The Cultural Contexts of Disease in Southeast Asia: Bile Duct Cancer in Northeast Thailand and Lao PDR

Type

Single Panel

Time & Location

Session 11
Fri 13:30–15:00 Room 1.403

Convener

Rachel Harrison University of London

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Papers

Co-Becoming in a Shore Zone: Human, Fish, Snail and Liver Fluke in the Shadow of Hydropower Development Visisya Pinthongvijayakul Australian National University

The prevalence of Cholangiocarcinoma (CCA), or bile duct cancer, is increasing around the world. The highest reported CCA incidence internationally is in Northeast Thailand (Isan), totaling 118.5 per 100,000 in Khon Kaen Province, which is some 100 times higher than the global rate. CCA in the region is associated with infection by the liver fluke (Opisthorchis viverrini) through raw fish consumption, a common dietary practice among villagers. Although major medical interventions have been attempted in recent decades to stop people from eating raw fish, the number of patients with bile duct infection and CCA has remained prominent.

The paper aims to look more broadly at biocultural assemblages of raw fish consumption in Isan. Drawing some literature on reservoir influences on disease transmission from parasitology and human geography into conversation with the naturecultural notion of “contact zone,” I explore my data on human and nonhuman lives around the fresh water shore in Khon Kaen. I argue that state’s infrastructural development that has shifted landscape and waterscape has spawned contact zones in which human, fish, snail, and liver fluke are mobilized and meet up. They become “messmates” as a result of dam construction. The paper shows that human health cannot be fully grasped without considering changes in ecologies and the assemblages of biocultural makeup in the region’s waterways.
Eating in Northeast Thailand: A Short Documentary Edoardo Siani Kyoto University

This short documentary explores the culture of eating in Northeast Thailand.
On Isan Villagers’ Understandings of Food and Health: A Critical Discourse Analysis Saowanee T. Alexander Ubon Ratchathani University

The Northeastern region of Thailand, known as Isan, is the poorest in the country. Its people are often looked down upon as ignorant and backward. It has also been the country’s political hotbed. In terms of health, Isan has the largest number of liver-fluke induced bile-duct cancer (Banchob & Chawalit, 2008). The main risk factor is consumption of cyprinoid fishes. To many Thais, Isan is not only a problem child, but also a sick one. Despite aggressive healthcare campaigns against raw fish consumption, many especially those from the lower echelon of the society, who have little choice when it comes to food, continue to practice this eating habit. Many of them are villagers living in areas where fresh cyprinoid fishes are available. The research was conducted in order to understand beliefs and values that contribute to people’s decision to eat raw fish. The data came from interviews with villagers living along the Mun River and observations of their daily-life routines. Interview data was analyzed for linguistic manifestations of deep-rooted sociocultural beliefs and assumptions about food and health.
Participatory Art and Self-Expression Workshops as Tools for Health Promotion Pierre Echaubard Mahidol University Rachel Harrison University of London

To date public health campaigns and medical engagement with patients in Thailand have been largely characterised by a top-down approach, in keeping with a more widespread, hierarchical social structure that tends to place rural citizens as socially inferior. This is reflected in interpersonal relations where open self-expression and agency among grassroots communities in formal contexts, such as engagement with local authorities, education and health officials, and even NGOs, has tended to be impeded. Furthermore, the relationship that pertains between the Thai state, centred in Bangkok, and the peripheral, rural hinterland of Isan is one of inequality, with the former deeming the latter to be culturally and civilisationally inferior (pa thuean). The practice of raw and fermented fish consumption that has long characterised Isan and Lao PDR is not shared by other regions of the country, which sees it as indicative of a lack of modernity and sophistication. The historically hierarchical nature of Theravada Buddhist society in Thailand has also tended to impede self-expression and agency among grassroots communities in formal contexts, such as engagement with local authorities, education and health officials.

While the difficulty of setting in place real and lasting grassroots engagement in public health campaigns in Thailand represents a significant barrier to sustainable health development, it also represents an opportunity to explore innovative and effective ways in which the voices of those deemed at risk can be expressed and listened to with respect. This paper describes a process through which new forms of self-expression ranging from visual arts, writing, filming, music play and self-reflection workshops are implemented in community contexts for actively involving grassroots communities in their own healthcare and well-being. The participatory process is described and analyzed. We also used a culturally contextualized version of Antonovsky’s Sense of Coherence SOC-13 questionnaire to: 1) initiate self-reflection and 2) assess a community’s sense of coherence used as a proxy for adaptive capacity and resilience. Comparing SOC among communities will help better understand how these forms of public engagement can be adapted and improved depending on the community’s SOC. The intended outcome of this work is to enable local communities in Isan and Lao PDR to contribute to and direct public health interventions in ways that are most meaningful to their everyday realities and health priorities.

Show Paper Abstracts

Abstract

Bile duct cancer (cholangiocarcinoma, abbreviated to CCA) is a rare disease in most parts of the world; but in the Mekhong delta areas of mainland South East Asia its high prevalence comes from chronic liver fluke infection. Medical evidence suggests that fluke infestation deriving from the centuries-old cultural tradition of eating raw, partially cooked or fermented river fish results in chronic bile duct inflammation leading to cancer in ca. 1–4% of cases. In Thailand this translates to around 20,000 deaths per year, with an estimated similar number in Lao PDR. The slow development of CCA remains asymptomatic until the later stages of the disease, as a result of which few can be effectively treated. It is also largely a disease of the poor and of rural communities who have little access to healthcare.

CCA frustrates medical specialists because the eradication of OV infection would prevent most cases altogether, hence saving thousands from dying a painful death. From their perspective, if only people would stop consuming raw fish, then the cancer rates would drop drastically. The complexity of the problem is not, however, solely a medical one. Much more, it is one that clearly requires a respectful and ethical engagement across disciplines and between people, recognizing our subjectivity as humans. The problem of CCA calls for interdisciplinary collaboration between medicine, the social sciences and the humanities – between the fields of public health and hygiene, epidemiology, parasitology, biochemistry, religious and spiritual belief patterns, history, geography, anthropology ecology, psychology, phenomenology, socio- linguistics, postcolonial theory, literature, the arts and cultural studies. But it also calls yet more urgently for an openness to dialogue and a willingness to listen to the Other. Decades of top-down public healthcare in Thailand have located the needs and cultural practices of rural rice-farming communities as irrelevant and symptomatic of a lack of “civilization”. And Bangkok-centric views of the regions affected by this disease can “classify” them almost sub-human. Only by fully and respectfully engaging with the grassroots populations that are most vulnerable to this disease – and to many others – can we make an ethical contribution to intervention.