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Theorising Tuberculosis in India

Aparna Nair (aparna.nair@ou.edu) is with the History of Science Department, University of Oklahoma.

Languished Hopes: Tuberculosis, the State and International Assistance in Twentieth-century India by Niels Brimnes, New Delhi: Orient BlackSwan, 2016; pp xiv + 318, price not indicated.

 

Growing up as the daughter of a physician in government service, the subject of tuberculosis featured often in family discussions at the dining table. My father would narrate the difficulties of ensuring the success of the directly observed treatment, short-course (DOTS) programme among tuberculosis-positive Indians, the worries regarding the surging multi-antibiotic-resistant disease, and the enduring relationships between poverty, access, and curing tuberculosis. I always had a sense of the disease as simultaneously easily controllable, but also extraordinarily elusive to the actors, and to the methods of biomedicine.

Diverse in its manifestations, and one of the oldest diseases to plague humanity, tuberculosis is a fascinating choice of subject. The disease has established itself firmly within both, the histories of medicine—by virtue of its relevance within urban, industrial spaces in the global North in the 19th century—as well as within literary constructions as a “romantic” affliction. Yet, little has been written about the trajectories of this disease in the majority worlds. In other respects too, there is no better time to be discussing tuberculosis. Multi-antibiotic-resistant tuberculosis is a spectre that menaces resource-strapped countries across the world, and continues to contribute towards the existing disease burden, economic costs, and social fractures. This is the disease that Niels Brimnes follows in his book, with methodical and detailed attention to a wonderfully rich body of evidence, culled from archives across the world. He, thus, makes a valuable and timely contribution to a field that has largely been restricted to the experiences of Europe and the Americas.

Brimnes begins his engagement at a time when the “tuberculinisation of India” hovered between the epidemic and the endemic, somewhere between that “of the African races, and the highly industrialised European races” (p 48). Disentangling late colonial narratives about tuberculosis in India, Brimnes traces the “cultural framing of tuberculosis,” through discourses that succeeded in blaming those who were living with the disease, while simultaneously “othering” Indians. For instance, he delineates briefly how race was important, even in a proximate sense, in explaining the patterns and prevalence of tuberculosis. Purdah as practice, and other social and cultural practices unique to India were drawn into explanatory narratives for tuberculosis, at the same time that the British acknowledged the bacteriological mechanisms underlying infections. Brimnes also pointed out that tuberculosis was perceived and understood as a disease of civilisation, industrialisation and modernity.

State Response Strategies

The author’s meticulous and detailed analysis of science within an ascendant nationalism in the decade before independence is particularly interesting, especially his critical reading of Gandhian attitudes to science and biomedicine. Brimnes traces how the Indian response to tuberculosis toys with the widespread use of sanatoriums, but ultimately chooses another route. The report of the Health Survey and Development Committee, also known as the Bhore Committee report, submitted in 1946, outlined the two fronts on which tuberculosis needed to be fought: the socio-economic domains of Indian life, as well as through a “direct attack on the reservoirs of infection” (p 68). These “direct attacks” took the form of vaccination and antibiotics, although the former always had a troubled history in South Asia. Unsurprisingly, the story of tuberculosis control in independent India is one of excellent intentions, problematic operationalisation, and erratic results. As Brimnes points out, the National Tuberculosis Control Programme was a juggernaut of planning, one that had the potential to impact a fifth of all humanity.

Stupendous as it was in scale, the story of how tuberculosis control in independent India was implemented is the more interesting tale. Brimnes glumly and rightfully concludes that the Bacillus Calmette–Guérin (BCG) vaccination “reached a fraction of its target population, far too few of the infections were discovered, patients on treatment did not collect their drugs—sometimes there were no drugs to collect.” One additional point he makes that is relevant to many aspects of the history of medicine and public health is that the staunch belief in abstract social planning needed to be supported by a nuanced and realistic understanding of social realities, financial constraints, cultural norms, and political will. This is a very important conclusion, and one that is necessary, in order to understand many of the major health crises that confront India today. Perhaps one of the most important points that Brimnes makes about tuberculosis is also the saddest: the slow pace of infection may indeed mean that it escaped the more rigorous attention that quickly progressing diseases have received. The tragedy of tuberculosis is that, although slow, it is nonetheless lethal and enervating.

With regard to the framing of the disease within the book, a brief discussion of the nature of the disease itself and its intimate connections to space and population would have made the author’s argument more robust. Brimnes himself acknowledges that the statistics used to limn the looming epidemiological crisis of tuberculosis in colonial records are, of course, problematic. Despite this caution, one would have been interested in learning how the state determined that “at most a quarter of deaths” from respiratory causes were due to phthisis. The book was also found wanting of a more detailed analysis, and engagement with the ways in which race, caste, and susceptibility to disease were imagined and constructed in both late colonial as well as postcolonial India. While Brimnes makes a fascinating discussion of the ways in which ideas about “race” intersect with the constructions of tuberculosis, one would have preferred a comprehensive understanding of those “racial” groupings believed to be more susceptible, and those considered more immune. Finally, one of the aspects of tuberculosis with which he does not engage (perhaps, he is right to restrict his focus) is how Indians negotiate a corporeal condition that teeters between infection and impairment. In fact, the lives and worlds of those living with tuberculosis are rather absent in this narrative, and that is likely a function of the archival matter chosen here.

 

 

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