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Local Microbiologies of

Tuberculosis: Insights from the

Republic of GeorgiaErin Koch

a

aDepartment 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

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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 squarelyinto the anthropological purview, underscoring dialectics of biology andculture in which infectious diseasesand knowledge and practices aboutthemare produced. In this article I provide an anthropological perspectiveof expert discourses about tuberculosis at a tuberculosis reference laboratoryin Tbilisi, Georgia. A latentactive dichotomy prevails in contemporary globalhealth responses to tuberculosis. Based on ethnographic research about every-day laboratory-based diagnostic work, I question the stability of this dichot-

omy and unsettle biological and cultural reductionism. In so doing,I highlight the theoretical and methodological contributions that anthropo-logical engagements with science, technology, and medicine bring to studiesof 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) fromcultures of Mycobacterium tuberculosis (Mtb), the bacterial causative agentof tuberculosis. Drug susceptibility tests are significant because they clarifybacterial strains in people, and shape treatment regimens. However, like thebacteria they enable laboratory technicians to typify, DST results are not static.

ERIN KOCHis 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 displace-

ment, 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: [email protected]

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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Preparing DSTs involves handling culture colonies from each sample thattechs (laboratory technicians) grind, suspend in sterile water, and saturate

in media prepared with four first-line drugs: rifampicin, isoniazid, ethambu-tol, and pyrazinamide. Lab techs take great care in decolonizing andgrinding Mtb colonies from cultures to ensure their personal safety andsample integrity. I sat next to Tamuna at the ventilated hood, unwrappingmortars and pestles as she needed them in order to grind colonies of Mtb. AsTamuna carefully removed samples from different locations in the testtubes, she emphasized that taking cultures from several different coloniesin each tube where Mtb has been cultivated gives a more accurate DSTanswer because there may be different strains growing in one sample.

Tuberculosis is plural, not singular, I thought. Next she placed thecolonies in a mortar and vigorously ground them, explaining that in a lab-oratory 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 exhaust-ing 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 readresults from DSTs that had been prepared three weeks prior. On this morning

we saw in those tubes many patterns of resistance and susceptibility. She toldme that you could see that some people were infected with the same strain. Butone person could be infected with different strains at once, and new forms ofresistance might develop during treatment. Although DST results are impor-tant in shaping treatment regimens for each patient, this information is notstatic; it might be fleeting or representative of something in transition. WhenI 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 howthey will change. We have to work with the information we have. DSTs arenot 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 mighthave changed since they gave the sample. Again, a gentle sigh and well, thetests are slow in part because it is a slow-growing bacterium. And in the labwe do not know everything about what is happening with the patient at homeor anything. We do the best we can.

That afternoon, as Tamuna recorded results, I thought about themultiple meanings single sputum samples could bear. For patients, sputum

is an element of physical discomfort, and a potentially stigmatizing markerof infection. For clinicians, a productive cough indicates that a patientmight have an active case of tuberculosis. Laboratory technicians interactwith 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 forgerelationships with bodily substances and bacteria, if any are present.

Mycobacterium tuberculosis, like all microbes, is a hybrid; its ecology is asecond nature determined at the intersection of economy, biology, and bio-medical standardization. Anthropological attention to microbes shows howorganisms biologies are shaped by time and place (Lock and Nguyen2010:100), affecting experiences of illness. From a purely biological perspec-tive, Mtb is characterized as a slow-growing and successful pathogen thatbears natural capacities for evading detection and developing antibioticresistance. 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 TBlaboratory work presented here. The Georgian context further highlightshow within standardized forms of knowledge production, the significanceof 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 statesactive or latentthat are perceived to be most readily diagnosable inthe laboratory. Drawing on ethnographic fieldwork in a tuberculosis labora-tory in Tbilisi, Georgias capital city, in this article I propose that active and

latent TB are not fixed biological states, but dialectical human-microbe rela-tionships that only emerge and become meaningful in particular contexts.I introduce the concept of local microbiologies to highlight and frame thesenuances. My goal is to bring the molecular properties of microbes squarelyinto the anthropological purview and to foster a more nuanced understand-ing of human-microbe relations. Attributes of microbes are made meaning-ful for processes such as classifying and rendering micro-organisms andintervening in infectious diseases. They are also made meaningful by peoplewho have stakes in establishing relationships with microbes, such as labora-

tory technicians. From the perspective of local microbiologies, however,that relationality is eclipsed when laboratory results are reduced to a fixedstate of active, resistant, and so on. Focusing on static microbial statesgives way to rigid treatment regimens, irrespective of a local microbiology,which in turn could undermine the effectiveness of the very protocoldesigned to control the spread of disease and cure cases.

Ironically, the molecular characteristics that biologists and laboratorytechnicians use to distinguish mycobacterium tuberculosis emphasizeadaptability and resilience rather than a fixed state of active or latent infec-

tion. The laboratory staff with whom I worked regularly talked about Mtbas if it were a key player in not only infection but in what they did on a dailybasis to try to detect and classify its presence in sputum samples throughsmear microscopy, culturing, and drug susceptibility tests. In a clinical TB

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laboratory, work is about cultivation, and cultivation is a relational processthat 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 ofbiomedical standards for its surveillance and management. The remainingtwo sections ethnographically anchor local microbiologies of tuberculosisin the main tuberculosis clinical laboratory in Tbilisi, Georgia. I explorehow and why laboratory technicians cultivate relationships with microbesto facilitate diagnosis and the ways in which these processes engage withspecific molecular, microbial attributes.

LOCAL MICROBIOLOGIES

The framework of local microbiologies emerges at the intersections ofmedical anthropology and science and technology studies and is motivatedby Margaret Locks concept of local biologies (1993, 2001). Lock empha-sizes a dialectal approach at the heart of local biologies to examine howknowledge 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 coproduced and dialectically reproduced (Lock 2001:484). In her compara-tive study of aging and menopause in Japan and the United States, Lockemphasized that both biology and culture are dynamic and contingent,rather than determinant. Lock was primarily concerned with how anassumed biological universality of the human body (Lock and Nguyen2010:83) in biomedical practices and knowledges eclipses the ways thatbiological and social processes come together temporally and spatially asartifacts of infinite possible biosocial outcomes. Local microbiologies

shift attention from the human body to human-microbe relations and referspecifically to how those attributes become meaningful in practice. In thecase of tuberculosis, microbes are manipulated and behave opportunisticallywithin local conditions.

Two recent anthropological studies accentuate why an understanding ofhuman-microbe interactions is important. In her ethnographic account ofraw milk cheese production in the United States, Heather Paxson arguedthat neglect of the microbe . . . continues to distort our anthropologicalview of the social world (2008:1920). To clarify the distortion, Paxson

offered the framework of microbiopolitics, which highlights the uniqueinsights that a focus on microbial social relations brings to local biologies.By microbiopolitics she means the creation of categories of microscopicbiological agents; the anthropocentric evaluation of such agents; and of

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appropriate human behaviors vis-a-vis microorganisms engaged ininfection, inoculation, and digestion (2009:17). For the raw milk cheese

producers with whom Paxson worked, bacteria bear many positive attri-butes. First, cheese artisans celebrate the health benefits of a diet rich inbacterial cultures. But the bacteria also give taste to the cheese; they are partof the character that cheese makers cultivate through human-microberelations. As the artisanal cheese makers get to know microbes, they arenot just cultivating bacteria, but in an artisanal local microbiology, cultivat-ing relationships with them. Paxson underscored a noteworthy ethnographicinsight that speaks to the significance of local microbiologies: in our anthro-pological 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 capitalistsunderscores the importance of bringing microbes into anthropologicalpurview. Microorganisms are key figures in debates about oceanic naturesand cultures, and laboratory research is central to rendering their evolution-ary and venture capital meanings legible, for example, in producing DNAlibraries. But the microbes that are the sea (not merely in it) do not immedi-ately lend themselves to genomic analysis. Within what I would call a local

microbiology, the genomic scientists with whom Helmreich worked reconfi-gured apparent biological obstacles into resources in ways that recast bothhuman-microbe socialities and debates about life and evolution. Hisethnography offers a critical insight for anthropological studies of infectiousdiseases: microbes do not simply shape social aspects of infection and treat-ment; local cultural politics of scientific (and biomedical) expertise alsoshape the status and meanings of microbes and how they relate withlaboratory cultures, bodies, and protocols.

Helmreichs study also emphasizes that laboratories are unique

environments for establishing local microbiologies because they are devicesfor creating significance, for separating figure from ground, for adjustingwhat counts as text and context (Helmreich 2009:57; see also Heath1997; Montoya 2007). In the clinical laboratory where I conducted research,Mtb emerges in a shifting terrain of disease governance. Laboratory testresults produce information critical for treating active cases and for deter-mining drug susceptibility so that individual patients can be treated withcase-appropriate antibiotics.

Mycobacterium tuberculosis spreads in droplets released when a person

with an active infection coughs or sneezes. Mycobacterium tuberculosiscan survive in the air for several hours; it displays natural resistance toantibiotics and can lay dormant in lungs or other spaces in the body whereit may establish residence and proliferate for long periods before


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reactivating and replicating (Cosma, Sherman, and Ramakrishnan2003:642). Because Mtb is characterized by its capacities to conceal itself,

lay dormant then reactivate, and develop resistance to antibiotics, it isknown as a successful pathogen (Hett and Rubin 2008; Vergne et al.2004). An ethnographic analysis shows that the significance of the biologicalattributes is only produced through social relationships; for example, inlocal microbiologies of diagnostic labs and of criteria for getting tested.Tuberculosis is a global health problem of epic proportions, and contempor-ary 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 multipledrug-resistant TB (MDR-TB) spiked so dramatically that in 1993 the WorldHealth Organization (WHO) declared a global TB emergency. This eventbrought renewed resources to TB programs that had been severely cut inthe 1960s through the 1980s, when international health officials declaredthat tuberculosis was nearly eradicated (Raviglione and Pio 2002). This

perspective accepted that TB was invisible to international donors andtaken to be a fact of life in the most-affected parts of the world (Dyeand Williams 2010:856). The rise of antibiotic-defying strains reframedtuberculosis, transforming it from a public health risk to a security threatin the West. The rise of extensively drug-resistant tuberculosis(XDR-TB)strains that are resistant to first- and second-line antibio-ticssimultaneously galvanized further resources for TB control andsharpened a biosecurity framework for its intervention; this transformationis an exemplary local microbiology in which bacteria outsmart immune sys-

tems, health systems, and antibiotics. This is not because strains of Mtb aresuccessful pathogens in an essential biological sense but because patternsof resistance are shaped by dynamics of human-microbe relationships, suchas political debates about appropriate treatment, poverty, and public healthneglect.

According to the WHO, in 2008 approximately 1.77 million adult deathsresulted from tuberculosis (World Health Organization 2009). One out ofevery three individuals worldwide (approximately 2 billion people) isinfected with Mtb, and the WHO estimates that one individual is newly

infected every second, and that one person dies from tuberculosis every 20seconds. A review of contemporary TB trends recently published in Sciencestates that as the number of new TB cases continues to rise annually, thereare 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 ofpeople newly infected with Mtb are infected with strains already resistant

to standard antibiotics. Although the tiny microbe harbors in the bodiesof billions of people, anti-tuberculosis medicines do not capture the atten-tion of drug companies because the vast majority of people with TB areyoung and poor and live in developing countries. Very often, neither thepeople nor their countries can afford TB drugs (Reichman 2001:176).Treatments and diagnostic tests for tuberculosis are outdated; innovationsin pharmaceutical research and development are not equally distributed tothe TB arena (Sassetti and Rubin 2007:279). No new anti-tuberculosismedicines have been available as treatment since rifampicin was brought

to the market in 1963. The standard clinical and laboratory tests for latentand active tuberculosis are more than 120 years old (Frieden, Lerner, andRutherford 2000:1088; Harries 2008). Although TB R&D is increasingand there are new tests, vaccines, and treatments in the pipeline (Ma et al.2010; Shi and Sugawara 2010), the focus on biomedical interventions foridentifying and killing bacteria eclipses structured social, political, and econ-omic inequalities that fuel antibiotic resistance (Altman 2008), and thatentrench 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 protocolbranded Directly Observed Treatment, Short-Course (DOTS). The DOTSprotocol is structured around laboratory-based diagnosis and treatmentregimens of first-line anti-TB drugs: rifampicin, isoniazid, ethambutol,and pyrazinamide, with direct observation of medicine ingestion 37 daysa week for 69 months. The goals of the protocol are to quickly identifyand 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 biomedicalintervention focused on killing bacteria took priority over other socialresponses to illness, such as alleviating poverty and improving nutritionand living conditions. As medical anthropologists have shown, in itsimplementation the global DOTS protocol is constantly recrafted in thecontext of local practices, forms of knowledge, and everyday life (Koch2006; Harper 2005; Nichter 2008; Shin et al. 2004). However, DOTS isprimarily a biological regimen that privileges a biomedical worldview overlarger structural and cultural contexts. The active and latent opposition sug-

gests a falseor at least a forceddichotomy that obscures the ways inwhich the microbe, the social context, and the body are all in motion(Bowker and Star 1999:169). This motion can be seen through ethnographicencounters in specific local microbiological contexts (e.g., Helmreich 2009).


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Laboratory-based tests are at the heart of the DOTS protocol. Withinthe framework of an effective TB control program, the identification and

treatment of infectious cases of pulmonary TB is the highest priority. Thelaboratory is therefore the focal point of the entire program (WHO=IUATLD 2000:79). The basic diagnostic is smear microscopy, in whichlab techs smear and stain sputum samples to look for bacteria. Accordingto the WHO, diagnosis by smear microscopy is ideal in resource-poorsettingssuch as that of Georgia discussed herebecause the process issimple, requires minimal equipment, and produces fast results (WHO2003). However, individuals only receive a definitive diagnosis afterproviding 23 samples over the course of 23 consecutive days. As Georgian

laboratory technicians and doctors often emphasized to me, this delaystreatment and discourages individuals who fear being stigmatized as a TBpatient from returning to the laboratory. Furthermore, the results of asmear could reveal that the individual has been infected with some type ofMycobacteriumof which there are 70 speciesbut not that it is necessarilyMtb. Some experts argue that sputum smears only detect 50 percent of posi-tive cases, in part because bacterium often spread from the lungs into thebloodstream 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 treatmentsfor both latent and active forms of tuberculosis. Even with the contempor-ary global health push for improving TB diagnostics and resources, biologystill takes center stage in the management of an illness that is an assemblageof biological, political, social, and economic factors.

Anthropologists who study infectious diseases bring to light the limitsof public health interventions that highlight culture and behavior asprimary factors in the spread of infection and antibiotic resistance (Briggsand Mantini-Briggs 2003; Farmer 1992, 1999). However, the ways in which

microbial attributes and human health are configured and reconfiguredthrough dialectical relationships with culture and behavior escapes consider-ation in these analyses (Orzech and Nichter 2008). If anthropologists are totranscend perspectives that see either culture as dominant and biology asessentially irrelevant or, conversely, biology as an immutable base andculture as a distortion, then it is essential that we acknowledge the plasticityof biology and its interdependence with culture (Lock 1993:373). To effec-tively treat tuberculosis as a complex comprised of bacterial ecology inrelation to social and cultural patterns, it is important to consider anthropo-

logicallynot only biologicallythe molecular and biological attributes ofmicrobes.

Nuances of host-pathogen interactions emerge on a threshold that is notsimply biological or cultural but also local microbiologically. Focusing on

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individuals actively sick with tuberculosis creates a paradox. Because DOTSis based on passive case finding and privileges diagnosis by smear

microscopy, the protocol only accounts for people who actively seek medicalattention and who have enough bacteria in their sputum for that diagnosticto establish infectiousness.

MANAGING TUBERCULOSIS IN GEORGIA

Countries that formerly comprised the Soviet Union constitute a hot zonein the contemporary Global TB Emergency (Koch 2008). After Georgia

separated from the Soviet Union in 1991, the centralized Soviet medicalinfrastructure was dismantled, leaving behind facilities lacking basicsupplies, health professionals who lost their positions or who were workingwithout salaries, and patients who lost a highly specialized system that theyknew how to navigate. There was no official health care system in operationuntil 1995 when the Government launched massive reforms (Belli, Gotsadze,and Shahriari 2004; Gotsadze, Zoidze, and Vasadze 2005). Those factorswere particularly favorable to the spread of tuberculosis, which is highlytransmissible with poverty and delayed or limited care. In Georgia, TB

services are primarily supported by the state and by international organiza-tions, and are distributed through a vertical program that is not integratedwith the rapidly changing primary health care system. Amid a shifting land-scape of service provision and economic barriers to care, many active casesare not diagnosed or treated until disease is advanced.

Many Georgian TB clinicians, laboratory workers, and administratorswith whom I worked expressed their views of the difficulty of implementingDOTS in Georgia. Tuberculosis doctors emphasized that even as resourcesand political will for combating tuberculosis increase, sick individuals are

generally unfamiliar with the protocols worldview. This worldview isanchored in passive case finding, meaning that health care workers do notprovide compulsory screening of the population. This requires that potentialpatients recognize symptoms and self-present to doctors in the face of jobloss (which often follows a TB diagnosis) or fear of being marginalized asa dirty or poor person, which is often the case. The political economy ofhealth in Georgia, when wedded with DOTS, produces a local microbiologyin which active cases are of primary concern. This has more to do with thepolitical economic relations that structure testing, treatment, and surveil-

lance than with biological attributes of microbes. Nowhere was this more evi-dent than in the diagnostic laboratory in Tbilisi where I conducted fieldwork.

The National Reference Laboratory (NRL) in Tbilisi is a level-threereference 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. InGeorgia, the NRL is one of the few laboratories equipped to grow cultures

of Mtb, and the only laboratory with the capacity to run drug susceptibilitytests. Working in the laboratory several days a week for six consecutivemonths, I developed finely tuned sensibilities about how sputum is manipu-lated to render bacteria, which is critical for diagnosis and for guiding andmonitoring treatment. I also developed fluency with procedures that identifybacteria through microscopic analysis of sputum smears, culture growth,and drug susceptibility tests. I began to see tuberculosis from the perspectiveof laboratory technicians. This perspective necessarily engages with Mtb asan 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 publichealth.

The Georgian government launched the NTP in 1995 under the auspicesof the Ministry of Health (now the Ministry of Labor, Health, and SocialAffairs), and with the assistance of a range of donor and aid organizations(Gzirishvili and Mataradze 1998). Headquartered in Tbilisi, the NTP ismanaged in accordance with DOTS, which confers legitimacy in inter-national public health networks and secures resources that the governmentis unable to provide. However, DOTS implementation has not been a seam-

less process because the protocol is not value-free. In Georgia, one factorhas been that diagnosis and treatment under the Soviet system and DOTSare very different. In contrast to passive case finding with DOTS, the Sovietmodel of TB control emphasized compulsory screening of the entire popu-lation (active case finding) by fluorography and x-ray, vaccinations, andlong-term hospitalization in sanatoria (Lapina 1970). Diagnosis was basedprimarily on x-ray evaluations, and treatment regimens relied heavily onthe professional expertise and knowledge of specialized TB doctors(Perelman 2000).

Analysis of smeared sputum samples has eclipsed x-ray images as aprimary indicator of tuberculosis. As Shorena, the administrative head ofthe laboratory, explained, this is largely for epidemiological reasons: Forsociety someone like this [TB positive] may be very dangerous . . . and wedo not know if they are spreading the bacteria. They are a risk. Epidemio-logically 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 examininglesions and determining the need for surgery, x-rays (and the clinic) are nolonger primary sites for diagnosis. Instead, laboratory-based diagnostics

that render and classify bacteria produce authoritative and reliableknowledge 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 beendonated by Emory University and the German Agency for TechnologicalCooperation (GTZ) seemed out of place inside crumbling walls. At thattime, 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 Georgiasprison system, and they needed laboratory facilities that could handle a highvolume of samples, as many as 30 per day, several days a week. Built accord-ing to WHO standards, the newer laboratory would have the capacity to

process tests for Georgias prison population and enable laboratorytechnicians to process tests for non-prisoners in a DOTS-appropriateenvironment.

When I started long-term fieldwork in 2001, the new NRL had been fullyfunctional for several months. On my first day, Lela, a microbiologist, com-pared the NRL to the conditions in laboratories she had recently visited inPoti and Batumi, smaller cities in western Georgia along the Black Seacoast. Displaying a lively combination of compassion and frustration witheveryday work and life in Georgia that I eventually learned was typical of

her and other Georgians, she yanked off her glasses and exclaimed: I dontknow how they work. They have no gloves or masks and they do not haveany hoods or exhausts systems. They are just working with open samples ofsputum that may be infected . . . they have no microscopes, they cannot docorrect smears . . . it is impossible to look at the slide. The impossibilityof conducting basic microscopic analyses in such conditions was at onceboth an unimaginable situation for a scientist and a reality of diagnosticlaboratory work in Georgia.

During my most intensive fieldwork I quickly became friends with

Tamuna, one of the younger laboratory technicians who was particularlyenthusiastic about my interest in the details of Georgian technicians workand lives. I first met Tamuna in 2000, during a brief tour of the older lab-oratory facilities, when our interactions were hindered by the short-termnature of my visit and by the masks we wore that prevented us from seeingmost of each others faces. When I returned the following year Tamuna,then in her late 20 s, excitedly recounted our first meeting, and interviewedme 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 attachedto gather sputum. She regularly became frustrated with the old, fragileloops, 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 occasionallycomplained.

During my first weeks working in the NRL I asked Tamuna why thesmear test is the standard diagnostic test, not only in Georgia but world-wide. She explained that Mycobacterium tuberculosis is a slow-growingbacterium surrounded by a waxy cell wall that protects it from detectionby the immune system (Saunders and Britton 2007:103). This wall alsoforms a biochemical matrix that renders the majority of available antibioticsineffective. Structurally and chemically Mtb has the capacity to exploit ahosts immune system to lay dormant in the lungs for long periods oftimein some cases for decadeswhere it can evade detection and poten-

tially reactivate itself (Cosma et al. 2003:666). The exact mechanisms bywhich all this occurs remain somewhat mysterious, but bear relevance forvaccine and drug development (Cosma et al.:654), and have determinedhow Mtb is imbued with meaning within laboratories, which in turndetermine the development of disease detection regimen.

RENDERING BACTERIA

Smearing sputum is a simple process, but must be conducted with care toprotect both the lab tech and sample from contamination. Once the smearhas been prepared, it is stained red, decolorized, and counterstained blueto highlight any bacteria that might be present. Technicians check slidesfor bacteria according to WHO standards, which dictate that each slidemust be visually divided into different fields of vision in which the numberof bacteria present must be counted. Lab techs use this information to assessthe risk of infection that an actively infected individual poses to others aswell as to determine the effectiveness of treatment. Smears provide enough

information to know if someones sputum is negative or positive for bacteriaand, if so, the level of bacteria in their sample. However, diagnostic tests donot provide static representations of pure biological states; an accuratereading of a slide does not provide a total picture of health or the risksan individual may pose to family members and to society at large.

Some medical service providers with whom I spoke expressed concernthat because DOTS only accounts for active cases, the protocol reveals aminimal number of those infected. One TB specialist also challenged theefficacy 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 popu-lation. 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 seriousto 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 alreadyvery advanced and this is not the proper way to prevent or cure this disease.

He went on to clarify that in his opinion DOTS is highly effective with peoplewho are newly infected and who are detected at an early stage of infection.

Nana, a representative of a local non-governmental organization withprior work experience with DOTS implementation in the prison system asan employee of the Ministry of Justice, echoed similar concerns. In heropinion, The DOTS approach is limited because it relies on only one diag-

nostic technique that is only concerned with active cases. . .

this system hasgreatly reduced TB-related mortality in the prison population [but] . . .smears only reveal actively replicating bacteria and this test is not 100 per-cent reliable in revealing those who are actively sick. She added that manyindividuals who may have tuberculosis do not even have access to smeartesting because they do not present standardized clinical symptoms. Toemphasize the potential consequences of these trends, she told me a storyabout one case that she had witnessed in a prison:

There was one patient who had a fever and other symptoms typical totuberculosis. His condition worsened, but no one [working in the prison]believed him because the smear test was negative. One supervisor of the prisonbeat him because they thought that he was making trouble (pretending to besick) and wanted to be transferred to another facility. One day he lost conscious-ness and was taken to the prison hospital. Only when an x-ray revealed cavitiesand pleurisies (inflamed lung tissue) was he admitted into the TB program.

Alarmingly, cases that develop chronic latency, then reactivate, are the mostlikely to develop forms of resistance that are incurable with existing antibio-

tics. These temporal factors bear serious consequences, including delayeddiagnosis and treatment, minimal detection of drug resistant strains and,ultimately, the spread of resistant strains between individuals and popula-tions (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 andnot another member of the Mycobacterium complex. Growing bacterial cul-tures also provides a sufficient amount of bacteria to run drug susceptibilitytests. From 1995 until late 2007 the NRL used a solid egg-based media for grow-

ing cultures and DST. However in solid media Mtb takes 8 weeks to grow. Drugsusceptibility tests take an additional 21 days to produce results.

Culturing in solid media begins with a sample of fresh sputum. Through aseries 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 apellet where any Mtb present will have settled. Next, lab techs grind the sedi-

ment, re-suspend it in sterile water, and distribute it in test tubes. In solidmedia, bacterial cultures resemble grainy white dots growing on the slopeof the media in the test tube that are colonies of bacteria. To test for drugsusceptibility, lab techs decolonize samples, grind and re-suspended themin sterile water, and distribute the liquid in media treated with antibiotics.Growth indicates that the strain is resistant to that antibiotic. This is arelatively simple procedure; the main drawback is that because Mtb is aslow-growing bacterium, it takes a long time to produce cultures, and thusa definitive diagnosis.

One faster method commonplace in resource-rich settings uses small testtubes that contain liquid media at the time of purchase. Lab techs test forgrowth hourly using a black light that illuminates bacteria growing in thefluorescent broth, or with a computer called Bactec that automatically readsthe samples. With support from the Global Fund, the NRL adopted liquidgrowth methods using Bactec. The reagents in the liquid media speed up thebacterial growth cycle of Mtb. Although microbial time, like cellular time,can be accelerated (Landecker 2007), the perspective of local microbiologiesunderscores the question: Is faster necessarily better? One lab worker critical

of the administration argued that faster processes of diagnosis and treat-ment are undermined precisely because the bacterium is a naturallyslow-growing microbe: They [administrators] dont want us to spendmoney on fluorography. They are waiting for someone to invent a little tab-let that will treat TB patients in two weeks. But that is impossible because ofthe biology of the TB microbe. Lab techs are important nodes within theassemblage of TB control, and are clearly attuned to the local microbiolo-gies in which they work and the ways in which temporalities of bacterialgrowth and nuances of activity and stagnancy shape them.

Thus, there are benefits and burdens to the upgrade to testing in liquidmedia. As we caught up about each others work and lives in 2007, Tamunaexplained the new processes to me in detail. Cultures are prepared from sedi-ments similarly to solid media. Technicians add two additional componentsto the broth in the tubes: a growth-promoter and an anti-contaminant thatcome premeasured and, once opened, have to be used within 24 hours.Sediment is re-suspended in saline, and added to the tubes. If preparing drugsusceptibility tests, the broth is also treated with antibiotics. The mainadvantage is temporal. In liquid media cultures grow in 814 days. With

drug susceptibility tests, liquid media affords results in 413 days ratherthan 3 weeks. Moreover, liquid media is 1520 percent more sensitive thansolid media; because some species (of mycobacterium) may only grow inliquid 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 brothare 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 versus35 percent in solid media.

It can also be difficult for techs to distinguish other bacteria frommycobacterium. As Lela explained, the growth cycle of Mtb is a factor:

In the lab it takes two to three weeks to grow visible colonies. It takes at leasttwo weeks to get an adult organism that has the ability to divide and formcolonies, 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 Bactecyou can see them earlier, but you cannot see them mature into colonies. In theliquid medium they are very young. All you can see is that something is grow-ing. But you cannot confirm that it is Mtb and not some otherMycobacteriumthat quickly.

For her, the key question is not how quickly they get results but the natureof those results.

Laboratory technicians also have concerns about the accuracy of testoutcomes with liquid media. Sometimes Bactec gives a negative answerfor a sample that had a positive analysis in the sputum smear. To resolve

these diagnostic contradictions, lab techs are required to smear and staina sample of liquid media from every tube that Bactec registers for positivegrowth to confirm the presence ofMycobacterium. Tamuna explained thatthe faster methods nearly double labor and time investments, whichexacerbate infrastructural obstacles. There are enough lab techs on staff,but there is not enough space. Because it is faster to test for Mtb in liquidmedia, they culture all diagnostic specimens and test them for drug suscep-tibility (previously they only ran culture tests for smear positive cases andsusceptibility tests by clinicians requests). But because samples treated in

liquid media are at a higher risk of contamination, all TB sensitive culturesmust also be smeared and read under a microscope for confirmation. Forthese reasons, Tamuna explained, this process is difficult to routinize inour conditions. Our technical expertise is fine, but we do not have the spaceor the time . . . for this lab in this country, Bactec could be good for researchexperiments, but it is not good for routine diagnostic testing and lab work.

In addition, the advantages of liquid media are challenged by financialand infrastructural constraints. Both the materials in which growth isfostered 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 overseasis held up in Georgian customs for months due to incomplete paperwork oraccusations 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 twothat 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 shiftingterrain of disease management. The technologies and techniques for manip-ulating those in the laboratory, and infrastructural, political, and economicforces impact the meanings and relevance of the newer technologies. Themicrobe is not simply active or passive as proponents of a standardizedtechnical intervention would have it.

CONCLUSION: LOCAL MICROBIOLOGIES, ANTHROPOLOGY,

AND GLOBAL HEALTH

Tuberculosis is not determined entirely by either social or biological forcesthat then influence one another; the DOTS protocol conceals as much as itreveals. Although it is imperative to cure active cases and stop chains ofinfection, 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 under-score the fuzzy nature of cultural lines that are taken for granted betweenmicrobial and social realms, and call into question how social scientistsconfront biology.

I have argued that Mtb bears attributes that when engaged with throughdiagnostic procedures encourage it to evade the protocol that is structuredto kill it. Focusing on active cases fosters tuberculosis. Why the focus onactive cases? From one perspective, the public health logic is clear andconvincing: identifying and treating actively infectious individuals reduces

the number of individual deaths and the spread of infection. However, 90percent of all TB-infected people have latent TB; nearly one-third of theworlds population is a reservoir for tuberculosis that could become infec-tious. According to Christopher Dye, Director of Health Information inthe Office of HIV=AIDS, Tuberculosis, Malaria, and Neglected TropicalDiseases at the WHO, we are never going to get to the [global TB] elimin-ation target unless we deal with the problem of latent infection (quoted inMarris 2007:267). Developing more accurate and faster ways of detectinglatency is essential because Mtb could reactivate after long periods, even

decades (Andersen 2006). Re-infection after reactivation is an importantissue in the current TB crises: Reactivation likely accounts for the greatmajority of active cases in areas of low tuberculosis transmission . . . in areaswhere 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 rapidlydetected? Are primarily biomedical interventions fundamentally flawed?Given the negative side effects of antibiotics, their widespread misuse bypeople who prescribe and ingest them, and the fact that only 510 percentof those latently infected will advance to active disease, arguments aboundagainst putting individuals latently infected with Mtb on antibiotics for 36months, as current treatment protocols for latent TB dictate. If the dayfinally arrives when new antibiotics are available, prescribing them in latentcases would likely exacerbate microbial resistance. These conundrums as

well as possible solutions persist in a zone of ambiguity formed by dialecticsof culture and biology.

These predicaments emphasize the importance of bringing microbessquarely into the anthropological purview to understand complex dynamicsof surveillance, infection, detection, and response in domains of infectiousdisease and global health. The framework of local microbiologies usesinsights from anthropological studies of science and technology to under-stand the cultural politics of global health interventions. Anthropologicalstudies of science, technology, and medicine demonstrate that it is no more

the case that microbes are external to sociality, and impact society, than it isthat 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 microbeswithout reproducing biological determinism. Responses to global healthdilemmas such as tuberculosis should advancebut not be limited tobiomedical interventions that emerge through highly nuanced dialectics ofcultural, biological, and political economic entities, institutions, and formsof knowledge.

ACKNOWLEDGMENTS

I am deeply indebted to friends and colleagues at the National TB Programin Georgia who made my research possible. The research on which thisarticle is based was supported by a Dissertation Improvement Grant fromthe Science and Technology Studies Program of the National ScienceFoundation; the Eurasia Program of the Social Science Research Council,

with funds provided by the US Department of State through the Title VIIIProgram; the Graduate Faculty of Political and Social Science at theNew School for Social Research; and the University of Kentucky. Portionsof this article were presented at the Annual Meeting of the American


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Anthropological Association (2007), the annual meeting of the Society forApplied Anthropology (2009), and at a conference for the Society of

Medical Anthropology (2009). I am grateful to Lenore Manderson andVictoria Team for their editorial expertise and to the anonymous reviewersfor Medical Anthropology for their astute suggestions and comments. Fortheir 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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