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Negotiating “The Social” and Managing Tuberculosis in Georgia

  • Symposium: Tuberculosis
  • Published:
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Abstract

In this paper I utilize anthropological insights to illuminate how health professionals and patients navigate and negotiate what for them is social about tuberculosis in order to improve treatment outcomes and support patients as human beings. I draw on ethnographic research about the implementation of the DOTS (Directly Observed Therapy, Short Course) approach in Georgia’s National Tuberculosis Program in the wake of the Soviet healthcare system. Georgia is a particularly unique context for exploring these issues given the country’s rich history of medical professionalism and the insistence that the practice of medicine is a moral commitment to society. I argue for critical attention to the ways in which treatment recipients and providers navigate what, for them, is “social” about therapeutic practices and their significance for avoiding biological and social reductionism.

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Notes

  1. Throughout I use “TB” as an adjective to describe institutions, professionals, etc., engaged with the National Tuberculosis Program in Georgia and “tuberculosis” to refer to the illness. Exceptions include the official acronyms for drug-resistant forms of tuberculosis and direct quotes from research interviews, when interviewees use “TB” in the way that I use “tuberculosis.”

  2. Strains of MDR-TB are resistant to both rifampicin and isoniazid—two of the most powerful and widely prescribed first-line antibiotics. The WHO defines XDR-TB as bacteria that are resistant to at least four antibiotics: rifampicin, isoniazid, any fluoroquinolone, and at least one of three injectable second-line drugs.

  3. This paper emerges from a larger study about DOTS implementation in Georgia, for which I conducted seventeen months of research during 2001–2007. Research was anchored at the National Tuberculosis Program in Tbilisi, Georgia’s capital city. I conducted semi-structured interviews with more than seventy scientists, healthcare workers, administrators, and representatives of international donor and aid organizations involved with TB control and healthcare reforms. I also conducted participant observation at the National TB Reference Laboratory (NRL), at DOTS training sessions, and in the prison sector. The project studied cultural and political aspects of DOTS implementation to examine how Georgian TB professionals navigate changes in what counts as “expert knowledge” amid shifting local and global regimes of medical management and knowledge production. I found that market reforms and standardized treatment programs have both facilitated and undermined the management of tuberculosis care and control in Georgia.

  4. All names are pseudonyms, with the exception of international organizations. All research participants referenced in this analysis consented to have their professional roles, experiences, and opinions included in academic and non-academic research publications and presentations. For Georgian names and terms, I use the Apridonidze-Chkhaidze transliteration system (Institute of Linguistics, Georgian Academy of Sciences).

  5. At the time of research, 19 per cent of the eight hundred tuberculosis patients registered in Tbilisi were registered to receive treatment at DOTS Spots. At the time of writing, there were fifteen DOTS Spots in Tbilisi that covered approximately 50 per cent of all registered tuberculosis cases in the city. The remaining 50 per cent receive treatment either through inpatient services or through outreach nurses. These statistics may have changed as the DOTS Spots approach continues to expand, including for treating patients with MDR-TB at six DOTS Spots in Tbilisi.

  6. The World Bank GDP per capita: http://data.worldbank.org/indicator/NY.GDP.PCAP.CD?page=1. Accessed September 22, 2015.

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Acknowledgements

I extend my deepest thanks to everyone at the NTP and MSCI in Tbilisi who helped me with my research. The project was supported by a Dissertation Improvement Grant from the Science and Technology Studies Program of the National Science Foundation; the Eurasia Program of the Social Science Research Council, with funds provided by the U.S. Department of State through the Title VIII Program; the Graduate Faculty of Political and Social Science at the New School for Social Research; and the University of Kentucky. Portions of this article, including ethnographic examples and theoretical analyses, have appeared in previous texts written by the author and published in the journals American Ethnologist and Medical Anthropology: Cross-Cultural Studies in Health and Illness and in the book Free Market Tuberculosis: Managing Epidemics in Post-Soviet Georgia (2013, Vanderbilt University Press). I am responsible for any errors.

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  1. Department of Anthropology, University of Kentucky, 211 Lafferty Hall, Lexington, KY, 40506-0024, USA

    Erin Koch

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Koch, E. Negotiating “The Social” and Managing Tuberculosis in Georgia. Bioethical Inquiry 13, 47–55 (2016). https://doi.org/10.1007/s11673-015-9689-6

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