Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal. TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected (CDC, 2012). Tuberculosis has been a problem in Nepal, which is a country located in South Asia. Since TB is spread through contact noted above, any social or cultural setting puts people at risk for contracting/facilitating the virus (and spreading it). In Nepal, the government and WHO implemented a plan in order to help stop the spread of the disease called DOTS (Directly Observed Therapy, Short-course). The government set up a program called the Nepal Tuberculosis Programme (NTP) in hopes to combat the disease as well.
As we learned in lecture, medical anthropologists are implemented to find out why a medical program or process is not working and find ways to make it work. Medical Anthropologist, Ian Harper writes an article on his fieldwork in Nepal with the DOTS and NTP programs. Harper was sent in to find out the problems with the programs. In his article called Anthropology, DOTS, and Understanding Tuberculosis Control in Nepal, we find out how crucial and important medical anthropologists are in combating global health disparities. A little background on DOTS; DOTS was introduced in 1996 after a joint His Majesty’s Government of Nepal (HMG/N)/WHO review of the National Tuberculosis Programme (NTP) revealed that only 30% of TB cases were registered under the NTP and of these, only 40% were treatment successes. The cure rate in the first cohort of DOTS patients was above 89%. By July 2000, the programme had been expanded to 183 treatment centres in 69 districts and covers 78% of population. The treatment success ratein the DOTS centres remains at approximately 89%, with the national treatment success rate now reaching almost 85%. Nationally, this year over 28,000 TB patients have been registered and are being treated under the NTP. Out of these, over 75% are being treated under DOTS (Bam, 2001). Harper got a first hand experience with this program through participant observation (how he conducted his research). Here are the problems he found:
1) Many with the disease, particularly younger women, wished to avoid the stigma associated with it. For many this was a disease linked to notions of impurity, and locally widely associated with dirt and poor habits like drinking and smoking. The shame associated with having the disease, and the understandable desire to remain anonymous while receiving treatment, became harder with this system. The increased surveillance made issues of patient confidentiality all but impossible. (Harper, pg 62)
2) A number of staff understood that DOT was not in the interests of the patients and ignored it, and attempted innovative ways of adapting their procedures, giving weekly drugs or more to the patients as they arrived, for example. But other health workers hid behind the DOTS ‘rules’ inflexibly. One DOTS worker I sat with would not give a week’s worth of drugs for patients to travel to his relative’s home at an important festival time. It was for reasons like this that another health worker dubbed the DOTS programme the ‘defaulter creation system’. (Harper, pg 62)
3) Patients not returning to the study due to various reasons. I followed up who had not returned to a health post with the FCHV as instructed had been too busy with the rice harvest. He had died without even receiving treatment. Another man I interviewed who had been severely debilitated as a consequence of his disease pointed out how difficult it was to walk anywhere in these steep mountainous regions if you had tuberculosis. (Harper, pg 62)
Harpers fieldwork helped identify some problems with this program. It was because of his work that he got to see culturally why some patients weren’t returning/going at all to their treatments (stigmas, transportation, not enough time etc). The article says it best, “at its best anthropology is able to ‘reconfigure the boundaries of the problem’, offering (new) conceptual frameworks, substantive knowledge and methodological insights” (Harper, 2006).
Centers for Disease Control and Prevention. March 13, 2012. “Tuberculosis (TB).” Centers for Disease Control and Prevention. Accessed August 4, 2014. http://www.cdc.gov/tb/topic/basics/default.htm
HARPER, IAN. 2006. “ANTHROPOLOGY, DOTS AND UNDERSTANDING TUBERCULOSIS CONTROL IN NEPAL.” Journal of Biosocial Science 38 (1): 57-67. Accessed August 4, 2014. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/203897765?accountid=12598.