Tuberculosis Is a Threshold: The Making of a Social Disease in Post-Soviet Georgia

Abstract

In this article I use Margaret Lock's concept of local biology as a standpoint to view tuberculosis as a threshold where distinctions between social and biological aspects of disease are negotiated. I conceptualize tuberculosis as a threshold in two ways: first as a passageway, and second as a space for navigating the limits of tolerance to therapeutics. The article is based on ethnographic research about responses to tuberculosis in post-Soviet Georgia. I focus on how health professionals and patients make claims to social aspects of illness by recuperating historical examples for tuberculosis treatment as a moral commitment to society, and in the context of emergent patient-centered treatment services.

Keywords:

• Georgia
• global health
• social disease
• tuberculosis

ACKNOWLEDGMENTS

Many 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 US 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. This article greatly benefited from the generous feedback and patience of P. Sean Brotherton and Vinh-Kim Nguyen. Lawrence Cohen's comments for an earlier conference paper (AAA 2011) helped me think through the notion of the threshold. Finally, I thank Lenore Manderson, Victoria Team, and three anonymous reviewers for their careful and insightful suggestions. I am responsible for any errors.

Notes

This analysis is part of a larger study about DOTS implementation in Georgia, for which I conducted 17 months of research during 2001–2007. Research was anchored at the National Tuberculosis Program in Tbilisi, Georgia's capital city. I conducted semistructured interviews with more than 70 scientists, health care workers, administrators, and representatives of international donor and aid organizations involved with TB control and health care reforms. I also conducted participant observation at the National TB Reference Laboratory, 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 TB care and control in Georgia.

In both senses, the threshold resembles anthropological analyses of liminality (Turner 1967) for example as an embodied aspect of chronic pain (Jackson 2005).

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.

‘Short course’ refers to the six to nine month duration of the fixed antibiotic regimen for treating antibiotic-susceptible strains. Treatment for drug-resistant TB is usually at least 18 months. The average cost for one full course of treatment under DOTS can be as low as $10, excluding direct or indirect (i.e., transportation) costs that patients might incur in seeking a diagnosis and treatment. Costs incurred by NTPs will vary widely based on governmental and international financial and technical support.

‘Default’ is an official category assigned to someone who has interrupted treatment for at least two consecutive months.

The International Committee for the Red Cross and the NTP documented high rates of MDR-TB in Georgia's prisons starting in the late 1990s (Aerts et al. 2000; Jugheli et al. 2008). The NTP began surveying TB patients and TB suspects in the general population for MDR-TB in the early 2000s (Lomtadze et al. 2009; Mdivani et al. 2008). The Global Fund began supporting treatment for MDR-TB in Georgia in 2005. Currently Georgia is one of 27 high MDR-TB burden countries as defined by the WHO (WHO 2011). According to the most recent Global Tuberculosis Report, an estimated 9.5% of new cases and 31% of retreatment cases are MDR (WHO 2011:22).

I thank Lawrence Cohen for this insight.

This argument is anchored in anthropological literature about everyday life the former Soviet Union. Anthropologists question macro-oriented assumptions that moving from socialist to market-based systems is a linear transition from one uniform type to another.

All names are pseudonyms, with the exception of international organizations. For Georgian names and terms, I use the Apridonidze-Chkhaidze transliteration system (Institute of Linguistics, Georgian Academy of Sciences).

At the time of research, 19% of the 800 tuberculosis patients registered in Tbilisi were registered to receive treatment at DOTS Spots. At the time of writing, there were 15 DOTS Spots in Tbilisi that covered approximately 50% of all registered TB cases in the city. The remaining 50% receive inpatient treatment 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.

Additional information

Notes on contributors

Erin Koch

ERIN KOCH is Assistant Professor of Anthropology at the University of Kentucky. As an anthropologist of medicine, science, and technology, her research in Georgia focuses on the global health industry, infectious disease, and social-structural vulnerability among disenfranchised populations.