MasonDegelingDenholm 2015 Sociocultural Dimensions of TB IJTLD 17April

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This is a pre-copyedited, author-produced PDF of an article accepted for publication in [International Journal of
Tuberculosis and Lung Disease] following peer review. The definitive publisher-authenticated version [Mason, P.H.,
Degeling, C., Denholm, J. (2015) Sociocultural dimensions of tuberculosis: an overview of key concepts, International
Journal of Tuberculosis and Lung Disease, 19(10), pp. 1135-1143, doi: http://dx.doi.org/10.5588/ijtld.15.0066] is available
online at http://dx.doi.org/10.5588/ijtld.15.0066.
Please cite as:
Mason, P.H., Degeling, C., Denholm, J. (2015) Sociocultural dimensions of tuberculosis: an overview
of key concepts, International Journal of Tuberculosis and Lung Disease, 19(10), pp. 1135-1143, doi:
http://dx.doi.org/10.5588/ijtld.15.0066.
Sociocultural Dimensions of Tuberculosis: An overview of key concepts
Paul H. Mason, Chris Degeling, Justin Denholm (2015)
Corresponding author: Paul H. Mason
Woolcock Institute of Medical Research, University of Sydney
Chris Degeling
Centre for Values, Ethics and the Law in Medicine, School of Public Health, University of Sydney
Justin Denholm
Victorian Tuberculosis Program, Melbourne Health and Department of Microbiology and
Immunology, University of Melbourne
Abstract:
Biomedical innovations are unlikely to provide effective and ethical TB control measures without
complementary social science research. However, a strong interest in interdisciplinary work is often
undermined by differences in language and concepts specific to each disciplinary approach.
Accordingly, biological and social scientists need to learn how to communicate with each other. This
article will outline key concepts relating to tuberculosis from medical anthropology and health
sociology. Distilling these concepts in an introductory framework is intended to make this material
accessible for researchers in laboratory, clinical and fieldwork settings, as well as to encourage more
social scientists to engage with tuberculosis research among target groups critical for successful
programmatic interventions. For pedagogical purposes, the relevant concepts are grouped into
three categories, (1) structures and settings, which includes overarching themes such as syndemics,
local biologies, medicalisation, structural violence and surveillance, (2) practices and processes,
encompassing gender, stigma, taboo, and victim blaming, and (3) experience and enculturation,
which includes illness narratives, biographical disruption and dynamic nominalism. By helping to
navigate this literature, we hope to foster more cross-disciplinary conversations between qualitative
and quantitative researchers. Tuberculosis, a quintessential social disease, will be controlled more
effectively using a multi-stranded research approach.

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Keywords: Gender, Stigma, Surveillance, Syndemics, Social determinants
Abstract in French
Les innovations du domaine biomédical ont peu de chances de fournir des mesures de lutte contre la
tuberculose (TB) à la fois efficaces et éthiques sans recherché complémentaire en sciences sociales.
Cependant, le grand intérêt vis-à-vis du travail interdisciplinaire est souvent entravé par des
différences de langage et de concepts spécifiques à chaque approche disciplinaire. Les chercheurs en
biologie et en sciences sociales doivent apprendre à communiquer entre eux. Cet article va exposer
les concepts clés relatifs à la TB en anthropologie médicale et sciences sociales. Distiller ces concepts
dans un cadre conceptuel introductif vise à rendre ce matériel accessible aux chercheurs dans les
laboratoires, en clinique et sur le terrain, ainsi qu’à encourager davantage de chercheurs en sciences
sociales à s’engager dans la recherche sur la TB au sein des groupes cibles cruciaux en termes de
succès des interventions. Pour des raisons pédagogiques, les concepts pertinents sont groupés en
trois catégories: 1) structures et contextes qui incluent des thèmes transversaux comme les
syndémies, la biologie locale, la médicalisation, la violence structurelle et la surveillance; 2) les
pratiques et processus incluant le genre, la stigmatisation, les tabous et la culpabilisation des
victimes; et 3) l’expérience et l’inculturation qui incluent les récits de maladies, la rupture
biographique et le nominalisme dynamique. En contribuant à s’y retrouver dans cette littérature,
nous espérons favoriser davantage de conversations interdisciplinaires entre les chercheurs du
domaine qualitatif et quantitatif. La TB, une maladie typiquement sociale, sera contrôlée plus
efficacement grâce à une approche multicanaux.
Abstract in Spanish
Es poco probable que las innovaciones biomédicas ofrezcan medidas eficaces y éticas para el control
de la tuberculosis (TB) si no se acompañan de una investigación complementaria en ciencias sociales.
Sin embargo, un interés acentuado en el trabajo interdisciplinario suele verse obstaculizado por
diferencias en el lenguaje y los conceptos especí́
ficosde los enfoques de cada disciplina. En
consecuencia, los investigadores de la sciencias biológicas y sociales deben aprendera comunicarse
entre sí. En el presente artí ́
culo se destacan conceptos básicos en materia de TB, desde la
perspectiva de la antropología médica y la sociología de la salud. Condensar estos conceptos en un
marco introductorio tiene por objeto hacer que este material sea más accessible a los investigadores
en los entornos de laboratorio y clínico y en el terreno, además de incitar cada vez más a los
científicos de las ciencias sociales a participar en la investigación de la TB dirigida a los grupos clave,
con el fin de mejorar la eficacia de las intervenciones programáticas. Con fines pedagógicos, los
conceptos primordiales se agruparon en las siguientes tres categorías: 1) estructuras y entornos, que
abarcan temas generales como las sindemias, las características biológicas locales, la medicalización,
la violencia estructural y la vigilancia; 2) las prácticas y los procedimientos, que comprenden el
género, los estigmas, los tabúes y la culpabilización de las víctimas; y 3) la experiencia y la
asimilación cultural, que incluyen los discursos sobre las enfermedades, la ruptura biográfica y el
nominalismo dinámico. Al ayudar a abordar esta literatura, se espera fomentar las conversaciones
interdisciplinarias entre los profesionales de la investigación cualitativa y cuantitativa. La TB es una

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enfermedad social por excelencia y su control será má́s eficaz cuando se aplique una estrategia
polifacética de investigación.

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Introduction
Social histories of tuberculosis (TB) are numerous. e.g. 1-7 Between them they cover the critical periods
between the characterisation of the contagiousness of the disease in the 1860s, the identification of
the causative agent, the development of the Bacillus Calmette–Guérin vaccination in the 1920s and
the advent of chemotherapy in the 1940s. Robert Koch’s elucidation of the causative agent of TB in
1882 attuned public attention to the central role of the microbe in the aetiology and pathogenesis of
the disease. The subsequent discovery of effective antimicrobial treatment for TB cemented the
dominance of biomedicine over already declining rates of incidence in the developed world. In the
developing world, however, the number of TB cases doubled in the thirty years between 1952-
1982.8 Increasing rates of incidence and morbidity amongst the world’s poorest and most
disadvantaged populations did little to push TB onto the global health agenda until the 1980s New
York TB epidemic stimulated renewed interest in developing better diagnostics, vaccines and
antibiotics.
Against this background, economist and epidemiologist Hans T. Waaler called for a re-evaluation of
basic principles, highlighting that increasing the detection and elimination of Mycobacterium
tuberculosis has dramatic consequences and simultaneously draws attention away from “the socio-
economic character of tuberculosis” and “the general living conditions in the generation of health.”9
The social determinants of TB are well known,10 but are not being adequately addressed.11,12
Consequently, the emergence of drug-resistant TB can be considered an iatrogenic outcome of
current biomedical and public health approaches to TB.13 The oft-repeated words of René and Jean
Dubos are particularly apt, that “the impact of social and economic factors on the individual be
considered as much as the mechanisms by which tubercle bacilli cause damage to the human
body”.14 Studying the microorganism without studying the conditions under which it proliferates is
like studying a seed but ignoring the soil.15
Despite the widespread availability of effective treatment, TB remains the second leading cause of
death from infectious disease worldwide with 95% of cases and deaths estimated to occur in the
developing world. In discussing the need to address deaths from preventable disease, this article
describes a number of key concepts to help conceptualise the individual, interpersonal and
structural issues related to TB (see figure 1). The three broad themes that this overview will address
are:
(1) Structures and settings: the conceptual frameworks that can be employed to situate TB
not simply as an object of medical concern but as a site of contested practices.
(2) Practices and processes: how the socially patterned attributes of stigma, gender, victim
blaming, and taboos variably influence health-seeking behaviour and treatment
adherence.
(3) Experience and enculturation: the ways in which people make sense of their illness
experience and the ways in which culture compels them to act.
Figure 1: Conceptualising socio-cultural considerations of tuberculosis care and prevention through
three mutually impacting spheres operating at individual, interpersonal and structural levels.

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Figure 1 in French:

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Figure 1 in Spanish:
Recognising that biomedical perspectives are one voice among many, this article is working towards
a holistic picture of effective TB care and prevention. Substantial shortcomings in case-detection are
not only due to the limitations in available diagnostic strategies and time-consuming laboratory
tests.15,16 Barriers to diagnosis and treatment also include social, economic, geographical, cultural,
and political challenges. Conceptual tools from health sociology and medical anthropology offer
useful ways to examine dimensions of public health that may escape the strictly biomedical
paradigm. By recognising cultural experience as a central force shaping human interactions with the
world, TB researchers and clinicians can develop a more nuanced consideration of how health,
illness, and medical treatment are understood, interpreted, and confronted. Greater competency in
understanding the social and cultural dimensions that impact TB patients presenting to doctors
contributes to developing ways to reduce diagnostic delay, increase effective TB healthcare delivery,
and stop the spread of TB disease.
1. Structures and Settings
Thirty years ago the epidemiologist Geoffrey Rose argued that medicine has a duty of care not only
to individual patients but also to the communities and populations to which we all belong.18 The
central thesis that underpinned much of this work is that populations can be unhealthy, and that sick
populations are more than the aggregate of sick individuals.19 Against this background, infectious
diseases such as TB, have, historically, most commonly been understood and approached in two
ways: as matters of contamination and as matters of configuration.20 From the perspective of
contamination – disease is the transfer and progress of infectious pathogens between and within
individuals. From the configuration perspective, the focus is not on the pathogen, but on the

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contexts, structures and power relationships that promote disease expression. Even as contact
exposure and host-pathogen interactions determine the disease state of individuals, these
interactions take place in a social and material environment that can be configured in ways that
enhance or inhibit pathogenicity. What this means is that social relationships and environments
appear to exert direct influences on morbidity and mortality, including from TB. The way that society
is organised exposes certain populations to a higher risk of TB infection, a greater chance of
developing active TB disease, and a lower likelihood of accessing effective TB healthcare. Australian
aboriginals, for example, are 11 times more likely to have TB than Australian-born non-Indigenous
persons.21
The emergence of the biomedical perspective of disease, and the dominance of its discourse in the
second half of the twentieth century, has had broader effects on society. Medicalisation is the
process through which “medical jurisdiction, authority and practices” are extended into broader
areas of people’s everyday lives.22 Undesirable biological and social differences are pathologised –
they become something that demands some form of medical intervention. Medicalisation orients
individuals and societies to accept dominant conceptions of medicine and voluntarily participate in
its practices. Whereas TB was previously primarily construed through the frame of configuration,
the development of chemotherapeutic agents against TB accelerated the medicalisation of TB in
public health discourse. Once primarily considered a social condition with a medical dimension, the
incidence of TB disease was removed from its social context in expert discourse and public debate.
Once the process of medicalisation begins, proposed solutions become increasingly technological,
isolationist and consumerist in orientation, where existing structures and systems are seen as
natural states, and, thereby, not amenable to reform.
Medicalisation is often co-constitutive of racialised understandings of disease – and this continues to
be the case with TB in indigenous and migrant populations.23,24 Genetic differences undoubtedly
have a role in susceptibility to active TB infection, but ascription of the influence of race or ethnicity
to susceptibility to TB remains, at best, controversial,25 especially as other correlates such as socio-
economic status can also explain why some populations have higher incidence of infection.26,27 Yet
social inequality in disease is only partially explained by the classic behavioural dimension of health
risk exposure. Structural conditions can perpetrate violence against distinct populations by
preventing them from meeting their most basic needs.28 Structural violence is often an intrinsic, and,
thereby, invisible feature of inequitable social arrangements where population differences in health
and welfare are treated as the consequences of individual biology rather than the prevailing socio-
structural conditions. Yet the susceptibility of indigenous populations to TB is not simply a product of
their relative lack of immunity to the pathogens carried by European colonisers but is also due to the
violence of colonisation: its dislocating influence on their daily lives, cultural practices and communal
well-being.29 Structural violence can occur in lockstep with medicalisation, but disproportionately
impacts the most socially disadvantaged. Violence that is the result of the way society is structured
can be explicit but is most often shrouded in shame, silence, or both. For many indigenous peoples,
the erasure of the history of harms from colonisation, or their valorisation as ‘progress’ by dominant
society, only compounds the effects of entrenched disadvantage for present generations.30-33
The influence of health inequalities, caused by poverty, structural violence and social disadvantage
can result in a syndemic – where social conditions promote the clustering, synergistic interaction and
additive negative health effects of two or more concurrent disease burdens in a population.34 The

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concept of a syndemic runs counter to the biomedical perspective that seeks to isolate pathological
mechanism and treat the resulting diseases as instances of individual dysfunction. The spread of TB
in populations and its course in individuals depends on co-factors such as HIV/AIDS and the
conditions of poverty (malnutrition, poor hygiene, and high population density), all of which can
promote public infection and activate latent TB in individuals. Of course, not all individuals exposed
to the same syndemic risks end up with active disease. On this point, Margaret Lock’s concept of
local biologies is a useful counterpoint to syndemic thinking.35 From the perspective of local
biologies, individual and population level variations in biological responses to TB infection suggest
that there is not a rigid separation between the biological and social aspects of the disease. These
categories are not universal constants but the products of localised negotiations between social and
biological processes and the material environment. At one level, syndemic thinking explains why
disease incidence is higher amongst specific groups tied to specific conditions. At another level, the
concept of local biologies, or perhaps more fittingly local mycobacteriologies, is an explanatory
resource to understand the variation in disease expression within each of these clusters.
The medical anthropologist Erin Koch draws on the concept of local biologies to highlight the
biosocial aspects of mycobacterial agency – especially as they are influenced by systems of care.36
For example, diagnostic practices and TB management systems treat the bacillus as a fixed and
stable entity whereas the boundary between “latent” and “active” infections in individuals is actually
a dialectic between biology and sociocultural processes which makes this threshold labile and fuzzy.
The TB cultured from a patient’s sputum sample is only a snapshot (rendered in a laboratory) of a
mutable relationship between two organisms (host and microbe) and their environments. Because
TB can enter and lay dormant in human and animal bodies, activate and cause disease, and if
challenged, develop antibiotic resistance, the current structures that focus on managing ‘active’ TB
in populations only cause the microbe to evade elimination. Using the word threshold in a
qualitative sense, Koch moves the focus away from TB as an object of intervention and towards TB
as a zone of contested practices where arrangements of resources, medical expertise, forms of
illness, and standards of biomedical response materialise through social, political and economic
transformations.37 TB is revealed or concealed according to the health-seeking behaviours of
individuals, the level of mycobacteria in their sputum, and the sensitivity and specificity of the
diagnostic tools available. The identification of latent TB infection (LTBI) as necessitating
preventative treatment in low-burden settings but not in high-burden settings is a pragmatic
example of how diagnostic labels emerge in concert with available resources, economic factors and
disease burden. The controversy about proposals to conduct LTBI screening prior to immigration to
low-burden countries such as Australia draws attention to how diagnosis can be used politically in
localised negotiations to become literally a boundary to entry.38
The border control practices of screening migrants for TB is one example of TB surveillance. 23,24,39-41
Other scales of surveillance include the contact investigation of active TB cases,42,43 the molecular
genotyping of TB to determine transmission networks,44-46 as well as the monitoring of TB patients
through Directly Observed Treatment (DOT), the standardised model of TB treatment advocated by
the WHO. DOT can interact synergistically or antagonistically with social stigma and socially-
acceptable gender practices by structurally reinforcing the notion that individuals with TB are
untrustworthy or not capable.33,47 Direct observation of TB patients comes out of a colonial model of
medical provision that was initiated in Madras and Hong Kong in the 1950s.48 However, this model
can be counterproductive in some settings,49 and partially effective in others.50 Surveillance has

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historical significance in many settings and particularly among marginalised populations. With
regards to TB among immigrant populations, anthropological research has moved the focus of
attention away from a narrow concern with the country of birth, and towards a concern with the
conditions of settlement and the circumstances that promote the reactivation of latent TB infection
in migrant communities, including poverty and discrimination, life history, and the experiences of
migrants in transit and after arrival.51 While monitoring TB at the border is important,
anthropologists have advocated that support for migrants, their social participation, access to health
care and rights to freedom from discrimination are also key to reducing reactivation of TB.52
Surveillance may be a hallmark of global health efforts. However, given its interaction with stigma,
gender and marginalisation, surveillance is, to borrow the words of medical anthropologist Mark
Nichter, “a practice that needs to be conducted reflexively” such that its goals and central
assumptions should be iteratively reassessed on an ongoing basis.53
The concepts of syndemic, local biologies, and threshold are useful because they seek to add
contextual dimensions to the biomedical perspective – they draw attention to the social, political
and historical context of disease incidence and the microbial agency that comprises much of the
dynamic nature of TB infections. As variations in the success of surveillance systems such as DOT
illustrates, treatments for TB in individuals and populations that do not simultaneously seek to
address its dynamic and syndemic features – and bend with local biosocial conditions – are less likely
to be effective.11,12 Informed by syndemic thinking and an appreciation that individual outcomes
depend on the local interaction of biological and social processes, from a settings perspective the
current emphasis on DOT and developing pharmaceutical solutions amounts to the medicalization of
poverty.54
2. Practices and Processes:
The ways people react to TB are shaped by broad social practices and cultural processes. Despite its
curability, TB can lead to social vulnerability. The coughing of people with active TB disease can
result in the production of bloody sputum, a bodily waste associated with physical contamination
and unacceptable contagion. People who exhibit the unpleasant bodily fluids of TB, or other
undesirable physical traits associated with the risks and dangers of TB, may withdraw or be
withdrawn from social contact in order to contain their discrediting symptoms within the private
domain. Compounded by local beliefs as well as associations to poverty and co-morbidities such as
HIV/AIDS, the stigmatisation of TB is not easily unpacked.
Taken from the work of symbolic interactionist, Erving Goffman (1922-1982), stigma is a useful
concept to analyse some of the issues facing people with tuberculosis.55 Stigma is the discrediting or
devaluing of an individual or group who exhibits persistent attributes, traits, or behaviours that are
viewed as inferior, culturally unacceptable, or worthy of punitive response. 56,57 Effects of stigma
include reduced social status, discrimination and exclusion. Denying specific individuals and groups
the opportunity to fully participate in and attain the rewards from a society adversely impacts upon
healthy living, health-seeking behaviour, and treatment outcomes.
Victim blaming is a common form of stigma surrounding TB where patients, particularly those who
have developed drug resistant disease, are seen as responsible for their own illness.58 A derogatory

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focus on the patient impacts upon the agency of an already vulnerable individual and draws
attention away from creating an enabling environment for successful treatment outcomes. Often
closely associated with structural violence, victim blaming detracts from bringing about necessary
social change for better public health by misdirecting attention away from assembling more
qualified human resources, improving health infrastructure, and building stronger health systems
that coordinate effectively with the private sector. Rather than locating illness in the context of
broader social, historical and political structures, stigma places shame, blame and embarrassment
on the individual.
Understanding stigma through social relations assists in examining various social taboos that people
with TB have to endure. Studies conducted in Zambia, South Africa, and Kenya show that family
members maintain various social taboos such as not sharing food, kitchen utensils, and beds with TB
patients even after they have commenced treatment.59-61 As a theoretical counterpart to stigma, the
study of taboos provides an insight into the social practices that accompany stigmatising medical
labels such as TB. Taboos shape social interactions by structuring vulnerable relations and help to
maintain social order by threatening specific dangers should they be broken.62
A cultural minefield of taboos can be opened up by the conspicuous symptoms of active TB disease,
which in some contexts may be strongly associated with physical contamination and unacceptable
contagion. But dominant taboos can weaken over time,63 and stigmas can be challenged.64 Learning
to understand the social basis of stigma and the social practice of taboos in any particular setting can
help TB clinicians and researchers to navigate and contest the isolating social practices that impact
negatively upon health-seeking behaviour and treatment compliance for a disease that is actually
treatable and unnecessarily stigmatised.
TB-related stigmas can greatly exacerbate existing gender inequalities.65-67 TB control programs
substantially neglect the gendered dimension of TB around the world.68 “Gender” encompasses the
variety of behaviours, expectations, and roles that exist within a social, economic, and cultural
context. The social construction of gender can variably influence lifestyle factors, health-seeking
behaviour, and ultimately life chances. A consideration of the role of gender is important when
addressing TB screening, diagnosis, and treatment adherence. The responsibilities associated to
specific gender roles prescribed by a society might place some individuals more at risk of contracting
and developing TB, affect compliance to a lengthy treatment program, or restrict the willingness to
participate in diagnostic procedures such as producing sputum.
Worldwide, TB cases among men exceed those found in women by a ratio of 2:1. However, this
global data conceals the local diversity of sex differences in TB rates. According to the notification
rates reported by country in the 2013 WHO Global Tuberculosis Report, male to female ratios of TB
can vary from 1:2 in Afghanistan, to 1:1 in Pakistan, to around 2:1 in India, and at its most extreme
3:1 in Vietnam.69 Evidently, context-specific gender dynamics are at play. Documenting the sex
distribution of notified TB cases in any one setting does not fully capture the relevance of social and
cultural dimensions of gender for TB care and prevention.70 The considerable divergence in TB ratios
is likely a result of local arrangements of biological, social and cultural variables including access to
care, structural factors, ethnicity, the particular strain of TB, and co-epidemics such as HIV/AIDS.71
Depending on context, culturally embodied gender norms may put one gender at a higher social risk
of being infected, expose them to more deleterious social outcomes as a consequence of active

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disease, and limit their full engagement in healthcare activities. For example, studies in India have
found that married women and single men experience lower levels of family support to initiate and
complete treatment.72,73 With fears of harassment by in-laws, rejection by their husband, and
dismissal from work, married Indian women found the strain of secrecy and the pressures of
housework to be significant obstacles to treatment adherence. Social studies of TB and gender are
imperative and should focus on asking how a diagnosis of TB challenges social constructions of
gender in diverse cultural contexts. Men and women follow different pathways to seek diagnosis and
treatment and in some settings these labyrinthine pathways can lead to a huge shortfall in the
number of people who present to TB clinics and complete treatment. Capturing how gender is
constructed, performed, and challenged in the social spaces where TB diagnoses are revealed and
concealed can lead to transformative healthcare practices that promote the social inclusion of all TB
patients.
3. Experience and enculturation:
TB is not just a clinical diagnosis but also a social experience. As the previous section makes clear,
our social interactions are culturally patterned. Not only do these patterns shape how people with
TB are perceived, but also how they perceive themselves, and how they experience the world. Prior
to the availability of an effective treatment, TB was thought of as a chronic disease.74 Considering
that effective TB treatment still fails to reach large populations in mainly developing nations, the
illness can still be thought of as chronic in many parts of the world. In such places, the onset of TB
can be conceptualised as a disruption to a person’s biography – their conception of themselves and
their future. Disruptions in biography alter assumptions about the healthy body, social relationships,
and the ability to mobilise material resources such that the:
erstwhile taken-for-granted world of everyday life becomes a burden, of conscious and
deliberate action. 75
Life stage and social situation mediate the effect of a diagnosis of a chronic illness.76 In complement
to the concept of biographical disruption, a constructive analytical device to interrogate the patient
experience is their illness narrative.77-80 Illness narratives are personal accounts that give meaning to
a condition, and are part of the process of ongoing self-construction. The illness narratives of TB
patients contrast markedly to the narratives presented by people afflicted by other diseases.81 Given
that the initial stages of TB disease can be indistinct from other diseases, the illness narratives of TB
patients can provide insight into diagnostic delay, barriers to treatment, and the obstacles in
achieving a successful treatment outcome. Chronic illness, however, is not only a cause of
biographical disruption, but can also be a consequence.76 For example, disruption caused by famine,
co-morbidity, or other factors might trigger the onset of TB illness. In both scenarios, attention to
illness narratives and biographical disruption champions the articulation of voices and concerns that
might not otherwise be heard. A consideration of biographical disruption and illness narratives helps
take into account the context within which TB occurs and the meanings through which patients
understand their condition.
As well as comprising points of biographical disruption, the diagnostic labels applied to people with
TB have consequences for their social identity and influence the forms of experience that are

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possible for them. The philosopher of science Ian Hacking called this “dynamic nominalism”, the idea
“that numerous kinds of human being and human acts come into being hand in hand with our
invention of the categories labeling them”.82 Dynamic nominalism is a useful way to think about the
lay and biomedical classifications of TB patients, and a particularly poignant way of thinking about
people who are labelled as noncompliant because they fail to adhere to treatment or those who
develop multidrug resistant TB (MDR TB). As a “looping effect”,83 classifications impact upon the way
people act, and their subsequent understanding, experience and behaviours evolve iteratively so
that classifications and descriptions in turn are constantly being revised. In this conceptual
framework, MDR TB, within certain contexts, can be seen as the flux of a looping effect between TB
patients and their treatment regimen. Diagnostic labels become embedded social norms that
mediate individual experience, and, thereby, have biological consequences.
Another example of dynamic nominalism is the “at-risk” classification of a diagnosis of latent TB
infection (LTBI). People labelled as having LTBI are diagnosed as being at-risk of an illness without
showing any signs or symptoms of disease. This classification exposes a vulnerability that can lead a
person to adopt measures to keep a latent illness in check either through treatment or frequent
surveillance.84 The vulnerability is not only biological, but also social, economic and political. A
dominant biomedical discourse encourages pre-symptomatic people labelled at-risk of developing
active TB disease to understand their bodies as needing to be sanitised. In the struggle against
vulnerability, new vulnerabilities, ambiguities and uncertainties are created.85,86 Is the LTBI a drug-
sensitive or drug-resistant strain of Mycobacterium tuberculosis? What are the short- and long-term
side effects of chemotherapy? What happens if an individual is potentially re-infected after LTBI
treatment? While the biomedical model asks which objective risks are acceptable, an
anthropological approach asks which vulnerability transformations are desirable.86 LTBI exists within
a ‘liminal’ space, at the junction between health and illness. Conceptualised as having a liminal
body,87 people with LTBI can be left trying to consider factors that may be unknowable and unable to
be completely taken into account. When ‘at-risk’ becomes a biomedical classification, the presence
of active disease is not always a prerequisite for defining who is a patient. Decision-making
processes about diagnostic categories and what constitutes an appropriate response to LTBI involves
more than just a consideration of diagnostic biomarkers of TB, but also a consideration of the ways
that medical labels are socially, economically and politically contested.
The strategies and forms of coping that people exhibit in the face of TB and LTBI are influenced by
cultural imperatives. A technological imperative, for example, can compel TB patients and healthcare
practitioners to use available technology even when it is excessive, futile, or detrimental.88 Using
technology because it exists rather than because it is clinically necessary can lead to problems. In
India, for example, suboptimal tests are administered to diagnose TB because they are available not
because they are effective and recommended by the WHO.89 The implementation of technology is
not simply driven by its efficacy but mediated by social, economic, and political processes. Examining
these dimensions of health care technology is important because the adoption and application of
technology is an intensely political and profitable activity. When technology is used regardless of
whether it is useful, superfluous, or injurious, the technological imperative needs to be assessed to
ensure ethical, accurate and economically sound decisions. Other cultural imperatives include an
imperative to be isolated, to travel long distances for treatment, or even an imperative to undergo
surgery. When, where, and how bodily conditions are diagnosed and treated are all questions open
to cultural influence and are all questions that should be regularly submitted to critical inquiry. A

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self-reflexive approach to biomedical practice can help us become more aware of the relationship
between social encounters and individual experience.
Concluding remarks
This article has attempted to bring key concepts from the social model to bear on the problem of TB
in order to create more balanced discussions and a space for researchers to share a common
vocabulary. Our aim is to assist researchers and practitioners in finding and interpreting scholarship
that is relevant to their interests and concerns and encourage more research that draws upon,
interrogates, and advances the integration of the sociocultural dimensions of TB in to policy and
practice. TB transmission and the medical practices that emerge in response to TB disease are social
enterprises. The ultimate success of any intervention depends upon social factors because
sociocultural determinants shape people's lives, exposure to disease, illness experience, response to
risks, ability to take action, and capacity to employ preventative measures. The social model reveals
the complexity of TB ecology beyond a simple chain of causation. The impacts of TB extend beyond
the individual through their social networks and to broader society. The burdens imposed are more
than the aggregated impacts of individual cases. Applying social science insights to contemporary
practices in TB clinics and research laboratories allows for biomedical developments to be employed
in ways that are most likely to be effective in local contexts. Beyond quantifiable outcomes, too,
incorporating these insights into refining TB services and strategies will encourage the establishment
of programs that “make sense” to both practitioners and affected communities. Only through
understanding the influences and priorities underlying our engagement with TB can we continue to
move beyond simple disease control and towards the elimination of every aspect of the pain and
suffering caused by this disease in our world today.
References:
1 Cronje G. Tuberculosis and Mortality Decline in England and Wales, 1851-1919. In: Woods R,
Woodward J. eds. Urban Disease and Mortality in Nineteenth Century England. New York: St.
Martin's Press, 1984; 79-101.
2 Caldwell M. The Last Crusade: The War on Consumption, 1862-1954. New York: Atheneum,
1988.
3 Smith F B. The Retreat of Tuberculosis, 1850-1950. London: Croom Helm, 1988.
4 Mesa J M. Historia de la tuberculosis en Espana, 1889-1936. Granada: University of Granada,
1989.
5 Bates B. Bargaining for Life: A Social History of Tuberculosis, 1876-1938, Philadelphia:
University of Pennsylvania Press, 1992.
6 Armus D. The Ailing City: Health, Tuberculosis, and Culture in Buenos Aires, 1870-1950. Durham
and London: Duke University Press, 2011.
7 Arnold M. Disease, Class and Social Change: Tuberculosis in Folkestone and Sandgate, 1880-
1930. Newcastle upon Tyne: Cambridge Scholars Publishing, 2012.
8 Styblo K. The number of cases of tuberculosis throughout the world has increased over the last
30 years. WHO/IUAT Information Kit, 1982.
9 Waaler H T. Tuberculosis in the World. Bulletin of the International Union Against Tuberculosis
1982; 57(3-4): 202-205.
10 Ali, M. Treating tuberculosis as a social disease. Lancet 2014; 383: 2195.

14 | P a g e
11 Raviglione M, Krech R. Tuberculosis: still a social disease [editorial]. Int J Tuberc Lung Dis 2011;
15 (Supplement 2): S6-S8.
12 WHO Sixty-Seventh World Health Assembly (2014). Global strategy and targets for tuberculosis
prevention, care and control after 2015. A67/11. Geneva: World Health Organization.
13 Isaakidis P, Smith S, Majumdar S, Furin J, Reid T. Calling tuberculosis a social disease—an excuse
for complacency? Lancet 2014; 384(9948): 1095.
14 Dubos R J, Dubos J. The white plague: tuberculosis, man, and society. Boston, MA: Little,
Brown, 1952.
15 Sutherland H. The soil and the seed in tuberculosis. British Medical Journal 1912; 2(2708):
1434-1437.
16 Engel N, Pai M. Tuberculosis diagnostics: Why we need more qualitative research. Journal of
Epidemiology & Global Health 2013; 3(3): 119-121.
17 Pai N P, Vadnais C, Denkinger C, Engel N, Pai M. Point-of-Care Testing for Infectious Diseases:
Diversity, Complexity, and Barriers in Low- And Middle-Income Countries. PLoS Med 2012; 9(9):
e1001306.
18 Rose G. Sick Individuals and Sick Populations. Int J Epidemiol 1985; 14 (1): 32-38.
19 Rose G. The Strategy of Preventative Medicine. Oxford: Oxford University Press, 1992.
20 Rosenberg C E. Explaining Epidemics: and Other Studies in the History of Medicine. Cambridge:
Cambridge University Press, 1992.
21 Bareja C, Waring J, Stapledon R. Tuberculosis Notifications in Australia, 2010. Commun Dis Intell
2014; 38(1): 36-48.
22 Clarke A E., Shim J K, Mamo L, Fosket J R, Fishman J R. 2003 Biomedicalization: Technoscientific
transformations of health, illness, and U.S. biomedicine. Am Sociol Rev 2003; 68: 161-194.
23 Horner J, Wood J G, Kelly A. Public health in/as ‘national security’: tuberculosis and the
contemporary regime of border control in Australia. Critical Public Health 2013; 23(4): 418-431.
24 Reitmanova S, Gustafson D L. Coloring the white plague: a syndemic approach to immigrant
tuberculosis in Canada. Ethn Health 2012; 17 (4): 403-418.
25 Möller M, De Wit E, Hoal E G. Past, present and future directions in human genetic
susceptibility to tuberculosis. FEMS Immunol Med Microbiol 2010; 58: 3-26.
26 Cantwell M F, McKenna M T, McCray E, Onorato I M. Tuberculosis and race/ethnicity in the
United States: impact of socioeconomic status. Am J Respir Crit Care Med 1998; 157(4): 1016-
1020.
27 Serpa J A, Teeter L D, Musser J M, Graviss E A. Tuberculosis disparity between US-born blacks
and whites, Houston, Texas, USA. Emerg Infect Dis 2009; 15(6): 899.
28 Galtung J. Cultural Violence. J Peace Res 1990; 27(3): 291-305.
29 Anderson W. 2000. The Third-World Body. In: Cooter R, Pickstone J V, eds. Companion to
medicine in the twentieth century. London: Routledge, 1990: pp. 235-245.
30 Farmer P. An Anthropology of Structural Violence. Current Anthropology 2004; 45(3): 305-325.
31 Green L. The Utter Normalization of Violence: Silence, Memory and Impunity among the Yup'ik
People of Southwestern Alaska. In: Six-Hohenbalken N, Weiss N, eds. Violence Expressed: An
Anthropological Approach. Surrey, England: Ashgate Publishing Limited, 2011: pp. 21-36.
32 Green L. To Die in the Silence of History: Tuberculosis Epidemics and Yup’ik Peoples of
Southwestern Alaska. In: Barber P G, Leach B, Lem W, eds. Confronting Capital: Critique and
Engagement in Anthropology. New York: Routledge, 2012: pp. 97-112.
33 Seeberg J. The Death of Shankar: Social Exclusion and Tuberculosis in a Poor Neighbourhood in
Bhubaneswar, Odisha. In: Skoda U, Nielsen K B, Fibiger M Q, eds. Navigating Social Exclusion

15 | P a g e
and Inclusion in Contemporary India and Beyond: structures, agents, practices. Anthem Press,
2013: pp. 207-226.
34 Singer M. Introduction to Syndemics: A Critical Systems Approach to Public and Community
Health. 2009 San Francisco, CA: Jossey-Bass.
35 Lock M. Encounters with Aging: Mythologies of Menopause in Japan and North America.
Berkeley: University of California Press, 1993.
36 Koch E. Local microbiologies of Tuberculosis: Insights from the Republic of Georgia. Med
Anthropol 2011; 30(1): 81-101.
37 Koch E. Tuberculosis Is a Threshold: The Making of a Social Disease in Post-Soviet Georgia. Med
Anthropol 2013; 32(4): 309-324.
38 Denholm J T, McBryde E S, Brown G V. Ethical evaluation of immigration screening policy for
latent tuberculosis infection. Australian and New Zealand Journal of Public Health 2012; 36(4):
325-328.
39 Kehr J. Blind spots and adverse conditions of care: screening migrants for tuberculosis in France
and Germany. Sociol Health Illn 2012; 34(2): 251-265.
40 Warren A. (Re)locating the border: Pre-entry tuberculosis (TB) screening of migrants to the UK.
Geoforum 2013; 48: 156-164.
41 Welshman J, Bashford A. Tuberculosis, migration, and medical examination: lessons from
history. J Epidemiol Community Health 2006; 60(4): 282-284.
42 Fox G J, Barry S E, Britton W J, Marks G B. Contact Investigation for Tuberculosis: A systematic
review and meta-analysis. Eur Respir J 2013; 41(1): 140-156.
43 Shah N S, Yuen C M, Heo M, Tolman A W, Becerra M C. Yield of Contact Investigations in
Households of Patients With Drug-Resistant Tuberculosis: Systematic Review and Meta-
Analysis. Clin Infect Dis 2014; 58(3): 381-391.
44 Sintchenko V, Gilbert G L. Utility of genotyping of Mycobacterium tuberculosis in the contact
investigation: A decision analysis. Tuberculosis 2007; 87: 176-184.
45 Sintchenko V, Iredell J R, Gilbert G L. Pathogen profiling for disease management and
surveillance. Nat Rev Microbiol 2007; 5, 464-470.
46 Gallego B, Sintchenko V, Jelfs P, Coiera E, Gilbert G G. Three-year longitudinal study of
genotypes of Mycobacterium tuberculosis in a low prevalence population. Pathology 2010;
42(3): 267-272.
47 Harper I. Anthropology, DOTS and understanding tuberculosis control in Nepal. Journal of
Biosocial Science 2006; 38(1): 57-67.
48 Bayer R, Wilkinson D. Directly observed therapy for tuberculosis: history of an idea. Lancet
1995; 345(8964): 1545.
49 Zwarenstein M, Schoeman J H, Vundule C, Lombard C J, Tatley M. Randomised controlled trial
of self-supervised and directly observed treatment of tuberculosis. Lancet 1998; 352(9137):
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50 Jasmer R M, Seaman C B, Gonzalez L C, Kawamura L M, Osmond D H, Daley C L. Tuberculosis
treatment outcomes: directly observed therapy compared with self-administered therapy. Am J
Respir Crit Care Med 2004; 170(5): 561-566.
51 Littleton J, Park J, Thornley C, Anderson A, Lawrence J. Migrants and tuberculosis: analysing
epidemiological data with ethnography. Aust N Z J Public Health 2008; 32(2): 142-149.
52 Park J, Littleton J. Ethnography Plus' in Tuberculosis Research. SITES: A journal for South Pacific
Cultural Studies 2007; 4(1): 3-23.

16 | P a g e
53 Nichter M. Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics
Matter. Tucson: University of Arizona Press, 2008.
54 Seeberg J. The Event of DOTS and the Transformation of the Tuberculosis Syndemic in India.
Cambridge Anthropology 2014; 32(1): 95–113.
55 Goffman E. Stigma: Notes on the management of spoiled identity. New York: Prentice Hall,
1963.
56 Williams S. Goffman, interactionism and the management of stigma in everyday life. In:
Scrambler G, ed. Sociological Theory and Medical Sociology, London: Tavistock, 1987, pp. 136-
164.
57 Susman J. Disability, Stigma and Deviance. Soc Sci Med 1994; 38(1): 15-22.
58 Lambert M L, Van der Stuyft P. Delays to tuberculosis treatment: shall we continue to blame
the victim? Trop Med Int Health 2005; 10(10): 945–946.
59 Edginton M, Sekatane C, Goldstein S. Patients' beliefs: do they affect tuberculosis control? A
study in a rural district of South Africa. Int J Tuberc Lung Dis 2002; 6(12): 1075-1082.
60 Godfrey-Faussett P, Kaunda H, Kamanga J, Van Beers S, Van Cleeff M, Kumwenda-Phiri R, Tihon
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systems research approach. Int J Tuberc Lung Dis 2002; 6(9): 796-805.
61 Liefooghe R, Baliddawa J, Kipruto E, Vermeire C, De Munynck A. From their own perspective. A
Kenyan community's perception of tuberculosis. Trop Med Int Health 1997; 2(8): 809-821.
62 Douglas M. Purity and Danger: An analysis of concept of pollution and taboo. London and New
York: Routledge, 2002[1966].
63 Chambers M M. When Is a Moral Taboo Really Formidable? Journal of Educational Sociology
1960; 33(8): 342–45.
64 Heijnders M, Van Der Meij S. The fight against stigma: An overview of stigma-reduction
strategies and interventions. Psychol Health Med 2006; 11(3): 353-363.
65 Karim F, Chowdhury A, Islam A, Weiss M G. Stigma, gender, and their impact on patients with
tuberculosis in rural Bangladesh. Anthropol Med 2007; 14(2): 139-151.
66 Long N H, Johansson E, Diwan V K, Winkvist A. Different tuberculosis in men and women:
beliefs from focus groups in Vietnam. Soc Sci Med 1999; 49(6): 815-822.
67 Johansson E, Long N, Diwan V, Winkvist A. Gender and tuberculosis control: perspectives on
health seeking behaviour among men and women in Vietnam. Health policy 2000; 52(1): 33-51.
68 Diwan V K, Thorson A. Sex, gender, and tuberculosis. Lancet 1999; 353(9157): 1000 –1001.
69 World Health Organization (WHO). Global tuberculosis report 2013. Geneva: WHO; 23 Oct
2013. Available from:
http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf
70 Weiss M G, Sommerfeld J, Uplekar M W. Social and Cultural Dimensions of Gender and
Tuberculosis. International Journal of Tuberculosis and Lung Disease 2008; 12(7): 829-830.
71 Ottmani S E, Uplekar M W. Gender and TB: pointers from routine records and reports.
International Journal of Tuberculosis and Lung Disease 2008; 12(7): 827-828.
72 Nair D M, George A, Chacko A K T. Tuberculosis in Bombay: new insights from poor urban
patients. Health Policy and Planning 1997; 12(1): 77-85.
73 Atre, S., Kudale, A., Morankar, S., Gosoniu, D., Weiss, M. G. Gender and community views of
stigma and tuberculosis in rural Maharashtra, India. Glob Public Health 2011; 6: 56-71.
74 Goetz T. The Remedy: Robert Koch, Arthur Conan Doyle and the Quest to Cure Tuberculosis.
New York: Gotham Books, 2014.
75 Bury M. Chronic Illness as Biographical Disruption. Sociol Health Illn 1982; 4(2): 167-182.

17 | P a g e
76 Williams S J. Chronic Illness as Biographical Disruption or Biographical disruption as chronic
illness? Reflections on a core concept. Sociol Health Illn 2000; 22(1): 40-67.
77 Bury M. Illness Narratives: Fact or Fiction? Sociol Health Illn 2001; 23(3): 263-285.
78 Kleinman A. The Illness Narratives: Suffering, Healing and the Human Conditions. New York:
Basic Books, 1988.
79 Ezzy D. Illness narratives: Time, hope and HIV. Soc Sci Med 2000; 50; 605-617.
80 Whitehead L C. Quest, chaos and restitution: Living with chronic fatigue syndrome/myalgic
encephalomyelitis. Soc Sci Med 2006; 62: 2236-2245.
81 Kelly S. Stigma and Silence: Oral histories of tuberculosis. Oral History 2010; 39(1): 79-90.
82 Hacking I. Making Up People. In: Biagioli M, ed. The Science Studies Reader. New York:
Routledge, 1999: pp. 161-171.
83 Hacking I. The Looping Effects of Human Kinds. In: Sperber D, Premack D, Premack A J, eds.
Causal Cognition. New York: Clarendon Press, 1995: pp. 351-394.
84 Nichter M. Harm Reduction: A Core Concern for Medical Anthropology. In: Harthorn B H, Oaks
L, eds. Risk, Culture, and Health Inequality: Shifting Perceptions of Danger and Blame.
Westport, CT: Praeger, 2003: pp. 13-33.
85 Lock M. Breast Cancer: Reading the Omens, Anthropology Today 1998; 14(4): 7-16.
86 Coeckelbergh M. Human Being @ Risk: Enhancement, Technology and the Evaluation of
Vulnerability Transformations, Philosophy of Engineering and Technology, Dordrecht, The
Netherlands: Springer, 2013.
87 Mason P H. The Liminal Body: Response to Privacy in the Context of ‘Re-Emergent’ Infectious
Diseases. J Bioeth Inq 2014; 11(4): 565-566.
88 Wolf S, Berle B B. The technological imperative in medicine: Proceedings of a Totts Gap
colloquium held June 15–17, 1980 at Totts Gap Medical Research Laboratories, Bangor,
Pennsylvania. New York: Plenum Press, 1981.
89 Bhargava A, Pinto L, Pai M. Mismanagement of tuberculosis in India: Causes, consequences,
and the way forward. Hypothesis 2011; 9(1): e7.
References in alphabetical order
Ali M. Treating tuberculosis as a social disease. Lancet 2014; 383: 2195.
AndersonW. The third-world body. In: Cooter R, Pickstone J V, eds. Companion to medicine in the
twentieth century. London, UK: Routledge, 1990: pp 235–245.
Armus D. The ailing city: health, tuberculosis, and culture in Buenos Aires, 1870–1950. Durham, NC,
USA and London, UK: Duke University Press, 2011.
Arnold M. Disease, class and social change: tuberculosis in Folkestone and Sandgate, 1880–1930.
Newcastle upon Tyne, UK: Cambridge Scholars Publishing, 2012.
at Totts Gap Medical Research Laboratories, Bangor, Pennsylvania. New York, NY, USA: Plenum
Press, 1981.
Atre S, Kudale A, Morankar S, Gosoniu D,WeissMG. Gender and community views of stigma and
tuberculosis in rural Maharashtra, India. Glob Public Health 2011; 6: 56–71.

18 | P a g e
Bareja C, Waring J, Stapledon R. Tuberculosis notifications in Australia, 2010. Commun Dis Intell
2014; 38: 36–48.
Bates B. Bargaining for life: a social history of tuberculosis, 1876–1938, Philadelphia, PA, USA:
University of Pennsylvania Press, 1992.
Bayer R, Wilkinson D. Directly observed therapy for tuberculosis: history of an idea. Lancet 1995;
345: 1545.
Bhargava A, Pinto L, Pai M. Mismanagement of tuberculosis in India: causes, consequences, and the
way forward. Hypothesis 2011; 9: e7.
Bury M. Chronic illness as biographical disruption. Sociol Health Illn 1982; 4: 167–182.
Bury M. Illness narratives: fact or fiction? Sociol Health Illn 2001; 23: 263–285.
Caldwell M. The last crusade: the war on consumption, 1862–1954. New York, NY, USA: Atheneum,
1988.
Cantwell M F, McKenna M T, McCray E, Onorato I M. Tuberculosis and race/ethnicity in the United
States: impact of socio-economic status. Am J Respir Crit Care Med 1998; 157: 1016–1020.
Chambers M M. When is a moral taboo really formidable? J Educ Sociol 1960; 33: 342–345.
Clarke A E, Shim J K, Mamo L, Fosket J R, Fishman J R. Biomedicalization: technoscientific
transformations of health, illness, and US biomedicine. Am Sociol Rev 2003; 68: 161–194.
Coeckelbergh M. Human being @ risk: enhancement, technology and the evaluation of vulnerability
transformations, philosophy of engineering and technology. Dordrecht, The Netherlands: Springer,
2013.
Cronje G. Tuberculosis and mortality decline in England and Wales, 1851–1919. In: Woods R,
Woodward J. eds. Urban disease and mortality in nineteenth century England. New York, NY, USA: St
Martin’s Press, 1984; 79–101.
Denholm J T, McBryde E S, Brown G V. Ethical evaluation of immigration screening policy for latent
tuberculosis infection. Aust N Z J Public Health 2012; 36: 325–328.
Diwan V K, Thorson A. Sex, gender, and tuberculosis. Lancet 1999; 353: 1000–1001.
Douglas M. Purity and danger: an analysis of concept of pollution and taboo. London, UK and New
York, NY, USA: Routledge, 2002.
Dubos R J, Dubos J. The white plague: tuberculosis, man, and society. Boston, MA, USA: Little Brown,
1952.
Edginton M, Sekatane C, Goldstein S. Patients’ beliefs: do they affect tuberculosis control? A study in
a rural district of South Africa. Int J Tuberc Lung Dis 2002; 6: 1075–1082.
Engel N, Pai M. Tuberculosis diagnostics: why we need more qualitative research. J Epidemiol Global
Health 2013; 3: 119– 121.
Ezzy D. Illness narratives: time, hope and HIV. Soc Sci Med 2000; 50: 605–617.
Fairchild A L, Oppenheimer G M. Public health nihilism vs pragmatism: history, politics, and the
control of tuberculosis. Am J Public Health 1998; 88: 1105–1117.
Farmer P. An anthropology of structural violence. Curr Anthropol 2004; 45: 305–325.

19 | P a g e
Fox G J, Barry S E, Britton W J, Marks G B. Contact investigation for tuberculosis: a systematic review
and metaanalysis. Eur Respir J 2013; 41: 140–156.
Gallego B, Sintchenko V, Jelfs P, Coiera E, Gilbert G G. Three year longitudinal study of genotypes of
Mycobacterium tuberculosis in a low prevalence population. Pathology 2010; 42: 267–272.
Galtung J. Cultural violence. J Peace Res 1990; 27: 291–305.
Godfrey-Faussett P, Kaunda H, Kamanga J, et al. Why do patients with a cough delay seeking care at
Lusaka urban health centres? A health systems research approach. Int J Tuberc Lung Dis 2002; 6:
796–805.
Goetz T. The remedy: Robert Koch, Arthur Conan Doyle and the quest to cure tuberculosis. New
York, NY, USA: Gotham Books, 2014.
Goffman E. Stigma: notes on the management of spoiled
Green L. The utter normalization of violence: silence, memory and impunity among the Yup’ik
people of Southwestern Alaska. In: Six-Hohenbalken N, Weiss N, eds. Violence expressed: an
anthropological approach. Farnham, UK: Ashgate Publishing Limited, 2011: pp 21–36.
Green L. To die in the silence of history: tuberculosis epidemics and Yup’ik peoples of Southwestern
Alaska. In: Barber P G, Leach B, Lem W, eds. Confronting capital: critique and engagement in
anthropology. New York, NY, USA: Routledge, 2012: pp 97–112.
Hacking I. Making up people. In: Biagioli M, ed. The science studies reader. New York, NY, USA:
Routledge, 1999: pp 161–171.
Hacking I. The looping effects of human kinds. In: Sperber D, Premack D, Premack A J, eds. Causal
cognition. New York, NY, USA: Clarendon Press, 1995: pp 351–394.
Harper I. Anthropology, DOTS and understanding tuberculosis control in Nepal. J Biosoc Sci 2006; 38:
57–67.
Heijnders M, Van Der Meij S. The fight against stigma: an overview of stigma-reduction strategies
and interventions. Psychol Health Med 2006; 11: 353–363.
Horner J, Wood J G, Kelly A. Public health in/as ‘national security’: tuberculosis and the
contemporary regime of border control in Australia. Crit Public Health 2013; 23: 418–431.
identity. New York, NY, USA: Prentice Hall, 1963.
In: Skoda U, Nielsen K B, Fibiger M Q, eds. Navigating social exclusion and inclusion in contemporary
India and beyond: structures, agents, practices. Anthem Press, 2013: pp 207–226.
Isaakidis P, Smith S, Majumdar S, Furin J, Reid T. Calling tuberculosis a social disease—an excuse for
complacency? Lancet 2014; 384: 1095.
Jasmer R M, Seaman C B, Gonzalez L C, Kawamura L M, Osmond D H, Daley C L. Tuberculosis
treatment outcomes: directly observed therapy compared with self-administered therapy. Am J
Respir Crit Care Med 2004; 170: 561–566.
Johansson E, Long N, Diwan V, Winkvist A. Gender and tuberculosis control: perspectives on health
seeking behaviour among men and women in Viet Nam. Health Policy 2000; 52: 33–51.
Karim F, Chowdhury A, Islam A, Weiss M G. Stigma, gender, and their impact on patients with
tuberculosis in rural Bangladesh. Anthropol Med 2007; 14: 139–151.

20 | P a g e
Kehr J. Blind spots and adverse conditions of care: screening migrants for tuberculosis in France and
Germany. Sociol Health Illn 2012; 34: 251–265.
Kelly S. Stigma and silence: oral histories of tuberculosis. Oral History 2010; 39: 79–90.
Kleinman A. The illness narratives: suffering, healing and the human conditions. New York, NY, USA:
Basic Books, 1988.
Koch E. Local microbiologies of tuberculosis: insights from the Republic of Georgia. Med Anthropol
2011; 30: 81–101.
Koch E. Tuberculosis is a threshold: the making of a social disease in post-Soviet Georgia. Med
Anthropol 2013; 32: 309–324.
Lambert M L, Van der Stuyft P. Delays to tuberculosis
Liefooghe R, Baliddawa J, Kipruto E, Vermeire C, De Munynck A. From their own perspective. A
Kenyan community’s perception of tuberculosis. Trop Med Int Health 1997; 2: 809–821.
Littleton J, Park J, Thornley C, Anderson A, Lawrence J. Migrants and tuberculosis: analysing
epidemiological data with ethnography. Aust NZ J Public Health 2008; 32: 142–149.
Lock M. Breast cancer: reading the omens. Anthropology Today 1998; 14: 7–16.
Lock M. Encounters with aging: mythologies of menopause in Japan and North America. Berkeley,
CA, USA: University of California Press, 1993.
Long N H, Johansson E, Diwan V K, Winkvist A. Different tuberculosis in men and women: beliefs
from focus groups in Viet Nam. Soc Sci Med 1999; 49: 815–822.
Mason P H. The liminal body: response to privacy in the context of ‘re-emergent’ infectious diseases.
J Bioeth Inq 2014; 11: 565–566. 89 Wolf S, Berle B B. The technological imperative in medicine:
proceedings of a Totts Gap colloquium held June 15–17, 1980
Mesa J M. Historia de la tuberculosis en Espana, 1889–1936. Granada, Spain: University of Granada,
1989. [Spanish]
Möller M, De Wit E, Hoal E G. Past, present and future directions in human genetic susceptibility to
tuberculosis. FEMS Immunol Med Microbiol 2010; 58: 3–26.
Nair D M, George A, Chacko A K T. Tuberculosis in Bombay: new insights from poor urban patients.
Health Policy Plan 1997; 12: 77–85.
Nichter M. Global Health: Why cultural perceptions, social representations, and biopolitics matter.
Tucson, AZ, USA: University of Arizona Press, 2008.
Nichter M. Harm reduction: a core concern for medical anthropology. In: Harthorn BH, Oaks L, eds.
Risk, culture, and health inequality: shifting perceptions of danger and blame. Westport, CT, USA:
Praeger, 2003: pp 13–33.
Ottmani S E, Uplekar M W. Gender and TB: pointers from routine records and reports. Int J Tuberc
Lung Dis 2008; 12: 827–828.
Pai N P, Vadnais C, Denkinger C, Engel N, Pai M. Point-of-care testing for infectious diseases:
diversity, complexity, and barriers in low- and middle-income countries. PLOS MED 2012; 9:
e1001306.

21 | P a g e
Park J, Littleton J. Ethnography plus’ in tuberculosis research. SITES 2007; 4: 3–23.
Raviglione M, Krech R. Tuberculosis: still a social disease [Editorial]. Int J Tuberc Lung Dis 2011; 15
(Suppl 2): S6–S8.
Reitmanova S, Gustafson D L. Coloring the white plague: a syndemic approach to immigrant
tuberculosis in Canada. Ethn Health 2012; 17: 403–418.
Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14: 32–38.
Rose G. The strategy of preventative medicine. Oxford, UK: Oxford University Press, 1992.
Rosenberg C E. Explaining epidemics: and other studies in the history of medicine. Cambridge, UK:
Cambridge University Press, 1992.
Seeberg J. The death of Shankar: social exclusion and tuberculosis in a poor neighbourhood in
Bhubaneswar, Odisha.
Seeberg J. The event of DOTS and the transformation of the tuberculosis syndemic in India.
Cambridge Anthropol 2014; 32: 95–113.
Serpa J A, Teeter L D, Musser J M, Graviss E A. Tuberculosis disparity between US-born blacks and
whites, Houston, Texas, USA. Emerg Infect Dis 2009; 15: 899.
Shah N S, Yuen CM, Heo M, Tolman AW, BecerraMC. Yield of contact investigations in households of
patients with drug resistant tuberculosis: systematic review and meta-analysis. Clin Infect Dis 2014;
58: 381–391.
Singer M. Introduction to syndemics: a critical systems approach to public and community health.
San Francisco, CA, ,USA: Jossey-Bass, 2009.
Sintchenko V, Gilbert G L. Utility of genotyping of Mycobacterium tuberculosis in the contact
investigation: a decision analysis. Tuberculosis 2007; 87: 176–184.
Sintchenko V, Iredell J R, Gilbert G L. Pathogen profiling for disease management and surveillance.
Nat Rev Microbiol 2007; 5, 464–470.
Smith F B. The retreat of tuberculosis, 1850–1950. London, UK: Croom Helm, 1988.
Styblo K. The number of cases of tuberculosis throughout the world has increased over the last 30
years. WHO/IUAT Information Kit. Geneva, Switzerland: WHO, 1982.
Susman J. Disability, stigma and deviance. Soc Sci Med 1994; 38: 15–22.
Sutherland H. The soil and the seed in tuberculosis. BMJ 1912; 2: 1434–1437.
treatment: shall we continue to blame the victim? Trop Med Int Health 2005; 10: 945–946.
Waaler H T. Tuberculosis in the world. Bull Int Union Tuberc Lung Dis 1982; 57(3–4): 202–205.
Warren A. (Re)locating the border: pre-entry tuberculosis (TB) screening of migrants to the UK.
Geoforum 2013; 48: 156–164.
Weiss M G, Sommerfeld J, Uplekar M W. Social and cultural dimensions of gender and tuberculosis.
Int J Tuberc Lung Dis 2008; 12: 829–830.
Welshman J, Bashford A. Tuberculosis, migration, and medical examination: lessons from history. J
Epidemiol Community Health 2006; 60: 282–284.

22 | P a g e
Whitehead L C. Quest, chaos and restitution: living with chronic fatigue syndrome/myalgic
encephalomyelitis. Soc Sci Med 2006; 62: 2236–2245.
Williams S J. Chronic illness as biographical disruption or biographical disruption as chronic illness?
Reflections on a core concept. Sociol Health Illn 2000; 22: 40–67.
Williams S. Goffman, interactionism and the management of stigma in everyday life. In: Scrambler G,
ed. Sociological theory and medical sociology. London, UK: Tavistock, 1987: pp 136– 164.
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