ARTIGO ARTICLE 461 Epidemiologists working together with anthropologists: lessons from a study to evaluate the epidemiological impact of a city-wide sanitation program Epidemiologistas e antropólogos trabalhando juntos: lições de um estudo para avaliar o impacto epidemiológico de um programa de saneamento urbano Los epidemiólogos y antropólogos que trabajan juntos: lecciones de un estudio para evaluar el Cristina Larrea-Killinger 1,2 Rita Franco Rego 3 impacto epidemiológico de un programa de Agostino Strina 4 saneamiento urbano Mauricio L. Barreto 4 Abstract Resumo 1 Departament This paper discusses the role of qualitative ap- Este artigo discute o papel das abordagens qua- d’Antropologia Cultural i Història d’Amèrica i Àfrica, proaches in epidemiological studies, beginning litativas em estudos epidemiológicos, começando Universitat de Barcelona, with a general discussion of epidemiological and com uma discussão geral de ambos os métodos. Barcelona, España. anthropological methods. It focuses on a case Centra-se em um estudo de caso sobre o impac- 2 Programa de Pós-graduação em Saúde, Ambiente e study of the health impact of an environmental to na saúde de uma intervenção ambiental em Trabalho, Universidade intervention carried out in Salvador, Bahia State, Salvador, Bahia, Brasil. A maioria de estudos Federal da Bahia, Salvador, Brazil. Most of the precedent studies fields, based nesta linha, que derivam de pesquisas de fonte Brasil. 3 Faculdade de Medicina, on primary date, use to devote little attention to primária, traz pouca discussão sobre as questões Universidade Federal da the methodological and theorethical questions at- metodológicas e teóricas envolvidas em estudos Bahia, Salvador, Brasil. tached to long-term studies. Four specific aspects em longo prazo. Quatro aspectos específicos des- 4 Instituto de Saúde Coletiva, Universidade Federal da of this experience are highlighted: (a) drawing up sa experiência são especialmente destacados: (a) Bahia, Salvador, Brasil. epidemiological study; (b) construction of an ob- elaboração de questionários para o estudo epide- servational instrument to measure hygiene hab- miológico; (b) construção de um instrumento ob- Correspondence C. Larrea-Killinger its; (c) an ethnographic study that was carried out servacional para medir os hábitos de higiene; (c) Departament d’Antropologia before the epidemiological study; (d) observation um estudo etnográfico que antecedeu a pesqui- Cultural i Història d’Amèrica i Àfrica, Universitat de of the effects of health intervention on health in- sa epidemiológica; (d) observação dos efeitos da Barcelona. equalities. Finally, the report details how the find- intervenção de saúde sobre as desigualdades de C/Miquel Reverter 9 (3-1), Sant ings of qualitative and quantitative studies might saúde. Finalmente, o estudo considera em deta- Just Desvern, Barcelona 08960, España. be synthesized. It provides a critical overview of lhe como os resultados dos estudos qualitativos e [email protected] follow-up strategies, illustrated with proper ex- quantitativos podem ser sintetizados. Ele fornece amples whenever possible. uma visão geral e crítica das estratégias de acom- panhamento, ilustrada, sempre que possível, com Medical Anthropology; Sanitation; Impacts on exemplos apropriados. Health Antropologia Médica; Saneamento; Impactos na Saúde Cad. Saúde Pública, Rio de Janeiro, 29(3):461-474, mar, 2013 462 Larrea-Killinger C et al. Introduction individuals who get ill and collective represen- tations of these processes. Despite the fact that A brief look at the history of social medicine medical anthropology seldom establishes gen- suggests that, at least in principle, epidemiol- eralized rules apt to explain human behavior in ogy and anthropology are natural allies in study- relation to the health-disease-care process, it al- ing diseases in human populations. Despite its lows more careful interpretations of this behavior conceptual and methodological evolution over within specific sociocultural contexts, as well as recent decades, however, modern epidemiology intercultural comparisons. has been subject, mainly from social sciences, The qualitative approach to the reality of the to a variety of criticisms, especially in relation to sociocultural contexts in which subjects live is its capacity to make significant contributions to- what leads anthropology to be sought by epide- wards understanding and solving the complex miologists, but, at the same time, to be turned health problems of populations. As a possible so- down, because of the lack of so-called “scientific lution to this theoretical and methodological in- rigor” as far as the theoretical and conceptual ertia, some authors have proposed to advance on bases of epidemiology. an interdisciplinary type of approach, through Anthropologists and epidemiologists have greater empirical proximity between epidemi- different ways to study the social and cultural ologists and anthropologists 1,2. context in their investigations. Anthropological The search for a wider-ranging comprehen- fieldwork relies on the principle of reflexivity 12, sion involving elements of high complexity with- which is often discarded when epidemiological in the health-disease process has not been com- data are collected, on the assumption that epide- pletely forgotten as an aspiration in epidemiol- miologists should adopt a neutral role through- ogy. Some authors 1,2,3,4 have indicated studies out the investigative process. According to an- with interdisciplinary or transdisciplinary ap- thropologists, epidemiologists are more distant proaches, or adopting multiple methods (trian- from the events investigated, and transform the gulation), as a means of empirical approxima- participants’ lives into a mere set of numerical tion to comprehend complex questions. variables, without any relationship with their so- Twenty-first century epidemiology would cial and cultural context 7. benefit from concentrating on integration of Anthropologists usually carry out their inves- concepts and methods from other disciplines tigations separately from other researchers and into the field social and human sciences, such as closer to the participants. This leads them, on anthropology, in order to comprehend new com- the one hand, to a greater commitment to the re- plexities by placing the center of analysis on the search subjects, and on the other hand, to a great- subject’s experience and the sociocultural con- er care in discussing, analyzing, and presenting text within which this experience is produced. data. Traditional anthropology requires spending Interdisciplinarity arises from recognition of the a significant amount of time in the field, usually limitations that a single field of knowledge has living together a population for years, and indi- with regard to solving wide-ranging and complex vidual authorship is more likely a result of scien- problems 3. tists studying a population by themselves, rather than unwillingness to share findings. In the epi- demiological approach the relationship between Collaboration between epidemiology the subjects and their social context is captured as and anthropology quantitative variables that must be collected in the same manner by all interviewers. Consequently, Studies of health-disease-care processes pro- teamwork strategies are developed within epi- duced through integration of epidemiology demiology, and these facilitate the discussion and anthropology started to become a reality and interchange of information published in sci- more than two decades ago. A body of literature entific articles with multiple authorship. These 5,6,7,8,9,10 has indicated contributions and limits of differences in the investigative modus operandi this integration in theoretical and methodologi- between these two fields of knowledge become cal development. In fact, interdisciplinary col- more evident during interdisciplinary practice. laboration, which was more apparent than real in Despite of conceptual and methodological, and the past, started to become more effective in the offered, in order to some authors have demon- twentieth century, especially during the 1980s 11. strated profitable experiences of collaboration be- Medical anthropology provides a compre- tween these two disciplines 1. hensive approach to interpreting the human Especially to study the impact of health inter- processes of falling ill by taking into account ventions on behavioral changes. Several theoreti- the combination of subjective interpretations of cal models have been proposed in health studies, Cad. Saúde Pública, Rio de Janeiro, 29(3):461-474, mar, 2013 EPIDEMIOLOGISTS WORKING TOGETHER WITH ANTHROPOLOGISTS 463 traditionally more concerned with how social historical origin of the analysis categories into cognitive models affect individual rather than consideration, thus limiting comparisons and in- community changes. For this reason, the aim of terpretations of the processes of becoming ill. using a more collaborative approach to under- Menéndez 7 highlighted epidemiological re- stand public health interventions is to explore ductionism and Almeida Filho 17 considered that critically the dimensions of culture 13. lack of theoretical validation for concepts that It should be emphasized that in both these epidemiology borrows from other disciplines disciplines, theoretical and methodological ef- favors uncritical and instrumental incorpora- forts have been made towards expanding col- tion of these concepts, thereby reducing them laboration,