One Health. Группа авторов
categories of study participants (including the researchers). Ethnographic research on the mental models of the local population concerning disease transmission between animals, humans and the larger environment showed most Maya people drew on broader values of Tzalajb’il (harmony), Nimb’el (respect), Sahil Wanq (coexistence) and Xbisbal li wan (balance) to define an exchange of ‘energies’ between the species. A deep-seated notion of an assumed benevolence of nature precluded seeing pathogens of animal origin. This proved a key finding for the later co-design of education and communication strategies aimed at local communities. Apart from strictly Maya or strictly biomedical models of (zoonotic) disease transmission, the team found numerous hybrid models held by local health providers as well as by community members, influencing health-seeking pathways and treatment of patients. For example, Maya midwives that also served as ‘health guardians’ for the public health system, referred to energetic diseases such as ‘hijillo’, a disease believed to be transmitted from a dog to a child via the dog’s energy (non-material contact) but also from contact with afterbirth fluids. The midwives and health guardians explained that symptoms such as fever, diarrhoea, vomiting and lethargy in children would inevitably result in death. While noting that hijillo could be cured only through a Maya ceremony and medicinal plants, they also prescribed antibiotics in very small doses. These various models along the biomedical–Maya spectrum were analysed jointly by team members to understand the diversity of epistemic (knowledge) systems influencing health-seeking behaviour.
The emics of One Health surveillance
Social scientists employed the Bidirectional Emic-Etic framework (Berger-González et al., 2016) to elicit local (emic) categories of disease and terms for illness in animals and humans, which could be better suited for use in the surveillance system. Epidemiologists suggested unequivocal definitions for terms such as ‘febrile syndrome’ or ‘acute respiratory syndrome’, for which there was no direct Maya Q’eqchi’ translation. Given that the project aimed to implement a community-based surveillance system relying on families’ reports of perceived ‘danger’ signals, the team needed to understand how risk and illness were perceived locally. Working with Maya linguists and community representatives, local categories for syndromic surveillance that were more culturally sensitive were elicited, including them in the training protocol of the local nurses who had to document the human health cases occurring in studied households. For example, the desired term ‘diarrhoeic syndrome’ found several local terms in Spanish and over a dozen terms in Q’eqchi’ (i.e. Xha’ chi sa’ – diarrhoea as water, K’ik sa’ – diarrhoea as water with blood, Sam ko’t – depositions with mucus, Xah’ chi kem – soft but rapid depositions, etc.) that allowed the team to define a more precise and sensitive syndromic surveillance system for both animals and humans.
Boundary management: a case for mutual learning
Medical systems present particular idiosyncrasies that are deeply related to the way in which the social world is perceived and acted upon (Levin and Browner, 2005). In Guatemala, social divides often preclude the modern biomedical system and the Maya medical system from easily interacting in public spaces, creating boundaries that are often detrimental to patients and successful public health interventions. The project addressed this divide via joint diagnostic protocols that allowed the bridging between the two medical systems. To examine explanatory models of concrete episodes and their treatment in more detail, the study team organized joint visits of patients where a Maya Ajkum (traditional healer) and a biomedical doctor would jointly diagnose and discuss response avenues for human patients, or an Ajkum and veterinary doctor would do the same for animal patients. In a visit with a woman suspected to have leptospirosis, the medical doctor asked questions about risk exposure and unspecific symptoms such as fever and lethargy, and recommended laboratory tests to confirm aetiology. The Maya healer used an ancient technique called ‘pulso’ to diagnose ‘a disease similar to dengue but coming from a much older disease transmitted by a mammal, possibly a bat’. Most importantly, he suggested the patient had a precondition called ‘susto’ (a well-known culture-bound syndrome relating to losing one’s vital energy or spirit) that had weakened her ‘blood’ (immune system) and had made her susceptible to the disease. An example of boundary management in One Health is illustrated in our short video: https://youtu.be/lfVQnsqLbas (accessed 15 July 2019).
Results
Discussions on treatment avenues showed indigenous patients preferred responses that incorporated both biomedical and Maya treatments collaboratively, providing valuable insights into the role of cultural pertinence for increasing treatment adherence to previously unknown zoonotic diseases. In other words, this intercultural diagnostic study showed that incorporating traditional medical system approaches facilitated compliance with biomedical response protocols that were otherwise too novel and frightening for indigenous patients. In the above-mentioned case, the woman was treated in a hospital for leptospirosis and brucellosis after laboratory confirmation, but was previously treated for ‘susto’ by the Maya Ajkum, having refused to go to the hospital without her spirit being called back first. For this approach to elicit respect and avoid promoting further divides, social scientists carefully designed and guided the exchanges to facilitate a process for mutual learning between the different kinds of health practitioners and research disciplines by attempting to understand each other’s emic views on human–animal disease transmission. These diverse understandings and their implications were used to stimulate discussions across explanatory models within the research team and with transdisciplinary partners.
Outcome
The analysis of the ‘pilot’ intervention undertaken as a local proof of concept was presented in workshops fed into a larger ‘scale-up’ intervention design. These interdisciplinary workshops and conferences were aimed at promoting the One Health approach to community surveillance at a national level.
Case study 3 illustrates a grounded open-ended adaptive approach to local identification of problems by the community and local health workers, and a co-creation of knowledge and interventions. It illustrates the existence of differing world views on the problems identified and the need to approach health and well-being in a transdisciplinary manner, recognizing the interwoven concepts of human lives, animal lives and the environment affecting health.
Case study 3. Atoifi Health Research Group (AHRG) – how a One Health social science approach is being used in the remote Solomon Islands. Contributed by David MacLaren and Humpress Harrington, James Cook University and AHRG and Chief Esau Fo`ofafimae Kekuabata, AHRG and Kwainaa’isi Cultural Centre.
Background
AHRG is a group of health researchers, health service professionals and community members committed to investigating locally appropriate ways to improve health and well-being in remote locations across the South Pacific Nation of Solomon Islands. Solomon Islands has 600,000 people, who belong to 80 different indigenous language groups. The majority (85%) of the population live in rural/remote villages located on tribal/customary land and are sustained through the subsistence economy or via remittances from family members who work in urban areas. Villages are located across the rainforest mountains, fertile valleys, coastal beaches and coral atolls. AHRG does much of its work in the remote East Coast of the Island of Malaita. Although only 120 km long and 30 km wide, the island of Malaita has ten distinctly different language groups, each following their own cultural traditions on their distinct tribal/customary land.
The AHRG is committed to a learn-by-doing approach to research that centralizes capacity building to enable Solomon Islanders to incorporate diverse social, cultural, spiritual and geographic contexts. This approach has been successfully used for more than a decade to address several social and health problems. (For more details, resources and videos of the AHRG work, see https://www.atoifiresearch.org.sb/ (accessed 15 July 2019).) The AHRG is a transdisciplinary