Social Dimensions of Infectious Diseases Research Paper

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Social Issues In Infectious Disease Control

Public health efforts directed at the control of infectious diseases need to take into account a wide range of social factors that explain emergence, determine transmission, affect control efforts and therapy, and facilitate preventive measures. Such social factors range from behavior of individuals as it influences transmission dynamics to large-scale economic and political forces as they shape the epidemiology of infectious disease and the opportunities for control.

Over the past 30 years, infectious diseases and their control have been the subject of research in various social science sub disciplines including medical sociology, medical anthropology, health economics, health policy research, health psychology, demography, social and cultural epidemiology, and medical geography. At the World Health Organization, the Special Programme for Research and Training in Tropical Diseases (TDR) has supported social science research on tropical diseases since 1979. In the international scientific literature, a considerable sub literature on social sciences in infectious diseases and their control has emerged, including various chapters in textbooks of tropical medicine (Rosenfield et al., 1990; Kendall and Zielinski, 1999; Walton et al., 2005), significant bodies of evidence in health economics, health policy research, and, within medical anthropology, a (medical) anthropology of infectious diseases (Inhorn and Brown, 1990, 1997). This research paper focuses on the social issues in the core public health functions of infectious disease control.

Infectious disease control can be defined as the ‘‘reduction of disease incidence, prevalence, morbidity or mortality [of an infectious disease] to a locally acceptable level as a result of deliberate efforts’’ (Dowdle, 1998). Immediate measures of epidemic disease control include the identification and subsequent reduction of infectious agents, the interruption of routes of transmission, and the identification of populations at risk. The core public health concerns of infectious disease control are (1) to reduce and limit the incidence of the disease (primary prevention); (2) to treat, cure, and shorten the duration of the disease (secondary prevention); and (3) to limit and reduce disabilities resulting from infectious disease (tertiary prevention). Primary prevention includes measures as diverse as immunization, sanitation, environmental management, and the maintenance of an adequate nutritional status. Secondary prevention includes disease detection at the community level and curative treatment. Tertiary prevention includes measures such as psychosocial care, orthopedic devices, or the prevention of secondary, opportunistic infections (KimFarley, 2002).

The core concerns for public health action on infectious diseases harbor a great number of social issues ranging from behavioral and cultural to economic and political dimensions of infectious diseases and their control. For the purpose of this review, such dimensions are grouped into (1) the emergence context and social determinants, (2) the social forces that affect individual and population risk and vulnerability, (3) transmission dynamics, and (4) public health alert and control.

Emergence And Social Determinants Of Infectious Diseases

As early as 1848, German physician Rudolf Virchow, while investigating a typhus epidemic in Upper Silesia on behalf of the Prussian government, blamed not the infectious agent but poverty, hunger, lack of education, and political oppression as the root causes of the epidemic. His insights into the social determinants of infectious disease led him to state, in November of that same year, that ‘‘medicine is a social science, and politics nothing else than medicine at large’’ (Virchow, 1848: 125).

Today, some 150 years later, contrary to hopes spawned at the dawn of the antibiotic era, infectious diseases have been neither eliminated nor eradicated. In spite of significant progress in the development of health technologies, infectious diseases remain a major contributor to the global disease burden and mortality, disproportionately affecting poor and disadvantaged populations thus obstructing social and economic development in resourcepoor countries.

Various anthropogenic factors commonly held responsible for the emergence of infectious disease include manmade ecological change, human demographics/behavior, international travel and commerce, technology and industry, microbial adaptation, and change and breakdown in public health measures (Morse, 1995).

Ecological change is a major driver of disease emergence.

Many emergent viruses, for example, are arboviruses which, with a few exceptions, are zoonotic in origin. The zoonotic origin of many of the newly emerging infectious diseases has led to the hypothesis that environmental change plays a strong role in the emergence of new infectious diseases. Environmental change can alter the ecology of an established host–vector relationship and dissemination patterns, and provide new opportunities for microbes to adapt. Environmental factors are to a large extent man-made and include environmental consequences of war and natural disasters.

The transmission cycles of vector-borne diseases are particularly affected by human activities. Deforestation has been related to the emergence of arboviral diseases among humans and to the resurgence of parasitic diseases such as malaria. Environmental change resulting from human intervention always has larger-scale economic and political roots. Human incursions into the Amazonian rainforest by nonindigenous populations is the result of economic forces that facilitate mass migration and smallscale logging.

Antimicrobial resistance is a problem increasingly associated with the resurgence of infectious diseases. Proximate patient factors commonly held responsible for the spread of antimicrobial resistance include inappropriate prescribing, extensive and indiscriminate use of antibiotics, and noncompliance with biomedical regimens. Critical medical-anthropological studies have suggested that these proximate patient factors need to be seen in the broader context of social and economic realities in which patient behavior evolves and medicine use occurs (Farmer, 2000).

In a rapidly globalizing world, infectious diseases, and the epidemics they bring about, are no longer isolated local events and there is an increasing need for transdisciplinary analyses of the impact of global changes on the emergence of infectious diseases. New insights suggest that infectious diseases emerge within the context of interacting molecular, biological, ecological, societal, cultural, and political factors and that disease emergence and re-emergence, therefore, cannot be understood in isolation from the combined analysis of biological, ecological, social, cultural, political, economic, and epidemiological factors (Wilson et al., 1994).

In light of the evolving understanding of the impact of the social context on health in general, and infectious diseases in particular, the World Health Organization, in 2005, established a Commission on the Social Determinants of Health to support countries and global health partners to address social determinants of ill health, including infectious diseases, focusing on factors such as unemployment, unsafe workplaces, urban slums, globalization, and lack of access to health systems. The Commission’s report is expected to be published in 2008.

Risk And Vulnerability

Traditional infectious disease epidemiology has focused, to a large extent, on measurable biological and behavioral risk factors at the level of the individual. Within the perspective of ‘risk factor epidemiology,’ epidemiologists focus their analytical work on proximate, individual-level risk factors. Social scientists, on the other hand, have a particular interest in elucidating the social context of risk and vulnerability to infectious diseases.

Proximate behavioral risk factors that shape infection, occurrence, and severity of the disease include individual and group behavior related, for example, to hygiene and sanitation, sexual behavior, food consumption, or movement (including travel, migration, and displacement).

Social scientists emphasize the ‘cultural logic’ underpinning individual behavior and argue that behavioral patterns, and, consequently, exposure to, and distribution of infectious disease risk, are the expression of larger-scale forces such as poverty, social inequalities, armed conflict, and other forms of social, economic, and political forces. To social scientists, basic notions such as ‘risk group,’ ‘patient compliance,’ and ‘community’ do not adequately grasp the complex social, cultural, and economic reality of populations. Consequently, in the social science literature, the social construct of vulnerability has widely replaced the epidemiological construct of ‘risk,’ providing a theoretical background for practical interventions that try to take into account how specific social contexts influence individual identity-constructions, while avoiding the risk of group discrimination.

Vulnerability to infectious disease results from several major overlapping factors, including socioeconomic, biological, and environmental factors. Macro-level social processes such as globalization and trade liberalization, unplanned rapid urbanization, widespread poverty, and inequalities lead to vulnerability of population subgroups.

Transmission Dynamics

Interrupting routes of transmission and identifying susceptible populations, an important core objective of public health, necessitates good research skills to explore the social context of transmission. The investigations can elucidate behavioral pathways in disease transmission as they relate to daily routines of individuals and community groups with respect, for example, to vectors.

Most infectious diseases have transmission patterns in which human behavior plays a critical role. The social analysis of human factors in direct contact transmission, for example, reveals how individual and group behavior is shaped by the larger social, cultural, and economic context. For example, recently, to investigate the epidemiology of sexually transmitted diseases, epidemiologists, informed by the social sciences, have looked at sexual networks.

Illness behavior and cognition related to infectious diseases are socially and culturally constructed. This construction process can be greatly elucidated through social research (e.g., Nichter, 1991). Once humans are infected, their culture-specific illness terminologies, knowledge, and illness behaviors determine how they interpret, deal, and cope with the disease. Awareness may depend on sign and symptom recognition, perceived risk, and perceived personal vulnerability. The lack of awareness and perceived risk are particularly important determinants of patient behavior relative to apparent or asymptomatic infections.

Transmission dynamics are to a large extent shaped by social, economic, and political forces. Poverty leading to poor living conditions, lack of water, hygiene and sanitation, and access to health care are major driving forces of infectious diseases. Increasing evidence suggests that the poverty context in which infectious diseases emerge and persist is exacerbated by social inequalities both within societies and between countries (Farmer, 1999).

Public Health Alert And Response

Emergence of an infectious disease to the level of a public health problem necessitates awareness, public health alert, and response. Popular knowledge, beliefs, and risk perception of disease, its etiology, transmission, and vectors may have a determining effect on whether individual patients, their social surroundings and communities, alert public health authorities of a disease outbreak and whether they collaborate with public health authorities in efforts to interrupt transmission.

Recognition of an epidemic process generates a whole set of questions relating to the social and professional perception of disease events and their respective amplification by public institutions such as the media. The process of recognition relates to the question of whether a disease is in fact identified as a deviation from the norm by the population concerned, whether or not it is perceived as a threat (Sommerfield, 1994).

Timely outbreak investigations, appropriate surveillance systems, and effective reporting of infectious diseases are important elements of national, regional, and global epidemiological intelligence. Epidemiological outbreak investigations can greatly benefit from social science methodologies. For example, social network analysis has been shown to be useful in investigating infectious disease epidemics. Standard field epidemiological methods are increasingly being complemented by rapid assessment procedures, including rapid ethnographic assessments.

Outbreak management, particularly of highly infectious diseases such as plague, Ebola, or SARS, can be seriously affected by public reactions including fear, rumors, panic, flight from the epicenter, and so on. These are, to a large extent, affected by the public’s assessment of the crisis management of health authorities. Outbreak management with measures such as quarantining in the case of SARS or culling of chicken to control Avian influenza are particularly prone to adverse or noncompliant public reactions. Such measures must be guided by existing outbreak alert and response principles and respect the sociocultural context of the disease-affected area, in full respect of international ethical standards, human rights considerations, and national and local laws.

Control program measures related to infectious disease surveillance, including community screening and active case finding at the community level, may result in rumors and even resistance among populations. Cultural factors, including knowledge of the disease and transmission, and attitudes toward the diseased, affect the detection and reporting of suspected cases. Community-based systems can greatly improve the quality of surveillance in resource-poor settings (Ndiaye et al., 2003). Access barriers may be reinforced by social inequalities, including socioeconomic, geographical, ethnic, or gender-based barriers to accessing health care.

Social processes determine the public understanding of risk as well as the willingness and capacity of response. Surveillance may not be economically viable and disease reporting may not have sufficient political backup. Eradication campaigns can be undermined by political interests. Public reactions to epidemic events can include panic, fear, and flight from the epicenter of the epidemic. Reports by the media can catalyze popular reactions to epidemic events and attitudes toward control measures. Media studies, although rare, are important to the understanding of popular reactions to infectious diseases.

The effective translation of results from social science research into infectious disease control measures, health program design, and health policy remains a central concern of, and challenge to social scientists. Changing individual and group behavior, knowledge, and attitudes, and affecting the psychosocial impact of infectious diseases, necessitates nuanced interventions grounded in social research evidence. Such interventions need to address the meaning that individuals attach to specific behaviors, reduce stigma and other forms of discrimination, empower vulnerable populations, improve their environment and living conditions, and enhance community support.

Preventive measures need to be technically feasible, economically viable, and socially acceptable. The success of preventive measures and behavior change programs necessitates a willingness, on the side of disease-affected populations and individuals, to effectively and sustainably change risk behavior.

Control efforts with respect to infectious diseases need to target a great variety of issues, ranging from affecting sexual behavior and its social patterns (HIV/AIDS, sexually transmitted diseases), bed net use (malaria), and adherence to therapy (tuberculosis) to the appropriate use of pharmaceuticals for treatment and chemoprophylaxis. Public health efforts for the prevention of infectious diseases are often pursued through health education measures and social marketing.

Information, education, and communication (IEC) measures for infectious diseases need to be sensitive to the local cultural (including linguistic) and social context. Often, such IEC measures, if focused exclusively on the provision of knowledge and raising awareness about the disease, its mode of transmission, prevention, and treatment, are not followed by appropriate behavior change. Effective behavior change is more likely to occur when control measures are based on what people are most concerned about, that is, perceived severity of the disease and perceived personal vulnerability to attract the disease. Formative social research prior to designing IEC materials is an important step. Social mobilization and communication efforts are increasingly common in community-based infectious disease control efforts. A relatively new approach is the communication for behavioral impact (COMBI) methodology (Parks and Lloyd, 2003).

Agency, the ability to change behaviors in the context of constraining social, economic, and political forces, is a notion brought forward by social scientists to describe the social context of people limiting their freedom and ability to change behavior. Increasing evidence suggests that successful behavior change programs must go beyond individual change models to address the causal factors underlying individual agency in specific situations and should include skill development, political efficacy, and lifestyle change.

Accessibility to medical technologies such as pharmaceuticals, diagnostics, and vaccines is a critical dimension of infectious disease control measures. The identification of social processes and health systems dynamics constraining access of population subgroups to health technologies is an important formative step prior to setting up a control program. Knowledge, based on in-depth social research, is needed to improve public health efforts to enhance access. Insights into social structures will facilitate the setup of community-based delivery mechanisms, including but not limited to village health workers, health volunteers, and school-based or civil-society-based programs.

‘Top-down’ approaches to infectious disease control through vertical programs are particularly prone to detrimental popular reactions. Community participation and ownership, for example, through community-directed treatment (ComDT), schemes are increasingly seen as alternatives to top-down approaches, particularly to combat infectious diseases such as onchocerciasis, whose prevention relies on the annual mass-drug administration of one drug (Ivermectin).

On some occasions, health technologies such as vaccines face popular re-interpretations and may, in the worst case, be fully or partially rejected by the target population. Community attitudes toward control programs may also be shaped by unrealistic or unfulfilled popular expectations. Structural and environmental interventions need to complement behavior change interventions targeted at individuals.

Access to health technologies and the improvement of treatment necessitates health systems research grounded in good social science research. Social research is also needed to understand the dynamics of infectious disease-related policy formulation as well as policy change. Health economics research is useful to elucidate costs of control programs, including monetary and transaction costs.

The development and full-scale employment of new health technologies generate a number of ethical issues and have legal and social implications as public awareness, acceptability, and adherence are prerequisites for the effectiveness and utility of these technologies.

As infectious diseases disproportionately affect ‘neglected’ populations, they also raise human rights issues. Individuals have rights to control their own health and access appropriate information, prevention, and therapy. Governments, on the other hand, face internationally established human rights obligations providing conditions conducive to population health, at both national and international levels. Social scientists, in cross-disciplinary collaboration with human rights experts, can play a crucial role in analyzing the structural context of human rights violations, giving rise to vulnerability to infectious diseases and related health-care needs of excluded groups. Such cross-disciplinary research will produce policy recommendations to enhance social justice and equity in infectious disease programs and policies.

Conclusion

Traditionally, in public health circles, social sciences were often seen as facilitators of public health interventions rather than as a framework for the fundamental understanding of the social determinants of disease processes and public health approaches grounded, in theory and method, in the social sciences. This assumption has been largely overcome by the production of increased scientific evidence and the emergence of various social science subdisciplines specialized in health. Contemporary social science research on infectious diseases employs innovative qualitative research methods such as focused ethnographic assessments, rapid assessment procedures, stakeholder analyses, community diagnosis, a series of quantitative research methodologies, and mixed method approaches. These continue to be highly relevant for elucidating the interface between health services, control programs, and community dynamics and the larger social, economic, and policy context. Health economics and health policy research are relevant to define program design and to understand the resource allocation and policy context of infectious disease programs in resource-limited settings. Innovative approaches to research such as ecosystem-to-health research, gender analysis, cultural epidemiology, and other cross and trans-disciplinary approaches will further advance the social sciences of infectious diseases in the future.

Over the past 30 years, the health social sciences have greatly contributed to elucidating the site-specific social contexts of vulnerability and related control challenges. Besides generating substantial scientific analyses, such research has contributed to the design of public health interventions and their implementation. Research on the social context of infectious disease is now widely considered a prerequisite for the understanding and successful control of infectious diseases.

The social production of infectious diseases has been a persistent theme in public health since Rudolf Virchow, one of the founding figures of social medicine, as early as 1848, reported on the typhus epidemic in Upper Silesia. Virchow emphasized the forces that lead to the social production of the disease and cause its control to depend on structural changes rather than medical technology (Taylor and Rieger, 1985).

Today, over 150 years later, infectious diseases persist and re-emerge due to a wide range of social factors, including political, economic, cultural, and gender-related forces, of local, national, and transnational nature. They are intrinsically ‘eco-bio-social’ events shaped by social, biological, and ecological factors and their interactions.

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