efforts, few individuals thought the
disease was preventable or were aware of the mode of transmission of the
parasite through contaminated drinking water. Rather, the disease was attrib-
uted to heredity, transmission through soil or blood, person-to-person contact,
or even the god of smallpox (2). In addition, efforts to prevent secondary
infections in dracunculiasis ulcers, a significant cause of absenteeism in
schools and agricultural settings throughout West Africa (126, 188), were
hampered by local methods of treatment, some of which exacerbated the
dracunculiasis wounds or prevented healing (73, 74).
African trypanosomiasis and brush removal Another example of the need

for ethnomedical studies revolves around African trypanosomiasis, or "sleep-
ing sickness." In the 1930s and 1940s, the British colonial government
attempted to rid the tribal Hausa peoples of northern Nigeria of the often fatal
disease through efforts by biomedical personnel to explain the nature of the
disease, its transport by flies, and the necessity of controlling it by slashing
brush near streams to eliminate fly breeding areas. But, as Miner (178)
explains, the Hausa refused to believe that brush was related to the illness,
which they attributed to spirit possession. The control program was eventually
carried out by force, and the Hausa were convinced to slash the brush once a
year, thereby virtually eliminating the disease. But, when asked later why
they cut the brush, the Hausa replied that they were forced to do so, and many
people wanted to discontinue the practice. In short, the biomedical connection
among brush, flies, and sleeping sickness never successfully replaced the
Hausa's indigenous beliefs about the etiology of the illness.
Malaria and traditional medicines and foods Other researchers working

among the Hausa have examined traditional means by which they have coped
with malaria. Etkin & Ross (75, 76) have identified 31 antimalarial plant
medicines used by either herbal specialists or the general population. Some of
these medicinal plants have been shown to change the oxidation-reduction
status of red blood cells, a physiological condition known to impede develop-
ment of the malaria parasite (71). Furthermore, parasitological tests of ex-

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106 INHORN & BROWN
tracts of these traditional medicines, using a mouse model of malaria, showed

that three of the substances were highly effective cures. Similarly, in China, a
promising compound, artemisinin, extracted by chemists from a traditional
antimalarial treatment (quing hao, or "green herb," related to Artemisia
annua), has recently been identified (139). Such biochemical evaluation of
native ethnopharmacopoeias for the effectiveness of antimalarial treatments,
which has its historical roots in the discovery of quinine, has gained added
significance with the evolution of chloroquine-resistant strains of the disease.
In addition, in dietary studies from Liberia, Jackson, who has examined
Liberian mothers' folk classification of malaria symptoms (128), has hypothe-
sized that regular cassava consumption may curtail parasite growth and
development in humans, because of the minute amounts of lethal cyanide
contained in traditional cassava foods (unpublished manuscript).
Trachoma and ethno-ophthalmological practices Trachoma, the leading

cause of preventable blindness in the world, is a bacterial eye disease whose
transmission is highly dependent on individual and community hygiene (for a
comprehensive review of social factors relating to trachoma transmission, see
165, 166). Medical anthropologists working in rural Egypt where the disease
is endemic have examined the behaviors that place individuals at risk of
trachoma (153) and described the traditional beliefs and practices surrounding
eye disease in general and trachoma in particular (177). Millar & Lane (177)
showed that Egyptian villagers had a complex repertoire of "ethno-
ophthalmological" practices to treat trachoma, including mineral substances
applied to the eyelids, surgical curettage of the inner surfaces of the eyelids
with a razor blade, and blood-letting from the temples to let the "bad blood"
out of the inflamed eyes. These practices can all be traced to earlier literate
medical systems in Egypt, dating back in some cases to Pharaonic times. Lane
& Millar argued that decisions to use traditional or biomedical treatment
depended more on the individual's status in the family or community than on
belief in traditional-vs-biomedical etiologies of the disease (154). As a result,
individuals with less social status, particularly adult women and children,
were more likely to receive less highly valued traditional remedies-despite
their elevated risk of trachoma and (among women) blindness.
Local Responses to Infectious Disease Control Programs

Given the small size of the discipline of anthropology, its contributions to
international health and disease control programs have been significant (216).
In their early role in such efforts, anthropologists served as cultural interpret-
ers and "troubleshooters," who were brought into programs following nega-
tive community responses. Anthropologists demonstrated that public health
interventions succeeded first by being acceptable to the public. This was

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especially important in international programs, where recognition of differ-

ences in community organization, cultural values, and preexisting health
beliefs was critical. Paul's edited volume, Health, Culture, and Community
(189), provided important case studies of community reactions to health
programs, most of which involved infectious disease prevention or control.
Thus, part of the early anthropological contribution to infectious disease
control programs involved identifying social and cultural "barriers" to local-
level acceptance of innovations. For example, a cholera vaccination program
in China, following epidemics in the 1940s (117, 118), was hindered by the
fact that villagers had their own ideas, both "scientific" and "magico-
religious," about the cause of the outbreak; for most villagers, prevention did
not involve acceptance of an injection. Similarly, in Bang Chan, Thailand,
only a handful of villagers availed themselves of diphtheria immunization,
because the channels of communication used by public health workers never
reached the majority of the rural populace (103). Heggenhougen & Clements
(107) have summarized more recent applied anthropological work on the
effective delivery of immunizations. Of particular interest is the "checklist" of
reasons for low immunization coverage developed by Brown (25); it includes
behavioral attributes of both the participating population and health providers.
Following initial anthropological activity in international health programs,
Foster, who had much experience in such work (85-87), warned of the danger
of inappropriately blaming "culture" for failures caused instead by the atti-
tudes and behaviors of health care planners and providers (85). This recogni-
tion was based in part on Polgar's (194) insightful analysis of "four fallacies"
afflicting international public health endeavors: (a) the fallacy of empty
vessels; (b) the fallacy of the separate capsule; (c) the fallacy of the single
pyramid; and (d) the fallacy of interchangeable faces. Such critical question-
ing of the intellectual premises underlying both biomedicine and the organiza-
tion of health care probably played a role in the development of "critical
medical anthropology." The tradition of ethnography applied to the critical
analysis of international health programs is best exemplified by the recent
work of Justice in Nepal (132).
Theoretically, the ultimate goal of infectious disease control programs is
the reduction of disease transmission to the point where the disease organism
becomes eradicated. Such an outcome has been achieved for only one dis-
ease smallpox through a coordinated, global effort completed in 1978
(116). This remarkable accomplishment of international public health in-
volved minimal anthropological expertise namely, Morinis's assessment of
the flow of smallpox case-detection information in rural markets in India
(180). Toward the end of the eradication effort, Foster & Deria (88) de-
veloped a culturally acceptable method of case isolation among Somalian
pastoralists by adapting a traditional technique used for sick camels.

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108 INHORN & BROWN
Yet, control programs aimed at reduction of a single disease identified by

outsiders can meet with resistance from local populations. Various programs
to eliminate hookworm (63, 85, 87, 125) and malaria (105) appeared, from
the people's point of view, too concentrated on a seemingly minor health
problem. In the tea plantations of Ceylon, the Rockefeller Foundation's
6-year program to eliminate hookworm through treatment and installation of
pit latrines was a failure. Far from being grateful to public health workers, tea
pickers actively opposed the program because of its dull routine and focus on
what they deemed an unimportant problem (190). Likewise, a malaria control
program using insecticide spraying in Surinam met resistance from local
populations; reasons for the reluctance ranged from fear of the insecticide and
its effects on animals and local gods to disbelief about the relationship
between mosquitoes and malaria (12). More recently, MacCormack (163),
who has worked in malaria control activities in Africa, has encouraged the
treatment of traditional sleeping nets with residual insecticides.
In addition to direct participation in malaria control programs, some an-
thropologists have focused on the demographic, economic, and cultural
effects of successful malaria control in such locations as Mexico (108),
Sardinia (29), Sudan (98), and Sri Lanka (31). Brown (28) has described this
approach as the anthropology of disease control, since these researchers view
health improvements as the result of outside influences on social and cultural
change. This approach contrasts with the application of anthropological
knowledge in disease control programs. An example of the latter approach is
provided by the work of Gordon (96), who examined the causes and local
perceptions of the vector-borne disease dengue fever in an urban area of the
Dominican Republic. As part of a mixed-strategy intervention program,
Gordon's survey demonstrated significant changes in people's explanatory
models of dengue, although such changes were not accompanied by a reduc-
tion of sources for the mosquito vector, Aedes aegypti.
Widespread medical anthropological interest in primary health care (PHC)
(19) including such key strategies as oral rehydration therapy (44) is, in
fact, aimed primarily at the reduction of infectious disease morbidity and
mortality. Because PHC requires more community participation and adapta-
tion of culturally acceptable and affordable health technologies than did the
older, vertically oriented disease control strategies, this is an area where
anthropological research contributions will be especially critical.
CONCLUSION: THE IMPORTANCE AND LEGITIMACY

OF INFECTIOUS DISEASE RESEARCH IN MEDICAL
ANTHROPOLOGY
Anthropological studies of infectious diseases comprise an impres

ture characterized by a broad range of theoretical paradigms and research

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methodologies. We have examined this rich body of research, categorizing it

according to three basic orientations biological, ecological, and sociocultur-
al. Note that research related to the interaction of humans and infectious
disease agents is not limited to medical anthropology. Indeed, this subject
requires discussion of classic research questions in biological anthropology,
archaeology, cultural ecology, ethnomedicine, and applied anthropology in
international health. A focus on infectious disease requires us to bridge the
gap between the cultural and biological subfields and to return to a holistic
perspective.
Nevertheless, there are four reasons why medical anthropologists in par-
ticular should pay increased attention to infectious disease research. First,
infectious diseases have acted throughout human history as important agents
of selection for both biological and behavioral characteristics of the species.
Second, the distribution of infectious diseases is significantly influenced by
human actions that affect ecology, since infectious agents make up an impor-
tant part of that ecology. As such, culturally coded behaviors provide critical
clues for understanding the social epidemiology and potential control of such
diseases. Third, infectious diseases represent the most important cause of
suffering and death in societies traditionally studied by anthropologists. The
origins of this suffering must be analyzed from both micro- and macro-
sociological perspectives, including the political-economic one. And, finally,
applied medical anthropologists must be equipped to work within the biomed-
ical paradigm if they hope to be effective in improving infectious disease
control programs or health care delivery. This does not imply, however, that
they should be limited to that paradigm.
In recent years, many medical anthropologists have abandoned the research
directions described in this review. Concepts such as adaptation to disease,
while still prominent in teaching texts (168), are receiving less than adequate
attention from researchers. Even worse, the charge has been made that
medical anthropologists who utilize biomedical categories (e.g. the diseases
described above or epidemiological concepts) have been "coopted" by the
intellectual hegemony of Western biomedicine. This accusation by critical
medical anthropologists has three basic elements: 1. that because all reality-
including the processes of sickness and health is socially constructed,
biomedicine is predicated upon culturally limited assumptions about fun-
damental categories like "causation"' and "disease"'; 2. that diseases are only
the proximate causes of human suffering, since the ultimate etiologies involve
political and economic inequality (the so-called "political economy of
health"); and 3. that the institution of biomedicine itself functions to maintain
social inequalities. These criticisms, which are not altogether new, have
merit; but they do not contradict the basic findings of the literature described
here, which does not advocate an unquestioning acceptance of biomedicine.
In fact, anthropological research in infectious disease reemphasizes the

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110 INHORN & BROWN
long-standing claim of medical anthropology that culture "manufactures"

disease in two ways. First, societies actively change their ecology so as to
increase or decrease the risk of particular diseases. Second, culture provides a
theoretical system for understanding and attempting to manipulate through
medicine the diseases that cause human suffering and death. As students
and interpreters of societies and cultures, anthropologists cannot afford to
ignore the infectious diseases, because coping with them is a universal aspect
of the human experience.
ACKNOWLEDGMENTS
We express appreciation to Frederick L. Dunn, who reviewed and revised

earlier drafts of this manuscript and whose interests in theoretical, method-
ological, and applied issues in the anthropological study of infectious disease
have been an inspiration. M. C. I. thanks Nelson H. H. Grabum and James
Anderson for reviewing an early draft of the manuscript, and P. J. B. thanks
Eric Johnson for bibliographic assistance.
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The Anthropology of Infectious Disease

Author(s): Marcia C. Inhorn and Peter J. Brown

Stable URL: https://www.jstor.org/stable/2155960

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Department of Anthropology, University of California, Berkeley, California 94720

Department of Anthropology, Emory University, Atlanta, Georgia 30322

KEY WORDS: evolution, disease ecology, behavioral research, ethnomedicine, infectious

Diseases caused by infectious agents have profoundly affected both human

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diseases through culturally coded patterns of behavior or through changes in

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forestation, effectively increasing the available breeding grounds for An-

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and increased physiological stresses indicative of malnutrition, characteristic

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Research Examples in Disease Ecology

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Human Behavior and Infectious Disease Transmission

THEORETICAL MODELS As we have argued elsewhere (33), any an-

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spective-of the kind advocated by Turshen (217) and exemplified in much of

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RESEARCH EXAMPLES The role of human behavior in increasing or limiting

Kuru and cannibalism Perhaps the best-known example of anthropological

Malaria and cultural adaptation Anthropologists interested in cultural

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Echinococcosis and companion dogs Echinococcosis (hydatid disease) is a

Schistosomiasis and water contact Schistosomiasis is a water-based parasit-

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the parasite and in its transmission to humans. Because of the importance of

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with a large number of men (155). Upon accumulating sufficient wealth,

AIDS and sexual behavior The above-described pattern of STD transmis-

Ethnomedical Beliefs Regarding Etiology, Diagnosis,

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anthropological studies that answer the all-important "why" question by

Diarrhea and folk beliefs In her study of indigenous beliefs surrounding

Dracunculiasis and contaminated water Dracunculiasis (guinea worm dis-

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transmit disease to humans, who ingest them while drinking. Dracunculiasis

African trypanosomiasis and brush removal Another example of the need

Malaria and traditional medicines and foods Other researchers working

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tracts of these traditional medicines, using a mouse model of malaria, showed

Trachoma and ethno-ophthalmological practices Trachoma, the leading

Local Responses to Infectious Disease Control Programs

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especially important in international programs, where recognition of differ-

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Yet, control programs aimed at reduction of a single disease identified by

CONCLUSION: THE IMPORTANCE AND LEGITIMACY

Anthropological studies of infectious diseases comprise an impres

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methodologies. We have examined this rich body of research, categorizing it

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long-standing claim of medical anthropology that culture "manufactures"