It’s been gratifying and humbling to read these six thoughtful essays. I probably would have benefited from their insights before I published the book! Each and every one hits on something critical about the book, allowing me to think about the subject in new ways — even articulating elements of the story I did not fully realize were there.
My major concern in Discovering Tuberculosis was pretty basic: I wanted to know why a disease that is so old and so well-known — that’s actually curable — was still killing nearly two million people per year. I came to realize that this was the main aim of the book well into the research. I had been collecting materials for some time, reading and rereading documents, all along waiting for that moment when I had immersed myself so thoroughly in the material that scholarly insight would magically appear. A novel theoretical claim or historiographical “intervention” would surely emerge. Neither happened. And so I settled on the rather more quotidian, but I think important, question of why we have failed so miserably to control TB.
My answer, very basically, is that across the twentieth century TB and the various interventions designed to control it have been and keep being rediscovered as novel. Any progress made is lost as we start over and over again. I examined this phenomenon by first looking at race and TB in the decades before World War II. Focused primarily on indigenous or “native” peoples in the US and Canada, parts of east Africa, and South Africa, this section of the book demonstrates the repeated discovery of TB among these populations and the quickly and crudely applied claim that race was the reason for so much TB. Eventually, in part as a result of the introduction of the x-ray (and especially its mobile version), it became clear that these populations resisted TB as well as white people. Poverty became the explanation for TB. The book next moves to the post-war period and discusses in detail the mass BCG campaign and the roll out of antibiotics. Both, for reasons made clear in the essays, failed. Next, Discovering Tuberculosis moves to HIV and its effect on TB, principally though not exclusively in eastern and southern Africa. These chapters are concerned with trying to explain why, at the very beginning of the epidemic, institutions like the WHO considered TB and HIV in tandem; then separated them; and then joined them again in the second decade of the twenty-first century.
As I noted in the book it was not until I had really dug into the material on TB and HIV that I began to see this process of rediscovery. I became increasingly incensed when reading, for example, documents collected in the WHO archives on chemoprophylaxis from the late 1980s and early 1990s — documents that made clear that the WHO and the researchers they supported recognized the synergistic relationship between HIV and TB. It was evident that the recent interest in TB and HIV (witness the Centers for Disease Control’s move this year to consolidate TB and HIV into one unit, the Division of Global HIV and TB) were a rediscovery of a problem abandoned in the mid-1990s. I realized that much the same thing happened with drug resistant TB: many people identified the problem as quite serious in the 1960s; very little was done. Then the problem was rediscovered as if new in the early twenty-first century.
Much of the problem, as Joanna Radin made clear to me, stems from the “dangers of confusing partial knowledge for total knowledge.” When looking at race, drug resistance, and TB/HIV, people thought they knew more than they did. The claim, for instance, that chemoprophylaxis for TB in HIV+ people was not cost effective was a claim based on little actual data and a lot of assumptions. Arguing that race explained susceptibility was done in the near total absence of any epidemiological work on the populations subjected to such claims.
Armed with only partial knowledge, but thinking they were in possession of sufficient knowledge, many TB workers made considerable errors. But this was not the only problem. As I suggest in the book, those in the world of TB control have little or no historical consciousness; they are always on the hunt for the new and novel. This is of course not a condition exclusive to those who work in global health. But that does not make it any less troubling to see things being rediscovered as novel when in fact this is not so. But in explaining all the failures Discovering Tuberculosis so depressingly narrates, David Jones notes I was hesitant to castigate those working in TB control. He’s right: I was much more inclined towards identifying overarching ways of seeing things, such as the near obsession with cost effectiveness that took over global health in the 1990s, than grappling with the responsibilities of individual actors. That said, I agree with David: “If we, as a global population, are ever to succeed against tuberculosis, individuals and institutions will need to take responsibility for controlling the disease.” Along these lines I do think that the book makes clear that the WHO does bear considerable responsibility for the disasters they had a hand in creating: drug resistant TB and the co-pandemic of TB/HIV.
Speaking of failure: Joanna Kehr wonders if my history of failures, if it is to meet its goal of helping people to transcend rather than nurture failure, must be predicated on a notion of progress. Do I, like Karl Popper, Kehr wonders, believe that we can learn from mistakes and make progress? I suppose that I am, perhaps naively, hopeful. But does this contradict my book? Is my hopeful belief in the possibility of progress at odds with the cycle of failure I chronicle? Perhaps. But as I make clear in the book I am not offering an ending; the book marches right up to the present moment (or the moment when I had to turn the book into the press) and purposefully does not make a claim about the irreversibility of the history I’ve written. I’m content both narrating failure and remaining hopeful. It’s possible that in my hope I am like some of the characters in the book. Yet I’d like to think that I am not, as those in my book are, driven by hope solely as a tonic against despair. Rather, as Erin Koch suggests, I think that recognizing the “tremendous costs of historical amnesia” is a possibility in toning down some of the hubris-driven public health campaigns.
Of the many challenges in writing Discovering Tuberculosis, one of the most daunting was veering into historical and historiographical terrain with which I was almost entirely unfamiliar. As Christoph Gradmann points out, the book is about the twentieth century and concerns itself not at all with the rather more well-known history and historiography of TB, and other diseases, up through the advent of antibiotics. As such, it’s a story that has more in common with Randall Packard’s work on post-World War II malaria control than it does (as David Jones notes) with Thomas McKeown’s on the decline of TB in England and Wales. Gradmann helpfully makes clear that much of Discovering Tuberculosis is about the “erosion of the notion of tuberculosis as a social disease in favor of approaches driven by pharmaceutical technology.” This process of erosion could only happen after antibiotics. While I did not put it nearly as succinctly in the book, Gradmann is right. But to come to such a conclusion meant stepping into a field — medical history — which I previously knew nothing about. (My first book is on American Indians and land claims.) I did so with some trepidation and, I hope, a healthy does of respect for the work that has come before mine. It was only after familiarizing myself with the field that I learned that a book on TB in the post-war period was necessary.
Yet, I was not only venturing into medical history. Niels Brimnes points to what was one of my biggest concerns when working on the book: would I mangle, oversimplify, simply get wrong, or what have you the many local histories I would necessarily skirt over as I attempted to write a global history? Luckily, Niels seems to think the book came out okay, but still asks, rightfully, what is missing when a book like mine so casually considers something like Kenyan independence? Niels asks, “Would a more conventional perspective, which would embed TB control more firmly in Kenyan history, have revealed that even if the TB experts did not mention decolonization, it still had a profound impact?” It’s an excellent question. And Niels is surely right: something is lost in the transnational approach. National structures are critical to understanding TB control on the ground in a place like Kenya and I would be delighted to read a more locally nuanced version of the story. There were times, in fact, when I was concerned that I was not going deep enough into the local or national context — when it came to American Indians, for example, as this is the field I knew best when embarking on this project. Was I helping readers enough to understand the context for the BCG trial? Should I say more about reservation conditions or the reforms instituted by John Collier, the Commissioner of Indian Affairs, in the 1930s? I chose to be as superficial with American Indian history as with others! That choice could have been a mistake. There were times, too, when I wanted to say more about something local and simply did not have the time or resources to do the research. I wrote in some detail about a successful TB control program run out of the Kibongoto Clinic in Tanzania in the late 1950s and early 1960s. But everything I knew about it came from the published medical literature rather than archival sources — sources that might have revealed details that would have allowed me to say something more substantial. Because it was so unique and so successful I wanted to know more. But, alas, it was not to be.
Again, I am grateful for the thoughtful commentaries on my book. Each of the essays displayed a careful and thorough reading and offered me much to think about.
Christian McMillen is professor of history at the University of Virginia. In addition to Discovering Tuberculosis, he is the author of Making Indian Law: The Hualapai Case and the Birth of Ethnohistory, as well the forthcoming Pandemics: A Very Short Introduction.