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Commentary on ‘the resurgence of disease: social and historical perspectives on the ‘new’ tuberculosis’
Social Science & Medicine 55 (2002) 397–398
Discussion
Commentary on ‘the resurgence of disease: social and historical perspectives on the ‘new’ tuberculosis’ John D.H. Porter, Jessica A. Ogden Departments of Public Health and Policy and Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Health Policy Unit, Keppel Street, London WC1E 6HT, UK
Gandy and Zumla (2002) offer a contribution to a burgeoning debate within the tuberculosis (TB) community, and public health more generally, around the need for inter-disciplinarity in research and intervention (e.g. Parker, 1996; Farmer, 1997, 1999; Porter & Grange, 1999; Porter, Ogden, & Pronyk, 1999a, b; Coker, 2000; Ogden, 2000). Perhaps to call it a debate is somewhat misleading: while a number of writers have made similar calls in recent years, the expected detractors appear not to exist. While it is disappointing that Gandy and Zumla do not engage with this workFeither to express fellowship or articulate differenceFtheir paper nevertheless, is further evidence of an apparent consensus among those of us working in TB. This consensus is based on the understanding that our research and intervention efforts would become more effective by using the whole range of perspectives and approaches at our disposal within the academy. Although this understanding may appear to be relatively recent, like much else in TB control it has historical roots. As far back as the middle of the 19th century, Louis Pasteur understood that ‘‘the microbe is nothing, the terrain everything’’ (quoted in Farmer, 1999, p. 37)Fsuggesting an understanding of the importance of social, historical and indeed geographical context in affecting and directing the course of illness, disease and health in communities. Thus, like the ‘‘new’’ TB itself, an understanding of the importance of interdisciplinarity is not so much emerging as re-emerging. At the start of a new century and a new millennium what we are witnessing in TB is a fascinating interplay between past and presentFtrying to learn from, and not repeat the mistakes of the past, while making best use of tools and technologies available today. What we hope to emerge out of this re-understanding of the past is a wholly new way forward for TB control. Once again, however, this ‘new’ way may in fact involve the application of some very old and too long forgotten human values, and human virtues (Horner, 2000). We contend, indeed, that new knowledge alone will not
bring about the control of this disease. In order to control TB in our communities, we first need to apply the knowledge we already have through a reconnection with, or a re-recalling of, what it means to be human. This may seem to be a curious claim and yet, history bears it out. Despite the extraordinary biomedical advances since the discovery of the tubercle bacillus in 1882 we have failed to bring this disease under control; the history of TB demonstrates that technology is not enough. Indeed, the introduction of new technologies can have the effect of further distancing us from the nitty–gritty of what it is to be humanFfrom the fragility of the human body and the complexities and nuances of healing. Although the ‘product’ itself (the new drug, the new diagnostics, the vaccine) is obviously needed, how it is delivered is equally important. Whatever new technologies are created through biomedical advances in the field of tuberculosis, it is ultimately human beings (scientists, health care workers, politicians, policy makersy) who need to apply these technologies for the benefit of those people who suffer from TB. The key issue in TB control as we see it, therefore, is not whether we should become more inter-disciplinary, or whether social science is important, or even whether the DOTS strategy is the answer. We believe that the real issue for TB control is ‘how’ we deliver care to patients. Much can be gained through thoughtful application of care, communication and social justice. One way to do this is to remember what we had before the organism was discovered. At the risk of glorifying the past (see Coker, 2000 for a discussion of the problems associated with previous approaches to TB control), we may do well to remember that there was once a system for treating people with TB that was centred on care. Since the ‘magic bullet’ of antibiotic treatment was not available, people had to be cared for and supported in their communities. There was a need for sensitivity to the context where TB treatment and control was being practiced; a need to concentrate on
0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 7 7 - 0
398
J.D.H. Porter, J.A. Ogden / Social Science & Medicine 55 (2002) 397–398
people’s lives and ways that health systems could support them. Thus, we readily support Gandy and Zumla’s efforts, but think it is time to take the discussion a step further. In keeping with what we have come to expect within TB, what we suggest is both a step forward, and a step back. It is a shift in perspective from a focus on the microbe to a focus on the terrain; from standardised, short term interventions with an emphasis on outputs, to an approach that is responsive to context, with longer term objectives and a focus on process (Porter, Ogden, & Pronyk, 1999b). This will assist in the integration of technical advances with the truly old fashioned (but by no means out-dated) ‘human’ aspects of disease control that emphasise relationship, community, partnership, and care. We welcome Gandy and Zumla’s call for a broader, more contextualised and socially informed approach to TB management. It heralds exciting times in prospect. In retrospect, let us also bear in mind a remark made by a distinguished anthropologist to his seminar class at the London School of Economics back in the 1950s: ‘‘Good anthropology’’ he advised them ‘‘is not when you say: ah! Now I understand. Good anthropology is when you say: ahy now I remember’’ (Sandra Wallman, personal communication). Engaging with what it is to be human, and applying that to our work, scholarship and relationships with each other, with patients and with communities, may be the easiest breakthrough yet in public healthFif we can remember how.
References Coker, R. J. (2000). From chaos to coercion. Detention and the control of tuberculosis. New York: St Martins Press. Farmer, P. (1997). Social Scientists and the new tuberculosis. Social Science and Medicine, 44(3), 347–358. Farmer, P. (1999). Infections and inequalities. The modern plagues. Berkeley, CA: University of California Press. Gandy, M., & Zumla, A. (2002). The resurgence of disease: Social and historical perspectives on the ‘new tuberculosis. Social Science and Medicine, this issue. Horner, J. S. (2000). The virtuous public health physician. Journal of Public Health Medicine, 22(1), 48–53. Ogden, J. A. (2000). Improving Tuberculosis Control: Social science inputs. Transactions of the Royal Society of Tropical Medicine and Hygiene, 94, 135–140. Parker, R. G. (1996). Empowerment, community mobilisation and social change in the face of HIV/AIDS. AIDS, 10(Suppl. 3), s31. Porter, J. D. H., Grange, J.G. (Eds.) (1999) Tuberculosis: An Interdisciplinary Perspective. London: Imperial College Press. Porter, J. D. H., Ogden, J. A., & Pronyk, P. (1999a). The way forward: an integrated approach to tuberculosis control. In J. D. H. Porter, & J. G. Grange (Eds.), TuberculosisFan interdisciplinary perspective (pp. 359–378). London: Imperial College Press. Porter, J. D. H., Ogden, J. A., & Pronyk, P. (1999b). Infectious disease policy: Towards the production of health. Health Policy and Planning, 14(4), 322–328.
Discussion
Commentary on ‘the resurgence of disease: social and historical perspectives on the ‘new’ tuberculosis’ John D.H. Porter, Jessica A. Ogden Departments of Public Health and Policy and Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Health Policy Unit, Keppel Street, London WC1E 6HT, UK
Gandy and Zumla (2002) offer a contribution to a burgeoning debate within the tuberculosis (TB) community, and public health more generally, around the need for inter-disciplinarity in research and intervention (e.g. Parker, 1996; Farmer, 1997, 1999; Porter & Grange, 1999; Porter, Ogden, & Pronyk, 1999a, b; Coker, 2000; Ogden, 2000). Perhaps to call it a debate is somewhat misleading: while a number of writers have made similar calls in recent years, the expected detractors appear not to exist. While it is disappointing that Gandy and Zumla do not engage with this workFeither to express fellowship or articulate differenceFtheir paper nevertheless, is further evidence of an apparent consensus among those of us working in TB. This consensus is based on the understanding that our research and intervention efforts would become more effective by using the whole range of perspectives and approaches at our disposal within the academy. Although this understanding may appear to be relatively recent, like much else in TB control it has historical roots. As far back as the middle of the 19th century, Louis Pasteur understood that ‘‘the microbe is nothing, the terrain everything’’ (quoted in Farmer, 1999, p. 37)Fsuggesting an understanding of the importance of social, historical and indeed geographical context in affecting and directing the course of illness, disease and health in communities. Thus, like the ‘‘new’’ TB itself, an understanding of the importance of interdisciplinarity is not so much emerging as re-emerging. At the start of a new century and a new millennium what we are witnessing in TB is a fascinating interplay between past and presentFtrying to learn from, and not repeat the mistakes of the past, while making best use of tools and technologies available today. What we hope to emerge out of this re-understanding of the past is a wholly new way forward for TB control. Once again, however, this ‘new’ way may in fact involve the application of some very old and too long forgotten human values, and human virtues (Horner, 2000). We contend, indeed, that new knowledge alone will not
bring about the control of this disease. In order to control TB in our communities, we first need to apply the knowledge we already have through a reconnection with, or a re-recalling of, what it means to be human. This may seem to be a curious claim and yet, history bears it out. Despite the extraordinary biomedical advances since the discovery of the tubercle bacillus in 1882 we have failed to bring this disease under control; the history of TB demonstrates that technology is not enough. Indeed, the introduction of new technologies can have the effect of further distancing us from the nitty–gritty of what it is to be humanFfrom the fragility of the human body and the complexities and nuances of healing. Although the ‘product’ itself (the new drug, the new diagnostics, the vaccine) is obviously needed, how it is delivered is equally important. Whatever new technologies are created through biomedical advances in the field of tuberculosis, it is ultimately human beings (scientists, health care workers, politicians, policy makersy) who need to apply these technologies for the benefit of those people who suffer from TB. The key issue in TB control as we see it, therefore, is not whether we should become more inter-disciplinary, or whether social science is important, or even whether the DOTS strategy is the answer. We believe that the real issue for TB control is ‘how’ we deliver care to patients. Much can be gained through thoughtful application of care, communication and social justice. One way to do this is to remember what we had before the organism was discovered. At the risk of glorifying the past (see Coker, 2000 for a discussion of the problems associated with previous approaches to TB control), we may do well to remember that there was once a system for treating people with TB that was centred on care. Since the ‘magic bullet’ of antibiotic treatment was not available, people had to be cared for and supported in their communities. There was a need for sensitivity to the context where TB treatment and control was being practiced; a need to concentrate on
0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 7 7 - 0
398
J.D.H. Porter, J.A. Ogden / Social Science & Medicine 55 (2002) 397–398
people’s lives and ways that health systems could support them. Thus, we readily support Gandy and Zumla’s efforts, but think it is time to take the discussion a step further. In keeping with what we have come to expect within TB, what we suggest is both a step forward, and a step back. It is a shift in perspective from a focus on the microbe to a focus on the terrain; from standardised, short term interventions with an emphasis on outputs, to an approach that is responsive to context, with longer term objectives and a focus on process (Porter, Ogden, & Pronyk, 1999b). This will assist in the integration of technical advances with the truly old fashioned (but by no means out-dated) ‘human’ aspects of disease control that emphasise relationship, community, partnership, and care. We welcome Gandy and Zumla’s call for a broader, more contextualised and socially informed approach to TB management. It heralds exciting times in prospect. In retrospect, let us also bear in mind a remark made by a distinguished anthropologist to his seminar class at the London School of Economics back in the 1950s: ‘‘Good anthropology’’ he advised them ‘‘is not when you say: ah! Now I understand. Good anthropology is when you say: ahy now I remember’’ (Sandra Wallman, personal communication). Engaging with what it is to be human, and applying that to our work, scholarship and relationships with each other, with patients and with communities, may be the easiest breakthrough yet in public healthFif we can remember how.
References Coker, R. J. (2000). From chaos to coercion. Detention and the control of tuberculosis. New York: St Martins Press. Farmer, P. (1997). Social Scientists and the new tuberculosis. Social Science and Medicine, 44(3), 347–358. Farmer, P. (1999). Infections and inequalities. The modern plagues. Berkeley, CA: University of California Press. Gandy, M., & Zumla, A. (2002). The resurgence of disease: Social and historical perspectives on the ‘new tuberculosis. Social Science and Medicine, this issue. Horner, J. S. (2000). The virtuous public health physician. Journal of Public Health Medicine, 22(1), 48–53. Ogden, J. A. (2000). Improving Tuberculosis Control: Social science inputs. Transactions of the Royal Society of Tropical Medicine and Hygiene, 94, 135–140. Parker, R. G. (1996). Empowerment, community mobilisation and social change in the face of HIV/AIDS. AIDS, 10(Suppl. 3), s31. Porter, J. D. H., Grange, J.G. (Eds.) (1999) Tuberculosis: An Interdisciplinary Perspective. London: Imperial College Press. Porter, J. D. H., Ogden, J. A., & Pronyk, P. (1999a). The way forward: an integrated approach to tuberculosis control. In J. D. H. Porter, & J. G. Grange (Eds.), TuberculosisFan interdisciplinary perspective (pp. 359–378). London: Imperial College Press. Porter, J. D. H., Ogden, J. A., & Pronyk, P. (1999b). Infectious disease policy: Towards the production of health. Health Policy and Planning, 14(4), 322–328.