One Health. Группа авторов
Inequities (in access, affordability, quality, health rights) may be embedded in policies developed for low-income and indigenous communities. Rock et al. (2017) in discussing rabies control programmes describes this as an ‘entangled phenomenon’ of animals, human injuries, public policies and rabies. These and other social science studies can contribute to gaining deeper insights into not just whether, but how, One Health as an approach for intervention and action may be achieved.
A better understanding of ‘knowledge’, ‘attitude’, ‘behaviour’ and ‘practice’ is key to advancing the One Health agenda, not just for studies on local actors who may be, for example, potentially at risk of being infected by parasites that are transmitted from animals to humans. Words like ‘knowledge’ are terms used in everyday language, but in social science research they must be conceptualized with reference to theory. As the prominent medical anthropologist Arthur Kleinman (2010) elaborated in a Lancet article, a foundational theory in the social sciences is known as ‘the social construction of reality’, introduced by Peter Berger and Thomas Luckmann in the 1960s. According to this theory, the real world not only has a material basis, ‘it is also made over into socially and culturally legitimated ideas, practices, and things’ (Kleinman 2010, p. 1518). As an example, he refers to the spread of the H1N1 influenza virus that was ‘made over’ by global actors into the socially threatening and culturally fearful ‘swine flu’ epidemic. But he also points out that global health problems and programmes can (and often do) take on culturally distinctive significance in different local settings. What may be considered as a highly threatening health risk by global health experts may be regarded as one among many other health challenges by national policy makers and regional or local practitioners, and may not be recognized as a ‘real’ phenomenon by people exposed to this risk. This often leads to tensions between global policies and local reality and poses a challenge to medical and public health practice. ‘A corollary of the social construction of reality is’, Kleinman (2010, p. 1518) concludes, ‘that each local world—a neighbourhood, a village, a hospital, a network of practitioners/researchers—realizes values that amount to a local moral context that influences the behaviour of its members.’
Social constructivist theory, as proposed by Berger and Luckman (1966), refers to an epistemological position in which knowledge – and values – is regarded as constructed on the basis of experiences, in interaction with other social actors and broader cultural, economic and political contexts, and is often not articulated in words but in practice. In this understanding, knowledge is not a ‘thing’ that can be easily elicited, for instance in a survey with predefined questions such as a KAP study, outside the vital context of experience. What constitutes a problem and what is a proper response to this problem is seen through a social lens.
Social constructivist theory is one among several social science theories that foster a deeper understanding of common sense terms like knowledge, attitude, behaviour and practice. We introduce it here because it provides a foundation for designing and conducting reflective and participative social science research in One Health as the following two case studies will show. Case study 2 highlights the deliberate inclusion and role of social sciences from the beginning to the end of a pilot intervention. It emphasizes the importance of reflections by all disciplinarians upon their approaches, beliefs and potentially unconscious biases towards Western science paradigms. It also illustrates the valuable role of the social scientists ‘contextualizing’ decisions to ensure truly participatory knowledge development and design – from conceptualization to policy development.
Case study 2. One Health participatory surveillance and response from diverse Guatemalan perspectives. Contributed by Mónica Berger-González and Brigit Obrist.
Background
Guatemala, like many LMICs, is facing rapidly changing ecosystems that increase the vulnerability of populations where public health care and animal health-care services are poorly implemented, often devoid of cultural pertinence or a good understanding of rural communities’ way of life. The One Health Poptún intervention project aimed to develop a transdisciplinary process (see also Berger-González et al., Chapter 6, this volume) in the subtropical lowlands of Petén, to develop a surveillance and response system for key zoonotic diseases. This is an ongoing proof of concept implementation research between the Swiss Tropical and Public Health Institute, University of Basel, Universidad del Valle de Guatemala, the Ministries of Health and Agriculture, animal production people, the private company Tigo Telecommications Co., the Maya Council of Elders and community development councils. The longer-term vision is to scale up improved interventions into the health system.
With a predominantly indigenous Maya Q’eqchi’ and Mestizo population, this ethnolinguistically diverse area is characterized by medical pluralism, where modern Western approaches to health care offered in the public domain coexist with a predominant Maya medical tradition in a situation of exclusion and inequity. The challenge was to produce a sensitive surveillance system that could capture local understandings of ‘disease’ and respond in culturally appropriate ways deemed desirable by locals. This was only possible through using a strong anthropological approach that articulated a mutual learning process between epidemiologists, medical doctors, nurses, veterinary doctors, Maya traditional healers, local animal and human health authorities and service providers, and community leaders. The project adapted the Explanatory Model of Illness approach (Kleinman, 1978) to examine how each of these groups understand and judge the relations between human–animal interactions, health and illness.
The importance of acknowledging diversity: issues of representation and participation
The project aimed to address stakeholder’s interests on an equal footing in order to increase legitimacy and buy-in of the design, and to facilitate overall implementation of the surveillance-response project. In a post-war setting plagued with mistrust and historical trauma (Chamarbagwala and Moran, 2011), this proved a hard concept to enact. Social scientists conducted contextual and historical research for the study area to understand emerging trends possibly precluding participation of expected groups. An intersectionality approach (McCall, 2005) identified the groups most vulnerable to be excluded or misrepresented within the project. Results showed a context of extreme power differentials triggered by specific conditions that were organized in categories (ethnolinguistic composition, gender, distance-access, literacy, multilinguistic capacity, socio-economic composition, racist attitudes-practices). These were used to redesign transdisciplinary workshops, which included exercises to address power disparities, value rather than fear diversity in representation, and induce reflexivity. Quotas for types of participants were created (i.e. Maya, female, rural, traditional healers) to promote agency of societal actors originally excluded from the project but who were identified locally as key to successful project implementation. Anthropologists also developed specific methods to curb ethnocentric behaviour of researchers that precluded them from understanding local views of the human–animal interface domain.
Approach to development of intervention
Pluri-epistemic systems: ethnography as a tool to uncover underlying models of ‘zoonosis’
Beginning with the conception and design of the project, anthropologists, veterinarians and public health experts from Guatemala and Switzerland worked hand in hand as equal partners, defining an initial interdisciplinary transversal study. Each disciplinary group also conducted its own studies. Veterinarians and epidemiologists studied animal and human samples to determine zoonotic diseases, while anthropologists analysed local understandings of how human–animal interactions may affect health and illness. In regular meetings and workshops, the research