Conversation with an Expert

1. Since the human-environment-culture interface is such a critical point of intervention in terms of mosquito control, what do you think could have been done differently during the epidemic to encourage more widespread community participation and reduce stigma?

I strongly believe that adopting a culturally sensitive bottom-up rather than a top-down approach to preventive public health measures is key to limiting the spread of infectious diseases and simultaneously reducing stigma. In my opinion, taking people’s own experiences, concerns and ways of living into account when designing and implementing interventions will ultimately foster compliance rather than resistance since it contributes towards building trust between public health authorities and the general public. This includes involving residents in for example the clearing of their own gardens from stagnant water by way of dialogue rather than demands. I also believe that teaching schoolchildren about the importance of vector control, and not the least having them carry out smaller educational interventions either at home or in their neighborhoods, can have a beneficial impact on the sensitization of communities and adoption of protective measures against mosquitoes.

 Most of the challenges during the 2005-07 chikungunya epidemic in Réunion boil down to the French authorities’ seeming lack of epidemic preparedness and very slow response. If information and awareness about the risk of vector-borne diseases and preventive measures such as those outlined above had already been in place at the time of the outbreak, I think that both the numbers of infected and criticism against how it was handled could have been reduced. The local resistance against for example the fogging carried out by metropolitan soldiers was not borne out of ignorance, but rather mistrust due to France’s seeming neglect of its overseas citizens in face of a public health emergency.

2. You allude to the fact that domestic cleanliness and sanitation was used by officials to place blame on the Réunionese people. How can we encourage community participation without shifting all responsibility to individuals?

At the top of my head, I would say collective collaboration. Instead of merely informing about risks or carrying out invasive measures such as fogging in people’s gardens, I believe that public health authorities should actively engage with local communities and encourage collective action for the greater good of all. I dare say that very few people enjoy the company of potentially disease-carrying mosquitoes. In calling for solidarity, the responsibility is not shifted to individuals as such, but rather to everyone.

3. The biology and transmission of chikungunya and other vector-borne diseases have been well established for a while now, yet we still see a plethora of alternative etiologies. Do you think it would be a good strategy to acknowledge these as legitimate etiologies in order to design future control and prevention strategies that are more widely accepted?

While I think it is important that the existence of different etiologies than biomedical is acknowledged and met with understanding rather than dismissal, we cannot ignore the fact that vector-borne diseases transmit by mosquitoes, ticks, flies etc. Preventive public health measures will therefore still need to target for example mosquito breeding grounds to keep vector-borne diseases from spreading and the general public safe from infection. Legitimizing alternative etiologies could therefore turn out to be counter-productive to important vector-control measures. Still, to gain wider public acceptance for prevention strategies I think public health communication has an essential role to play in terms of negotiating between medical- and lay knowledge, or biomedical and alternative etiologies. Rather than persuading people to believe otherwise, people’s concerns need to be heard. Moreover, authorities’ communication should be transparent. This does not merely entail disclosure of information, but also accountability for mistakes and tolerance for criticism. If you compare resistance to public health interventions with vaccine hesitancy, several studies show for example how transparent communication increases trust in public health authorities which, in turn, is essential for vaccine compliance. I think this would be the case for vector-control strategies as well.

4. In your work on chikungunya and other vector-borne diseases throughout the Indian ocean, what were the major differences you saw in how epidemics were perceived and managed between Réunion, Mauritius, and Madagascar? How did their respective cultural practices, societal structure, and political history play into disease management?

I have not worked on chikungunya in Madagascar, but on uptake of contraception and abortion- so a different field altogether. While I have worked on chikungunya in Mauritius, I still need some more time to analyze my data before I can adequately compare the two islands. For now, I guess I can say that quite a lot of the etiologies on chikungunya resembled each other across the islands. As an international tourist hub, it also appears as if the Mauritian government responded much quicker to the chikungunya epidemic than what was the case in Réunion. If not, the financial consequences would have been devastating to the island’s economy. There is however speculation concerning the transparency of numbers of infected and casualties in Mauritius, and claims that the actual numbers were hidden so as not to scare away tourists.

5. Réunion has quite a unique colonial history, seeing as it was uninhabited upon discovery with no indigenous peoples. Instead, it is somewhat of an ethnic melting pot with blurred racial boundaries due to its history of slavery and indentured labor. What kind of effect does this have in terms of attitudes towards metropolitan France, government and public health officials, and therefore the perception of epidemic management?

The relevant division here is in my opinion primarily (geo)political rather than say ethnic or religious and relates to Réunion’s status as a French overseas department (DOM). This entails, at least in theory, that the Réunionese are fully fledged French citizens, but as illustrated by the chikungunya epidemic the island’s population is not always treated as such by the French government. Instead, many Réunionese feel as secondary citizens living on an island which continues to be neglected since it is not situated on the French mainland. Réunion has for example the highest number of unemployed in all the French departments. A central rhetorical question raised during the chikungunya outbreak was therefore: Would the French government have ignored, or allowed the epidemic to escalate to the extent that it did, had the outbreak taken place in say Paris? In this regard, the island’s status as a DOM located in the Western Indian Ocean played an essential part in local perceptions of how the epidemic was handled by the French authorities.

6. Through the work of scholars such as yourself, Weinstein, and Ravi, we now have a fairly good idea of what went wrong in the 2005-2007 epidemic. Have the lessons learned been used by public health officials and government leaders to make improvements in surveillance, reporting, and vector control?

I did ethnographic fieldwork on chikungunya in Réunion in 2009-10. Since then, I have moved on to other research projects, and am therefore no longer able to say much about recent public health improvements on the island. However, already at the time of my fieldwork local sanitary agents would conduct so-called garden inspections for mosquito breeding grounds. This was done in dialogue and collaboration with residents which I find to be an improvement. In addition, chikungunya and dengue was included in the French notifiable disease outbreak surveillance system at the end of the epidemic.

7. Similarly, we know that there will be more outbreaks of vector-borne diseases, both established and emerging pathogens. What can be done in the meantime to prepare for these outbreaks and prevent future epidemics? How can both community and international involvement be encouraged in the absence of urgency?

Rather than thinking of vector-borne diseases as outbreaks, I think we need to learn how to live with vector-borne diseases as a constant risk. This is not only the case in these islands but also concerns an increasing number of countries worldwide. As average temperatures rise, eco-systems become disrupted, and pathogens and their hosts spread to and thrive in geographical regions where they were previously unknown. Climate-sensitive tropical diseases such as for example chikungunya and dengue, are therefore also becoming an increasing global health threat coined by epidemiologists as a “chronic pandemic.”

8. As you mentioned, most studies of chikungunya and other infectious disease epidemics are quantitative and focused on the objective. How are studies like yours typically received in the scientific world? Can you reflect on the relationship between ethnographic and biomedical research?

I think a problem encountered by many medical anthropologists working on issues at the interface of biomedicine and public health, is that knowledge produced from ethnographic case studies sometimes are conceived of as “unscientific” within the “hard sciences” since they are not generalizable due to our different research methods. Instead of including medical anthropologists in for example the design of randomized control trials or implementation research, we are rather often brought in at the very end to explain “what went wrong”. Working more closely together cross-disciplinary could help solve some of these issues. At the launch of its 2021-2030 neglected tropical diseases (NTDs) roadmap in January 2021, the WHO stated for example a need for more critical and anthropological perspectives on NTDs such as chikungunya.