Ineffective responses to unlikely outbreaks: Hypothesis building in newly-emerging infectious disease outbreaks.

Over the last 30 years, there has been significant investment in research and infrastructure aimed at mitigating the threat of newly emerging infectious diseases (NEID). Core epidemiological processes, such as outbreak investigations, however, have received little attention and have proceeded largely unchecked and unimproved. Using ethnographic material from an investigation into a cryptic encephalitis outbreak in the Brong-Ahafo Region of Ghana in 2010-2013, in this paper we trace processes of hypothesis building and their relationship to the organizational structures of the response. We demonstrate how commonly recurring features of NEID investigations produce selective pressures in hypothesis building that favor iterations of pre-existing "exciting" hypotheses and inhibit the pursuit of alternative hypotheses, regardless of relative likelihood. These findings contribute to the growing anthropological and science and technology studies (STS) literature on the epistemic communities that coalesce around suspected NEID outbreaks and highlight an urgent need for greater scrutiny of core epidemiological processes.

Seeking exposure: conversions of scientific knowledge in an African city.

Transnational medical research has become a common feature in many parts of Africa. This paper explores the contribution such activity makes to the social and economic lives of those involved, including both trial subjects and local staff. By considering the value of the 'exposure' that involvement brings to staff and research participants, we reflect on the conversion of scientific knowledge into practical knowledge and its value to sustaining precarious livelihoods in an economically fragile city. We consider the interplay between science and sociality and argue for a need to take seriously the circulation of scientific knowledge beyond the confines of expert spaces.

A home for science: The life and times of Tropical and Polar field stations.

A 'halfway house' between the generic, purified space of the laboratory and the varied and particular spaces of the field, the field station is a controlled yet uncontained setting from which nature can be accessed and anchored. As living quarters for visiting scientists, field stations are also enmeshed in the routine and rhythms of everyday domestic life, and in longer cycles of habitation, wear, and repair. This introduction considers the empirical and conceptual significance of Polar and Tropical field stations as homes for scientific work and scientific lives. The field station's extra-territorial yet intimate character affects the credibility and circulation of knowledge along science's frontiers. The challenge of making a home in the (non-temperate) field and the mundane experiences of expatriation and appropriation establish particular political dynamics of knowledge-making in these locations. They bring into focus the imaginaries of nature and science that drive transnational research and put into relief the aesthetic and affective dimensions of work and life in these distant homes for science. All these themes are pursued and amplified in a different medium by the artists who contributed to our research and are also featured in this special issue.

Field station as stage: Re-enacting scientific work and life in Amani, Tanzania.

Located high in Tanzania's Usambara Mountains, Amani Hill Station has been a site of progressive scientific endeavours for over a century, pushing the boundaries of botanical, zoological and medical knowledge, and providing expertise for imperial expansion, colonial welfare, national progress and international development efforts. The station's heyday was from the 1950s to the 1970s, a period of global disease eradication campaigns and the 'Africanization' of science. Today, Amani lies in a state of suspended motion. Officially part of a national network of medical research stations, its buildings and vegetation are only minimally maintained, and although some staff report for duty, scientific work has ceased. Neither ruin nor time capsule, Amani has become a quiet site of remains and material traces. This article examines the methodological potentials of re-enactment - on-site performances of past research practices - to engage ethnographically with the distinct temporalities and affective registers of life at the station. The heuristic power of re-enactment resides in its anachronicity, the tensions it introduces between immediacy and theatricality, authenticity and artifice, fidelity and futility. We suggest that re-enacting early post-colonial science as events unfolding in the present disrupts straightforward narratives about the promises and shortfalls of scientific progress, raising provocative questions about the sentiments and stakes of research in 'the tropics'.

Engaging communities to strengthen research ethics in low-income settings: selection and perceptions of members of a network of representatives in coastal Kenya.

There is wide agreement that community engagement is important for many research types and settings, often including interaction with 'representatives' of communities. There is relatively little published experience of community engagement in international research settings, with available information focusing on Community Advisory Boards or Groups (CAB/CAGs), or variants of these, where CAB/G members often advise researchers on behalf of the communities they represent. In this paper we describe a network of community members ('KEMRI Community Representatives', or 'KCRs') linked to a large multi-disciplinary research programme on the Kenyan Coast. Unlike many CAB/Gs, the intention with the KCR network has evolved to be for members to represent the geographical areas in which a diverse range of health studies are conducted through being typical of those communities. We draw on routine reports, self-administered questionnaires and interviews to: 1) document how typical KCR members are of the local communities in terms of basic characteristics, and 2) explore KCR's perceptions of their roles, and of the benefits and challenges of undertaking these roles. We conclude that this evolving network is a potentially valuable way of strengthening interactions between a research institution and a local geographic community, through contributing to meeting intrinsic ethical values such as showing respect, and instrumental values such as improving consent processes. However, there are numerous challenges involved. Other ways of interacting with members of local communities, including community leaders, and the most vulnerable groups least likely to be vocal in representative groups, have always been, and remain, essential.

INTRODUCTION: SUSTAINING THE LIFE OF THE POLIS.

How are publics of protection and care defined in African cities today? The effects of globalization and neo-liberal policies on urban space are well documented. From London to São Paulo, denationalization, privatization, offshoring and cuts in state expenditure are creating enclaves and exclusions, resulting in fragmented, stratified social geographies (see Caldeira 2000; Ong 2006; Harvey 2006; Murray 2011). 'Networked archipelagoes', islands connected by transnational circulations of capital, displace other spatial relations and imaginaries. Spaces of encompassment, especially, such as 'the nation' or simply 'society' as defined by inclusion within a whole, lose practical value and intellectual purchase as referents of citizenship (Gupta and Ferguson 2002; Ferguson 2005). In African cities, where humanitarian, experimental or market logics dominate the distribution of sanitation and healthcare, this fragmentation is particularly stark (see, for example, Redfield 2006, 2012; Fassin 2007; Bredeloup et al. 2008; Nguyen 2012). Privilege and crisis interrupt older contiguities, delineating spaces and times of exception. The 'public' of health is defined by survival or consumption, obscuring the human as bearer of civic rights and responsibilities, as inhabitants of 'objective' material worlds 'common to all of us' (Arendt 1958: 52). Is it possible, under these conditions, to enact and imagine public health as a project of citizens, animated in civic space?

STUCK IN RUINS, OR UP AND COMING? THE SHIFTING GEOGRAPHY OF URBAN PUBLIC HEALTH RESEARCH IN KISUMU, KENYA.

Since the Second World War, the Kenyan city of Kisumu has been an important site of medical research and public health interventions - on malaria and other vector-borne diseases, and lately on HIV and related infections. This article compares the work and lives of two generations of local workers in public health research, each central to science in the city at their time: staff of the Ministry of Health's Division of Vector Borne Disease (DVBD) in the decades after independence, and temporary employees of the Kenyan Medical Research Institute (KEMRI) in its collaboration with the US government's Centers for Disease Control and Prevention (CDC) in the early twenty-first century. Against the backdrop of changes to the city, which stagnated during the 1970s and 1980s, became an epicentre of the East African AIDS epidemic, and underwent an economic boom of sorts from the late 1990s - at least partly driven by HIV research and intervention programmes - the article examines the spaces and movements of health research workers, and their experience of the city in time. The now elderly DVBD workers' accounts are pervaded by memories of anticipated progress and the convergence of life and work in the civic wholes of nation and city; by chagrin about decay; and by nostalgia for lost hopes. Today's young KEMRI/CDC workers' short-term contracts, and the fragmented city they inhabit and study, make for less bounded and predictable spaces and temporalities. Their urban lives and work take shape between remainders and remembrances of past projects, the exhaustion of everyday struggles to make a living and a meaningful life, and the search for new forms of urban order and civic purpose.

Depuis la Seconde Guerre mondiale, la ville kenyane de Kisumu est un haut lieu de la recherche médicale et des interventions en santé publique, notamment pour le paludisme et autres maladies transmises par un vecteur, et plus récemment le VIH et infections associées. Cet article compare le travail et l'existence de deux générations de travailleurs locaux impliqués dans la recherche en santé publique, chacune occupant à son époque un rôle central pour la science dans la ville : des employés du DVBD (Division of Vector Borne Disease, département du ministère de la Santé responsable des maladies transmises par vecteur) durant les décennies qui ont suivi l'indépendance, et des employés temporaires de l'institut de recherche médicale KEMRI (Kenyan Medical Research Institute) dans le cadre de sa collaboration avec le CDC (Centers for Disease Control and Prevention, département américain responsable du contrôle et de la prévention des maladies) au début du vingt-et-unième siècle. Avec en toile de fonds les changements intervenus dans la ville qui a connu une période de stagnation dans les années 1970 et 1980 avant de devenir un épicentre de l'épidémie de SIDA en Afrique de l'Est et de connaître un certain essor économique à partir de la fin des années 1990 (insufflé, du moins en partie, par les programmes d'intervention et de recherche sur le VIH), l'article examine les espaces et les mouvements des travailleurs de recherche en santé, et leur expérience de la ville. Les récits des employés du DVBD, aujourd'hui âgés, sont imprégnés de souvenirs de progrès attendu et de convergence de la vie et du travail dans la totalité civique de la nation et de la ville, de dépit face au déclin, et de nostalgie d'espoirs perdus. Les contrats à court terme des jeunes employés du KEMRI/CDC, et la ville fragmentée dans laquelle ils habitent et étudient aujourd'hui, se traduisent par des espaces et des temporalités moins délimités et prévisibles. Leur existence et leur travail dans la ville prennent forme entre ce qu'il reste des projets passés et de ce que l'on en retient, l'épuisement d'une lutte quotidienne pour la subsistance et une existence décente, et la quête de nouvelles formes d'ordre urbain et de sens civique.

'Transport to Where?': Reflections on the problem of value and time à propos an awkward practice in medical research.

Based upon Kenyan ethnography, this article examines the gap between the bioethics aversion to value transfers in clinical trials, and research participants' and researchers' expectations of these. This article focuses upon so-called 'transport reimbursement' (TR): monetary payments to participants that are framed as mere refund of transport expenses, but which are of considerable value to recipients. The interest in this case lies not so much in the unsurprising gap between regulatory norms and poor study subjects' lives, but in the way in which this discrepancy between bioethical discourse and materialities of survival is silenced. In spite of the general awareness that TR indeed is about the material value of research, about value calculation, and expectations of return, it is not publicly discussed as such - unless ironically, in jest, or in private. This double-blindness around 'reimbursement' has provoked discussions among ethicists and anthropologists, some of which propose that the work that generates scientific value should be recognised as labour and participants, accordingly, paid. Here, this paper argues that such a re-vision of trial participation as work rather than as a gift for the public good, risks abrogating the possibility of 'the public' that is not only a precondition of public medical science, but also its potential product. The supposedly radical solution of tearing away the veils of misrecognition that 'free' gifting ideology lays upon the realities of free labour, though analytically plausible, fails to recognise the utopian openings within clinical trial transactions that point beyond the present - towards larger forms of social association, and towards future alignments of scientific possibilities and human lives.

Active compounds and atoms of society: plants, bodies, minds and cultures in the work of Kenyan ethnobotanical knowledge.

This paper examines a sequence of investigations in parasitology, botany, pharmacology, psychometrics and ethnopsychology focused on Kenyan village children's knowledge of medicinal herbs. We follow this work of making and ordering of knowledge, showing that the different disciplinary perspectives on bodies, medicines, knowledges, children and cultures produced by this research all sought the foundation of knowledge in reference to objective reality, and that they aimed to make the world known in the specific form of distinct and comparable entities with individual properties and capacities. Based on subsequent ethnographic observations of healing in the same village, we outline a different, contrasting modality of knowing, which places ontology above epistemology. Medicinal knowledge and its transformational capacity are here not located within entities but between them; not in objective reality but in effects; 'to know' means 'to come together' with the implication of having an effect on one another. We use this ethnographic sketch of a different form of knowing as a foil against which to contrast the imaginary that had shaped our previous research. Beyond the stark contrast between herbal village healing and pharmacological laboratory analysis, we expand our argument by moving from natural science to social science, from studies of plants and substances to those of humans, minds and cultures; from laboratories to ethno-psychological tests, cultural models, and eventually econometrics. We suggest that by reiterating a particular scientific imaginary, remaking humans (and non-human beings) as known things, a specific notion of man and a related political economy of knowledge is naturalized. Looking back at our involvement with this sequence of research, we realize that, contrary to our intentions, our inclusion as 'social scientists' into a multidisciplinary scientific project may have exacerbated rather than mitigated its potentially problematic effects.

The effect of iron and multi-micronutrient supplementation on Ascaris lumbricoides reinfection among Zambian schoolchildren.

A randomised, placebo-controlled, double-blind trial was conducted among schoolchildren in Chawama, Lusaka, Zambia, to determine the effect of iron and multi-micronutrients on reinfection with Ascaris lumbricoides. Supplementation was given on every school day for 10 months. Baseline A. lumbricoides prevalence and geometric mean intensity among positives were 43.4% and 2526 eggs per gram (epg) faeces, respectively. Serum ferritin <12microg/l was associated with higher egg counts than serum ferritin >or=12microg/l (4728 vs. 2036epg, P=0.033). Of 406 children recruited, 378 (93.1%) were examined at baseline and all infected children were treated and cure ascertained. The mean number of tablets taken per week was 2.5, giving 50% compliance. At six months 283 (74.9%) children complied, and reinfection intensities in those receiving iron were lower than in those receiving placebo (1600 vs. 3085epg, P=0.056). This effect disappeared at 10 months, where 215 (56.9%) complied. Iron had no effect on A. lumbricoides reinfection rates and multi-micronutrients had no effect on reinfection rates or intensities. Iron appears to affect reinfection intensity with A. lumbricoides, but further investigations are required to confirm this effect and elucidate the mechanisms involved.

'He is now like a brother, I can even give him some blood'--relational ethics and material exchanges in a malaria vaccine 'trial community' in The Gambia.

This paper explores social relations within the 'trial community' (staff and volunteers) of a Malaria Vaccine Trial (MVT), implemented by the Medical Research Council (MRC) in The Gambia between 2001 and 2004. It situates ethical concerns with medical research within the everyday life of scientific fieldwork. Based upon discussions with volunteers and staff, we explore processes of mediation between scientific project and study population, and between formal ethics, local ethical debates and everyday practice. We observe that material contact and substantial transactions, notably of blood and medicine, are central to the construction of the MVT. These transactions are guided by a concrete and relational form of ethics, which contrasts with the abstract and vertical formal ethical principles underwriting the scientific study protocol. The success of the MVT owed much to these kinship-like ethics. One possible conclusion from these observations is that research ethics should be understood, not just as a quasi-legal frame but also as an open, searching movement, much in the same way that kinship is not merely a juridical institution and a prescriptive frame of rules, but a network made through relational work. However, this conclusion raises new problems: by contrasting formal, abstract principles to intimate, immediate relations, and economic justice to personal morality, we accept that the order of medical research is moved further out of the public and political, and into the domains of either quasi-legal claims or of private morality. Irrespective of the undeniable importance of clear-cut rules and of good face-to-face relations, a third essential foundation of medical research ethics is the democratically constituted public sphere, including equitable health services, and transparent institutions to facilitate open debate and regulate particular interests. Ultimately, the ethics of global science can rely neither on principles nor trust but requires citizenship and democratic government.

Ethics and the ethnography of medical research in Africa.

The ethics of medical research have grown as an area of expertise and debate in recent years, with two broad approaches emerging in relation to transnational research: (1) the refinement of guidelines and strengthening of review, processes primarily to protect the right of individual research participants and strengthen interpersonal relations at the micro-level; and (2) considering more centrally, as crucial ethical concerns, the wider interests of whole populations, the functioning of research institutions, the processes of collaboration, and the ethics of inequitable international relations. We see the two areas of debate and action as complementary, and believe that social science conducted in and around transnational medical research environments can bring these two perspectives together in a more 'situated ethics' of research. To explore this idea for medical research in Africa, we organized a conference in December 2005 in Kilifi, Kenya. In this introduction we outline the two emerging approaches to medical ethics, summarise each of seven papers selected from the conference for inclusion in this special issue on ethics and ethnography, and finally highlight two areas of lively debate at the conference itself: the appropriateness and value of ethics guidelines and review boards for medical research; and the ethical review of social science research. Together, the papers and debates point to the importance of focusing on the ethics of relationships and on justice in both biomedicine and social science research, and on giving greater voice and visibility to the field staff who often play a crucial and under-supported role in 'doing ethics' in the field. They also point to the potential value of social science research on the range of relationships operating at different levels and time scales in medical research, including those surrounding community engagement activities, and the role and functioning of ethics review boards. We conclude by highlighting the ethical priority of capacity strengthening in medical research, social science and research ethics in Africa to ensure that local and national priorities and concerns are considered at both the micro and macro levels.

The relationship of acceptance or denial of HIV-status to antiretroviral adherence among adult HIV patients in urban Botswana.

Adherence to antiretroviral therapy among HIV patients is the most important patient-enabled factor related to virological failure and can lead to drug resistance. It is important to avoid virological failure, especially in resource-limited settings where treatment options are limited and the effects of treatment failure are profound. This qualitative study aimed to identify the psycho-social factors related to adherence behaviour in Gaborone, Botswana, a high prevalence setting in southern Africa. One-to-one, in-depth interviews were conducted with adult antiretroviral patients in the private and public health sectors who had been on antiretroviral therapy for a minimum of 6 months. A grounded theory approach was adopted and patients were selected purposively and theoretical sampling determined the final sample size. Thirty-two patients were interviewed, 22 from the public-sector, the mean age was 9.5 years and 53% were women. We found that acceptance of HIV-status, the ability to avoid internalising stigmatising attitudes and identification of an encouraging confidante were key factors related to good adherence. Encouraging confidantes (including clinicians) and contributed to promoting hope and acceptance of HIV-status, enabling patients to develop a positive therapeutic relationship with their antiretrovirals and make lifestyle changes that promoted adherence. Active participation in a social network and a desire to avoid being thin and visibly identifiable as HIV-positive were also adherence-motivating factors. Conversely, participants who expressed some degree of denial about their HIV-status tended to express emotions associated with depression, and internalised stigma that inhibited the development of a relationship with a confidante. We feel it is important to identify individuals with HIV who are still in some degree of denial about their status and to identify depression among patients on antiretrovirals. This will enable more targeted, individualised support in the management of individuals' HIV disease.

Geophagy among pregnant and lactating women in Bondo District, western Kenya.

Geophagy was studied among 827 pregnant women in western Kenya, during and after pregnancy. The women were recruited at a gestational age of 14-24 weeks and followed-up to 6 months post-partum. The median age (range) of the women was 23 years and median parity 2. At recruitment, 378 were eating earth, of which most (65%) reported earth-eating before pregnancy. The preferred type of earth eaten was soft stone, known locally as odowa (54.2%) and earth from termite mounds (42.8%). The prevalence remained high during pregnancy, and then declined to 34.5% and 29.6% at 3 and 6 months post-partum respectively (P < 0.001). The mean daily earth intake was 44.5 g during pregnancy, which declined to 25.5 g during lactation (P < 0.001). A random sample of 204 stools was collected from the women and analysed for silica content as a tracer for earth-eating. The mean silica content was 2.1% of the dry weight of stool. Geophagous women had a higher mean silica content than the non-geophagous ones (3.1% vs. 1.4%, P < 0.001). Faecal silica and reported geophagy were strongly correlated (P < 0.001).

Effects of iron and multimicronutrient supplementation on geophagy: a two-by-two factorial study among Zambian schoolchildren in Lusaka.

Geophagy has been associated with iron deficiency and anaemia, but no causal relationship has been established. To clarify this, we conducted a two-by-two factorial randomised, controlled trial on the effect of iron and multimicronutrient supplementation on geophagy in Zambian schoolchildren in Lusaka, from February to December 2001. Of the 406 children, 212 (52.2%) were girls and the mean (range) age was 10.2 (7-15) years. Geophagy was reported by 302 (74.4%) and more often in girls than in boys (80.2 vs. 67.7%, P = 0.007). The mean (range) daily earth intake was 25.2 (1-200) g. Geophageous children had more often geophageous relatives than non-geophageous children (79.5 vs. 1.9%, P < 0.001). Geophageous children had lower serum ferritin (20.5 vs. 25.0 microg/l, P = 0.032) but not haemoglobin (Hb) (129.2 vs. 130.4 g/l, P = 0.59), than non-geophageous. Among those with Hb < 130 g/l, geophageous children had significantly higher prevalence (53.7 vs. 30.6%, P = 0.024) of Ascaris lumbricoides infection than non-geophageous. The prevalence of geophagy (74.4 to 51.6%) and the intake of earth (25.3 to 15.0 g/day) declined (P = 0.001 and P < 0.001, respectively) among the 220 (54.2%) children followed-up. In bivariate analysis, non-iron supplementation reduced the prevalence of geophagy more than iron supplementation did, but this was not confirmed in the multiple logistic regression analysis. Multimicronutrients had no effect on either geophagy prevalence or earth intake. Geophagy was prevalent and associated with iron deficiency, but iron supplementation had no effects on geophageous behaviour. Geophagy could be a copied behaviour and the association between geophagy and iron deficiency due to impaired iron absorption following earth eating.

Effects of multimicronutrient supplementation on helminth reinfection: a randomized, controlled trial in Kenyan schoolchildren.

A randomized, placebo-controlled, double-blind, two-by-two factorial trial was carried out among 977 schoolchildren from 19 primary schools in Nyanza Province, Kenya from February 1995 to February 1996. The interventions were multimicronutrient supplementation (vitamin A, 1000 micrograms; vitamin B1, 1.4 mg; vitamin B2, 1.6 mg; vitamin B6, 1.7 mg; vitamin B12, 2.0 micrograms; folate, 150 micrograms; niacin, 16 mg; vitamin C, 50 mg; vitamin D, 5 micrograms; vitamin E, 8 mg; iron, 18 mg; zinc, 20 mg; copper, 2.0 mg; iodine, 150 micrograms; selenium, 40 micrograms) and multihelminth chemotherapy (albendazole 600 mg in a single dose and/or praziquantel 40 mg/kg in a single dose). This paper reports the effects of the supplementation given on all school days on reinfection with hookworm, Ascaris lumbricoides, Trichuris trichiura and Schistosoma mansoni after 11 months. Baseline prevalence and geometric mean intensity for hookworm, A. lumbricoides, T. trichiura and S. mansoni in all children investigated were 54.7%, 13.8%, 45.6% and 70.0%, respectively and 8.6, 2.7, 5.9 and 19.4 eggs per gram (epg), respectively. Children received a mean of 2.3 multimicronutrient/placebo tablets per school week, giving a compliance rate of 46%. Children given multimicronutrients had a slightly, but significantly, lower intensity of S. mansoni reinfection compared with children given placebo (5.5 epg vs. 7.7 epg, P = 0.047). Multiple linear regression analyses controlling for baseline infection status confirmed this, as children who received micronutrients were reinfected with S. mansoni at only 69% of the intensity of those who received placebo. Multiple logistic regression analyses revealed that micronutrient supplementation was associated with a lower S. mansoni reinfection rate (odds ratio = 0.7) although this was only of borderline significance (P = 0.090). There were no significant differences in reinfection rates or intensities of hookworm, A. lumbricoides and T. trichiura. The effect on S. mansoni infection intensity is particularly interesting given the low compliance, suggesting that full micronutrient supplementation might have a role to play in S. mansoni control programmes.

Geophagy and its association with geohelminth infection in rural schoolchildren from northern KwaZulu-Natal, South Africa.

The social pattern of geophagy (soil-eating) and its possible role in the transmission of Ascaris lumbricoides, Trichuris trichiura and hookworm were investigated in a rural area of South Africa between March 1998 and July 1999. Schoolchildren (median age = 10.7 years; interquartile range 8.3-14.8 years) were examined for geohelminth infection at baseline and re-examined 3 and 29 weeks after treatment with albendazole. Interviews were conducted with the pupils in order to find out about their socio-economic background and their behaviour regarding geophagy. Soil-eating was less frequent in boys (39%), where it decreased with age, than in girls (53%), where no such age trend was apparent. The habit was more common in children from families of higher socio-economic status. The baseline prevalence of A. lumbricoides infection was higher in pupils who regularly ate soil from termite mounds (28%) when compared with non-geophageous pupils (19%; prevalence ratio (PR) = 1.46; 95% confidence interval (95% CI) 1.04-2.03). In contrast it was markedly lower in the groups who preferred eating tree termite soil (13%; PR = 0.67; 95% CI 0.43-1.04) or soil from other sources (8%; PR = 0.40; 95% CI 0.15-1.04). This pattern was still apparent after adjusting for possible confounders and was also found when analysing A. lumbricoides reinfection. In contrast, differences in prevalence of T. trichiura and hookworm infection between groups with different soil preference were small.