Jeffrey Lesser

Director of the Halle Institute for Global Research and Learning at Emory University

Samuel Candler Dobbs Professor of History at Emory University's Department of History

Curriculum vitae

Personal website

Project
Metropolis, Migration and Mosquitoes: Historicizing Health Outcomes in São Paulo, Brazil
by Jeffrey Lesser (History) and Uriel Kitron (Environmental Sciences)

Objectives and Aims
What is the relationship between cultural attitudes, exposure to infectious diseases, and access to health care? Our project analyzes current disease patterns within a historical perspective in order to contribute to future preventive measures. By using paired neighborhoods in Sao Paulo that have historically had different incidences of, and responses to, mosquito-borne diseases, our project aims to create better health outcomes by analyzing how “health” is understood by both the populations and providers over time using new methodologies.  Furthermore, our project is tied to a new interdisciplinary course that will integrate classroom and field experiential learning.

The co-PIs have expertise in the urban environment, human migration, geography, ecology and epidemiology.  This enables us to analyze, over time, the spatial dynamics of migration, disease transmission, and response to illness using both a Historical Geographic Information Systems (HGIS) approach and a new methodology that we term “Epidemiological Ethnography.”  These two methods enable us to analyze jointly data that have traditionally been separated by discipline or approach.  HGIS, for example, allows us to plot incidence of disease, settlement patterns, poster campaigns focused on eradication, and health clinic construction over time because it works three-dimensionally.

Given the challenges that health interventions have faced with regard to mosquito control (whether community based or centrally applied) and the utilization of improved health care facilities, our project will provide alternative ways of understanding cultural obstacles to health care while creating novel strategies to overcome them.  This project has particular urgency as Chikungunya, a new mosquito-borne virus, entered northern Brazil last year and is likely to arrive in São Paulo this year.

To achieve our goals we will:

a. Investigate the century-long relationship between disease and prevention in two areas of São Paulo where internal and international migrant residential spaces are adjacent but divided, using new methods that allow us to link historical, ethnographic and epidemiological data.

b. Examine the disease ecology, demographic patterns and health discourses of Yellow Fever (19^th century), dengue (20^th century) and Chikungunya (21^st century) in our study neighborhoods, with interdisciplinary methodologies derived from epidemiological ethnography of living spaces and HGIS.

c) Teach an interdisciplinary course in the Spring semesters of Years II and III of the proposed fellowship, with an opportunity for student-faculty joint summer research in Brazil during the subsequent summers.  We will disseminate the research outcome and the teaching approach widely through proposals for a University Course, and for The Encounter with Evidence Lecture (sponsored by Emory’s Quality Enhancement Plan) for all the freshmen in Fall 2017.  In addition, we will share our findings with a global public via our Brazilian partners for who the question of disease prevention is much more than "academic."

Our interdisciplinary collaboration brings together vast experience in urban and disease ecology, migration, and Brazilian urbanization.  Our use of both epidemiological ethnography and Historical GIS integrates urban eco-epidemiology, history, anthropology, sociology and geography.  We propose to use these interdisciplinary methods jointly to address the following questions:

a) How have the histories of migration and local spatial development produced particular health patterns, in terms of disease and access to health care?
b) Can we discern patterns in the shared or contrasting experiences of the neighborhoods?  
c) How do elite perceptions of the neighborhoods (as foreign or dirty, for example) affect access to health care and interventions?  
d) What are the differences in reporting and in access over time?

Background and justification
Urban population growth is occurring around the world at unprecedented rates, and this has led to major shifts in social and economic systems, urban ecology, and human disease. In the proposed project we use a novel integrated approach drawing on methods from the humanities (historical analysis) and natural and social sciences (ecology, epidemiology) to answer questions about immigration, mosquito-transmitted diseases, and health outcomes.  . We will compare findings across two pairs of neighborhoods (See Figures 1a, 1b, 1c) with distinct immigration histories over the last one hundred years in São Paulo, Brazil, the largest city in the Western Hemisphere (See Figure 2). Results from this project will allow us to analyze health patterns within an urban environment, and how public health messages are conveyed.

Over the past century (and for millennia before) migrants, whether domestic or foreign, have been associated with disease outbreaks. While immigrant newcomers are often linked to contagion in the Americas, Brazil provides an important counter-example. In São Paulo, neighborhoods inhabited by foreign immigrants have traditionally been seen by the media, politicians and the elites as ascendant and modern, exemplifying social mobility and dynamism.  Adjacent areas inhabited largely by internal migrants from the impoverished Northeast are generally linked with disease and crime. This juxtaposition renders the study of disease particularly vibrant as the spaces are small, yet the discourses and outcomes so different.  Living on one side of a street or another may define how a person’s health status and risk are perceived and have an impact on their actual health status.

We propose to consider three specific viral diseases (Yellow Fever, Dengue, Chikungunya), all carried by the same house-dwelling mosquito, in these contained but demographically varied urban spaces. Our hypothesis is that images of different parts of single neighborhoods over the last century, as expressed by policy-makers, health care officials and the media, have a direct impact on both public (i.e., what people do at  home to prevent mosquito infestation) and formal (i.e., the ways in which state-sponsored disease prevention takes place) responses to disease.

Methods
Our project will approach health challenges in São Paulo through the use of two novel methodologies: Epidemiological Ethnography and Historical Geographic Information Systems (HGIS). These approaches provide both qualitative and quantitative information to aid informed decision-making and planning needed to create both viable and sustainable cities. Furthermore, these methods allow us to integrate data that in the past have been deemed the purview of one discipline or another.

We have selected two neighboring areas —Luz/Bom Retiro, with a joint population of 70,000 in 2010 and Liberdade/Cambuci, with a joint population of about 90,000—on the basis of a compelling relationship of disjuncture (Fundação Seade - Prefeitura de São Paulo, 2011). Each neighborhood has a section considered by the broad population as “foreign” and ascendant and another section deemed “Brazilian” and stagnant.  São Paulo is noted for its adjoining foreign-ascendant and Brazilian-impoverished areas and the urban patterns of ascendance adjoining stagnation are a feature of Brazil’s urban landscape, whether in Porto Alegre in the south, Belem in the north or Campo Grande in the west. Consequently, our approach will have applications for other cities in Brazil, and relevance beyond the geographical extent and specific diseases. Our interdisciplinary strategy will also have applications for other urban challenges.

The joint methodologies that we propose for this interdisciplinary project are novel.  By placing our epidemiological ethnographies on a historical axis we will gather rich, spatially-linked data from the past and present in order to speak to the future.  We will be asking questions about patterns of ‘Where?’, ‘When?’ and ‘Who?’, while seeking to understand the long-term mechanisms driving these patterns:

1) Historical GIS. This tool allows us to map quantitative data (e.g., demography, infrastructure planning, disease cases) against qualitative information (e.g., ‘sick’ vs. ‘healthy’ spaces) by allowing us to collect relevant information for landscape change and dengue transmission of São Paulo dating as far back as 1881.  By mapping cases of a mosquito-borne illness and health care facility construction over time we will test whether presumptions related to ethnicity and wealth have led to a disconnect between placement of health care facilities and interventions with the occurrence of actual outbreaks. We will map spaces historically presented by the public, politicians and the media as particularly sick or healthy using both archival data and by asking participants in our epidemiological ethnographies to take us on neighborhood tours.  We will couple humanistic techniques (analysis of discourse, biographical methods to document lives and ideas via personal documentary sources, lived experiences, media, and materials produced from political processes) with social science analytic approaches such as grounded theory to uncover data patterns and content analysis to determine the presence of certain words or concepts within historical texts.  We will use a GPS device to pinpoint neighborhood sites that they identify as significant in relation to health, and then synthesize this information into maps, and analyze the georeferenced databases.  Using HGIS will reveal – in both visual and interpretative ways – correlations between ideas about health, disease outbreaks, and disease control.

2) Epidemiological ethnographies. We have created a novel methodology in order to allow the co-researchers to collect both quantitative and qualitative data that will generate unique data.  Our long experience in the research neighborhoods means that we already have a wide range of contacts, from health officials, to residents, to small business people.  These contacts will aid us in making new contacts (the snowball method) so that we can gather oral and ethnographic data from residents of the neighborhoods about their own ideas about space and health. We plan to use a combination of structured interview questions (which we will code), open-ended conversations, and oral histories that will generate qualitative data.  As the research areas are small (See Figures 1a, 1b, 1c) we plan to speak to people on every street in each neighborhood.  Epidemiological analysis allows us to associate and contrast the geographical data, the historical data and the data collected through popular voices and interviews, to derive a deeper understanding of risk, perception and intervention targeting access to health care and dengue virus transmission.

3) Georeferenced data mapping. We will purchase high-resolution satellite images that will allow us to identify each house in the neighborhood, and use these images together with GPS readings to generate a georeferenced map of the four neighborhoods (or to validate existing municipal maps), and of all Yellow Fever, Dengue and Chikungunya cases and health centers locations. Data will be combined with popular voices- oral histories that allow neighborhood residents to voice their own impressions and experiences with space and health (Farraz et al 2012), focus groups and structured interviews to determine perceptions of access to health services and of risk and exposure to dengue virus (Ferreira et al 2009),and walking observations of the neighborhoods.   We plan at least three joint walks through the neighborhoods, a first impressionistic walk, a following visit, in which we will be accompanied by community members and local health workers, to characterize houses and larger spatial units with and without disease cases, and a third one following the mapping and characterization of the neighborhood.

Outcomes
As the themes, methodologies and approaches make clear, this is a unique project.  The faculty research team has a range of expertise that allows for the construction and analysis of data that rarely are put into the same conversation.  The outcomes of the project are broad, ranging from suggestions for public policy on urbanization and public health to understanding the ways in which past experiences inform the present.  By transcending disciplinary boundaries and cross-translating specialized approaches, our project develops innovative strategies for understanding and addressing evolving urban environments.

The new methods allow us to analyze the popular and formal responses to diseases that have been present for centuries (Yellow Fever), arrived in the second half of the 1900’s (Dengue), or are poised to arrive this year (Chikungunya) as part of a longer discourse about relationship between disease, perceptions of disease, and elite and popular conceptions of neighborhood demographics.

E/paper book proposal
We will write an ebook coupled with a linked website project, tentatively titled, “Metropolis, Migration and Mosquitoes: The Case of São Paulo, Brazil.”  New technologies, and the recent award of a Mellon Monograph Publication in the Digital Era grant to Emory (Lesser is a member of the steering committee), make this project outcome particularly exciting.  We will apply for a CFDE Digital Media Support grant.  Duke University Press and the University of California Press have expressed enthusiasm about producing such a work, both for its content (health and the humanities) and its approach (digital).

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• Researcher Analyzes Actions and the Perception of Health in the History of "Bom Retiro" - June 27, 2019
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• Refuge, Return, E/Immigration: Languages, Identities, Mental Health, Beliefs, Territory - November, 2015

• Jeffrey Lesser, New Visiting Professor, Will Study Cultural and Health Habits in São Paulo - August 24, 2015

• What Brazil's Protests Mean - CNN on August 17, 2015

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