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Global Public Health: An International Journal for Research, Policy and Practice
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Free market tuberculosis: Managing epidemics in post-Soviet Georgia

Jennifer J. Carroll
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University of Washington, Seattle, WA, USA Published online: 03 Oct 2013.

To cite this article: Jennifer J. Carroll (2013) Free market tuberculosis: Managing epidemics in post-Soviet Georgia, Global Public Health: An International Journal for Research, Policy and Practice, 8:9, 1087-1088, DOI: 10.1080/17441692.2013.840007 To link to this article:

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Global Public Health, 2013 Vol. 8, No. 9, 10871088,

BOOK REVIEW Free market tuberculosis: Managing epidemics in post-Soviet Georgia, by Erin Koch, Nashville, TN, Vanderbilt University Press, 2013, 240 pp., US$27.95 (paperback), ISBN 9780826518934 In 2000, all the United Nations (UN) member nations and many international organisations, including the World Health Organization (WHO), adopted eight Millennium Development Goals significant steps towards improving health and quality of life on a global scale that they sought to achieve by the year 2015. Among these goals was the successful control of tuberculosis (TB) through the expansion of the WHO-endorsed directly observed treatment, short-course (DOTS) strategy. Medical anthropologist Erin Koch began the research presented in her new book, Free Market Tuberculosis, in the first years of this global push towards DOTS-based TB control practices, which included standardised treatment regimens, lab-based diagnostics and passive (symptomatic) case finding. With the year 2015 fast approaching, Kochs analysis of DOTS implementation in the Republic of Georgia offers a timely and necessary perspective on the successes and failures of the last 13 years and especially on the lessons that should be taken from efforts to control infectious diseases like TB through a primarily biomedical approach. In her analysis of Georgias transition from Soviet-era TB control to current, standardised protocols, Koch turns her attention to the gaps that exist between the invisible social assumptions of DOTS and the lived social realities in Georgia today. While numerous supporters of the DOTS programme laud it as a purely technological intervention, Koch shows the reader that DOTS requires a significant amount of fit with local political, social, and economic contexts in order to function successfully. In other words, Free Market Tuberculosis shows that DOTS is inextricably caught up in capitalist and free market logics, which are not universally applicable or translatable. Throughout the book, Koch considers two overarching questions: (1) does DOTS have the potential to be a successful TB control strategy in Georgia? and (2) could current efforts to expand DOTS in Georgia be driving the TB epidemic? Ultimately, and with thorough consideration, Koch answers both questions with an emphatic yes, presenting her book as a cautionary tale about the unintended consequences of biomedical standardisation and stove-piping that have become a defining feature of the contemporary global health industry (31). Through her detailed attention to the force and influence of international donors, the economic uncertainties inherent to a state plagued by deficit, and the simultaneous flourishing of hope, care, and mistrust that occurs on the interpersonal level, Koch deftly begins to pry up the floorboards of the DOTS strategy, revealing a foundation below that is neither as rigid nor as self-contained as we might want it to be. Koch begins her book with a chapter summarising the social history of TB in Georgia, from the earliest manifestations of medical practice to recent decades of economic and political upheaval. Today, TB control efforts in Georgia take place in a conflict-filled terrain. International groups are pushing to scale up DOTS, but their efforts are often met with resistance from physicians, who are reluctant to surrender their clinical

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Book Review

authority and expertise to laboratory-based diagnostic practices. This first chapter, entitled The Hand of Media, does the necessary work of situating DOTS-based programmes in the cultural, historical, and political contexts of Georgia. Koch smartly identifies places of friction and mismatch between the social assumptions underlying the DOTS approach and the realities of medical infrastructure, medical practice and material limitations in Georgia. Unsurprisingly, medical and philosophical pluralisms challenge the authority and rightness of the international DOTS approach. In Chapter two, Medicines on the Market, Koch uses a combination of observational research and interview data to juxtapose DOTS-based TB control programmes with those of the Soviet era. Koch delicately articulates the contradictions, troubles, and slippages that arise when efforts are made to close down the principles and philosophies of one system and replace them with the other. She also drives home the very important observation that the DOTS approach is just as rooted in free market ideologies as Sovietera programmes were in communist and Stalinist ideologies. In one example, Koch explains that material deficits in the health care system foster intense competition for resources among facilities. This encourages doctors and hospitals to hyper-diagnose cases of TB in order to inflate their numbers, thus creating a direct conflict between the old (need and resource-based) and new (standardised) diagnostic approaches. In Chapter three, Rendering Tuberculosis, Koch takes a solidly ethnographic approach and follows a group of lab technicians through the daily doldrums of bacterial testing. In her analytical dissection of these minor routines and boring tasks with microscopes and autoclaves, Koch renders apparent the fragility of DOTS technology as a mechanism for producing biological or biomedical information. Many of DOTS most technical components rely on the harmonisation of clock time, human resources, material resources and numerous microbiological agents in order to perform properly. Kochs main message here one that is important to consider when scaling up DOTS anywhere is that TB diagnostics are the outcomes of social relationships not transparent representations of something biological (142). In her fourth and final chapter, Free Market Tuberculosis Incarcerated, Koch turns her attention to Georgias prison system, a place where DOTS-based TB control should have the highest chance for success, as the restriction of movement and constant surveillance are inherent parts of the prison complex. In a tragic irony, though, Koch observed during her research that abhorrent living conditions within Georgian prisons drive TB infection through the prison population in ways that the DOTS strategy was not able to overcome. Additionally, the scale-up of DOTS services in prisons generated new behaviours among prisoners, such as cheating: faking a TB diagnosis by sharing sputum with an infected prisoner. Emergent responses to DOTS services, such as cheating, not only fuel the TB epidemic but also bend the moral arch of self-care, of treatment and of the very meaning of illness. This book offers powerfully necessary insights for students and practitioners of public health and is highly recommended for this audience. As an ethnographic work, it offers a unique and comprehensible presentation of complex qualitative data. It would, therefore, also be an excellent addition, whole or in part, to any course syllabus on ethnography, medical anthropology, medical geography or international development.

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Jennifer J. Carroll University of Washington, Seattle, WA, USA 2013 Jennifer J. Carroll