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Negotiating “The Social” and Managing Tuberculosis in Georgia

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.

References

  • Abdullaev, N. 2000. Tuberculosis rages in the Caucasus. Prism 6(10). http://www.jamestown.org/single/?tx_ttnews%5Btt_news%5D=27962&no_cache=1#.VnglWYT8-_s. Accessed June 19, 2003.

  • Aerts, A., M. Habouzit, L. Mschiladze, N. Malakmadze, et al. 2000. Pulmonary tuberculosis in prisons of the ex-USSR state Georgia: Results of a nation-wide prevalence survey among sentenced inmates. International Journal of Tuberculosis and Lung Disease 4(12): 1104–1110.

    CAS  PubMed  Google Scholar 

  • Bazylevych, M. 2011. Vaccination campaigns in postsocialist Ukraine: Health care providers navigating uncertainty. Medical Anthropology Quarterly 25(4): 235–256.

    Article  Google Scholar 

  • Bonnet, M., V. Sizaire, Y. Kebede, et al. 2005. Does one size fit all? Drug resistance and standard treatments: Results of six tuberculosis programs in former Soviet countries. International Journal of Tuberculosis and Lung Disease 9(10): 1147–1154.

    CAS  PubMed  Google Scholar 

  • Cohen, L. 2000. No aging in India: Alzheimer’s, the bad family, and other modern things. Berkeley: University of California Press.

    Google Scholar 

  • Dubos, R., and J. Dubos. 1992. The white plague: Tuberculosis, man and society. New Brunswick, NJ: Rutgers University Press.

    Google Scholar 

  • Ecks, S., and I. Harper. 2013. Public–private mixes: The market for antituberculosis drugs in India. In When people come first: Critical studies in global health, edited by J. Biehl and A. Petryna, 252–275. Princeton: Princeton University Press.

    Google Scholar 

  • Farmer, P.E. 1999. Infections and inequalities: The modern plagues. Berkeley: University of California Press.

    Google Scholar 

  • Farmer, P.E. 2003. Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press.

    Google Scholar 

  • Garner, P., and J. Volmink. 2003. Directly observed treatment for tuberculosis: Less faith, more science would be helpful. British Medical Journal 327(7419): 823–824.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gelmanova, I.Y.D.V., S.P. Taran, A.A. Mishustin, A.V. Solovyova Golubkov, and S. Keshavjee. 2011. “Sputnik”: A programmatic approach to improve tuberculosis treatment adherence and outcome among defaulters. International Journal of Tuberculosis and Lung Disease 15(10): 1373–1379.

    CAS  Article  PubMed  Google Scholar 

  • Harper, I. 2006. Anthropology, DOTS, and understanding tuberculosis control in Nepal. Journal of Biosocial Science 38(1): 56–67.

    Google Scholar 

  • Harper, I. 2010. Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis Anthropology and Medicine 17(2): 201–214.

    PubMed  Google Scholar 

  • Harper, I. 2014. Development and public health in the Himalaya. London: Routledge.

    Google Scholar 

  • Isaakidis, P., S. Smith, S. Majumdar, J. Furin, and T. Reid. 2014. Calling tuberculosis a social disease—an excuse for complacency? The Lancet 384(9948): 1095.

    Article  Google Scholar 

  • Kleinman, A., V. Das, and M.M. Lock (eds.). 1997. Social suffering. Berkeley: University of California Press.

    Google Scholar 

  • Koch, E. 2006. Beyond suspicion: Evidence, (un)certainty, and tuberculosis in Georgian prisons. American Ethnologist 33(1): 50–62.

    Article  Google Scholar 

  • Koch, E. 2013. Free market tuberculosis: Managing epidemics in post-Soviet Georgia. Nashville: Vanderbilt University Press.

    Google Scholar 

  • Koch, E. 2015. Protracted displacement in Georgia: Structural vulnerability and “existing not living.” Human Organization 74(2): 135–143.

  • Lakoff, A. 2010. Two regimes of global health. Humanity: An International Journal of Human Rights, Humanitarianism, and Development 1(1): 59–79.

    Article  Google Scholar 

  • Latour, B. 2007. Reassembling the social: An introduction to actor-network-theory. Oxford, UK: Oxford University Press.

    Google Scholar 

  • Lessem, E. 2014. Tuberculosis drug development hobbles forward. In 2014 pipeline report, edited by A. Benzacar, 19–21. New York: i-Base/Treatment Action Group.

  • Lessem, E., H. Cox, H. Daniels, et al. 2015. Access to new medications for the treatment of drug-resistant tuberculosis: Patient, provider and community perspectives. International Journal of Infectious Diseases 32(March): 56–60.

    Article  PubMed  Google Scholar 

  • Lindenbaum, S. 1978. Kuru sorcery: Disease and danger in the New Guinea Highlands. Mountain View, CA: Mayfield Publishing Company.

    Google Scholar 

  • Lock, M. 1993. Encounters with aging: Mythologies of menopause in Japan and North America. Berkeley: University of California Press.

    Google Scholar 

  • Lock, M. 2001. The tempering of medical anthropology: Troubling natural categories. Medical Anthropology Quarterly 15(4): 478–492.

    CAS  Article  PubMed  Google Scholar 

  • Lomtadze, N., R. Aspindzelashvili, M. Janjgava, et al. 2009. Prevalence and risk factors for multidrug-resistant tuberculosis in the Republic of Georgia: A population-based study. International Journal of Tuberculosis and Lung Disease 13(1): 68–73.

    CAS  PubMed  PubMed Central  Google Scholar 

  • Martin, E. 1987. The woman in the body: A cultural analysis of reproduction. Boston: Beacon Press.

    Google Scholar 

  • McMillen, C.W. 2015. Discovering tuberculosis: A global history, 1900 to the present. New Haven, CT: Yale University Press.

    Book  Google Scholar 

  • Mdivani, N., E. Zangaladze, N. Volkova, et al. 2008. High prevalence of multidrug-resistant tuberculosis in Georgia. International Journal of Infectious Disease 12(6): 635–644.

    Article  Google Scholar 

  • Moshin, A. 2014. Treating tuberculosis as a social disease. The Lancet 383(9936): 2125.

    Google Scholar 

  • Packard, R.M. 1989. White plague, black labor: Tuberculosis and the political economy of health and disease in South Africa. Berkeley: University of California Press.

    Google Scholar 

  • Peuch, J. 2002 Georgia: Official says TB epidemics contained, but warns against too much optimism. Radio Free Europe/Radio Liberty (RFE/RL), October 29. http://www.rferl.org/content/article/1101224.html. Accessed March 13, 2005.

  • Porter, J., K. Lee, and J. Ogden. 2002. The globalization of DOTS: Tuberculosis as a global emergency. In Health policy in a globalizing world, edited by K. Lee, K. Buse, and S. Fustukian, 181–194. Cambridge, UK: Cambridge University Press.

    Google Scholar 

  • Quesada, J., L.K. Hart, and P. Bourgois. 2011. Structural vulnerability and health: Latino migrant laborers in the United States. Medical Anthropology 30(4): 339–362.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rasanathan, K., A. Sivasankara Kurup, E. Jaramillo, and K. Lönnroth. 2011. The social determinants of health: Key to global tuberculosis control. International Journal of Tuberculosis and Lung Disease 15(6): S30–S36.

    Article  PubMed  Google Scholar 

  • Shin, S., J. Furina, J. Bayonab, K. Matec, J. Yong Kim, and P. Farmer. 2004. Community-based treatment of multidrug-resistant tuberculosis in Lima, Peru: 7 years of experience. Social Science and Medicine 59(7): 1529–1539.

    Article  PubMed  Google Scholar 

  • Seeberg, J. 2013. The death of Shankar: Tuberculosis and social exclusion in a poor neighbourhood in Bhubaneswar, Odisha. In Navigating social exclusion and inclusion in contemporary India and beyond, edited by K.B. Nielsen, M. Fibger Qvortrup, and U. Sudoka, 207–226. London: Anthem.

    Google Scholar 

  • Seeberg, J. 2014. The event of DOTS and the transformation of the tuberculosis syndemic in India. Cambridge Anthropology 32(1): 95–113.

    Article  Google Scholar 

  • Street, A. 2014. Biomedicine in an unstable place: Infrastructure and personhood in a Papua New Guinean hospital. Durham, NC: Duke University Press.

    Book  Google Scholar 

  • Trostle, J. 2005. Epidemiology and culture. Cambridge, UK: Cambridge University Press.

    Book  Google Scholar 

  • Virchow, R. 1958. Disease, life, and man. Translated by I.J. Rather. Stanford, CA: Stanford University Press.

    Google Scholar 

  • World Health Organization. 2015. Global tuberculosis report. Geneva: World Health Organization. http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf?ua=1. Accessed November 30, 2015. 

  • Zachariah, R., A.D. Harries, S. Srinath, et al. 2012. Language in tuberculosis services: Can we change to patient-centered terminology and stop the paradigm of blaming the patients? International Journal of Tuberculosis and Lung Disease 16(6): 714–717.

    CAS  Article  PubMed  Google Scholar 

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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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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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Keywords

  • Tuberculosis
  • Global health
  • Social disease
  • Georgia