Social Science & Medicine 209 (2018) 145–151

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Tuberculosis patients and resilience: A visual ethnographic health study in T

Khayelitsha, Cape Town
Anne Lia Cremersa,b,∗, René Gerretsb, Christopher James Colvinc, Monwabisi Maqogic,
Martin Peter Grobuscha
a
Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam,
Amsterdam, the Netherlands
b
Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, the Netherlands
c
Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

A R T I C LE I N FO A B S T R A C T

Keywords: Khayelitsha, one of the biggest and poorest townships in South Africa, has a well-resourced tuberculosis (TB)
Tuberculosis programme with an interdisciplinary approach addressing the medical, social, and economic forces impacting TB
Visual ethnography care. Nevertheless, the area remains burdened with one of the highest TB rates in the world. Using a resilience-
South Africa based approach, we conducted a critical ethnographic study to develop deeper insights into the complexities of
Resilience
patients' experiences with TB and care. Between October 2014 and March 2015, we approached 30 TB patients,
10 health-care workers, 10 pastors, and 10 traditional healers, using participant observation, in-depth inter-
views, and focus group discussions. In addition, seven key informants were filmed on a daily basis by the lead
researcher. The work reported here (both text and short videos) illustrates the various manifestations of resi-
lience that patients demonstrated and how these impacted on decisions involving treatment seeking and ad-
herence. We have synthesized the data into the following inter-related themes: TB aetiologies and treatment; the
embodied experience of TB treatment; alcohol consumption; financial constraints; and support and stigma. The
findings from this research highlight patients' strategies for adapting to adversities, such as pausing TB treatment
when lacking food to avoid becoming psychotic, consuming alcohol to better cope, obtaining social grants, and
avoiding stigmatizing attitudes. Some manifestations of resilience may interact and, inadvertently, undermine
TB patients' health. Other aspects of resilience, such as strong community ties, elicited long-term health benefits.
TB programs would benefit from a resilience-building approach that builds on pre-existing strengths and vul-
nerabilities of TB patients and their communities. With the use of short videos, we provided patients with an
alternative path for expressing their experiences, which we hope will support synergies between patients, re-
searchers, and policy-makers for improved TB programmes.

1. Introduction susceptible (DS) TB and drug-resistant (DR) TB burdens in the world

South Africa faces one of the worst tuberculosis (TB) epidemics and
highest human immunodeficiency virus (HIV) rates in the world (WHO,
2013). Khayelitsha, a township in Cape Town, is a focal point in this TB
epidemic. The public healthcare system in Khayelitsha—and especially
its TB services—is actively supported by the international non-gov-
ernmental organization Médecins Sans Frontières (MSF). Together, they
have launched a comprehensive interdisciplinary TB control pro-
gramme ('the Khayelitsha programme') that addresses the medical,
cultural, social, and economic aspects of TB care. Despite this com-
prehensive programme, this area still has one of the highest drug-
(MSF, 2011a,b).
Quantitative studies have provided insights into what factors in-
fluence the functioning of South African TB Programmes, such as TB
rates (Wood et al., 2011), DR-TB development, HIV co-infection
(SANAC, 2012), socio-economic determinants (Harling et al., 2008;
Pronyk et al., 2001), alcohol misuse (Otwombe et al., 2013), organi-
zational obstacles (Colvin et al., 2003), an integrated HIV/TB policy
(Uyei et al., 2014), and collaboration between traditional healers and
TB health facilities (Colvin et al., 2003). However, these studies gen-
erally do not afford an in-depth understanding of how these factors play
out in the everyday lives of TB patients. In contrast, published

∗
Corresponding author. Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands.
E-mail addresses: a.l.cremers@amc.uva.nl, a.l.cremers@amc.nl (A.L. Cremers), rgerretswork@outlook.com (R. Gerrets), cj.colvin@uct.ac.za (C.J. Colvin),
monwamaqogi@yahoo.com (M. Maqogi), m.p.grobusch@amc.uva.nl (M.P. Grobusch).

https://doi.org/10.1016/j.socscimed.2018.05.034
Received 11 August 2017; Received in revised form 13 May 2018; Accepted 16 May 2018
Available online 25 May 2018
0277-9536/ © 2018 Elsevier Ltd. All rights reserved.
A.L. Cremers et al.
qualitative research on patients' experiences with TB and TB care in
urban South Africa offers insights into patient's MDR-TB and TB treat-
ment adherence (Birch et al., 2016; Daftary et al., 2014), the combi-
nation of TB and HIV treatment (Daftary and Padayatchi, 2013), and
TB-related stigma (Daftary, 2012). However, most of these qualitative
studies in South Africa were conducted at clinics and few used more in-
depth ethnographic methods.
This ethnographic study examined patients' experiences with TB
and TB treatment and aimed to enhance our understanding of why the
Khayelitsha programme is still struggling to quell the TB epidemic.
Ethnography provides context-specific insights as researchers immerse
themselves into the lives of research subjects by fostering in-depth re-
lationships over an extended period of time. This approach enabled us
to examine gaps between policy and practice, the slippage between
what people say they do and what people actually do in everyday life
(Lambert and McKevitt, 2002). Practices may reveal what lies beyond
our respondents' words (Panter-Brick and Eggerman, 2017). Under-
standing patients' complex realities and their practices and perspectives
within these realities enables a richer understanding of how TB policies
play out in the day-to-day lives of those with TB, and, in turn, of how
these policies shape patients' responses to treatment. Globally, various
ethnographies have examined TB programs and patients' treatment
adherence (Gerrish et al., 2013; Koch, 2013; Harper, 2006; Greene,
2004). However, there remains a need for more ethnographic research
to understand context-specific factors and dynamics in order to better
tailor TB services to people's realities (Mason, 2014; Harper, 2006;
Farmer, 2000).
TB is one of many adversities people in Khayelitsha face, as they are
confronted daily with disease, pervasive poverty, hunger, unemploy-
ment, traffic accidents, and violence. Such adversities are often asso-
ciated with poor health outcomes (Wexler et al., 2009). The public
health literature on the social determinants of health has put a great
deal of effort into examining the pathways between social injustices and
poor health (Farmer, 2000). In contrast, resilience-based approaches to
health provide an alternate emphasis: while acknowledging the health
consequences of suffering, vulnerability, victimization, and risk, these
approaches also highlight strengths, capabilities, and capacities for
well-being (Panter-Brick, 2014). Thus resilience-based approaches seek
to examine these experiences within a broader context that highlights
agency as people deal with adversity. Individuals, families, and com-
munities often find creative ways to support and sustain themselves and
others. They seek to counter, transform or mitigate challenges they
encounter in life. Our TB patients' narrations of suffering and hardship
likewise offered compelling accounts of resilience. In this article, the
concept of resilience refers to how individuals are able to socially
function and emotionally adapt themselves despite living in a context of
severe adversities (Masten, 2006).
The concept of resilience has been widely applied in the global
health literature to describe people's diverse attempts to overcome
adversities, for example, through resource negotiation (Woodward
et al., 2017), psychological coping strategies (Waugh and Koster, 2015),
and the strengthening of social structures, community functioning, and
social relationships (Perez-Brumer et al., 2017; Zraly and Nyirazinyoye,
2010; Wexler et al., 2009). Resilience is often linked to better-than-
expected social, psychological, and physical outcomes given the sig-
nificant challenges individuals and communities often face (Vanderbilt-
Adriance and Shaw, 2008).
Our findings confirm that the link between resilience and health
benefits is complex, as many TB patients struggle to survive in a context
with multiple and varying adversities. A person may show resilience in
one domain (family life), but not in another (employment) (Southwick
et al., 2015). Moreover, resilience is not static and uniform but arises
through processes and may change over time (Fergus and Zimmerman,
2005). In this article, we would like to add that the various manifes-
tations of resilience may interact with each other, i.e. resilience in one
domain can influence vulnerability in another domain. Consequently,
146
Social Science & Medicine 209 (2018) 145–151
such multiple manifestations of resilience may have divergent impacts
on TB patients' well-being.
A resilience-based approach may inform TB programmes about the
importance and complexities of pre-existing strengths and vulner-
abilities of TB patients and their communities. With the use of visual
ethnography and short videos, we offered patients a voice and hope-
fully contributed to the creation of new synergies between patients,
researchers, and policy-makers for improved TB programmes.
Moreover, visual methods may strengthen the impact of ethnographic
health research on policies and discourse (Cremers et al., 2016).
1.1. Context and research setting
South Africa is facing a TB incidence of 1003/100,000, 8.5% drug-
resistant (DR-) TB, and a 65% TB-HIV co-infection rate. The overall TB
mortality rate is about 228/100,000 (WHO, 2013). In 2012, only 6494
of the 15,419 multidrug resistant (MDR-)TB-patients started treatment
(WHO, 2013). About 1/3 of MDR-TB patients ceased treatment pre-
maturely (Shean et al., 2008).
Our research took place in the South African township of
Khayelitsha, the largest township in Cape Town with nearly 1,000,000
inhabitants. Half of its inhabitants are not officially registered and the
majority live in informal dwellings. As a result of the segregationist
policies of the Apartheid regime, the inhabitants continue to be pre-
dominantly from the Xhosa ethnic group (CoCT, 2006). Crime rates are
very high in Cape Town (Jean-Claude, 2014), and especially in
Khayelitsha (Nleya and Thompson, 2009). Major contributors to high
crime rates are poverty and high unemployment rates (Jean-Claude,
2014). South Africa is an upper middle-income country (World Bank,
2016), but has high levels of economic inequality, resulting in pervasive
poverty. Black Africans were strongly marginalised and discriminated
against during the Apartheid regime, and this still impacts on their
socio-economic and health status in post-Apartheid South Africa (Jean-
Claude, 2014; Packard, 1989). Consequently, this part of Cape Town is
known as “Cape Town's poverty trap” (CoCT, 2006).
TB care (integrated with HIV care) is available in, amongst others,
the Khayelitsha Site B Ubuntu Community Health Clinic and a smaller
primary health care clinic in Town 2. Here, TB patients on Direct
Observed Therapy (DOT) collect their anti-TB drugs at the clinic on a
daily basis from Monday to Friday during a treatment course of six
months. A community-based Direct Observed Therapy (DOT) pro-
gramme was piloted: after two weeks of DOT, patients may continue
treatment at home instead of at the clinic, provided that a community
care worker (CCW) considers them sufficiently responsible to manage
their own care (Atkins et al., 2011).
Moreover, Khayelitsha is one of the few places worldwide where
new DR-TB drugs are both highly needed and available (MSF, 2016).
MDR-TB signals TB infection that is resistant to the first-line anti-TB
drugs isoniazid and rifampicin, and extensively drug resistant TB (XDR-
TB) indicates resistance to isoniazid and rifampicin, to any fluor-
oquinolone, and to any of the injectable anti-TB drugs (WHO, 2010). At
the time of this research, MDR-TB patients followed a treatment of 21
pills daily for two years and one injection daily for eight months. MSF
has launched the first project for treatment of DR-TB-patients at pri-
mary health care level. Additionally, the Khayelitsha programme ad-
dresses social and economic risk factors via counselling, sensitization
programmes, community care workers, social grants, and food supple-
ment programmes (MSF, 2005; MSF, 2011a,b).
2. Methods
One researcher (ALC) and a local research assistant (MM) conducted
a five-month ethnographic research project in Khayelitsha, with sup-
port from a local researcher [CC], between October 2014 and March
2015. Through chain-referral sampling-techniques, 30 DS-TB and DR-
TB-patients were recruited for various in-depth interviews at their
A.L. Cremers et al. Social Science & Medicine 209 (2018) 145–151

Table 1
Methodological approach for study in Khayelitsha, Cape Town.
Method Participants Timing/frequency/place Research topic

Participant observation
In-depth interviews
Focus group discussions
Visual methods, e.g. in-depth
interviews, participant
observation
TB-patients and For 5 months on a daily basis on various places in the Relation between patients and health care services,
their families. community; medication, stigma, poverty, death, hope, position in
Health workers Patients' homes, visits to the clinics and hospitals, churches, society, social support, group dynamics
Community- houses of traditional healers, pharmacies, shopping, market,
members organizing TB-grants, meetings and presentations of NGOs,
(preparation for) funerals, celebrations, social events,
barbeques
30 TB-patients 1-3 interviews with each respondent of 1–2 h at patients' TB-perceptions, medical knowledge, poverty, social
10 health-workers homes or at MM's home support, TB-grant, stigma, structural obstacles to TB-
10 traditional 1-2 interviews with each respondent of 1 h at respondents' treatment
healers homes or at MM's home TB-policy, TB-treatment, patient contact, TB-
10 pastors perceptions, poverty, stigma, structural obstacles to
TB-treatment, work relation with other healers in the
area
10 TB-patients 2 meetings of 2–3 h in MM's church Interaction and discussion between participants
10 TB patients regarding concerns, struggles, ideas, wishes, norms,
and values
5 TB-patients Daily visits during the 5 months study period in various places Life, community, social support, stigma, poverty,
1 community-care in the community treatment, experience with TB, funerals
worker

homes. Included respondents consisted of patients with active (extra-)
pulmonary DS-TB or DR-TB-infection who had just started, were re-
ceiving, had previously received anti-tuberculosis treatment, or had
recurrent TB (i.e. had TB for the second/third time through relapse of
previous TB infection or infection with a new strain) (Chaisson and
Churchyard, 2010). Patients were above the age of eighteen and at-
tended or had attended one of the ambulatory TB clinics at Site B
Ubuntu or Town 2. Additionally, two focus group discussions (FGDs)
(10 patients per group) took place in the Town 2 community. We also
interviewed 10 employees of clinics (nurses and CCWs), Treatment
Action Campaign (TAC), and MSF, 10 traditional healers, and 10 pas-
tors to gain more insight into the social context. Participant observation
took place from morning until evening, during weekdays and on
weekends, at respondents' homes, neighbourhoods, churches, and fun-
erals.
Of the 60 respondents, five patients, one pastor and one CCW were
additionally asked to participate as key informants for the visual
component of the project and were filmed on a daily basis by ALC
(Table 1). Selection occurred after one month of ethnographic research
and was based upon respondents' willingness to discuss TB-related
matters, their ability to speak fluently and coherently, and their passion
to change the marginalized situation that most people living in Town 2
were facing. The video camera was not taken on all occasions and even
if the camera was present, this did not seem to hinder interaction with
participants as the camera was either in a corner on a tripod or hand
held. Due to the unstructured character of the interviews and partici-
pant observation, respondents were able to guide the visual data col-
lection telling the researcher what to film. They explained they had the
feeling that they were given a platform to speak their minds. During our
fieldwork, we sometimes looked back at the filmed materials together
with our key respondents to illustrate what kind of data we collected
and how they were presented. They all agreed to the lack of anonymity
that is associated with interviews captured on film. We did agree that
respondents would always be informed if the visuals were used.
The in-depth interviews contained semi-structured, open-ended
questions in English or translated in isiXhosa by MM (isiXhosa-
speaking). Questions covered TB perceptions, medical knowledge, so-
cial support, structural obstacles to TB treatment, poverty, and sensitive
topics such as stigma. This was supplemented by the FGDs, which
elaborated on these topics and initiated interaction and discussion re-
garding conflicting perceptions, opinions, and experiences of partici-
pants. To enhance group dynamics, we used various research techni-
ques, such as word clouds, theme selection, ranking, and poster
presentations. Participant observation generated rich data regarding
the social and cultural context and patients' everyday life experiences
with TB. This information partially overlapped with visual data col-
lection, which led to intense researcher-respondent engagement, gen-
erating a high level of trust and valuable informal conversations. To
foster informal interview settings, we used photo-elicitation techniques
(Harper, 2002) and asked respondents to keep a diary (Elliott, 1997).
The additional value of these alternative methods was to gain a deeper
understanding of the richness and complexity of people's experiences
and to collect data regarding emotions and non-verbal behaviour and
interactions.
During and after data collection, we used an inductive approach to
analysis (Glaser and Strauss, 2009). In-depth interviews and FGDs were
audio- and sometimes video-recorded, transcribed verbatim, and
screened multiple times by ALC. Field notes of participant observations,
films, and transcripts were first coded into meaning units and then
divided into categories and subcategories. This was checked by MM.
Open data collection techniques led to the emergence of themes for-
mulated by respondents in order to avoid researcher-defined categories.
With Qualitative Data Analysis and Research Software (ATLAS.ti, 7th
edition), we identified recurring themes, analysed structures, meaning,
and context.
Ethical clearance for the study was obtained from the University of
Cape Town (HREC REF 726/2014). Verbal informed consent was re-
ceived from each participant before recruitment, interviews, and ob-
servation. We presented ourselves as researchers who wanted to gain a
better understanding about TB and how TB may affect people's life in
Town 2. We explained our goals to write an article and make a film with
the hope that people's experiences might help inform health policies.
Because of the relations built with patients and community members
and the fact that we attended many events in the course of five months,
we were able to attend churches (services) and funerals in an integrated
fashion. We used pseudonyms and unidentifiable descriptions of re-
spondents throughout this article to ensure anonymity and con-
fidentiality. The key respondents participating in the visual ethno-
graphic part of this study signed separate consent forms, because they
will not remain anonymous.
3. Results
The average age of the TB patients in our study (N = 30) was 37
[range 19–89 years]. Thirteen were male, 14 were in a relationship, and
nine were employed. Twelve patients had DS-TB, seven MDR-TB, and

147
A.L. Cremers et al.
one XDR-TB. Ten patients had recurrent TB. We have synthesized the
data into the following inter-related themes: TB treatment and aetiolo-
gies; the embodied experience with TB treatment; alcohol consumption; fi-
nancial constraints; and support and stigma. We present our findings with
text and short videos to engage the senses of our readers and create a
more empathetic understanding about experiences of patients with TB
and care.
3.1. TB aetiologies and treatment
The majority of respondents explained they had received a lot of
health education about TB. Most patients stressed the fact that everyone
could obtain TB. Yet, various respondents cautiously explained that TB
was more often found in poor and dirty households. Health workers
often stressed that HIV, smoking, and drinking were risk factors for TB.
During FGDs and interviews, respondents often mixed up risk factors
with TB aetiologies. Health workers explained that the Impundulu myth
(about a big bird that kicks you in the chest so you start coughing blood),
and the idea of edliso (a black poison caused by witchcraft) were TB ae-
tiologies used in the past, but rarely mentioned nowadays. More current
TB aetiologies mentioned were cold weather, wetness, sleeping around,
heredity (referred to as family-TB), and sharing glasses or cutlery with
TB-infected people (S0277953618302776).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
I was so shocked before, that one. The first TB. I never get sick. And I
am 52 now. And I asked myself where does it come from, this TB? Even
in my family, no one has TB, where does this TB come from? I was
thinking that maybe I was infected by my friend. Maybe I shared the
glass with my friend. Or we share the same cigarette (George, DS-TB
patient).
All patients attended or had attended a clinic for biomedical TB
treatment. A few patients mentioned they additionally had visited faith
or traditional healers to cure their TB. Most traditional healers and all
faith healers we spoke with explained they were not able to cure TB
(alone) and referred people to the clinic.
3.2. The embodied experience of TB-treatment
The harsh side-effects of MDR-TB treatment were a central theme
for both patients and health workers and led to difficulties with treat-
ment adherence. DS-TB patients also referred to very similar bodily
experiences, especially in the case of comorbidities. Patients intensely
described how the high load of toxic medications seemed to destroy
their bodies. They mentioned how the TB pills made them throw up and
feel nausea, dizziness, weakness, and hunger. Moreover, both DS-TB
and DR-TB patients described psychotic incidences due to the medica-
tion (Video 2).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
During participant observation, respondents sometimes warned the
researcher that they had just taken drugs that could potentially trigger
unpredictable behaviour. Various DS-TB and DR-TB patients explained
they feared becoming crazy because of the drugs and potentially
harming themselves or people around them. Some respondents men-
tioned they particularly feared DR-TB patients for their dangerous be-
haviour (Video 3).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
There is another TB, I am scared of that. MDR. The people they say
it's too dangerous. Because the people who have MDR-TB, they pass
away. Because most of the people that got MDR, they just loose their
minds. While I am talking with you, I am not talking the way we talk.
They just talk nonsense. So they've got … That TB. So they are dan-
gerous (Tamtam, DS-TB-patient).
In this study, every MDR-TB patient described the daily MDR-TB
148
Social Science & Medicine 209 (2018) 145–151
injections as a horror. Side-effects were described in detail during FGDs
and informal conversations and consisted of haematomas on the but-
tocks, painful legs hindering walking, and hearing loss. One patient said
he was relieved his MDR-TB turned into XDR-TB, because that meant no
more injections. Few patients continued with injections. Some decided
to only continue with oral medication. Yet others discontinued all
treatment, because they feared dying of side-effects (Video 4).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
When I tell my side effects to the nurses, no one seems to listen to
listen to me. She shouts at me all the time. And she threatened me that
she would stop my government grant. After that, I tell myself, this is not
right. Because I will end up dead. I know what I was doing, it was
wrong. To leave my treatment. To not finish. […] But I can't do it
anymore. I can't (Nokuzola, MDR-TB-patient).
Nokuzola continued injections for months despite reporting severe
side-effects at the clinic. She explained that health workers accused her
of non-adherence with treatment in order to receive a governmental
grant. This resonated with some respondents who argued that people
were purposely getting infected with TB in order to get a grant.
Nokuzola, however, worried about losing her hearing, and additionally
explained being afraid of losing her mind and sight, as her complaints
remained unheard. This was the reason why she decided to stop
treatment and rely on prayers only.
3.3. Alcohol consumption
Many patients were aware of the devastating effects of alcohol on
their TB and the potential development of drug resistance.
Nevertheless, about one third consumed alcohol, and at times, a couple
of our male and female patients seemed too drunk for interviews.
Pastors explained some patients had been drunk for days. Some older
respondents who had been politically engaged in the fight against the
Apartheid regime described feeling disillusioned, because persisting
economic constraints hindered them from living life to its fullest po-
tential. They explained how alcohol consumption helped to reduce
feelings of vulnerability (Video 5).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
Something is wrong. I just want to drink. You understand? Even in
the morning, during the day. [I am] unemployed. With him [son] in the
school. There is no income. I can't sleep. I'm just restless and vulnerable.
I'm just telling myself, I go to the clinic, I go … Up until I was taken to
the hospital (Khulish, DS-TB-patient).
Alcohol gave some patients a feeling of being in control again, to
forget problems, and free their minds. Some respondents explained that
alcohol consumption allowed them the chance to ignore their health
status up until they developed a severe manifestation of TB.
3.4. Financial constraints and social grants
Patients with a low socio-economic status received a social grant
from the government and patients weighing under 40 kg received food
supplements. During participant observation, the grant and extra food
was often shared with the whole family; for some turning the patient
into a bread-winner. A few respondents mentioned that relapse or MDR-
TB-patients were often non-compliant TB patients who wanted a grant
from the government (Video 6).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
Most TB patients had financial problems, mostly due to unemploy-
ment, that interfered with treatment. During participant observation,
TB patients did not always take all their pills because lack of food
worsened side-effects (Video 7).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
A.L. Cremers et al.
No, I can't take those pills. The food is finished, Lianne. I'm going to
throw it in the bin. Now. I don't want, I am not going to take these.
These pills make me mad. I'm going to drink this, only this (Chumisa,
MDR-TB patient).
3.5. Support and stigma
Khayelitsha is divided into different quarters that are characterised
by close communities and social structures of support. During FGDs,
interviews, and participant observation, respondents often referred to
‘the spirit of ubuntu’ to explain how neighbours took care and cooked for
each other, and accompanied patients to the hospital (Video 8).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
Some people explained DS-TB-patients were no longer stigmatised,
e.g. kicked out of the house, beaten up, or socially isolated. During this
study, these examples of stigmatisation were indeed not observed or
heard of, but some respondents (themselves sometimes former TB pa-
tients) did talk in a stigmatising way about TB patients (Video 9).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
They [TB patients] shrink. Because they don't want to eat, they don't
want to do anything, they don't want to talk. They are smelly. If like
now you smell, I smell poopoo in this house, somebody has got a TB.
[…] That one is not going to survive (Tamtam, DS-TB-patient).
Tamtam made a distinction between herself and ‘those patients who
carried a lot of diseases’. TB patients were often suspected of carrying a
wide range of diseases, including HIV. Many respondents said that only
HIV patients were stigmatised because it was ‘a personal problem’, re-
ferring to behaviour such as sleeping around. On the contrary, TB could
be obtained by anyone through the air. However, various respondents
explained that social consequences for HIV and TB were often inter-
mingled (Video 10).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
They [TB-patients] are not open. They don't want to share. Anything
with TB, it's just that they don't accept the TB. […] I think they're
having a problem with thinking that TB is only for HIV people. But a
person that has a normal TB with no HIV, a normal person, just gets TB
with no HIV. She doesn't accept that. It means you are a whore. That's
what they say (Vuyelwa, CCW).
Respondents explained there is an assumption that only HIV pa-
tients are susceptible for TB. Various respondents described that TB was
considered by many a disgrace and some also explained that one's po-
sition in society was in danger of being degraded (Video 11).
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
Khulish described how many people already have a vulnerable po-
sition and are not able to cope with unexpected events, such as TB.
One respondent had obtained TB on the mountain, referring to the
site of his initiation ritual into manhood. For him, and for men in
general, TB was additionally complicated and shameful as men are
expected to be strong and healthy. Many respondents stated men only
seek care when they are bed-ridden. Various respondents explained
their concern for a (male) coughing family member who refused to seek
care.
Some health workers and patients labelled DR-TB patients as irre-
sponsible and a danger to their social environment. Sensitization pro-
grammes warned against incorrect drug intake as this might lead to
drug resistance; yet various respondents remained unaware of direct
transmission of DR-TB. DR-TB-patients said they additionally had dif-
ficulties with wearing a mask as it signalled TB and sometimes triggered
fear and rudeness of bystanders. The danger of MDR-TB-infection was
often equalled with Ebola.
Another problem mentioned by participants was stigmatizing atti-
tudes of nurses at the clinic (Video 12).
149
Social Science & Medicine 209 (2018) 145–151
Supplementary video related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2018.05.034.
But the way she [the nurse] was treating me, I didn't like it. She puts
the injection in that lump. But she can see, that lump is bleeding. But
she carries on to put that injection in that lump. So that is why I didn't
want to go there, to the clinic of Town 2. I hate them. I don't want to go
there. I talk the truth, now I hate the clinic. […] I feel like I am not a
person. The nurse shouting at me like that (Nokuzola, MDR-TB-patient).
Some patients described feelings of frustration and dehumanization
because of nurses' treatment. Several health workers explained feeling
threatened by TB patients who complained about treatment as this
potentially signalled patients being non-compliant, increasing the risk
of infection. Clinics were often understaffed, resulting in excessive
workloads, long waiting queues, and at times, rude attitudes of both
health workers and patients towards each other.
Various health workers and researchers had a pessimistic attitude
about the functioning of the Khayelitsha programme, a frustration
amplified by huge health inequalities within South Africa. They often
blamed mismanaged TB interventions, limited political will and re-
sources, and patients' irresponsible behaviour for the expanding
number of TB patients.
4. Discussion
Our resilience-based approach may provide a deeper understanding
of how TB patients in Khayelitsha negotiate adversities while dealing
with TB and TB care. Most of these adversities - poverty, hunger, stigma
- were related to tenacious social, political, and economic inequalities.
However, we want to complement our investigation of vulnerability
and victimization with a perspective that better integrates patients'
strengths and competencies. We focus here on patients' manifestations
of resilience that may influence their wellbeing and more indirectly, the
outcomes of the Khayelitsha programme. We argue that TB patients in
this study were strong-willed, proud, and showed substantial agency in
making informed decisions despite difficult circumstances. Below, we
will explain how decision-making was shaped by the contingencies of
respondents' daily experiences and discuss under what conditions we
might consider these as manifestations of resilience.
All patients included in this study were living in dire poverty.
Numerous authors have argued that poverty and malnourishment are
two principle obstacles to TB care (Ndegwa et al., 2007; Waaler, 2002).
The side effects of treatments for both DS-TB and DR-TB patients,
worsened by a lack of food, and their negative impact on treatment
adherence have been reported (Chalco et al., 2006; Törün et al., 2005;
Yee et al., 2003). Nevertheless, many of our patients stated that they
were not being heard about this aspect of TB treatment. While our
patients were generally well-informed about TB and the importance of
treatment adherence, issues such as medications' side-effects sometimes
forced them to deviate from treatment guidelines, especially when food
was scarce. At times, some patients decided to pause or stop treatment
in order to avoid becoming psychotic. In these moments, patients' re-
silience manifested as protecting their psychological health. While this
enabled them to live a more dignified life in the short run, they worried
that TB might kill them in the long term. In this context, patients
weighed alternatives. However, this decision-making did not necessa-
rily translate into long-term health benefits. This resonates with the
idea that individuals may be resilient in one domain or phase of their
lives, but not in others (Southwick et al., 2015; Vanderbilt-Adriance and
Shaw, 2008). Resilience may manifest variably in different contexts and
additionally, these different manifestations of resilience potentially
interact with each other.
Many patients used alcohol, countering treatment guidelines and
despite knowing its disastrous effects on health and potential drug re-
sistance. Nevertheless, drinking alcohol appeared to be an important
coping strategy to promote a sense of well-being. At the same time,
however, this coping strategy often caused delay or interruption of TB
A.L. Cremers et al.
care. TB patients' alcohol use may be lowered by poverty alleviation
and consequently improve TB outcomes, as a South African study il-
lustrated (Louwagie et al., 2014). Interestingly, this study focused on
men, while our study showed that women also used alcohol.
Since 1999, social grants have reduced poverty in South Africa
(Armstrong et al., 2008). Yet, as Merton already noted in 1936 (Merton,
1936), social interventions can exert both intended and unanticipated
consequences. TB social grants are supposed to financially support re-
cipients and improve their adherence to treatment. Those who complete
TB treatment eventually lose access to such grants. Several patients,
health workers, and pastors said that some patients prolonged access to
such a grant by avoiding or delaying getting cured, or by getting re-
infected. Various TB patients did indeed become breadwinners thanks
to their grant; their illness and lives at risk assured financial income for
their family. Paradoxically, grants may feed into the poverty cycle
whereby patients continue to be ill or face recurrent TB, remain un-
employed, and stay dependent on these external financial resources.
The use of social grant resources to address socio-economic adversity
could be considered as enhancing economic resilience, while negatively
impacting other domains of resilience, undermining health.
Some authors have argued that unconditional cash transfers to the
poor are the way forward (Ferguson, 2015). If most people in Khaye-
litsha would be able to receive money regardless of TB status, chal-
lenges with TB grants as described above may potentially be avoided.
The discussion of social grants remains complex as questions arise
around whether the structural aspects of this problem are properly
addressed, who would be responsible for such payments, and how this
would be applied to an everyday context. Instead of grants for in-
dividual patients, governments could invest in the wider community
(including patients who are no longer infectious) by creating jobs,
fostering education, and promoting rights in order to stimulate sus-
tainable economic development. Moreover, TB programmes could be
mandated to pressure employers to provide fair compensation for em-
ployees who develop active TB.
Narratives of patients deliberately pursuing TB grants may, how-
ever, be fuelled by social processes of stigmatization. Some respondents
described TB patients in a stigmatizing way and various patients
(especially men) mentioned that they felt ashamed of having TB, often
hindering TB disclosure and seeking of health care. TB was linked by
many to HIV, leading to a double stigma (Cremers et al., 2015; Daftary,
2012). DR-TB patients faced another dimension of stigma, as they were
often considered dangerous and irresponsible (assuming they had pre-
viously been non-adherent with treatment). This discourse of respon-
sibility is strengthened by the Khayelitsha programme that allows ‘re-
sponsible patients’ home-based care and warns that non-adherence to
treatment leads to drug resistance. South Africa is one of the few
countries where second- and third-line TB-drugs are available, ex-
plaining the lack of studies reporting on DR-TB-related stigma.
The persistence of strong community ties may heighten vulner-
ability to TB stigma. At the same time, this kind of intense social in-
terconnection can also serve as a critical resource for enhancing resi-
lience among people living in Khayelitsha and a source of support for
their TB treatment. Close connections between people of a community
may play an important role in interventions to sustain well-being and
health of patients (Hawe and Shiell, 2000; Seeman, 1996).
In sum, TB patients' responses to the Khayelitsha programme must
be examined in relation to the manifold adversities they encounter and
negotiate in their daily lives. Within this context, resilience among
people with TB may differ from time to time and across various do-
mains of life. Moreover, these various manifestations of resilience may
interact with each other. Resilience in one life domain may, para-
doxically, lead to vulnerability in others. The Khayelitsha programme
may currently have limited impact on patients' situations in the face of
dire circumstances. However, a resilience-focused approach could make
a unique contribution to this effort by identifying the complex and
varying ways resilience manifests itself. TB programmes would benefit
150
Social Science & Medicine 209 (2018) 145–151
from a resilience-building approach that considers pre-existing
strengths and vulnerabilities of TB patients and their communities.
Our visual ethnographic study allows for the sharing of knowledge
and interpretations that reside beyond medical and scientific rationales,
offering alternative ways of understanding and explaining TB (Cremers
et al., 2016). A trailer of the longer ethnographic health film “TB in
Town 2” can be found at: https://vimeo.com/244487053. The use of
visual ethnography raises the question of what platforms can be given
to TB patients and what roles patients could play within the field of
research, knowledge construction, and policy making. TB-related acti-
vism in South Africa remains limited, with the exception of the TAC and
a few other small NGOs and networks (TAC, 2017). In considering
lessons learned from the fields of HIV (Epstein, 1995), Ebola
(Abramowitz et al., 2015), and Lyme disease (Zavestoski et al., 2004),
we call for more research on how synergies can be created between
communities, researchers, and policy-makers and the role of visual
ethnography herein.
4.1. Limitations and strengths
Our study participants (N = 72) were recruited in one township
characterized by high crime rates, social and racial tensions, intense
levels of poverty and marginalization, and advanced TB programmes.
This may complicate translation to other settings in South Africa and
beyond. However, this information sheds light on the vulnerabilities
and the capabilities within communities with high TB risk that may be
considered as exemplary in other settings. This study focused on adults
and included only one XDR-TB patient, consequently experiences of
children and XDR-TB patients remains unknown and future ethno-
graphic research is needed.
The strengths of this ethnographic study include a critical inquiry
into the functioning of the Khayelitsha programme and how this im-
pacts the lives of its patients. Our approach to forming long-term re-
lationships with respondents revealed the complexities of TB patients'
experience with TB and care. The camera functioned as a catalyst as
respondents reacted positively and explained that they hoped their
struggles related to TB treatment would reach beyond this research.
Patients' narratives captured on film may provide insights on the sub-
jectivities attributed to TB. Finally, the need to broaden the impact of
ethnographic health research on policy agendas and public discourse
(Panter-Brick and Eggerman, 2017; Hansen et al., 2013) may be ad-
dressed by the use of video recordings.
5. Conclusion
Our ethnographic study assessed patients' experiences with TB and
TB care using a resilience-based approach. The findings may enhance
understanding of why the Khayelitsha programme is still struggling to
quell the epidemic. We aimed to identify and understand the complex
and varying manifestations of resilience in contexts profoundly shaped
by economic and health inequalities. TB programmes can benefit from
this approach by understanding and drawing on pre-existing strengths
and vulnerabilities among TB patients and their communities. By using
visual ethnography and short videos, we aimed to present patient
perspectives and hope to contribute to improving TB programmes by
creating novel synergies between patients, researchers, and policy-
makers.
Conflicts of interest
None.
Funding
No specific funding was received for this project.
A.L. Cremers et al. Social Science & Medicine 209 (2018) 145–151

Acknowledgments Merton, R.K., 1936. The unanticipated consequences of purposive social action. Am.
Socio. Rev. 1, 894–904.
MSF, 2005. Report on the Integration of TB and HIV Services in Site B. Médecins Sans
We thank all respondents for their time and commitment, with Frontières. http://webdav.uct.ac.za/depts/epi/ideufiles/tb_integration_progress_
special thanks to our key-respondents partaking in the visual ethno- report_02205.pdf, Accessed date: 1 June 2015.
graphic study. MSF, 2011a. Scaling up Diagnosis and Treatment of Drug-resistant Tuberculosis in
Khayelitsha, South Africa. Médecins Sans Frontières. http://www.msfaccess.org/
sites/default/files/MSF_assets/TB/Docs/TB_report_ScalingUpDxTxKhaye_ENG_2011.
References pdf, Accessed date: 1 February 2015.
MSF, 2016. DR-tb Drugs under the Microscope. Sources and Prices for Drug-resistant
Tuberculosis Medicines, fourth ed.citon. Médecins Sans Frontières. http://apps.who.
Abramowitz, S.A., McLean, K.E., McKune, S.L., Bardosh, K.L., Fallah, M., Monger, J.,
int/medicinedocs/en/d/Js22344en/ (accessed January 2017).
et al., 2015. Community-centered responses to Ebola in urban Liberia: the view from
MSF, 2011b. Activity Report. Ten Years of HIV/TB Care at Primary Health Care Level.
below. PLoS Neglected Trop. Dis. 9 e0003706.
Médecins Sans Frontières. http://www.msf.org/en/article/khayelitsha-activity-
Armstrong, P., Lekezwa, B., Siebrits, K., 2008. Poverty in South Africa: a Profile Based on
report-2001-2011-10-years-hivtb-care-primary-health-care-level (accessed February
Recent Household Surveys. Matieland: Stellenbosch Economic Working Paper, 4.
2015).
Atkins, S., Lewin, S., Jordaan, E., Thorson, A., 2011. Lay health worker-supported tu-
Ndegwa, D., Horner, D., Esau, F., 2007. The links between migration, poverty and health.
berculosis treatment adherence in South Africa: an interrupted time-series study. Int.
Evidence from Khayelitsha and Mitchell’s Plain. Soc. Indic. Res. 81, 223–234.
J. Tubercul. Lung Dis. 15, 84–89.
Nleya, N., Thompson, L., 2009. Survey methodology in violence-prone Khayelitsha, Cape
Birch, S., Govender, V., Fried, J., Eyles, J., Daries, V., Moshabela, M., et al., 2016. Does
Town, South Africa. AIDS bulletin 40, 50–57.
treatment collection and observation each day keep the patient away? An analysis of
Otwombe, K.N., Variava, E., Holmes, C.B., Chaisson, R.E., Martinson, N., 2013. Predictors
the determinants of adherence among patients with Tuberculosis in South Africa.
of delay in the diagnosis and treatment of suspected tuberculosis in HIV co-infected
Health Pol. Plann. 31, 454–461.
patients in South Africa. Int. J. Tubercul. Lung Dis. 17, 1199–1205.
Chaisson, R.E., Churchyard, G.J., 2010. Recurrent Tuberculosis: Relapse, Reinfection, and
Packard, R.M., 1989. White plague, Black Labor: Tuberculosis and the Political Economy
HIV. The University of Chicago Press, Chicago.
of Health and Disease in South Africa. University of California Press, Berkeley.
Chalco, K., Wu, D., Mestanza, L., Munoz, M., Llaro, K., Guerra, D., et al., 2006. Nurses as
Panter-Brick, C., 2014. Health, risk, and resilience: interdisciplinary concepts and ap-
providers of emotional support to patients with MDR-TB. Int. Nurs. Rev. 53, 253–260.
plications. Annu. Rev. Antrhopol 43, 431–448.
CoCT, 2006. Socio-economic Profiling of Urban Renewal Nodes - Khayelitsha and
Panter-Brick, C., Eggerman, M., 2017. The field of medical anthropology in Social Science
Mitchell's Plain. University of Stellenbosch, Stellenbosch.
& Medicine. Soc. Sci. Med. https://doi.org/10.1016/j.socscimed.2017.10.033.
Colvin, M., Gumede, L., Grimwade, K., Maher, D., Wilkinson, D., 2003. Contribution of
Perez-Brumer, A.G., Reisner, S.L., McLean, S.A., Silva-Santisteban, A., Huerta, L., Mayer,
traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa.
K.H., Lama, J.R., 2017. Leveraging social capital: multilevel stigma, associated HIV
Int. J. Tubercul. Lung Dis. 7, S86–S91.
vulnerabilities, and social resilience strategies among transgender women in Lima,
Cremers, A.L., de Laat, M.M., Kapata, N., Gerrets, R., Klipstein-Grobusch, K., Grobusch,
Peru. JIAS (J. Iowa Acad. Sci.) 20 (1).
M.P., 2015. Assessing the consequences of stigma for tuberculosis patients in urban
Pronyk, P., Makhubele, M., Hargreaves, J., Tollman, S., Hausler, H., 2001. Assessing
Zambia. PLoS One 10 (3) e0119861.
health seeking behaviour among tuberculosis patients in rural South Africa. Int. J.
Cremers, A.L., Gerrets, R., Grobusch, M.P., 2016. Visual ethnography: bridging anthro-
Tubercul. Lung Dis. 5, 619–627.
pology and public health. Pract. Anthropol. 38 (4), 7–11.
SANAC, 2012. National Strategic Plan on HIV, STIs and TB 2012Á2016. Pretoria, South
Daftary, A., 2012. HIV and tuberculosis: the construction and management of double
Africa. South African National AIDS Council.
stigma. Soc. Sci. Med. 74, 1512–1519.
Seeman, T.E., 1996. Social ties and health: the benefits of social integration. Ann.
Daftary, A., Padayatchi, N., 2013. Integrating patients' perspectives into integrated tu-
Epidemiol. 6, 442–451.
berculosis-human immunodeficiency virus health care. Int. J. Tubercul. Lung Dis. 17,
Shean, K., Willcox, P., Siwendu, S., Laserson, K., Gross, L., Kammerer, S., et al., 2008.
546–551.
Treatment outcome and follow-up of multidrug-resistant tuberculosis patients, West
Daftary, A., Padayatchi, N., O'Donnell, M., 2014. Preferential adherence to antiretroviral
Coast/Winelands, South Africa, 1992–2002. Int. J. Tubercul. Lung Dis. 12,
therapy over tuberculosis treatment: a qualitative study of drug-resistant TB/HIV co-
1182–1189.
infected patients in South Africa. Global Publ. Health 1–10.
Southwick, S.M., Pietrzak, R.H., Tsai, J., Krystal, J.H., Charney, D., 2015. Resilience: an
Elliott, H., 1997. The use of diaries in sociological research on health experience. Socio.
update. PTSD RQ 25 (4), 1050–1835.
Res. Online 2 (2).
TAC, 2017. Campaign areas. Treatment Action Campaign. https://tac.org.za/campaign-
Epstein, S., 1995. The construction of lay expertise: AIDS activism and the forging of
areas/, Accessed date: 16 August 2017.
credibility in the reform of clinical trials. ST & HV 20, 408–437.
Törün, T., Güngör, G., Özmen, I., Bölükbaşı, Y., Maden, E., Bıçakçı, B., et al., 2005. Side
Farmer, P.E., 2000. The consumption of the poor: tuberculosis in the 21st century.
effects associated with the treatment of multidrug-resistant tuberculosis. Int. J.
Ethnogr. 1, 183–216.
Tubercul. Lung Dis. 9, 1373–1377.
Fergus, S., Zimmerman, M.A., 2005. Adolescent resilience: a framework for under-
Uyei, J., Coetzee, D., Macinko, J., Weinberg, S.L., Guttmacher, S., 2014. The influence of
standing healthy development in the face of risk. Annu. Rev. Publ. Health 26,
integrated tuberculosis and human immunodeficiency virus service delivery on pa-
399–419.
tient outcomes. Int. J. Tubercul. Lung Dis. 18, 315–321.
Ferguson, J., 2015. Give a Man a Fish: Reflections on the New Politics of Distribution.
Vanderbilt-Adriance, E., Shaw, D.S., 2008. Conceptualizing and re-evaluating resilience
Duke University Press, Durham.
across levels of risk, time, and domains of competence. Clin. Child Fam. Psychol. Rev.
Gerrish, K., Naisby, A., Ismail, M., 2013. Experiences of the diagnosis and management of
11 (1–2), 30.
tuberculosis: a focused ethnography of Somali patients and healthcare professionals
Waaler, H.T., 2002. Tuberculosis and poverty [editorial]. Int. J. Tubercul. Lung Dis. 6,
in the UK. J. Adv. Nurs. 69, 2285–2294.
745–746.
Glaser, B.G., Strauss, A.L., 2009. The Discovery of Grounded Theory: Strategies for
Waugh, C.E., Koster, E.H., 2015. A resilience framework for promoting stable remission
Qualitative Research. Transaction publishers.
from depression. Clin. Psychol. Rev. 41, 49–60.
Greene, J.A., 2004. An ethnography of nonadherence: culture, poverty, and tuberculosis
Wexler, L.M., DiFluvio, G., Burke, T.K., 2009. Resilience and marginalized youth: making
in urban Bolivia. Cult. Med. Psychiatry 28, 401–425.
a case for personal and collective meaning-making as part of resilience research in
Hansen, H., Holmes, S., Lindemann, D., 2013. Ethnography of health for social change:
public health. Soc. Sci. Med. 69, 565–570.
impact on public perception and policy. Soc. Sci. Med. 99, 116–118.
WHO, 2010. Multidrug and Extensively Drug-resistant TB (M/XDR-tb): 2010 Global
Harling, G., Ehrlich, R., Myer, L., 2008. The social epidemiology of tuberculosis in South
Report on Surveillance and Response. World Health Organization, Geneva.
Africa: a multilevel analysis. Soc. Sci. Med. 66, 492–505.
WHO, 2013. Global Tuberculosis Report 2013. World Health Organization, Geneva.
Harper, D., 2002. Talking about pictures: a case for photo elicitation. Vis. Stud. 17, 13–26.
Wood, R., Lawn, S.D., Johnstone-Robertson, S., Bekker, L.-G., 2011. Tuberculosis control
Harper, I., 2006. Anthropology, DOTS and understanding tuberculosis control in Nepal. J.
has failed in South Africa: time to reappraise strategy. SAMJ (S. Afr. Med. J.) 101,
Biosoc. Sci. 38, 57.
111–114.
Hawe, P., Shiell, A., 2000. Social capital and health promotion: a review. Soc. Sci. Med.
Woodward, E.N., Banks, R.J., Marks, A.K., Pantalone, D.W., 2017. Identifying resilience
51, 871–885.
resources for HIV prevention among sexual minority men: a systematic review. AIDS
Jean-Claude, M., 2014. Townships as crime ‘Hot-Spot’Areas in Cape Town: perceived root
Behav. 21 (10), 2860–2873.
causes of crime in site B, Khayelitsha. Mediterr. J. Soc. Sci. 5, 596.
World Bank, 2016. Gross Domestic Product 2016. http://databank.worldbank.org/data/
Koch, E., 2013. Free Market Tuberculosis: Managing Epidemics in Post-Soviet Georgia.
download/GDP.pdf, Accessed date: 1 January 2017.
Vanderbilt University Press, Nashville.
Yee, D., Valiquette, C., Pelletier, M., Parisien, I., Rocher, I., Menzies, D., 2003. Incidence
Lambert, H., McKevitt, C., 2002. Anthropology in health research: from qualitative
of serious side effects from first-line antituberculosis drugs among patients treated for
methods to multidisciplinarity. BMJ 325, 210.
active tuberculosis. Am. J. Respir. Crit 167, 1472–1477.
Louwagie, G.M., Wouters, E., Ayo-yusuf, O.A., 2014. Poverty and substance use in South
Zavestoski, S., Brown, P., McCormick, S., Mayer, B., D'Ottavi, M., Lucove, J.C., 2004.
African tuberculosis patients. Am. J. Health Behav. 38, 501–509.
Patient activism and the struggle for diagnosis: gulf War illnesses and other medically
Mason, P., 2014. Tuberculosis: More Anthropologists Wanted. https://culturematters.
unexplained physical symptoms in the US. Soc. Sci. Med. 58, 161–175.
wordpress.com/2014/07/26/tuberculosis-more-anthropologists-wanted/, Accessed
Zraly, M., Nyirazinyoye, L., 2010. Don't let the suffering make you fade away: an eth-
date: 1 December 2017.
nographic study of resilience among survivors of genocide-rape in southern Rwanda.
Masten, A.S., 2006. Promoting resilience in development: a general framework for sys-
Soc. Sci. Med. 70, 1656–1664.
tems of care. In: Flynn, R.J., Dudding, P.M., Barber, J.G. (Eds.), Promoting Resilience
in Child Welfare. University of Ottawa Press, Ottawa, pp. 3–17.

151