UC San Diego UC San Diego Electronic Theses and Dissertations Title Control, Cure, and Prevention: Situating Global Response to Tuberculosis in San Diego County Permalink https://escholarship.org/uc/item/6nd0r66d Author Friedman Aytes, Laurel H. Publication Date 2016 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California UNIVERSITY OF CALIFORIA, SAN DIEGO Control, Cure, and Prevention: Situating Global Response to Tuberculosis in San Diego County A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Communication by Laurel Hodges Friedman Ayteş Committee in charge: Professor Brian Goldfarb, Chair Professor Patrick Anderson Professor John H. Evans Professor Shelley S. Streeby Professor Elana Zilberg 2016 Copyright Laurel Hodges Friedman Ayteş, 2016 All rights reserved. The Dissertation of Laurel Hodges Friedman Ayteş is approved, and it is acceptable in quality and form for publication on microfilm and electronically: Chair University of California, San Diego 2016 iii DEDICATION For Samantha “Mance” Renfroe Wilson and Carolyn Cusic Hodges, two strong women whose memory I keep with me wherever I go. iv TABLE OF CONTENTS Signature Page ................................................................................................................... iii Dedication .......................................................................................................................... iv Table of Contents ................................................................................................................ v List of Abbreviations ....................................................................................................... viii List of Figures .................................................................................................................... ix Acknowledgements ............................................................................................................. x Vita .................................................................................................................................... xii Abstract of the Dissertation ............................................................................................. xiii Introduction ....................................................................................................................... 1 Situating the Study of Tuberculosis Beyond the Body-as-Machine Metaphor .............. 2 The Etiology of Tuberculosis .......................................................................................... 7 San Diego County as a Site of Study .............................................................................. 9 Situating Theoretical and Methodological Orientations ............................................... 12 Chapter Overview ......................................................................................................... 15 Chapter One: Theoretical Orientation and Research Design ..................................... 21 An Interdisciplinary Critical Health Communication Framework ............................... 23 Illness Narratives .................................................................................................. 24 Disabilities Studies................................................................................................ 26 Critical Health Communication ............................................................................ 29 Ethnography as Theory and Method ............................................................................. 32 Thick Description and Moving Beyond Culture as Text ...................................... 34 Subjects Who Cannot or Choose Not to Speak .................................................... 37 Identity and Subjectivity ....................................................................................... 38 Research Design and Methodology .............................................................................. 39 Research Design .................................................................................................... 40 Document Review ................................................................................................. 41 Direct Observation ................................................................................................ 43 Participant Observation ......................................................................................... 48 Interviewing TCP Employees and Other Community Supports ........................... 49 Interviewing TCP Patients .................................................................................... 51 Chapter Conclusions ..................................................................................................... 54 v Chapter Two: Situating Tuberculosis Control in San Diego County ........................ 56 A Brief Survey of Public Health and its Links to Tuberculosis Control ...................... 56 Quarantine and Sanitary Science .......................................................................... 58 Interpersonal Hygiene ........................................................................................... 59 Interpersonal Hygiene: Dispensary Gaze .............................................................. 64 Interpersonal Hygiene: Sanatoria .......................................................................... 65 The ‘New’ Public Health and Public Health Promotion ....................................... 68 Introducing the TCP ...................................................................................................... 74 The TCP’s Location .............................................................................................. 80 Physical Layout of the TCP .................................................................................. 82 Leadership and Organizational Structure of the TCP ........................................... 85 Daily Activities at the TCP Clinic ........................................................................ 87 Orienting Vignette ........................................................................................................ 89 Chapter Three: Cure as Prevention – Considering DOTS as a strategy for Tuberculosis Control ...................................................................................................... 98 Situating DOTS Historically ....................................................................................... 103 Programmatic Links to Surveillance and a Global Platform ...................................... 109 The Establishment of DOTS as a Protocol and as a Branded Approach .................... 112 Challenges to DOTS ................................................................................................... 115 Critiques of the DOTS Design ............................................................................ 115 Questions of Efficacy .......................................................................................... 117 A Continued Embrace of DOTS ......................................................................... 121 San Diego’s TCP: Implementing Global Tuberculosis Control at the Local Level ... 122 Adrian Alarcon .................................................................................................... 124 Responding to Noncompliance ........................................................................... 130 Reflecting on Noncompliance and Discipline .................................................... 133 Introducing the Cruzes and Self-Regulated Patients .......................................... 136 Discipline and Compliance ................................................................................. 139 Discipline and Resistances .................................................................................. 141 Chapter Conclusions ................................................................................................... 144 Reconsidering DOTS .......................................................................................... 146 Chapter Four: Global Public Health Policy and Local Frictions with the Cure as Prevention Framework ................................................................................................. 152 Medication Shortages .................................................................................................. 155 Shrinking Budgets ....................................................................................................... 164 Research and Development Divestment ............................................................. 164 Diminishing Budgets for Tuberculosis Control Programs .................................. 171 Moments of Formal and Informal Response to Local Context ........................... 177 Race and Ethnicity in the Characterization of the Border as a Site of Contagion ...... 180 Chapter Conclusions ................................................................................................... 192 Working with Diverse and Vulnerable Populations ........................................... 192 Inverting Cure as Prevention .............................................................................. 195 A Community-Centered Approach ..................................................................... 198 vi Chapter Five: Tuberculosis as a Boundary Object – Negotiating Among Situated