SOAS Research Online

Abstract

Tuberculosis (TB) has re-emerged as a major threat in the developing world and is one of the leading infectious disease killers globally (UN 1999; WHO 2005). In Malawi, one of the poorest countries in sub-Saharan Africa, the National TB Control Programme (NTP) is struggling in a setting where an HIV pandemic combined with extreme poverty is undermining its efforts. There has been an upsurge in TB case rates and falling cure rates. Despite such deteriorating statistics, this programme is nevertheless regarded as a 'model' by the World Health Organisation (WHO 1995; WHO 2001), which applauds the early and sustained implementation of the DOTS strategy - seen as the most effective strategy for TB control. This apparent 'disconnect' between WHO praise for DOTS implementation and the deteriorating TB outcomes suggests that further investigation should examine why this is the case, and what can be done to improve it. This thesis, therefore, investigates tuberculosis and its control in the Malawian setting, and aims to understand it from the point of view of ordinary people who are most at risk, from the perspective of policy making and implementation, and from the experience of care providers. Using a qualitative case study approach in a severely affected country, it shows that the failure of TB programmes to understand in-depth the environment in which they operate will limit their ability to recognise and respond to the particular needs of their public with practical service provision options, thus contributing to continued poor TB outcomes. One of the overarching policy implications concerns the common reluctance of TB control experts to allow systematic social science research to uncover the complexities of the context in which they are situated. Biomedical control is instead promoted as a means to contain and avoid complexity, yet in doing so, ultimately precludes what may bring positive change.