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Tuberculosis, DOTS and the Government of Health: From international to global, 1970 to 2015

A conference by the GLOBHEALTH network

Du 8 au 10 décembre 2016

Cermes3, salle de réunion,7 rue Guy Môquet, 94800 Villejuif

Convenors: Jean-Paul Gaudillière (Cermes3, Paris) and Christoph Gradmann (University of Oslo).

In 1993, when a booming HIV epidemic – through co-morbidity – had put the issue of tuberculosis back on the agenda of international health, WHO rang the alarm. It proclaimed a global emergency necessitating a worldwide concerted attack based on the so-called Directly Observed Treatment, Short Course strategy. In the following decade DOTS and its permutations such as StopTB became a major component of a global health enterprise, concurrent with an increasing involvement of the World Bank in health whose proclaimed intention is to provide more efficient and cost-effective solutions to the health challenges, which Southern countries face. The paradox of this generalization is however that DOTS was not innovative, at least in any biomedical sense of the term. Although it targeted new problems, i.e. the increases in TB morbidity especially in Africa, the new strategy did not rely on innovative drugs, therapeutic protocols or diagnostics. Dwelling on combination chemotherapies from previous decades it provided a new organizational framework based on five features: national programs, diagnostics based on smear microscopy, provision of drugs, standardized short course treatment, direct observation of drug consumption by a third-party in order to secure compliance.

Looking at the inception and further development of the strategy in comparative perspective, this workshop will explore the dynamics that DOTS carried as lens to study the transition from an elder international public health to contemporary global health as it emerged in the 1980s.

In the context of the research project GLOBHEALTH that hosts the conference, this transition is a matter of changing actors, forms of knowledge, tools and practices. The advent and generalization of DOTS highlights specific tensions underlying the present globalization of health, namely

  • the reconfiguration of health economic governance around the markets
  • the emergence of post-national institutions of health governance
  • the multiple epidemiological transitions and the management of risks
  • the limits of the therapeutic revolution and drug access policies

 With these general patterns in mind, we invite historical and anthropological studies of DOTS that help to understand a rarely discussed dimension of global health: the return of “vertical” programs after a period of eclipse in the 1970s and 1980s, which had seen international public health focus on primary health care and more “horizontal” and contextual approaches of health maters. This return could appear as innovative because the memory of (failed) world wide enterprise like malaria eradication had faded away, because tuberculosis had disappeared from the agenda, becoming a neglected disease, and because new actors in global health strongly promoted disease-centred therapeutic initiatives. Yet in the case of the dots, the revival of vertical programs met with novel challenges, i.p HIV-TB co-morbidity and the presence of drug resistance of an unprecedented severity and amount (MDR-, XDR-TB).

The workshop seeks to approach the manifold dimensions of DOTS through a series of specific and local studies in order to grasp how disease categories, standardized treatment regimens, industrial products, management tools or specific medicines have become elements in our present global government of tuberculosis. We invite both historical and anthropological investigations of both international and local sites. We have a strong wish for contributions addressing: a) the changing roles of WHO; b) the influence exerted by other global actors such as the World Bank or the IUATLD c) the trajectories originating in non-Western countries, India and East Africa in the first place.

The workshop aspires to study the history of the advent and development of the DOTS with the aim of providing insight into and reflection on the role of large scale health interventions in global health. Historical and anthropological studies should help to investigate some features of global health that are often underestimated:

  1. That of global health as a revival of vertical health interventions, of a set of practices that despite its well-known cloaking in a language of innovation and disruptions with the past, is shaped by traditions.
  2. That of global health as outcome of localization AND generalization, i.e. as an appropriative process which is shaped by its recipients. Paying attention to the variations in global health regimes, as the conference aspires to, highlights local dynamics that also shape what is called the global.