MEDICAL ANTHROPOLOGY, 28(3): 199206

Copyright # 2009 Taylor & Francis Group, LLC ISSN: 0145-9740 print=1545-5882 online DOI: 10.1080/01459740903070451

Pathogens Gone Wild? Medical Anthropology and the Swine Flu Pandemic
Merrill Singer

Beginning in April 2009, global attention began focusing on the emergence in Mexico of a potentially highly lethal new influenza strain of porcine origin that has successfully jumped species barriers and is now being transmitted around the world. Reported on extensively by the mass media, commented on by public health and government officials across the globe, and focused on with nervous attention by the general public, the so-called swine flu pandemic raises important questions, addressed here, concerning the capacity of medical anthropology to respond usefully to such disease outbreaks and their health and social consequences.
Key Words: A(H1N1) influenza; biosocial models; influenza; medical anthropology; pandemics; swine flu; syndemics

The anthropological study of epidemics, as Lindenbaum (2001:380) observed, provides a unique point of entry for examining the relationships among cultural assumptions, particular institutional forms, and states of mind. At the same time, it offers a window on the underlying structures of social relationship within and across group boundaries, including the mechanisms used to sustain complex social architectures of inequality over

MERRILL SINGER is a Professor in the Department of Anthropology and Senior Research Scientist at the Center for Health, Intervention and Prevention at the University of Connecticut and an Associate Editor of this journal. Additionally, he is affiliated with the Center for Interdisciplinary Research on AIDS at Yale University. He has published more than 200 articles and book chapters and authored or edited 20 books. He is the recipient of the Rudolph Virchow Prize, the George Foster Memorial Award for Practicing Anthropology, the AIDS and Anthropology Paper Prize, and the Prize for Distinguished Achievement in the Critical Study of North America. Correspondence may be directed to him at Merrill.Singer@Uconn.edu

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time. In this, it is clear that in addition to the existence of a microbiopolitics, in which, as Paxson (2008:16) argued, social disagreements over how to live with microorganisms reflect disagreement about how humans ought live with one another, there is also a macrobiopolitics in which the cultural construction of infectious disease reflects structures and contestations in human social relationships. These dual and mutually influencing biopolitical processes are of particular note of late in that the enduring threat from infectious diseases creates a world very different from the one imaged 50 years ago by many health experts. As Binder et al. (1999:1311) indicated, the widespread optimism in developed countries after World War II that good sanitation, vaccines, and antimicrobial agents would conquer infectious diseases was followed by ominous developments, such as the recognition of the extent of the HIV=AIDS epidemic and the resurgence of diseases such as tuberculosis. Globally, in fact, infectious diseases remain the leading cause of death almost ten years into the 21st century, and even in highly developed nations like the United States infections rank third among causes of mortality. Moreover, the danger posed by infectious agents has been growing. There has, for example, been a mounting concern among public health officials, health care providers, and the general public about an increasingly long list of emerging diseases. The discovery of new pathogens, some of which are already widespread in human populations by the time they are recognized, is now occurring at a rapid pace. On average, three new human infectious diseases are identified every two years, with a new pathogen being reported in the health literature every week. One indicator of the level of attention now being given to the new killer germs is the launch by Springer Publishing Company of a book series titled Emerging Infectious Diseases of the 21st Century with ten new titles. Of historic note, the series editor is I. W. Fong, Chief of Infectious Disease at St. Michaels Hospital in Toronto, a facility that during the SARS epidemic of 2003 (which caused 43 deaths in Toronto and cost the city about 15% of its annual economy) was forced to cancel all elective surgery for three months. As a consequence of the lingering memory of this frightening experience, which created an air of anxiety at St. Michaels (Sullivan 2004), the hospital quickly posted on its Web site a reassuring message informing would-be patients that the current swine flu outbreak is not SARS and that St. Michaels is taking every precaution to ensure the health and safety of patients, staff, and students. Similar reassurances have been issued by many hospitals, the Centers for Disease Control and Prevention, the World Health Organization, state and provincial health departments, ministries of health, and the President of the United States (while asking Congress for an increase of $1.5 billion in influenzarelated funding).

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Truly we live in a time of perplexing vulnerability and high anxiety. From a crashing global economy linked in part to the self-serving deeds of corporate criminals, to shadowy bomb-wielding terrorists, to would-be pirates on the high seas, to raging microbes, there are enemies at the gate everywhere we look. It bears asking: Are these phenomena linked together in some fashionby underlying cultural assumptions, social practices, and particular states of mind, as Lindenbaum might suggestor do they represent a mere temporal coincidence? From the perspective of anthropology, the current rapid appearance and spread of emerging diseases among human populations (as well as other challenges we face) appears in no small part to be a consequence of major environmental changes like deforestation and reforestation, intensification of agriculture, dam construction and irrigation, housing and road building, concentration of people in overcrowded and densely packed cities, the fast-paced movement of people around the planet, the global reorganization of food production following an industrial model, the development of pathogenic resistance to overused and misused antibiotics, unregulated and unsustainable economic activities, and global climate change. Because all of these anthropogenic global changes are expected to continue and even to accelerate in coming years, the threat of new and renewed pathogens is significant, particularly in developing nations, where comorbid old and new infectious diseases are common; immunohealth may be compromised by dietary deficiencies, prior infection, and stress; and health prevention and intervention infrastructures are weakest. So too with the poor of rich countries, people who often experience a novel infection as yet another encounter with a prevailing pattern of socially produced health disparities. In short, while emergent pathogens are components of nature, their appearance among humans and their health and social impacts are mediated by microsocial processes embedded within large-scale inegalitarian social structures and their environment-shaping influences. Thus, so-called risk behaviors, common targets of epidemiological response to the spread of disease, are shaped by social environments and relationships more so than they are products of individual acts, attitudes, and understandings. Moreover, as seen in the HIV=AIDS pandemic, social and biomedical responses, from stigmatization to the inadequate allocation of intervention resources, reflect underlying social patterns and socially constituted attitudes. Consequently, in a world in which pathogens seemingly have gone wild (i.e., act in ways that frustrate human initiative and desire), a field like medical anthropology that brings unifying biosocial and micro-=macrobiopolitical perspectives to the on-the-ground examination of social and contextual factors in health may be of particular value. It is in this light that we can ask: What can medical anthropology bring to the

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(epidemiologically titled) novel strain H1N1 influenza A (popularly named swine flu) pandemic? The answer, I suggest, involves three responses: (1) field monitoring of the pandemic as a biosocial phenomenon; (2) assessment of the biosocial origins and ongoing social influences on the pandemic; and (3) research-based and culturally informed involvement in public health applications.

MONITORING THE SOCIAL PANDEMIC Like the bodies they afflict, diseases are simultaneously physical and symbolic artifacts that are both naturally and culturally produced, and securely anchored in a particular historical moment (Scheper-Hughes and Lock 1997:7). Public health and more so biomedicine, however, tend to focus on the biology of disease, and certainly at the moment of a rapidly spreading lethal pandemic, express heightened interest in identifying medical magic bullets. One lesson of the HIV=AIDS pandemic, however, is that effective vaccines for viral infections are not easily acquired (both because viruses hijack and reproduce in body cells and because they can rapidly change their genetic composition). Additionally, from the standpoint of people living with infection, the press of the social disease (i.e., how they feel treated by others) can outweigh the biological burden of infection. In a small qualitative study of MSM in London, for example, Owen (2008) found people feel heavily stigmatized because of having hepatitis C. As one participant reported: I think how it makes you feel is worse than the actual thing itself. . . . The fear of rejection, the fear of the stigma and all that is actually more toxic than the disease itself (Owen 2008:603). Similarly, in a study of SARS-related stigma in Amoy Gardens, the site of a significant community outbreak in Hong Kong, Lee et al. (2005) found that residents feel shunned, insulted, marginalized, and rejected in interpersonal relationships, acquiring services, employment, and education. These researchers report that their findings underline the roles played by inconsistent health policy responses and the risk of miscommunication by the media in amplifying stigma during an emergent disease breakout. Stigmatization does not emerge in a vacuum, however. Rather, it adheres to and provides undergirding for prevailing axes of social division. An important social function of stigmatization is the legitimation of unequal group status in society. As such, the cultural construction of stigmatization serves as a hegemonic hierarchy-legitimizing myth for both dominant and subordinate social strata. In the case of the H1N1 influenza pandemic, a geography of blame was quick to be invoked. As Fuller (2009) reported, Radio, TV and newspaper

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personalities have jumped on the illness as a platform to attack illegal aliens for being responsible for carrying the disease across the Mexican border and infecting innocent Americans. For example: During the April 24 edition of his nationally syndicated radio show, Michael Savage made the unsubstantiated claim: Make no mistake about it: Illegal aliens are the carriers of the new strain of human-swine avian flu from Mexico. . Conjuring up a conspiratorial plot, during the April 27 edition of his nationally syndicated radio show, Neal Boortz asked his listeners: [W]hat better way to sneak a virus into this country than give it to Mexicans? Right? I mean, one out of every ten people born in Mexico is already living up here, and the rest are trying to get here. So . . . you let this virus just spread in Mexico, where they dont have a CDC. . In one of his broadcasts, Boston talk show host Jay Severin stated: So now, in addition to venereal disease and the other leading exports of Mexico . . . now we have swine flu.
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Overreaction and stigmatization was not limited to editorial commentary in the media, but has extended to official government pronouncements and actions. For example:
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China, Russia, and the Ukraine moved to ban pork imports from Mexico and several parts of the United States. Israeli Deputy Health Minister Yakov Litzman announced that Israel would call the new disease Mexico flu so as to avoid using the term swine. In May 2009, China placed 70 Mexican, 26 Canadian, and four American travelers in quarantine, although these individuals exhibited no sign of illness. Government officials in Hong Kong announced that they were preparing camps to quarantine patients. Mexican President Felipe Calderon, saying that some countries and places are taking repressive and discriminatory measures because of ignorance and disinformation, publically complained of a backlash against Mexicans abroad.

Identifying, analyzing, and offering evidence-based critique of the healthdamaging, discriminatory, and disparity-legitimizing elements of the social pandemic of H1N1 influenza or any subsequent disease outbreak are tasks well-suited to the methods and theoretical frames of medical anthropology.

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BIOSOCIAL ORIGINS OF THE PANDEMIC Since the early 1980s, medical anthropologists have regularly examined the social origins of disease. Two questions already have been raised about the social origins of H1N1 influenza. First, there are the facts that this influenza strain developed in pigs (suggesting the importance of monitoring potentially zoonotic animal diseases) and the initial epicenter of the outbreak is in a part of Mexico that is home to the massive Smithfield Foods (company motto: Good Food. Responsibly) pig production center, which supplies approximately one million hogs annually to the global market. Industrial farm animal production (IFAP) centers like Smithfield, however, produce more than animals. They also create quantities of animal waste that are too vast, concentrated, and toxic to be converted into manure. In their national report on IFAPs, the Pew Charitable Trusts and Johns Hopkins Bloomberg School of Public Health (2008:4) pointed out the lack of necessary treatment of the enormous amount of animal waste generated at such facilities may result in contamination of nearby waters with harmful levels of nutrients and toxins, as well as bacteria, fungi, and viruses. Among the prominent concerns explicitly raised in this report is the potential of IFAPs, with their dense populations of host animals and continual cycling of viruses through the herd, to contribute to the emergence of a novel virus that could lead to human disease and human-to-human transmission. In other words, there are grounds for investigating whether the origin of the H1N1 influenza virus was tied to profit-oriented corporate farm production methods. Second, the H1N1 mortality pattern seen in Mexico may reflect an interspecies syndemic interaction under a given set of social conditions. As Davis (2006) indicated, damage and destruction of the ciliated epithelial cells of the lungs and the resulting loss of their ability to push microorganisms from the respiratory track allows superinfection by bacteria. This creates the potential for a lethal synergy . . . between influenza A and pneumonic bacteria, with Staphylococcus aureus and Streptococcus pneumoniae being particularly vicious; thus, bacterial pneumonia is the most common, or at least the most clearly associated cause of influenza deaths. This type of pathogenic interaction is believed to be the source of the lethality of the influenza pandemic of 1918, which caused at least 100 million deaths. Additionally, as is always a concern with influenza, world health officials are expressing concern about the interaction between H1N1 and other health conditions like asthma, diabetes, and tuberculosis. An appeal of the syndemics approach within medical anthropology, as Nichter (2008:159) observed, is its unification of both an explicit emphasis on examining connections between health and development and its attention

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to routes of transmission that affect clusters of interrelated health problems. By exploring the social origins of an epidemic, medical anthropologists can help to pinpoint social risk patterns that may be of far greater importance to mobility and mortality than individual risk behaviors.

INFORMING PUBLIC HEALTH APPLICATION For the past 20 years anthropologists have been involved in applied work in the HIV=AIDS pandemic, an arena of experience that has led to applied contributions targeted at a number of other infectious disease outbreaks as well. Notably, this work has not been characterized by playing narrow supportive roles in epidemiologically defined efforts, but rather has often involved critiques of established models and the development of alternative, ethnographically informed approaches. Independent of HIV=AIDS, anthropologists have participated in applied initiatives in response to dengue, respiratory diseases, STDs, tuberculosis, and several other contagious conditions. Roles filled by medical anthropologists in these efforts have ranged from formative research used to inform program design, to program implementation and management, to process and outcome evaluation. In particular, medical anthropologists have championed participatory community-based models of intervention. Public education is another role taken up by medical anthropologists, such as Ron Barretts May 2, 2009 interview on National Public Radiodrawing on his experience with plague in Surat, Indiaabout the ways disease fear and stigma can cripple a public health system.

CONCLUSION While the H1N1 influenza initial mortality rate in Mexico (i.e., 30% of known cases compared to .1% for a normal flu season) suggested the potential start of a deadly influenza pandemic, the first wave of the pandemic has proven to be comparatively mild in most settings (relative, again, to a normal flu wave, which globally can cause as many as one million deaths). In the United States, the hospitalization rate thus far also is typical of seasonal outbreaks. By the middle of May 2009, there were over 9,000 confirmed cases spread across 40 countries, and 75 deaths, mostly in Mexico (six in the United States, which now reports more confirmed H1N1 infections than Mexico). What these patterns foretell about the fall=winter 2009 influenza season (as the virus undergoes further mutation) remains to be seen. Whatever

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the tomorrow of H1N1, influenza remains a significant threat to human wellbeing, especially among highly vulnerable populations worldwide, and hence it is an arena in which medical anthropology is called on to make a difference.

REFERENCES
Binder, S., Levitt, A., Sacks, J., and Hughes, J. 1999 Emerging Infectious Diseases: Public Health Issues for the 21st Century. Science 284(5418):13111313. Davis, M. 2006 The Monster at Our Door: The Global Threat of Avian Flu. New York: Holt Paperbacks. Fuller, B. 2009 Hate-Mongering Conservative Commentators Using Swine Flu to Promote Racism! The Huffington Post. http://Hate-Mongering Conservative Commentators Using Swine Flu to Promote Racism! (accessed May 5, 2009). Lee, S., L. Chan, A. Chau, K. Kwok, and A. Kleinman 2005 The Experience of SARS-related Stigma at Amoy Gardens. Social Science and Medicine 61(9):20382046. Lindenbaum, S. 2001 Kuru, Prions, and Human Affairs: Thinking About Epidemics. Annual Review of Anthropology 30:363385. Nichter, M. 2008 Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter. Tucson: University of Arizona Press. Owen, G. 2008 An Elephant in the Room? Stigma and Hepatitis Transmission among HIV-Positive Serosorting Gay Men. Culture, Health and Sexuality 10(7):601610. Paxson, H. 2008 Post-Pasteurian Cultures: The Microbiopolitics of Raw-Milk Cheese in the United States. Cultural Anthropology 23(1):1547. Pew Charitable Trusts and Johns Hopkins Bloomberg School of Public Health 2008 Putting Meat on the Table: Industrial Farm Animal Production in America, Executive Summary. http://www.ncifap.org/_images/PCIFAPSmry.pdf (accessed May 6, 2009). Scheper-Hughes, N. and M. Lock 1997 The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology. Medical Anthropology Quarterly 1(1):641. Sullivan, P. 2004 SARS Had Lingering Impact, Toronto Hospital Finds. Canadian Medical Association. http://www.cma.ca/index.cfm?ci_id=4444&la_id=1 (accessed May 4, 2009).