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Medical Anthropology: CrossCultural Studies in Health and Illness

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Local Microbiologies of Tuberculosis: Insights from the Republic of Georgia

Erin Koch
a a

Department of Anthropology, University of Kentucky Published online: 07 Jan 2011.

To cite this article: Erin Koch (2011) Local Microbiologies of Tuberculosis: Insights from the Republic of Georgia, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 30:1, 81-101, DOI: 10.1080/01459740.2010.531064 To link to this article: http://dx.doi.org/10.1080/01459740.2010.531064

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MEDICAL ANTHROPOLOGY, 30(1): 81101

Copyright # 2011 Taylor & Francis Group, LLC ISSN: 0145-9740 print=1545-5882 online DOI: 10.1080/01459740.2010.531064

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Local Microbiologies of Tuberculosis: Insights from the Republic of Georgia

Erin Koch

The perspective of local microbiologies brings attributes of microbes squarely into the anthropological purview, underscoring dialectics of biology and culture in which infectious diseasesand knowledge and practices about themare produced. In this article I provide an anthropological perspective of expert discourses about tuberculosis at a tuberculosis reference laboratory in Tbilisi, Georgia. A latentactive dichotomy prevails in contemporary global health responses to tuberculosis. Based on ethnographic research about everyday laboratory-based diagnostic work, I question the stability of this dichotomy and unsettle biological and cultural reductionism. In so doing, I highlight the theoretical and methodological contributions that anthropological engagements with science, technology, and medicine bring to studies of global health.
Key Words: Georgia; global health; microbes; tuberculosis

Laboratory Fieldnotes Excerpt, June 12, 2001: When I arrived this morning Tamuna1 was waiting for me to prepare drug susceptibility tests (DSTs) from cultures of Mycobacterium tuberculosis (Mtb), the bacterial causative agent of tuberculosis. Drug susceptibility tests are significant because they clarify bacterial strains in people, and shape treatment regimens. However, like the bacteria they enable laboratory technicians to typify, DST results are not static.

ERIN KOCH is Assistant Professor in the Department of Anthropology at the University of Kentucky specializing in medical anthropology, ethnography of science and technology, and global health. Her current research in the Republic of Georgia focuses on health and displacement, medical interventions, and politics of care. Correspondence may be directed to her at University of Kentucky, Department of Anthropology, 211 Lafferty Hall, Lexington, KY 40506, USA. E-mail: erin.koch@uky.edu

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Preparing DSTs involves handling culture colonies from each sample that techs (laboratory technicians) grind, suspend in sterile water, and saturate in media prepared with four first-line drugs: rifampicin, isoniazid, ethambutol, and pyrazinamide. Lab techs take great care in decolonizing and grinding Mtb colonies from cultures to ensure their personal safety and sample integrity. I sat next to Tamuna at the ventilated hood, unwrapping mortars and pestles as she needed them in order to grind colonies of Mtb. As Tamuna carefully removed samples from different locations in the test tubes, she emphasized that taking cultures from several different colonies in each tube where Mtb has been cultivated gives a more accurate DST answer because there may be different strains growing in one sample. Tuberculosis is plural, not singular, I thought. Next she placed the colonies in a mortar and vigorously ground them, explaining that in a laboratory possessing more resources a machine might do this work. It took just over 2 hours to set up susceptibility tests for 14 samples. It was exhausting to watch, and later she told me that the work was exhausting to perform. In 3 weeks we would have the results of the tests.
Laboratory Fieldnotes Excerpt, June 20, 2001: Today Tamuna and I read results from DSTs that had been prepared three weeks prior. On this morning we saw in those tubes many patterns of resistance and susceptibility. She told me that you could see that some people were infected with the same strain. But one person could be infected with different strains at once, and new forms of resistance might develop during treatment. Although DST results are important in shaping treatment regimens for each patient, this information is not static; it might be fleeting or representative of something in transition. When I asked Tamuna about this, she lightly sighed and said we do the best we can. This is how it is with tuberculosis, with these bacteria. You never know how they will change. We have to work with the information we have. DSTs are not covered by the state TB program, so most people cant afford this test anyway. I asked her if she thought that because the test results take so long (8 weeks to grow TB cultures, 3 weeks for DST results), someones TB might have changed since they gave the sample. Again, a gentle sigh and well, the tests are slow in part because it is a slow-growing bacterium. And in the lab we do not know everything about what is happening with the patient at home or anything. We do the best we can.

That afternoon, as Tamuna recorded results, I thought about the multiple meanings single sputum samples could bear. For patients, sputum is an element of physical discomfort, and a potentially stigmatizing marker of infection. For clinicians, a productive cough indicates that a patient might have an active case of tuberculosis. Laboratory technicians interact with sputum as a work-object with which they perform diagnostic tests to

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render and classify bacteria. Through their routine work, lab techs forge relationships with bodily substances and bacteria, if any are present. Mycobacterium tuberculosis, like all microbes, is a hybrid; its ecology is a second nature determined at the intersection of economy, biology, and biomedical standardization. Anthropological attention to microbes shows how organisms biologies are shaped by time and place (Lock and Nguyen 2010:100), affecting experiences of illness. From a purely biological perspective, Mtb is characterized as a slow-growing and successful pathogen that bears natural capacities for evading detection and developing antibiotic resistance. Paradoxically, biomedical interventions reify bacterium as static, but in fact, they are constantly changing, thereby undermining treatment. This paradox is evident in the ethnographic analysis of diagnostic TB laboratory work presented here. The Georgian context further highlights how within standardized forms of knowledge production, the significance of microbes is made meaningful in practice (Helmreich 2009). Standardized global health protocols for tuberculosis control categorize, respond to, and, I argue, reduce tuberculosis to fixed biological states active or latentthat are perceived to be most readily diagnosable in the laboratory. Drawing on ethnographic fieldwork in a tuberculosis laboratory in Tbilisi, Georgias capital city, in this article I propose that active and latent TB are not fixed biological states, but dialectical human-microbe relationships that only emerge and become meaningful in particular contexts. I introduce the concept of local microbiologies to highlight and frame these nuances. My goal is to bring the molecular properties of microbes squarely into the anthropological purview and to foster a more nuanced understanding of human-microbe relations. Attributes of microbes are made meaningful for processes such as classifying and rendering micro-organisms and intervening in infectious diseases. They are also made meaningful by people who have stakes in establishing relationships with microbes, such as laboratory technicians. From the perspective of local microbiologies, however, that relationality is eclipsed when laboratory results are reduced to a fixed state of active, resistant, and so on. Focusing on static microbial states gives way to rigid treatment regimens, irrespective of a local microbiology, which in turn could undermine the effectiveness of the very protocol designed to control the spread of disease and cure cases. Ironically, the molecular characteristics that biologists and laboratory technicians use to distinguish mycobacterium tuberculosis emphasize adaptability and resilience rather than a fixed state of active or latent infection. The laboratory staff with whom I worked regularly talked about Mtb as if it were a key player in not only infection but in what they did on a daily basis to try to detect and classify its presence in sputum samples through smear microscopy, culturing, and drug susceptibility tests. In a clinical TB

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laboratory, work is about cultivation, and cultivation is a relational process that emerges through and expresses social relations, not a simple biological fact or state. In the following section, I lay out the framework of local microbiologies. Next, I discuss contemporary global tuberculosis and the cultural politics of biomedical standards for its surveillance and management. The remaining two sections ethnographically anchor local microbiologies of tuberculosis in the main tuberculosis clinical laboratory in Tbilisi, Georgia. I explore how and why laboratory technicians cultivate relationships with microbes to facilitate diagnosis and the ways in which these processes engage with specific molecular, microbial attributes.

LOCAL MICROBIOLOGIES The framework of local microbiologies emerges at the intersections of medical anthropology and science and technology studies and is motivated by Margaret Locks concept of local biologies (1993, 2001). Lock emphasizes a dialectal approach at the heart of local biologies to examine how knowledge about biology is informed by the social and the social is in turn informed by the reality of the material . . . the biological and the social are co produced and dialectically reproduced (Lock 2001:484). In her comparative study of aging and menopause in Japan and the United States, Lock emphasized that both biology and culture are dynamic and contingent, rather than determinant. Lock was primarily concerned with how an assumed biological universality of the human body (Lock and Nguyen 2010:83) in biomedical practices and knowledges eclipses the ways that biological and social processes come together temporally and spatially as artifacts of infinite possible biosocial outcomes. Local microbiologies shift attention from the human body to human-microbe relations and refer specifically to how those attributes become meaningful in practice. In the case of tuberculosis, microbes are manipulated and behave opportunistically within local conditions. Two recent anthropological studies accentuate why an understanding of human-microbe interactions is important. In her ethnographic account of raw milk cheese production in the United States, Heather Paxson argued that neglect of the microbe . . . continues to distort our anthropological view of the social world (2008:1920). To clarify the distortion, Paxson offered the framework of microbiopolitics, which highlights the unique insights that a focus on microbial social relations brings to local biologies. By microbiopolitics she means the creation of categories of microscopic biological agents; the anthropocentric evaluation of such agents; and of

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appropriate human behaviors vis-a-vis microorganisms engaged in infection, inoculation, and digestion (2009:17). For the raw milk cheese producers with whom Paxson worked, bacteria bear many positive attributes. First, cheese artisans celebrate the health benefits of a diet rich in bacterial cultures. But the bacteria also give taste to the cheese; they are part of the character that cheese makers cultivate through human-microbe relations. As the artisanal cheese makers get to know microbes, they are not just cultivating bacteria, but in an artisanal local microbiology, cultivating relationships with them. Paxson underscored a noteworthy ethnographic insight that speaks to the significance of local microbiologies: in our anthropological engagements with microbes, we should consider them in terms of what they do, not what they are (Paxson 2008:26). From a very different vantage, Stephan Helmreichs (2009) ethnography of oceanic life and life sciences, marine biologists, and venture capitalists underscores the importance of bringing microbes into anthropological purview. Microorganisms are key figures in debates about oceanic natures and cultures, and laboratory research is central to rendering their evolutionary and venture capital meanings legible, for example, in producing DNA libraries. But the microbes that are the sea (not merely in it) do not immediately lend themselves to genomic analysis. Within what I would call a local microbiology, the genomic scientists with whom Helmreich worked reconfigured apparent biological obstacles into resources in ways that recast both human-microbe socialities and debates about life and evolution. His ethnography offers a critical insight for anthropological studies of infectious diseases: microbes do not simply shape social aspects of infection and treatment; local cultural politics of scientific (and biomedical) expertise also shape the status and meanings of microbes and how they relate with laboratory cultures, bodies, and protocols. Helmreichs study also emphasizes that laboratories are unique environments for establishing local microbiologies because they are devices for creating significance, for separating figure from ground, for adjusting what counts as text and context (Helmreich 2009:57; see also Heath 1997; Montoya 2007). In the clinical laboratory where I conducted research, Mtb emerges in a shifting terrain of disease governance. Laboratory test results produce information critical for treating active cases and for determining drug susceptibility so that individual patients can be treated with case-appropriate antibiotics. Mycobacterium tuberculosis spreads in droplets released when a person with an active infection coughs or sneezes. Mycobacterium tuberculosis can survive in the air for several hours; it displays natural resistance to antibiotics and can lay dormant in lungs or other spaces in the body where it may establish residence and proliferate for long periods before

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reactivating and replicating (Cosma, Sherman, and Ramakrishnan 2003:642). Because Mtb is characterized by its capacities to conceal itself, lay dormant then reactivate, and develop resistance to antibiotics, it is known as a successful pathogen (Hett and Rubin 2008; Vergne et al. 2004). An ethnographic analysis shows that the significance of the biological attributes is only produced through social relationships; for example, in local microbiologies of diagnostic labs and of criteria for getting tested. Tuberculosis is a global health problem of epic proportions, and contemporary global health efforts that focus primarily on active (infectious) tuberculosis might be part of the problem.

GLOBAL TUBERCULOSIS In the late 1980s and early 1990s, rates of tuberculosis and multiple drug-resistant TB (MDR-TB) spiked so dramatically that in 1993 the World Health Organization (WHO) declared a global TB emergency. This event brought renewed resources to TB programs that had been severely cut in the 1960s through the 1980s, when international health officials declared that tuberculosis was nearly eradicated (Raviglione and Pio 2002). This perspective accepted that TB was invisible to international donors and taken to be a fact of life in the most-affected parts of the world (Dye and Williams 2010:856). The rise of antibiotic-defying strains reframed tuberculosis, transforming it from a public health risk to a security threat in the West. The rise of extensively drug-resistant tuberculosis (XDR-TB)strains that are resistant to first- and second-line antibioticssimultaneously galvanized further resources for TB control and sharpened a biosecurity framework for its intervention; this transformation is an exemplary local microbiology in which bacteria outsmart immune systems, health systems, and antibiotics. This is not because strains of Mtb are successful pathogens in an essential biological sense but because patterns of resistance are shaped by dynamics of human-microbe relationships, such as political debates about appropriate treatment, poverty, and public health neglect. According to the WHO, in 2008 approximately 1.77 million adult deaths resulted from tuberculosis (World Health Organization 2009). One out of every three individuals worldwide (approximately 2 billion people) is infected with Mtb, and the WHO estimates that one individual is newly infected every second, and that one person dies from tuberculosis every 20 seconds. A review of contemporary TB trends recently published in Science states that as the number of new TB cases continues to rise annually, there are expected to be 9.8 million new cases in 2010, more than in any previous

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year in history (Dye and Williams 2010:856). Approximately 5 percent of people newly infected with Mtb are infected with strains already resistant to standard antibiotics. Although the tiny microbe harbors in the bodies of billions of people, anti-tuberculosis medicines do not capture the attention of drug companies because the vast majority of people with TB are young and poor and live in developing countries. Very often, neither the people nor their countries can afford TB drugs (Reichman 2001:176). Treatments and diagnostic tests for tuberculosis are outdated; innovations in pharmaceutical research and development are not equally distributed to the TB arena (Sassetti and Rubin 2007:279). No new anti-tuberculosis medicines have been available as treatment since rifampicin was brought to the market in 1963. The standard clinical and laboratory tests for latent and active tuberculosis are more than 120 years old (Frieden, Lerner, and Rutherford 2000:1088; Harries 2008). Although TB R&D is increasing and there are new tests, vaccines, and treatments in the pipeline (Ma et al. 2010; Shi and Sugawara 2010), the focus on biomedical interventions for identifying and killing bacteria eclipses structured social, political, and economic inequalities that fuel antibiotic resistance (Altman 2008), and that entrench tuberculosis in individuals, families, and communities. In response to the emergency, the WHO first recommended a program of short-course chemotherapy that evolved into a highly standardized protocol branded Directly Observed Treatment, Short-Course (DOTS). The DOTS protocol is structured around laboratory-based diagnosis and treatment regimens of first-line anti-TB drugs: rifampicin, isoniazid, ethambutol, and pyrazinamide, with direct observation of medicine ingestion 37 days a week for 69 months. The goals of the protocol are to quickly identify and cure people who are actively sick, thus cutting chains of infection. The DOTS protocol is the global gold standard of tuberculosis control (Porter, Lee, and Ogden 2002). In 2006 the strategy was incorporated as an integral element of the WHOs Stop TB Strategy. As a result, a biomedical intervention focused on killing bacteria took priority over other social responses to illness, such as alleviating poverty and improving nutrition and living conditions. As medical anthropologists have shown, in its implementation the global DOTS protocol is constantly recrafted in the context of local practices, forms of knowledge, and everyday life (Koch 2006; Harper 2005; Nichter 2008; Shin et al. 2004). However, DOTS is primarily a biological regimen that privileges a biomedical worldview over larger structural and cultural contexts. The active and latent opposition suggests a falseor at least a forceddichotomy that obscures the ways in which the microbe, the social context, and the body are all in motion (Bowker and Star 1999:169). This motion can be seen through ethnographic encounters in specific local microbiological contexts (e.g., Helmreich 2009).

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Laboratory-based tests are at the heart of the DOTS protocol. Within the framework of an effective TB control program, the identification and treatment of infectious cases of pulmonary TB is the highest priority. The laboratory is therefore the focal point of the entire program (WHO= IUATLD 2000:79). The basic diagnostic is smear microscopy, in which lab techs smear and stain sputum samples to look for bacteria. According to the WHO, diagnosis by smear microscopy is ideal in resource-poor settingssuch as that of Georgia discussed herebecause the process is simple, requires minimal equipment, and produces fast results (WHO 2003). However, individuals only receive a definitive diagnosis after providing 23 samples over the course of 23 consecutive days. As Georgian laboratory technicians and doctors often emphasized to me, this delays treatment and discourages individuals who fear being stigmatized as a TB patient from returning to the laboratory. Furthermore, the results of a smear could reveal that the individual has been infected with some type of Mycobacteriumof which there are 70 speciesbut not that it is necessarily Mtb. Some experts argue that sputum smears only detect 50 percent of positive cases, in part because bacterium often spread from the lungs into the bloodstream and other tissues, producing false negatives (Marris 2007). The only way global tuberculosis can be addressed in the long term is by developing new and more effective diagnostics, vaccines, and treatments for both latent and active forms of tuberculosis. Even with the contemporary global health push for improving TB diagnostics and resources, biology still takes center stage in the management of an illness that is an assemblage of biological, political, social, and economic factors. Anthropologists who study infectious diseases bring to light the limits of public health interventions that highlight culture and behavior as primary factors in the spread of infection and antibiotic resistance (Briggs and Mantini-Briggs 2003; Farmer 1992, 1999). However, the ways in which microbial attributes and human health are configured and reconfigured through dialectical relationships with culture and behavior escapes consideration in these analyses (Orzech and Nichter 2008). If anthropologists are to transcend perspectives that see either culture as dominant and biology as essentially irrelevant or, conversely, biology as an immutable base and culture as a distortion, then it is essential that we acknowledge the plasticity of biology and its interdependence with culture (Lock 1993:373). To effectively treat tuberculosis as a complex comprised of bacterial ecology in relation to social and cultural patterns, it is important to consider anthropologicallynot only biologicallythe molecular and biological attributes of microbes. Nuances of host-pathogen interactions emerge on a threshold that is not simply biological or cultural but also local microbiologically. Focusing on

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individuals actively sick with tuberculosis creates a paradox. Because DOTS is based on passive case finding and privileges diagnosis by smear microscopy, the protocol only accounts for people who actively seek medical attention and who have enough bacteria in their sputum for that diagnostic to establish infectiousness.

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MANAGING TUBERCULOSIS IN GEORGIA Countries that formerly comprised the Soviet Union constitute a hot zone in the contemporary Global TB Emergency (Koch 2008). After Georgia separated from the Soviet Union in 1991, the centralized Soviet medical infrastructure was dismantled, leaving behind facilities lacking basic supplies, health professionals who lost their positions or who were working without salaries, and patients who lost a highly specialized system that they knew how to navigate. There was no official health care system in operation until 1995 when the Government launched massive reforms (Belli, Gotsadze, and Shahriari 2004; Gotsadze, Zoidze, and Vasadze 2005). Those factors were particularly favorable to the spread of tuberculosis, which is highly transmissible with poverty and delayed or limited care. In Georgia, TB services are primarily supported by the state and by international organizations, and are distributed through a vertical program that is not integrated with the rapidly changing primary health care system. Amid a shifting landscape of service provision and economic barriers to care, many active cases are not diagnosed or treated until disease is advanced. Many Georgian TB clinicians, laboratory workers, and administrators with whom I worked expressed their views of the difficulty of implementing DOTS in Georgia. Tuberculosis doctors emphasized that even as resources and political will for combating tuberculosis increase, sick individuals are generally unfamiliar with the protocols worldview. This worldview is anchored in passive case finding, meaning that health care workers do not provide compulsory screening of the population. This requires that potential patients recognize symptoms and self-present to doctors in the face of job loss (which often follows a TB diagnosis) or fear of being marginalized as a dirty or poor person, which is often the case. The political economy of health in Georgia, when wedded with DOTS, produces a local microbiology in which active cases are of primary concern. This has more to do with the political economic relations that structure testing, treatment, and surveillance than with biological attributes of microbes. Nowhere was this more evident than in the diagnostic laboratory in Tbilisi where I conducted fieldwork. The National Reference Laboratory (NRL) in Tbilisi is a level-three reference laboratory. Following guidelines for global TB control set by

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the WHO, it is the central nervous system of any National TB Program. In Georgia, the NRL is one of the few laboratories equipped to grow cultures of Mtb, and the only laboratory with the capacity to run drug susceptibility tests. Working in the laboratory several days a week for six consecutive months, I developed finely tuned sensibilities about how sputum is manipulated to render bacteria, which is critical for diagnosis and for guiding and monitoring treatment. I also developed fluency with procedures that identify bacteria through microscopic analysis of sputum smears, culture growth, and drug susceptibility tests. I began to see tuberculosis from the perspective of laboratory technicians. This perspective necessarily engages with Mtb as an active agent, but in ways that bring to bear what Mtb does relationally not what it is. This is contrary to discourse of molecular biology and public health. The Georgian government launched the NTP in 1995 under the auspices of the Ministry of Health (now the Ministry of Labor, Health, and Social Affairs), and with the assistance of a range of donor and aid organizations (Gzirishvili and Mataradze 1998). Headquartered in Tbilisi, the NTP is managed in accordance with DOTS, which confers legitimacy in international public health networks and secures resources that the government is unable to provide. However, DOTS implementation has not been a seamless process because the protocol is not value-free. In Georgia, one factor has been that diagnosis and treatment under the Soviet system and DOTS are very different. In contrast to passive case finding with DOTS, the Soviet model of TB control emphasized compulsory screening of the entire population (active case finding) by fluorography and x-ray, vaccinations, and long-term hospitalization in sanatoria (Lapina 1970). Diagnosis was based primarily on x-ray evaluations, and treatment regimens relied heavily on the professional expertise and knowledge of specialized TB doctors (Perelman 2000). Analysis of smeared sputum samples has eclipsed x-ray images as a primary indicator of tuberculosis. As Shorena, the administrative head of the laboratory, explained, this is largely for epidemiological reasons: For society someone like this [TB positive] may be very dangerous . . . and we do not know if they are spreading the bacteria. They are a risk. Epidemiologically it is very important to find if [sputum tests] are positive or negative. We cannot tell by X-Ray. Although clinicians still use x-rays for examining lesions and determining the need for surgery, x-rays (and the clinic) are no longer primary sites for diagnosis. Instead, laboratory-based diagnostics that render and classify bacteria produce authoritative and reliable knowledge in Georgias shifting terrain of disease management and expertise. The laboratory at the NTP changed dramatically as I tracked its work, and at the time of writing, diagnostic test procedures are undergoing new

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changes. When I visited the NTP during preliminary research in April 2000, it consisted of three small run-down rooms in a dilapidated building; the high quality binocular microscopes and centrifuge machines that had been donated by Emory University and the German Agency for Technological Cooperation (GTZ) seemed out of place inside crumbling walls. At that time, the building that currently houses the NRL was under construction, with support from the International Committee of the Red Cross (ICRC). The ICRC was in charge of the program to control tuberculosis in Georgias prison system, and they needed laboratory facilities that could handle a high volume of samples, as many as 30 per day, several days a week. Built according to WHO standards, the newer laboratory would have the capacity to process tests for Georgias prison population and enable laboratory technicians to process tests for non-prisoners in a DOTS-appropriate environment. When I started long-term fieldwork in 2001, the new NRL had been fully functional for several months. On my first day, Lela, a microbiologist, compared the NRL to the conditions in laboratories she had recently visited in Poti and Batumi, smaller cities in western Georgia along the Black Sea coast. Displaying a lively combination of compassion and frustration with everyday work and life in Georgia that I eventually learned was typical of her and other Georgians, she yanked off her glasses and exclaimed: I dont know how they work. They have no gloves or masks and they do not have any hoods or exhausts systems. They are just working with open samples of sputum that may be infected . . . they have no microscopes, they cannot do correct smears . . . it is impossible to look at the slide. The impossibility of conducting basic microscopic analyses in such conditions was at once both an unimaginable situation for a scientist and a reality of diagnostic laboratory work in Georgia. During my most intensive fieldwork I quickly became friends with Tamuna, one of the younger laboratory technicians who was particularly enthusiastic about my interest in the details of Georgian technicians work and lives. I first met Tamuna in 2000, during a brief tour of the older laboratory facilities, when our interactions were hindered by the short-term nature of my visit and by the masks we wore that prevented us from seeing most of each others faces. When I returned the following year Tamuna, then in her late 20 s, excitedly recounted our first meeting, and interviewed me about my research interests in the laboratory. Throughout her month-long rotations on the smear work team, I would perch next to Tamuna at one of the hoods in the smear room, watching her use a sterilized loop of thin metal with a long handle attached to gather sputum. She regularly became frustrated with the old, fragile loops, as she lost precious work time repairing them or looking for a better

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one. We cant even afford to buy the disposable loops, she occasionally complained. During my first weeks working in the NRL I asked Tamuna why the smear test is the standard diagnostic test, not only in Georgia but worldwide. She explained that Mycobacterium tuberculosis is a slow-growing bacterium surrounded by a waxy cell wall that protects it from detection by the immune system (Saunders and Britton 2007:103). This wall also forms a biochemical matrix that renders the majority of available antibiotics ineffective. Structurally and chemically Mtb has the capacity to exploit a hosts immune system to lay dormant in the lungs for long periods of timein some cases for decadeswhere it can evade detection and potentially reactivate itself (Cosma et al. 2003:666). The exact mechanisms by which all this occurs remain somewhat mysterious, but bear relevance for vaccine and drug development (Cosma et al.:654), and have determined how Mtb is imbued with meaning within laboratories, which in turn determine the development of disease detection regimen.

RENDERING BACTERIA Smearing sputum is a simple process, but must be conducted with care to protect both the lab tech and sample from contamination. Once the smear has been prepared, it is stained red, decolorized, and counterstained blue to highlight any bacteria that might be present. Technicians check slides for bacteria according to WHO standards, which dictate that each slide must be visually divided into different fields of vision in which the number of bacteria present must be counted. Lab techs use this information to assess the risk of infection that an actively infected individual poses to others as well as to determine the effectiveness of treatment. Smears provide enough information to know if someones sputum is negative or positive for bacteria and, if so, the level of bacteria in their sample. However, diagnostic tests do not provide static representations of pure biological states; an accurate reading of a slide does not provide a total picture of health or the risks an individual may pose to family members and to society at large. Some medical service providers with whom I spoke expressed concern that because DOTS only accounts for active cases, the protocol reveals a minimal number of those infected. One TB specialist also challenged the efficacy of passive case finding:
[This approach] does not work in our country. Before [under the Soviet model] case finding was active, and medical professionals screened the entire population. But now we are waiting for people to come to us. It is not enough

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for Georgia . . . . In Georgia patients usually wait until a disease is very serious to go to a doctor, because of social stigma and limited financial resources. As a TB clinician I see what kind of patients are coming. The tuberculosis is already very advanced and this is not the proper way to prevent or cure this disease.

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He went on to clarify that in his opinion DOTS is highly effective with people who are newly infected and who are detected at an early stage of infection. Nana, a representative of a local non-governmental organization with prior work experience with DOTS implementation in the prison system as an employee of the Ministry of Justice, echoed similar concerns. In her opinion, The DOTS approach is limited because it relies on only one diagnostic technique that is only concerned with active cases . . . this system has greatly reduced TB-related mortality in the prison population [but] . . . smears only reveal actively replicating bacteria and this test is not 100 percent reliable in revealing those who are actively sick. She added that many individuals who may have tuberculosis do not even have access to smear testing because they do not present standardized clinical symptoms. To emphasize the potential consequences of these trends, she told me a story about one case that she had witnessed in a prison:
There was one patient who had a fever and other symptoms typical to tuberculosis. His condition worsened, but no one [working in the prison] believed him because the smear test was negative. One supervisor of the prison beat him because they thought that he was making trouble (pretending to be sick) and wanted to be transferred to another facility. One day he lost consciousness and was taken to the prison hospital. Only when an x-ray revealed cavities and pleurisies (inflamed lung tissue) was he admitted into the TB program.

Alarmingly, cases that develop chronic latency, then reactivate, are the most likely to develop forms of resistance that are incurable with existing antibiotics. These temporal factors bear serious consequences, including delayed diagnosis and treatment, minimal detection of drug resistant strains and, ultimately, the spread of resistant strains between individuals and populations (Raviglione and Smith 2007). The limits of smear microscopy can be redressed by growing Mtb in culture. Culturing confirms that the acid-fast bacteria revealed on the slide are Mtb and not another member of the Mycobacterium complex. Growing bacterial cultures also provides a sufficient amount of bacteria to run drug susceptibility tests. From 1995 until late 2007 the NRL used a solid egg-based media for growing cultures and DST. However in solid media Mtb takes 8 weeks to grow. Drug susceptibility tests take an additional 21 days to produce results. Culturing in solid media begins with a sample of fresh sputum. Through a series of closely timed decontamination events (to kill any other types of

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bacteria in the sample) and centrifuge spins, sputum is transformed into a pellet where any Mtb present will have settled. Next, lab techs grind the sediment, re-suspend it in sterile water, and distribute it in test tubes. In solid media, bacterial cultures resemble grainy white dots growing on the slope of the media in the test tube that are colonies of bacteria. To test for drug susceptibility, lab techs decolonize samples, grind and re-suspended them in sterile water, and distribute the liquid in media treated with antibiotics. Growth indicates that the strain is resistant to that antibiotic. This is a relatively simple procedure; the main drawback is that because Mtb is a slow-growing bacterium, it takes a long time to produce cultures, and thus a definitive diagnosis. One faster method commonplace in resource-rich settings uses small test tubes that contain liquid media at the time of purchase. Lab techs test for growth hourly using a black light that illuminates bacteria growing in the fluorescent broth, or with a computer called Bactec that automatically reads the samples. With support from the Global Fund, the NRL adopted liquid growth methods using Bactec. The reagents in the liquid media speed up the bacterial growth cycle of Mtb. Although microbial time, like cellular time, can be accelerated (Landecker 2007), the perspective of local microbiologies underscores the question: Is faster necessarily better? One lab worker critical of the administration argued that faster processes of diagnosis and treatment are undermined precisely because the bacterium is a naturally slow-growing microbe: They [administrators] dont want us to spend money on fluorography. They are waiting for someone to invent a little tablet that will treat TB patients in two weeks. But that is impossible because of the biology of the TB microbe. Lab techs are important nodes within the assemblage of TB control, and are clearly attuned to the local microbiologies in which they work and the ways in which temporalities of bacterial growth and nuances of activity and stagnancy shape them. Thus, there are benefits and burdens to the upgrade to testing in liquid media. As we caught up about each others work and lives in 2007, Tamuna explained the new processes to me in detail. Cultures are prepared from sediments similarly to solid media. Technicians add two additional components to the broth in the tubes: a growth-promoter and an anti-contaminant that come premeasured and, once opened, have to be used within 24 hours. Sediment is re-suspended in saline, and added to the tubes. If preparing drug susceptibility tests, the broth is also treated with antibiotics. The main advantage is temporal. In liquid media cultures grow in 814 days. With drug susceptibility tests, liquid media affords results in 413 days rather than 3 weeks. Moreover, liquid media is 1520 percent more sensitive than solid media; because some species (of mycobacterium) may only grow in liquid media, the tests might be more reliable. However, liquid media is

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more hazardous because it can spill and because microbes growing in broth are more likely to circulate in the air than those affixed to solid media. There is also a higher risk of sample contamination, 78 percent in liquid versus 35 percent in solid media. It can also be difficult for techs to distinguish other bacteria from mycobacterium. As Lela explained, the growth cycle of Mtb is a factor:

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In the lab it takes two to three weeks to grow visible colonies. It takes at least two weeks to get an adult organism that has the ability to divide and form colonies, so you can confirm that you are witnessing Mtb. This is because [Mtb] is a slow-growing bacterium. You need this time in the lab. With Bactec you can see them earlier, but you cannot see them mature into colonies. In the liquid medium they are very young. All you can see is that something is growing. But you cannot confirm that it is Mtb and not some other Mycobacterium that quickly.

For her, the key question is not how quickly they get results but the nature of those results. Laboratory technicians also have concerns about the accuracy of test outcomes with liquid media. Sometimes Bactec gives a negative answer for a sample that had a positive analysis in the sputum smear. To resolve these diagnostic contradictions, lab techs are required to smear and stain a sample of liquid media from every tube that Bactec registers for positive growth to confirm the presence of Mycobacterium. Tamuna explained that the faster methods nearly double labor and time investments, which exacerbate infrastructural obstacles. There are enough lab techs on staff, but there is not enough space. Because it is faster to test for Mtb in liquid media, they culture all diagnostic specimens and test them for drug susceptibility (previously they only ran culture tests for smear positive cases and susceptibility tests by clinicians requests). But because samples treated in liquid media are at a higher risk of contamination, all TB sensitive cultures must also be smeared and read under a microscope for confirmation. For these reasons, Tamuna explained, this process is difficult to routinize in our conditions. Our technical expertise is fine, but we do not have the space or the time . . . for this lab in this country, Bactec could be good for research experiments, but it is not good for routine diagnostic testing and lab work. In addition, the advantages of liquid media are challenged by financial and infrastructural constraints. Both the materials in which growth is fostered and the computers that automatically monitor for growth are costly. Repairing or acquiring a new Bactec machine in Tbilisi is difficult, especially because much of the laboratory equipment shipped from overseas is held up in Georgian customs for months due to incomplete paperwork or accusations of incomplete paperwork, for example. As Tamuna showed me

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how the Bactec machines operate, she pointed out that only one of the two that were crammed into the culture room was operational. No one was sure when the second would be repaired. An apparent technological advancement becomes both meaningful and locally burdensome by local microbiologies that are formed in a shifting terrain of disease management. The technologies and techniques for manipulating those in the laboratory, and infrastructural, political, and economic forces impact the meanings and relevance of the newer technologies. The microbe is not simply active or passive as proponents of a standardized technical intervention would have it.

CONCLUSION: LOCAL MICROBIOLOGIES, ANTHROPOLOGY, AND GLOBAL HEALTH Tuberculosis is not determined entirely by either social or biological forces that then influence one another; the DOTS protocol conceals as much as it reveals. Although it is imperative to cure active cases and stop chains of infection, disease burdens cannot be alleviated only by killing microbes. Microbes are part of unique social matrices, and their biochemical attributes are only made meaningful in particular contexts. These dynamics underscore the fuzzy nature of cultural lines that are taken for granted between microbial and social realms, and call into question how social scientists confront biology. I have argued that Mtb bears attributes that when engaged with through diagnostic procedures encourage it to evade the protocol that is structured to kill it. Focusing on active cases fosters tuberculosis. Why the focus on active cases? From one perspective, the public health logic is clear and convincing: identifying and treating actively infectious individuals reduces the number of individual deaths and the spread of infection. However, 90 percent of all TB-infected people have latent TB; nearly one-third of the worlds population is a reservoir for tuberculosis that could become infectious. According to Christopher Dye, Director of Health Information in the Office of HIV=AIDS, Tuberculosis, Malaria, and Neglected Tropical Diseases at the WHO, we are never going to get to the [global TB] elimination target unless we deal with the problem of latent infection (quoted in Marris 2007:267). Developing more accurate and faster ways of detecting latency is essential because Mtb could reactivate after long periods, even decades (Andersen 2006). Re-infection after reactivation is an important issue in the current TB crises: Reactivation likely accounts for the great majority of active cases in areas of low tuberculosis transmission . . . in areas where tuberculosis is prevalent, primary infection is a prominent factor and

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re-infection probably plays a greater role than was previously appreciated, especially among HIV-positive persons (Cosma et al. 2003:655). What happens if or when latent cases are more accurately and rapidly detected? Are primarily biomedical interventions fundamentally flawed? Given the negative side effects of antibiotics, their widespread misuse by people who prescribe and ingest them, and the fact that only 510 percent of those latently infected will advance to active disease, arguments abound against putting individuals latently infected with Mtb on antibiotics for 36 months, as current treatment protocols for latent TB dictate. If the day finally arrives when new antibiotics are available, prescribing them in latent cases would likely exacerbate microbial resistance. These conundrums as well as possible solutions persist in a zone of ambiguity formed by dialectics of culture and biology. These predicaments emphasize the importance of bringing microbes squarely into the anthropological purview to understand complex dynamics of surveillance, infection, detection, and response in domains of infectious disease and global health. The framework of local microbiologies uses insights from anthropological studies of science and technology to understand the cultural politics of global health interventions. Anthropological studies of science, technology, and medicine demonstrate that it is no more the case that microbes are external to sociality, and impact society, than it is that technology impacts society from outside (Franklin and Lock 2003; Latour 2000; Rapp 1999). Rather, microbes co-constitute social fabrics. The case discussed here shows how tricky it is to account for microbes without reproducing biological determinism. Responses to global health dilemmas such as tuberculosis should advancebut not be limited to biomedical interventions that emerge through highly nuanced dialectics of cultural, biological, and political economic entities, institutions, and forms of knowledge.

ACKNOWLEDGMENTS I am deeply indebted to friends and colleagues at the National TB Program in Georgia who made my research possible. The research on which this article is based was supported by a Dissertation Improvement Grant from the Science and Technology Studies Program of the National Science Foundation; the Eurasia Program of the Social Science Research Council, with funds provided by the US Department of State through the Title VIII Program; the Graduate Faculty of Political and Social Science at the New School for Social Research; and the University of Kentucky. Portions of this article were presented at the Annual Meeting of the American

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Anthropological Association (2007), the annual meeting of the Society for Applied Anthropology (2009), and at a conference for the Society of Medical Anthropology (2009). I am grateful to Lenore Manderson and Victoria Team for their editorial expertise and to the anonymous reviewers for Medical Anthropology for their astute suggestions and comments. For their generous assistance with versions of this paper I thank Anne Galvin, Suzanne Simon, Sarah Lyon, Cristina Alcalde, Karen-Sue Taussig, Matthew Wolf-Meyer, Paul Manning, Kristin Bright, Vincanne Adams, Emily Burrill, Lucinda Ramberg, Srimati Basu, and Jonathan Stillo. NOTE
1. All names in this article are pseudonyms.

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