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199 notes introduction 1. Bacteria are among the most abundant species of life on earth, and antibiotic resistance is an adaptive process. Multiple, intersecting factors influence the mechanisms by which bacteria develop resistance to drugs. They can include genetic transmission; the use of antibiotics in animal farming and agriculture; the use of antibiotics in over-the-counter products such as hand soaps, clothing, and disposable pens; over-prescription; duration of treatment; the biochemical makeup of specific families of bacteria; and so on. The unprecedented explosion of antibiotic resistance that has emerged since the 1980s has to be accounted for by a multiplier effect of those and other influences, including “a significant and steady decrease in the number of approvals of new antibacterials in the last 10–15 years” (Alanis 2005, 701). Yet, although new treatments for tuberculosis and other bacterial diseases are needed, “more antibiotics” is also not the answer, in part because bacteria will readily adapt to them. 2. Strains of MDR-TB are resistant to both rifampicin and isoniazid—two of the most powerful and widely prescribed first-line antibiotics. The WHO defines XDR-TB as bacteria that are resistant to at least four antibiotics: rifampicin , isoniazid, any fluoroquinolone (a class of antibiotics that inhibit DNA replication and transcription in the microbe), and at least one of three injectable second-line drugs capreomycin, kanamycin and amikacin. 3. It also legitimated the systematic use of quarantine as a preventive and treatment measure against the spread of the disease, calling into question boundaries between public health and human liberties (Coker 2000, Specter 1992). 4. As Svea Closser’s ethnography of polio eradication in Pakistan makes clear, misguided optimism along with political and economic inequalities can create barriers for eradicating the very disease the initiative is designed to combat (2009). 5. An article published in 2004 in the newspaper Rezonansi raised similar concerns. That article attributed the country’s TB problem to administrative failures. Specifically, it castigated the first director of the NTP whose budget provided him with expensive office furniture while some inpatient facilities did not have running water. The article also voiced concerns about the level and distribution (or lack thereof) of staff salaries, and raised allegations that antibiotics donated by international organizations 200 noTes To Pages 5–21 were reportedly being sold in the outdoor markets, and specifically at the one in Vagzali square (Rezonansi 2004). 6. The Commonwealth of Independent States (CIS) is a regional group of states committed to promoting democracy and cooperation in anti-crime activities, trade, and so on. Georgia is no longer a member. 7. “Short course” refers to the relatively short duration of the fixed antibiotic regimen at the heart of DOTS, which is usually six to nine months for patients being treated for antibiotic-susceptible strains. 8. The average cost for one full course of treatment under DOTS can be as low as $10. But this does not include direct or indirect (i.e. transportation ) costs that patients might incur in seeking a diagnosis and prior to the onset of treatment, regardless of whether diagnosis should officially be free of cost according to a National TB Program. Costs incurred by NTPs will vary widely based on local political and economic factors, including governmental and international financial and technical support. 9. I have provided all individuals with pseudonyms, with the exception of authors of scientific publications on topics relevant to this book who asked to be referred to by name. 10. “Biomedicine” writ large, then, is grounded in reductionist, monotheistic, and materialist (Kleinman 1995) claims to epistemology and ontology that draw on enlightenment-era notions about the natural world, about distinctions between “the biological “ and “the social” and ways of knowing that privilege objectivity (Gordon 1988). In this analysis, I do use “biomedical ” as an adjective, rather than “biomedicine” as a noun, to refer to the ways in which such normative assumptions and claims to legitimacy are at play in contemporary efforts to diagnose and control tuberculosis. This is specifically evident, for example, in the privileging of microbiological perspectives and techniques for producing definitive diagnoses and of antibiotics for treating infection. 11. A person who is infected with and actively sick from Mtb usually develops a “productive cough,” that is, a cough that produces droplets of sputum that are the vehicle for transmitting Mtb from person to person. 12. In 2007, against the advice of medical professionals who had diagnosed him with inactive MDR-TB, Speaker flew from the United States to...

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