The cause of multi-drug-resistant tuberculosis (MDRTB) has always been assumed to be a social one: that is, patients not taking their medications properly. Unfortunately, rarely were the causes of that "non-compliance" investigated; blaming patients remained the most comfortable option. Farmer and his group marshalled the diagnostic power of Harvard University hospitals to investigate an outbreak of MDRTB in the shantytowns of Lima, Peru. This research demonstrated the importance of new biotechnologies to understanding emerging biosocial phenomena, and of establishing a dialogue across the biological and social disciplines. Interestingly enough, as this case illustrates, biological knowledge demonstrates the role of large-scale social forces in producing epidemics.
The investigation used molecular epidemiological techniques to identify the distribution and evolution of drug-resistant TB strains over time in the Peruvian community where they were working. They were able to disprove the prevailing view that this epidemic was due to poor adherence to treatment. Farmer and colleagues, ethnographically attuned to local realities, were skeptical of this claim, as it did not reflect their experience with the community. Aware that the inaccessibility of health care was leading to careless antibiotic usage, they suspected that patients were being infected by TB strains that were already resistant to one or two drugs. This meant that subsequent treatment with the standard three-drug regimen in public TB control clinics would be inadequate, as only one or two of the drugs would be active against the bacteria. These investigators hypothesized that TB control programs were generating a multi-drug-resistant epidemic by treating individuals with already partially resistant TB.
This hypothesis was borne out by molecular resistance testing of bacteria isolated from patients. Development of drug resistance was attributed to the breakdown in curative public health services and the partial availability of antibiotics in the private sector. This is a product of social inequalities increasingly visible throughout the developing world, where a lucky few turn to private health care, creating a market for biomedicines. As a result, the poor are able to gain access to antibiotics through the informal economy; however, that access is partial and fragmented and leads to improper use and, consequently, the risk of drug resistance. The evolution of MDRTB is tied to growing social inequalities and the "privatization" of global health care through policies elaborated far from the communities where they have their impact. Privatization was due to economic structural adjustment programs mandated by Washington-based Bretton Woods institutions. These required that cash-strapped Third World governments slash social spending—and public health programs—in order to meet the conditions for further loans. However, in a world where knowledge of the efficacy of biomedicines is truly globalized, it is difficult to scale back the expectations of the sick, even when they are poor (Kim, Irwen, Millen, & Young et al., 2000).
The pathogenic potential of the conjugation of pathogenic socio-economic shifts with biomedical globalization is visible in the outbreak of MDRTB in the former Soviet Union. There, in the aftermath of communism, social insecurity, coupled with growing social inequality, has been blamed for skyrocketing crime. Increased crime has led to increased incarceration rates; the inability of the criminal justice system to hear the cases means that thousands are incarcerated while awaiting trial. Simultaneously, breakdown of the public health system has been implicated— through drug shortages—in the emergence of MDRTB epidemics. The Russian prison system plays an important role in amplifying the epidemic, as the cramped and overcrowded conditions favor the spread of already-resistant TB from ill inmates. The pathogen is then spread back into the community as prisoners are released (Farmer, 1999; Hous, 1999; Kimmerling, 2000; Shilova & Dye, 2001). The Peruvian experience has been used as a model to develop an ambitious control program for Russia that has garnered impressive international support, demonstrating the potential for medical anthropology to lead the way in the development of programs to control emerging infections.
Farmer's Peruvian research was innovative because it used molecular biological evidence in dialogue with ethnographic data. It also broke new ground by emphasizing social change—rather than immobile cultural practices, such as funereal rituals—as the key process on the cultural side of the bio-social equation. Consonant with the anthropological understanding of culture prior to the 1980s, studies of kuru and other earlier epidemics often assumed a timeless, unchanging quality to culture and, as a result, social practices. What social change was observed was assumed to result in adaptation and acculturation.
The case of MDRTB indicates that anthropologists could no longer be content to attribute the phenomena at hand to timeless cultural structures, nor to assume that the sphere of analysis did not extend beyond the local. The dramatic scope of the MDRTB epidemic in the former Soviet Union only too clearly illustrates how "macro" transformations in political economy—and the large-scale social forces that drive them—register at the "micro" level of everyday practice and patterns of resort. Increasingly, the "culture" that explains pathogen emergence and transmission is not the "traditional" culture so prized by classical anthropologists, but the "culture" of international institutions that enact and regulate global economic policy and public health implementation.
Biomedicine plays an important role in mediating the emergence of new infectious diseases for four, linked reasons. Hospitals and clinics are places where the sick congregate in search of treatment, and as a result they concentrate pathogens and multiply the chances of cross-contamination. Secondly, the biomedical repertoire includes practices that represent exceptional powerful interventions into the biological realm, and thus have unprecedented power to change organisms and modify disease ecologies. Thirdly, biomedical efficacy requires extensive infrastructure—working hospitals, laboratories, and public health bureaucracies—in order to ensure the effectiveness of its biological interventions. This infrastructure is extraordinarily resource-hungry—a fact that motivated the move to less expensive and, it was hoped, more sustainable primary health care in developing countries in the 1970s. In an era of decreased expenditure on health care, the "downsizing" of public health has made under-funded hospitals dangerous places. Finally, confronted by the global public's desire and need for curative biomedical services, a vast private—and largely unregulated—private market for biomedical services and bio-commodities (from pharmaceuticals to organs) has proliferated around the world. This private market has led to increasingly irrational use of biologically active substances, further increasing the risk of emerging epidemics.
The iatrogenic potential of biomedicine can be seen both in settings of poverty and wealth. In Africa, lack of sterilizing equipment has most dramatically been implicated in outbreaks of Ebola; however, anecdotes of improper sterilization practices and re-use of injection equipment are legion and are widely believed to have played a role in spreading blood-borne pathogens such as HIV and Hepatitis C. In wealthy countries, increasingly invasive procedures on sicker patients has led to greater instrumentation of patients whose immune systems are less robust. As a result, intensive care units have become breeding grounds for drug-resistant "super-bugs" such as MRSA and VRE. Spread to other patients is enhanced when overworked staff do not have the time to ensure proper hygiene. Both in wealthy and poor countries, the iatrogenic potential of biomedicine is evident although, in conditions of poverty, the consequences are far more devastating.
Perhaps more worrisome has been the unwitting implication of earlier public health campaigns in the propagation of unrecognized pathogens. It has been hypothesized that the HIV epidemic was triggered by the administration to over a million Africans in the 1960s of batches of an experimental oral polio vaccine that was inadvertently contaminated with HIV's simian ancestor, SIVcpz (Hooper, 1999). While this is unlikely, it does point to the potential for large-scale use of biologicals to unwittingly transmit pathogens, a potential that has been acknowledged in other hypotheses about the epidemic's origins (see Weiss & Wain-Hobson, 2001). In Egypt, it appears that 15% of the population has been contaminated with Hepatitis C as the result, it is believed, of earlier campaigns to eradicate schistosomiasis using parenteral treatments with inadequately sterilized injection equipment (Frank et al., 2000). Data on Hepatitis C from developing countries is still sparse, but it is not unreasonable to expect that re-use of injecting equipment in the past has spawned a major epidemic across the world that may, in time, come to dwarf the HIV epidemic.
Ethnographic studies of the therapeutic itineraries resorted to by the ill, as well as examinations of the everyday life of the clinical encounter, illuminate how the individual experience of illness is negotiated through cultural frames, enacted in social relations, and constrained by political and economic conditions. As a result, they describe how biomedicine is deployed according to local circumstances and offer crucial insights into how biomedical practices may inadvertently contribute to the emergence of epidemics, as in the case of the Peruvian and Russian MDRTB epidemics. Ethnographies of public health in developing countries have painted a devastating picture of breakdown in public health and the consequences of power struggles over increasingly meagre resources (Hours, 1985). From the point of view of preventing drug-resistant epidemics, too little biomedicine is worse than none at all. However, with the globalization of biomedical commodities and desires, the "nothing" option does not exist. Too much biomedicine can also lead to difficulties, as in the case of drug-resistant epidemics fanning out from intensive care units demonstrates.
Because biomedicine has become an increasingly important mediator of the global disease ecology, the conditions that compromise or distort its impact (such as partial antibiotic use) may set the stage for emerging epidemics. Close attention to biomedical practices—or those that are inspired by biomedicine's modernist promise of healthy living—in different geographical and social contexts provides important evidence for understanding how patchiness in the implementation of biomedicine textures the disease landscape. In an era of intensified and accelerated global exchanges of peoples and goods, both organic and inorganic, this patchwork biosocial landscape offers new opportunities for new pathogens to spread, as well as new breeding grounds for existing pathogens such as tuberculosis. New infections such as HIV, Hepatitis C, or West Nile virus are known examples; however, increases in genetic manipulation and in the circulation of biologicals—already cited in evaluations of the threat of bioterrorism—raise concern for the future. As we have seen in the case of MDRTB, medical anthropology has an important role to play, as a critical examination of the conditions under which biomedicine is both globalized and localized, and as a critique of the institutional practices and representations that inform global health policy.
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