1. Toward a “Sociology of Disease Outbreaks & Other Health- Threatening Events” Kai-Lit Phua, PhD FLMI Associate Professor School of Medicine & Health Sciences Monash University Malaysia

2. Biographical Details Kai-Lit Phua received his BA (cum laude) in Public Health & Population Studies from the University of Rochester and his PhD in Sociology (Medical Sociology) from Johns Hopkins University. He also holds professional qualifications from the insurance industry. Prior to joining academia, he worked as a research statistician for the Maryland Department of Health and Mental Hygiene and for the Managed Care Department of a leading insurance company in Singapore. He was awarded an Asian Public Intellectual Senior Fellowship by the Nippon Foundation in 2003.

3. Recent Disease Outbreaks in Asia-Pacific Region (some examples) So-called Coxsackie virus – Sarawak (Malaysia) So-called Coxsackie virus – Sarawak (Malaysia) Nipah virus – Perak & Negri Sembilan states (Malaysia) Nipah virus – Perak & Negri Sembilan states (Malaysia) Hand-foot-mouth (HFM) disease - Singapore Hand-foot-mouth (HFM) disease - Singapore SARS – Singapore, China, Canada etc. SARS – Singapore, China, Canada etc. Avian influenza – Vietnam, Indonesia etc. Avian influenza – Vietnam, Indonesia etc.

4. Traditional Public Health Approach to Disease Outbreaks Who are affected (i.e. who are the hosts, is there an intermediate host)? Who are affected (i.e. who are the hosts, is there an intermediate host)? What is the disease-causing entity (i.e. what is the agent responsible)? What is the disease-causing entity (i.e. what is the agent responsible)? What environmental conditions promoted or hindered the negative effects of the disease- causing agent on the human host? What environmental conditions promoted or hindered the negative effects of the disease- causing agent on the human host? What is the “mode of transmission”? What is the “mode of transmission”? Is there clustering (persons, place, time)? Is there clustering (persons, place, time)? Focuses on: Agent-Host-Environment relationship Focuses on: Agent-Host-Environment relationship

5. How Sociological Analysis Can Contribute What social factors led to the disease outbreak? What social factors led to the disease outbreak? What social factors affected its severity, rate and extent of spread? What social factors affected its severity, rate and extent of spread? How did individuals, social groups and the State react to it? How did individuals, social groups and the State react to it? What are the short term and long term effects on individuals, social groups and the larger society? What are the short term and long term effects on individuals, social groups and the larger society?

6. Shortcomings of the Traditional Public Health Approach Especially with respect to: (3) Reactions of individuals, social groups and the State and (4) Short term and long term effects on individuals, social groups and the larger society Especially with respect to: (3) Reactions of individuals, social groups and the State and (4) Short term and long term effects on individuals, social groups and the larger society

7. (1) Social Conditions that Facilitate the Appearance of Disease Outbreaks Situations of economic crisis e.g. hyperinflation, unemployment leading to widespread poverty and malnutrition (as in Eastern Europe and former USSR after collapse of Communist regimes) Situations of social chaos e.g. natural disasters and war (coupled with refugee movements) natural disasters and war (coupled with refugee movements)

8. (1) Social Conditions that Facilitate the Appearance of Disease Outbreaks Social factors that promote zoonoses (1) Increasing intrusion of humans into (1) Increasing intrusion of humans into habitats of wild animals (economic activities such as forestry, oil exploration, mining, plantations and newer phenomenon such as “ecotourism”) habitats of wild animals (economic activities such as forestry, oil exploration, mining, plantations and newer phenomenon such as “ecotourism”) (2) “Factory farming” e.g. antibiotic misuse, Mad Cow disease (2) “Factory farming” e.g. antibiotic misuse, Mad Cow disease Bioterrorism and biological warfare

9. (3) Reactions to Disease Outbreaks Reactions by individuals e.g. in Medieval Europe during bubonic plague epidemics (widespread panic, changes in behaviour, scapegoating of Jews, population movements) Reactions by individuals e.g. in Medieval Europe during bubonic plague epidemics (widespread panic, changes in behaviour, scapegoating of Jews, population movements) Reactions by individuals today e.g. rapes of baby girls by HIV positive men in South Africa Reactions by individuals today e.g. rapes of baby girls by HIV positive men in South Africa Reactions by social groups e.g. fundamentalist religious views of HIV/AIDS, stigmatisation of sufferers and survivors Reactions by social groups e.g. fundamentalist religious views of HIV/AIDS, stigmatisation of sufferers and survivors Reaction of the State e.g. denial, attempts to suppress the truth versus strong action Reaction of the State e.g. denial, attempts to suppress the truth versus strong action

10. (4) Short Term & Long Term Effects of Outbreaks on Individuals, Groups and Society Individuals: coping with physical and mental aftereffects, stigmatisation Individuals: coping with physical and mental aftereffects, stigmatisation Social groups: impact on despised ethnic minorities, sexual minorities, sex workers etc. Dominant groups may use it to reinforce their dominance or to push their agendas or to reinforce social conservatism Social groups: impact on despised ethnic minorities, sexual minorities, sex workers etc. Dominant groups may use it to reinforce their dominance or to push their agendas or to reinforce social conservatism Society: economic effects, population effects (deaths, orphans), culture change (AIDS temples in Thailand and India) Society: economic effects, population effects (deaths, orphans), culture change (AIDS temples in Thailand and India)

11. “Sociology of Disease Outbreaks”: Analysis of Nipah Virus Epidemic 1. What social factors led to the outbreak? (Destruction of habitats of fruit bats? Smuggling of sick pigs from Perak to Negri Sembilan?) 2. What was the reaction? (People flee from the affected areas? Misappropriation of funds raised to help the victims and their families?) 3. What is the physical and mental health of people who were infected but who did not die? What about the physical and mental health of their family members?

12. “Sociology of Disease Outbreaks”Analysis of Nipah Virus Epidemic 4. Has the outbreak resulted in negative short term and long term effects on survivors, their families and the community as measured by reduced household income, higher unemployment and underemployment, significant financial loss, higher rates of indebtedness, discord among family members, outmigration/population decline?

13. “Socio of Disease Outbreaks” Analysis of Nipah Virus 5. How did affected parties who have not emigrated compare with residents of neighbouring unaffected communities? Are the former worse off in terms of mental health (including substance abuse and domestic violence), socioeconomic status etc?

14. “Socio of Disease Outbreaks” Analysis of Nipah Virus 6. Was there any “rebound” from the disaster? Were community bonds (“social capital”) strong enough prior to the outbreak to enable the community to rebuild itself, recover and perhaps even to flourish? Can we use Kai Erickson’s “destruction of community” approach to study this?

15. Conclusion There is a need to combine the traditional public health approach with sociological analysis to develop a strengthened “sociology of disease outbreaks and other health-threatening events” There is a need to combine the traditional public health approach with sociological analysis to develop a strengthened “sociology of disease outbreaks and other health-threatening events” This will enrich both public health and sociological theory as well as help in the development of better programmes to combat disease outbreaks and to help survivors, their families and their communities to better cope with the aftermath This will enrich both public health and sociological theory as well as help in the development of better programmes to combat disease outbreaks and to help survivors, their families and their communities to better cope with the aftermath

16. THE END THANK YOU