Date of Degree

9-2017

Document Type

Dissertation

Degree Name

Ph.D.

Program

Anthropology

Advisor

Ida Susser

Committee Members

Katherine Verdery

Jeff Maskovsky

Salmaan Keshavjee

Subject Categories

Social and Cultural Anthropology

Keywords

medical anthropology, tuberculosis, infectious disease, post-socialism, Romania

Abstract

Despite being an upper-middle income country and part of the European Union, in recent years Romania has recorded some of the worst treatment success rates for drug-resistant tuberculosis (TB) in the world. Between 2008 and 2011, less than 20 percent of people were successfully treated, while other countries in the region surpassed 60 and even 75 percent. The most recent available data shows only a modest increase to 35 percent. Individual poverty, alcohol use, and other typically “social” explanations fail to answer why so many people are dying of this curable disease. Using a biosocial approach to analyze this situation, this dissertation argues that the study of “social diseases” should place greater emphasis on the “sick” systems that create the conditions for medical failure. Extensive participant observation among patients and medical staff at multiple treatment sites, including the Romanian National Pulmonology Institute and one of the country’s largest sanatoria, documented how persistent drug shortages and inadequate diagnostic technology prevented people with TB, both wealthy and impoverished, from receiving proper treatment.

The Romanian situation offers a particularly interesting case: although TB was relatively well controlled under socialism, today the National TB Program does not meet international standards for the treatment of drug-resistant TB. This dissertation argues that the Romanian health care and social welfare systems have been hollowed out, in a manner similar to the cavities TB creates in people’s lungs, through a lack of state investment in the Romanian National TB Program. This disinvestment began toward the end of the socialist era and has continued to the present day, and Romania’s health system funding currently lags far below most other countries in the region. Disinvestment in social welfare, combined with policies which miss those who need support. For example, since 2010, people with TB are not eligible for illness pensions, even though treatment takes between 6 months and 3 years and often comes with side-effects that prevent the person from returning to work. This creates an economic burden for wealthy and poor families.

Neither wealthy nor poor people in Romania are able to receive appropriate treatment in the majority of cases due to a general lack of availability of required antibiotics. Persistent drug shortages lead middle-class patients and their doctors to attempt to “bootleg” treatment, proving that while poverty certainly contributes to Romania’s TB problem, it is not the sole cause, or even the most important one. Failures at the level of the system—including the legal and regulatory environment—are important “social” explanations for Romania’s drug-resistant TB crisis. The findings of this research suggest that the tendency to focus on poverty, alcohol use, and other challenges that individual patients face may distract attention from the greater systemic problems. The dissertation concludes with a discussion of how Romania could begin to treat the “tubercules” of its TB treatment program and rebuild the strength of its health care and social welfare systems, using examples from neighboring countries and Romania’s own past policies and initiatives.

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