Cross-disciplinary, interdisciplinary and multidisciplinary collaboration, however it may be labelled, plays a pivotal role in tuberculosis (TB) research. Simandan’s emotive commentary (Simandan, Reference Simandan2017) reminds us that we should not understate the harmful social consequences experienced by TB patients, nor should we ignore the impact of structural adjustment policies upon infectious disease transmission. The observation that neoliberal restructuring in many countries has been strongly connected to an increase in TB incidence is compelling. Adding nuance to this picture, economic development in high-income countries prior to the development of antibiotics is correlated with a decrease in TB prevalence (Holloway et al., Reference Holloway, Staub, Rühli and Henneberg2014), but ironically economic transformation in low- and middle-income countries after the development of antibiotics is associated with increasing prevalence of drug-resistant TB. In Papua New Guinea, for example, strain replacement of drug-susceptible TB by drug-resistant TB is imminent within the next decade (Trauer et al., Reference Trauer, Denholm, Waseem, Ragonnet and McBryde2016). The cost-effectiveness measures of neoliberal governance are visibly working in favour of disease transmission and the evolution of drug resistance (Spiliotopoulou et al., Reference Spiliotopoulou, Boni and Yadav2013; McMillen, Reference McMillen2015).
New interdisciplinary research alliances, not just with medical anthropologists, health sociologists and social cognitive psychologists, but with social geographers, policy analysts and health economists, will no doubt be essential to investigating the patterns of relationships between economic movement and host–pathogen interactions. We actively encourage new multidisciplinary research projects in this area. Delineating clear links between socioeconomic transitions, global health policy and the evolution of drug-resistant pathogens is vital. Given that strategies to effectively use the currently available antimicrobials are not being implemented, then resistance to drugs developed in the future will be likely to continue. Which discipline is best positioned to understand the biological, clinical and policy dimensions of this problem? The history of TB research, care and prevention has revealed that TB cannot be singularly configured as a biomedical problem requiring a biomedical solution. Interdisciplinary TB research needs to begin by listening to TB patients, but not stop until it has a meaningful impact on transformative policy making.
Simandan graciously notes the distance we have travelled to incorporate diverse epistemological frameworks from psychology, sociology and anthropology to promote integrative analytical methods to study the spread and control of TB (Mason et al., Reference Mason, Sweetland, Fox, Halovic, Nguyen and Marks2016a). Adding to this framework, Simandan deftly brings social geography into the fold with the reminder that interdisciplinary TB research has travelled far, but not far enough. Building robust theoretical frameworks for this genre of qualitative research is a strong start, but what TB sufferers urgently need is our engagement on the ground. Sadly, and frustratingly, funding is not always aligned to interdisciplinary work. In our experience, social science funding bodies can deem multidisciplinary TB research too medical, and medical research funding bodies can find it too social. The most appalling grant rejection that one of our authors received was, ‘Of humanitarian interest, of little theoretical value’. For academics to break out of their ivory towers and work towards solutions for problems as large and as challenging as TB control, an enabling funding environment that encourages and supports them to do so is required. No single research framework is currently straddling the global situation. Local particularities in the spread and control of TB in diverse cultural settings demand a variety of projects on the ground with context-driven priorities.
The Journal of Biosocial Science article (Mason et al., Reference Mason, Roy, Spillane and Singh2016a) covered a breadth of essential material to be tackled in TB research with more left to be detailed about TB and gender (Mason, Snow et al., Reference Mason, Snow, Asugeni, Massey and Vineyin press), TB and mental health (Mason et al., Reference Mason, Sweetland, Fox, Halovic, Nguyen and Marks2016b; Halovic, Reference Halovic2016), the technological imperative in global TB care (Mason, Oni et al., Reference Mason, Oni, van Herpen and Coussensin press), TB and migration (Horner, Reference Horner2016), and the constellations of human activity in the Anthropocene that drive the syndemic of diabetes (an immunomodulatory disease) and TB (Littleton & Park, Reference Littleton and Park2009; Yamada et al., Reference Yamada, Riklon and Maskarinec2016), among other topics. Tuberculosis research needs to be ethically driven and open to solutions outside the strictly biomedical. Tuberculosis thrives under conditions of poverty, and neglecting co-morbidities among these vulnerable populations is unethical, but should not be used as an excuse for biomedical imperialism to piggyback on global TB infrastructure.
Social exclusion, as Simandan highlights, is a severe issue to be brought to the forefront of TB research. Seeberg’s (Reference Seeberg2013) ethnographic research with Shankar Pradhan, who passed away from TB at a time when free TB treatment services had been introduced in his city, uncovers how social exclusion unfolds in Bhubaneswar, Odisha, India. Silva et al. (Reference Silva, Dawson and Upshur2016) emphasize that reciprocity needs to be more greatly valued in global TB care, especially given that TB patients are simultaneously acting for the benefit of others (by reducing disease transmission) by completing TB treatment. Across diverse cultural contexts, social exclusion is probably a consistent theme, but the social apparatuses through which social exclusion operate are divergent and demand patient-led collaborative fieldwork. Class, gender and ethnicity intersect variably with stigma in ways that shape and augment the challenges people living with TB face on the one hand and the discrete range of opportunities available to overcome these barriers on the other (Somma et al., Reference Somma, Thomas, Karim, Kemp, Arias and Auer2008). Ethnographic work on this topic is powerful, convincing but sparse. Macdonald et al. (Reference Macdonald, Abney, Abrams and Truyts2016) provide constructive insight into the methodological idiosyncrasies of ethnographic work with TB patients. Novel mixtures of focus group discussions, drama performances and graffiti walls inspire creative research designs for collaborative research with diverse communities (Schmidt et al., Reference Schmidt, Abrams and Tameris2016). In combination with the voices of TB patients, geographical considerations will help to map the contours of TB transmission and recrudescence.
The bifurcation of contempt into hot and cool phenomenological responses to TB, as outlined by Simandan, offers insightful hypotheses that could be tested in countries with a high burden of TB. Such fruitful new avenues of research into stigma and social exclusion have significant translatability to other conditions and should be complemented by research that actively prefigures the agency of patients, their ability to overcome the challenges they face and the enabling environments that foster favourable treatment outcomes. To identify some of the support needs of TB patients in Vietnam, the Woolcock Institute of Medical Research has been trialling a coping self-efficacy scale for TB treatment. The scale has four principal domains: (1) communication with health care provider, (2) support seeking, (3) disclosure of diagnosis, and (4) medication adherence (Singh & Mason, Reference Singh and Mason2014). A coping self-efficacy scale is certainly not the only psychometric tool that could be adapted for use in diverse cultural settings. Informed by ethnographic data, other validated instruments and psychiatric screening tools to measure psychosocial factors and mental health could be adapted as well (Sweetland & Verdeli, Reference Sweetland and Verdeli2013). Preliminary findings from the Vietnamese TB patients who have completed the self-efficacy scale indicate that confidence for seeking support and disclosing a diagnosis to family and friends was lower and much more variable than confidence in communicating with a doctor and adhering to a medication regimen (Mason et al., Reference Mason, Singh, Nhung, Ho, Nguyen, Fox and Marks2015). This may be a case where community-wide stigma-reduction strategies would improve health-seeking pathways, reduce the stress of treatment, decrease the risk of transmission and provide an enabling environment for people whose lives are affected by TB. In working with Vietnamese partner institutions, the Woolcock Institute’s international research paradigm focuses on reciprocity building in establishing long-lasting partnerships and change, with the understanding that the lessons learnt are bi-directional. Seeking opportunities for reciprocity, and building upon them, at all levels of TB research, care and prevention, is perhaps the foremost necessity in reducing TB prevalence worldwide.
