Tuberculosis in black and white.

186 www.thelancet.com/respiratory Vol 2 March 2014 Pictures have the power to give a voice to individuals who have not been given the opportunity to be heard. They can infl uence public opinion and ultimately aff ect the course of history. Works of documentary photographers such as James Nachtwey have been proven to infl uence decision making related to conflict and war. But Nachtwey also marked people’s memories with his poignant photographs of health workers and patients with drug-resistant tuberculosis, for which he travelled to remote places in countries such as South Africa, Cambodia, and India. Because of improper use of treatment and inadequate control of the spread of disease, multidrug-resistant tuberculosis is threatening progress in tuberculosis care and control worldwide. This form of the disease is emerging in parts of the world that are generally poor and where people have inadequate access to health care. Because these areas are remote, their problems seem to be far from the reach of decision makers around the world. Misha Friedman—a documentary photographer who has worked with various non-governmental organisations and has portrayed patients with tuberculosis—thinks that photographs can help with this issue. He believes that the photographer’s role is not only to respectfully and compassionately portray patients with tuberculosis, but also to make sure his or her photographs reach the people who have the power to improve the situation. “In most countries across the world, decision makers personally know someone who has cancer or is HIV positive, while rarely do they know or see people with tuberculosis”, he says. Before becoming a photographer, Friedman worked for 7 years with Médecins Sans Frontières in Africa, Asia, and the former Soviet Union. At fi rst, photography was his hobby; he took pictures of his colleagues and what he was working on. When photography became his profession, he continued to focus on some of these issues, and that is when his long-term project on tuberculosis came to life. His work on multidrug-resistant tuberculosis in the former Soviet Union compellingly illustrates in black and white the truth about an avoidable problem. The photographs of his subjects, who are pictured in and around utilitarian health centres, are nevertheless emotionally rich. The graininess of the photographs lends to the soviet atmosphere, while the blurriness suggests they are out of place with what is expected of modern medicine. To be the person behind the camera is not a simple job. A photographer must remain invisible and observe diffi cult and devastating circumstances with the permanent aim to portray the reality of the situation. What does the photographer feel? “It depends”, says Friedman. “When working for Médecins Sans Frontières, one feels that their work is actually saving lives, whereas for a photographer this is not always the case. A photographer witnesses something, so sometimes I felt my pictures were helping people, other times I felt like an intruder and I felt nothing positive.” If documentary photography does not always help the patient directly, it can surely aff ect health workers’ experiences. By being photographed, aid workers can have their eff orts recognised and promoted, and agencies can also reach wider audiences. The more widely information about the work of aid agencies is disseminated, the more likely it is to reach potential funders and policy makers. However, the mainstream media can sometimes be discouraging. As Friedman notes, tuberculosis is not often a popular subject, unless World TB Day (on March 24 every year) is near. To touch someone and to bring about humanity and compassion, a photographer needs to have a certain sensibility and be able to portray the desperation of a situation. To paraphrase Nachtwey, the aim of photographers is to reach someone’s best instincts: generosity, a sense of right and wrong, the willingness and ability to identify with others, and the refusal to accept the unacceptable. Friedman sees it in a similar way: “I hope that when [policy makers] see photographs of patients with tuberculosis they also see people like themselves and not simply statistics, and this should make it easier for them to understand the patients’ problems and to act on them”.