History is often as much about things that have happened as it is about those which — mostly for very clear reasons — do not materialize from a historical situation that would have made them possible. The history of tuberculosis in the twentieth century that Christian McMillen is taking his readers through is an example of the latter. There are many merits to this book, which gives us the first true twentieth-century history of tuberculosis, covering subjects such as racial theories, drug therapies, tuberculosis control in American Indian communities, India, and Africa. For virtue of a pointed argument I want to focus on one that I find particularly interesting. McMillen shifts historiographic perspective away from industrialized countries and the nineteenth century to low-income countries and communities, accounting for tuberculosis as a twentieth-century concern.
Tuberculosis had after all almost disappeared from the epidemiology of industrialized countries before it returned to the attention of international and later global health. There is much to learn from McMillen’s account: the history of tuberculosis after World War II in the global south is deeply shaped by its tradition in industrialized countries before. Despite the promise of future chemotherapies, harbored in the identification of a pathogen in 1882, this history evolved in the absence of highly efficacious drug therapies. Instead, tuberculosis was conceptualized as a social disease. In its epidemic dimensions, tuberculosis was controlled through hygiene and improving social conditions such as housing or nutrition. To these measures, vaccines and therapy would eventually be added. Upon the arrival of antibiotics after World War II, nobody thought that changes to the therapeutic perspective would devalue these other elements of prevention. As McMillen shows us, the pioneers of chemotherapeutic protocols — many of whom came from Britain — were keenly aware that effective therapies would make little impact if the deeper social drivers of the epidemic were not given attention.
Despite best intentions, in the decades after the war came the erosion of the notion of tuberculosis as a social disease, replaced by approaches at control driven by pharmaceutical technology. As McMillen shows us, it was those long-desired and late-arriving technologies — antibiotic chemotherapies and the BCG vaccine — that, when they finally went into global distribution, sidelined approaches to control the condition that emphasized changes to social conditions. Of course, the task of fully extending the approach taken by industrialized countries to control and prevent disease in other parts of the globe would have been gargantuan, further necessitating a degree of welfare, public health, and clinical care that was all but lacking outside of the industrialized world.
On their own, drugs failed miserably. Treatment failures in places like East Africa, where McMillen found most of his evidence, would be blamed on the patients’ failure to comply, when in fact it simply exposed the lack of medical infrastructure that helped European patients make it through what in the 1950s still was an almost two-year therapy. What evolved was a typical case of international health as a parody of medicine as it was practiced in the cool north. Short course regimes were intended to make up for the lack of resources in care, but fell well-short of that aim. The challenge of antibiotics resistance, of which there was ample evidence in the 1960s, was downplayed in favor of treating susceptible cases. Epidemiological work and systematic case finding, which had provided physicians with a road map in industrialized countries, remained rudimentary at best.
The result of an exaggerated faith in technological solutions, in combination with an epidemic driven by urbanization in the global South, was an evolving disaster. Solemnly ignored in the Health-for-All 1970s, it only erupted to full recognition when the advance of HIV/AIDS resulted in MDR patients in high-income countries. Impressed by MDR patients in New York, the world took notice of an epidemic of tuberculosis that had predated HIV, but that had grown to devastating proportions in combination with it. Directly Observed Therapy Short Course (DOTS) became the preferred approach to control tuberculosis in the era of global health (from 1995), yet it suffered from some of the same shortcomings and pretensions that its predecessors in the 1960s had — it put pills at the center (in short course therapy) and ignored the social drivers of the epidemic, accelerating the development of multi-drug resistance by focusing on treating drug sensitive cases, while sidelining sensitivity testing for drug resistance.
All in all, the drug-centered approach to global health has done something similar to tuberculosis as what antibiotics at large have done to infectious disease: hailed as solutions they have all but modernized the problem they were intended to solve. Drug-resistant tuberculosis is now one of the true twenty-first-century challenges that global health is attempting to control — a monster that it has created. To master that challenge it would be advisable to remember the lessons that the author of these lines has drawn from McMillen’s excellent book: any approach that does not tackle the social drivers of the global tuberculosis epidemic is doomed to result in a continuation and modernization of the problem it attempts to control.
Christoph Gradmann is Professor of the History of Medicine at the Section for Medical Anthropology and Medical History at the University of Oslo, Norway. He is associated with CERMES3 in Paris through working on the ERC project GLOBHEALTH. His larger field of research is the history of infectious disease, nineteenth century to present, which he currently pursues through a history of TB-drug resistance in global health.