tuberculosis as survival? shifting meanings and strategies ... · elsewhere (koch, 2006) i have...

Tuberculosis as Survival? Shifting Meanings and Strategies for Wellness in post-Soviet Georgia

Erin Koch Visiting Assistant Professor of Anthropology

Middlebury College [email protected]

Paper prepared for “Challenges, Choices and Context: Health Behaviors in Eastern Europe and Eurasia” March 23-24, 2007 The University of Texas at Austin. Conference draft, do not cite or circulate.

Koch “Tuberculosis as Survival?” draft 2

Introduction: Standards, Vulnerability, Agency? Tuberculosis is widespread in the Georgian prison system, as it is in prisons throughout

much of the former Soviet Union, where overcrowding, restricted access to sunlight and fresh air,

and malnutrition exacerbate its spread. These conditions of incarceration and overcrowding of

detainees not only exposes them to disease, they also deprive them of the status and social and

material capital of citizens.

In Georgia TB services for incarcerated individuals are uniformly provided by the

International Committee of the Red Cross (ICRC) in collaboration with the Ministry of Justice

and the National Tuberculosis Program. Ironically, these services are better than those available

to the public at large.1 During my ethnographic research about tuberculosis and responses to

tuberculosis in contemporary Georgia, I witnessed the conditions that make prison a reservoir for

disease and a laboratory for testing the implementation of globalized standards for TB treatment

and control.2

People go to great lengths to complete their prison sentences in better facilities. A

particularly compelling illustration of this is the exchange of infected sputum within and between

sites of detention, primarily in the form of dried flakes. According to people with whom I

worked in the lab, prisoners produce such flakes by drying sputum on windowpanes. Sputum is a

substance that one would not expect to carry value. Detainees transform sputum into a barterable

1 The ICRC began working in Georgia’s prison system in 1997 when they conducted a survey of TB rates among detainees. At that time the civilian rate was .12% for drug-susceptible TB. The prison rate was 6.5% for drug-susceptible TB, and 21.8% for MDR-TB. As of 2005, drug-susceptible TB within the prison population is 4.5% and MDR si 6.16%. While rates of MDR TB remain unknown for the civilian population, the rate of drug-susceptible TB is .06%. (ICRC representative personal communication, June 2005, Tbilisi). 2 This draft paper draws on 15 months of ethnographic research in Tbilisi that was based at the National Tuberculosis Program. The larger study investigates the implementation of the WHO-mandated DOTS protocol in Georgia (Koch, Nd). Ethnographic fieldwork consisted of interviews with scientists, health care workers, administrators and representatives of international donor and aid organizations. I also conducted extensive participant-observation in the National TB Reference Lab, at training sessions for TB professionals, in hospitals, and in the prison sector where tuberculosis cases concentrate.


form of cultural capital with which they attempt to secure a false positive diagnosis and, thereby,

access to the prison facility for TB-positive detainees where living conditions are “better”.

To be sure, the people with whom I worked at the National Tuberculosis Reference Lab

(NRL) and ICRC all emphasized that they “understand why” prisoners exchange sputum. They

also emphasized that this practice—that they have labeled “cheating”—is unfair; should

detainees successfully secure a false TB diagnosis, they divert resources from individuals who

are “really” sick with tuberculosis. An individual is unlikely to actually contract pulmonary

tuberculosis by placing someone else’s sputum in his or her mouth, as this does not provide the

bacteria access to the lungs. Moreover, as I discuss below, “cheating” has increased the suspicion

and surveillance to which detainees are already subjected to such an extreme that they are

unlikely to actually succeed in securing a false TB diagnosis.

Elsewhere (Koch, 2006) I have examined these practices and responses to them in terms

of relations between morality and health. Specifically, I approach “cheating” as a moral

diagnostic in terms of which the recalcitrance of detainees is presupposed and reinforced. I

situate these practices more generally within the shifting context of incarceration and

tuberculosis in Georgia to understand how the state and other governing bodies reach into

marginal social domains, and struggle for control over techniques and practices that fall outside

the rule of law (Das and Poole 2004, 4, 25-9).3

3 My analysis draws on Paul Farmer’s (1999:6-9) concept of “structural” violence, which provides a particularly useful perspective for understanding the ways in which institutions, environment, poverty, and power reproduce, solidify, and naturalize the uneven distribution of disease and access to resources. Farmer has been resolute in his criticism of anthropologists and other social scientists that use “cultural differences” to mask political-economic inequalities and fall into the trap of cultural reductionism. These issues are critical in studying discourses about the former Soviet Union and particular populations (namely prisoners) carry the burden of a “high risk” population, who become a danger—“real” and/or imagined—to “at risk” groups who may be exposed (in this case) to infectious pathogens.


Here, I revisit this material with the goal of opening up a space for theorizing two critical

aspects of health in light of post-Socialist transitions. First, I argue that the transformation of

tuberculosis into a potential form of constrained agency calls for an investigation of the ways in

which vulnerability itself, and the making and governing of vulnerable populations in the post-

socialist context, may take on aspects of health agency or advocacy. What, after all, is the

meaning of “cheating” under circumstances of such intense duress that prisoners will

permanently risk their health to avoid the greater violence and hazards of prison existence?

Second, I suggest that the conditions of incarceration in which tuberculosis becomes part of the

punishment as well as a vector of agency among detainees provide a compelling lens for

furthering anthropological studies “of policy” in which development and aid organizations,

policy institutions and (in the case discussed here) global standards for disease control are

incorporated within the ethnographic inquiry and analysis (e.g. Singer and Castro 2005, xiii;

Wedel and Feldman 2005, 2). How do intertwined processes of social upheaval, displacement,

and standardization (in tuberculosis control) contribute to the naming, governing and

disenfranchisement of “vulnerable” or “high risk” populations?

Global TB Emergency

Once believed to be under medical control, tuberculosis resurgent—and drug resistant—

is one of the primary infectious causes of adult deaths worldwide. In 1993, in an unprecedented

move, the World Health Organization declared a Global Tuberculosis Emergency. This

international alert was issued to raise concern about the dramatic rise of tuberculosis and

multidrug-resistant TB (MDRTB) in the late 1980s and early 1990s worldwide, and to urge

public health officials at local, regional and national levels to put tuberculosis back on the map.


Tuberculosis in new more virulent and drug resistant forms had “re-emerged” as a result

of public health neglect in the 1970s and onward, when the WHO as well as national public

health institutions, such as the CDC in the US, dramatically cut back funding for TB. Behind the

veil of overconfidence in public health and the assumption that TB was basically eradicated, this

perspective ignored the fact that the illness had never disappeared from vulnerable populations

(Gandy and Zumla, 2003).

However, no novel anti-TB medicines have been introduced to the market in fifty years.

As Dr. Lee Reichman, a world-renowned tuberculosis specialist has argued, anti-tuberculosis

medicines drugs do not capture the attention of drug companies because “the vast majority of

people with TB are young and poor and live in developing countries. Very often, neither the

people nor their countries can afford TB drugs” (2001, 176).4 These inequities, along with the

“new tuberculosis” as the epidemic is widely described in public health literature, are fueled by

processes of globalization and the neoliberal reforms that exacerbate poverty (Kim et al. 2000).

In response to the emergency, the WHO first recommended a program of short-course

chemotherapy that evolved into a highly standardized protocol branded Directly Observed

Treatment, Short-Course (DOTS). The DOTS protocol is structured around lab-based diagnosis

and 6-8 month durations of ingesting (again, under direct observation) first-line anti TB drugs–

rifampicin, isoniazid, ethambutol, and pyrazinamide.5 The protocol emphasizes not only the

direct observation of medicine ingestion, but a multi-sectoral approach rooted in local and

transnational partnerships. It requires the cooperation and support of local governments, and is 4 In his analysis, Reichman delves deeper into efforts to promote TB drug research, development, testing, and marketization, which are ongoing. There are also efforts underway to improve the Bacille Calmette-Guérin (BCG) vaccination which is used worldwide with highly variable and often ineffective results. Other ongoing scientific work includes developing novel vaccines using DNA technology to recombine bacteria strains, and to directly deliver DNA to target and encode genes involved with immunity to TB infection, for example (see Doherty et al 2003). 5In Georgia, as in many places worldwide, streptomycin—more readily available and affordable—is also often integrated into the first line drug regimen.


geared towards greater efficiency in terms of the length and cost of treatment, as well as a

heightened accuracy of diagnoses based on laboratory tests of sputum, rather than X-rays.6

Standardization is an important aspect of responses to the global TB emergency – DOTS is

designed to increase cure rates and slow the rise of multi-drug resistant, or MDR TB (Raviglione

and Pio 2002: 359).

Officials account for the rise and spread of these microbes by blaming both national

public health programs and individual patients for not properly following standards. In both

cases, an emphasis on institutional and individual noncompliance masks the fact that DOTS is

quite difficult to implement and follow in its standardized form. This is because the technical

components are embedded in cultural and economic assumptions that presuppose a functioning

primary health care system.

More than a decade later, despite the production and global distribution of DOTS as a

standardized protocol for diagnosis, treatment and management, not much has changed. Today,

one-third of the world’s population is infected with tuberculosis, with one new infection

occurring every second, and approximately two million adult deaths annually.7 This is especially

alarming, given that tuberculosis is preventable and curable, emphasizing that it is a political as

well as medical issue.

I argue that an anthropological analysis of everyday experiences with standards and

standardization is central for an understanding of how large-scale projects (such as DOTS) fall

short on the ground. According to anthropologists Adriana Petryna and Arthur Kleinman, “global

6 The DOTS protocol consists of five official components: Government Commitment to sustained TB control activities; Case detection by sputum smear microscopy among symptomatic patients self-reporting to health services; Standardized treatment regimen of six to eight months for at least all sputum smear positive cases, with directly observed therapy (DOT) for at least the initial two months; A regular uninterrupted supply of all essential anti-TB drugs; A standardized recording and reporting system that allows assessment of treatment results for each patient and of the TB control programme performance overall. 7 Statistics from the Global Alliance for TB Drug Development. http://www.tballiance.org/2_1_C_AGlobalThreat.asp. Accessed November 3, 2003


standards are difficult to enforce…they are much more than cross-cultural quality assurance

mechanisms …as standards travel, their social and economic embeddness is revealed” (Petryna

and Kleinman 2006: 12. See also Bowker and Star 2000: 17).

However, because western biomedicine operates so forcefully with the status of value-

neutrality, the implementation of biomedical protocols in the former Soviet Union provides an

important entry point for local governments to demonstrate their position within a shifting global

order. Such processes also offer a critical site for anthropological investigations of how social

problems become medical problems, of how health protocols are value-laden and morally

charged, and the ways in which cultural values are masked behind discourses of biology and

nature (Castro and Singer 2004; Rivkin-Fish 2005, 21). These concerns are critical in the case of

DOTS, because “the DOTS strategy can be seen as an extension of the biomedical approach that

has dominated disease-control programs for many decades. The medical paradigm has become

globalized as the ‘gold standard’ for all countries to follow” (Porter, Lee and Ogden 2002, 182).

Standardization is not linear, but rather a fragmenting process in particular cultural

contexts: The implementation of the DOTS protocol and the imperative to provide desired

outcomes, which also secures further international support for the local NTP. Implementation

also creates tensions and contradictions in disease control, drawing service providers and seekers

into a confusing maze of categories, institutions and priorities (all of which are the subject of my

larger study).

Former Soviet Context

The former Soviet Union is one of the official hot spots of the global TB emergency.

Massive social and economic changes have led to extremely high levels of poverty, crowded


living conditions and shortages of food, energy supplies and health services. These factors make

TB widespread in the region, where the number of cases has more than doubled since the mid-

1990’s. The collapse of the Soviet health care system resulted in a range of severe health related

shortages – shortages in technology, the means to pay staff, clinical and laboratory supplies, and

simple facility maintenance.

Georgia’s separation from the Soviet Union in1991 was immediately followed by ethnic

civil wars primarily between Georgia and breakaway regions Abkhazia and South Ossetia. As a

result of these conflicts, economic and social conditions worsened, and the country was left

without a healthcare system or TB infrastructure until 1995, when the National Tuberculosis

Program, and the first DOTS pilot project were officially launched.

In addition to having a rich history of relative openness, involving trade, communication,

and cosmopolitanism dating back to the fifth century, Georgia was also one of the first former

republics of the Soviet Union to welcome aid and interventions from the United States and

Europe. Despite the success of the centralized Soviet medical system that provided basic services

to the entire population, this emphasis on specialization is seen as a lack of modernity in the

current era of primary health care. However, as one representative of an aid organization

working on DOTS implementation in Georgia told me “DOTS does not make sense in Georgia.”

My research findings show that even though the technologies and practices central to DOTS

are standardized, many countries such as Georgia simply do not have the parallel necessary

“standard” infrastructure to maintain the prescribed program. These limits are not just about the

absence of a functional primary health care system but also, for example, the electricity required

to operate microscopes and store TB culture samples is simply not always available. Nor can


facilities consistently afford the clinical, laboratory, or pharmaceutical resources necessary for

supporting DOTS in the long-term.

The forms of knowledge and expertise that distinguish the DOTS protocol are also

dramatically different than the Soviet model of tuberculosis control, which comprised an

important and largely successful aspect of the centralized Soviet medical infrastructure.8

However from the perspective of DOTS and western biomedicine, the Soviet system was

irrational and inefficient. The system consisted of too many facilities, x-ray screening is

considered to have been a waste of money and unnecessarily exposed people to radiation, non-

standardized drug regimens created drug resistance (which is a reasonable critique), and the

population of specific TB doctors was too specialized. Basically it is seen as having been chaotic.

Thus, in the language of the World Bank, the WHO, and other supranational

organizations governing health care reforms and other aspects of democratization in the former

Soviet Union, the successful transition to a market-based primary health care system requires

“rationalization” and “optimization” in infrastructure (re)building. Overwhelmingly, such

processes involve adopting standardized protocols. Throughout the former Soviet Union and

eastern Europe, standardization is a key element of post socialist transition and brings much-

needed capital to fledgling economies (Dunn 2004b:175–177). Worldwide, DOTS

implementation confers legitimacy in international public-health networks and secures resources

that the state cannot provide. DOTS is marketed and distributed as a medical–technical

intervention—as a mobile protocol that can be successfully implemented regardless of context.

8 Elsewhere I provide a detailed analysis of the Soviet model of TB control (Koch: n.d.). In summary, from the period immediately following the October revolution until the dissolution of the USSR, the Soviet TB control program emphasized mass screening, vaccinations, and long-term hospitalization in sanatoria, as well as mass training of TB specialists. In short, widespread primary prevention and identification limited knowledge on a one-to-one basis. Diagnosis was based primarily on X-ray evaluations, and treatment regimens relied heavily on the professional expertise and knowledge of individual TB doctors. Although treatment generally consisted of surgery combined with anti-TB drugs, there was limited emphasis on standardized case definitions or treatment regimes (Perelman 2000).


As such, “DOTS is seen as an essentially technical intervention that, in and of itself, is value-

neutral. DOTS, it is claimed, provides a ‘common language’ through which to develop national

and local strategies…however, there remains a limited view of the importance of socio-economic

determinants of health.” (Porter, Lee and Ogden 2002, 190-191).

Without attention to cultural, political and economic determinants, standards indicate a

baseline according to which compliance to “rational” and “efficient” forms of care are measured,

without attention to the social matrix in which knowledge about and experiences of illness are

produced and articulated. In Georgia’s post-Soviet context, new forms of governance are

instantiated by the introduction of medical and scientific standards such as the DOTS protocol.

This is an instance when “medicine becomes a political intervention-technique with specific

power-effects” (Foucault 2003:252). As many analysts argue, however, the DOTS protocol falls

short because of the overemphasis on the biomedical—on the ingestion of antibiotics—without

accounting for or utilizing local systems of knowledge and meanings about illness, treatments,

and community and family networks (Keshavjee and Becerra 2000). Biomedical rationality

never falls on neutral ground: Its interventions are subject to local interpretations, resistance, and

subversion.

Technical advisors and donors often imagine that the components of DOTS will

accommodate any local context. As one representative of an international organization involved

with DOTS implementation in Georgia explained to me, adopting the protocol should be

relatively straightforward. If the NTP is supported by the state using DOTS, other social factors

that contribute to TB are not major obstacles:

[With DOTS] your TB program works under whatever conditions: in refugee camps, in prison, wherever. If you take your patients sputum, you diagnose correctly, you get results.’ That’s a good message. …If you do your program you can forget about the big social economic approach.


In Georgia, however, administrators from the Tbilisi based NTP face numerous obstacles

to conducting routine surveillance and monitoring, especially in mountainous regions which are

largely inaccessible to outreach teams. These are not minor obstacles, but disabling structural

conditions that include shortages of staff, of modes of transportation, and of funds to pay for fuel

and accommodations.9 In rural and mountainous regions, DOTS is difficult to administer because

patients, nurses and physicians alike lack the funds necessary to travel from one region to

another on a regular basis. As is the case throughout the Caucasus region, many physicians

express resistance to the DOTS protocol not only because it undermines their expertise, but

because the treatment and monitoring standards are impossible to meet in conditions of social

upheaval, war, and economic collapse. The control of tuberculosis among incarcerated

populations holds ramifications for disease governance as bodies politic—individual, population,

social, and Georgian—are brought into shifting relations of power, as responsibilities for the

health of detainees’ shifts in the context of new market strategies and institutions. At the same

time, prison offers a laboratory for testing the implementation of DOTS; the immobility of

prisoners ensures that their daily routines can be organized around the distribution and observed

ingestion of antibiotics.

“Cheating” Reconsidered

The treatment of prisoners with tuberculosis, and the transformation of meanings of

infection or a positive diagnosis into a survival strategy provide an optic for studying shifting

9 Several administrators explained this situation to me, emphasizing that it is not possible for them to stay as guests with doctors while conducting supervisory visits. Occupying the role of guest in Georgia, hosted by those they are monitoring, would risk compromising their objective position, as generous hosts might expect a generous evaluation in return.


alignments of medical and carceral institutions and post-Socialist state transformations in

Georgia.

I am reluctant to analyze cheating as prisoners’ resistance to the inhumane conditions in

which they are contained, and the forms of suffering they endure. Medical anthropologist Arthur

Kleinman captures the heart of my concerns when he argues that anthropological accounts of

suffering and experience which “fault biomedicine for its failure to respond to the teleological

requirements of suffering” give way to reductionism—cultural reductionism, as they argue

against biological reductionism. In these cases, anthropological analyses “fall prey to a type of

social scientific appropriation of suffering” (Kleinman 1995, 145) and a reification of experience.

Here I want to avoid this kind of interpretative misappropriation—and exoticization—of prison

and the lives of detained individuals. Rather, I seek to develop a theoretical perspective for

linking the processes and institutions implicated in both DOTS implementation (and

standardization more broadly) and the making of vulnerable and at risk (not to mention

dangerous) populations. I propose that the intersections of these forces of post-socialist transition

create ruptures within which new forms of health agency in which disease and illness are

survival strategies, become possible.

I initially encountered cheating during my first full week in the lab, prior to having

visited any prison facilities. One afternoon, while watching Tamuna prepare smears for

microscopic examination, I saw the word “cheated” written in English on two of the containers

containing fresh sputum samples from prisoners. Later, while we were eating, Khatuna, a

microbiologist, joined us very upset about one of the three samples from a prisoner. The

registration form showed that his sample from the previous day had been negative, but that the

sample from that day was ochti plusi (four plus), indicating a very high amount of bacteria in the


sputum and a highly infectious individual. She said it was impossible to have such a discrepancy

in the amount of bacteria from one day to the next, and that the person had cheated. The word

cheated is written on the person’s sample cup, a moral label that stands for a complex

sociocultural practice.

She and Tamuna went on to explain that many prisoners cheat their samples, that people

who are positive (for tuberculosis) sell their sputum for vodka, cigarettes, and so on. People who

are TB negative “buy” the sputum because they want to be transferred to the prison TB colony in

Ksani, approximately thirty kilometers outside of Tbilisi. They both emphasized that they

understand why people “cheat”—the conditions in the prison colonies and pre-detention centers

are deplorable, and life is better in Ksani. While being transferred to Ksani can create further

distance between a prisoner and his family, limiting access to food, clothing, and other

necessities provided only through visitors.10 Nonetheless, getting into Ksani by whatever means

necessary is worth the sacrifice, as well as the health risks of exposure to unnecessary, powerful

drugs, or refusing to consistently ingest medicine so as to stay “positive” for TB. In these cases,

many people try to avoid a positive diagnosis when they do have TB, perhaps also by “cheating”

by not ingesting anti-TB pills.11

The structural violence of the prison system leads to internalized violence: prisoners not

only try to feign illness, they are perfectly willing to take powerful, dangerous drugs, should they

successfully secure a false diagnosis to get into Ksani. Through their interactions with ICRC TB

program staff, prisoners are educated in public health terms about the risky nature of tuberculosis:

10 In this chapter the detainees I discuss are primarily men. There are no women at Ksani, and in Georgia’s prison for women, overcrowding is not a serious problem. The ICRC team effectively eradicated TB from the women’s prison in 1999 (Philippe Creach, head of the ICRC’s TB prison program in Georgia, 2001). 11 This raises a whole other set of inquiries about surveillance in DOTS, here specifically about the “direct observation” aspects of the protocol.


how the bacteria spread; why uninterrupted treatment is crucial for curing the disease; and the

potential side effects of anti-TB medicines. Tuberculosis consciousness is high in the prisons, but

not for the reasons that the WHO, the ICRC, or the NTP desire.

Sputum circulates in Georgia’s prison system as a bodily substance but also constitutes

and defines TB in a local sense. “Having TB” entails not only a medical diagnosis of a very

serious, potentially fatal disease, but also an unofficial form of expert knowledge. This local

form of expert knowledge is an unintended consequence of DOTS implementation.

The implementation of DOTS entails a classic case of biopower of both individuals and

populations. Following the language of Foucault, “anatomopolitics” is inscribed in individual

subjects as “biopolitics” is enumerated in populations (Foucault, 1978). At the level of the

individual, enrollment in specific treatment regimens becomes the organizing principle of

everyday life for TB positive prisoners. Following Nikolas Rose, I argue that biopower “is more

a perspective than a concept: it brings into view a whole range of more or less rationalized

attempts by different authorities to intervene upon the vital characteristics of human existence”

(2007, 54). From the perspective of biopower, incarcerated men with tuberculosis are made into

patient populations as the institutions of public health—national and international—map and

intervene in the illness and health of the subjects of national governance. At the same time, I

would argue that they are not only objects and subjects of “different authorities” but also agents

of biopolitics which Rose refers to as “strategies involving contestations over the ways in which

human vitality, morbidity, and mortality should be problematized, over the desirable level and

form of the interventions required, over the knowledge, regimes of authority, and practices of

intervention that are desirable, legitimate, and efficacious” (Ibid.). Albeit constrained,

incarcerated individuals who attempt to “cheat” are thus producers of these strategies.


As in the carceral institutions that Foucault analyzed in Discipline and Punish, here

surveillance is a key factor. However, this is not a case of perfectible power, in which the

appropriation of techniques of correction, control, and surveillance emerge as effects of self-

disciplining regulatory practices. In Foucault’s words, “the panopticon is a privileged place for

experiments on men, and for analyzing with complete certainty the transformations that may be

obtained from them. The panopticon may even provide an apparatus for supervising its own

mechanisms” (1977, 204 emphasis added). While the situation I analyze here does resonate with

this description, and the ways in which the Panopticon served as a laboratory “to experiment

with medicine and monitor their effects” (1977, 203) “cheating” and responses to it run counter

to the perfectibility of power the Panopticon seemed to enable.

The conditions in prison are inextricable from the overall political and economic

instabilities throughout Georgia, including misdirection of funds at the level of state government

ministries, such as the MoLSHA and Ministry of Justice, bribery, and minimal salaries that

rarely reach employees in a timely fashion, if at all. Power is relational and, as Stern argues,

larger social transformations create new pressures. In the former Soviet Union, she argues, “first,

widespread and sudden poverty led to an increase in crime. Second, economic insecurity led to a

fear of crime and a public demand for greater protection. So, the number of arrests rose” (2003,

182). This led to a serious overcrowding problem, which in turn fuels the spread of

tuberculosis.12

Once an individual is arrested, he or she is generally held for several days in police

custody. If the case is formally pursued, he is next sent to a SIZO, a pre-trial detention center, to

12 As numerous ICRC representatives informed me in formal and informal conversations, under Shevardnadze’s administration numerous amnesties were given to prisoners. In most cases they were political prisoners who had been incarcerated during civil war who were pardoned if they had been fighting for Georgia’s territorial integrity. These amnesties create difficulties for the control of TB, because there are no resources in place to track detainees once they are released into “civil society.”


be held until the time of their trial and sentencing. The conditions in the SIZOs are the worst, and

arrestees are often held there for long periods of time. In an interview with the regional director

of PRI in Tbilisi, I learned that arrestees are often stuck in a SIZO without trial for as long as two

years. SIZOs are widely recognized as unstable environments, where the constant traffic of

detainees, combined with the poor conditions, exacerbates exposure to disease (Salvukij et

al.2002; Stern 1999, 13). More often than not, arrestees are denied their right to medical

inspection and consultation with a lawyer within the first twenty-four hours of being detained.

Once a detainee is finally sentenced, he is sent to a prison colony in proximity of family,

or to the high security facility located on the outskirts of Tbilisi. Under the Soviet system penal

colonies used to be labor camps. Prisoners were enemies of the state, but they were also a means

of production, put to work as part of the incarceration (Stern 2003, 182). In the wake of socialism,

relationships between prisoners and the state have changed dramatically, as the centralized

infrastructures for coordinating them have unraveled. But the prison colonies still exist, and the

hierarchies within, the “caste system” remaining from the Soviet gulag remains powerful forces

in structuring social relations and everyday life, and thus the movement and politics of diseases,

and responses to them.13

Located in Ksani, approximately 30 kilometers northwest of Tbilisi, the capital city, the

prison colony for TB-positive detainees is referred to as the “five-star hotel” of Georgia’s

penitentiary system by detainees, prison workers, and others in and outside of the penal system

because the conditions there are better than in other sites of detention. In this case, “better

conditions” mean access to sunlight and fresh air, a higher-calorie diet, cleaner, more spacious

living quarters, and reduced exposure to violence and social hierarchies among detainees.

13 In the larger study I provide a detailed description of this caste system, and the ways in which the hierarchies among detainees also operates as a social determinant of health.


In the prison context, positive disease status becomes a form of constrained agency, a

possible pathway to serve out a sentence in more livable conditions. To a certain extent, these

efforts operate as a form of “biological citizenship” in the sense Adriana Petryna has articulated

(2002). Cheating leads to a discussion of biological citizenship, but not in terms of citizens

making entitlement claims through categories of suffering and illness. Rather, prisoners are

already robed of the status of citizens, and attempting to claim illness while incarcerated will not

change their relation to the state. In the prison context, positive disease status becomes a form of

active agency, a possible pathway to serve out a sentence in more livable conditions.

Cheating is seen as immoral behavior that threatens resource management and rational

TB control. Talking with Zaza, a member of the ICRC’s active case-finding team, I asked about

cheating and how the team tries to control it. Zaza explained that they cheat because the

conditions in the TB hospital in Ksani are better; they have better housing, the doctors are always

there, the food is better, and they are more or less free in this colony. “So they are doing their best

to cheat us.”

Here, the us–them dichotomy is striking, as behavior that could be recognized as a

survival strategy and used to push harder for improving overall prison conditions is

operationalized as a moral diagnostic, in terms of which the control of prisoners’ behavior and

the control of tuberculosis become inextricable. Zaza went into gross detail about the range of

practices people have developed to attempt to forge their sputum samples, revealing both the

moral pathologies and inappropriate crossings of a nature–culture divide that make these forms

of exchange illicit :

Some of them, they have this sputum under a fingernail. Some used to put it in a syringe, and hide it in the sleeves of their shirt, especially in winter when they wear more clothes ... then sometimes, the worst thing is that they bring sputum in their mouth. They put the sputum in their mouth and during the coughing they get it in the cup. That is the


most disgusting. There are such schemes even as they are rinsing their mouth, they can keep this sputum, hide it somehow. Sometimes they have a [dried] piece, sometimes they have it in their nose and they force it from nose to mouth when they cough.

Imagine the autoviolence: Prisoners willingly take a powerful disease entity into their mouths as

a gamble on better prison accommodations. At the same time, the moral worldview that

underpins ICRC mandates is incorporated into everyday work practices under the auspices of the

DOTS protocol. The practices categorized as cheating, however, challenge the perfectibility of

the DOTS protocol and the assumption that biomedical technical interventions are value free and

can be implemented intact universally. The suspicion surrounding prisoners as possible cheaters

is part and parcel of the ambivalences and ambiguities that are inherent in the cultural politics of

standards. The exchange of sputum among detainees reflects their agency, not as resistance but

as part of their struggles for survival on the margins of society and of the state. To a certain

extent, this agency is perceptible in the invisibility of the circuits through which sputum travels

within and between sites of detention. As one member of the ICRC TB team explained, to the

best of the team’s knowledge, “the exchange of sputum is informal. I cannot say if it is for

nothing or costs something, or if there is trade going on. If that is the case, if people are trading

[sputum for goods], it is so confidential that we cannot know about it. Otherwise it wouldn’t be

cheating, it would be business” (personal communication, Tbilisi, June 2005). It is also

significant that lab techs still find (typically) moral culpability among cheaters. In a certain

sense, DOTS requires and encourages this surveillance, as doctors and lab techs are also forced

to comply with the protocol.

My single visit to Ksani was intended to show me the space as well as the daily work

routines of the ICRC and prison staff. After watching nurses organize pills to be distributed the

following morning, donning a lab coat, and pocketing a mask and gloves for later use, I

proceeded with my hosts to the sputum collection room.


As we approached a stairway to the upper floor of one of the buildings, the ICRC doctor

told me to put on my gloves and mask: “We are entering the infected area.” At Ksani, routine

sputum collection takes place in a special room built by the ICRC for that purpose (see figure 1).

The room measures approximately 12 feet by 20 feet and has a sink in one corner and acrylic

plastic dividers along the opposite wall, creating stalls where prisoners stand while they cough

up sputum. As part of the larger project of rehabilitation of the facilities, the construction of the

room reflects both the importance of reducing risk of infection from patient to sputum collector

and the role of suspicion in routinized medical protocols.

Prisoners are under tremendous surveillance, under suspicion of cheating. A team of five

nurses and one doctor oversees the collection of sputum. When we arrived, about 20 men were

standing around outside the collection room waiting. As we entered the room, the five nurses

took their places: one at the door at the end of one long wall; a second against the center of that

same wall; a third at the sink; and one each behind the outer walls of the stalls. A space separates

the wall of the room and the outer sheets of acrylic plastic on either side of the stalls.


SPUTUM COLLECTION ROOM (figure 1)

SINK NURSE #3

NURSE

NURSE

DETAINEE

DETAINEE

ICRC DOCTOR

DOOR NURSE #1

NURSE #2


First the prisoner gives his name to the first nurse, who checks the schedule for that day

and compares his face to a photograph. The second nurse writes his ID# on a collection cup

while he goes to the sink. There, he shows his hands to the third nurse, washes them and rinses

out his mouth. The second nurse hands his cup to one of the nurses behind a stall, hands it

around the space in between and holds it while he coughs into it. The ICRC doctor oversees

entire process and checks each sample for what they call “suspicious particles”. If they have

forged a sample the sputum flake will appear as a black speck.

Staff and delegates from the ICRC deliver samples from detainees around the country

several days a week in insulated plastic coolers in the morning, and samples from the civilian

population are delivered by individual patients. The source of samples is identifiable by the

containers used: prison samples arrive in small, clear plastic containers with colored lids that

look like pieces from a food-storage set. Samples from civilian patients arrive either in the small

containers purchased from the lab or in jars from home originally used for mayonnaise, honey,

and other condiments. In other words, the first are standardized and the second are not.

When sputum enters the NRL it is, thus, already stratified as “civilian” or “prison,” and

its origins must be recorded and tracked throughout its diagnostic transformation. Although the

three main procedures that sputum analysis sustains—smear microscopy, TB culture growth, and

drug-susceptibility analysis—may be run for samples from all populations, samples from

prisoners carry an added weight of suspicion.

The work lab techs do with samples from prisoners entails looking for “suspicious

particles” that the Dr was also on the lookout for. This surveillance reconfigures the work of

sputum collectors and lab techs, whose professional responsibilities take on aspects of policing—


one might label this biopolicing—for the ICRC and the state. The policing of sputum in the lab

contributes to the carceral system. Structurally, culturally, and politically routine laboratory work

participates in the policing and enforcing of boundaries between criminal and civilian worlds,

standardizing the first while dividing it from the second.

As in English, the Georgian sense of someone who is a matquara (cheater or deceiver,

მატყუარა) is of one who knows the rules of the game and breaks them to gain access to

resources to which he or she is not entitled. My inquiries about exactly who is being cheated and

of what often brought about heated responses concerning detainees who are milking resources to

which they do not have a right. At the same time, the ICRC delegates and Georgian staff with

whom I worked emphasized that they “understand why” detainees cheat. As the current head of

the ICRC’s TB program so poignantly said about cheating, “It is unbelievable for any

nonsentenced or any civilian or any person who is outside. It is unbelievable for me. But to tell

you honestly, I am not sure if I were them, if I would not do the same. It is very difficult to judge

them. But cheating remains a serious problem” (personal communication, Tbilisi, June 2005).

Medical staff also clearly advocate through their individual actions and interactions for improved

living and health conditions among prisoners.

In an effort to control cheating, the ICRC is gradually decentralizing DOTS, that is,

implementing the protocol in other sites of incarceration, so that a positive TB diagnosis will not

guarantee transfer to Ksani. The need to decentralize and the obstacles posed by the caste system

exemplify how DOTS is taken up and transformed to meet competing local needs and pressures

on the ground.

In summer 2002 I visited Georgia’s high security prison and the largest SIZO—pretrial

detention center in the country, both located on the outskirts of Tbilisi. DOTS had recently been


introduced in both facilities. Every afternoon, nurses organize the pills to be distributed the

following morning, from 6 to 12 pills per person each day. While we were waiting for the nurses

to finish preparing the syringes, the doctor from the SIZO told ICRC team members that the

previous day a group of ten prisoners had refused to take the anti-TB medicines. They were

using their status as TB patients to negotiate. Again, standardized knowledge and regimens of

DOTS acquire local meaning and value, as compromised health emerges as both an aspect of

punishment and a form of constrained agency.

The doctor explained that one reason for their protest was that the quality of their food

had fallen since they had moved to the TB ward. Before being diagnosed with tuberculosis, they

were held in horrible cells but were given some potatoes and oil regularly and could cook them

on a hot plate, which brought the added benefit of heat to the cold cells. On their transfer to the

TB floor, this privilege was taken away. They were also protesting the physical side effects of

the anti-TB drugs, such as cramps and potential liver damage, which made the poor quality of the

food even more intolerable. On hearing about the anti-antibiotic strike, the ICRC doctors turned

around and marched off to the prisoners’ cell. I followed.

The cell was a box-shaped room, approximately 12 feet by 12 feet in size. This space

housed six men, who slept in three sets of bunk beds packed along one wall, in front of windows

covered with large metal shutters meant to keep prisoners from talking to those in other cells or

to guards. In the center of the room was a table with two benches, where people kept personal

possessions such as bowls and spoons. Other important possessions—clothing, pictures, and

magazines—were kept close to individual bunks. In one corner of the room, a thin bedsheet

shielded what I presumed to be a toilet or urinal that may or may not have been supplied with

running water. The walls of the cell were cracked, and the door was solid metal with a small


opening about one foot up from the bottom, resembling a mail slot. While we were in the cell

that morning, it was obvious to me that the doctors’ main concern was with the immediate well-

being of the men involved, rather than with “meeting standards” at an abstract level.

We stayed there for about 20 minutes, talking about why the men were refusing the

medicines and about the risks involved. Our conversation was halted by the nurses. They wanted

to begin distributing the medicines, which required us to leave the cell and lock the door: Only

one cell door can be open at a time.

We left the room and followed the nurses as they proceeded from one cell to another with

the patients’ charts and a cart of pills appropriately sorted into small cups, observing as they

administered the treatment. Each prisoner entered the hall with a cup of water, as instructed, and

ingested the pills. A nurse checked his hands and his mouth to make sure he swallowed the pills.

As inmates filed out of the last cell the doctor pointed out one young man and said, “That

one is only 20, and he has been here for two years. He was arrested for a petty crime, but no one

will say what the crime was. He was not a criminal when he was arrested, but he will become a

criminal in prison. Here, he has been sentenced with TB and with the life of a criminal.”

Following that stint of research, I turned to public health literature and human rights

resources concerning incarceration in the former Soviet Union, specifically concerning

tuberculosis and other communicable diseases, to whatever extent possible. I located a wealth of

human rights materials, but surprisingly little of it mentioned anything resembling the “cheating”

I had encountered in Tbilisi. For example, in an edited volume entitled Sentenced to Die? The

Problem of TB in Prisons in Eastern Europe and Central Asia, published by the International

Centre for Prison Studies at King’s College of London, only one article mentioned the


circulation of sputum samples by prisoners. In their essay, Reyes and Conix cautioned about the

devious practices of prisoners

Poorly paid prison doctors may turn a blind eye to exchanges of sputum, after taking bribes from wealthy prisoners. They may even put pressure on laboratory technicians to find bacilli in negative sputum samples … prisoners who have taken the treatment may try to substitute the sputum of an infectious patient for their own, so they can continue to stay on the programme and continue to receive better food and more medicines. (1999, 204-05).

However, from a human rights perspective based on UN decrees, “cheating” says more

about conditions of incarceration and ICRC ideologies about “desperate” prisoners than it does

about the incarcerated men themselves. Why not make conditions more livable, rather than

purvey humane treatment through individual rights discourse and resolution?

Conclusion: Standardization, Vulnerability, Agency?

Insisting that global forces support DOTS implementation in Georgia and, indeed,

throughout the world is imperative. The protocol is a hope for health and recovery that boasts

important rates of success in curing tuberculosis worldwide through biomedical standardization.

An anthropological analysis of standardization and its unintended consequences speak to the

larger issues of disease governance in relation to Georgian historical consciousness, competing

logics of expertise, and whether DOTS ‘makes sense’ in Georgia. Not only is DOTS a

marketable commodity but the protocol also operates under the premise that, if given the

opportunity, every rational individual will “do the right thing” or make the right choice. It is

geared toward changing the behavior of individuals but does not address the need to change the

institutional, political, and economic context within which its limits are manifest. Concretely,

these limits often produce MDR tuberculosis.


The subversive traffic in sputum challenges the flawless status of Western biomedical

rationalities and standards of disease control. Trafficking also gives rise to new forms of

surveillance that are leveled against prisoners who are suspected of having tuberculosis and of

engaging in the illicit exchange of sputum.

These alarming trends that contribute to the rise of drug-resistant tuberculosis that are

emerging from efforts to transform the ‘old’ system from something irrational to a ‘new’ and

more modern version of standardized tuberculosis control are among the unintended

consequences of DOTS implementation in Georgia, and elsewhere. Among other findings not

discussed here are the lack of trust patients have for the emergent primary health care system in

Georgia, and how DOTS seems to exacerbate the social stigma that they face as people with

tuberculosis. What remains to be seen is how the connected processes of standardization and the

management of vulnerable populations in the post-socialist context create ruptures within which

new forms of health agency—constrained agency in which disease itself becomes a survival

strategy—become possible.


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