Political Ecology of TB in New Zealand

A project funded by the Health Research Council of New Zealand and the University of Auckland which ran between 2002 and 2006.

Project outline

This section is a copy of the original research proposal to the Health Research Council in 2002.

Political Ecology of Tuberculosis in New Zealand – past and present

Lay Summary of Research

Qualitative and Geographic Information Systems analyses address how cultural and socio-economic forces interact in the lives of people affected by tuberculosis. What are the implications of these interactions and how do they intersect with societal attitudes and structures to influence the transmission of tuberculosis and its successful prevention and treatment?

Brief background to the research

Tuberculosis is estimated to cause three million deaths each year and to infect one third of the world’s population. It is a resurgent disease. The rates in New Zealand have been slowly increasing over the last two decades, and in the last few years have been around 10-12 per 100000. However, this rate masks large internal differences characterised in the statistics by ethnicity but equally characterisable in terms of socio-economic inequality. The rates per 100,000 are approximately: Pakeha 2.7, Maori 10, Pacific Islands 27, and “other ethnicities” 82. The last two rates are rising. For every notified case, it is estimated that approximately 10 people will have TB infection. One-third of all notifications are of New Zealand born people. As multi-drug resistant TB and co-infection with HIV are relatively small problems in New Zealand, considerable improvement can be expected in the rates. Published research and consultations to date reveal that there are social, cultural, political and economic, as well as medical, dimensions of TB that pose challenges. TB treatment and control is an important part of the MoH strategy to reduce the burden of communicable respiratory disease.

Goals

  1. to investigate and describe these social, cultural, political and economic dimensions in five groups (Pakeha, Maori, Pacific, two in recent migrants/refugees) in greater Auckland and to combine these five separate but parallel studies with
  2. historical research on TB since 1940,
  3. analysis of contemporary media attention to TB and to the ethnic groups involved, especially more recent migrant groups, and
  4. analysis of stakeholder interviews.

More specifically, we propose to delineate the multi-dimensional issues that facilitate or create barriers to seeking medical advice, obtaining a diagnosis, and adhering to treatment or control regimens. This research will be based largely on general community members’ and patients’ perspectives, and our analysis of those, and will include information on “cultures of health”, explanatory frameworks for “TB”, perceptions of services, including relationships between services, experience of treatment, experiences of (possible) stigmatisation and discrimination, immigration and residency issues, social networks, economic circumstances, social and economic costs of TB and treatment. This information will be contextualised spatially using GIS and publicly available social and economic data, historically, via historical research, and culturally and politically, using media analysis and publications. Stakeholder interviews will explore experiences and perceptions of TB treatment and control, and seek input to our developing analyses. A further function of stakeholder interviews is to ensure effective institutional uptake of research findings, a function also provided, along with advice and support, by the Advisory Group.

In summary, this Auckland-based research will address issues identified internationally as key to TB treatment and control, theorised in terms of political ecology. It will provide information and analysis specifically relevant to Aotearoa New Zealand while contributing to current scientific knowledge in this international field.
The research is funded by the Health Research Council of New Zealand, with supplementary grants from the University of Auckland Research Committee. The research is based in Anthropology at the University of Auckland.

Objectives and Timeline of the Research

  1. To ascertain what social, economic and cultural factors facilitate early presentation to doctors by TB patients, leading to timely diagnosis, in five ethnic groups in the Auckland region (Mercer to Warkworth).
  2. To ascertain what social, economic and cultural factors facilitate or create barriers to adherence of TB disease and prophylactic treatment for TB infection and diagnostic testing for infection in these same groups.
  3. To understand the dynamics of patient-clinician and patient-health protection professional interactions, and the interactions between these dyads.
  4. To work with clinicians, health protection professionals and other stakeholders to present the findings in ways that will assist in reducing TB rates and encourage completion of treatment, in line with the goals of the “Integrated Approach to Infectious Diseases” (Draft) of the Ministry of Health.
  5. As part of the above, to use already published research and community-based fieldwork to document explanatory frameworks relevant to health for the above groups and the specific “cultures of health” relevant to TB.
  6. To contexualise this research through historical analysis of TB in New Zealand and the Pacific from the post WWII period to the present, building on earlier historical research.
  7. To enrich the applied social research skills and expertise of a multi-ethnic health research workforce.
  8. To publish and disseminate the results of this research.

Feedback of results to research participants and colleagues in TB care

Each student working in a specific community undertook to return research results to their participants and the communities from which they came in the most appropriate way possible. In some cases, due to sensitivities around TB this was on an individual by individual basis or in small groups, but with the Indian community in Auckland, Anneka participated in a TB awareness programme, and, on the completion of her doctorate, she led an open workshop arranged by TANI (the Asian Network Incorporated) , an NGO concerned with health and wellbeing.

All the presentations that the team had given in Canada were also given in a day-long workshop in Auckland, which was co-sponsored by our research team, Lung Health-Auckland, and ARPHS. Eighty participants involved in work with TB came from all over the North Island. Colleagues in sciences from the University of Auckland, Professor Ted Baker (School of Biological Sciences) and Dr Brent Copp (Chemistry) also presented to the great interest of the audience on work currently being carried out on tuberculosis.

Post-doctoral writing project

Julie Park and Judith Littleton made a successful application BRCSS (Building Research Capacity in the Social Sciences), an organisation funded by the Tertiary Education Commission in New Zealand, late in 2007. The project was called: Historical and contemporary migrant social inclusion: a focus on health and tuberculosis.

The purpose of this funding was to provide post-doctoral writing fellowships for the three doctoral scholars who had all completed their PhD work by the end of 2007: Anneka Anderson, Anthropology, Deborah Dunsford, History, and Jody Lawrence, Geography, all of the University of Auckland. These part-time fellowships which began in 2008 and ran for seven months, allowed these recent graduates to extend, develop and add value to the “Political ecology of tuberculosis” project. This project had been one of the foundation projects of BRCSS.

The fellowships provided opportunities for the three emerging scholars to work on sole-authored articles and chapters based on their individual theses as well as on jointly authored comparative, inter- or trans-disciplinary pieces. These latter are based on their reflective conversations about their scholarly journeys in what began as a multi-disciplinary research team, but through the fellowship period, transformed into a more solid inter-disciplinarity. As in the original research group, regular reading/writing meetings with the applicants, Julie and Judith, and the guidance of their other former supervisors, Robin Kearns and Linda Bryder, were crucial to the development of inter-disciplinary frameworks and analysis.

Anneka and Deborah attended two BRCSS workshops in Auckland and Wellington and found them beneficial to the project by providing opportunities to network with other social scientists and broadening their understandings of social science perspectives.

Four articles by the scholars and/or the applicants were published or accepted for publication. Several more were in various stages of review, completion or planning when the fellowships ended in September. In early September Drs Anderson, Dunsford and Dr Lawrence (in absentia) led a lively BRCSS access grid seminar (08/09/08) reflecting on the movement towards trans-disciplinarity through a focus on TB and Citizenship. Details of the published or accepted articles are listed in the Publications section.

The three postdoctoral fellows gave an insightful presentation on the promise and pitfalls of transdisciplinarity at the BRCSS celebration in June 2009, and repeated this at the First Annual Workshop of the Transnational Pacific Health research team on July 16 2009.

Download the pdf of their presentation: "Practical and Personal".

Download more information about the original project Political Ecology Project”.

Link to more information about BRCSS.

Researchers

Project team members include academic researchers from the University of Auckland, international collaborators, and researchers
 

Canadian collaboration

Political ecology team
Anneke Anderson (left) Political ecology team (from left: Jody Lawrence; Anneka Anderson; Deborah Dunsford)

With the help of a UofA strategic development grant, and a Royal Society ISAT grant, three Canadian colleagues, Professors Ann Herring, Kue Young and Paul Hackett visited the Auckland team early in 2005 for a workshop and informal sharing of ideas.

Approximately 18 months later, in June 2006, a large group of the Auckland team and colleagues from Auckland Regional Public Health Service travelled to Hamilton Ontario for a much larger workshop which took place at McMaster University and drew in colleagues from several parts of Canada, all working on different social scientific aspects of tuberculosis.

This enterprise was funded from a range of sources, including the Social Sciences and Humanities Research Council of Canada, Canadian Institutes for Health Research through the Indigenous Health Research Development Program at the University of Toronto and McMaster University, Professor Kue Young of University of Toronto, the Department of Anthropology at McMaster, the University of Auckland's Research Collaboration Fund, the Royal Society of NZ's ISAT fund, and the University of Auckland Research and Study Leave Grants.

Ann Herring and the two New Zealand editors got together in Auckland to work on the text in 2007 and this work came to fruition in the form of an 18 chapter co-edited volume entitled Multiplying and Dividing: Tuberculosis in Canada and Aotearoa New Zealand, which was launched by Merrill Singer in July 2008 in Auckland, and simultaneously celebrated in Ontario, linked by Skype videophone.

We are deeply indebted to all those colleagues who undertook the external reviewing of the contributions to this volume.

Access this volume Multiplying and Dividing: Tuberculosis in Canada and Aotearoa New Zealand