Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis

Abstract

This paper explores the issue of compliance by focusing on the control of tuberculosis. In the last ten years, patient compliance in tuberculosis control has discursively shifted from 'direct observation' of therapy to more patient-centred focus and support drawing on rights-based approaches in dealing with health care provision. At the same time, there has been an increased international concern with the rise of drug resistant forms of tuberculosis, and how to manage this. This paper looks at these issues and the tensions between them, by discussing the shift in discourses around the two and how they relate. Drawing on experience from work in Nepal, and its successful tuberculosis control programme, it looks at debates around this and how these two arenas have been addressed. The rise of increasingly drug resistant forms of tuberculosis has stimulated the development of new WHO and other guidelines addressing how to deal with this problem. The links between public health, ethics and legal mandate are presented, and the implications of this for controlling transmission of drug resistant disease, on the one hand, and the drive for greater patient support mechanisms on the other. Looking forwards to uncertain ethical and public health futures, these issues will be mediated by emergent WHO and international frameworks.

Social, Historical and Cultural Dimensions of Tuberculosis

“…In post-Soviet Georgia, the monitoring of the DOTS protocol was described as 'more stereotypically Stalinist in its implementation than the former Soviet system' (Koch, 2013b, p. 90). Medical anthropologist Ian Harper has also argued that the rigid reporting structures of WHO's DOTS strategy meant that patients who do not fit into the patient categories defined by WHO were often denied access to treatment -the most severe and complex cases of TB were excluded from care (Harper, 2010). Examples such as these suggest that standardized approaches to improving adherence can be counterproductive if they are implemented with a rigid or heavy handed approach.…”

The Political and Ethical Challenge of Multi-Drug Resistant Tuberculosis

“…However, it is now becoming clear that the reification of this simple standardised approach to TB diagnosis and treatment has harmed the development of locally appropriate programs. Indeed in some ways, DOTS has been in tension with, and, thereby, a hindrance to, on-the-ground efforts to deal with MDR-TB emergence (Keshavjee and Farmer 2012;Harper 2010). Experiences with implementing DOTS and our extensive knowledge of the biosocial and structural drivers of incidence and resistance tell us that a multilayered approach is necessary.…”

The Global in Global Health is Not a Given

“…6 The branding of Directly Observed Therapy short-course (DOTs) therapy has been politically successful in attracting funding, but has also created tensions when implemented prescriptively in diverse cultural contexts. 4,7 The focus of DOTs on treatment outcomes, for example, has perpetuated power relations between medical professionals and patients and simultaneously compromised patient support and the control of drug resistance. 7,8 Importantly, generalized and top-down approaches to decision-making may not simply create tensions in their local adaptation, but may also have other adverse consequences, such as fostering the emergence of multidrug resistance through the use of standardized drug regimens on patient populations with heterogeneous strains of tuberculosis.…”

“…4,7 The focus of DOTs on treatment outcomes, for example, has perpetuated power relations between medical professionals and patients and simultaneously compromised patient support and the control of drug resistance. 7,8 Importantly, generalized and top-down approaches to decision-making may not simply create tensions in their local adaptation, but may also have other adverse consequences, such as fostering the emergence of multidrug resistance through the use of standardized drug regimens on patient populations with heterogeneous strains of tuberculosis. 9,10 With the continuation of existing programmatic strategies in countries like Papua New Guinea, for example, the proportion of incident cases attributable to drugresistant tuberculosis are projected to more than double within a decade.…”