Even in the twenty-first century tuberculosis is a major public health concern, with an estimated 8.9 million new cases and 1.7 million deaths in 2004 Dye, 2006. TB is an infectious disease caused by a bacterium called Mycobacterium tuberculosis and it primary affects the lungs however it can also affect organs in the circulatory system, nervous system and lymphatic system as well as others. Commonly in the majority of cases an individual contracts the TB bacterium which then multiplies in the lungs often causing pneumonia along with chest pain, coughing up blood and a prolonged cough. As the bacterium spreads to other parts of the body, it is often interrupted by the body’s immune system. “The immune system forms scar tissue or fibrosis around the TB bacteria and this helps fight the infection and prevents the disease from spreading throughout the body and to other people. If the body’s immune system is unable to fight TB or if the bacteria breaks through the scar tissue, the disease returns to an active state with pneumonia and damage to kidneys, bones, and the meninges that line the spinal cord and brain” (Crosta, 2012). Thus, TB is generally classified as either latent or active; latent TB is the state when bacteria are present in the body however presents no systems therefore is inactive and not contagious. Whereas, active TB is contagious and can consists of numerous aforementioned symptoms. This essay will attempt to illustrate the ways in which social constructions of TB reflect wider socio-cultural values within contemporary global society. In the first part I will examine the historical context of TB and its link with poverty which continues on in present time. Secondly, I will explore the stigmatism and isolation with TB and finally I will relate the social construction of TB with the work of Emile Durkheim.
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It is important to recognise the geographical disparities in the prevalence of TB. For example, countries such as Australia have a “relatively low incidence of the disease with new cases primarily being identified in migrant populations a decade after their settlement. In some European nations with substantial public healthcare facilities, TB continues to be a problem particularly within large thriving cities such as London. This disproportionate increase in disease incidence compared with other community groups and national rates can be found in those who are socially disadvantaged including homeless, drug and alcohol addicted, people with HIV, prisoner populations as well as refugees and migrants…” (Smith, 2009: 1). This demonstrates the negative connotations society denotes to TB infected individuals as well as suggesting that in order to better understand the social construction of TB, the history of the bacterium needs to be explored. In 1882 Koch isolated the Mycobacterium tuberculosis and it was acknowledged that the disease was spread through overcrowded conditions, insufficient nutrition and a penurious lifestyle. It can be argued that TB has been constructed in two main ways: socially and biologically. “Biologically through science as an organism and socially by the community as a slow wasting death that was often associated with pale individuals being removed from the community” (Smith, 2009: 1).
Throughout history TB has been ambiguously represented. Much of the Western nineteenth century fictional literature highly romanticized the disease and reinforced the prevailing practices and beliefs. Often referred to as ‘consumption’; people were described as being consumed and exhausted by the disease as symptoms were assumed to be individuals looking ‘delicate’, ‘pale’ and ‘drained’ of energy. Treatment during this period in history mirrored these romanticised notions. Medical care was commonly described as a combination of fresh air, companionship and rest. In contrast, many non-European countries “negatively popularised TB as part of vampire myths as people tried to make sense of the disease symptoms (Smith, 2010). As a result, diseased bodies were exhumed and ritually burnt to remove vampire’s existence” (Smith, 2009: 1). This demonstrates the contrasting representations of TB within differing societies, suggesting that the hegemonic socio-cultural values of a disease in this case TB plays a crucial role in the social representations of a disease. As well as illustrating the importance of considering the impact of spatial and temporal differences.
Following the identification of the disease the discovery of streptomycin and other anti-tuberculosis medications quickly emerged. This gave the impression that TB was no longer a major health problem but instead incurable and controllable. Despite being important for treating TN, streptomycin, isoniazid and other anti-tuberculosis drugs contained limits for treatment. Resistance quickly developed and resistant strains of the bacterium quickly emerged limiting the use of many drugs. Consequently, to stop resistance several of the anti- TB drugs are required in combination and need to be taken for a period between 6 months and two years during therapy (Gandy and Zumla, 2002). However, recent outbreaks of multi-drug (MDR) TB have once again brought the disease to the forefront of global health problems. MDR TB is said to have emerged due to inadequate treatment of TB, commonly due to over- prescribing or improper prescribing of anti-TB drugs. Problems with treatment generally occur in immunocompromised patients, such as malnourished patients and Immune Deficiency Syndrome (AIDS) patients (Craig et al., 2007). In addition, it can be observed that the increase in TB closely reflects the rise cases of human immunodeficiency virus (HIV) and AIDS globally. Frequently, individuals with “immune disorders are not only more likely to contract and develop TB, they are also more likely to be in contact with other TB patients due to often being placed in special wards and clinics, where the disease is easily spread to others” (Gray, 1996: 25). In 2009, 12% of over 9 million new TB cases worldwide were HIV-positive, equalling approximately 1.1 million people (WHO, 2010). One of the most significantly affected countries is South Africa, where 73% of all TB cases are HIV-positive (Padarath and Fonn, 2010).
Furthermore, in the early twentieth century improved medical knowledge and technology allowed for better diagnosis. During this period words such as ‘contagion’ and ‘plagues’ were popularly used in negative terms in association to judge societies. TB was reported as “a form of societal assessment, infecting the ‘bad’ and the ‘good’ being disease free. A number of reports suggest a sense of apprehension became apparent as differing tuberculosis beliefs began to emerge (Smith, 2009: 1). This highlights the importance of social representations in terms of common terms associated with a disease play in the social constructions of TB. Moreover, it could be argued that people’s perceptions of a disease are not only shaped by their direct experiences and the impressions received from others but also significantly through media representations of the disease (Castells, 1998). It is important to recognise the symbiotic relationship between media representations of a disease and the dominant public discourses. It should be acknowledged that the term ‘discourse’ has multiple meanings, nevertheless this essay will employ Lupton’s (1992) assessment that ‘discourse’ as “a set of ideas or a patterned way of thinking which can be discerned within texts and identified within wider social structures”. The discourses that are founded and circulated by the media (mainly newspapers) can be regarded as working to produce what Foucault (1980) calls ‘particular understandings about the world that are accepted as “truth” (Waitt, 2005). Thus in the process of disseminating such “truths”, it could be argued that the media as a collective and commercial institution is implicated in ‘governing populations’. Meaning that “the power of the media can (directly or indirectly) influence the conduct of its audiences” (Lawrence et al., 2008: 728). This illustrates that media representations of a disease (TB) impact and are themselves influenced by dominant societal discourses thus helping to shape the social constructions of TB.
Moreover, it could be argued that there is strong link between those associated with TB and stigmatism and isolation as well as poverty and dirt (Scambler, 1998). Historically, TB was romanticised and referred to as ‘consumption’, however once it’s infectious nature was recognised this notion quickly changed. By the early twentieth century, the prevailing social and cultural values at the time generally believed that the disease festered in environments of dirt and squalor and was known as the diseases of the poor which could then be spread to the middle and upper classes. However, by the twenty-first century this discourse shifted from “the ‘poor’ (although marginalised groups such as the homeless and those with AIDS were still implicated) to the role played by Third World populations in harbouring the disease which threatens to ‘explode’ into the developed world” (Lawrence et al., 2008: 729). This demonstrates that as society’s socio-cultural values change the way in which disease is constructed and perceived also changes. It is important to consider the ways which these socio-cultural values change as well as acknowledge the interlinked relationship between dominant discourses, media representations and prevailing socio-cultural values. The relationship between TB and poverty has been recognised (Elender, Bentham and Langford, 1998) and arguably may not only “reflect medical and social characteristics of poor individuals, but also characteristics of housing and neighbourhood which foster airborne spread of TB infection, such as crowding and poor ventilation. Population groups with an increased prevalence of latent infection (such as new immigrants) are disproportionately found in poor areas- often with lower quality housing” (Wanyeki et al,. 2006: 501). This illustrates that not only socio-cultural values influence the social constructions of TB but socio-economic factors such as income and housing play a key role too.
Additionally, it is important to recognise the global disparities with TB. For example, Dodor et al (2008) argue that in countries where treatment for TB is not readily available, the disease has become highly stigmatised and infected individuals are exceedingly discriminated. According to Link and Phelan (2001) “stigma arises when a person is identified by a label that sets the person apart and prevailing cultural beliefs link the person to undesirable stereotypes that result in loss of status and discrimination” (Gerrish, Naisby and Ismail, 2012: 2655). This can be illustrates in common cases where people with TB often isolate themselves in order to avoid infecting others may try to hide their diagnosis to reduce the risk of being shunned (Baral et al,. 2007). From research in Thailand, Johansson et al. (2000) distinguish two main forms of stigma; one based on social discrimination and second on fear from self-perceived stigma. Furthermore, patients commonly experience social isolation in family sphere where they are obligated to eat and sleep separately (Baral et al,. 2007). This is a common case in countries such as India where little factual knowledge exists about the causes and treatments of TB and access to the necessary healthcare is diminutive (Weiss and Ramakrishna, 2006). As well as many rural communities where knowledge is passed through previous generations; stigmatism and isolation related to TB is substantial- representing the social cultural beliefs of the community.
It is important to recognise that the stigma and its associated discrimination have a significant impact on disease control (Macq, Solis and Martinez, 2006). Concern about being identified as someone with TB can potentially put off people who suspect they have TB to get proper diagnosis and treatment. These delays in diagnosis and treatment mean that people remain infectious longer thus are more likely to transmit the disease to others (Mohamed at al,. 2011). In a study conducted by Balasubramanian, Oommen and Samuel (2000) in Kerala, India stated that stigma and fears about being identified with TB were responsible for 28% of patients and this was a significantly greater problem for women (50%) than men (21%). This illustrates those socio- cultural values, for example the gender inequality highly present in Indian societies has a crucial impact on the social construction of TB. Also, in another study of social stigma related to TB conducted in Maharashtra, India, showed that stigma and discrimination of the disease resulted in late diagnosis and treatment. Moranker et al,. (2000) found that 38 out of 80 patients they studies (40 women and 40 men) reported to actively attempting to hide their disease from the community. “Social vulnerability contributed to women’s reticence to disclose TB, and such women were typically widows or married and living with joint families (Weiss, Ramakrishna and Somma, 2006: 281). This demonstrates the extent to which negative socio-cultural beliefs and values about TB can help to construct the disease- in terms of diagnosis, treatment and contagion.
Emile Durkheim’s (1915) work can help to better understand the argument that social constructions of TB reflect wider socio-cultural values. One of Durkheim’s core arguments was his claim that ‘the ideas of time, space, class, cause and personality are constructed out of social elements’. This allows us to examine the human body not only as a reflection of social elements but it draws attention to changes over time. Durkheim’s idea that space and classification are socially constructed stems from the collective experience of the social group. According to Durkheim the fundamental social division is dualistic in that one is between the social group and the other not the social group; which he applied to religion resulted in the ‘sacred’ and the ‘profane’. This central framework can then be used to various ways of viewing the world. Simply put as one geographic space could be labelled as ‘A’ and another as ‘not A’. Social anthropologist Mary Douglas (1966) extended this Durkheimian vision and discerned that:
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“far from a chasm separating the sacred and profane, as Durkheim had argued, there was a potential space which existed outside the classification system: this ‘unclassified’ space polluted the purity of classification and was therefore seen as potentially dangerous…Douglas’s analysis of purity and danger can equally be applied to the rules underpinning public health which are concerned with maintaining hygiene. The basic rule of hygiene is that some things are clean and others are dirty and therefore dangerous. Danger arises primarily from objects existing outside the classification system and therefore by determining what is dangerous and where it comes from it is possible to reconstruct the contemporary classification system” (Armstrong, 2012: 16-17).
This illustrates the essay’s central argument that social constructions of TB reflect wider socio- cultural values- meaning that till present day in many parts of the world TB is still perceived as an unknown variable and thus outside of society’s normal classification system therefore is commonly professed synonymously with connotations of ‘danger’ and ‘dirt’. These results in significant stigmatism, isolation and discrimination associated with individuals with TB (Heijnders and Van Der Meij, 2006). Furthermore, this highlights the fluid nature of social constructions of TB- meaning that since societies change over time so do their values and beliefs resulting in changes in the ways in which disease are socially constructed. Therefore, in order to fully understand how social constructions of TB reflect wider socio-cultural values, the historical context in which these factors are based and the dominant discourses must be considered.
For example, in the mid nineteenth century public health, mainly relied on quarantine as a preventative method, slowly began to classify new sources of ‘danger’ in objects and processes such as “faeces, urine, contaminated food, smelly air, masturbation, dental sepsis, etc.” The prevailing public health strategy at the time of ‘Sanitary Science’; which monitored objects entering the body (air, food, water) or leaving it (faeces, urine, etc.). Whereas, in the twentieth century new sources of ‘danger’ emerged including venereal disease and TB .Thus, a new public health regime of Interpersonal Hygiene developed. “Interpersonal Hygiene identified the new dangers not as emerging from nature and threatening body boundaries but as arising from other human bodies. TB, which had been a disease of insanitary conditions in the nineteenth century, became a disease of human contact, of coughing and sneezing” (Armstrong, 2012: 18). This further demonstrates the changing and interlinking relationship between socio-cultural values and social constructions of TB.
In conclusion, this essay has attempted to explore the various ways in which social constructions of TB reflects wider socio-cultural values in contemporary global society, by briefly examining the history of the disease and its prevalence in present time. As well as exploring the relationship between TB and poverty- statistically it can be observed that individuals with TB often belong to marginalised social groups and economically impoverished groups. Also, global disparities of TB prevalence was noted demonstrating that since each society is different and has varying socio-cultural beliefs and in lieu of the social constructionist theory this essay has adopted it could be argued that each society has its own particular social construction of TB influenced by its unique socio-cultural beliefs. This may be problematic given that if social constructions of TB are diverse but TB is perceived as a global health problem thus requiring global action then the nuances between the diverse social constructions of TB will be overlooked thereby arguably hindering the possibility of improving TB diagnosis and treatment. This also points to the need for not only considering the medical sphere of TB but also if we argue that TB is socially constructed then it is important to recognise the need for including the social aspects to health policies.
Furthermore, this essay examined the link between TB and stigmatism, isolation and discrimination through time and present day. Establishing that there are two main types of stigma associated with people with TB; self-stigmatism and societal stigmatism. Both are results of the negative connotations TB has held throughout time. Also, I briefly examined the role media representations play on the social construction of TB- particularly newspapers where the reader is viewed as an active agent. Finally, I utilised Emile Durkheim’s work to better understand and link the arguments presented in the essay. Durkheim states that ideas of time, space, class, personality are all produced with social elements. This highlights the argument that not only does the social construction of TB reflect wider socio-cultural values but that these values change over time thus the social construction of TB also correspondingly changes.
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