. . . » . .tluriti S .. . v5 2 4.. .§ 1. 4 daatniai a a 1:)... .3: a‘!.« i: 23...? 2.... M“ m“: 1 . C .n .122; .1 . . .. a. . fr, $3.1. iwkgnn. .. . . KL : .51 E . . 027.30 a: 1...... .. .ln. .. . .i: .1551: .. nun.” .1 91!)...3 :I. I , - .. £33Rmfi. 5: its... il‘l .. .1... 3.0.1:...“- .;. .w .i . 5, . all 37.21). 2:... :.u ; . 1 3. 3.3.2... .1. . t . . ‘9 . u: 1. .01-.“ $563... m: 2. d :1. v7 . . ‘33.. Hanna» 1 2 . .u 3.5..» n. 3.. v 2\’V ‘I- l . 3.. 4a.... . x l . J .3... t1... v t... 9 .. 13.32.1515 13' $6 .3. .v. .25 natal . .émuwmw .. A ._ . a .. 1.193%? c: . .. fimmflm; .L Wan-“mug. . .. . , may . ., . , . . thummmmflfifl) \ mass 2 LIBRARY 2007 Michigan State | University This is to certify that the dissertation entitled Globalization and Health Knowledges in the Philippines: Tuberculosis and the Infectious Other presented by Mary Ann J. Ladia has been accepted towards fulfillment of the requirements for the PhD. degree in Anthropology (”d/4 7. 014 9&1\ (flajor Pl'ofessor’s Signature Jpn é oi :1“ 30 0!? Date MSU is an affinnative-action, equalopportunity employer - —.-.-.-‘—._.—.-._._u.—.—.-._.-r PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE .08 I 0 .7 n)! 5/08 K:IProj/Acc8Pres/ClRC/DateDue indd GLOBALIZATION AND HEALTH KNOWLEDGES IN THE PHILIPPINES: TUBERCULOSIS AND THE INFECTIOUS OTHER By Mary Ann I. Ladia A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Anthropology 2008 ABSTRACT GLOBALIZATION AND HEALTH KNOWLEDGES IN THE PHILIPPINES: TUBERCULOSIS AND THE INFECTIOUS OTHER By Mary Ann J. Ladia Allan Young (1982) asserts that ”all knowledge of society and sickness is socially determined” and that we need ”critical understanding of how medical facts are predetermined by the processes through which they are conventionally produced in clinics and research settings. Thus, the task at hand is not simply to demystify knowledge, but to critically examine the social conditions of knowledge production" (p.277). And if I may add, this is especially relevant in the era of globalization, where personal, local, national and international constructions of health are thrown into regular contact, and where actors at all levels negotiate these domains. How these diverse constructions interact and affect discourse, knowledge, and behavior is an important but not yet well-understood phenomenon. My preliminary research in Baguio City, Philippines revealed that knowledges of tuberculosis (TB) exist at three distinct levels of the health care system. TB prevention and control has a long history in the country as well as in the cleanest and greenest city frequented by foreigners and locals from uplands and lowlands. With the recent outbreak of meningococcemia, the image of Baguio City dramatically changed to a site of infection and the ”politics of disease” began. By focusing on two infectious diseases, TB and meningococcemia, my research shall determine the re/ production of health knowledges across three levels of the health care system: 1) policy makers and program managers, 2) health providers, and 3) persons affected by TB and the lay persons. My main research questions are: 1. How are disease knowledges constructed or contested by different key actors in the health care system, and beyond? 2. How does the ”politics of disease,” especially infectious ones, shed light on the understanding of globalization and health? My research methods were primarily ethnographic and qualitative. I analyzed my data by using both macro and micro perspectives. The discussion of the ”politics” of meningococcemia, locally called ’meningo,’ provided an interesting lens for thinking about TB over time. Using the comparison of the two infectious diseases, I attempted to contribute to earlier theorizing about globalization and health. My research contributes to the nexus of the anthropologies of globalization, infectious disease, and public health. Apart from its contributions to anthropology, the dissertation positions basic research in anthropology at the core of contemporary scholarship. To my generous aunt and kind mother, and to the loving memory of my cool father iv ACKNOWLEDGMENTS To arrive at this point in my life and career required enormous encouragement and understanding from generous institutions and supportive individuals. My dissertation humbly represents the many blessings that I will always be grateful for. The completion of this undertaking received financial support from the following institutions through grants and awards: Michigan State University’ 5 Graduate School: Graduate Student Research Enhancement Award (2002), Food, Nutrition and Chronic Disease Award (2004), and Dissertation Completion Fellowship (2007) University of the Philippines-Baguio: Pre Dissertation Grant (2002), Dissertation Aid (2004-2005), and Administrative Fellowship (2005) Philippine Council for Health Research and Development: Thesis Grant (2004-2005) Philippine Social Science Council: Research Award Program (2005) Michigan State University’ 5 Council of Graduate Students: Degree Completion Grant (2008) I was likewise very fortunate to have a model committee whose professional demeanor, unceasing dedication, and hard work prove worthy to emulate. My adviser, Prof. Judy F. Pugh, and my committee members, namely, Prof. Linda M. Hunt, Prof. Ann V. Millard, and Dr. Terrie E. Taylor, University Distinguished Professor from the College of Osteopathic Medicine, together actively advanced the realization of the dissertation. I am also indebted to Professor Emeritus June Prill-Brett of the University of the Philippines-Baguio for V acting as my local committee member while I was gathering my data in the Philippines. During the data gathering phase, the following institutions and offices facilitated my work: Cordillera Studies Center at University of the Philippines- Baguio, Baguio City Council, Department of Health-Cordillera Administrative Region, and Baguio Health Department. I am truly grateful to this invaluable assistance. Iwould also like to express my gratitude to my interviewees such as the policy makers and program managers, the health providers, and persons affected by tuberculosis (PATB) and the lay persons. Their profound answers to my interview guide provoked more questions, not on them, but to me as academician and civilian. Quite many extended their moral support, kindness, and understanding in the pursuit of my doctoral degreeas well as to the success of the dissertation. For the sake of brevity, I will simply enumerate most of them at random. I shall try to thank them in their specific contribution in my own personal and intimate way if I have not yet done so. Department of Anthropology’ 5 Chairs, Faculty, and Staff, most especially to Lynne Goldstein, Robert Hitchcock, Lawrence Robbins, Anne Ferguson, John Davis, Susan Applegate Krouse, Mindy Morgan, Adan Quan, late Jacob Climo, Gail Barricklow, Nancy Smith, Margaret Medler; Cordillera Studies Center and UP Baguio Officers and Staff (2000-2008), most especially to Lorelei Mendoza, Bienvenido Tapang, Jr., Celia Austria, Raymundo Rovillos, Jocelyn Rafanan, Alicia Follosco, Giovanni Rualo, Raulita Gutierrez, Gloria Rodriguera, Emma Tarlit; Mentors, colleagues, and friends, here and abroad, most especially to Marion Loida Difuntorum, Marissa Cabato, Virginia Anceno, Arlene Suyam, Carmel Chammag, Marie Olga Difuntorum, Emilie Daquipil, Angelita dela Cruz, Erlinda Castro-Palaganas, Ma. Elena Chiong—Javier, Pilar Ramos-Jimenez, Marlene de Castro, Mary Janet Amado, Kari Lynn Bergstrom-Henquinet, Arunima Kashyap, Ma. Leticia San Luis, Rosalina Mendigo, Minerva Chaloping-March, Jacqueline Calsiman, Benjamin Abellera, Mary Anne Alabanza- Akers, Juvy Lizette Gervacio, Ma. Victoria Bautista, the Gillard Family, John Reed; MSU Filipino Club officers, members, and friends most especially to Rudie and Letlet Altamirano, Christian Canlas, Benildo Reyes, Gina and Dante Vergara, Danilo Ortillo, Ela Viray, Ma. Cecilia Samonte, Arvin Vista, Gizelle Torrizo, Carmen Arpa, Lara Marie Devilla, Maricris Lodriguito, Lea Petrona and Sonny Javier, Anna Marie Medrano, Carmille Joanna Bales, Raymund and Shella Narag, Neneng and John Spielberg, Blanca Baker, Aurora Abuan, Dexter and Malen Estrada; and Owen Hall officers and staff (2000-2008); and friends and acquaintances, most especially to Wendy Anderson, Jeff Scheffler, Mary McAuliffe, Gail Degood, Mary Ehmann, Lisa Davis, Anna Gutierrez, Tenecia Ross, Cassandra McReynolds, Jakkar Aimery, Terri Gillard, Renee Dabney, Stacy Vatne, Chun-I Wu, Eidi Victoria Alvarado. My referees and mentors in research, namely Steven Rood, Cecilia Santos- Acuin, and Rene ”Ray” Somera, Ithank them for serving as guideposts in my career path. In order to trek this long and narrow path, tremendous support was provided by my large family of relatives. I can never thank them enough for all _ the love they showered me season after season. Marianita Ladia, or ”Auntie vii Nitz” as we fondly call her, and Rolando Rodriguez or ”Uncle Dandy’ ’ made it possible for me to start my program, to say the least. Apart from my relatives in the Philippines, I am equally thankful for my relatives here in the US. most especially to Louella Ladia or Manang Ella, my cousin who makes my Christmas breaks unforgettable holidays. The family tradition of perseverance and excellence inculcated by my parents and reminded among my siblings - Joy, Jojie, Jon, and Jing — through time ushered me to this beautiful day. I am blessed; I am very grateful to one and all. Maraming, maraming salamat sa inyong lahat. TABLE OF CONTENTS Page List of Tables ....................................................................................... xii List of Figures ..................................................................................... xiii Abbreviations and Acronyms ................................................................. xiv PART I. THE RESEARCH BACKGROUND Chapter I: Introduction: The Problem and Theoretical Concerns... ...1 A. Research Questions .................................................................. 2 B. Highlights of Preliminary Research ............................................... 5 C. Significance of the Study ............................................................ 5 Chapter 11: Research Setting and Methods..... 11 A. Baguio City: Images and Infections ............................................. 11 B. Data Gathering Strategies ......................................................... 16 C. ’Meningo’ and Me22 D. Data Management ................................................................... 22 Chapter III: ’Meningo’: The Infectious Other? - -- - 2'3 A. ’Meningo’ and ’Praninggococcemia’: From Disease to Health Identity ................................................................................. 24 B. Market or Baguio City: Space or Place? ................................................... 28 C. To Whom It May Confuse ......................................................... 33 D. Public Health Responses: Global and Local, then and now? ................ 39 E. Concluding Remarks ............................................................... 46 PART II. TB PREVENTION AND CONTROL IN THE HEALTH CARE Chapter IV: TB Prevention and Control 1n the Philippines: An Overview... .. .....48 1910-1929: The Anti-TB Organization in the Dark .............................. 49 1930-1949: The National Government Scratches the Surface ................. 54 1950-1969: BCG and Triple Therapy as Prevention and Control if You May .................................................................. 54 ix 1970-1989: Public and Private Partnership Begins .............................. 55 1990-2006: The More, the Merrier? .................................................................. 59 Concluding Remarks .................................................................... 71 Chapter V: TB in the Health Care System in Baguio City... ...72 A. Health Care System of Baguio City, Philippines ............................. 73 B. TB in Black and White ............................................................... 76 C. TB from the Key Actors’ Point of View ........................................ 83 D. Concluding Remarks ............................................................... 89 Chapter VI: ”Find TB, Cure TB”... ...90 A. TB from Biomedical Standpoint and Public Health Perspective.........90 B. Finding and Curing TB in Baguio City ......................................... 95 C. Concluding Remarks .............................................................. 100 PART III. BODIES AND BOUNDARIES... .....101 Chapter VII: Human Bodies: Social Boundaries of Globalization .............. 102 A. ”TB Patients” and their Daily Lives ........................................... 103 B. Breaking the Public-Private Line ............................................... 107 C. Concluding Remarks .............................................................. 110 Chapter VIII: Stigma and Spaces of No Flows... ....111 Concluding Remarks .................................................................. 124 Chapter IX: The Anthropologies of Epidemic Diseases: The Challenges to Global Health...... ....125 A. Globalization and Common Themes in the literature ................... 125 B. TB and Meningococcemia ........................................................ 130 C. Future Directions .................................................................. 134 Chapter X: SUMMARIES, CONCLUSIONS, AND RECOMMENDATIONS: THE MAKING AND REMAKING OF PUBLIC HEALTH A. Summaries .......................................................................... 135 B. Conclusions ......................................................................... 137 C. Recommendations ................................................................. 138 1. Prevention and Control of Infection ..................................... 138 X 2. Theory-building and Analysis of Global Public Health ............. 140 3. Conduct of Global Health Research ...................................... 140 List of Tables Table Number Page Table H11 Percentage of Key Actors and their Reactions during the Upsurge of Meningococcemia in Baguio City ........................... 43 Table IV.1 Discoverers of Pathogens, Drugs, and Vaccines ........................ 51 Table V.1 Number of Government Health Professionals in Baguio City, 2003 ................................................................................. 74 Table V.2 Morbidity and Mortality Rates of TB in Baguio City, 1998 to 2003 ................................................................................. 76 Table V.3 Sputum Smear Results Prior to Treatment, January to May 2005 ................................................................................. 81 Table V.4 Percentage of Key Actors who said TB is Curable, Preventable, or Contagious ................................................................... 84 Table V.5 Percentage of Key Actors and TB Diagnostic Method ................ 84 Table V.6 Percentage of Key Actors who Think Risk is Associated with Class, Gender, or Age ......................................................... 87 Table VII.1 Socioeconomic Profile of 14 Interviewed PATB ....................... 104 Table VII.2 Forms of Diagnoses and Results Known to 14 Interviewed PATB ............................................................................. 108 Table VIII.1 Top Five Popular Perceptions / Misconceptions of Filipinos on How a Person could Acquire TB ...................................... 117 Table VIII.2 Means of TB Transmission as Perceived by Men and Women ....118 Table VIII.3 Knowledge of the Cause of TB by Women and Men ................. 121 List of Figure Page Figure 1. Location Map of Baguio City, Philippines ..................................... 12 AFB AO AHMOP BAHAI BAMARVA BCG BGH BGHMC BHD BHS BHW BMC BNAO BNS BSPO CAR CAVACAT CDC CESU CHD CICAT CORCAT CRUSH TB CSC CSF CUP DaCiCAT DOH DOTS ECC ECP EO EPI FETP FIND GFATM GSIS HSRA IEC ABBREVIATIONS AND ACRONYMS Acid Fast Bacilli Administrative Order Association of Health Maintenance Organizations of the Philippines Baguio Association of Hotels and Inns Baguio Market Vendors Association Bacille Calmette-Guerin Baguio General Hospital Baguio General Hospital and Medical Center Baguio Health Department Barangay Health Station Barangay Health Worker Baguio Midland Courier Barangay Nutrition Action Officers Barangay Nutrition Scholars Barangay Service Point Officers Cordillera Administrative Region Cagayan Valley Coalition against TB Centers for Disease Control City Epidemiology and Surveillance Unit Center for Health Development Citizens Iloilo Coalition against TB Cordillera Coalition against TB Collaboration in Rural and Urban Sites to Halt TB Cordillera Studies Center Cerebrospinal Fluid Comprehensive Unified Policy Davao City Coalition against TB Department of Health Directly Observed Treatment Short-coursei Employees Compensation Commission Employees Confederation of the Philippines Executive Order Expanded Program for Immunization Field Epidemiology Training Program Foundation for Innovative New Diagnostics Global Fund to Fight AIDS, TB, and Malaria Government Services Insurance System Health Sector Reform Agenda Information, education campaign IDSCP IN H ISCC IUALTD JICA KALCAT LCP LGC LGU LHB MC MDRTB MSU NCC NCIP NEC NEDA NIT NPS NSCB NTP OIF OSHP OWWA PAS PATB PCCP PCHRD PCSO PDI PhilCAT PhilHealth PhilTIPS PHC PIAS PMA PPD PPM PSMID PSSC PTSI QI RA Infectious Disease Surveillance and Control Project Isoniazid Intermittent Short-course Chemotherapy International Union Against Tuberculosis and Lung Diseases Japanese International Cooperation Agency Kalinga Coalition against TB Lung Center of the Philippines Local Government Code Local Government Unit Local Health Board Memorandum Circular Multi-drug Resistant TB Michigan State University National Coordinating Committee National Council for Indigenous Peoples National Epidemiology Center National Economic Development Authority National Institute of Tuberculosis National Prevalence Survey National Statistics Coordination Board National Tuberculosis Program Oil Immersion Field Occupational Safety and Health Center Overseas Workers and Welfare Administration Para-amino Salicylate People Affected by TB Philippine College of Chest Physicians Philippine Council for Health Research and Development Philippine Charity Sweepstakes Office Philippine Daily Inquirer Philippine Coalition Against Tuberculosis Philippine Health Insurance Corporation Philippine Tuberculosis Initiatives for the Private Sector Primary Health Care Philippine Islands Anti-Tuberculosis Society Philippine Medical Association Purified Protein Derivative Public-Private Mix Philippine Society for Microbiology and Infectious Disease Philippine Social Science Council Philippine Tuberculosis Society, Incorporated Quezon Institute Republic Act XV RAP RESU RITM RHU SLU SR SSC SSS SWS TB TBCF TBCS TDF TUCP UNICEF USAID UPB WB WHA WHO WPRO Research Award Program Regional Epidemiology and Surveillance Unit Research Institute for Tropical Medicine Rural Health Unit Saint Louis University Standard Regimen Short-Course Chemotherapy Social Security System Social Weather Stations Tuberculosis TB Clinic Foundation TB Control Service Tropical Disease Foundation Trade Union Congress of the Philippines United Nations Children’s Fund United States Agency for International Development University of the Philippines - Baguio World Bank World Health Assembly World Health Organization Western Pacific Regional Office i It is not an acronym anymore due to the incorrect emphasis on direct observation, rather a title provided to the TB treatment strategy (Thomas 2002). In the manual of procedures for the national TB control program, DOTS is ”a comprehensive strategy to control TB” (2005: x). xvi PART I: The Research Background Introduction: The Research Problem and Theoretical Concerns Research Setting and Methods ’Meningo’: The Infectious Other Chapter I INTRODUCTION: THE PROBLEM AND THEORETICAL CONCERNS Allan Young (1982) asserts that ”all knowledge of society and sickness is socially determined” and that we need ”critical understanding of how medical facts are predetermined by the processes through which they are conventionally produced in clinics and research settings. Thus, the task at hand is not simply to demystify knowledge, but to critically examine the social conditions of knowledge production” (p.277). And if I may add, this is especially relevant in the era of globalization where personal, local, national and international constructions of health are thrown into regular contact, and where actors at all levels negotiate these domains. How these diverse constructions interact and affect discourse, knowledge, and behavior is an important but not yet well-understood phenomenon. Whiteford and Nixon (2000) pose the question in relation to the globalization of health: ”Are health-care systems becoming more alike as globalization connects our economic and political systems, e-mail thrusts our communications across continents with speed, accuracy and ease, and people and pathogens fly greater distances with more frequency than even before?” (p.444) The relationship between globalization and health may be viewed in two ways. First, many authors argue that the former affects the latter. They have determined the impact of globalization on health, specifically its implications and challenges to public health directions (Lee 2000; Henry and Farmer 1999; Beaglehole and Mc Michael 1999) as well as to health governance (Poku and Whiteside 2002; Turmen 1999) to achieve health equity around the globe. Others (Lee 1999; Cash and Narasimhan 1999; Tolhurst1999) have examined globalization effects specifically in the management of communicable diseases. Second, poor health is recognized as a ”global problem and a global goal and globalization is seen as an asset for health” (Berlinguer 1999). Following the same vein, Daulaire (1999) argued for the recognition of globalization’s opportunities and threats to the well-being of humankind. Recently, the faster movement of people within and across borders accounts for the changing patterns of infectious diseases and reintroduces the surge of old diseases. Infectious diseases like tuberculosis (TB) pose significant challenges for public health measures designed to prevent and control their spread. TB is a global health threat to everyone: the rich who travel for pleasure and the poor who migrate for greener pastures. TB prevention and control is a global health priority, as well as a national and local health concern in the Philippines, a country ranking seventh among the ”top 22 high burden countries” for TB (WHO 2002:9). Responses to prevent and control TB, usually in the form of health programs, are supported by international organizations, and, by national and local governments that function according to geo-political boundaries. The Philippines is a recipient of grants from the Global Fund to Fight AIDS, TB and Malaria (GFATM) aimed at 3 reducing TB prevalence, incidence, and mortality in half by 2010. Other support to combat TB in the country comes from the so-called ”international partners” like the World Health Organization (WHO), The World Bank (W B), the Japan International Cooperation Agency (JICA), Medicos Del Mundo, World Vision, United States Agency for International Development (USAID), and others. Apart from financial support, they provide technical assistance as well as participate in monitoring and evaluation activities. As technical advisors, they likewise participate in the current organizational structures of the national TB program (NTP). While communicable diseases like TB are highly recognized for funding support by international organizations, meningococcemial, a reemerging infectious disease seems to be unnoticed in the global health arena as well as in the local public health sphere. In the Philippines, the sudden increase in the number of meningococcemia cases in Baguio City in late 2004 dramatically changed the responses of various sectors near or far towards the disease and illness. 1 Throughout the dissertation, I use meningococcemia to refer to the disease while ’meningo,’ the local term for the disease refers to the illness. According to Kleinman (1980:73), ”disease and illness are explanatory concepts, not entities.” He explained, ”Disease and illness exist, then, as constructs in particular configurations of social reality. They can be understood only within defined contexts of meaning and social relationships. As we shall see, they are explanatory systems and social structural arrangements comprising the separate sectors (and subsectors) of local health care systems. Disease/ illness can be thought of as expressing different interpretations of a single clinical reality, or It is interesting to study both diseases, namely, TB and meningococcemia within the purview of public health during the globalization of infectious diseases. A. Research Questions By focusing on two infectious diseases, namely TB and meningococcemia, my research shall determine the re / production of health knowledges across three levels of the health care system: 1) policy makers and program managers, 2) health providers, and 3) persons affected by TB (PATB)2 and lay persons in Baguio City, Philippines. My main research questions are: 1. How are disease knowledges constructed or contested by different key actors in the health care system, and beyond? 2. How does the ”politics of disease,” especially infectious ones, shed light on the understanding of globalization and health? B. Highlights of Preliminary Research My preliminary research in Baguio City, Philippines in 2002 revealed that knowledges of TB exist at three distinct levels: the programs, the providers, and the persons. I observed that health knowledges are contested or in flux. These observations have led me to a number of questions explored in this dissertation. representing different aspects of a plural clinical reality, or creating different clinical realities” (Kleinman 1980:73). See also Kleinman 1980 p. 77. 2 I am using the term, persons affected by TB (PATB) to refer to the so called ”TB patients” or ”TB cases” on a local listing. I neither confirm nor deny their affliction with the disease. Rather, I put emphasis on their personhood. 5 On a programmatic level, TB is a public health issue. To the health providers, both those working in the public domain and those in private practices, TB is a disease of individuals, and must be addressed clinically. In clinical settings, TB appears greatly under-diagnosed. There has been a low case finding3 rate in the city, with only 27 new smear positive4 cases reported from public clinics in 2001 (Bautista and Paran 2002). Public health providers, who follow international procedures and standards, use sputum smear examination results to determine their ”TB patients”. On the other hand, my preliminary interviews with health personnel there indicate that private physicians diagnose the disease on the basis of chest x-ray results. At the public level, the disease may confer a social stigma (Nichter 1997). In others, it may be a less value-laden condition, considered as simply a ”lung 3 Case finding is ”an activity to discover or find TB cases” (Manual of Procedures for the National TB Control Program, Philippines. 4““ Edition, 2005:x). There are two ways namely, active case finding and passive case finding. Active case finding is defined as ”a health worker’s purposive effort to find TB cases (among TB symptomatic in the community) who do not consult with personnel in a DOTS facility” (Manual of Procedures for the National TB Control Program, Philippines. 4th Edition, 2005:18). Passive case finding is ”finding TB cases among TB symptomatic who present themselves in a DOTS facility’ ’ (Manual of Procedures for the National TB Control Program, Philippines. 4th Edition, 2005:18). 4 According to the Manual of Procedures for the National TB Control Program in the Philippines (2005:xi), ”when a direct sputum smear microscopy (DSSM) has at least two positive results,” it is called smear-positive. When a DSSM has all three negative results, it is smear-negative. It is the principal diagnostic method adopted by the NTP because: 1. It provides a definitive diagnosis of active TB; 2. The procedure is simple; 3. It is economical; and 4. A microscopy center could be put up even in remote areas (Manual of Procedures for the National TB Control Program, Philippines. 4th Edition, 2005:18). 6 weakness” (Nichter 1997) or uyek (Ilokano term for cough). Lay persons are generally not aware of the symptoms of the disease, or they may have misconceptions about its symptoms and causes, and they may understand with their own folk illness categories. It appears, then, that ”patients” and providers hold varied concepts of TB and take various stances toward its diagnosis and management. Knowledges about TB are negotiated in various contexts (the public health area, the clinic, the community) but do not seem to be shared by the key actors in the health care system including policy makers and program managers, the health providers, and PATB and the lay public. While the TB problem spans over almost a century, the recent outbreak5 of meningococcemia in Baguio City can shed light on examining trends in TB approach. The ”politics of disease” as exemplified by the meningococcemia outbreak foregrounds my dissertation research. Furthermore, the comparison between chronic and acute infectious diseases, TB and meningococcemia respectively offers interesting perspectives towards examining globalization and health. C. Significance of the Study Anthropology’ 5 wide range of approaches and methods have made remarkable contributions in understanding global health issues such as emerging and reemerging infectious diseases. The political-economic approach or critical medical anthropology, or political economy in medical anthropology, as Morsy (1996) puts it, analyzes the health care system from different levels (Baer, Singer, Johnsen 1986; Baer 1997) and is concerned about macro-level structures and processes as well as micro-level phenomena. I attempt to utilize these approaches in my dissertation. My research contributes to the nexus of the anthropologies of globalization, infectious disease, and public health. It shall contribute to earlier theorizing about the anthropology of globalization (Inda and Rosaldo 2002) and its effects on human well-being. Anthropologists argue that de/ territorialization occurs in globalization (Inda and Rosaldo 2002; Gupta and Ferguson 2002; Appadurai 1996), and there are dimensions (Lee 2000) and processes (Doyal 2002) in which this occurs. Specifically, this research uses this earlier theorizing about the globalization process within and among interconnected locations of health knowledges. It explores the issue of space and place central in anthropological theory (Gupta and Ferguson 2002) as they relate to, perhaps, difference or hybridity of knowledges about TB, a disease that knows no geographic boundaries. Thereby it contributes to further theorizing on the linkages of globalization and infectious diseases as well as to the understanding of how contemporary globalization impacts health. 5 I am using the term outbreak to refer to the sudden occurrence of epidemic in a relatively limited geographic area (Greenberg 1993). 8 The research shall also contribute to the ”anthropologies of infectious diseases” (Inhorn and Brown 1997; Inhorn and Brown 1990; eg., Rube] and Moore 2001; Ito 1999; Nichter 1997; Farmer 1996; Farmer 1999; Farmer 1999; Farmer 2003) as it transects other fields of study such as public health (Hahn 1999), health social science, and epidemiology (Frankenberg 1993; True 1996; Trostle and Sommerfeld 1996). The conduct of this research, where both program and lay people’s concepts and responses are taken into consideration, shall demonstrate the role of medical anthropology in the public health agenda at both local and international levels (Inhorn and Brown 1997). By understanding local perspectives, it may translate local health knowledges to public health personnel and policymakers. This could help them to be more effective in meeting their public health objectives (e.g., Manderson 1998; Farmer 1999) of encouraging a ”public health by the public” (Hahn 1999). This work could strengthen previous studies on infectious diseases that demonstrated the effects of differences or similarities in perspectives (Nichter 1997; Garro 1986; Lazarus 1988) on the spread of infection. Earlier TB studies conducted in other parts of the country or the world (e. g., Farmer 1996; Farmer 1999; Graham 2000; N ichter 1997; Nachman 1993; Portero et al. 2002; Ito 1999; Rubel and Moore 2001) do not deal with the global and local processes of knowledge construction, contestation, and circulation. This project shall complement them in this respect. Thus, rather than compartmentalizing anthropology, I will draw on and combine insights from the literature and advance anthropological theory and 9 method forward in an era of globalization of disease. I shall attempt to posit theoretical debates to each or all of them (i.e., anthropology of globalization, anthropology of infectious disease, and anthropology of public health). In addition, I hope to challenge existing boundaries of the anthropological discipline and foster alliances with other sub-disciplines or fields of study. Apart from its contributions to anthropology, the dissertation positions basic research in anthropology at the core of contemporary scholarship. 10 Chapter II RESEARCH SETTING AND METHODS In this chapter, I will discuss the research setting and methods employed in my dissertation. Chapter H covers various aspects of the research site, Baguio City, Philippines: its history, geo-political boundaries, health facilities and personnel, and disease patterns. Various images of the city as well as the prevalence of TB and the recent meningococcemia outbreak are discussed in relation to the flows of people. I will attempt to argue that Baguio City represents a space of globalization. Chapter H likewise discusses the research methods employed, including sampling, and the selection and number of respondents and key informants for the overall dissertation. Each succeeding chapter describes the methods and data used specific to the chapter. A. Baguio City: Images and Infections Baguio City is approximately 250 kilometers north of Metro Manila. It is situated in the province of Benguet in the Cordillera Administrative Region (CAR) of northern Philippines. It is geographically bounded on the north by La Trinidad, the capital town of Benguet, on the east by Itogon, and to the south and west by Tuba as shown on Figure 1. Road networks allow accessibility to the city for services, activities, and needs such as health, tourism, education, trade and administration. Baguio City 11 .Eu 3:»:— .....f 52595 E: 24 6535.; «A Ume mmcfimzfim Stu 2:me Co 32 5:83 ofimooa .>> 2352 £23 meow m