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Social, Historical, Cultural Dimensions of TB

Lecture for postgraduate Global Health students at Macquarie University.
by

Paul Mason

on 21 October 2016

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Transcript of Social, Historical, Cultural Dimensions of TB

Paul Mason
Global Health: Tuberculosis
Mason, P.H., Degeling, C., Denholm, J. (2015) Sociocultural dimensions of tuberculosis: an overview of key concepts. International Journal of Tuberculosis and Lung Disease, 19(10), pp. 1135-1143, doi: http://dx.doi.org/10.5588/ijtld.15.0066.

Mason, P.H., Roy, A., Spillane, J., Singh, P. (2016) Social, Historical & Cultural Dimensions of Tuberculosis. Journal of Biosocial Science, 48(2), 206-232. doi: 10.1017/S0021932015000115

Mason, P.H. Degeling, C. (2016) Beyond Biomedicine: Relationships and Care in Tuberculosis Prevention, Journal of Bioethical Inquiry, 13(1), 31-34. doi: 10.1007/s11673-015-9697-6.
Lecture on tuberculosis
based on the following texts:
From Consumption to Tuberculosis
The discovery of microorganisms that caused the white plague gave rise to the notion that these microorganisms must be eliminated wherever they might be and the body must be strengthened to fight against them.
Emergence of reforms to people's morality, sociability, sexuality and daily habits with a focus on hygienic participation in the world
Increasing medicalisation bolstered by fears of contagion.
Hygiene was not just an imperative,
it was a right.
From sanatoria to DOTS
From surveillance of Tuberculars in treatment centres to surveillance of individuals in daily lives.
Loss of community among people with Tuberculosis
1860s-1880s
1922-1924
1942-1952
Drug Susceptible TB
Current Therapy:
4 drugs >6 month therapy

Unmet Needs:
shorter simpler therapy
TB/HIV co-infection
Current Therapy
: drug-drug interactions with HIV medications
Unmet Needs
: ability to co-administer TB regimens with ARVs
Drug Resistant TB
(MDR-TB & XDR-TB)
Current Therapy:
few effective drugs,
injectable, toxicity, >5yrs
Unmet Needs
: oral, shorter, more efficacious, safer and lower cost therapy

Latent TB infection
Current Therapy:
6-9 months of treatment

Unmet Needs:
shorter, safer preventive therapy
Children
Current Therapy:
makeshift use of
inappropriate formulations

Unmet Needs:
formulations with correct closing
Contemporary medical efforts are oriented towards developing better vaccines, biomarkers and antibiotics

BUT, these categories of Tubercular experience are bifurcated by dynamic social processes...
Adoptable
Affordable
Available
Biologically Reductive Narrative History of TB
Stigma
Treatment is lengthy but Tuberculosis can be treated. Nonetheless, a diagnosis of Tuberculosis can lead to social vulnerability. The effects of stigma can be unpredictable and can include:
resistance to diagnose
resistance to diagnosis
non-compliance to a lengthy treatment
social isolation
worst-case scenario: suicide
Liminal Body
One-third of the world's population has a latent Tuberculosis infection (LTBI). People diagnosed with LTBI have been infected by TB bacteria but are not (yet) ill with disease and cannot transmit the disease. They are 'at risk' of developing active Tuberculosis disease but they do not show any signs or symptoms of active disease.
Surveillance
Ethnographic research has been shown to be an effective way of assessing the quality and effectiveness of Direct Observation Treatment (DOTS),
Medicalisation
The dominant biomedical discourse treats social issues and natural biological events as biological problems for which medical treatment is available. When antibiotic treatment for tuberculosis became available, therapy shifted away from sanatoria and there was a corresponding loss of community among people with active Tuberculosis disease. Patients began to be treated individually.
Technological Imperative
If technology is available, health care workers and health-seeking patients often feel compelled to use it. Technologies are sometimes used because they exist not because they are clinically necessary. For example, the use of sub-clinical tests for Tuberculosis is prolific in India and related to cultural factors, not scientific reasons.
Gender
Our social interactions with each other and the environment shape our knowledge and interpretation of gender. The social construction of gender can variably influence lifestyle factors, health-seeking behaviour, and ultimately life chances. A consideration of the role of gender is important when addressing screening, diagnosis, and treatment adherence.
Biographical Disruption
The onset and trajectory of a chronic illness impacts upon personal identity and social experience. The process by which people with a chronic illness construct, interpret and reinterpret their past, present and future forms an illness narrative. This narrative offers insights into the personal, social and adaptive processes of living with chronic illness.
Syndemic
Historical narratives
Book Reviews
Tuberculosis
Towards a multifactorial model
Latent tuberculosis infection
Pidoux wanted to enter nonspecific social and environmental variables into the etiological equation of tuberculosis.
Hermann Pidoux (1802-1882)
Multidrug resistance
Common genes controlled by multiple regulators e.g.
MMPL operons (cell membrane transporters),
Lipases and esterases (lipid metabolism),
PPE proteins (unknown function).
multiple different copies of similar proteins e.g.
annotated succinate dehydrogenases (allows respiration under different conditions)
nicotinamide dinucleotide dehydrogenase (an otherwise useful drug target because no mammalian homologues)
Source: Mason, P.H., Snow, K., Asugeni, R., Massey, P.D., Viney, K. (In press) Tuberculosis and Gender in the Asia-Pacific Region, Australian & New Zealand Journal of Public Health.
Individual experience
e.g. illness narratives
biographical disruption
dynamic nominalism



Interpersonal processes
e.g. gender, stigma, surveillance, taboo, victim blaming

Structural organisation
e.g. syndemics
local biologies
medicalization
structural violence


The co-occurrence of two or more epidemics that interact synergistically. At the level of the body, the conditions that constitute a syndemic reinforce one another. e.g. TB and HIV mutually reinforce each other: tuberculosis augments the immunopathology of HIV and accelerates the damaging progression of the disease; HIV creates a biological environment that enhances the opportunity for TB to develop & spread.
see Seeberg & Meinert 2015
http://www.medanthrotheory.org/read/5313/can-epidemics-be-non-communicable
"When diabetes prevalence is plotted against TB prevalence for 195 countries (Figure 1), the severity of the TB-diabetes co-epidemic in the Pacific is immediately apparent."

From: http://devpolicy.org/in-brief/visualising-the-tb-diabetes-co-epidemic-in-the-pacific-20150423/
and
http://devpolicy.org/wp-content/uploads/2015/04/Devpolicy-TB-diabetes-prev-log.jpg
A case study: TB & diabetes in the Asia Pacific
Mason, P.H., Oni, T., van Herpen, M.M.J.W., Coussens, A.K. (In press) TB Prevention must integrate technological and basic care innovation, European Respiratory Journal.
Chilhood TB
difficult to diagnose
neglected in clinical trials
neglected in drug development (e.g. lots of big pills)

Yamada, S., Riklon, S., & Maskarinec, G. G. (2016). Ethical responsibility for the social production of tuberculosis. Journal of bioethical inquiry, 13(1), 57-64.

Articles by:
Silva, D. S., Dawson, A., & Upshur, R. E. (2016). Reciprocity and ethical tuberculosis treatment and control. Journal of bioethical inquiry, 13(1), 75-86.

Koch, E. (2016). Negotiating “the social” and managing tuberculosis in Georgia. Journal of bioethical inquiry, 13(1), 47-55.

Armus, D. (2016). On TB vaccines, patients’ demands, and modern printed media in times of biomedical uncertainties: Buenos Aires, 1920–1950. Journal of bioethical inquiry, 13(1), 35-45.

Halovic, S. (2016). Effective therapeutic relationships using psychodynamic psychotherapy in the face of trauma. Journal of bioethical inquiry, 13(1), 159-160.

Watts, K. N. (2016). MDR-TB, Isolation, and Anomie: Has Anyone Referred to Social Work?. Journal of bioethical inquiry, 13(1), 157-158.

Articles by:

Horner, J. (2016). From exceptional to liminal subjects: Reconciling tensions in the politics of tuberculosis and migration. Journal of bioethical inquiry, 13(1), 65-73.


Denholm, J. (2016). Ethics, tuberculosis, and compassion: Lessons from praxis. Journal of bioethical inquiry, 13(1), 161-162.


Carroll, J. (2016). The ethics of isolation for patients with tuberculosis in Australia. Journal of bioethical inquiry, 13(1), 153-155.

The Nazi treatment of Jews in 1940s Germany is a chilling example of dynamic nominalism, whereby the disease–crime labels in Nazi portrayals of the Jews became self-fulfilling prophecies in the ghettos and concentration camps where Jews contracted contagious diseases and turned to crime for survival.
dynamic nominalism
Ageism
Victim blaming
The practice of placing the responsibility for negative consequences upon those least able to access solutions
Discrimination against the elderly.




What happens when interpersonal discrimination becomes systemic?

e.g. is global health ageist?
Structural violence
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