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Оглавление7 The Role of Social Sciences in One Health – Reciprocal Benefits
MAXINE WHITTAKER1* BRIGIT OBRIST2,3 AND MÓNICA BERGER-GONZÁLEZ2,4,5
1 James Cook University, Townsville, Australia; 2 Swiss Tropical and Public Health Institute, Basel, Switzerland; 3 Institute of Social Anthropology, University of Basel, Basel, Switzerland; 4 University of Basel, Basel, Switzerland; 5 Universidad del Valle de Guatemala, Guatemala City, Guatemala
Introduction
This chapter discusses the role of social sciences in developing a deeper understanding of diverse perspectives of health and illness in animals and humans, as well as in contributing to improve services and programmes using a One Health approach. Drawing on evaluated and ongoing examples from various countries, the authors demonstrate the added value of social sciences to address common local or global health problems using a One Health approach. The presentation and discussion of these examples allows for an exploration of various key aspects, ranging from diverse understandings of health risks, protection, responses, implementing interventions and health communications as well as questions of equity of access and benefit. Theories and approaches in anthropology and other social sciences frame the discussion. This analysis adds further value to social sciences’ contribution to One Health and One Health’s contribution to social sciences in research and in programme implementation.
Background
Rüegg et al. (2018) note that:
Many current health challenges, such as spread of zoonotic infectious diseases, environmental pollutants, antimicrobial resistance, climate or market-driven food system changes with consequences on food and feed supplies, malnutrition including obesity and many more arise from the intertwined spheres of humans, animals, and the ecosystems constituting their environment.
(Rüegg et al., 2018, p. 2)
They argue that such wicked problems require transdisciplinary and integrated approaches that take a systems approach, and that One Health provides such a framework.
A call for social science contributions to One Health is not new. As Dentinger (2017) has shown, Calvin W. Schwabe’s pioneering work built on, and was reflected in, his efforts to understand the tapeworm Echinococcus granulosus as a biological and a cultural phenomenon, shaped by social relationships. In his studies in Beirut, among the Turkana in Kenya and later in California between 1956 and 1975, Schwabe expanded on the parasitological research tradition of examining biological host–parasite interactions in his explicit inclusion of social behaviour and cultural practice.
Since then, many natural scientists have emphasized the importance of human behaviour and cultural practices, for example for understanding risk exposure, transmission routes and the development of behaviour change interventions. Robertson and Thompson (2002) pointed to the need of educating dog and cat owners for managing enteric parasitic zoonoses in humans and their animals. The parasitologist Macpherson (2005) drew attention to the pivotal role human behaviour plays in the macro and microepidemiology of emerging or re-emerging parasitic diseases. The entomologist Gillett (1985) discussed the forgotten factor – human behaviour – and the complex relationships that exist between human behaviours and public works, urbanization, packaging, agricultural practices – and the transmission of vector-borne diseases. Dung et al. (2007) investigated the epidemiology of fish-borne zoonotic trematodes in Vietnam and suggested that behavioural factors warrant greater collaboration between epidemiologists and anthropologists in designing approaches for mitigating risk in a population with great resistance to change in eating habits. In discussing integrated rabies control, Lechenne et al. (2015) highlighted the importance of understanding the ecology of rabies, animal behaviour and human beliefs and behaviours in order to have effective programmes. Wildlife scientists Alexander and McNutt (2010) used data from a comparative study conducted in Kenya and Botswana to investigate the relationship between divergent cultural practices of pastoralists and contact between domestic dogs and African wild dogs. Based on this study and other examples, they developed a conceptual model of the potential influence of human behaviour on pathogen emergence at the human–domestic animal–wildlife interface and call for greater inclusion of the social sciences in emerging infectious disease research.
The outbreaks of SARS (severe acute respiratory syndrome), MERS-CoV (Middle East respiratory syndrome-related coronavirus), Ebola and Zika have further highlighted the need for social science approaches and actions. However, in 2017, the World Health Organization’s (WHO) Health Emergency Programme and the Wellcome Trust noted that:
Medical anthropologists and social scientists have been used to investigate and manage disease outbreaks, but social science interventions are not yet systematically used in all health emergencies, nor are social scientists trained to work with response teams effectively.
To address this concern a consultative meeting was organized, bringing together 72 experts and partners from more than 40 agencies (WHO, 2018).
Since the first edition of this book (Whittaker, 2015; Zinsstag, et al. 2015), there has been an increase in publications on social science research in the field of One Health. This includes special issues in the journals in Social Science and Medicine (2015) and Medical Anthropology Theory (2018). A particular focus has been the role that social science inputs and insights can play in supporting health security issues like major infectious disease outbreaks.
This chapter discusses several approaches that expanded the One Health research and interventions to include social and cultural dimensions. The first set of approaches frame the research interest and concerns theoretically and practically in the disciplinary context of parasitology, epidemiology and other natural and public health sciences, even if they address social and cultural dimensions of the phenomena under study. This mirrors the fact that, in spite of its programmatic emphasis on interdisciplinarity, the biological paradigm clearly dominates the ways in which pathways to improve human, animal and environmental health are framed. The second set of approaches offer more opportunities for contributions and engagement that move theoretical and empirical concerns of the social sciences into the foreground of One Health research and interventions.
Social science can also inform and stimulate reflectivity of practitioners and researchers, to ensure a ‘more holistic approach to joint problem solving and collective knowledge development’ (Cole, 2017, p. 127). Transdisciplinarity, one of the pillars of One Health, behoves us to embrace local and indigenous knowledge, and not privilege Western science knowledge over the vast cultural continuum of knowledge (Schelling and Zinsstag, 2015).
Examining Social and Cultural Aspects of Human–Animal Interactions
The well-known public health tool of the knowledge, attitude and practice (KAP) survey, also called the knowledge, attitude, behaviour and practice (KABP) survey, is widely used in One Health research. Most KAP surveys use predefined questions and the format of a standardized questionnaire to discover characteristic traits in knowledge, attitude and behaviour about health risks, disease and ill health related to religious, social and traditional factors (Médecins du Monde, 2012). The underlying assumption is that these factors may be the source of misconceptions or misunderstandings that often represent obstacles to behaviour change. Numerous KAP surveys have been conducted in response to the Ebola outbreak in West Africa, for instance in Guinea (Buli et al., 2015), Nigeria (Iliyasu et al., 2015) and Sierra Leone (Jalloh et al., 2017). For example 3 months into the 2014 Ebola outbreak in Sierra Leone, Jalloh and colleagues (2017) conducted a national KAP survey. They found a high awareness of Ebola among all respondents. Without being prompted, 60% of respondents correctly cited fever, diarrhoea and vomiting as signs/symptoms of Ebola. Most respondents knew that avoiding infected blood and bodily fluids (87%) and contact with an infected corpse (85%) could prevent Ebola. But they also found widespread misconceptions, for instance the belief that Ebola can be prevented by washing with salt and hot water (41%). Nearly all respondents (95%) expressed at least one discriminatory attitude towards Ebola survivors. Unprompted, self-reported actions to avoid Ebola infection included handwashing with soap (66%) and avoiding physical contact with patients with suspected Ebola (40%). The findings of Jalloh and colleagues directly informed the development of a national social mobilization strategy in the early stages of the epidemic.
Although KAP surveys address topics that are of key interest to social scientists, they have not been developed for research in the social sciences but to conduct operational or implementation research in the field of family planning and populations studies (Launiala, 2009). Since then they have become increasingly popular, mainly for practical reasons; they can be used for low-cost rapid assessments by researchers with little or no social science background (Manderson and Aaby, 1992). At the same time, they have been criticized by social scientists and public health specialists mainly because the underlying assumptions are based on common sense and highly simplified psychological theories about the relationship between knowledge, attitude and behaviour and completely disregard the importance of contextual influences (Manderson and Aaby, 1992; Launiala, 2009; Muleme et al., 2017).
More sophisticated models, such as the behaviour change wheel (BCW) (Michie et al., 2011), which is grounded in a synthesis of psychological and sociological theories, have not, to our best knowledge, yet been used in One Health research. Although the BCW approach also takes as self-evident that biomedical knowledge, attitude and practice provide the golden standard for health improvement, it opens a space for studying what study participants do in real life – not just what they should do – and how their thinking and acting is shaped by the particular context in which they live.
Contextual influences are often conceptualized as social determinants of health, i.e. ‘the circumstances in which people are born, grow, work, live, and age’, and the wider set of systems and forces: ‘economics, social policies, and politics’ (CSDH 2008, p. 35). Woldehanna and Zimicki (2015), for example, have proposed an expanded One Health model that highlights the social and cultural determinants of human–animal interaction on the local level, with a focus on emerging viral diseases transmitted from animals to humans by direct or indirect contact. The key determinants they have identified are: (i) biological characteristics of individuals, for example gender; (ii) social characteristics of individuals, households and communities, including norms, livelihood systems and settlement patterns; and (iii) at the public policy level, local and international governance and politics (Fig. 7.1).
Fig. 7.1. Socio-cultural determinants of One Health. Adapted from Dahlgren and Whitehead, 2006; CSDH, 2008; Woldehanna and Zimicki, 2015.
The newly emerging animal and human infectious diseases arise from, and are spread by, a multitude of social determinants and ecological causes interacting at multiple scales, from the local to the regional, national, international to global levels, and across diverse domains. As Weiss and McMichael (2004) have argued these changing contexts are due to increases in population size and density, urbanization and human encroachment on forests and wildlife, poverty, the increased number and movement of people, food and animals around the globe, and conflict and warfare.
Much attention has been focused on identifying the environmental, ecological and social dynamics underlying epidemic outbreaks of emerging zoonotic diseases like Ebola or Nipah. The Nipah virus, for instance, emerged in Malaysia in 1998 when deforestation destroyed the fruit bat habitat. The bats moved to trees near livestock pens where they spread Nipah to pigs, from which humans were subsequently infected. The intensification of pig farming associated with the spillover of the virus from bats to pigs to humans was backed by companies and land deals and by broader economic shifts in regional stockbreeding underpinning local dynamics (Epstein et al., 2006; Otte and Grace, 2012; Pulliam et al., 2012). In later outbreaks of Nipah virus infections in Bangladesh and India, no clear evidence of transmission through pigs has been found. Rather, drinking traditional liquor made from date palm sap contaminated by bat excreta was one of the main sources of infection (Luby et al., 2006).
Other studies have shifted the attention from epidemic outbreaks attracting high media attention to endemic and neglected zoonotic diseases. They have examined the complex interactions of poverty and ecosystems in settings where zoonotic transmission usually occurs. Such transmission is often associated with rapid environmental and land-use change and the close contact between humans and wild and domestic animals (Okello et al., 2014). This analysis of the zoonotic transmission takes diverse and context-specific pathways into account (Cunningham et al., 2017).
Complementary to studies emphasizing a contextual analysis of social determinants, comparative research delving in depth into one determinant, such as gender, across diverse settings also contributes to expanding the social One Health agenda, as illustrated by the following case study of a gender analysis of food safety (Case study 1).
Case study 1. How understanding gender can contribute to understanding and improving food safety. Contributed by Delia Grace, International Livestock Research Institute, Nairobi, Kenya.
Background
Food safety is a One Health issue. Foodborne disease (FBD) has a health burden comparable to malaria, HIV-AIDS or tuberculosis (Havelaar et al., 2015). The majority of the quantified causes of FBD are zoonoses and animal source food is an important source of illness (Grace, 2015). Most FBD burden falls on low- and middle-income countries (LMIC) and is the result of food purchased in wet or informal markets where the poor buy and sell.
Motivation for research
To improve food safety, we first had to understand it, and that meant identifying who was involved in making food risky or safe and their knowledge, practices and motivations. We knew women and men in LMICs have important, but usually different, roles in producing, processing, selling and preparing food. We hypothesized that these roles, as well as biological differences between men and women, may have negative and positive impacts on their health, and also lead to differences in health outcomes. This case study summarizes findings on gender roles, risks and opportunities from studies in 20 informal livestock and fish value chains in Africa and Asia (Grace et al., 2015).
Findings
Men were seen as having greater responsibility for keeping cattle, capturing fish and market-oriented production, giving them opportunity for income generation. Where value chains had an important processing stage, this was usually dominated by women (e.g. smoking or drying fish and producing traditional dairy products in West Africa). In all the value chains studied, the majority of meat and fish was sold in small-scale, traditional markets (which may also be called ‘informal’ or ‘wet’ markets). In such markets, women sell fish and poultry, but meat is typically sold by men (Vietnam was an exception). Overall, this means women were more exposed to occupational hazards such as chemicals and risk of injury. On the other hand, participation also increased their access to food and income. As processing became modernized, the role of women often declined.
In all the case studies, women were responsible for preparing and cooking food for family consumption within the household. Men’s and women’s consumption within the household was generally reported to be similar. There was a tendency for women to consume riskier foods such as offal. However, in many cultures, there were taboos about pregnant women eating risky foods such as tripe and dog meat, which may have reduced risk. Moreover, men tended to consume more meat and fish outside households, often in outlets which also sold alcohol: this exposed them to higher risk of meat-borne disease. In most countries, milk was given preferentially to children.
Gender analysis showed how women and men carried out different activities, which led to different health risks. In around half the value chains, women were more at risk and in half men were more at risk. Understanding this helped develop gender-sensitive interventions that would work for the gender most at risk. Our finding that when value chains become more formal, they tend to exclude women who dominate more traditional value chains, drew attention to a possible unintended consequence of modernizing food systems. Such insights into social dynamics can help ensure development is inclusive and ultimately more effective.
Designing and Conducting Reflective and Participatory Social Science Studies and Collaborations in One Health
In their introduction to a special issue of Social Science & Medicine on social science engagement with the One Health agenda, Craddock and Hinchliffe (2015, p. 1) claim that ‘without proper social science engagement, the One Health approach is at risk of derailment’. In order to increase the efficacy and legitimacy of the knowledge produced, their argument goes, One Health research has to: (i) recognize and respect diversity regarding approaches to and understandings of health; (ii) acknowledge and appreciate social and cultural difference; (iii) analyse and take into account uneven power relations; and (iv) pay attention to how associations between disparate social worlds are configured. We affirm that research approaches also need to include consideration of the impacts and contributions of humans on human, animal and environmental health.
Building on Craddock and Hinchliffe’s (2015) argument, this chapter emphasizes the importance of a reflective stance in all stages of the research process. What do we mean by ‘integration’ and ‘partnership’, two key terms used in defining One Health approaches? Who integrates whom under what terms? What are the assumptions underlying the relationship between partners? Who are the experts, whose knowledge and practice counts, when, for whom and why? Improving health, solving health problems and responding to disease outbreaks and other types of ill health seem to be universal human goals. However, if we start to investigate how actors of diverse cultural, gender, social and economic backgrounds understand and judge what experts (e.g. those trained in biomedical sciences, clinical, environmental and veterinary sciences) conceptualize as health problems, emerging or resurgent diseases and proper interventions, we begin to realize that these are not just biological but also cultural phenomena – as already observed by Calvin W. Schwabe.
One Health itself can be analysed as a cultural phenomenon, shaped by social and political relationships. Looking back on its history, Cassidy (2017) sees One Health as a response mounted by specific scientists, clinicians and policy makers, working in specific institutional and organizational contexts, to problems that manifested themselves at particular times and in particular places. Cassidy comments: ‘In contrast to advocates’ claims, it is not a self-evidently beneficial phenomenon, nor the result of inevitable progress, but a contingent and context-bound activity that is actively and continually created through persuasive rhetoric and alliance-building’ (Cassidy, 2017, p. 196). This becomes even clearer when social scientists trace how the One Health movement travels around the globe, for instance to African countries. Okello and colleagues (2014) have shown for Uganda, Nigeria and Tanzania, the ‘goodwill’ of practitioners and policy makers is there, but they face many challenges in planning, executing and budgeting for joint interventions. Inequities (in access, affordability, quality, health rights) may be embedded in policies developed for low-income and indigenous communities. Rock et al. (2017) in discussing rabies control programmes describes this as an ‘entangled phenomenon’ of animals, human injuries, public policies and rabies. These and other social science studies can contribute to gaining deeper insights into not just whether, but how, One Health as an approach for intervention and action may be achieved.
A better understanding of ‘knowledge’, ‘attitude’, ‘behaviour’ and ‘practice’ is key to advancing the One Health agenda, not just for studies on local actors who may be, for example, potentially at risk of being infected by parasites that are transmitted from animals to humans. Words like ‘knowledge’ are terms used in everyday language, but in social science research they must be conceptualized with reference to theory. As the prominent medical anthropologist Arthur Kleinman (2010) elaborated in a Lancet article, a foundational theory in the social sciences is known as ‘the social construction of reality’, introduced by Peter Berger and Thomas Luckmann in the 1960s. According to this theory, the real world not only has a material basis, ‘it is also made over into socially and culturally legitimated ideas, practices, and things’ (Kleinman 2010, p. 1518). As an example, he refers to the spread of the H1N1 influenza virus that was ‘made over’ by global actors into the socially threatening and culturally fearful ‘swine flu’ epidemic. But he also points out that global health problems and programmes can (and often do) take on culturally distinctive significance in different local settings. What may be considered as a highly threatening health risk by global health experts may be regarded as one among many other health challenges by national policy makers and regional or local practitioners, and may not be recognized as a ‘real’ phenomenon by people exposed to this risk. This often leads to tensions between global policies and local reality and poses a challenge to medical and public health practice. ‘A corollary of the social construction of reality is’, Kleinman (2010, p. 1518) concludes, ‘that each local world—a neighbourhood, a village, a hospital, a network of practitioners/researchers—realizes values that amount to a local moral context that influences the behaviour of its members.’
Social constructivist theory, as proposed by Berger and Luckman (1966), refers to an epistemological position in which knowledge – and values – is regarded as constructed on the basis of experiences, in interaction with other social actors and broader cultural, economic and political contexts, and is often not articulated in words but in practice. In this understanding, knowledge is not a ‘thing’ that can be easily elicited, for instance in a survey with predefined questions such as a KAP study, outside the vital context of experience. What constitutes a problem and what is a proper response to this problem is seen through a social lens.
Social constructivist theory is one among several social science theories that foster a deeper understanding of common sense terms like knowledge, attitude, behaviour and practice. We introduce it here because it provides a foundation for designing and conducting reflective and participative social science research in One Health as the following two case studies will show. Case study 2 highlights the deliberate inclusion and role of social sciences from the beginning to the end of a pilot intervention. It emphasizes the importance of reflections by all disciplinarians upon their approaches, beliefs and potentially unconscious biases towards Western science paradigms. It also illustrates the valuable role of the social scientists ‘contextualizing’ decisions to ensure truly participatory knowledge development and design – from conceptualization to policy development.
Case study 2. One Health participatory surveillance and response from diverse Guatemalan perspectives. Contributed by Mónica Berger-González and Brigit Obrist.
Background
Guatemala, like many LMICs, is facing rapidly changing ecosystems that increase the vulnerability of populations where public health care and animal health-care services are poorly implemented, often devoid of cultural pertinence or a good understanding of rural communities’ way of life. The One Health Poptún intervention project aimed to develop a transdisciplinary process (see also Berger-González et al., Chapter 6, this volume) in the subtropical lowlands of Petén, to develop a surveillance and response system for key zoonotic diseases. This is an ongoing proof of concept implementation research between the Swiss Tropical and Public Health Institute, University of Basel, Universidad del Valle de Guatemala, the Ministries of Health and Agriculture, animal production people, the private company Tigo Telecommications Co., the Maya Council of Elders and community development councils. The longer-term vision is to scale up improved interventions into the health system.
With a predominantly indigenous Maya Q’eqchi’ and Mestizo population, this ethnolinguistically diverse area is characterized by medical pluralism, where modern Western approaches to health care offered in the public domain coexist with a predominant Maya medical tradition in a situation of exclusion and inequity. The challenge was to produce a sensitive surveillance system that could capture local understandings of ‘disease’ and respond in culturally appropriate ways deemed desirable by locals. This was only possible through using a strong anthropological approach that articulated a mutual learning process between epidemiologists, medical doctors, nurses, veterinary doctors, Maya traditional healers, local animal and human health authorities and service providers, and community leaders. The project adapted the Explanatory Model of Illness approach (Kleinman, 1978) to examine how each of these groups understand and judge the relations between human–animal interactions, health and illness.
The importance of acknowledging diversity: issues of representation and participation
The project aimed to address stakeholder’s interests on an equal footing in order to increase legitimacy and buy-in of the design, and to facilitate overall implementation of the surveillance-response project. In a post-war setting plagued with mistrust and historical trauma (Chamarbagwala and Moran, 2011), this proved a hard concept to enact. Social scientists conducted contextual and historical research for the study area to understand emerging trends possibly precluding participation of expected groups. An intersectionality approach (McCall, 2005) identified the groups most vulnerable to be excluded or misrepresented within the project. Results showed a context of extreme power differentials triggered by specific conditions that were organized in categories (ethnolinguistic composition, gender, distance-access, literacy, multilinguistic capacity, socio-economic composition, racist attitudes-practices). These were used to redesign transdisciplinary workshops, which included exercises to address power disparities, value rather than fear diversity in representation, and induce reflexivity. Quotas for types of participants were created (i.e. Maya, female, rural, traditional healers) to promote agency of societal actors originally excluded from the project but who were identified locally as key to successful project implementation. Anthropologists also developed specific methods to curb ethnocentric behaviour of researchers that precluded them from understanding local views of the human–animal interface domain.
Approach to development of intervention
Pluri-epistemic systems: ethnography as a tool to uncover underlying models of ‘zoonosis’
Beginning with the conception and design of the project, anthropologists, veterinarians and public health experts from Guatemala and Switzerland worked hand in hand as equal partners, defining an initial interdisciplinary transversal study. Each disciplinary group also conducted its own studies. Veterinarians and epidemiologists studied animal and human samples to determine zoonotic diseases, while anthropologists analysed local understandings of how human–animal interactions may affect health and illness. In regular meetings and workshops, the research team engaged in reflections about similarities and differences of explanatory models held by different categories of study participants (including the researchers). Ethnographic research on the mental models of the local population concerning disease transmission between animals, humans and the larger environment showed most Maya people drew on broader values of Tzalajb’il (harmony), Nimb’el (respect), Sahil Wanq (coexistence) and Xbisbal li wan (balance) to define an exchange of ‘energies’ between the species. A deep-seated notion of an assumed benevolence of nature precluded seeing pathogens of animal origin. This proved a key finding for the later co-design of education and communication strategies aimed at local communities. Apart from strictly Maya or strictly biomedical models of (zoonotic) disease transmission, the team found numerous hybrid models held by local health providers as well as by community members, influencing health-seeking pathways and treatment of patients. For example, Maya midwives that also served as ‘health guardians’ for the public health system, referred to energetic diseases such as ‘hijillo’, a disease believed to be transmitted from a dog to a child via the dog’s energy (non-material contact) but also from contact with afterbirth fluids. The midwives and health guardians explained that symptoms such as fever, diarrhoea, vomiting and lethargy in children would inevitably result in death. While noting that hijillo could be cured only through a Maya ceremony and medicinal plants, they also prescribed antibiotics in very small doses. These various models along the biomedical–Maya spectrum were analysed jointly by team members to understand the diversity of epistemic (knowledge) systems influencing health-seeking behaviour.
The emics of One Health surveillance
Social scientists employed the Bidirectional Emic-Etic framework (Berger-González et al., 2016) to elicit local (emic) categories of disease and terms for illness in animals and humans, which could be better suited for use in the surveillance system. Epidemiologists suggested unequivocal definitions for terms such as ‘febrile syndrome’ or ‘acute respiratory syndrome’, for which there was no direct Maya Q’eqchi’ translation. Given that the project aimed to implement a community-based surveillance system relying on families’ reports of perceived ‘danger’ signals, the team needed to understand how risk and illness were perceived locally. Working with Maya linguists and community representatives, local categories for syndromic surveillance that were more culturally sensitive were elicited, including them in the training protocol of the local nurses who had to document the human health cases occurring in studied households. For example, the desired term ‘diarrhoeic syndrome’ found several local terms in Spanish and over a dozen terms in Q’eqchi’ (i.e. Xha’ chi sa’ – diarrhoea as water, K’ik sa’ – diarrhoea as water with blood, Sam ko’t – depositions with mucus, Xah’ chi kem – soft but rapid depositions, etc.) that allowed the team to define a more precise and sensitive syndromic surveillance system for both animals and humans.
Boundary management: a case for mutual learning
Medical systems present particular idiosyncrasies that are deeply related to the way in which the social world is perceived and acted upon (Levin and Browner, 2005). In Guatemala, social divides often preclude the modern biomedical system and the Maya medical system from easily interacting in public spaces, creating boundaries that are often detrimental to patients and successful public health interventions. The project addressed this divide via joint diagnostic protocols that allowed the bridging between the two medical systems. To examine explanatory models of concrete episodes and their treatment in more detail, the study team organized joint visits of patients where a Maya Ajkum (traditional healer) and a biomedical doctor would jointly diagnose and discuss response avenues for human patients, or an Ajkum and veterinary doctor would do the same for animal patients. In a visit with a woman suspected to have leptospirosis, the medical doctor asked questions about risk exposure and unspecific symptoms such as fever and lethargy, and recommended laboratory tests to confirm aetiology. The Maya healer used an ancient technique called ‘pulso’ to diagnose ‘a disease similar to dengue but coming from a much older disease transmitted by a mammal, possibly a bat’. Most importantly, he suggested the patient had a precondition called ‘susto’ (a well-known culture-bound syndrome relating to losing one’s vital energy or spirit) that had weakened her ‘blood’ (immune system) and had made her susceptible to the disease. An example of boundary management in One Health is illustrated in our short video: https://youtu.be/lfVQnsqLbas (accessed 15 July 2019).
Results
Discussions on treatment avenues showed indigenous patients preferred responses that incorporated both biomedical and Maya treatments collaboratively, providing valuable insights into the role of cultural pertinence for increasing treatment adherence to previously unknown zoonotic diseases. In other words, this intercultural diagnostic study showed that incorporating traditional medical system approaches facilitated compliance with biomedical response protocols that were otherwise too novel and frightening for indigenous patients. In the above-mentioned case, the woman was treated in a hospital for leptospirosis and brucellosis after laboratory confirmation, but was previously treated for ‘susto’ by the Maya Ajkum, having refused to go to the hospital without her spirit being called back first. For this approach to elicit respect and avoid promoting further divides, social scientists carefully designed and guided the exchanges to facilitate a process for mutual learning between the different kinds of health practitioners and research disciplines by attempting to understand each other’s emic views on human–animal disease transmission. These diverse understandings and their implications were used to stimulate discussions across explanatory models within the research team and with transdisciplinary partners.
Outcome
The analysis of the ‘pilot’ intervention undertaken as a local proof of concept was presented in workshops fed into a larger ‘scale-up’ intervention design. These interdisciplinary workshops and conferences were aimed at promoting the One Health approach to community surveillance at a national level.
Case study 3 illustrates a grounded open-ended adaptive approach to local identification of problems by the community and local health workers, and a co-creation of knowledge and interventions. It illustrates the existence of differing world views on the problems identified and the need to approach health and well-being in a transdisciplinary manner, recognizing the interwoven concepts of human lives, animal lives and the environment affecting health.
Case study 3. Atoifi Health Research Group (AHRG) – how a One Health social science approach is being used in the remote Solomon Islands. Contributed by David MacLaren and Humpress Harrington, James Cook University and AHRG and Chief Esau Fo`ofafimae Kekuabata, AHRG and Kwainaa’isi Cultural Centre.
Background
AHRG is a group of health researchers, health service professionals and community members committed to investigating locally appropriate ways to improve health and well-being in remote locations across the South Pacific Nation of Solomon Islands. Solomon Islands has 600,000 people, who belong to 80 different indigenous language groups. The majority (85%) of the population live in rural/remote villages located on tribal/customary land and are sustained through the subsistence economy or via remittances from family members who work in urban areas. Villages are located across the rainforest mountains, fertile valleys, coastal beaches and coral atolls. AHRG does much of its work in the remote East Coast of the Island of Malaita. Although only 120 km long and 30 km wide, the island of Malaita has ten distinctly different language groups, each following their own cultural traditions on their distinct tribal/customary land.
The AHRG is committed to a learn-by-doing approach to research that centralizes capacity building to enable Solomon Islanders to incorporate diverse social, cultural, spiritual and geographic contexts. This approach has been successfully used for more than a decade to address several social and health problems. (For more details, resources and videos of the AHRG work, see https://www.atoifiresearch.org.sb/ (accessed 15 July 2019).) The AHRG is a transdisciplinary partnership between academic researchers, health service professionals and community leaders that jointly identify local health issues, jointly design locally appropriate studies, jointly record results and jointly inform locally appropriate action. A One Health social science approach characterizes the AHRG and enables a detailed and nuanced understanding of the human–animal–environment interface in specific locations. Because of the hyper-diversity that exists across humans, animals and environments in relatively small geographic locations, the group advocates two mantras: ‘small is beautiful’ and ‘one village at a time’. Thus, the researcher-service provider–community leader network that makes up the AHRG combines skills and approaches to investigate human, animal and environmental issues concurrently or sequentially, and supports cross-village learning. The social sciences are purposely embedded into the design of health studies designed and conducted by the group. This deliberate approach allows for a nuanced practical and theoretical understanding of infectious and non-infectious diseases in their local contexts in order to design or influence the provision of health services to their communities. Use of social sciences allows for the deliberate investigation and incorporation of culture, gender, spirituality, economics, ecology, cosmology, politics, history and indigenous knowledge. Through these lenses, family and household structure, gender, land use, food production, domestic and wild animal ownership/usage, religious and philosophical worldviews, traditional and contemporary political organization, cultural communication, local and external economics, personal and collective hygiene and sanitation and gender roles are incorporated into health and well-being projects. It is our experience that these are all fundamental to subsequent human, animal or environmental action. Examples include the following.
Soil-transmitted helminths
Social science was embedded from the very beginning of our soil-transmitted helminth studies. How villages were engaged in the studies was part of their success. Village engagement included: (i) open community information sessions during church gatherings; (ii) social, cultural and gender considerations for human and animal faeces collection, testing, transport and disposal; (iii) feedback of results to villagers through village forums; and (iv) discussion of location and design of water and sanitation actions to reduce parasite transmission. Local actions to improve male and female toilets, including their design and location in villages, were informed by local cosmological designation of ‘male’ or ‘female’ appropriate locations (Harrington et al., 2015; Bradbury et al., 2017, 2018). For documentaries on how social science was purposely embedded in the design and conduct of the studies see: Parasites in Paradise: a Soil- transmitted Helminth Survey in Marovo (available at: https://youtu.be/ZRzg4C7Mmas) and Toilets and Taboos in the Tropics (available at: http://www.youtube.com/watch?v=FMtc3f6xESU) (both accessed 15 July 2019).
Traditional knowledge of medicinal plants
In the face of large-scale logging in many parts of Malaita, many of the communities involved in the project wanted to preserve areas of the rainforest as a ‘living pharmacy’ to sustain health and well-being for the humans, animals and environment. Social science was embedded throughout this project to document the taxonomy of rainforest plants used by local people for medicine and food. The project worked with local tribal groups in order to document local knowledge of medicinal rainforest plants and create a bilingual book (Kwaio language and English) and set of videos as a health education resource for the community and outsiders. The success of this project was dependent on intimate knowledge of the land ownership structures, local political leadership, gendered knowledge systems, access to remote parts of the rainforest and support for local archive systems at the Kwainaa’isi Cultural Centre. Subsequent action by the community saw the formation of conservation areas designated by local ancestral spiritual decrees that blocked commercial logging as a way to conserve plants and animals in these locations. The conservation areas are managed locally by tribal leaders on their own tribal land and act as an example of the One Health human–animal–environment interface (Esau and the Kwaio Medicinal Plants Project Team, 2015; Atoifi Health Research Group, 2018). Short videos from the medicinal plant project are available at: https://www.youtube.com/playlist?list=PL-m8H163iwTAxHB7bg4JJTfZWlmHyHLSj (accessed 9 June 2020).
Mental and spiritual health and well-being
Colonial history and politics are a constant reality in this ex-British colony. A colonial era massacre in East Malaita in the 1920s involving the Australian military had never been resolved. In 2018, a traditional reconciliation ceremony was facilitated between Australian researchers and local Kwaio tribal leaders to acknowledge the events of the past and plan for the future. Pigs and traditional shell money were exchanged in a sacred site near Kwainaa’isi Cultural Centre. This deeply cultural process required an intimate understanding of culture, gender, spirituality, cosmology, economics, ecology, politics, history and indigenous knowledge by all involved and informed by villagers. This holistic One Health approach with embedded social science methods was able to inform historic and contemporary health and well-being activities implemented at local level by health services in partnership with villagers across the human–animal–environment continuum (Flannery, 2019).
Health impacts of climate change
The AHRG also studies the health impacts of climate change. Villagers living on coral atolls or in low-lying villages experience periodic inundation and loss of productive land as sea levels continue to rise. This reduces arable land and impacts food production. In some villages, the surrounding mangroves are used as toilets. During normal tidal flows, human waste is washed out to sea, but during times of inundation, human waste is washed into areas inhabited by humans and animals. Sea level impacts mental health as villagers become increasingly anxious prior to the high tide season, when they know they will be inundated. This impacts both the living and the dead as burial grounds are inundated and eroded. Because people live on tribal land, most are unable to move and so other responses to sea level change are being considered by the communities rather than migration (Asugeni et al., 2017). See also Adapting to Sea level Rise: a Young Woman’s Story, available at: https://youtu.be/VoDCtcIcAOs (accessed 15 July 2019).
Conclusion
The ‘small is beautiful’ and ‘one village at a time’ approach used by AHRG is a One Health social science means to understand the human–animal–environment interface in these remote locations in order to improve health and well-being and the related services in a scientifically sound and culturally respectful manner. It continues to be used by the AHRG locally as well as through their participatory approach to capacity development in other locations in Solomon Islands.
Case study 3 also illustrates how the combined effects of environmental, human and animal behavioural changes create a cycle of changes in the health of each of these three domains.
Medical anthropology has placed limited focus on non-human species in understanding disease and health (Rock, 2016) and on environmental or ecological anthropology (Moran, 2008). There are some studies emerging on interspecies relations in social anthropology in general and especially in the sub-field of research in ecological and environmental anthropology. One example is Ruhlmann’s work (2018) on highly contagious animal diseases and their spread to other animals and humans. This work explores the complex spaces of veterinary and human medical ethnographies of the herders, coexistence between and meaning of the relationships between humans and their animals, political economies, and veterinary public health practices. It is an example that can provide valuable insights for addressing serious infectious diseases that affect production animals, economic value, and transmission to humans. The ‘reverse zoonosis’ pathway, that is of animals being infected by humans is also under-addressed. Yet it could have major economic, animal (including wildlife) and human consequences (e.g. production pigs being infected by ‘flu’ from human carriers working in the industry, and the rarer and fascinating cases of elephant tuberculosis coming from humans) (Laine, 2018). The emerging field of multispecies ethnography provides an opportunity to reorientate social science approaches to better examine human–animal–environment entanglement and ‘revisit theorizations’ of central topics in medical anthropology’ (Brown and Nading, 2019, p. 5; see also Kirksey and Heimreich, 2010).
Designing and Implementing One Health Approaches with Social Science Integration
There remain few descriptions of integrating social science in the planning, implementation, monitoring and evaluation of One Health interventions in the published literature, especially beyond pilot research projects. Case study 2 adds another valuable contribution to address this knowledge gap. In Chad, deliberative integration of social science research in the design phrase enabled the findings to be utilized to develop health-care programmes for nomadic pastoralists (Schelling and Zinsstag, 2015). In Fiji, social science was one of the disciplines engaged in the transdisciplinary process to develop the National One Health Control Programme (Reid and Kama, 2015). One of the barriers to integration remains lack of appreciation of the value that social science can add to the design and implementation of interventions, and their outcomes and impact. Beyond having baseline and endline KAP, there are few descriptions of a fully integrated transdisciplinary approach to a One Health problem. One example is in Nunavik, Canada where the Inuit people, anthropologists and veterinarians started working together to develop more culturally suitable and respectful dog management practices. The aim is for more effective implementation for rabies control and to address other common health issues (Levesque, 2018). Additional examples are included in Chapters 18–27, this volume.
It should be noted that there are also limited published quality evaluations of any One Health intervention around the issue of the integration of social science. However, a review of ‘proof of concept for the One Health approach to emerging disease threats provides evidence that transdisciplinary integration among the sectors of human, animal, and environmental health is feasible’ (Rabinowitz et al., 2013, p. 6).
Rwanda has developed a One Health strategic plan to ‘streamline cross-sectoral and institutional interventions, minimize duplication of efforts, and maximize the use of public resources’ (Nyatanyi et al., 2017, p. 3). Included in this plan is the promotion of interprofessional collaboration in research and innovation and its linkages to programme development and implementation. However, it is early days yet, and although they hope for a broad approach to problems like food security, antimicrobial resistance, animal and human infectious disease outbreaks, it will take time. Some newly announced projects, such as Operationalizing One Health Interventions in Tanzania (UK Research and Innovation, 2018), are designed to incorporate social science into the design, and may provide valuable insights to address this knowledge and practice gap. In Switzerland, One Health plans have been developed by the local government in some cantons to address some priority health issues of non-communicable diseases, mental health and health hazard surveillance (Meisser and Goldblum, 2015).
One way to increase appreciation of and integration of social science into One Health approaches is through engagement and dialogue across disciplines and professions. Rock et al. (2017) discussed how, in order to have rabies and dog bite research enhance policy alignment and task integration between animal control and public health services, they developed a forum to share the results of their research with animal control officers and public health officials in a variety of settings. Many anthropologists have advocated for ‘greater social science involvement in One Health initiatives, seeing possibilities to attend to new dimensions of inequalities revealed at human–animal interfaces within enlarged understandings of pathology’ (Craddock and Hinchliffe, 2015, p.1) and ‘others have identified opportunities for “critical and constructive social science engagement with One Health” ’ (Brown and Nading, 2019, p. 9). (For further discussions see also Rock et al. (2009) and Dzingirai et al. (2017).) There is a need for better documentation of how social science has made changes to the effectiveness of joint and integrative identification of problems, design of interventions and their implementation, including their success in being relevant to, culturally appropriate for and meeting the requirements of those in greatest need.
Discussion
Discussing the added value of integrated approaches in One Health strikes at the core of complexity studies, where we acknowledge that the interconnectedness of the human–animal–environment interface requires a multiplicity of lenses to capture enough information to make syntheses typical of academic research a reasonable endeavour. Social scientists, trained to understand emic models of self and other, are well positioned to address the interpretative nature of paradigms shaping particular knowledge systems within the professions and disciplines (e.g. the diverse interpretations of veterinary doctors or epidemiologists as to what variables need to be addressed in One Health), facilitating intra-team dialogues to better represent the human–animal–environment subsystems.
Going beyond state-of-the art scientific production, One Health claims include the dimension of producing socially robust approaches contributing to public health. The role of social sciences then becomes evident as foundational for the co-production of interdisciplinary understandings of One Health by linking disciplinary experts in relevant approaches to particular complex health problems and various societal contexts. As the case studies show, a socially robust orientation requires contextualized thinking, an approach sensitive to cultural, historical and gender aspects shaping determinants of human, animal and environmental health. Additionally needed are mechanisms to see the linkages and feedback loops of human behaviour and observable disease, with the animal world and environments, and a capacity to address and integrate multiple ontologies and epistemologies of diverse stakeholders. The social sciences can provide evidence around power relationships, and the differential positions of various groups of people in social settings and economic markets, which support addressing the inequities often seen in accessing health interventions (Craddock and Hinchcliffe, 2015). Craddock and Hinchcliffe (2015, p. 2) note that social science brings to the One Health agenda an ability to ‘foreground uneven geographies, uneven power relations, discrepant risks and variable access to resources’.
Social science also fosters participatory approaches that recognize multiple epistemologies and join academic disciplines, engaging partners, including communities, in mutual understanding of practices and explanatory models. It assists in examining the ‘myriad configurations, textures and dynamics of human and non-human relations’ (Craddock and Hinchcliffe, 2015, p. 3; see also Fuentes, 2010) and supports recognition of the voices, agency and expertise of the ‘oft-forgotten’ – communities, minorities and vulnerable populations. This was illustrated in Case study 1 for women food producers in Africa and Asia, in Case study 2 for indigenous populations in Guatemala and in Case study 3 for the Kwaio peoples of the Solomon Islands. This participatory transdisciplinary approach will undoubtedly yield robust interventions that are more effective in achieving desired outcomes and impacts and more likely to be sustainable.
However, as we have shown, social science interventions are not yet systematically used in One Health programme design and evaluation, which is often developed as research to address a problem with or without linkage to a service delivery. Lapinski et al. (2015, p. 52) note that ‘there is a paucity of research regarding efficacious approaches’. This requires social science to be utilized in programme development. What should be done about this underutilization of social science approaches in One Health programmes and interventions?
There remain other questions about the level of integration of social science approaches and the insights they provide into One Health programmes and approaches, and especially, the territory beyond infectious diseases. These include the following.
• Are social scientists partnered with to conceptualize a programme, to value the unique insights provided in complex and adaptive systems?
• Are social scientists undertaking these studies in parallel to programme developers, where the value of integration is not yet fully appreciated?
• Are they only used to help access communities and populations, so that interventions are ‘accepted’ (tolerated) by the ‘target populations’?
• Are well-trained social scientists being employed, or are social science methods being used by others without robustness, to try to improve acceptability of their programmes, or at least foster community engagement and health education? For example Keck (2019, p. 38), when reviewing social science engagement in programmes of zoonotic infection control, questioned whether the social scientists were being engaged to bring ‘intellectual interest and ontological challenges of an anthropology of zoonosis beyond the regular calls for expertise on epidemiological contagion or on social participation’.
• Are we really seeing One Health social science or animal, human and environmental social sciences methods that are siloed? As demonstrated, if a social science approach is used, medical anthropology seems to be the dominant approach to develop a One Health understanding of human health problems, with little integration with environmental, ecological and non-human species anthropologies. However, emerging sub-disciplines like multispecies ethnographies are challenging this dominance, and platforms like the One Health–Social Science Initiative Hub may assist in crossing these ‘boundaries’.
Conclusion
As outlined in this chapter, social science adds value in identification, design and implementation of One Health interventions. It has been used to provide insights into the importance of reflexive methodologies, how knowledge systems help shape the research and intervention outcomes, the ethnocentricity of etic explanatory models and the significance of emic views or multiple epistemologies, and how such understanding helps generate more robust data and mechanisms for implementation of these interventions.
The One Health approach enables a broad range of social science disciplines to come together to examine these issues, fostering theoretical and integrative innovations in understanding culture, economics, gender, ecology, behaviours, political contexts and indigenous knowledge.
There remains a need for social science to take a more active role in the design and conceptualization phase of programmes, and in helping multidisciplinary teams address potential design bias, inaccurate representation of various agencies, or cultural myopia. There is also a need to develop more robust approaches to evaluation of the success and sustainability of transdisciplinary approaches and the integration of social science into One Health programmes. In addition, the focus of the social sciences in One Health needs to be broadened to include tools, approaches and theories that truly embrace the human–animal–environment interface (Brown and Nading, 2019) and resilience strengthening (Obrist et al., 2010) and adaptations that occur within each of these and in the interfaces. Social science in One Health is applicable and adds value to understanding and meeting many of the grand challenges facing the planet, as delineated in the Sustainable Development Goals. There continues to be a need for publication and dissemination of successful models of social science integration in One Health approaches and the impact this integration brings to interventions, and a need for such approaches to be robustly evaluated and available beyond discipline-specific peer-reviewed publications.
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