The Journal of Biosocial Science paper by Mason et al. on the social, historical, and cultural dimensions of tuberculosis (Mason et al., Reference Mason, Roy, Spillane and Singh2016) provides a welcome integrative framework for conceptualizing in a deeper and richer way this disease. In the spirit of the paper, this commentary offers two observations that will significantly strengthen the analytical grasp of their proposed framework.
Firstly, as has been shown in previous work (Simandan, Reference Simandan2001), tuberculosis has a political dimension, in addition to the social, historical and cultural dimensions identified by Mason et al. Specifically, much of the global political scene since the mid-1970s and continuing to the present day has been shaped by the ideology of neoliberalism (Simandan, Reference Simandan2011). Neoliberalism is a set of interlinked beliefs in the beneficial effects of free markets and the detrimental effects of state intervention, which relies on a social ontology of atomistic self-determination and personal responsibility. This ideology has provided the moral justification for widespread attacks on social welfare provision and for the imposition by the International Monetary Fund in the developing world and post-socialist countries of structural adjustment policies. The massive layoffs and the uncertainty of employment conditions induced by neoliberal policies have led to a public upsurge of fear and anxiety, which in turn explain why the incidence of tuberculosis has increased in countries undergoing neoliberal restructuring (Simandan, Reference Simandan2001).
Secondly, whereas the authors recognize the role of social stigma in the lives of people suffering from tuberculosis, it is important to point out that the social sentiment of contempt is an even more insidious process by which the healthy majority devalues and socially excludes those afflicted with tuberculosis. In a path-breaking paper in the cognitive-affective sciences, Gervais and Fessler (Reference Gervais and Fessler2016) have shown in detail that contempt is best conceptualized as a ‘sentiment’, that is, as a combination of a stable attitude of disdain with various accompanying emotions that depend on specific situational triggers. Tuberculosis patients tend to be devalued by social peers, and this attitude underwrites the complex emotions and behaviours that are described by the shorthand ‘contempt’. On the one hand, contempt can take the form of disgust with the sufferers of tuberculosis, which in turn generates a hot phenomenology of behaviours that include laughing at, excluding and being intolerant of tuberculosis victims. On the other hand, and more insidiously, contempt can manifest itself as a lack of compassion, which in turn produces a cold phenomenology of behaviours such as willingness to exploit the contemptible, indifference towards the suffering of tuberculosis patients and lack of interest in their well-being (Simandan, Reference Simandan2014). As has been shown elsewhere (Simandan, Reference Simandan2010), the experience of social exclusion has direct clinical implications because it heightens the already high allostatic load of tuberculosis patients, and thereby fuels a dangerous reinforcing feedback process whereby tuberculosis → social contempt → social exclusion → higher allostatic load of tuberculosis patients → worsened ability to fulfil everyday duties → heightened social contempt → (repeat the causal chain).
