Practices, knowledge, and the next pandemic: a lesson from a failed participatory public health intervention

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My time doing public health work in Guatemala in the 1990s and early 2000s has shaped how I think about emergencies. Working for an underresourced health system, my sensation was that we were always trying to implement new programs in the midst of a perpetual institutional crisis. On top of that, we would have to leave everything to deal with a new emergency every once in a while. I remember cholera, measles, and Hurricane Mitch in the 1990s, as well as rotavirus, rabies, maternal mortality, and Hurricane Stan in the 2000s. More recently, my public health colleagues there have dealt with tropical storms, volcano eruptions, H1N1 influenza, Zika, undernutrition, and more. While doing ethnographic work in Guatemala for over a decade, I have seen how public health workers chart their professional trajectories in relation to those emergencies they have been part of (Cerón 2018, Cerón 2019). As we all live through the COVID-19 pandemic, I keep thinking about the extent to which emergency response is shaped by practices that are cultivated during non-emergency times, as I have argued elsewhere (Cerón 2017), and I think that there is a lesson to be drawn from a pandemic influenza project I was part of a few years ago. In a nutshell, if that project had not failed, the response to COVID-19 in some rural communities of Guatemala could have been a little better than it is.

Highly pathogenic avian influenza is a global health priority. Predicting hotspots for influenza virus reassortment is considered a fundamental step in preventing future potential pandemics. Implementation of early detection epidemiologic surveillance in such hotspots presents a challenge, and some have suggested it can only be achieved with effective community participation. The wetlands in the Guatemalan Pacific Coast represent a potential hotspot because they facilitate close contact between migratory wildlife, domestic animals, and humans.

Over a period of almost three years, I worked on a research project aimed at designing an epidemiological surveillance system focused on animal and human influenza in two rural communities of Guatemala, as part of a multidisciplinary team that included several biomedical specialists and two anthropologists. The ethnographic work I was involved in intended to understand animal health-seeking behaviors, patterns of human-animal contact, therapeutic repertoires, and community health needs. At the preliminary stage of our findings, we had documented a series of ideas about the nature of a virus, the uses of vaccines and antibiotics, as well as local names for animal illnesses. We had also documented that there were no competent veterinarians or veterinarian technicians available for people to consult. Anthropologists observed and talked to government officials, local business owners, community leaders, researchers, and private health care providers in the region. The other members of the team were collecting samples of body fluids from backyard animals such as ducks, chickens, and pigs, and they conducted prevalence surveys to determine signs of illness among backyard animals as well, with the aim of characterizing the seasonal prevalence of influenza viruses in this epidemiological hotspot. Fieldwork spanned from 2013 to 2014.

Although the research project was successful in collecting data and producing published findings, it also failed because the team’s stated ultimate goal was to collaboratively design a surveillance system that took into account the perspectives of the community members and the relevant public health officials. For the past few years, and especially in the months since COVID-19 arrived in Guatemala, I have been thinking about why we were not able to reach the shared goal of building a participatory surveillance program. I have identified some suspected culprits: I know that the tension between utilitarian and empowering conceptions of community participation among public health researchers and practitioners played a role. I know that research funding played a role, especially since it came through a complicated cooperative agreement between a university in Guatemala and sources from the United States Federal Government, without a clear role for the Ministry of Health in the implementation and follow-up of the project. Community buy-in may have played a role, since local authorities were not fully engaged, although there were two groups of very active and influential women who were very interested in taking part of this project and especially in the potential follow-up. But looking through my fieldnotes and interview transcripts, it caught my attention that the ways different actors talked about the virus evolved over time, and may shed some light on the reasons behind our failure. I think that this “virus talk” precluded conversations about public health practices that would have been potentially more productive. A close examination of such “virus talk” should not obscure the politics involved, but rather help illuminate the threads that link this episode to the micropolitics and macropolitics of infectious disease (Singer 2014: 237).

In October 2012, the research team paid an initial visit to health officials and community leaders to talk about the project and to coordinate accordingly with the communities. We explained that the project aimed to find out if potentially dangerous viruses that were known to be present in wild animals in the region were also present in backyard animals. After introducing the project to the nurse aide in charge of a local health post, he gave us a tour of the facilities, and I had a little chat with him, a man with more than twenty years of working for the Ministry of Health. When I mentioned that I had worked in a health post like him, and that I remembered how much I disliked all the administrative work, he replied:

“I don’t mind the administrative stuff. It’s everything else they pile on us what worries me. [The Ministry of Health authorities] keep having more ideas of what we should be doing, but look, I am on my own here, so I am stuck doing everything. So, what I wonder is, let’s say you guys find the virus you are looking for… am I going to get more support or just more work?”

On the same day, we visited the president of the community council, a well-respected and well-off man in his sixties, laying on his hammock. After patiently listening to us, he replied in a soft tone:

“Look, we like to collaborate with [projects] that will bring some benefice to our community, like what you are telling me. But I want you to know that a while ago my wife bought one hundred chickens. She vaccinated them and the next day almost all of them were dead. Many of us here do not want to vaccinate our animals. Then, if that virus you are talking about will mean that we will need to vaccinate [our animals], I don’t know how people will react. Many of us will not agree [with vaccinating].”

A few months later, in February 2013, the two anthropologists participated in a pig butchering, and observed a cockfight that took place for the annual festivities in one of the communities. We talked to many people about what we were doing there, namely learning about their ideas and practices related to backyard animal health. Of the many people we talked to, nobody mentioned viruses as being a problem, and they told us that the main causes of health problems for their animals were the presence of unburied dead animals, changes in weather, and lack of hygiene.

In October 2013, after two rounds of taking samples from backyard animals, we held a community meeting in each of the communities. The original purpose of the meeting was to give preliminary results to anybody interested. At that point the main result was that we were not finding the dreaded highly pathogenic viruses, but we were finding other viruses. However, as the date of the meeting approached, the biomedical researchers wanted to shift the focus to educating the community about the viral etiology of influenza. They wanted to make sure that people understood the different types of virus that may affect their animals. They also wanted to clarify that we were getting samples to identify viruses, instead of vaccinating or giving vitamins or medicines to their animals, as suggested by some rumors in the community. The two anthropologists did not agree with this change in focus because we saw it as unnecessary, and no more than a response to the biomedical researchers’ anxieties about not finding the exact virus they were hoping to find, and about the possibility of people refusing participation in the final stages of the project.

So we ended up compromising in the following terms. The anthropologists were going to conduct the community meetings, explaining why we were taking blood samples, and we were going to try to generate a discussion with the community. Biomedical researchers were going to be present but would not take leading roles in the community meeting to avoid focusing too much on the virus itself. About twenty to thirty people participated in each community meeting and they were basically saying that animals get sick from the dust, changes in weather, lack of hygiene, and unburied dead animals. They conceded that perhaps the virus the project was talking about used those as vehicles for making animals sick. The meetings went well and we thought that they served their purpose. In the following months, sample collection was successfully completed and there were no major issues for the project, and community work with two groups of women continued, discussing community needs, organization and potential ways for addressing health needs.

In August 2014, at the last community meeting we had in one of the communities, the research team had already told the women who had been participating in the project that it was not going to continue because there was no funding. This was basically because we did not find the highly pathogenic forms of the virus among backyard animals, although there were other viruses that were identified. These women were very understanding but at the same time kept trying to argue in favor of some form of technical support related to animal health, saying that “there are other viruses and the animals will still get sick, right?” or “what if the virus was not here this year but comes next year?” They were in favor of creating a program where they could volunteer as local community health workers, and would have periodic visits and technical assistance from veterinarian technicians. But local public health authorities who thought positively of such a program would not be able to fund it, and the research team did not see as its role to help implementing an intervention.

In December 2014, the research team met to analyze data, plan manuscripts, and to make final decisions about follow up. Although there was some tension between figuring out ways to keep working on the idea of collaborating with the community to develop a participatory surveillance system, in the end we abandoned that goal, basically because we did not find any highly pathogenic viruses, which made follow-up funding unfeasible. The team decided to move on to work on a proposal on antibiotic resistance, maybe in the same communities but this time sampling dog feces. Both anthropologists decided not to take part of potential new projects.

In his study of Paris during the second Cholera pandemic, Françoise Delaporte asserts “that ‘disease’ does not exist. It is therefore illusory to think that one can ‘develop beliefs’ about it or ‘respond’ to it. What does exist is not disease but practices” (1986:6). In our case, looking back at all our “virus talk” reveals some aspects that led to the project’s failure. Finding the right virus represented professional success to the researchers, while it represented potential trouble to the nurse aide and the community leader. To the women who participated in the project, the virus became the key to having animal health services locally available. Paying attention to practices involves not analyzing opposing beliefs about the disease as “stemming from antagonistic principles and look instead for differences in practical effect” (Delaporte 1986:148). By failing to do this, our “virus talk” was a distraction, because while we were all talking about the presence or absence of the right viruses or about people’s animal health beliefs, we missed the opportunity to talk about what was really important: how to mobilize the resources that would improve access to health care to these communities while also improving the control of potential epidemiological outbreaks. Now I just hope that all of us who were involved will at least learn that lesson.

Alejandro Cerón is an anthropologist interested in the social and cultural aspects of health, especially sociocultural epidemiology, public health practice, and the right to health. Prior to earning a doctoral degree in anthropology (University of Washington, 2013), he graduated as physician and Master in Public Health in 2000 and 2006, respectively, from Universidad de San Carlos de Guatemala. He is currently Associate Professor of Anthropology at the University of Denver.

Works cited:

Cerón, Alejandro (2017). “Anthropology of epidemics in emergency and normal times in Guatemala.” Practicing Anthropology, 39(4): 6-9.

Cerón, Alejandro (2018). Epidemiología neocolonial: Prácticas de salud pública y derecho a la salud en Guatemala. [Neo-colonial epidemiology: Public health practice and the right to health in Guatemala.] Serie Autores Invitados No. 28 [Invited Authors Series, #28.] Guatemala: Asociación para el Avance de las Ciencias Sociales en Guatemala (AVANCSO). 174 p. ISBN: 978-9929-663-13-8.

Cerón, Alejandro (2019). Neo-Colonial Epidemiology: Public health practice and the right to health in Guatemala. Medicine Anthropology Theory 6 (1): 30–54; https://doi.org/10.17157/mat.6.1.647.

Delaporte, François (1986). Disease and civilization: The Cholera in Paris, 1832. Translated by Arthur Goldhammer. Cambridge, MA: MIT Press. 270 p. ISBN: 9780262040846.

Singer, Merrill (2014). Anthropology of Infectious Disease. Walnut Creek, CA: Left Coast Press.

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