ABSTRACT
The United States’ Surgeon General’s claim in 1967 that ‘it is time to close the book on infectious disease’ is held up as a canonical moment because, in retrospect, it actually marked a turning point and upsurge in infectious diseases. Today, despite instances of success (e.g. smallpox eradication coordinated by the World Health Organization (WHO)) the ambition to conquer infectious disease no longer has the same purchase in global public health. It is not simply the re-emergence of infectious disease that has muted such aspirations. Rather, by the mid 1990s a significant transformation in the basic concepts used to understand infectious disease had taken hold in microbiology, virology, immunology, and epidemiology: viruses are increasingly understood as recombinant, unpredictable, and continually in the process of becoming – in short, as emergent (Lederberg 1996; Cooper 2006). Moreover (as the 1992 US Institute of Medicine report, quoted above, indicates) the threat of emergence was increasingly understood as an ever-present threat to populations across the globe, and not one from which the Global North is immune. The transformation entailed in thinking of viruses as emergent echoes an earlier transfor-
mation in biomedical notions of the immune system (and one familiar to medical sociologists) (Martin 1994). The immune system had been characterized as a fixed entity akin to a hierarchical command-control centre that defended the body from invasion through its capacities to recognize ‘outsiders’. This notion has been contested by biomedical research that characterizes the immune system as an inherently conflicted network, a non-hierarchal distributed system that no longer operates by discriminating between inside and out, self and other, protector and invader. The immune system is now understood as a distributed system for which ‘[c]ontext is a fundamental matter, not as surrounding “information”, but as co-structure and co-text’ (Haraway 1991: 214). Similarly, contemporary characterizations of infectious disease foreground how viruses are not relatively fixed entities that can be studied and known, rather they are
unpredictable, unstable modes of existence whose transformations cannot be separated from the contexts in which they arise (Cooper 2006). Viruses are described as situated in the sense that they are ‘but one component of a dynamic and complex global ecology, which is shaped and buffeted by technologic, societal, economic, environmental, and demographic changes, not to mention microbial change and adaptation’ (Satcher 1995: 4-5). Such accounts of emergence cast viruses as ever-changing, recombining and re-assorting in unpredictable ways. By the mid 1990s the notion of emergence had a firm foothold in public health; for
instance, the Centers for Disease Control (CDC) in the United States of America (USA) launched a new journal, Emerging Infectious Diseases (EID), in 1996. Here, EID are defined as ‘infections that have newly appeared in a population or have existed but are rapidly increasing in incidence or geographic range’ (Morse 1995: 1). The pages of EID are devoted to emerging and re-emerging diseases (e.g. HIV, TB, malaria, influenza, staph, Ebola, RiftValley fever virus, norovirus). The resurgence of infectious disease is commonly explained by those working on EID by
invoking ‘globalization’:‘global factors’ are cast as having intensified the risks of bringing people into contact with unfamiliar microbes and of facilitating the dissemination of familiar ones (Lederberg 1998: 464). Thus, in public health discussion, globalization is understood as a set of factors that include: (1) ecological factors, such as dam building or changes in agricultural practices, which have been connected to a range of diseases including influenza and Bolivian hemorrhagic fever (Morse 1995); (2) industrialization and associated demographic changes such as the increased density of populations to be found living in megaslums; and (3) the rapidity of travel and contact between people. All of these in turn have been associated with EID (Davis 2006; Lederberg 1998). As Lederberg (1998) argues, today there is nothing ‘exotic’ about diseases that were previously found in far-flung corners of the globe – the amount and rapidity of people’s travel around the world together with the extent that goods are being transported means that diseases travel. In addition to the three factors above, EID are explained as a result of (4) technological changes across the globe, for example, air conditioning, which has been associated with Legionnaire’s disease, tampons with toxic shock syndrome and faulty water purification with cryptosporidium (Lederberg 1998). As the opening quote from an early 1990s report on infectious disease within the USA
suggests, what has become apparent are the limitations of successfully deploying familiar public health strategies that rely on national border protection as a means of safeguarding the nation (Institute of Medicine 1992). Epidemiological accounts of EID identify the social changes and the ongoing expansion of global markets as contributing to disease. However, in the absence of research into how these social and economic shifts actually unfold, what they mean to people and how they are contested, there is real risk that public health ends up repeating a clichéd mantra that globalization triggers infectious disease rather than opening specific entry points into understanding the connections and the best mode of responding. By connecting EID to ‘global factors’, EID are cast as situated in particular social contexts.
Yet, public health discussions of the ‘global factors’ contributing to infectious disease neglect, in Farmer’s words, how social factors, such as inequalities, ‘sculpt not only the distribution of emerging diseases, but also the course of disease in those affected by them’ (Farmer 1996: 265). This neglect arises in part,we argue, because possibilities for public health understanding of and capacity to act on the specificities of different social contexts are under-explored.We develop this argument by examining the failure to grapple with social practices and contexts in the global response to one EID, HIV. The public health response to HIV is rarely informed by analyses of: the power relations at play between high-and low/middle-income countries; the tensions between different forms of knowledge about disease; or tensions between public health
responses that privilege ‘exportable’, packaged clinical interventions into disease and social interventions that need to be grounded in an engagement with the specificities of local contexts in order to be effective.
