Taylor_Book Review_Free Market Tuberculosis.docx.docx Anthropology of East Europe Review 31(2) Fall 2013 91 Free Market Tuberculosis: Managing Epidemics in Post-Soviet Georgia. By Erin Koch. Nashville: Vanderbilt University Press, 2013. xiv, 231 pp. Glossary. Notes. Bibliography. Index. Photographs. Maps. $27.95, paper. Sara Taylor, Indiana University The global medical community reports that, as of 2011, nearly one third of the world’s population is infected with tuberculosis, and increasingly drug-resistant strains of the disease more commonly referred to as TB result in more than 1.5 million annual deaths. Since 1995, the World Health Organization’s Stop TB Department has dominated global care initiatives through the implementation of DOTS (directly observed treatment, short-course) and the Stop TB Strategy, an approach focused on government commitment to a centralized system of diagnosing, monitoring, and recording active tuberculosis cases. In light of their reports of having successfully treated 51 million people and saved 20 million lives with these methods, few have publicly criticized the WHO’s global approach to disease management. However, in her book Free Market Tuberculosis: Managing Epidemics in Post-Soviet Georgia, Erin Koch provides a comprehensive critique of what she regards as the mixed success of poorly regulated biomedical standardization in the contemporary global health arena. With an ethnographic approach that focuses on the critical perspectives of Georgian physicians, scientists, laboratory technicians, and administrators, she evaluates the “efficacy and effects” of the monolithic DOTS and calls for a serious overhaul of its approach that has become “an unofficial requirement for national TB programs that seek financial and technical support from governments and aid organizations” (2013:6-7). While Koch’s monograph is not an epidemiological study, her research nevertheless bridges the gap between the quantitative methods of public health policy experts and the more individualized studies of cultural anthropologists. Drawing both from large pools of metadata and her own experience in the region, she demonstrates that in spite of seemingly positive statistics from the WHO, public health programs which consider only the biomedical components of disease pathologize disease-carriers by focusing on the enforcement of treatment standards rather than addressing the inherent “inequalities that can influence exposure and risk” (2013:9). The inevitable marketization of such treatment strategies also calls into question the ethics of “the role of philanthropy in global health” (2013:23), implying that the interests of the Western biomedical establishment may lie more in expanding the international drug market than in the health of developing nations. Failure to keep faith with local expertise on the cultural and political aspects of disease, Koch warns, might “perpetuate rather than ‘cure’ tuberculosis” in Eastern Europe (2013:28). By layering insights from participant observation, historical research, and institutional practice, Koch’s analysis offers an unprecedented investigation of local knowledge of TB along Anthropology of East Europe Review 31(2) Fall 2013 92 with changes in “knowledge production and service distribution” in Georgia (2013:56). In particular, she examines how Georgian medical service providers “navigate changes in what counts as ‘expert knowledge’” as their centuries-old holistic diagnostic criteria and residential treatment strategies for TB are pushed aside for regimented sputum-smear bacteriology, supervised drug treatment, and a centralized database of patient statuses and outcomes (2013:7). In her deconstruction of accepted medical practice, Koch is able to effectively reveal a source of stagnation in world health practice and boldly diagnose potential causes of the tuberculosis emergency plaguing Eastern Europe. This perspective proves instructive not only to those studying the effects of disease in post-Soviet countries, but also suggests evaluative criteria for epidemiologists and medical anthropologists looking at measures of disease and health throughout the developing world. Organized into four chapters followed by a forward-looking conclusion, each section of the book addresses from a different perspective the disparity between the humanitarian goals of many public health programs and the fraught nature of their implementation. As the book progresses, Koch systematically dismantles what seem, on the surface, to be thoughtful and reasonable treatment approaches which in fact frequently exacerbate health problems at both the local and national levels. Chapter one describes the role of the story of Medea, the so-called “mother of medicine” whose mythical origins in western Georgia serve as a point of pride for the citizenry who see their country as a historical site of medical innovation. Koch demonstrates how the devaluation of local knowledge production weakens doctor-patient relationships and marginalizes the sick through “a narrow view of their disease status vis-à-vis the presence or absence of bacteria” (2013:35). In chapter two, Koch describes her visits to several TB hospitals and treatment centers, where clinicians are constantly frustrated by funding-tied obligations to the DOTS protocols. These issues are further fleshed out in chapter three with accounts of underfunded diagnostic laboratories revealing the long delays associated with the DOTS method of verifying cases exclusively through bacteriological smears. This diagnostic method is further challenged in chapter four by Koch’s description of prison inmates’ practice of buying TB-positive sputum to appear infected and thus be moved to more favorable living quarters while receiving the DOTS treatment. This practice not only wastes money and resources on non-infected patients, but also increases the likelihood of creating antibiotic-resistant bacteria. Through these clever juxtapositions of history, personal narrative, and statistical analysis, Koch makes a persuasive argument against the “pharmaceuticalized” and market-oriented strategies of health care management that fail to consider the cultural, social, and political aspects of disease. However, she must devote so much space to developing her argument against “managerial” medical care that she spends less time addressing meaningful alternatives to a market approach. Though she describes the presence of new social movements that draw on anti- tuberculosis initiatives from Georgian history, she goes into little detail about how plans for collective responsibility of disease might be implemented in regions where doctors and nurses frequently work without pay and patients must provide their own food and bedding. Nevertheless, Koch does acknowledge the difficulty in achieving innovative solutions in a state Anthropology of East Europe Review 31(2) Fall 2013 93 of affairs that relies almost exclusively on international donor aid, and instead of encouraging revolution, focuses her immense energy on thoughtfully and accurately describing the shortfalls of DOTS while still accepting it as the best of all available alternatives. With luck, her ethnography will encourage those who design the next generation of exportable health care protocols to leave room in their marketing packages for increased physician-feedback and patient personalization.