Holly High is Associate Professor of Anthropology at the University of Sydney and has been working in Laos for 20 years. This was her sixth visit to Kandon, an ethnic Kantu village in south-eastern Laos, and she wanted to settle in for five months to factcheck a book and observe how women gave birth, which was usually rapid and often at night.
Ed Annand specialises in treating horses and was working towards his PhD in epidemiology, with an interest in zoonosis – infectious diseases that spread from animals to humans – and One Health, a multi-disciplinary approach to the interrelated health of humans, animals and the environment.
Their work in Laos was partly supported by a grant from the Sydney Social Sciences and Humanities Advanced Research Centre and the Marie Bashir Institute for Infectious Diseases, and High gave this interview for SSSHARC in February 2020 as coronavirus was spreading around the world.
“There’s not many cases where an outbreak of H5N1 has been observed by an epidemiologist from the beginning,” she said. “And it’s unusual to have an anthropologist observe a whole outbreak and observe an epidemiology response.”
Hoping to feed their children, aged 2 and 4, with fresh eggs and meat, the couple bought four chickens from a market 30 kilometres from Kandon and a neighbour agreed to keep them with her chickens. When one died two days later, they assumed it was from heat stress, but within days the other died and the neighbour’s chickens were becoming sick and dying.
After consulting the owner and the village chief, Annand contacted epidemiology and veterinary colleagues in Australia, who put him in touch with Lao experts, and he sent samples by bus for testing in Vientiane. Within 24 hours, the laboratory had confirmed Highly Pathogenic Avian Influenza (HPAI) H5N1. Genetic sequencing by the Australian Research Laboratory later linked the virus to other Asian outbreaks that could be traced back to China.
This was the first confirmed outbreak in south-eastern Laos, but two people elsewhere in the country were reported as dying from H5N1 in 2018. Unlike coronavirus (COVID-19), H5N1 is not readily transmitted between humans. However, since the first human death in Hong Kong in 1997 the disease has been detected in 16 countries and confirmed as the cause of 860 human deaths and millions of poultry deaths. The greatest risk is to people handling poultry, and the fear is that the virus could mutate to become highly transmissible between humans.
Annand decided it was essential to cull the rest of the flock, which he did reluctantly and carefully. High’s expertise kicked in as she recorded interviews and observed a range of responses to the outbreak.
People in the village told her chickens were always dying and they didn’t worry much, often eating the dead birds, but they never bought chickens from the disease-ridden market. They were more concerned about the chemicals sprayed later by agricultural staff.
The district vet told Annand and High they should have reported the outbreak to them and ordered them not to take any further action. An epidemiological team from Vientiane declared the village the “red zone” of the outbreak but cleared the market of any risk.
At a village meeting, health staff advised residents not to eat dead chickens and to seek medical attention if they had flu-like symptoms. Some were sick with coughs, colds and flu, which they said was normal at “change of season”. The officials seemed to blame the villagers for not reporting their illness.
Local attitudes were also influenced by beliefs in the power of spirits and fate, personal and social responsibility. Before High left the village months later, she apologised again to her neighbour. She learnt that the spirits of the house had been offended when the chickens were put in the neighbour’s yard, because in the first year of construction things should enter a house but not leave. The spirits had caused the outbreak to teach that lesson.
In a narrative account of the outbreak, which she hopes will become part of a book-length ethnography, High analysed the various responses, including Annand’s decision to cull and her own anxiety for her family.
She concluded: “For all their speculativeness, the timescapes of pandemic preparedness seem to produce an odd kind of certainty in the people who subscribe to them: this is the certainty that something must be done, and urgently. Grisly imaginings of a possible viral attack draw our attention and care. Pandemic preparedness works through emotions, not least of which is fear.
“If there is one lesson I have taken from the outbreak as I saw it experienced by my neighbours…it is this: outbreaks are an occasion to ask, in the relational-reparative mode, ‘how have we been relating to one another, to animals, and to things? And how can we respond in a way that acknowledges that our lives reverberate in and depend on these wider relationships?’ ”
High also co-wrote a paper with Annand and other scientific experts in Australia, Laos and elsewhere, which reports in detail the process of detection and the “potential for improved surveillance and management in endemic regions”.
In 2019 they held a workshop with SSSHARC and the Marie Bashir Institute (MBI) where they discussed their experience with 20 participants including Jonathan Happold from Ausvet, an epidemiological consultant, who spent a month as a visiting fellow at Sydney University and “tried to help us work out the difficulties and potentials of social scientists and epidemiologists working together”.
High has proposed to MBI a node on ethnography and epidemiology to bring together experts working at the intersection of infectious disease and human behaviour, culture, politics and economics.
“I think it is a problem in One Health that often the science is fairly clear, like with coronavirus: it didn’t take long for them to isolate the virus and start working on a vaccine,” she said. “The problem is the human side of things – the lack of reporting, inadequate surveillance, the politics of these things. People working in One Health express quite a lot of mystification about why local people don’t just do X, Y or Z.”
There are, however, challenges for working together across disciplines that “speak in different languages”. For an anthropologist, writing an article that recounts and analyses events is itself the outcome of the work, while an epidemiologist often aims to recommend guidelines or interventions.
“In social science there’s a freedom to talk about how things are rather than how they should be,” High said. “Anthropologists are better at pointing out what the problems are than what the solutions might be.”
In this case, epidemiology and anthropology together produced a clear result. High said: “The cultural perception is that these viruses are coming from wild animals and spill over to domestic animals and it’s somehow uncontrollable. But this showed it’s traceable back to industrialised agriculture where animals are farmed intensively, and travels through trade and into rural areas through rural markets, and this tallies up perfectly with what people in the village told me.
“Markets have become vectors of diseases coming out of China. That’s a very different story from ‘it comes from wild birds and infects village birds and village people are so ignorant and poor and dirty that they eat the birds anyway and exacerbate the spread’.”
This was not the first landmark virus Annand and High have uncovered together, she said with a laugh. “One of our first dates was interrupted with him being called out to a horse that he diagnosed as having lyssavirus, which was the first case of a rabies-like virus being diagnosed in an animal other than bats and humans in Australia.”
High traces her interest in Laos back to her parents, who were peace activists in the anti-Vietnam War movement. Laos, she thinks, always had a mystique because of the Americans’ scandalous “secret war” there, and Laos’ embrace of socialism. She did Asian Studies at high school and turned to Laos during her PhD because so little ethnography had been written about the country.
As a cultural anthropologist she became interested in how socialism was lived on the ground and adapted by village communities. Her first book, Fields of Desire, was about an ethnic Lao village that rebelled against the country’s socialist government but, by the time of High’s fieldwork, had shifted to a sense of resigned disgruntlement.
Her next book, Projectland, is about Kandon, the village that had the H5N1 outbreak. The people came from the highlands, where they had been fiercely independent traders and “brokers of difference” until French blockades left them in poverty. They were among the first to join the Ho Chi Minh cadre against the French in the 1940s and are held up as a socialist success story within Laos today.
In 2018 High brought a Belgian anthropologist to Sydney University to conduct an Ultimate Peer Review of Projectland. This process of critical reading and roundtable discussion, devised and funded by SSSHARC, was helpful in polishing the manuscript and speeding its acceptance by a publisher.
Despite her role as a professional observer, High saw signs while she was in Laos that she and Annand might help to change the response to future outbreaks of avian flu. As well as working with Lao experts and officials, she heard from a village chief that he had reported a dead chicken and had it tested in Vientiane. “He would never have done that before.”