approaches to health care offered in the public domain coexist with a predominant Maya medical tradition in a situation of exclusion and inequity. The challenge was to produce a sensitive surveillance system that could capture local understandings of ‘disease’ and respond in culturally appropriate ways deemed desirable by locals. This was only possible through using a strong anthropological approach that articulated a mutual learning process between epidemiologists, medical doctors, nurses, veterinary doctors, Maya traditional healers, local animal and human health authorities and service providers, and community leaders. The project adapted the Explanatory Model of Illness approach (Kleinman, 1978) to examine how each of these groups understand and judge the relations between human–animal interactions, health and illness.
The importance of acknowledging diversity: issues of representation and participation
The project aimed to address stakeholder’s interests on an equal footing in order to increase legitimacy and buy-in of the design, and to facilitate overall implementation of the surveillance-response project. In a post-war setting plagued with mistrust and historical trauma (Chamarbagwala and Moran, 2011), this proved a hard concept to enact. Social scientists conducted contextual and historical research for the study area to understand emerging trends possibly precluding participation of expected groups. An intersectionality approach (McCall, 2005) identified the groups most vulnerable to be excluded or misrepresented within the project. Results showed a context of extreme power differentials triggered by specific conditions that were organized in categories (ethnolinguistic composition, gender, distance-access, literacy, multilinguistic capacity, socio-economic composition, racist attitudes-practices). These were used to redesign transdisciplinary workshops, which included exercises to address power disparities, value rather than fear diversity in representation, and induce reflexivity. Quotas for types of participants were created (i.e. Maya, female, rural, traditional healers) to promote agency of societal actors originally excluded from the project but who were identified locally as key to successful project implementation. Anthropologists also developed specific methods to curb ethnocentric behaviour of researchers that precluded them from understanding local views of the human–animal interface domain.
Approach to development of intervention
Pluri-epistemic systems: ethnography as a tool to uncover underlying models of ‘zoonosis’
Beginning with the conception and design of the project, anthropologists, veterinarians and public health experts from Guatemala and Switzerland worked hand in hand as equal partners, defining an initial interdisciplinary transversal study. Each disciplinary group also conducted its own studies. Veterinarians and epidemiologists studied animal and human samples to determine zoonotic diseases, while anthropologists analysed local understandings of how human–animal interactions may affect health and illness. In regular meetings and workshops, the research team engaged in reflections about similarities and differences of explanatory models held by different categories of study participants (including the researchers). Ethnographic research on the mental models of the local population concerning disease transmission between animals, humans and the larger environment showed most Maya people drew on broader values of Tzalajb’il (harmony), Nimb’el (respect), Sahil Wanq (coexistence) and Xbisbal li wan (balance) to define an exchange of ‘energies’ between the species. A deep-seated notion of an assumed benevolence of nature precluded seeing pathogens of animal origin. This proved a key finding for the later co-design of education and communication strategies aimed at local communities. Apart from strictly Maya or strictly biomedical models of (zoonotic) disease transmission, the team found numerous hybrid models held by local health providers as well as by community members, influencing health-seeking pathways and treatment of patients. For example, Maya midwives that also served as ‘health guardians’ for the public health system, referred to energetic diseases such as ‘hijillo’, a disease believed to be transmitted from a dog to a child via the dog’s energy (non-material contact) but also from contact with afterbirth fluids. The midwives and health guardians explained that symptoms such as fever, diarrhoea, vomiting and lethargy in children would inevitably result in death. While noting that hijillo could be cured only through a Maya ceremony and medicinal plants, they also prescribed antibiotics in very small doses. These various models along the biomedical–Maya spectrum were analysed jointly by team members to understand the diversity of epistemic (knowledge) systems influencing health-seeking behaviour.
The emics of One Health surveillance
Social scientists employed the Bidirectional Emic-Etic framework (Berger-González et al., 2016) to elicit local (emic) categories of disease and terms for illness in animals and humans, which could be better suited for use in the surveillance system. Epidemiologists suggested unequivocal definitions for terms such as ‘febrile syndrome’ or ‘acute respiratory syndrome’, for which there was no direct Maya Q’eqchi’ translation. Given that the project aimed to implement a community-based surveillance system relying on families’ reports of perceived ‘danger’ signals, the team needed to understand how risk and illness were perceived locally. Working with Maya linguists and community representatives, local categories for syndromic surveillance that were more culturally sensitive were elicited, including them in the training protocol of the local nurses who had to document the human health cases occurring in studied households. For example, the desired term ‘diarrhoeic syndrome’ found several local terms in Spanish and over a dozen terms in Q’eqchi’ (i.e. Xha’ chi sa’ – diarrhoea as water, K’ik sa’ – diarrhoea as water with blood, Sam ko’t – depositions with mucus, Xah’ chi kem – soft but rapid depositions, etc.) that allowed the team to define a more precise and sensitive syndromic surveillance system for both animals and humans.
Boundary management: a case for mutual learning
Medical systems present particular idiosyncrasies that are deeply related to the way in which the social world is perceived and acted upon (Levin and Browner, 2005). In Guatemala, social divides often preclude the modern biomedical system and the Maya medical system from easily interacting in public spaces, creating boundaries that are often detrimental to patients and successful public health interventions. The project addressed this divide via joint diagnostic protocols that allowed the bridging between the two medical systems. To examine explanatory models of concrete episodes and their treatment in more detail, the study team organized joint visits of patients where a Maya Ajkum (traditional healer) and a biomedical doctor would jointly diagnose and discuss response avenues for human patients, or an Ajkum and veterinary doctor would do the same for animal patients. In a visit with a woman suspected to have leptospirosis, the medical doctor asked questions about risk exposure and unspecific symptoms such as fever and lethargy, and recommended laboratory tests to confirm aetiology. The Maya healer used an ancient technique called ‘pulso’ to diagnose ‘a disease similar to dengue but coming from a much older disease transmitted by a mammal, possibly a bat’. Most importantly, he suggested the patient had a precondition called ‘susto’ (a well-known culture-bound syndrome relating to losing one’s vital energy or spirit) that had weakened her ‘blood’ (immune system) and had made her susceptible to the disease. An example of boundary management in One Health is illustrated in our short video: https://youtu.be/lfVQnsqLbas (accessed 15 July 2019).
Results
Discussions on treatment avenues showed indigenous patients preferred responses that incorporated both biomedical and Maya treatments collaboratively, providing valuable insights into
