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Recasting the “ethno” in “epidemiology”

a
Michael Agar
a
Anthropology , University of Maryland , College Park, Maryland, 20742
Published online: 12 May 2010.

To cite this article: Michael Agar (1994) Recasting the “ethno” in “epidemiology”, Medical Anthropology: Cross-Cultural
Studies in Health and Illness, 16:1-4, 391-403, DOI: 10.1080/01459740.1994.9966123

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Recasting the "Ethno" in "Epidemiology"

Michael Agar

Collaboration between ethnography and epidemiology has a long and noble history, longer and
nobler than most people realize. This article presents the argument that the growing interest in
ethnography is, in fact, a way to reestablish nineteenth century epidemiology's concern with
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host and environment. Ethnography features meaning and context in ways that epidemiology
used to, and features them in epistemological as well as methodological ways.

Key words: epidemiology, ethnography, epistemology, methodology, drug/alcohol use

Epidemiology and ethnography, at first glance, look like quite different territories
in the intellectual landscape. Epidemiology examines the distribution of disease in
large populations to isolate the risk factors that enable intervention and, ultimately,
control. Ethnography features intensive contact with a small number of people to
learn their particular way of viewing and acting in their world.
On second glance, however, different territories can form alliances to accomplish
interesting joint events. Epidemiology is, after all, the study of human disease, and
those humans are busily thinking, feeling and acting on their own terms> terms
which may not be understandable to an outsider. To the extent that a "disease"
involves subjective worlds—and recent knowledge of interacting neuroanatomical
systems shows that all of them do—then ethnography with the capacity to docu-
ment those worlds can offer up missing epidemiological data. Epidemiology, on
the other hand, can add ways to generalize ethnographic results. In fact, much
collaboration between ethnography and epidemiology accomplishes those goals.
Yet, on third glance, recent forays into the literature on anthropology and epi-
demiology convince me that something more profound is going on. Some observa-
tions:
1. During the 1980s collaborations between epidemiology and ethnography in-
creased, and they included numerous health-related areas in addition to the
drug field (see Janes, Stall, and Gifford 1986 for examples; recent works such as
Kunitz 1994 and Kunitz and Levy 1994; as well as recent issues of Medical
Anthropology and Social Science and Medicine).
2. "Health-related areas" increasingly include all manner of things, including
poverty, violence, stress, and racism.

MICHAEL AGAR currently splits his time between academic and consulting work on a number of projects to
integrate ethnography and the culture concept into a variety of settings. His recent book, Language Shock, was
just published by William Morrow. Reprint request should be sent to Anthropology, University of Maryland,
College Park, Maryland 20742.

391
 392 M.Agar

3. Virtually all the collaborations between ethnography and epidemiology report

positive results, but virtually all of them qualify the results as experimental,
exploratory, or not well worked out (see, for example, the classic statement by
Fleck and Ianni 1958; and more recent examples such as True 1990; Jenkins and
Howard 1992; Inhorn and Buss 1993).
Both the enthusiasm and the tentative nature of the mix can be explained, I think,
by noticing that most of the discussion so far is in terms of method. One adds some
ethnographic methods to epidemiology to identify new variables or risk factors.
One adds some epidemiologic methods to an ethnography to test the patterns
uncovered in a small group against a broader population. There is, of course,
nothing wrong with either of these strategies.
But, even more interesting to consider is this: instead of links between two
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different methods, we are witnessing the emergence of a distinct conceptual con-

figuration, something advocated by Rubinstein and Perloff (1986). Epidemiology,
like so many other fields as we approach the turn of the century, is changing. It
must. What it studies, the world in which it studies, the uses to which its results
are put—all have changed in ways that render old frameworks that grew up with
infectious disease inadequate. And epidemiology, like all fields today, transforms
in a world where global shifts affect it, shifts from isolation to multiculturalism,
from hierarchical to participatory structures, from clean disciplinary boundaries to
fluid interdisciplinary collage.
Epidemiology is changing. In this article, I argue that ethnography is not just a
methodological adjunct; instead, it is the fuel for the transformation. Ongoing
experiments with the Community Epidemiology Work Group and the Interna-
tional Epidemiology Work Group at the National Institute on Drug Abuse, in
partnership with Nicholas Kozel, together with the efforts of others in numerous
areas of public health, count as pioneering moves in this change. The results,
glimpsed at this point in outline only, will be neither epidemiology as we currently
know it, nor ethnography as it is usually thought of in anthropology or sociology.
Instead, they will approximate an epidemiology of context and meaning, or a
focused ethnology of health. It is enjoyable to play with words and suggest
"epnography" or "ethnodemiology," because the transformation now underway
deserves a linguistic tag to signal its importance.
One could reasonably argue that epidemiology's problems are more deep-seated
than this, that they reflect the inappropriate extension of the medical profession
into areas which it is ill-suited to handle. I take the position that the entrenched
power and authority of medicine in the United States is a fact, that it is worth trying
to direct that power at significant problems, and that the integration of ethnogra-
phy and epidemiology serves that purpose.

THE ROOTS

The transformation of epidemiology is, to some extent, a rediscovery of lost roots,

for in the nineteenth century epidemiology was fundamentally social in nature.
 Recasting the "Ethno" 393

Trostle, from whose historical work this section draws heavily, summarized this
epidemiology with three principles:
health is a social concern; social and economic conditions have an important effect on health
and disease; and social and individual measures must be taken to promote health and
prevent disease [Trostle 1986a:44].

As striking as the social roots of epidemiology are the epidemiological roots of

the then budding sociology and anthropology. Rudolf Virchow, a German founder
of social medicine, taught a student named Franz Boas, who later migrated to the
United States and established American anthropology at Columbia University.
During the nineteenth century, Emile Durkheim wrote Suicide, a foundational
work of social theory for both sociologists and anthropologists, a work that is
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epidemiological at its base. Durkheim wanted to establish a societal level of

understanding that could not be reduced to individual acts. Suicide, that most
private of acts, would serve as the test case. By showing that suicide was differen-
tially distributed in the population, and that the differences had to do with such
things as religion, he showed that there were—in his now classic phrase—social
facts that could not be reduced to individual intention.
Personally, I find this eerie in light of what is currently going on. An epidemi-
ologic study helped found sociology. The founder of American anthropology
received training in social medicine. John Snow—who found the water source that
caused cholera in nineteenth century England—introduced the concept of field-
work and described the natural experiment as well: the idea that one could
organize variation that occurred naturally with the logic of experimental design.
A look back at the development of epidemiology in the nineteenth century
reveals a field, in close kinship with anthropology and sociology, that set out to
understand disease in its human context, outside the laboratory in the world of the
"infected." In broad brush strokes, this is exactly what the new use of ethnography
in contemporary epidemiology is meant to accomplish.
To some extent, then, the transformation of modern epidemiology reinvents
nineteenth century themes which had been lost to some remarkable successes. In
the late nineteenth and early twentieth century, epidemiology attacked the scourge
of acute infectious diseases—leprosy, anthrax, typhoid, tuberculosis, cholera,
diphtheria, meningitis, plague, malaria, etc.—(Trostle 1986b). The epidemiologists,
with their ability to fine-tune analyses and pinpoint the way that infection was
transmitted, led the modern revolution in health care (see Kozel, Sanborn, and
Kennedy 1991 for a similar historical sketch).
But nothing spoils like success. In a feedback loop characteristic of the history of
knowledge, success in one corner of a field leads to increasing concentration in that
corner, which leads to more success, which leads to more concentration, until the
corner eventually defines the field as a whole. Epidemiology's success with acute
infectious disease had two results relevant to the discussion here:
1. Focus on the agent. In the classic model of the "epidemiological triad," one sets
out to understand how an agent infects a host in a given environment. Host and
environment were part of the nineteenth century focus. With the dramatic
 394 M.Agar

successes of infectious disease epidemiology, agent ascended into prominence;

host and environment fell into neglect. The critical question for intervention
became, "how is the disease transmitted from one human to another? What is
the agent that carries the infection?"
2. The doctrine of specific etiology. Success with infectious disease led to a general
principle: each disease has a single cause. If you find that cause, you can control
the disease. "Cause" did not necessarily have to be one event. In the new
language growing out of the Vienna Circle in the early part of this century, there
might be several of them that were "necessary and sufficient" for the disease to
occur. But the assumption remained—one disease, one cause, or "causal assem-
blage."
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Powerful and helpful as these assumptions were in the study and control of
acute infectious disease, they overshadowed the initial themes of nineteenth cen-
tury epidemiology. Host and environment sank into a subordinate role, as vari-
ables or risk factors to help pinpoint the workings of the agent. The quest for
specific etiology washed out the variable and complex patterns of society and
history that the nineteenth century founders knew were important in answering
the question, "why some people and not others."
Epidemiology did not lock into this framework in a simple way until modern
times. It is, however, worth pausing for a moment to consider a couple of ways that
these two principles—focus on agent and doctrine of specific etiology—still haunt
modern epidemiological presentations in the drug field.
The analogue to "agent" in the drug field is, of course, the drug. The drug is
passed from one person to another, who then consumes it and therefore becomes
"infected." Among other things, the focus on agent helps explain the tendency to
present epidemiological data in terms of the drug—how many are using heroin,
how many cocaine, etc. Who is using, why are they using, under what circum-
stances, are critical questions that tend to receive less attention. Another conse-
quence of an agent focus is the tendency to emphasize where the agent comes from,
how it appears and "infects" the hosts. As a result, popular explanations often
attribute use to "outsiders" who bring the "agent" in and "infect" the locals, and
drug policy tends to focus on supply rather than demand. What this approach
misses is that some users seek out drug induced experiences; that some users
control and moderate use; and that some users binge picking the time and place.
Now consider the influence of the doctrine of specific etiology. According to this
doctrine, drug use is a disease with a single cause. We know this is not true. A
particular psychoactive substance, used in various frequencies and dosages, can
contribute either constructively or destructively to different lifeways, especially if
we broaden our perspective to other societies and other historical periods. Even so,
the doctrine haunts modern interpretations of epidemiological data.
For example, when drug professionals discuss the recent increase in marijuana
use they often attribute it to the so-called blunt phenomenon, named after the cigar
that is emptied of tobacco and then re-rolled with marijuana. Blunts are used
primarily by young urban African-American men. They are associated with a
lifestyle that includes a preferred brand of alcohol, clothing, music, and media
presentations. The blunt phenomenon is the kind of pattern that the traditional
 Recasting the "Ethno" 395

indicators pick up. Like most indicators, they ovemepresent poorer urban minority
residents. Blunts are a poor urban African-American male pattern; hence, the
marijuana indicator rises dramatically.
The doctrine of specific etiology, in coordination with the biased nature of the
indicator, leads us to equate the rise in marijuana use with the blunt phenomenon.
Numerous media accounts and anecdotes suggest that the situation is more com-
plicated than that. There are at least two other patterns contributing to the increase
in marijuana use. First, some patterns of use continued through the 1980s, but they
went underground with the repressive polices of that period. Now those patterns,
which never disappeared, are simply appearing more frequently in public. Second,
use among young people is on the increase, though this use is not centered on the
blunt pattern, but rather involves use that ranges from experimental to social-
recreational to problematic, among a number of cultural and class segments in the
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United States. Recent increases in marijuana use, in short, are not due to a specific
"etiology."
The ghosts of agent focus and specific etiology remain, in the drug field and in
other health-related areas. But they are ghosts now, not living forms that com-
pletely dominate the stage. Epidemiology has reacted and changed in response to
new and challenging events. In fact, the twentieth century saw a return of interest
in the neglected social factors for several reasons.
First of all, as the infectious diseases came under control, the chronic noninfec-
tious diseases characteristic of industrial civilization, like cancer, heart disease, and
diabetes, ascended into prominence. Isolating the bacteriological agent for these
diseases simply made no sense, and the concept of a unique etiology vanished into
the various kinds of complex circumstances that could cause the disease to occur.
Furthermore, variables having to do with the experienced world of the "patient"
came into play, variables that had to do with elusive factors like lifestyle and
occupation.
Second, the rise of modern psychiatry introduced a host of new "illnesses" and
competing theories oi "cause" that complicated the picture considerably. Not only
did matters of agent and unique etiology grow more complicated; but also the
clinical definition of the "disease" became more problematic than it had ever been
before, since "diagnosis" relied on symbolic processes as well as, or rather than, on
biological ones. Diagnosis relied on an interpretation of meaning rather than a lab test
result. The issues this raised appear in several controversies in psychiatric epide-
miology, such as the heated discussions around revisions to the Diagnostic and
Statistical Manual over the years.
Third, the development of health programs in non-Western settings raised issues
of cultural differences. Trostle (1986b) traces the career of John Cassel as one
illustration. Cassel started with the Polela program in South Africa right after
World War II, working with different cultural groups on health care programs. In
Cassel's (1962) landmark piece he described a case study "as an illustration of the
insight provided by knowledge of the cultural patterning and social situation into
behavior which would otherwise appear as a series of inexplicable unrelated acts"
(1962:238). Cassel, along with other pioneers like Fleck and Ianni (1958), established
that the "new" diseases involved matters of interpretation, of the subjective worlds
of effected populations, of local practices in which were embedded both risks and
 396 M.Agar

preventive measures, of variable notions of what counted as a "disease," indeed, of

what a "disease" even was.
The rise of chronic noninfectious diseases, the development of psychiatry, and
the growing number of encounters among different cultures around health care
issues—all these historical forces mitigated the bacteriological focus of early twen-
tieth century epidemiology. The ghosts of that era—agent focus and unique
etiology—are still with us, as demonstrated by the drug examples given earlier
but, epidemiology also stretched to try and accommodate the new situation. It
stretched from unique cause to multiple, probabilistic "risk factors." It stretched
from cause to "causal assemblages." It shifted its gaze, through the medium of
person and place variables, back toward host and environment.
But somehow the stretch does not quite reach the goal of documenting, under-
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standing, and successfully intervening in the phenomenon of interest. Causal

assemblages grew more and more cumbersome, with bidirectional causal arrows
linking large numbers of variables. Agents became more and more complicated
with an understanding that such concepts as "portals of exit" and "entry" and
"vector" were symbolic for the "new" diseases, and symbolic systems had to be
decoded before they could be understood. Host and environment were more than
a cluster of the usual demographic variables and a street address. Risk factors were
more than ratios based on socioeconomic variables; they were practices embedded
in people's daily routines, practices that could only be accessed and understood if
the world of those people was explored. And finally, as the focus broadened to
phenomena like homicide and accidents, the concept of "disease" itself did not
apply at all.
As Nations writes, citing what she calls "the epidemiological paradox" from a
paper presented by Dunn at an academic meeting, there is a:
decreasing ability to deal quantitatively with causal assemblages as their size and complex-
ity increase, and as their scope extends into the psychosocial domains [Nations 1986:119].
The time had come to reawaken the nineteenth century, and ethnography served as
the morning cup of coffee.

TOWARD A NEW EPIDEMIOLOGY

The key that unlocks the new mix of epidemiology and ethnography is this: instead
of thinking of the enterprise as tacking methods from field X onto problems of field
Y, think of X and Y as interacting at the conceptual level instead. Rubenstein and
Perloff, in an article subtitled, "On Integrating Epidemiological and Anthropologi-
cal Understandings," explain it like this:
Questions of method become meaningful only after epidemiological and anthropological
understandings have been used together to conceptualize a research project. Our approach
therefore contrasts with some discussions in anthropology and in epidemiology which have
been conducted as though problems of method can be considered alone [Rubenstein and
Perloff 1986:3031.
In fact, they argue, once the conceptualization of the problem is straightened out,
"the conceptual integration may be successful yet the research question can
 Recasting the "Ethno" 397

be appropriately answered using methods from only one of the disciplines"

(1986:303).
A review of some of the issues outlined in the historical sketch shows why their
resolution leads to an inevitable, conceptual relationship between ethnography
and epidemiology. First of all, consider the problem of the shift from a focus on the
agent to include, once again, the host and the environment at center stage.
The host is a human. In the days of infectious disease, a materialist explanation
was used to describe how infection came about. In the psychosocial realm, the
analogy would be the old behaviorist model, where the host reacts in certain law-
like ways to external stimuli. This explanation no longer serves as an adequate
account of human behavior. For example, a founding premise of symbolic inter-
actionism in sociology is W. I. Thomas's famous dictum that when people perceive
situations as real, the consequences of those situations are real as well. In artificial
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intelligence one speaks of "intentional systems," programs that depend for their
understanding and action on models of purpose and pattern, models that learn
over time. In literary theory the reader is now understood to actively participate in
the construction of textual meaning, on both the levels of individual biography and
historical period.
One way to contrast the two models is to imagine a billiard game. The materialist
model works pretty well. One hits the cue ball, which travels in a predictable
direction given the shot. Then it strikes another ball, with a predictable effect given
speed, angle, and spin. But now imagine an intelligent cue ball. True, once struck
it has to move. Material explanation isn't irrelevant; but neither is it adequate. Depend-
ing on how the intelligent cue ball feels, what it thinks, and what it wants to do, it
might speed up, slow down, change direction, spin a different way, or jump the
table and leave the game.
Hosts in the new epidemiology are like the intelligent cue ball. They have
intentions and participate in learned conventions that guide their actions. They see
things in a certain way and behave in a certain world that may very well mean
something different to them than it does to an outsider (See Hall 1994; Marin 1989,
as two of many examples). In some cases the difference might be idiosyncratic,
biographical, variations on some shared themes. In other cases, the differences
might be systematic, anchored in a different way of life characteristic of a different
social identity. There is no way to know for sure—whether there are differences,
which differences are biographical and which are social or cultural—until the
meanings of the host are investigated, documented, and understood. Ethnography
has a hundred-year history of investigating the meanings by which such "hosts" organize
their experience (Agar 1994).
Finally, what about the environment, the other neglected item in the agent-host-
environment triad? In the heyday of the impressive successes of infectious disease
epidemiology, the environment was also accounted for in materialist terms. The
question was, what sort of material conditions obtain such that the agent flourishes
and potentially infects humans who occupy the same environment? The famous
story of John Snow figuring out the relationship between water supply and cholera
comes to mind.
As with the host, materialist explanations in the new epidemiology will not
disappear, nor should they. Cholesterol causes plaque to build up in coronary
 398 M.Agar

arteries. Carcinogens exist. But, as with the host, materialist explanations do not
give us the whole story. Hosts live in symbolic environments as well as material
ones. In fact, when we shift from material environments as seen by the biologically
sophisticated to environments as seen by their inhabitants, we speak of contexts
instead (see, for example, Zavertnik 1993).
Why did Robbins, Helzer, and Davis (1975) find that returning Vietnam vets who
had used heroin in Vietnam but not at home stopped using on their return?
Apparently something about the two contexts made a difference. Why did Stall
(1986) find that drinking patterns shifted as one aged if the social network shifted,
though the shift might represent either an increase or a decrease? Something about
the context made a difference. Why did some addicts in New York shift from heroin
to methadone as their preferred narcotic in the early 1970s? Because the context had
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changed. Why did Zinberg (1984) find that some users of marijuana, narcotics, or'
hallucinogens could control use better than others? Because of what he called set
and setting, two aspects of context.
The new epidemiology now struggles with a shift from clearly defined material
environments to symbolic contexts that are real for the hosts who occupy them.
Context refers to several possible levels of analysis as well. At the micro end, it
refers to the immediate situation the human faces. At the macro, end, it refers to the
political economy, the moment in history, according to which nations and their
institutions take their shape.
Contexts are symbolic. Contexts are in the eyes of the beholder. The human, the
host, moves through them and reads them for the signals of where he/she is, what
might be possible, what sorts of outcomes might occur. In some ways, specification
of context is identical to figuring out the host, namely, investigating the meanings
that the human uses to organize his/her experience. In other ways, though, it isn't
so simple.
It isn't so simple because the host isn't aware of all aspects of the context. The
host will experience a "thereness," a sense that "this is how things are," but why
things are that way and how they came to be are beyond his/her ability to
articulate. No addict taught me that methadone became a political football be-
tween then Mayor Lindsey of New York City and then Governor Rockefeller. No
addict showed me a graph of methadone patient slots in the metropolitan area that
grew from almost nothing to roughly 40,000 in a matter of a few years. The context
for narcotic addicts shifted as dramatically as a material-environmental change on
fast-forward. The shift in context helped explain what I saw, but the data came
from archives, not from the words or acts of anyone on the streets.
The investigation of environment, of the various levels of context, requires a
careful study of the meanings and actions of the institutions that shape the world
hosts encounter. In the new epidemiology, the study of environment calls into play
the study of contexts, from immediate circumstance to broad characteristics of
political economy. And, once again, ethnography has a hundred-year history of investi-
gating the contexts in terms of which some group organizes its activities.
To summarize, one trend in epidemiology—a rediscovery of the field's nine-
teenth century roots—is the renewed significance of host and environment. Given
the study of the sorts of old and newly defined public health problems in the late
twentieth century, the subjectively perceived world of hosts and the various levels
 Recasting the "Ethno" 399

of context through which hosts move must be part of the equation. To understand
host and environment in the new epidemiology, one commits to understand
meaning and context. The investigation of meaning and context is, in fact, one
working definition of what ethnographic research is all about.
Previously, I argued that the relationship between epidemiology and ethnogra-
phy was a conceptual one, that ongoing changes in epidemiology set up conditions
where an ethnographic approach not only makes sense, but is inevitable. The
second major part of my argument consists of the second connection between the
new epidemiology and ethnography, again at the conceptual level, motivated by
the doctrine of specific etiology. With infectious disease, the doctrine of specific
etiology emerged from successes in isolating a bacteriological agent that caused a
disease. Once recognized, steps toward prevention could be taken.
After the infectious diseases came under control and the chronic diseases
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stepped to the fore, epidemiological life became more complicated. Consider

cancer. First, cancer is not a single disease. Second, several things might contribute
to "causing cancer," including diet, lifestyle, air quality, residence, occupation,
stress, and several other "risk factors." No single agent is responsible. Epidemiolo-
gists shifted their language from "specific etiology" to "causal assemblage" to
better represent this complex web of sociocultural and political economic "risk
factors" that interacted with the biological processes.
But "causal assemblage" does not adequately remedy the problem. The more
psychosocial the "disease," the more obvious its limitations. For example, in his
study of stress that leads to suicide among young Inuit in Canada, O'Neil (1986)
showed that shifting political economic circumstances, taken together with differ-
ent ways that the young men adapted to those changes, accounted for both success
and suicidal failure. Rubenstein and Perloff (1986) write of the "new morbidity"
among children, a constellation of problems that occur in different ways and that
come and go depending on context. Risk factors and causal assemblages do not
explain what the disease is, why and how it occurs in some but not in others, and
what interventions would help to alleviate it.
In the substance (ab)use field, the issue becomes even more complicated. In spite
of impressive and important advances in our understanding of the neurophysiol-
ogy of human/drug interactions, we still don't know why some experiment, some
maintain controlled use, and some turn into compulsive users; why some quit and
others don't—with or without help; or how substance (ab)use fits and doesn't fit
into the flow of life for different individuals in different societies at different times.
We think that substance (ab)use correlates with poverty and minority status in the
United States. But, even this is suspect because, on the one hand, the conclusion is
based on indicators that tap into institutions that deal with just those populations;
and, on the other hand, even the most unsystematic anecdotal data indicate that
this picture is, at best, incomplete. We don't know what causes drug abuse. We
don't even truly know what "drug abuse" is.
To some extent, the problem here echoes the earlier issue of host and environ-
ment; namely, understanding disease calls for a more sophisticated understanding
of meanings and contexts. But the problem also goes beyond this issue, for the
meanings and contexts—not to mention the material explanations and biological
processes—need to be woven together into explanations. Multiple interactions
 400 M.Agar

among a variety of elements define a system rather than a causal assemblage.

Teasing "cause" out of such a complex, interacting, emergent system is no easy
task.
Epidemiology is moving in the direction of medical ecology (Dunn and Janes
1986). In fact, this systemic, or holistic, point of view is often cited as a key
conceptual link between epidemiology and ethnography. True (1990:301) writes
that both fields provide "a holistic view of the processes of disease and health, and
this provides the basis for further collaboration." True argues that an integration of
biological and sociocultural factors is, in fact, the kind of "holism" that lies at the
foundation of anthropology, a foundation that, ironically enough, many contem-
porary anthropologists argue should be abandoned. For the new epidemiology,
holism is essential.
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With the shift from the doctrine of specific etiology to medical ecology, ethnogra-
phy again enters the epidemiological picture (see Rubel and Garro 1992 for an
example). Ethnographic analysis features the construction of a systemic, a holistic,
a patterned account of how aspects of group lif e interact to provide an understand-
ing of how particular situations come about. Most research approaches emphasize
isolation of variables and controlled manipulation of some small number of them.
Ethnography discovers previously unknown components of a system, at several
different levels, and builds models to explain how these components interact.
The problem here is that investigation of a medical ecological system calls for a
focus on specific cases rather than measurement of indicators across a large popu-
lation. But, once a series of local systems are well understood, hypotheses can be
generated to harness the strength of traditional epidemiological approaches. Janes,
Stall, and Gifford describe it like this, though they still use the term "causal
assemblage" rather than "medical ecology":
A method that still employs basic epidemiologic methods and yet incorporates the elucida-
tion of causal assemblages is that of the 'bottom-up' approach. In this method an under-
standing of risk is derived from the naturalistic observation of data and its interrelation-
ships. What is then supplied for epidemiologic investigation are a set of potentially
significant factors that reflect processes meaningful to the individual or population exam-
ined. Hence, an anthropology of disease is a topsy-turvy epidemiology, a method of deriv-
ing quantitative measures from qualitative analyses [Janes, Stall, and Gifford 1986:204].

A move to medical ecology signals an understanding that modern "disease" is

situated in complex systems whose workings must be understood before the
nature of that "disease" and appropriate interventions can be formulated. Investi-
gation of such systems requires an intensive focus on local examples. And once
again, to echo earlier statements, ethnography has a hundred-year history of investigat-
ing and modeling local human systems.
Trestle (1986b) makes an interesting statement, one that bears repeating in view
of my own recent readings in chaos and complexity theory. Medical ecology is
based on systems-theoretic and cybernetic models that arose shortly after World
War II, models that inspired the computer revolution that we now take for granted.
Recently, physicists and economists weary of inadequacies in their own theories
are developing newer mathematical models. Such models make explicit assump-
tions that are similar to, if not identical to, those which underlie ethnographic
 Recasting the "Ethno" 401

research. The notion of "complexity theory" as the study of complex, adaptive,

emergent systems is enough to show the parallels. Unfortunately, I am not compe-
tent to develop this theme further, but I predict that the new epidemiology that
takes shape over the next several years will interact with, draw inspiration from,
and contribute to the new field of complexity theory.
There are other areas to discuss. For example, epidemiology in recent times
displays a self-awareness, a reflexivity about its concepts and its methods of study.
From a traditional research point of view, such reflexivity disrupts old notions of
objectivity and replicability. But from another point of view, it signals progress in
incorporating the epidemiologist, with his/her presuppositions and activities, as
part of the study and hence a factor in shaping the results. Once again, ethnography
has a hundred-year history of struggling with the problem of the ethnographer as part of the
study that he/she conducts.
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Such reflexivity will assist epidemiology in its transformation. For example,

Gifford (1986) writes of how "risk" is both socioenvironmental in epidemiologic
analyses and biographical in clinical practice. Translations between the two con-
texts are difficult at best. As another example, an ethnographic examination of the
social processes by which quantitative data are generated would be useful. Such
reflexivity would benefit traditional epidemiology in issues as general as the
famous "numerator problem" (True 1990) and as specific as the way drug mentions
are handled at the actual moment when a patient enters the emergency room.

CODA

Epidemiology, to once again chant a leitmotif of this article, is changing. It has to

change. The kinds of problems it tangles with, the complex web of interacting
factors that produce them, the well-established interdependence of biological and
symbolic systems, our growing sophistication at linking macro with micro levels
of analysis—these and other features of the contemporary research world unite to
challenge traditional epidemiology to describe and analyze "disease" in ways that
go well beyond what the field's founders envisioned.
At the same time, the "new" challenges echo old epidemiological themes, for the
nineteenth century founding of the field carried with it a concern with social, cul-
tural, and political aspects of the human situation as well as the biological nature of
disease. The challenges, then, involve reestablishing some historical themes in light
of material not available earlier.
This new material is ethnographic, though not just in terms of method, of specific
ways of gathering different kinds of data. The new material is conceptual, rooted in
the epistemology of anthropology and the ethnographic goal of constructing theo-
ries of person and action characteristic of the traditional concept of culture.
The connection between epidemiology and ethnography lies in the solution of
two problems. First, the renewed emphasis on host and environment implies a
concern with meaning and context, and the investigation and modeling of mean-
ing and context are, in fact, the primary goal of ethnographic research, since
"culture" names exactly that class of models. Second, the shift from cause to
ecology implies a systemic model, a holistic model, rather than a simple linear one.
 402 M. Agar

Ethnography, in contrast to most other research perspectives, has always built

synthetic models rather than analytic ones, that is, culture is built to show the
interactions among different components at multiple levels.
The ties between epidemiology and ethnography, then, represent a conceptual
shift, a transformation in epidemiology that responds to diseases that are more
than biological, hosts whose subjective experience influences outcomes, environ-
ments that are perceived in addition to material, and worlds that are intercon-
nected rather than linear. The ties are more than a blend of methods, though such
blends are useful. Instead, they signal a new epidemiology, one better equipped to
renew epidemiology's traditional power with infectious disease in the domain of
the diverse and complex "diseases"—if diseases they are—of late twentieth cen-
tury life.
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ACKNOWLEDGMENTS

I gratefully acknowledge the support of Contract NO1DA-3-52011, State and Local Epidemiology
Planning and Information Development.

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