Green (2004) An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia

Green. 2004. An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia. Culture, Medicine and Psychiatry 28: 401-425.
Working with five patients on a clinic in a suburb neighborhood in La Paz, Bolivia Green tries to understand how Aymara people (before the very radical changes brought by Evo Morales) although confident of biomedical diagnosis and treatment of Tuberculosis could not keep up with the long treatment due to structural poverty and lack of government aid. Normally a TB treatment would take up to 6-8 months with the first 2 having to go everyday to the hospital for the medicines. In the last decades a specific form of treatment arise, a short-course directly observed therapy (DOTS) in which patients must be present every day for as long as 4 to 6 weeks (then would be once every week) in order to take their pills. TB is the first cause of death in adults in Latin America, but in Bolivia within indigenous people the rate is 5 to 8 times higher than the national average. Nonadherence is considered when a patient doesn’t or can’t finish his or her treatment. At least four causes explain the widespread of TB, the correlation with HIV/AIDS, the relation between TB and adverse social conditions, the rise of drug resistant and multi-drug resistant traits due to nonadherence to treatment, and the incessant risk of contagion of inadequately treated patients. These four causes are enhanced by four more common factors: the blaming on the patient; the patient’s psychological structure; demographic factors such as gender, sex or income; and cultural and linguistic differences produced by the lack of knowledge about the local culture. Citing Farmer, Green considers that the “structural violence” is what can explicate how “poor adherence within an ethnically marginal group is often better explained by economic or political constraints than by folk-cultural constraints” (403). Some of this socio-economic-political constrains are “structural variables such as geographic and temporal availability of health care, hidden costs of treatment, and quality of available care” (404). The informants have to make a big effort to go everyday to the clinic to receive the medication, sometimes they could not afford to pay the bus so they would walk for 1 or 2 hours each way to the clinic and back home. They also have difficulties to keep up their job if they have one, or to look for one if they were unemployed, because going to the clinic would take a big chunk of time (they would be waiting and waiting for a whole morning). So when they could not carry on with the treatment for any reason (always very logical) then they were afraid of the reprimands by the doctors and social workers who would treat them, sometimes, discriminatorily. If social workers would complain that patient are putting their life in risk, patients would say that they need to support their families and can’t afford not to work. Although patients do feel sometimes that guilty for having “abandoned” treatment and this further complicate the decision to go back to the TB control program. All the patients were using both traditional and biomedical medicine, and they all agree that for TB biomedicine was better suited to cure it instead of the palliative treatment provided by traditional healers. I think this article is interesting to see how patients were using multiple forms of care and cure, and although they wanted to be treated by biomedicine for curing TB, they could not keep up with the treatment due to structural constrains such as hidden costs of the treatment (transport and additional costs such as X-Rays) and professional discrimination against Aymara population.