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| March 2011 I N F O C U S

Cities, Infectious Diseases and the Embodiment of PlaceAlex Nading U Wisconsin–Madison

Recent urban ethnography shows how the transforma-tion of slums and shantytowns through new infrastruc-tures, including water services, roads, sewage, and air and sea lines can lead to new forms of citizenship. In this commentary, I use lessons from medical anthropology to examine how new or transformed infrastructures affect the ways in which cities take on meaning as places.

Bodies in pain, under medical surveillance, or in illness are distinctive, carefully observed and even mapped. To adopt the incisive framework of Nancy Scheper-Hughes and Margaret Lock, the body is a tripartite construction. It is biophysical, social and—through the construction and contestation of knowledge about its biophysical and social aspects—political. Ecological and environmental anthropology shows us that places are also biophysical, social and political constructions. If medical anthro-pology is the study of the micro-geographies of power and knowledge, then medical anthropology’s ideas about the embodiment of disease might lead to new concep-tions of place.

Cholera and Place When a cholera outbreak made its way to Port-au-Prince, Haiti in November 2010, violence erupted among those living in the city’s refugee camps. Urban Haitians had heard press reports that traced the outbreak to Nepalese peacekeepers (a charge the Nepalese army denied). They also saw the cholera emergency as accelerated by the absence of basic infrastructure, a result of the January 2010 earthquake. Cholera can only be contained if water supplies are secure and sufficient enough to support the population, and if people have the means to avoid re-contamination. In short, isolating the sick, rapidly improving water and waste management, and changing individual hygienic behavior are the only ways to contain cholera. The solution—like the problem—is intensive, local and costly.

Cholera tends to strike spaces of exclusion: slums, squatter settlements and refugee camps. In its reinforce-ment of the vulnerabilities of life in exclusion, cholera produces a specific sense of place. Its victims are abject in a way familiar to followers of humanitarian crises. In their illness, they sit both within global health discourse (visible globally on television and in emergency reports) and painfully outside the cosmopolitan infrastructure of medical tools and knowledge that humanitarians and health practitioners occupy.

Dengue Fever and PlaceDengue patients embody place in quite a different way. This is partly because dengue is less deadly than cholera, and partly because of its changing spatial dynamics. Dengue has long been a neglected tropical disease, a

relatively minor health problem that, like cholera, was restricted to crowded, low-income areas and, unlike cholera, limited to tropical cities. In recent decades, however, dengue has spread to new areas.

The four strains of the dengue virus are transmitted by Aedes aegypti, a species of mosquito that lives exclu-sively in human habitats. Ae aegypti’s favorite breeding spots include old car tires, sinks, cisterns and water barrels. As a result of the mosquito’s dependence on anthropogenic water sources, for many decades dengue prevention looked strikingly similar to cholera preven-tion. It emphasized the elimination of mosquito habi-tats through short-term house-to-house management of water and waste sources and long-term improve-ments in urban infrastructure, including the instal-lation of window screens, pipes, sewers and system-atic garbage collection. In the 1990s, such localized efforts, supplemented by public education and chemical mosquito abatement campaigns, were enacted across Latin America and Southeast Asia.

These localized abatement efforts have failed to stop dengue from spreading. Indeed, the problem is more widespread than ever, thanks in large part to transna-tional trade and travel. History of medicine students recognize that mosquitoes and microbes have always moved with people and products along global routes of trade and travel, but in the last two decades, such move-ments have become more intense and more rapid. Today Ae aegypti commonly stows away in international ship-ments of used car tires, and dengue viruses migrate with laborers as they travel by air, sea and land over borders and across oceans.

New MobilityThis mobility has brought dengue to new places, and made it worse in already-endemic places, including Managua, Nicaragua, where I carried out ethnographic research from 2007 to 2009. There, dengue epidemics are a yearly occurrence. Press reports and local conver-sations include repeated reminders of how the global circulation of people, insects, microbes and goods has produced a vulnerability to dengue. Still, Nicaragua’s capital is probably not a city most of us imagine when we think about locations of regular infectious disease pandemics. Managua produces few globally consumed products, has a small population (1–2 million), and is a net exporter of labor. Managua’s residents live partially inside and partially outside the main routes of trade and travel that constitute the “global” in “globalization.” For example, in an informal trade between dumps, neigh-borhood brokerages and shipyards, people buy and sell recyclable or reusable items, including paper, plastic, tires and textiles. International trade of these items nearly always includes the movement of mosquitoes. When Nicaraguan laborers migrate to Costa Rica, El Salvador or Panama to find work, they may come home with new

viruses. A case of dengue in a contemporary Managua household brings these connections and disconnections painfully into focus.

While cholera made news in 2010 for its impact on a familiar set of victims (disaster refugees in a poor country), dengue gained notoriety for its impact on groups previously presumed to be insulated: Asian and Latin American middle class as well as the popula-tions of the US and the Mediterranean. In January 2010, Michael Ruslim, CEO of Indonesian manufacturing and agribusiness giant PT Astra, died of dengue hemor-rhagic fever, one of several wealthy victims that year. In the middle of 2010, a dengue outbreak was declared in Florida, the first non-travel related dengue event in that state since the mid-20th century. In Delhi, the threat of dengue in the athlete’s village threatened to dismantle the Commonwealth Games before they even began.

Policy ChangesThanks to a recent infusion of donor support and venture capital, efforts are underway to develop and market a dengue vaccine. The vaccine was previously thought to be both impractical and cost-prohibitive. Any effective vaccine would have to confer immunity to the four distinct strains of the virus simultaneously; more-over, cash-strapped governments and victims would have trouble paying for it. Dengue’s high-profile infil-tration of middle-class spaces and bodies has made the vaccine seem more marketable, while advances in genetic technology are allowing scientists to develop vaccines that can protect against the four strains.

As dengue spreads, awareness of bodies as inexo-rably connected—even across traditional urban dividing lines—has led to different senses of place, both within dengue hotspots like Managua and Delhi, and outside them. While cholera’s potential victims embody the terror of being beyond global connection, dengue’s embody the fear of being consumed by it. We need to pay more attention to the lessons that these etiological and clinical differences contain for our understandings of place.

While a global cholera pandemic is most unlikely, the last 30 years have seen a global dengue pandemic emerge. This has led to new senses of place in dengue endemic cities. It also begs new place-based questions. Will cities like Managua, with a small middle class and cash-strapped public health service, see the benefits of vaccines? How will megacities like Delhi or São Paolo look different after vaccines become available? Finally, if a vaccine does not become available soon, how will the increasing spread of dengue alter urban social relations?

Addressing the connections between bodies and places will require bridging the environmental and medical subsets of our discipline. The benefit will be a new suite of tools for situating global humanitarian and biomedical trends in particular geographic and histor-ical contexts—for putting global health, in its various guises, in its place.

Alex Nading is a PhD candidate in anthropology at the University of Wisconsin–Madison. Most of his field research has taken place in Latin America, and his current research interests include the political ecology of infectious disease, biosecurity and the body, and the ethical challenges of dengue vaccine research.

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