Anthropology, DOTS and Understanding TB control in Nepal

This paper argues for the inclusion of ethnography as a research
methodology for understanding the effects of public health policy. To do this,
the implementation of DOTS (Directly Observed Therapy, Short-course) –
the World Health Organization (WHO) prescribed policy for the control
of the infectious disease tuberculosis – is explored in the context of Nepal. A
brief history of DOTS and its implementation in Nepal is outlined, and the
way it has been represented by those within the Nepal Tuberculosis
Programme (NTP) is described. This is followed by an outline of the research
done in relation to this, and the ethnographic methods used. These
ethnographic data are then interpreted and analysed in relation to two
specific areas of concern. Firstly, the effects around the epidemiological uses
of ‘cases’ is explored; it is argued that a tightening of the definitional
categories so necessary for the programme to be stabilized for comparative
purposes has profound material effects in marginalizing some from treatment.
Secondly, the paper examines some of the implications and effects relating to
the way that the ‘directly observed’ component was implemented. The
discussion explores how current debate on DOTS has been played out in
some medical journals. It argues for the importance of ethnography as a
method for understanding certain questions that cannot be answered by
particular, and increasingly dominant, research ideologies informed by
randomized controlled trials. This raises important issues about the nature of
‘evidence’ in debates on the relationship of research to policy.