Open Encyclopedia of Anthropology - Syndemics

Diabetes

Rebecca Tishler — Mon, 01 May 2023 08:04:50 +0000

Person getting tested for high blood pressure and diabetes at Prince Mshiyeni Memorial Hospital in South Africa in 2012. Photo: GovernmentZA

Shir Lerman Ginzburg

Massachusetts College of Pharmacy and Health Sciences

Initially published 1 May 2023

http://doi.org/10.29164/23diabetes

Abstract:

Type 2 diabetes mellitus is a global disease that involves the body’s impaired ability to regulate blood sugar (glucose) due to malfunctioning insulin, a hormone produced in the pancreas which is responsible for transporting the glucose into the cells. Anthropologists have provided meaningful insights into the causes (aetiologies) and prevalence of diabetes, particularly focusing on the social, political, and economic factors that underlie the ways in which diabetes continues to afflict millions of people worldwide. As a chronic illness with no cure, diabetes poses unique challenges for people struggling to manage medications, food changes, and multiple medical appointments, particularly for those who are already suffering from other structural barriers to health. Furthermore, anthropologists have highlighted the importance of identifying the overlaps between diabetes and other chronic diseases in order to provide better treatment options and to understand the underlying structural conditions that contribute to diabetes, such as poverty and unemployment. The ‘syndemics’ framework is a useful tool for considering the multileveled approaches to diabetes aetiologies and preventions.

Introduction

Diabetes, a cluster of diseases that impact the body’s ability to process insulin, is well-established as a chronic illness, having been described as such as early as 1500 BCE, when an Egyptian manuscript described a ‘too great emptying of the urine’, although Apollonius of Memphis was the first to call the disease ‘diabetes’ in 250 BCE (Trikkalinou et al. 2017). Several centuries later, an unnamed seventeenth-century English surgeon called diabetes ‘the pissing evile’ due to the frequent urination common to people with the disease (Karamanou et al. 2016; Kelleher 1988). Unfortunately, most diabetes itself is rather less colourful, albeit equally dangerous if left unchecked. Diabetes is a chronic disease characterised by high glucose due to the body’s inability to produce and/or process insulin, a hormone that helps the body use energy (Carruth et al. 2019; Mendenhall et al. 2010; Schoenberg et al. 2005). People are clinically diagnosed with diabetes if their fasting glucose blood test levels are over 126 mg/L or have a three-month average hemoglobin (HbA1c) level of at least 6.0%.^[1] The number of adults (ages 20-79) worldwide living with diabetes reached 537 million people in 2021 and researchers estimate that by 2045, 783 million individuals worldwide will have diabetes.^[2]

Symptoms for diabetes include increased urination and thirst, unintentional weight loss, blurred vision, exhaustion, tingling hands and feet, and dry skin. Diabetes is sometimes called ‘the silent killer’ because these symptoms are so common that they are oftentimes attributed to other things, leading to worsening disease outcomes and decreased quality of life before a diagnosis is even made. Untreated diabetes can lead to coronary artery disease, renal failure, and blindness, and is correlated with high blood pressure (hypertension), high cholesterol (dyslipidaemia), arthritis, and depression (Mendenhall 2019; Trikkalinou et al. 2017).

Healthcare providers generally diagnose individuals as having one of three broad types of diabetes: type 1, type 2, and gestational. All three types share the same general symptoms and basic cause (a cellular inability to absorb glucose for fuel due to a failure to recognise insulin) but differ in the physiological details and cultural paradigms of aetiology and treatment. This entry will begin by outlining the three general types of diabetes and then discuss how anthropologists shed light on interacting cultural models of diabetes diagnosis, treatment, and long-term care.

Types of diabetes

Type 1 diabetes mellitus is an autoimmune reaction wherein the body’s defence system attacks the cells that create insulin, causing a severe insulin shortage in the body and allowing for a dangerous accumulation of glucose in the blood. Unchecked type 1 diabetes can contribute to nerve damage (neuropathy), kidney damage (nephropathy), eye damage (diabetic retinopathy), foot damage, heart disease, and skin infections.^[3] It is linked to both genetic and environmental factors, although the exact causes are not yet known and there is no known cure. Type 1 typically develops in children and young adults and requires individuals to inject insulin daily to remain healthy.^[4] Approximately 10% of people worldwide have type 1 diabetes as of July 2020.^[5]

Gestational diabetes develops in pregnant women who did not already have diabetes prior to pregnancy. This type of diabetes physiologically resembles the other types in that the body struggles to recognise insulin, which leads to higher levels of glucose in the bloodstream. While glucose levels generally return to normal after giving birth, women who have gestational diabetes are at higher risk for developing type 2 diabetes later in life.^[6]The precise origins of gestational diabetes are unknown, yet researchers suggest that the mother’s pre-pregnancy weight, physical inactivity during pregnancy, being of certain races or ethnicities (such as Black, Hispanic, and American Indian), having a family history of diabetes, and having polycystic ovarian syndrome are all contributing factors.^[7] Approximately 14% of women worldwide had gestational diabetes during pregnancy in 2021 (Wang et al. 2022).

Type 2 diabetes has become a pandemic, catching the attention of researchers and healthcare providers alike due to the urgent nature of its scope. Like the other diabetes types, type 2 involves high blood glucose levels, but unlike the other types, in type 2 the pancreas produces sufficient insulin. Instead, cells resist insulin’s efforts to transport glucose into the cells (insulin resistance), resulting in rising blood glucose levels and causing the pancreas to create more insulin. However, the cells continue to resist the insulin’s efforts, resulting in even higher glucose levels which can cause major health problems, such as heart disease, liver and kidney failure, and vision loss.^[8] Type 2 diabetes accounts for 95% of diabetes cases worldwide, with physical inactivity, being overweight or obese, and socioeconomic factors like poverty being major contributing factors.^[9]

This entry focuses on type 2 diabetes due to its overwhelming global prevalence and due to the biomedical focus on solely individual behaviours. Diabetes is commonly known among biomedical healthcare providers as the ‘lifestyle type’ due to its association with overconsumption and sedentary behaviours, which are generally blamed on individual patients (Carruth et al. 2019; Yates-Doerr 2011). However, this framing ignores the social, economic, and political contexts that impact the diabetes experiences of many patients. While anthropologists acknowledge the different clinical diabetes types, they also recognise the limitations of clinical diagnosis in getting to the deeper causes of diabetes.

Structural roots and barriers to care

Diabetes is what medical anthropologists term a ‘disease of modernisation’ due to its association with structural factors, such as poverty, unemployment, and colonisation (Baglar 2013; Ely et al. 2011; Mendenhall et al. 2010; Singer 2020; Wiedman 2012). At the same time, diabetes management has become exponentially more expensive due to the rise in transportation, housing, healthcare, and food costs, which negatively impact many peoples’ ability to consistently afford the many changes that are recommended by healthcare providers, particularly when many individuals are already struggling to pay for rent and other necessary living expenses (Mendenhall 2015; Thorsen et al. 2020; Vest et al. 2013; Weaver 2018). High costs of diagnosis and treatment contribute to diabetes being diagnosed later in its development and enable it to have more destructive effects.

Quality of life for people with diabetes depends on their financial resources, geographic proximity to healthcare services and social support networks, physical pain or discomfort levels, and dietary patterns. The uncertain, long-term benefits of living with minimal complications often conflict with the day-to-day difficulties of diabetes maintenance, which negatively impacts stress levels (Black et al. 2017; Speight et al. 2019). Anthropologists tend to note that not all populations experience the same quality of life in living with diabetes, as some communities face additional social, economic, and racial disparities on top of pre-existing health disparities that make a life of diabetes much harder (e.g. Rock 2003a; Wiedman 2021 and Weaver 2018). For example, Janet Page-Reeves and colleagues (2013) note that individual decisions and human agency is heavily constrained by social environments (structure) when it comes to diagnosing and treating diabetes. The social environment that Page-Reeves and others study is that of Hispanics in the state of New Mexico. They incorporate specific conceptual models of illness such as emotional regulation of symptom experience and biomedical diabetes aetiology, and core cultural values such as religiosity and prioritising the family to understand and deal with the disease. Page-Reeves and colleagues observe that in situations with limited economic resources, deciding where to spend money can be a difficult choice, particularly if family members with diabetes need to buy healthier (and more expensive) foods on top of multiple visits to the doctor.

The structural nature of diabetes reflects community-level inequalities in access to different foods, healthcare, education, and other necessary resources. While diabetes is currently present in all populations worldwide, it disproportionately affects low-income populations due to multiple factors that intersect with poverty, such as unemployment, food insecurity, unaffordable healthcare, and non-existent social support (Ferzacca 2012; Lerman Ginzburg 2020; Mendenhall et al. 2017; Rock 2003a; Solomon 2016; Weaver 2018).

A significant ethnography on the structural experiences of vulnerable populations with diabetes is Carolyn Smith-Morris’ 2006 ethnography of diabetes among the Akimel O’odham (colloquially known by outsiders as the Pima), a Native American tribe based by the Gila River in the state of Arizona and the northern Mexican desert. Smith-Morris found that the sweltering Arizona heat, unemployment, and poverty were all factors in the Akimel O’odham developing diabetes. Here, starkly high levels of unemployment and high reliance on government assistance coupled with limited economic resources, reduced physical exercise due to the heat, limited affordable healthy food options on the Pima reservation, and use of food as a comfort against daily struggles, were all contributing factors to developing diabetes. Although the Akimel O’odham have lived near the Gila River for centuries and are familiar with the high temperatures, their responses to it have changed in the past hundred years. As the Gila River has dried up, the Akimel O’odham lost their traditional farms and increasingly relied on government-subsidised foodstuffs (Smith-Morris 2006). Notably, the drying up of the Gila River was not a natural phenomenon, but resulted from the Arizona government’s extensive irrigation efforts as well as damming by non-Native farmers. However, policies of the US Department of Agriculture (USDA), which extended into the 1980s, forbade the Akimel O’odham from receiving help from agricultural loans. Combined with the loss of traditional food pathways, these policies forced the Akimel O’odham to obtain sedentary jobs and rely on high-calorie, poor-nutrition governmental food handouts (Booth et al. 2017; Smith-Morris 2006). Indeed, diabetes is so ubiquitous in the Akimel O’odham that participants in Smith-Morris’ research naturalised it more and more, observing, ‘it’s just how Pimas are’ (2006: 33).

Smith-Morris’s work with the Akimel O’odham highlights how political and economic factors contributed to diabetes aetiology in a population already facing racism and other abuses from the very government that was supposed to care for them. Recent work in Nepal supports these findings. Here, governmental inaction in the face of rigid social hierarchies and discrimination against the Dalits–members of the lowest social caste–creates structural situations of high diabetes risk (Thapa 2014). While caste-based discrimination is officially illegal in Nepal, social hierarchies forbid Dalits from participating in many social, religious, educational, and employment opportunities, forcing them into poverty, food insecurity, and occupational and housing uncertainty—all of which elevate diabetes risk. Given that existing social hierarchies are deeply entrenched, the Nepalese government has found it difficult to enforce anti-discrimination laws; in doing so, the Nepalese government failed to take care of its most vulnerable members and reduce Dalit diabetes risk. In this example, it is government negligence, rather than active mismanagement, that increases diabetes risk.

Additionally, colonisation is a structural factor that boosts diabetes risk, particularly as its effects continue for generations after the dissolution of the original colonising state. Indigenous communities that have experienced colonisation face extremely high diabetes rates due to a loss of traditional lands and food sources, cycles of food insecurity, and mental distress from oppressive regimes. In Canada, the diabetes prevalence rate is four times higher among Indigenous communities than in the general population due to decades of the Canadian government enforcing starvation, stress, food insecurity, and the environmental degradation of traditional food sources such as fishing (Temblay et al. 2021). Similarly, high diabetes rates in the Marshall Islands have been linked to the World War II-era devastation of breadfruit trees, which were a traditional food source for Indigenous communities (Duke 2017). The US began distributing canned meat and white rice when it colonised the Marshall Islands after the war. This abrupt change in food acquisition and preparation negatively impacted the Marshallese’s relationship with their environments and their bodies by increasing their reliance on imported canned foods, which are high in additives, rather than on fresh and local resources.

The geographic diversity of these case studies emphasises an urgent need for studying the complex historical, structural, and traumatic roots of diabetes in greater depth. Prolonged exposure to colonialism is associated with a profound loss of traditional food acquisition, preparation and consumption, and subsequently high levels of food insecurity and malnutrition even when a colonising regime no longer exists. The loss of traditional livelihoods and diminished community self-determination undermine socioeconomic development among oppressed communities. Particularly, it leaves rural communities in debilitating working conditions with only limited access to comprehensive primary care or physical activity options, like walking trails, that are weather-safe for year-round use (Rice et al. 2016; Tremblay et al. 2021).

The colonial roots of diabetes serve as a stark reminder that health is due as much to structural environments as it is to biology. As these and other ethnographies demonstrate, structural environments contribute to diabetes being a social disease as participants shared stories about their etiological foundations of diabetes and the ways in which adjusting to a new life required new perspectives.

Diabetes and biopower

Although, as the ethnographies above elucidate, anthropologists have studied diabetes susceptibility among different populations, anthropological literature has also cautioned against relying on rigid, overly simplistic ethnic categories to understand diabetes because they miss the nuanced biological human variations between and among ethnic groups that contribute to diabetes risk (Montoya 2007). Labelling individuals or entire populations as ‘at risk’ for diabetes based on easy single-gene categories risks ‘naïve genetic determinism’ that glosses over the need for deeper analysis of the social and environmental histories of different populations that shape their susceptibility to diabetes (Montoya 2007). Anthropologists have contributed valuable insight into the social, political, and environmental pressures that individuals and populations face, particularly by incorporating biopower—the regulation of human life at the population and individual body levels—and the politics of health, body image, illness metaphors, and explanatory models into the frameworks of diabetes aetiologies and lived experiences (Ferzacca 2012).

For example, research on the clinical encounters of diabetes highlights the difference between clinicians’ perspectives on diabetes and the perspectives of patients with diabetes (Guell 2011; Hernandez 1995; Hunt et al. 1998). Cheri Hernandez (1995), in an ethnographic study on the clinical parameters of diabetes management, observed that while healthcare providers emphasise maintaining acceptable glucose levels and adhering to medication and weight loss regimens, patients prioritise learning how to live with diabetes. Patients with diabetes often found biomedical explanations for diabetes to be insufficient and attributed their diabetes to personally-relevant triggering events and behaviours. Those who believed that their own behaviours were causes of diabetes tended to be more involved in their treatment; the act of being involved in treatment was associated with long-term behaviour change (Hunt et al. 1998).

While Hernandez and Linda Hunt et al. focused on the individual’s biomedical encounters for diabetes treatment, others have expanded this approach to the collective diabetes experience. Cornelia Guell (2011) draws attention to the conflicting hierarchies of diabetes knowledge in Germany that arose among Turkish migrants in Berlin. Tensions arose between Turkish healthcare providers and layperson self-help groups over conflicting values and knowledge hierarchies about diabetes. Along with fierce competition for limited funding for community diabetes clinics and health education classes, these differences in diabetes knowledge not only pitted the community and healthcare providers against one another but also created rifts in a community already facing severe marginalisation. Similarly, healthcare providers frequently place the responsibility for diabetes management squarely on the patient, making them ‘morally liable for their own ill health’, as Rebecca Seligman and colleagues have highlighted in their work on Mexican immigrants with diabetes in the city of Chicago (2015: 64). Many physicians believed that structural and social interventions were not part of their jobs, preferring to focus solely on clinical treatments without being concerned for the underlying social and structural roots of diabetes (Mendenhall et al. 2017). This arbitrary dividing of responsibility is harmful and perpetuates the deeper structures contributing to diabetes. It also conflicts with how people living with diabetes view their own diabetes aetiologies. Many people who spoke with Seligman et al. (2015) attributed their diabetes to structural factors, such as interpersonal violence, poverty, and unemployment, indicating that the biomedical emphasis on individual patient responsibility overlooks patients’ lived experiences with diabetes.

Diabetes management is complex and fraught with overlapping layers of meaning. A major theme in the anthropological literature on diabetes is that of responsibility and control over diabetic bodies. Biomedicine, in its fervent pursuit of individualised health, places the locus of control directly onto the patient to manage self-care; when diabetic bodies do not behave according to biomedically prescribed plans, the onus of responsibility falls squarely on the patient. Biopower, or the regulation of human life at the population and individual body levels, is used to discipline misbehaving bodies into docile conformity through state-controlled sites, such as schools, hospitals, and prisons (Foucault 1976). Bodies become political and economic battlegrounds between policymakers and healthcare providers as debates rage over the best ways to prevent and treat diabetes, while at the same time these forces exert control over the individuals who are inhabiting the very bodies at the centre of these debates (Gibson and Dempsey 2015).

One example of biopower in a colonisation framework is among Indigenous communities in Canada. Indigenous children at residential schools in Canada developed negative relationships with food due to malnourishment, abuse, punishment, and humiliation perpetuated in the residential school environment (Howard 2014). These collective traumas and negative lived experiences of residential school food were passed on to subsequent generations, where, aided by a loss of traditional food pathways due to aggressive colonisation by the Canadian government, they are embodied as diabetes among Canada’s Indigenous communities. Indigenous interactions with contemporary healthcare systems in Canada have reinforced colonisation through racism, stereotyping, and discrimination (Jacklin et al. 2017). Patients reported being repeatedly ignored or patronised at medical appointments despite having travelled long distances for check-ups. Physician shortages and geographic isolation from clinics contributed to diabetes mismanagement, as patients sometimes waited for several months without seeing a physician or having their medications refilled. In both cases, colonialism reinforced the stereotype of misbehaving diabetic bodies and placed the blame firmly on Indigenous communities for their own diabetes while diffusing blame from the state-sanctioned violence of colonisation that is responsible for diabetes perpetuation.

One of the most fundamental contributing factors to biopower and diabetes is the question of control over the very parameters of health. US doctors who led medical missions to Belize taught the locals that diabetes was the individual’s responsibility, rather than the doctor’s liability (Moran-Thomas 2019). This biomedical focus on patient responsibility for diabetes maintenance absolved doctors of the obligation to consider the roles of broader social, economic, and political milieus in which their patients lived. Doctors did not spend much time helping patients identify the early warning signs of diabetes but simply told them to lose weight and get more physical activity, despite limited access to healthy, affordable foods, safe infrastructure for outdoor activity, or disposable income for gym memberships. Amy Moran-Thomas notes that this lack of comprehensive medical care is notable because, as diabetes is not transmitted between people, there is less biomedical focus on the ways in which people’s interactions propagate the disease and more on the individual’s genetics and decisions that make someone more at risk for diabetes, despite the blatant social risk factors. As such, patients are blamed for noncompliance, frequently without evidence, despite the structural factors that exacerbate diabetes risk.

The physical body is also shaped by cultural metaphors of health and diabetes and naturalises certain cultural norms while stigmatising others (Martin 1987; Solomon 2016; Hardin 2018). This is evident in the ways in which diabetes is stigmatised due to its socially perceived associations with uncontrollable food consumption (Aghamohammadi-Kalkhoran and Valizadeh 2016; Broom and Whittaker 2004; Ferzacca 2012; Lee et al. 2015). For example, Amanda Willig and colleagues (2014) found that African American women with diabetes reported experiencing diabetes stigma when they were the only ones in their extended families with the disease, as they were perceived as having no self-control over their health and were treated as children without the ability to make decisions for themselves. Denise Bockwoldt and colleagues (2016) found that African Americans are less likely to adhere to insulin-based medication regimes due to a plethora of negative emotions associated with insulin, such as self-blame, frustration, fear of complications, and of being a burden on loved ones. Some study participants admitted to hiding their insulin from their loved ones so as to not be outed as insulin dependent. These results were replicated by Kryseana Harper et al. (2018), who found that family-based diabetes stigma was common in their mixed-gender African American cohort. This stigma both perpetuated a reduction in diabetes self-management and created resentment towards diabetes for the disruption it caused to peoples’ personal lives.

Additionally, healthcare providers sometimes stigmatise people with diabetes if they do not lose weight or adhere to their prescribed medication regimens, which further discourages people from visiting a healthcare provider (McNaughton 2013; Shahab et al. 2019). People with diabetes who need to inject insulin may also be mistaken for and stigmatised as drug users should they need to inject insulin in public (Balfe and Jackson 2007; Bock 2012). In the United States, a country in which productivity is highly valued, any loss of individual productivity is devalued and stigmatised, particularly if the cause of that loss is concealed or is a manageable disease, as diabetes is commonly thought to be (Ferzacca 2012; Hopper 1981; Shahab et al. 2019). External stigma over perceived loss of productivity and lack of individual discipline that are thought to contribute to diabetes become internalised among those living with diabetes or are involved in its treatment, and perpetuate individual and biomedical diabetes mismanagement (Aghamohammadi-Kalkhoran and Valizadeh 2016; Ferzacca 2012; Seligman et al. 2015).

Anthropologists reject the overly simplistic categorisations of diabetes as a disease of racial and genetic determinism, preferring instead to trace the overlapping intersections between biological pathways and structural factors. In her work with the Native community in Chicago, Margaret Pollak (2018) notes that anthropologists reject the thrifty genotype hypotheses, which speculates that people are biologically predisposed to diabetes, which is then triggered by social environments. Instead, the alarmingly high diabetes rates among certain communities are explored in relation to external influences, such as colonisation and land loss among American Indians in Chicago. Diabetes care is also a multigenerational, life-long social activity in Native communities, with friends and family helping one another inject insulin, manage medication schedules, and eat diabetes-friendly meals. In this way, diabetes is transformed from a biological disease into a form of social cohesion against colonial forces that attempt to destroy Native physical and collective bodies.

As these studies and ethnographies highlight, the biological and social spheres of diabetes consistently intersect, and these intersections manifest differently depending on the population and their social, psychological, and structural circumstances.

Syndemic interactions

In keeping with the anthropological emphasis on complex, multileveled interactions that underscore disease perpetuations, scholars have drawn attention to the ways in which structural factors exacerbate diabetes outcomes by focusing on parts of the world that have reported abrupt increases in diabetes prevalence (Mendenhall 2012; Weaver 2018).

The theory of syndemics has gained traction in anthropological diabetes research, as it provides a framework for understanding the social, political, and economic underpinnings of illness and disease interactions. Syndemics examines the concentration and deleterious interaction of two or more diseases or other health conditions in a population, particularly as a consequence of social inequality and the unjust exercise of power (Singer 2009: xv). Multiple anthropologists have observed that diabetes is a common component of syndemics research due to its increased incidence and prevalence (Everett and Wieland 2013; Lerman 2017, 2022; Mendenhall 2012; Ryan and Raja 2016; Weaver 2018; Weaver and Mendenhall 2014). Specifically, diabetes interacts synergistically with two other common occurrences: depression and food insecurity.

Research indicates that slightly over one-third of individuals with diabetes will develop depression and vice versa, and that individuals with diabetes are twice as likely as individuals without diabetes to develop depression (Gask et al. 2011; Katon et al. 2010; McSharry et al. 2013; Mendenhall 2012). While some evidence implicates depression as a precursor and major contributor to diabetes (Joseph and Golden 2017; Mendenhall 2015; Vrshek-Schallhorn et al. 2013), diabetes also increases the risk for developing depression (Katon 2010; Gask et al. 2011; Nash 2013). Depression, in turn, contributes to decreased diabetes self-care and access to healthcare, including decreased glucose monitoring, missed medical appointments, and increased likelihood of diabetes complications through diabetes mismanagement (Nash 2013; Weaver and Hadley 2011). Conversely, diabetes contributes to depression by deteriorating social networks, draining financial resources, and changing dietary patterns (Katon et al. 2010; McSharry et al. 2013). Food is a cohesive force: holidays, meetings, family meals, and casual gatherings often include food sharing (Lerman Ginzburg 2022b). When an individual cannot partake due to diabetes-related dietary limitations, the ensuing feelings of guilt or shame may provoke reluctance to attend the event, adding to social isolation. This is particularly true of women, who tend to be the primary cooks in their families and do not always receive support from their families to prepare healthier meals (Lerman Ginzburg 2022b).

The relationship between food insecurity and diabetes is rooted in structural factors. For example, Olayinka Shiyanbola and colleagues (2018) found that African Americans with diabetes attributed their disease outcomes to eating habits that were rooted in slavery and an ensuing consistent lack of healthy foods. Shiyanbola and colleagues’ work adds on to Lisa Sumlin and Sharon Brown (2017), who found that African American women attributed their diabetes rates to dietary patterns and cultural culinary practices that are grounded in slavery and expounded by centuries of poverty. Populations that have been abruptly introduced to and adopted Westernised dietary patterns, such as the Pima Native Americans in Arizona and the Nauruan Islanders in Micronesia, are exceptionally vulnerable to developing diabetes due to rapid changes in nutrition, through increased consumption of highly processed foods that are high in sodium, fats, and carbohydrates (Hardin 2015; Smith-Morris 2006; Solomon 2016; Weaver 2018). Western eating patterns were oftentimes forcibly imposed on unwilling communities, and these forced eating patterns went hand-in-hand with overlapping structural factors that accentuated the incidence of diabetes among the affected communities (Hardin 2015; Smith-Morris 2006).

Diabetes and food insecurity are also correlated with poverty, particularly in combination with the absence of affordable healthcare and housing (McNaughton 2013; Mendenhall 2015; Vest et al. 2013). In their study on diabetes among Canadians living in poverty, Dennis Raphael and colleagues (2012) found that since the government’s public policy dictates the incidence and experience of poverty, and that poverty and ensuing material deprivation are contributors to increased rates of diabetes, mitigating diabetes levels require changes at the government level, and not merely at the individual level. Studies such as these serve as a reminder that food insecurity cannot be attributed merely to individual-level food decisions, but also depends on government policies that impact access to financial assistance for low-income families. For example, my research in Puerto Rico explores participants’ experiences of eating whichever food was most easily economically and geographically accessible due to an influx of food taxes, high-end supermarkets in gated communities, and economic and political instability (Lerman Ginzburg 2022a). Thus, merely turning health and treatment into easy formulae ignores the agricultural, historical, social, and political specificities that are interwoven into food consumption (Emily Yates-Doerr 2015). This critical scholarship underscores the need for ethnographic research that situates food insecurity and diabetes not merely within biomedical milieus, but also as products of social, political, and economic forces.

Just as structural factors, such as interpersonal violence and poverty, are critical syndemic perpetuators, similarly community responsibility and collective care play a role in diabetes management. Jessica Hardin (2018), in her ethnographic work on cardiometabolic disorders in Samoa, highlights how healing is both individualistic and collective that both ‘transform individual bodies while impacting the broader community, making evident the problems of the collective in the bodies of individual Christians’, a process which she calls ‘embodied critique’ (5-6). Hardin found that her Samoan participants encouraged one another to link illness events with the state of their relationships. Concepts such as embodied critique move beyond individual bodies to encompass the broader community and the structural factors that underlie diabetes aetiology. While part of the responsibility was on the individual to manage their diabetes, including taking medications, structural factors like poverty and unemployment also contributed to diabetes, which made it harder for study participants to make the necessary changes.

In Puerto Rico too, the participants I worked with linked diabetes with broader socio-political problems, such as Puerto Rico's status as a US territory (Lerman Ginzburg 2017, 2022a). The 1917 Jones Act forced food shipped to Puerto Rico to be marked up in price to compensate for the shipping, but this cost is borne by Puerto Ricans. Their experiences of eating whichever foods were most easily economically and geographically accessible connected food insecurity and diabetes with US colonisation and political nepotism. People developed depression because of the high unemployment and crime rates, ate large quantities of cheap high-fat food because of food insecurity and food apartheid, and developed diabetes. Similarly, in tracing the syndemic underpinnings of diabetes and COVID-19, anthropologists like Merrill Singer (2020) have commented that NAFTA created ‘diabetes-inducing’ environments in Mexico by triggering a growing dependence on unhealthy food imports, mostly from the US, amid a national agricultural deficit that limited Mexicans’ access to the fresh produce grown in their own backyards. The rapid change in agricultural output and ensuing urbanisation created situations of stress, identity loss, and profound changes in dietary practices that contributed to diabetes risk.

Corporate influences on diabetes

Most of this entry has focused on the structural factors that impact the lived experiences of diabetes. However, there is also a corporate component to diabetes that impacts the quality of care. Medical anthropologists studying diabetes in the United States have argued that clinical care in the country is increasingly driven by large corporations, with a mounting emphasis on financial and managerial logics that reduce diabetes care to a narrow set of quantifiable metrics (Hunt et al. 2019). Healthcare providers measure successful diabetes management by monitoring glucose and HbA1c levels, medication regimen adherence, and significant weight loss, all of which are easily enumerated but difficult to achieve due to the multiple structural barriers associated with diabetes. Health insurance plans in the US use these quantitative parameters to determine approval of healthcare expenses while ignoring the underlying structural and social barriers that might prevent patients from managing their diabetes. Scholars also argue that screening, diagnosis, and treatment guidelines over the past forty years have changed under pressure from the pharmaceutical industry despite weak evidence of efficacy in order to benefit from promoting expensive medications to unsuspecting patients (Hunt et al. 2019). Additionally, easing the diagnostic criteria for diabetes means that more people are diagnosed with the illness, and therefore required to take medications. In tracing these linkages, scholars have recommended that individual vigilance over diabetes management be augmented with systemic surveillance by healthcare providers and by policymakers who are at the forefront of medical innovations, healthcare funding, and institutional policies (Rock 2003b). Such recommendations reiterate that structural factors that impact underserved populations with high diabetes rates are rooted in unjust policies that can only be remedied at a higher political level.

Conclusion

Diabetes continues to be a globally pervasive disease, particularly in low- and middle-income countries which are facing rapid changes in the mechanisation of labour, political stability, economic independence, and profound social unrest. Despite the advances in biomedical treatment options, diabetes continues to afflict millions of people around the world, which indicates that there is a pressing need for accessible treatment options. For example, the price of insulin is ten times more expensive in the US than in any other developed country, leading many people with diabetes to ration their insulin and risk their health if their health insurance doesn’t cover the cost (Rajkumar 2020). This travesty highlights the need for thorough healthcare reform in the US in particular. Furthermore, it is imperative that the structural factors underlying diabetes in societies throughout the world be considered during treatment. Multiple, overlapping factors, such as colonisation, poverty, and unemployment are inexorably linked to diabetes, and it is those factors which we must address as we move forward with diabetes treatment options. Thinking of syndemics is a useful way for digging more deeply into the aetiologies of diabetes, so that culturally-specific and affordable preventions might be developed and rapidly implemented.

References

Aghamohammadi-Kalkhoran, Masoumeh and Sousan Valizadeh. 2016. “Fears and concerns of Iranian diabetic women: A phenomenological study.” Journal of Health Psychology 21, no. 7: 1322–30.

Baglar, Rosslyn. 2013. “Oh God, save us from sugar”: An ethnographic exploration of diabetes mellitus in the United Arab Emirates.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 32, no. 2: 109–25.

Balfe, Myles and Peter Jackson. 2007. “Technologies, diabetes, and the student body.” Health & Place 13, no. 4: 775–87.

Berkowitz, Seth A., Travis P. Baggett, Deborah J. Wexler, Karen Huskey and Christina C. Wee. 2013. “Food insecurity and metabolic control among U.S. adults with diabetes.” Diabetes Care 36: 3093–99.

Black, Stephen, Catherine Maitland, Julieanne Hilbers and Kirsty Orinuela. 2017. “Diabetes literacy and informal social support: a qualitative study of patients at a diabetes centre.” Journal of Clinical Nursing 26, no. 1: 248–57.

Bock, Sheila. 2012. “Contextualization, reflexivity, and the study of diabetes-related stigma.” Journal of Folklore Research 49, no. 2: 153–78.

Bockwoldt, Denise, Beth A. Staffileno, Lola Coke and Lauretta Quinn. 2016. “Perceptions of insulin treatment among African Americans with uncontrolled type 2 diabetes.” Journal of Transcultural Nursing 27, no. 2: 172–80.

Booth, Clayton, Maziar M. Nourian, Shannon Weaver and Bethany Gull. 2017. Policy and social factors influencing diabetes among Pima Indians in Arizona, USA.” Public Policy and Administration Research 7, no. 3: 35–9.

Broom, Dorothy and Andrea Whittaker. 2004. “Controlling diabetes, controlling diabetics: Moral language in the management of diabetes type 2.” Social Science & Medicine 58: 2371–82.

Bunkley, Emma. 2021. “Diagnosing diabetes, diagnosing colonialism: An ethnography of the classification and counting of a Senegalese metabolic disease.” Medical Anthropology Theory 8, no. 2: 1–26.

Carruth, Lauren, Sarah Chard, Heather A. Howard, Lenore Manderson, Emily Mendenhall, Emily Vasquez and Emily Yates-Doerr. 2019. “Disaggregating diabetes: New subtypes, causes, and care.” Medical Anthropology Theory 6, no. 4: 119–26.

Duke, Michael. 2017. “Neo-colonialism and health care access among Marshall Islanders in the United States.” Medical Anthropology Quarterly 31, no. 3: 422–49.

Ely, John, Tony Zavaskis and Susan L. Wilson. 2011. “Diabetes and stress: An anthropological review for study of modernizing populations in the US-Mexico border region.” Rural and Remote Health 11, no. 3: 1758.

Everett, Margaret and Josef Wieland. 2013. “Diabetes among Oaxaca’s transnational population: An emerging syndemic.” Annals of Anthropological Practice 36, no. 2: 295–311.

Everson, Susan A., Siobhan C. Maty, John W. Lynch and George A. Kaplan. 2002. “Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes.” Journal of Psychosomatic Research 53, no. 4: 891–5.

Ferzacca, Steve. 2000. “‘Actually, I don’t feel that bad’: Managing diabetes and the clinical encounter.” Medical Anthropology Quarterly 14, no. 1: 28–50.

———. 2012. “Diabetes and culture.” Annual Review of Anthropology 41: 411–26.

Foucault, Michel. 1976. The history of sexuality, volume 1. Translated by Robert Hurley. New York: Vintage Books.

Gask, Linda, Wendy Macdonald and Peter Bower. 2011. “What is the relationship between diabetes and depression? A qualitative meta-synthesis of patient experience of co-morbidity.” Chronic Illness 7, no. 3: 239–52.

Gibson, Kristina and Sarah Dempsey. 2015. “Make good choices, kid: Biopolitics of children’s bodies and school lunch reform in Jamie Oliver’s Food Revolution.” Children’s Geographies 13, no. 1: 44–58.

Greenhalgh, Susan and Megan Carney. 2014. “Bad biocitizens? Latinos and the US ‘obesity epidemic’.” Human Organization 73, no. 3: 267–76.

Guell, Cornelia. 2011. “Candi(e)d action: Biosocialities of Turkish Berliners living with diabetes.” Medical Anthropology Quarterly 25, no. 3: 377–94.

Hardin, Jessica. 2018. Faith and the pursuit of health: Cardiometabolic disorders in Samoa. New Brunswick, N.J.: Rutgers University Press.

Harper, Kryseana, Chandra Y. Osborn and Lindsay Satterwhite Mayberry. 2018. “Patient-perceived family stigma of type 2 diabetes and its consequences.” Families, Systems, & Health 36, no. 1: 113–7.

Hay, M. Cameron. 2010. “Suffering in a productive world: Chronic illness, visibility, and the space beyond agency.” American Ethnologist 37, no. 2: 259–74.

Hernandez, Cheri A. 1995. “The experiences of living with insulin-dependent diabetes: Lessons for the diabetes educator.” The Diabetes Educator 21, no. 1: 33–7.

Howard, Heather A. 2014. “Canadian residential schools and urban Indigenous knowledge production about diabetes.” Medical Anthropology Quarterly 33, no. 6: 529–45.

Hunt, Linda M., Miguel Valenzuela, & Jacqueline Pugh. 1998. “Porque me tocó a mi? Mexican American diabetes patients’ causal stories and their relationship to treatment behaviors.” Social Science & Medicine 26, no. 8: 959–69.

Hunt, Linda M., Hannah S. Bell, Anna C. Martinez-Hume, Funmi Odumosu, and Heather A. Howard. 2019. “Corporate logic in clinical care: The case of diabetes management.” Medical Anthropology Quarterly 33, no. 4: 463–82.

Hunt, Linda M., Elisabeth A. Arndt, Hannah S. Bell, and Heather A. Howard. 2021. “Are corporations re-defining illness and health? The diabetes epidemic, goal numbers, and blockbuster drugs.” Journal of Bioethical Inquiry 18, no. 3: 477–97.

Jacklin, Kristen M., Rita I. Henderson, Michael E. Green, Leah M. Walker, Betty Calam and Lynden J. Crowshoe. 2017. “Health care experiences of Indigenous people living with type 2 diabetes in Canada.” Canadian Medical Association Journal 189, no. 3: E106–12.

Joseph, Joseph J. and Sherita H. Golden. 2017. “Cortisol dysregulation: The bidirectional link between stress, depression, and type 2 diabetes mellitus.” Annals of the New York Academy of Sciences 1391, no. 1: 20–34.

Karamanou, Marianna, Athanase Protogerou, Gregory Tsoucalas, George Androutsos and Effie Poulakou-Rebelakou. 2016. “Milestones in the history of diabetes mellitus: The main contributors.” World Journal of Diabetes 7, no. 1: 1–7.

Katon, Wayne, Mario Maj and Norman Sartorius, eds. 2010. Depression and diabetes. West Sussex, UK: Wiley-Blackwell.

Kelleher, David. 1988. “Coming to terms with diabetes: Coping strategies and non-compliance.” In Living with chronic illness: The experience of patients and their families, edited by Robert Anderson and Michael Bury, 137–55. Boston: Unwin Hyman.

Lee, See-Muah, L.C. Lim, and David Koh. 2015. “Stigma among workers attending a hospital specialist diabetes clinic.” Occupational Medicine 65, no. 1: 67–71.

Lerman, Shir. 2017. “Disordered minds and disordered bodies: Stigma, depression, and obesity syndemics in Puerto Rico.” In Foundations of biosocial health: Stigma and illness interactions, edited by Shir Lerman, Bayla Ostrach and Merrill Singer, 47–83. Lanham, MD: Lexington Press.

Lerman Ginzburg, Shir. 2022a. “Colonial comida: The colonization of food insecurity in Puerto Rico.” Food, Culture & Society 25, no. 1: 18–31.

Lerman Ginzburg, Shir. 2022b. “Sweetened syndemics: Diabetes, obesity, and politics in Puerto Rico.” Journal of Public Health: From Theory to Practice 30, no. 1: 701–9.

Martin, Emily. 1987. The woman in the body: A cultural analysis of reproduction. Boston: Beacon Press.

Manderson, Lenore and Carolyn Smith-Morris, eds. 2010. Chronic conditions, fluid states: Chronicity and the anthropology of illness. New Brunswick, N.J.: Rutgers University Press.

McNoughton, Darlene. 2013. “‘Diabesity’ and the stigmatizing of lifestyle in Australia.” In Obesity: The meaning of measures and the measure of meanings, edited by M. B. McCullough and Jessica H. Hardin, 71–86. New York: Berghahn Press.

McSharry, Jennifer, Felicity L. Bishop, Rona Moss-Morris and Tony Kendrick. 2013. “‘The chicken and egg thing’: Cognitive representations and self-management of multimorbidity in people with diabetes and depression.” Psychology & Health 28, no. 1: 103-19.

Mendenhall, Emily. 2015. “The ‘cost’ of health care: Poverty, depression, and diabetes among Mexican immigrants in the United States.” In Global mental health: Anthropological perspectives, edited by Brandon Kohrt and Emily Mendenhall, 205–20. Walnut Creek, Calif.: Left Coast Press.

Mendenhall, Emily. 2019. Rethinking diabetes: Entanglements with trauma, poverty, and HIV. Ithaca: Cornell University Press.

Mendenhall, Emily, Rebecca Seligman, Alicia Fernandez and Elizabeth A. Jacobs. 2010. “Speaking through diabetes: Rethinking the significance of lay discourses on diabetes.” Medical Anthropology Quarterly 24, no. 2: 220–39.

Mendenhall, Emily, Brandon A. Kohrt, Shane A. Norris, David Ndetei and Dorairaj Prabhakaran. 2017. “Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations.” The Lancet 389, no. 10072: 951–93.

Montoya, Michael. 2007. “Bioethnic conscription: Genes, race, and Mexicana/o ethnicity in diabetes research.” Cultural Anthropology 22, no. 1: 94–128.

———. 2011. Making the Mexican diabetic: Race, science, and the genetics of inequality. Berkeley: University of California Press.

Moran-Thomas, Amy. 2019. Traveling with sugar: Chronicles of a global epidemic. Oakland: The University of California Press.

Nash, Jen. 2013. Diabetes and wellbeing: Managing the psychological and emotional challenges of diabetes types 1 and 2. Hoboken, N.J.: John Wiley & Sons.

Page-Reeves, Janet, Shiraz I. Mishra, Joshua Niforatos, Lidia Regino, and Robert Bulten. 2013. “An integrated approach to diabetes prevention: Anthropology, public health, and community engagement.” The Qualitative Report 18, no. 2: 1–22.

Pollak, Margaret. 2018. “Care in the context of a chronic epidemic: Caring for diabetes in Chicago’s Native community.” Medical Anthropology Quarterly 32, no. 2: 196–213.

Rajkumar, S. Vincent. 2020. “The high cost of insulin in the United States: An urgent call to action.” Mayo Clinic Proceedings 95, no. 1: P22–8.

Rasmussen, Nicolas. 2019. Fat in the Fifties: America’s first obesity crisis. Baltimore: Johns Hopkins University Press.

Rice, Kathleen, Braden Te Hiwi, Merrick Zwarenstein, Barry Lavallee, Douglas Edward Barre, Stewart B. Harris, and the FORGE AHEAD program team. 2016. “Best practices for the prevention and management of diabetes and obesity-related chronic disease among Indigenous peoples in Canada: A review.” Canadian Journal of Diabetes 40, no. 3: 216–25.

Rock, Melanie. 2003a. “Sweet blood and social suffering: Rethinking cause-effect relationships in diabetes, distress, and duress.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 22, no. 2: 31–74.

———. 2003b. “Death, taxes, public opinion, and the Midas touch of Mary Tyler Moore: Accounting for promises by politicians to help avert and control diabetes.” Medical Anthropology Quarterly 17, no. 2: 200–32.

Ryan, Maria Emanuel and Veena Raja. 2016. Diet, obesity, diabetes, and periodontitis: A syndemic approach to management.” Current Oral Health Reports 3: 14–27.

Schoenberg, Nancy, Elaine M. Drew, Eleanor Palo Stoller and Cary S. Kart. 2005. “Situating stress: Lessons from lay discourses on diabetes.” Medical Anthropology Quarterly 19, no. 2: 171–93.

Seligman, Rebecca, Emily Mendenhall, Maria D. Valdovinos, Alicia Fernandez and Elizabeth A. Jacobs. 2015. “Self-care and subjectivity among Mexican diabetes patients in the United States.” Medical Anthropology Quarterly 29, no. 1: 61–79.

Shahab, Yasin, Olataga Alofivae-Doorbinnia, Jennifer Reath, Freya MacMillan, David Simmons, Kate McBride and Penelope Abbott. 2019. “Samoan migrants’ perspectives on diabetes: A qualitative study.” Health Promotion Journal of Australia 30, no. 3: 317–23.

Shiyanbola, Olayinka O., Earlise Ward and Carolyn Brown. 2018. “Sociocultural influences on African Americans’ representations of type 2 diabetes: A qualitative study.” Ethnicity & Disease 28, no. 1: 25–32.

Singer, Merrill. 2009. Introduction to syndemics: A critical systems approach to public and community health. San Francisco: John Wiley & Sons.

———. 2020. “Deadly companions: COVID-19 and diabetes in Mexico.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 39, no. 8: 660–5.

Smith-Morris, Carolyn. 2006. Diabetes among the Pima: Stories of survival. Tucson: University of Arizona Press.

Solomon, Harris. 2016. Metabolic living: Food, fat, and the absorption of illness in India. Durham, N.C.: Duke University Press.

Speight, Jane, Elizabeth Holmes-Truscott, Christel Hendrieckx, and Soren E. Skovlund. 2019. “Assessing the impact of diabetes on quality of life: What have the past 25 years taught us?” Diabetic Medicine 37, no. 3: 483–92.

SturtzSreetharan, Cindi L., Sarah Trainer, Amber Wutich and Alexandra A. Brewis. 2018. “Moral biocitizenship: Discursively managing food and the body after bariatric surgery.” Journal of Linguistic Anthropology 25, no. 2: 221–40.

Sumlin, Lisa L. and Sharon A. Brown. 2017. “Culture and food practices of African American women with type 2 diabetes.” The Diabetes Educator 43, no. 6: 565–75.

Thapa, Tirtha B. 2014. “Living with diabetes: Lay narratives as idioms of distress among the low-caste Dalit of Nepal.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 33, no. 5: 428–40.

Thorsen, Maggie, Ronald McGarvey and Andreas Thorsen. 2020. “Diabetes management at community health centers: Examining associations with patient and regional characteristics, efficiency, and staffing patterns.” Social Science & Medicine 255: 113017.

Tremblay, Marie-Claude, Maude Bradette-Laplante, Holly O. Witteman, Maman Joyce Dogba, Pascale Breault, Jean-Sebastien Paquette, Emmanuelle Careau, and Sandro Echaquan. 2021. “Providing culturally safe care to Indigenous people living with diabetes: Identifying barriers and enablers from different perspectives.” Health Expectations 24, no. 2: 296–306.

Ulijaszek, Stanley and Hayley Lofink. 2006. “Obesity in biocultural perspective.” Annual Review of Anthropology 35: 337–60.

Vest, Bonnie M., Linda S. Kahn, Andrew Danzo, Laurene Tumiel-Berhalter, Roseanne C. Schuster, Renee Karl, Robert Taylor, Kathryn Glaser, Alexandra Danakas, and Chester H. Fox. 2013. “Diabetes self-management in a low-income population: Impacts of social support and relationships with the health care system.” Chronic Illness 9, no. 2: 145-55.

Vrshek-Schallhorn, Suzanne, Catherine B. Stroud, Leah D. Doane, Susan Minekia, Richard E. Zinbarg, Michelle G. Craske and Emma K. Adam. 2013. “The cortisol awakening response predicts major depression: predictive stability over a 4-year follow-up and effect of depression history.” Psychological Medicine 43, no. 3: 483–93.

Wang, Hui, Ninghua Li, Tawanda Chivese, Mahmoud Werfalli, Hong Sun, Lili Yuen et al and the IDF Diabetes Atlas Committee Hyperglaecemia in Pregnancy Special Interest Group. 2022. “IDF diabetes atlas: Estimation of global and regional gestational diabetes mellitus prevalence for 2021 by International Association of Diabetes in Pregnancy Study Group’s criteria. Diabetes Research and Clinical Practice 183: 109050. https://doi.org/10.1016/j.diabres.2021.109050

Weaver, Lesley Jo. 2018. Sugar and tension: Diabetes and gender in modern India. New Brunswick, N.J.: Rutgers University Press.

Weaver, Lesley Jo and Craig Hadley. 2011. “Social pathways in the comorbidity between type 2 diabetes and mental health concerns in a pilot study of urban middle- and upper-class Indian women.” Ethos 29, no. 2: 211–25.

Weaver, Lesley Jo and Emily Mendenhall. 2014. “Applying syndemics and chronicity: Interpretations from studies of poverty, depression, and diabetes.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 33, no. 2: 92–108.

Weaver, Lesley Jo, Carol M. Worthman, Jason A. DeCaro and S.V. Madhu. 2015. “The signs of stress: Embodiment of biosocial stress among type 2 diabetic women in New Delhi, India.” Social Science & Medicine 131: 122–30.

Wiedman, Dennis. 2012. “Native American embodiment of the chronicities of modernity: Reservation food, diabetes, and the metabolic syndrome among the Kiowa, Comanche, and Apache.” Medical Anthropology Quarterly 26, no. 4: 595–612.

Willig, Amanda L., Brittany S. Richardson, April Agne and Andrea Cherrington. 2014. “Intuitive eating practices among African-American women living with type 2 diabetes: A qualitative study.” Journal of the Academy of Nutrition and Dietetics 114, no. 6: 889–96.

Yates-Doerr, Emily. 2015. The weight of obesity: Hunger and global health in postwar Guatemala. Oakland: The University of California Press.

Note on contributor

Shir Lerman Ginzburg is an assistant professor of public health at Massachusetts College of Pharmacy and Health Sciences. Her research interests include mental health, diabetes, food insecurity, health disparities, Hispanics, obesity, syndemics, and colonisation. She earned her PhD in medical anthropology from the University of Connecticut. She practices yoga and meditation in her free time.

[1] International Diabetes Federation. 2021. “Diabetes facts & figures.” https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed 18 January 2022.

[2] International Diabetes Federation. 2021. “Diabetes facts & figures.” https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed 18 January 2022.

[3] Mayo Clinic. 2022a. “Type 1 diabetes.” https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011. Accessed 28 November 2022.

[4] Mayo Clinic. 2022a. “Type 1 diabetes.” https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011. Accessed 28 November 2022.

[5] International Diabetes Federation. 2020. “Type 1 diabetes.” https://idf.org/aboutdiabetes/type-1-diabetes.html. Accessed 28 November 2022.

[6] Mayo Clinic. 2002b. “Gestational diabetes.” https://www.mayoclinic.org/diseases-conditions/gestational-diabetes/symptoms-causes/syc-20355339. Accessed 29 November 2022.

[7] National Institute of Diabetes and Digestive and Kidney Diseases. 2022. “Gestational diabetes.” https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational. Accessed 29 November 2022.

[8] Harvard Medical School. 2022. “Type 2 diabetes mellitus.” https://www.health.harvard.edu/a_to_z/type-2-diabetes-mellitus-a-to-z. Accessed 29 November 2022.

[9] International Diabetes Federation. 2021. “Diabetes facts & figures.” https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed 18 January 2022.

Editor:

Riddhi Bhandari

Pandemics

Rebecca Tishler — Wed, 02 Mar 2022 17:15:36 +0000

Frédéric Keck

Laboratory of Social Anthropology (CNRS-Collège de France-EHESS)

Initially published 2 Mar 2022

http://doi.org/10.29164/22pandemics

Abstract:

Pandemics tend to be defined as large epidemics, i.e. as sudden and widespread rises in disease incidence that occur over a very wide area, cross international boundaries, and affect a great number of people. However, this conventional definition neglects the fact that some diseases that reach a global scale, such as influenza or Severe Acute Respiratory Syndrome (SARS), are usually considered to be pandemics while other diseases that are similarly widespread, such as tuberculosis, are not. It is therefore necessary to investigate how scientific and medical knowledge led experts to frame only some pathogens as actually or potentially pandemic. The history of past pandemics shows the extension of both the human species and its parasitic microbes over the globe, foregrounding that humans and pathogens co-evolved and that immunity is as much a process as it is a state of being. As the Industrial Revolution and the rise of capitalism have accelerated environmental change and caused the emergence of new pathogenic microbes, the medical concept of ‘emerging infectious diseases’ was developed in the 1970s. It relied on the technical possibility to track microbes as they cross borders between species and territories, turning microbes into objects of surveillance under a logic of security and emergency. Preparing for and responding to pandemics has since transferred technologies of anticipation from civil defence to public health, and the collective management of uncertainty associated with pandemic preparedness and response redefined the publics of medical care. Social anthropology improves our understanding of these publics and processes by enlightening the entanglements between species, the co-infections between diseases, and the structural violence of inequalities that drive pandemics, particularly in the Global South. Studying pandemics as fundamentally social phenomena also allows anthropologists to investigate figures such as the prophetic expert or the virus hunter, who question the efficacy of science at a time when infectious diseases become more and more commonplace.

Introduction

The World Health Organization (WHO) has recently defined a pandemic as ‘the spread of an infectious disease over three continents’ (Doshi 2011). This definition was implemented to anticipate the emergence of influenza viruses by global warning systems, and to control their spread through public health measures in nation-states. Since December 2019, the WHO has faced a respiratory disease pandemic caused by the coronavirus SARS-CoV-2, and the number of victims has rapidly and dramatically increased despite strong measures such as population lockdowns and mass vaccination applied worldwide. Anthropologists have been engaged in this and previous pandemic emergencies on both applied and more theoretical levels, trying to understand which public health measures work best, what such measures mean for populations, what long-term conditions enable the emergence and severity of pandemics, and what pandemics themselves can teach us about the human condition (Abramowitz 2017; Higgins, Martin and Vesperi 2020).

Past pandemics have shown that an infectious disease does not just limit itself to a series of individual cases on human bodies but instead questions the very foundations of social life. Pandemic pathogens raise fears about the effects of human contact and contagion because they cross the boundaries of social groups, which tend to define people in terms of immunity as well as purity and even moral decency (Farmer 1992). Pandemics also show that the human species does not control its autonomous development in the domestication of nature, but is entangled with other species in unstable ecosystems. This makes pandemics one of the most pressing challenges for the human species, because they reveal the fragile conditions in which we co-evolve with microbes that can become pathogenic (Latour 2020). Investigating the human fabric of pandemics leads anthropologists not only to question how pandemics are configured as global threats but also to study how they emerge at the ecological scale of the planet.

Since anthropology studies the relations between humans and non-humans in local sites (Descola 2013), it can ask how these relations produce pandemics at a global scale, but also how some aspects of these relations are ignored or left aside through, for example, models of calculation and techniques of anticipation. How is an infectious disease configured as a pandemic, and can the notion be extended to non-infectious diseases? What kinds of vulnerabilities do pandemics reveal in the globalised infrastructures of human societies? How does the scale of ‘totality’ (pan-) that pandemics rely on transform what we understand society to be? Are societies defined by the immune protection of different human groups exposed to a disease?

This entry will describe four aspects of pandemics that have been covered in some depth by social anthropology. Pandemics expose vulnerabilities in global connections, they amplify existing social inequalities, they serve as horizons in that they force us to anticipate the future, and they foreground entanglements of relations between human and non-human species.

Vulnerabilities in global connections

The term ‘pandemic’ was first used to describe the effect of climate at the scale of the planet. In 1862, the British army doctor Robert Lawson invoked ‘pandemic waves’ to account for global fluctuations in the spread of infectious diseases by a mix of social, hygienic, and meteorological forces (Harrison 2016: 131). When the Ancient Greeks coined the term epidemic to describe how diseases moved from one body to another, they did not think that it could spread to the whole human species. The term pandemos was used by Plato for a vulgar and pathological form of love extended to all human bodies, in contrast to the intellectual love of ideas, and referred to self-government rather than to the government of the human species (Foucault 2005). Epidemics such as bubonic plague moved from the East to the West, following the movements of persons and commodities across burgeoning cities and spreading empires, and were most often interpreted as divine punishments (McNeill 1976). When humans, animals, and plants circulated massively between the Old World and the New World, smallpox and tuberculosis ravaged the Amerindian population while syphilis came to Europe (Crosby 1976). As epidemics were increasingly related to global trade, discussions on how to control the contagious transmission of diseases were linked to debates on how to regulate flows of commodities and persons (Delaporte 1986).

The development of microbiology as a laboratory science in the nineteenth century led to the replacement of climate as a vague causality for epidemics with a more precise causality: the infection of human bodies by invisible microbes. While Robert Koch discovered the bacteria causing tuberculosis and cholera in land fields and water sources, Louis Pasteur showed that pathogens could be modified in the laboratory and be used to cure diseases. Following Bruno Latour (1993), the strength of Pasteurian medicine, by contrast with public hygiene, was its capacity to displace relations between humans and microbes from the laboratory to another site, the countryside or the colonies. If pandemics are diseases of globalisation, the microbiological response to pandemics is the globalisation of the laboratory as a space where serums and vaccines are made to mitigate their effects (Latour 1983). Society itself was defined by the study of the mechanisms of immunity, separating good microbes from pathogens in their encounter with the human body. Thus, Emile Durkheim (1916) compared what it feels like to live and think in a society to the inoculation of a small amount of pathogens through vaccines, since they allow the body to know what is proper and not proper under a collective form of memory (Esposito 2011). The organisation of public health relied on maps of distribution of infectious diseases and on access to vaccines and drugs, following the principle of solidarity between all participants of a social group.

The First World War confirmed the microbiological revolution while challenging it at the same time. The globalisation of war multiplied contacts between bodies but also standardised military forms of control, leading to the decrease of cholera or yellow fever by simple techniques of hygiene and social distancing. Yet new pandemics appeared with this accelerated form of globalisation. The influenza pandemic of 1918-1919 killed more humans than the war itself, and apparently caused diseases independently from social classes or climates (Crosby 1989). As the search for the microbe that caused it failed, despite the discovery of an associated bacteria by Richard Pfeiffer in Germany, no vaccine could be made (Honigsbaum 2020). While the influenza pandemic moved from America to Europe and Africa through the circulation of soldiers, pandemics of plague moved from Asia to Europe through steamship and railway, revealing the acceleration of global transportation by war and colonialism. The use of surgical masks against pneumonic plague in Manchuria in 1910 was extended to the United States against influenza in 1918, which shows that prophylactic measures could be invented against pathogens for which no vaccine or treatment was available or effective (Lynteris 2016).

It took a century after two global wars to redefine how we understand the relations between humans and microbes in the sociological notion of immunity. If ecosystems in which humans co-evolve with microbes are constantly changing, immunity must be remade by adapting treatments and vaccines to new pathogens and being attentive to their conditions of emergence. This was the foundation of the ecology of infectious diseases, a medical form of thinking illustrated by immunologist Frank Macfarlane Burnet in Australia and bacteriologist René Dubos in the United States, who argued that medical intervention should ‘run’ to keep nature in a state of balance (Anderson 2004). These two prophetic voices were confirmed with the emergence of new pathogens in the 1970s, such as Ebola or Lassa, which could spread rapidly through accelerated means of transportation. In 1996, microbiologist Joshua Lederberg declared,

we come then to social intelligence as our remaining option to counter the evolutionary drive of the microbial world. That intelligence must include a profound respect for the ecological factors that enhance our vulnerabilitity. From this perspective, we have never been more vulnerable (King 2002, 768).

Ledeberg encouraged biologists to ‘think from the microbe’s perspective’ and saw globalisation, with its increasingly rapid connections between distant points of the world, as multiplying opportunities for microbes to thrive. Latour, following the works of James Lovelock and Lynn Margulis, has described relations between humans and microbes through the concept of Gaia, a symbiotic entity conceived at the scale of the planet and its atmosphere. He asks how it is possible to reassemble the social in the ‘critical zones’ where pathogens signal disruptions and call for attention (Latour and Weibel 2020). Relations between humans and microbes, in that perspective, are sites of vulnerability which require local forms of investigation, rather than a rigid sociological definition of immunity as a kind of border.

Social inequalities, from local causes to global amplifications

If pandemics are caused by microbes spreading globally through human means of transportation, they are also caused by social inequalities, which they amplify. Epidemics are often ‘syndemics’, as the effects of one pathogenic microbe are added to other social factors of vulnerability, including other infections (Singer 2009). Unequal access to health care is caused by poverty, racism, hierarchy, discrimination, and violence, thus contributing to the emergence and spread of infectious diseases (Nguyen and Peschard 2003). Pandemics produce global inequalities and prejudices, between populations in the Global North who are often protected from these diseases by their governments, and populations in the Global South who are predominantly affected by them and tend to be depicted as the origins of emerging pathogens (Wald 2008). Anthropologists have questioned global health interventions by the WHO or the Bill and Melinda Gates Foundation for example, because when focusing on pandemic pathogens that they want to anticipate, mitigate, or eradicate, they tend to ignore or simplify the social distribution of pandemic pathogens. Here, microbiology must be connected to epidemiology, which studies the differential exposure to infectious diseases, and to social anthropology, which reflects patients’ vulnerabilities as well as feelings of suffering and injustice.

The virus causing AIDS (Acquired Immunodeficiency Syndrome), identified in the United States in 1981, spread to a slow pandemic, killing around 30 million people. While it first affected gay urban communities who could mobilise to promote research on medical treatments, it reached poor communities through sexual relations or blood transfusion with little access to a cure (Epstein 1996). Paul Farmer, as a physician and anthropologist, studied the transmission of infectious diseases in Haiti and the local idioms in which people made sense of their suffering, such as through accusations of sorcery. Refusing to oppose the cultural explanations rooted in belief and the biological causality of the microbe, Farmer followed narratives of illnesses in which AIDS occurred in long-term infections such as tuberculosis (Farmer 1999). For him, the global narrative of AIDS connected places where different and sometimes contradictory idioms to make sense of illness were used. ‘The AIDS pandemic is a striking reminder that even a village as “remote” as Do Kay is linked to a network that includes Port-au-Prince and Brooklyn: voodoo and chemotherapy, divination and serology, poverty and plenty’ (Farmer 1992, 8). Indeed, these different idioms can enter in tension when a migrant worker from Haiti arrives in New York with AIDS, and seeks medical treatment at hospitals while making sense of the disease in his own concepts.

The contradictions between idioms of illness produce what Paul Farmer calls a ‘geography of blame’, which traces pandemics to poor territories where they are considered to emerge. AIDS became a target of global health measures a few years after the Ebola virus was detected in Central Africa after 1976. This coincidence raised concerns that Ebola could infect North Americans, thus reinforcing security measures to control its spread on the African continent. Some anthropologists, such as João Biehl and Adryana Petryna, want social anthropology to enter into a critical dialogue with global health. They show that the technologies to detect pandemic emergencies predominantly as a security concern tend to forget the people who are affected and the narratives by which they make sense of their suffering. These aspects should play a role in the mitigation of pandemics:

Global health players can become impervious to critique as they identify emergencies, cite dire statistics, and act on their essential duty of promoting health in the name of “humanitarian reason” or as an instrument of economic development, diplomacy or national security (Petryna and Biehl 2013, 7)

In his ethnography of AIDS in South Africa, Didier Fassin (2007) analysed the accusations launched by president Thabo Mbeki that the disease was caused by poverty and not by a virus, and that treatments proposed by Northern countries were too costly and non-effective. These claims, portrayed as heresy in the language of global health, were accepted by many South African citizens because the context of the post-apartheid regime made sense of experiences of suffering and inequality. For Fassin, the national accusations of a president captured local experiences of disease in a long history of colonisation and racism, which became public with the Truth and Reconciliation Commission.

When they emerged in China in 1997 and 2003, H5N1 avian influenza and SARS (Severe Acute Respiratory Syndrome) were described as potentially the first pandemics of the twenty-first century, as they revealed the increasing connections between China and the global economy. They were also understood as epidemics of information, because a ‘viral network’ coordinated by the WHO followed the mutations of respiratory pathogens in real-time as they circulated from one country to another, which raised the question of how to distinguish true information from fake news in social networks (MacPhail 2014). Arthur Kleinman and others analysed these diseases with a biosocial approach of inequalities between humans faced with emerging pathogens. In the US, members of the Chinese diaspora were stigmatised by prejudices about wet markets as sites of contagion (Kleinman and Watson 2003). In Southeast Asia, small poultry breeders were replaced by big industrial farms which could implement biosecurity measures (Kleinman et al. 2008). While biological approaches in global health tend to correlate target and response, biosocial approaches take into account the local, national, and global scales that shape the context of the response.

A biosocial approach may question why some diseases are considered as pandemics while others are not, even if they also spread globally and are caused by social inequalities. Thus, obesity and diabetes have been described by global health authorities as epidemics because they followed the globalisation of sugar and Western modes of consumption. And yet they are not objects of mobilisation with the same urgency as infectious diseases, because they do not jump borders rapidly and cannot be expressed in the language of security. Moreover, their causes in the unequal distribution of food are more complicated to target with a standardised distribution of medical treatments (Moran-Thomas 2019; Sanabria 2016; Yates-Doerr 2015). While the origins of obesity and diabetes are apparently more complex than the emergence of a new pathogen, their outcomes are more difficult to model than infectious diseases. Beyond the opposition between biological and social causes of epidemics, anthropologists can thus ask how the notion of pandemics has become a tool to anticipate the future at a global level.

Horizons to anticipate the future

How are experts led to think that a disease will become a pandemic in the future, and how does this mode of reasoning affect relations between living beings? Pandemics have become one of the horizons to generalise a contingent event, resonating with other forms of anticipation in environmental knowledge, such as climate change or nuclear accidents. They are what Charles Briggs and Clara Mantini-Briggs called a ‘chronotope, a narrative device for connecting social, biological and spatial elements and ordering them in temporal sequences and interpretive frameworks’ (2003, 276). Thus cholera, one of mankind’s oldest diseases caused by a bacteria that spreads through water, was described by the WHO in 1961 as a pandemic, and retrospectively six pandemics of cholera were traced to Asia as its region of origin. When it reached Venezuela in the 1990s, the state, ruled by Hugo Chavez, tended to under-report cases to avoid quarantine, in such a way that the voices of the Warao people affected by cholera were unheard in the global discourse of pandemics. Such obstacles to making sense of pandemics have led global experts to anticipate them without relying exclusively or even heavily on national statistics but rather by involving populations in the imagination of pandemics as catastrophic events.

According to Andrew Lakoff, the emergence of infectious diseases in the 1970s has been framed in a new form of anticipation of the future. Infectious diseases such as tuberculosis or cholera were managed by public health experts in the last two centuries through techniques of prevention, based on the calculation of risks shaped by territory and the ability of distributing treatment. Infectious diseases after Ebola and AIDS were described by global health experts as ‘events’ whose probability cannot be calculated but whose catastrophic consequences can only be mitigated. Pandemics are now imagined through worst-case scenarios as events for which populations must be prepared, in order to contain panic when they do occur. Pandemic planning regulates the distribution of vaccines and treatments that are being stockpiled and secured to avoid looting. Pandemic preparedness is about creating a constant state of vigilance and readiness produced by techniques of anticipation of the future, such as exercises simulating an outbreak of smallpox in the New York City subway. ‘Preparedness envisions the future not to predict what is going to happen but to generate knowledge about the vulnerabilities in the present’ (Lakoff 2017, 23).

With Stephen Collier (2021), Lakoff has traced the history of techniques of preparedness in the US to the beginning of the Cold War, when civil defence experts identified vulnerabilities in ‘vital systems’, such as public transportation, the food industry, or banking systems, that could be targeted by a nuclear attack. These experts organised exercises or simulations to imagine such improbable events and mitigate their consequences. After the end of the Cold War, this style of reasoning was transferred from civil defence to national security in order to anticipate ‘generic threats’, a range of unpredictable events from terrorist attacks to hurricanes and floods. By shifting from national security to global health, pandemic preparedness has become one of the languages to think and act in a world struck by disasters, be they intentional or not, short-term or long-term, by simulating their effects rather than modifying their causes (Samimian-Darash 2009).

Carlo Caduff has studied how pandemic preparedness has transformed the work of microbiologists, particularly in the domain of influenza viruses. Because these viruses are constantly mutating, public health authorities have to anticipate new influenza viruses when a new strain replaces another, as in the cases of the 1918, 1957, and 1968 pandemics. When virologists study viral mutations in the lab, they have to bet which strain will become pandemic, leaving aside other strains considered as not ‘potentially pandemic’. This leads some of them to make what Caduff calls ‘prophetic claims’ by projecting previous pandemics into the future (2015, 7). When the H5N1 avian influenza virus emerged in Hong Kong in 1997, with a high lethality but a low transmissibility (12 persons were infected, out of whom 8 died), virologist Robert Webster warned of a pandemic more severe than the 1918 ‘Spanish Flu’ which had killed around 50 million people. These prophetic claims draw on apocalyptic images when they predict disasters at the global level. However, they are not promises of redemption but rather invitations to act in order to mitigate the disaster they announce. ‘At the core of pandemic prophecy is a particular prospect: destruction without purification, death without resurrection - in short, dystopia without utopia’ (Caduff 2015, 7).

Edwin Kilbourne, the founder of the department of microbiology at the Mount Sinai School of Medicine in New York City where Caduff did his fieldwork, promoted a policy of stockpiling vaccines for future flu pandemics with the motto: ‘better a vaccine without a pandemic than a pandemic without a vaccine’ (Caduff 2015, 61). The US Strategic National Stockpile also included masks and antivirals distributed during exercises to test for the allocation of scarce resources during a pandemic. These simulations of pandemics, based on scenarios similar to those used in novels or films, produce a sense of disaster imminence, and engage participants in a presumably realistic course of action. They blur the distinction between reality and fiction in such a way that a pandemic, when it happens, is taken as a simulation of the next one. Hence the 2009 H1N1 pandemic, which killed fewer persons than seasonal flu, could have led to a disengagement in preparedness, but the ‘lessons learned’ in stockpiling masks have been used, for better or worse, during the Covid-19 pandemic. In China, criticisms for the failure to control SARS in 2003 led public health authorities to take the H1N1 pandemic as an exercise, showing their ability to trace contacts and control its spread better than their US counterparts (Mason 2016).

Pandemic preparedness can be criticised as privileging the future over the present, calibrating faith and reason. Caduff analyses precautionary measures as a way to justify action by betting on the future in a competition between truth-claims about viral mutations where the most catastrophic claim wins over others. The logic of pandemic preparedness defers the present for a future that it indicates or signals. It is not regulated by the opposition between true and false, since no false signal can be criticised for failing to anticipate the pandemic.

The fact that this form of preparedness is causing too many signals can also be seen as a sign of its sensitivity: it actually constitutes a part of its functionality. The false alarm is a consequence of the exceptional vigilance that is considered necessary to prepare for the inevitable pandemic (Caduff 2015, 135).

This preference for the future in the logic of preparedness has produced new kinds of ‘publics’ (Prince 2019) in the neoliberal management of uncertainty. Vinh-Kim Nguyen (2010) has studied patient groups anticipating the end of the AIDS pandemic through their participation to clinical research projects. He shows that the possibility to treat HIV/AIDS with antivirals has led global health experts to collect narratives about living with the virus in West Africa, thus operating a triage between those who could receive treatments and those who could not. Although it has colonial antecedents, triage is in part a simulation technique of global health, since it defines priority populations for the administration of treatments in times of pandemics. These populations can become publics, in the sense that they are trained by NGOs and activists to argue reflectively. They institute forms of sovereignty below the nation-state, by referring to themselves as responsible subjects.

If Nguyen is critical of the social boundaries set up by exercises of triage because of the violence they institute, he is more positive about software simulations of pandemics that retrospectively track emerging viruses. These simulations reflect possibilities of social life. Based on pandemic scenarios, they calculate probabilities of new pandemics and imagine modes of ending existing ones, often through the problematic notion of ‘eradication’. Working as a health professional during the Ebola outbreak in West Africa in 2014, Nguyen testifies to the differences between slow epidemics such as AIDS and a fast epidemic such as Ebola: while the origins of HIV/AIDS were traced by phylogenetic analysis to a transmission from apes to humans in Central Africa in the 1920s amplified by human trade, the arrival of Ebola in West Africa by contact between bats and humans in a village in Guinea was much more difficult to prove. Anthropologists are called upon by biologists to speculate on the speed at which viruses travel across global infrastructures, and not only to understand cultural obstacles to public health measures. ‘In effect, an anthropology of infectious diseases must be attentive not only to the social drivers of biological emergence but also to the conditions which allow biological events to be detected and made tangible in situ’ (Nguyen 2019, 166). Participating in debates about the origins of pandemic viruses allows anthropologists to imagine alternative futures based on ethnographic knowledge, and thus question and improve techniques of preparedness.

Entangled relations between human and non-human species

Concepts such as ‘vital systems’ and ‘interspecies contacts’, which play a central role in pandemic preparedness, have led anthropologists to rethink social life not only as shared vulnerabilities in a human collective but also as changing webs of relations in which pathogens emerge. Pandemics are often caused by ‘zoonoses’, diseases transmitted across species by ‘spillover events’ (King 2002; Keck and Lynteris 2018). While some infectious diseases are transmitted by mosquitoes, such as malaria or dengue, and others by water, such as cholera, some pathogenic microbes circulate without symptoms among animals before spreading to humans, such as tuberculosis among badgers, coronaviruses among bats, or influenza among waterfowl. To describe these chains of transmission from ‘animal reservoirs’ to infectious outbreaks, the epidemiological concept of contact is not sufficient, because it presupposes that zoonotic emergence is a unique event. More ethnographic concepts are necessary, such as habit, proximity, and entanglement, to describe long-term relations that condition emergence (Brown and Kelly 2014; Nading 2014; Narat et al. 2017). How humans perceive and treat the animals they live with is a structural factor in the early detection of zoonoses, either in the use of apes and bats as bushmeat, or in the consumption of poultry and pigs as domesticated animals. New modes of human habitat have brought humans closer to mosquitoes and ticks carrying pathogens, whose behaviour has been modified by climate change. Under the concept of ‘One Health’, reframed and extended as ‘planetary health’, environmentalists, veterinarians, and physicians share information on relations between human and non-human animals to prepare for and fight against pandemics. If these associations are driven by demands of biosecurity, they can also be attentive to biodiversity, which increasingly appears as a protection against pathogenic emergence (Hinchliffe 2015).

Here again, the anticipation of an avian influenza pandemic has been a field of experimentation for virologists and anthropologists alike. The massive precautionary killings of poultry suspected of carrying influenza viruses has raised concern regarding the shared immunities that have been lost by the globalisation and commodification of the industrial chicken (Haraway 2007). In the Indonesian archipelago, the dispersion of backyard poultry has led villagers to resist biosecurity measures, which can be related to the mode of existence of viruses as ‘clouds’ of information (Lowe 2010). In Vietnam, the massive vaccination of poultry promoted veterinarians as central actors in a national ‘war’ against influenza viruses, but raised suspicions about the advantages they offered to industrial farms (Porter 2019). In Hong Kong, unvaccinated chickens were placed as sentinels at the entrance of poultry farms, while birdwatchers monitored the health of wild birds (Keck 2020). In mainland China, the recent scaling up of industrial breeding remained compatible with small poultry farms mixing wild and domestic birds (Fearnley 2020). The global scale of a pandemic affecting humans has led anthropologists to study the different scales at which humans perceive the movements of birds, from farms to markets and migratory flyways.

When they are seen from the perspectives of animal reservoirs in which they mutate, emerging pathogens such as influenza viruses and coronaviruses are not only warning signals of future pandemics but also signs of communication between species in disrupted ecosystems. Christos Lynteris (2019) has proposed to take seriously the idea that pandemics should be understood not only as extending epidemics globally but also as reminding of the potential extinction of the human species. While humanity has caused the ‘sixth extinction’ by its impact on other species’ conditions of life, the multiplication of zoonoses in the recent decades has led many observers to interpret pandemics as a ‘revenge of nature’—a popular idea quite different from René Dubos’s evolutionary race between nature and humanity. When pandemics reveal the vulnerabilities of infrastructures of social life, leading to the massive interruption of human activity to stop contagion, they question more generally the claim to autonomy which separates humans from other species. ‘The pandemic is imagined as striking not simply human populations – or even the human species as a whole – but rather at the heart of humanity as a project for mastery’ (Lynteris 2019, 9). Pandemic preparedness can thus be interpreted as a way in which humanity confronts alterity in the process of domesticating nature, either focusing on spillover events on the side of animals or superspreader events on the side of humans. This reversal of apocalyptic time is compared by Lynteris to mythological narratives in Amazonian societies, where humans have been separated from animals by an original conflict which serves to explain the diversity of species (2019).

While the figure of the prophet can be mobilised to understand how experts of pandemics make truth-claims about the future, the figure of the shaman can explain how scientists manipulate past relations between humans, animals, and microbes in new forms of ritual practices. The regular sampling of animals to check if they have potentially pandemic pathogens turns them into allies for global health: if a virus is declared the enemy of humankind, birds or bats carrying this virus offer biologists the possibility to ‘take the enemy’s point of view’ (Viveiros de Castro 1992). While biosecurity interventions separate subjects of care from sacrificial victims when they cull animals or conduct triage, the attention to biodiversity as a limitation of pandemic risks produces more inclusive forms of surveillance and monitoring. Borders between species and territories have become sites of intense production of knowledge under the horizon of future pandemics. The border between China and Russia was a site of rehabilitation of the knowledge of marmot hunters at the time of the pneumonic plague (Lynteris 2016), and the border between China and Hong Kong was constantly monitored by birdwatchers to prevent outbreaks of avian influenza (Keck 2020). Pandemic preparedness has transformed natural sites into reservoirs of signs of the future perceived by ‘virus hunters’, who can read microbial mutations to describe continuities and discontinuities between populations and between species.

Conclusion

Pandemics are among the main drivers of the globalisation of knowledge, as they lead experts to follow a pathogen at the scale of the planet and recommend measures to control it. As such, they have had complex and often contradictory impacts on human-animal relations, global social policy, belief in the efficacy of science, and visions of planetary solidarity. Lessons from the past show that pandemics start and end with environmental changes, but they do not provide models on how to anticipate the next pandemic. The technological capacity to detect potentially pandemic pathogens at their early start and to raise alarm has led global authorities to manage pandemics as security issues by targeting microbes as enemies. But the unfolding of a pandemic as a long-term process reveals an entanglement of relations between social groups, non-pathogenic microbes, and animal species that does not follow the logic of eradication, which requires cleaning animal reservoirs and distributing medical treatment. By reaching the scale of the planet, the notion of pandemics can reduce the work of science to globalised networks of surveillance, or enlarge the understanding of diseases to the complex web of causes that interlaces different forms of trouble, from remembering past illnesses to detecting future pathogens, often producing violence and inequality. Social anthropology can contribute to the redefinition of solidarity at the time of pandemics, because it stands at the borders crossed by pathogens between species, territories, and populations. It can usefully ask what kind of experience and knowledge is produced at these borders, how such knowledge travels, and how it can be translated to speak to everyone. Pandemic preparedness could thus become a new language to think about a disrupted planet and fragile environments.

References

Abramowitz, Sharon. 2017. “Epidemics (especially Ebola).” Annual Review of Anthropology 46: 421–45.

Anderson, Warwick. 2004. “Natural histories of infectious diseases: Ecological vision in twentieth-century biomedical sciences.” Osiris 19: 39–61.

Biehl, João and Adriana Petryna. 2013. When people come first: Critical studies in global health. Princeton: Princeton University Press.

Briggs, Charles and Clara Mantini-Briggs. 2003. Stories in the time of cholera: Racial profiling during a medical nightmare. Berkeley: University of California Press.

Brown, Hannah and Ann Kelly. 2014. “Material proximities and hotspots: towards an anthropology of viral hemorrhagic fevers.” Medical Anthropology Quaterly 28, no. 2: 280–303.

Caduff, Carlo. 2015. The pandemic perhaps: Dramatic events in a public culture of danger. Oakland: University of California Press.

Collier, Stephen and Andrew Lakoff 2021. The government of emergency: Vital systems, expertise and the politics of security. Princeton: Princeton University Press.

Crosby, Alfred. 1976. The Columbian exchange: Biological and cultural consequences of 1492. Westport: Greenwood.

———. 1989. America's forgotten pandemic: The influenza of 1918. Cambridge: Cambridge University Press.

Delaporte, François. 1986. Disease and civilization: The cholera in Paris, 1832. Cambridge, MA: MIT Press.

Descola, Philippe. 2013. Beyond nature and culture. Chicago: The University of Chicago Press.

Doshi, Peter. 2011. “The elusive definition of pandemic influenza.” Bulletin of the World Health Organisation 89: 532–8

Durkheim, Emile. 1915. Elementary forms of religious life. Translated by Joseph Ward Swain. London: Allen & Unwin.

Epstein, Steven. 1996. Impure science: AIDS, activism, and the politics of knowledge. Berkeley: University of California Press.

Esposito, Roberto. 2011. Immunitas: The protection and negation of life. London: Polity Press.

Farmer, Paul. 1992. AIDS and accusation: Haiti and the geography of blame. Berkeley: University of California Press.

———. 1999. Infections and inequalities: the modern plagues. Berkeley: University of California Press.

Fassin, Didier. 2007. When bodies remember: Experiences and politics of AIDS in South Africa. Berkeley: University of California Press.

Fearnley, Lyle. 2020. Virulent zones: Animal disease and global health at China's pandemic epicenter. Durham, N.C.: Duke University Press.

Foucault, Michel. 2005. The hermeneutics of the subject: Lectures at the Collège de France 1981-1982. London: Palgrave MacMillan.

Haraway, Donna. 2007. When species meet. Minneapolis: University of Minnesota Press.

Harrison, Mark. 2016. “Pandemics.” In The Routledge history of disease, edited by Mark Jackson, 129–46. London: Routledge.

Higgins, Rylan, Emily Martin and Maria D. Vesperi. 2020. “An anthropology of the Covid-19 pandemic.” Anthropology Now 12, no. 1: 2–6.

Hinchliffe, Steve. 2015. “More than one world, more than one health: reconfiguring interspecies health.” Social Science & Medicine 129: 28–35.

Honigsbaum, Mark. 2020. The pandemic century: A history of global contagion from the Spanish Flu to Covid-19. London: Penguin.

Keck, Frédéric. 2020. Avian reservoirs: Virus hunters and birdwatchers in Chinese sentinel posts. Durham, N.C.: Duke University Press.

——— and Christos Lynteris. 2018. “Zoonosis: prospects and challenges for medical anthropology.” Medicine, Anthropology, Theory 5, no. 3: 1–14.

King, Nicholas. 2002. “Security, disease, commerce: ideologies of postcolonial global health.” Social Studies of Science 32, nos. 5–6: 76389.

Kleinman, Arthur and James Watson. 2003. SARS in China: Prelude to pandemic? Stanford: Stanford University Press.

———, Barry Bloom, Anthony Saich, Katherine Mason and Felicity Aulino. 2008. “Avian and pandemic influenza: a biosocial approach.” Journal of Infectious Diseases 197: S1–S3.

Lakoff, Andrew. 2017. Unprepared: Global health in a time of emergency. Oakland: University of California Press.

Latour, Bruno. 1983. “Give me a laboratory and I will raise the world.” In Science observed: Perspectives on the social study of science, edited by Karin Knorr-Cetina and Michael Mulkay, 141–70. London: Sage.

———. 1993. The pasteurization of France. Cambridge, MA: Harvard University Press.

——— and Peter Weibel. 2020. Critical zones: The science and politics of landing on earth. Boston: MIT Press

Lynteris, Christos. 2016. The ethnographic plague: Configuring disease on the Chinese-Russian frontier. London: Palgrave Macmillan.

———. 2019. Human extinction and the pandemic imaginary. London: Routledge.

Lowe, Celia. 2010. “Viral clouds: becoming H5N1 in Indonesia.” Cultural Anthropology 4: 625–49.

MacPhail, Theresa. 2014. Viral network: A pathography of the H1N1 influenza pandemic. Ithaca: Cornell University Press.

Mason, Katherine. 2016. Infectious change: Reinventing Chinese public health after an epidemic. Stanford: Stanford University Press.

McNeill, William. 1976. Plagues and peoples. New York: Anchor Press.

Moran-Thomas, Amy. 2019. Traveling with sugar: Chronicles of a global epidemic. Oakland: University of California Press.

Nading, Alex. 2014. Mosquito trails: Ecology, health, and the politics of entanglement. Oakland: University of California Press.

Narat, Victor, Lys Alcayna-Stevens, Stephanie Rupp and Tamara Giles-Vernick. 2017. “Rethinking human-nonhuman primate contact and pathogenic disease spillover.” Ecohealth 14, no. 4: 840–50.

Nguyen, Vinh-Kim. 2010. The republic of therapy: Triage and sovereignty in West Africa’s time of AIDS. Durham: Duke University Press.

———. 2019. “Of what are epidemics the symptom? Speed, interlinkage and infrastructure in molecular anthropology.” In Anthropology of epidemics, edited by Ann Kelly, Frédéric Keck and Chistos Lynteris, 154–77. London: Routledge.

Nguyen, Vinh-Kim and Karine Peschard. 2003. “Anthropology, inequality and diseases.” Annual Review of Anthropology 32: 447–74.

Porter, Natalie. 2019. Viral economies: Bird flu experiments in Vietnam. Chicago: University Press.

Prince, Ruth. 2019. “Pandemic publics: how epidemics transform social and political collectives of public health.” In Anthropology of epidemics, edited by Ann Kelly, Frédéric Keck and Chistos Lynteris, 135–53. London: Routledge.

Sanabria, Emilia. 2016. “Circulating ignorance: complexity and agnogenesis in the obesity ‘epidemic’.” Cultural Anthropology 31, no. 1: 131–58.

Samimian-Darash, Limor. 2009. “A pre-event configuration for biological threats: preparedness and the constitution of biosecurity events.” American Ethnologist 36, no. 3: 478–91.

Singer, Merrill. 2009. Introduction to syndemics: A critical systems approach to public and community health. San Francisco: Jossey-Bass.

Viveiros de Castro, Eduardo. 1992. From the enemy's point of view: Humanity and divinity in an Amazonian society. Chicago: The University of Chicago Press.

Yates-Dorr, Emily. 2015. The weight of obesity: Hunger and global health in postwar Guatemala. Berkeley: University of California Press.

Wald, Priscilla. 2008. Contagious: Cultures, carriers, and the outbreak narrative. Durham: Duke University Press.

Note on contributor

Frédéric Keck is a Senior Researcher at the Laboratory of Social Anthropology (CNRS-Collège de France-EHESS). After working on the history of social anthropology and contemporary biopolitical questions raised by avian influenza, he was the head of the research department of the musée du quai Branly between 2014 and 2018.

Frédéric Keck, Laboratoire d’anthropologie sociale, 52 rue Cardinal Lemoine, 75005 Paris. frederic.keck@cnrs.fr