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Doctor Public Health 2526 Tulane University, U.S.A.
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Master of Public Health 2518 Hebrew University, lsrael
(Social Medicine)
Bachelor of Science 2506 Johns Hopkins University,
(Sociology) U.S.A.

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45
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q
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46
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48
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A v a I u uAl YY -e--.vl-! etArvvA

1\ Ovtasno n?lil1 9llua 0 qlun?1ilTYl Lfi a{n:u n?u ttJ
q tiJuqruuSoqiooqql $dsfi?'llll*unoout0.l (esteem)
, e oY u q y4- ' ' -..-r4-.-...^r^-d
qn il 6i u $ n s 9t 0 { il $'l 14 un v'l a 0 v tfi t n o n'] : tlJ fl u u ttu fl .l Yl '!J0.1t1J1
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sr rur:not il a nD'il fl a 0n1:tu (Health regimen) uultlu'lflut0 tlJ9l.:oau:o tiltUun
q 6 e a -, i . . rl-r
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t|st
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u vA s .l t rar.ldv
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eoale
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& <t e e r ll r.l rv . .i A e laoa
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o d e q Y e' -. A a T etled T 4 a A
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l-ata I e ua q
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49
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tu uCI? t fl TtJ n1 R.l il q n nTT il ul.l a u1.1 1'l tlj'l [o Yl1 tu un ? lt T 0 R ?',] tJ 0 1 l uo't
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n1 il U(Uq
A ,r"ru vA e a a o .l e I e v A- vv a a a e
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4tl , I q .l <1,1 , X X u i" -t , ,i a
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58
tur8.:pJm:ru rriu'|,f:r.:r"nurinuro.:rirula.:fiaurn'[oi' tfioi'rror raio0uuarul#ouro.:rirR.:firou td.:hiki
rdu dolotlirytrioruro.r dariq:fi.rerueri nourRirn vrq6n::rufioio.:nr:uJfiuuy loi riluoiu

References.
1. Becker, M. H. ed. The Health Belief Model and 5. Sackett, D.L. and Haynes R.B; eds. Compliance
Personal Health Behavior. Health Education with Therapeutic Regimens Bltimore : Johns Hopleins
Monograph , 1974. University Press. 1976.
2. Becker, M. H. and Maiman, L.A., Socio behavioral 6. Suchman, E.A. Preventive Health Behavior: A Model

Deferminants of Compliance with Health and Medical for research on Community Health Compaigns. Joumal

Care recommendations. Medical Care, 1975. of Health and Social Behavior, 1967.
3. Bardura, A. Sociel Leaming Theary. Manisform, New 7. Barofsky, l;ed. Medication Compliance: a Behavioral

Jersey: Geueral Learning Press, 1971. Management Approach Thorofare, New Jersey :

4. Kasl, S.V. lssues in Datient Adherence to Health Charles B. Sleck, lnc. 1977.
Care Regimens. Joumal of Human Stress. 1975.

59
SOCIAL EPIDEMIOLOGY OF
TROPICAL DISEASES

What is socialepidemiologY ? Another rationale of social epidemiology was

Social Epidemiology is the study that attempts that current preoccupation with investigative strategies

to relate social and cultural factors to specific diseases regarding the "causes of disease" are products of

found in a population or social group. An immediate historically successful identifications of infectious

aim of this study is to demonstrate the prevalence diseases. Diseases that are amenable to a closed-

and/or incidence of disease and its distribution in space system mechanistic and single-cause model. Such a

or in a social system bear a relationship to such factors model is clearly inappropriate for many diseases that

as cultural exclusivi$, ethnic identity, social class, or are prominent todaY,

any other variable that may be linked to social

processes. An ultimate aim of such a study is to uncover Figure I Chain of event
leads that will help clarify how these types of factors
may contribute to the cause of disease. direct acting on

The term "social epidemiology" may sound

redundant since "epidemiology" is the study of disease
in human populations and therefore implies a social biochemical agent

framework. But the adjective "social" is used to focus biophysical agent

attention on those social factors which influence the

occurrence, distribution and control of disease as (disease producing (host) (disease)

distinct from the biological, geographical and ecological agent)

factors which have been more exhaustively studied.

60
 The social epidemiology, therefore, is an host is susceptible may depend on his genetic make
attempt to adopt as open, multilevel and multicausal up, his previous experiences and possible immunities,

model that acknowledges social, psychological, and and his general physical and mental status. The last
cultural factors. two factors, of course, may be strongly affected by
social institutions. Thus, the ubiquitous tubercle bacillies

Theoretical foundation of social epidemiology is more likely to produce clinically recognizable disease

in an individual from the lower classes. Non-behavioral

A disease may be considered as a tissue environmental factors (sunlight, diet and genetically
change toward a morbid state, brought about by some determined characteristics may figure importantly in
biochemical or biophysical agent acting directly on the the chain, as with skin cancer and diabetes respectively.

tissue, (figure 1) Usually this action is the last in a Even here, however, social factors such as occupations

series of events that put the host in contact with the involving exposure to the sun or diet, may significantly
disease-producing agent. Traditionally, those interested alter the affect of the non-social environment. (figure
in etiology have used epidemiology to discover the 2)
agent or vector bringing about the tissue change. Social

epidemiology points out the importance of studying Figure 2

other factors earlier in the etiological chain. Such a
chain of events may start with an occupational or other
group, drawn typically, but not necessarily, from a given

social class, which may engage in a pathogenie pattern

of behavior. The behavior pattern of a social situation
modify the exposure of modify the action & effect of DPA

may act directly on the organism (as in accidents, Tissue change (Dis.)

alcoholism) or it may put the individual into contact

with an agent that can cause disease (malaria, smoking,
no tissue change (no D)
leprosy, filariasis, leptospirosis etc). In susceptible
(Dissease Producing Agent) (host)
hosts, tissue change may result. Whether or not the

61
 The social epidemiology of malaria and infection is enhanced by intimate and mntinued contact,

cholera in Vietnam graphically illustrates the impact of as in infection with mycobacterium tuberculosis or
culture in protecting against or producing diseases. Hansen, a small group, such as a family or kin group,

Although the malaria-bearing mosquito is ubiquitous in can continue as the source of infection for considerable

certain parts of Vietnam, many inhabitants are protected periods of time.

by housing built on stilts. They sleep farther above

ground than the mosquito flies. On the other hand, the Social Environment and Disease
culture exposes the to cholera and other diseases The roles of sociodemographic and
through the custom of work in rice-paddies flooded with psychological factors in disease occurrence and
sewage-laden water. distribution can be deliniated as following:
Sex : sex differences in morbidity data are
Exposure marked. In leprosy, for example, males are affected
The incidence or prevalence rates of infection more frequently than females often in the ratio of 2:1.
are dependent on the exposure of a susceptible The sex difference in leprosy is often
population group to specific infecting organisms. A attributed to ascertainment bias, it is possible that
continuing source of the agent is needed if the infection because leprosy workers are mostly men, the
is to remain in the community. Where the source of examination of women is less complete and less
infection is human and the power of infecting is of satisfactory, particularly in certain cultural situations,
short duration, an epidemic episode might be followed resulting in under-detection of leprosy among the
by no further infection. This has been recorded in many females.
small or relatively isolated communities in which the The relatively low prevalence of leprosy
reservoir of the infecting agent disappears and no new among females may be due to social or biological
infection is infection is initiated until contact is factors. Males in generalexpose themselves to greater
established with a source from outside the community. risks of infection as a result of their life stytes. Clothing
On the other hand, in those infections where the power habits of covering their bodies among females in the
of infection is of long duration and the chance of East contributed to reduction of opportunity for skin
62
contact. This also accounts for the absence of sex with improved socioeconomic conditions. The failure
differences in prevalence in many parts of Africa where of imported leprosy cases to produce secondary cases
men and women tend to dress alike and thus cover in Europe is partly attributed to high socio-economic
their bodies to about the same extent. levels.
The physical deformity in leprosy which is

Socioeconomic status: permanent and often progressive, results in both

Social epidemiologists equate Socioeconomic reduced employment opportunities for the patients and
status to social class, which is defined differently in socio-economic loss to the community. The
different societies and by different investigators. consequences of these are much more pronounced
Nevertheless, social class correlates highly with due to the added effects of social disability resulting
economic conditions, education, way of life, attitudes from the stigma attached to the disease.
and expectations, and exposure to different types and
degrees of stress. The social class differences in health Ethnicity:
have been related to differences in behavior, in the Ethnicity is probably related to the
environment, and in material resources. Behavioral epidemiology of a number of diseases. Ethnic
differences relevant to health have been described in background implies group homogeneity of dietary,
many practices, such as diet, cigarette smoking, hygiene, education, religious and other customs. lf this
behavior in illness and the use of medical care facilities, customary behavior may predispose the individual to
infant and child rearing, and assortative mating. The a given disease or protect him form it, we would expect

differences in environment and material resources of ethnic background to be related to several of the chronic
various social classes include the physical and social diseases. lt is found, for example, that Europeans,
conditions of the neighbourhood, income, housing, and Chinese, and Burmese are highly susceptible to the
clothing. Socioeconomic status can have both lepromatous type of leprosy as compared with African,
antecedent and consequent effects on diseases such Indians and Malanesians.
as in the case of leprosy. lt was found that the decline
of leprosy in many parts of the world is associated
63
Religions: disease or disability.
Like ethnicity, the religion of a group may
sometime dictate certain distinctive behavior patterns. Social structure of the communitY
Thus, a correlation between a specific religion and The social structure and functioning of a

etiology of a disease may be observable. Belief and population group influences transmission of the agent.

life-style factors, including the significant role of social The frequency of contact between people of different
supports prescribed by religion, have important segments of the community is obviously influenced by
demonstrated effects on leprosy. the network of relationships, especially those involving
face{o-face contact. There are rural communities in
Family characteristics : which the homestead, with extended family units living
Just as various cultural patterns peculiar to as joint families, are built as discrete units rather than

religious groups may be related to the risk of a given in more compact villages. Neighbouring homesteads
disease, so may behavioral traits peculiar to individual may be some distance apart and their members are
families. Most geneticists and sociologists now realize often not in one another's immediate network of
that the aggregation of disease in certain families can relationships or primary groups.
be due to either social or genetic inheritance. Thus,
for example, the occurrence of leprosy more frequently Socio-cultural and Social psychological processes.
in certain clusters, particularly family cluster, is well The significance of the more dynamic features

recognized. Besides sharing the same genetic of the social environment on the etiology, course and
predisposition, the risk of leprosy had been reported outcome of diseases include cultural change, mobility
to relate to the degree of intimacy of contact. On the and migration, status inconsistency, life changes and
other hand, fairly consistent flndings in different cultures life events. These processes can have widely varying
also suggest that the characteristics of the individual's consequences, positive and negative, for the health of
immediate social environment, e.9., participation in a different groups and individuals. Migration of patients,
cohesive family and the availability of group support, for example, may artificially reduce or increase the
function as buffers against the influences that cause prevalence areas. Rural to urban migrations in some

64
 @untries are not uncommon as a result of the social been noted. More emphasis was recommended on
ostracism, as in case of leprosy, to which patients are approaches focusing on the general non-specific effects
exposed in their rural environment. Migration also of psychosocial variables on the risk of developing a
facilitates introduction of new diseases into unaffected variety of illnesses.
areas, i.e., Chinese leper immigrants into the pacific
lslands, and African immigrants into America. ln the Occupational stress and strain
case of Malaria, presistent transmission is due to the The incidence of ill health in a variety of
complex internal migration of the population, especially occupations has been found to be associated with job
migrant labourers from non-malarious to malarious dissatisfaction, uncertainty about the future, boredom,
areas which are newly opened hilly and semi-forested low participation and poor social support from co-
agricultural land and vise versa; the movement of workers and supervisors. Behavior and attitudes.
people across national boundaries through hilly, conditioned both by culture and by the physical
mountainous, and forested areas, especially refugees environment, play a direct role in the inception and
from the countries of Indo-china; and the habits of the spread of widely prevalent non-communicable
rural people who prefer to stay outdoors during their conditions, like malnutrition, and communicable
leisure time. diseases. The project on schistosomiasis in the Lake
Adverse psychological effects of cultural Volta area demonstrated that a sociological approach
change, migration, urbanization and industrialization to the health-related behavior of individuals can suggest
are usually observed in situations of rapid change which specific ways to increase the effectiveness of prevention
strip away the habitual supports and protection with of a communicable disease.
which traditional culture surrounds the individual.
External events, physical and mental Urbanization
constitution, intrapsychic conflicts, and hypothetical The rapid and accerating increase in the
"mental mechanisms" that trigger maladaptive urban population in developing countries is largely
physiological responses and produce specific attributable to migration from rural areas in which the
psychosomatic disorders involving tissue change has lack of economic development fails to provide work
65
for the rising populations. This migration is largely
disease
poor
With respect to specific tropical diseases'
motivated by the desire to escape from a hopeless
housing which can piovide harbourage for
the triatomid
rural situation and not by opportunities for work in the
bug is an important factor in the transmission of Chaga's
cities; in such places, migrants are destined for a state
disease; in the same way, poor housing encourages
of semi-urlcanization (Joespy, 1970) living in and around
the ornithodorus ticks responsible for relapsing fever'
city but lacking any integration into it' The rate of net
The effects of urbanization on mosquito-borne
rural-urban migration are notably high in some South
the
disease through a greatly increased population of
American countries, WestAfrica and Asia' The situation
has been aggravated by the refugee exodus, as in SE
Aedes Agypti mosquito is responsible for the urban

Asia, in which, indeed, refugee populations present epidemics of yellow fever, chikungunya and dengue
(Surtee'
important disease Problems. while culex faligans is responsible for filariasis

Lack of an established social structure 1971). There is at least suggestive evidence that the

amongst migrants has led to increased rated of crime'

epidemic and fatal form of dengue hemorrhagic fever

venereal disease, drug abuse, alcoholism' inchi|dreninthecitiesofreopica|Asiaisaftributab|e

psychosomatic and psychoneurotic diseases (Lambo' to the high rate of infection with dengue viruses'
1995). Malnutrition, particularly among babies who are resulting from exceptionally dense' Ae', Aegypti

weaned early, is inevitably aggravated in the stress of

populations. In places where the domestic water

migration and, in the poor environmental conditions of storage is being steadily reduced by the provision of
piped water supplies, extensive new breeding places
semi-urbanization, combines with infection and
infestation to create wide-spread disease and mortality' are often being provided in the increasing urban litter

The unplanned growth of towns in developing of tin cans and car tires.

countries has many serious consequences for disease'

In tropical Asia, urban growth has been

Poor sanitation and poor provision of adequate water followed by a dramatic increase in Bancroftian filariasis

supplies, sewage disposal and housing lead to very transmitted by C. fatigans, which readily breeds in

high prevalence and death-rate from diarrheal diseases, latrines, cesspits, and sewage-polluted waters' The

respiratory diseases as well as many others forms of

prevalence of the disease is related to human

66
population density and inversely to the standard of lmported laboratory monkeys were recently responsible
sanitation. for some 28 cases and 7 deaths from Marburg disease
"Man-made malaria" can also result from the in Germany and Yugoslavia (Smith 1971\. There was
neglect of elementary and often well-tried precautions no general spread because the infection was
(frequently because of an excessive reliance on transmitted by blood contact. As travellers, mosquitoes
insecticides) against the creation of innumerable are potentially even more serious hazards;Ae, aegypti
breeding foci of Anopheles mosquitoes. In Karachi, owes it very wide distribution to its travelling with man,
much malaria results from increased breeding of usually breeding on board ships. Ticks may also be
Anopheles in shallow pools, borrow pits, and puddles introduced to new areas. Especially on domestic
left by uncontrolled building activity in the rapidly animals and by migrant birds.
spreading urban periphery (U.S. Public Health services,
1968). Agricultural and Engineering developments.
Large scale expansion of agricultural and
Transport and population movement. engineering resources is necessary in all developing
At all levels from mass migration to countries. Particularly to provide more and better food,
individuals, population movement is increasing a pace and to provide power (mainly hydro-electric) for industrial
due to political, commercial and religious reasons as progress. Such development can have profound effects
well as for tourism. Great new roads are bridging natural on the prvalence of diseases that, because their origins
barriers to the spread of disease. Rural villages or and mechanisms are often poorly understood, are
islands, formerly isolated by lack of roads and difficult to predict or control.
communication by vehicles, sea, or air are increasingly The eadiest stages of economic development
exposed to all the catagories of infection. often involve forest clearance. This can have a number
Migrant workers, students, with-risk laboures of important effects. For instance, the grazing of cattle
tourists, the military as well as pilgrim, have been in forests can greatly enhance tick populations
adjusted responsibly labourers in high-risk occupations responsible for outbreaks of Kyasaanur Forest disease
for spreading diseases. Not only people travel, however. (Worle, 1958). Zoonosis that are maintained in ground-
living, small memmals (e.g.,scrub typhus, leptospirosis) most important disease of irrigation projects' (Jordan'
1972) Leptospirosis is another disease associated with
commonly affect forest workers. Forest clearance can
also increase the risk of infections by changing the irrigation in places where there are dense populations

biting habits of blood-sucking flies. From feeding on of infected rodents and where the surface water is

wild psecies to feeding on man. On the other hand' neutral of alkaline (Smith & Turmer, 1961)'

deforestation may eliminate or greatly reduce the

population of certain vertebrate or arthropod Psychosocial influences on the course and
maintenance hosts of infections; drainage of swamps outcome of disease.

will similarly cause population changes by reducing

mosquito breeding. Recovery and failure to recover from illness

Dam building is required for urban water is also related to psychosocial influences. The stigma

supplies, irrigation or electric purposes. lt's adverse that socie$ attaches to certain diseases, for example

effects have been noted. Man-made lakes become mental disorder, epidepsy and leprosy, has been

potent sources of mosquito breeding and cause malaria described as being a major contributor to disability

epidemics. lrrigation is also a source of profile mosquito resulting from such conditions, regardless of their

breeding and the higher relative humidity it creates clinical severity. Even in the absence of stigma, social

may increase the longevi$ of the mosquitoes and factors such as the complexity of the modern urban

hence the number of infections they transmit. Japanese environment play an important role in the genesis of

encephalitis, throughout its distribution, is particularly disability

associated with inigated rice-fields, a breeding place Social conditions and psychosocial factor also

for culex vishnui. lmportant Anopheles species play a direct role in the process leading from acute to

responsible for maalaria transmission are associated chronic disease and impairment, and then to disability'

with irrigated rice-fields. Desalination of surface water

by irrigation can make them more suitable for breeding Social epidemiology and prevention

dangerous mosquitoes responsible for transmitting The costs of illness arb always best avoided

malaria or arboviruses. Schistosomiasis is perhaps the and the importance of prevention of chronic diseases

68
is particularly obvious. These are diseases with long- Clearly, this is a type of preventive condition that can
term effects and consequences. The suffering and be given greater attention. Strengthening the social
economic costs must sometimes be borne over many supports and affiliative networks of the individuals,
years so thus the need for prevention is especially particularly those who may be exposed to a greater
acute. Social epidemiology can provide some of the risk of disease, would appear to be a positive step.
tools of prevention. Most importantly in prevention efforts, many
Most practitioners would agree that if leprosy factors identified as possible etiologic factors in chronic
can be caught in the early stages, more cases would diseases are societal or structural in character. lt is
be cured. Early discovery of primary signs and necessary to initiate controls on the producer of
symptoms can prevent the development of invasive disease, such as legislation regulating production and
advanced cases. lf people could be persuaded to dissemination of unreasonably harzadous toxic
undergo physical examination; the disease could be substances, social engineering of the environment, etc.
recognized and treated and even prevented. Additional
problems occur when patients postpone seeking care Social Epidemiology and control.
or have irregular attendance of treatment units. Similar Malaria has had a significant impact on
findings are obtained for malaria: the habits of people society and, in turn, social development have greatly
who do not sleep in mosquito-net and/or prefer to stay affected malaria. The processes of intensive cultivation,
outdoors during their leisure time in the early evenings leveling and adequate drainage of the land, appropriate
which coincides with the activities of vector mosquitoes construction and maintenance of irrigation canals to
of malaria; less community participation in the DDT prevent wastage of water, improvement of housing,
residual house-spraying operation. Other factors relate urbanization, piped water supplies and sanitation all
to the irregularities in drug{aking of chemoprophylaxis resulted in the elimination of mosquito breeding places
or chemotherapy, resulting in chronic cases which act and in reducing non-vector contact. These changes
as reservoirs of malaria in the area, etc. caused malaria to disappear from most of Europe and
The role of social supports is of critical North America before specific measures were taken
importance in the occurrence of disease and illness. towards its eradication.
69
 Several attempts have been made the relate adapted to local conditions, which will make for more

the favourable evolution of malaria control and the efficient use of scare resources.

eventual achievement of eradication to the degree of The failure of malaria control has not been

economic development. Although such correlation can due so much to the lack of effectiveness of the
be demonstrated in general, this cannot be taken as a measures to be applied but to a set of mainly social

scientific law. The are many counter examples: from barriers which has affected its implementation' An

Northern Germany and Holland, from Southern Turkey, appropriate knowledge of the social epidemiology of

and from many areas of Latin America where economic malaria therefore, must be included in the process of

development alone did not lead to the elimination of designing and implementing control plans. A program

malaria but, in many instances, resulted in for acquiring and improving such knowledge should
intensifi cation of transmission. be developed. Whether a team should include social

It must be emPhasized that social science specialists or whether the malariologist should

epidemiology should be considered foremost a branch receive adequate training in social sciences
or an aspect of epidemiology. Social epidemiology menthodologies will depend on the complexity of the

contributes to the possibility of understanding better social problems involved and the magnitude of their

the real dynamics of the disease in the population impact on the epidemlology and control of malaria.

and of being able to design better control approaches

70