No disease has had more influence on the medical social sciences than tuberculosis. René Dubos famously named it a “social disease” and demonstrated its dependence on economic and political conditions. Thomas McKeown used tuberculosis to critique the pretensions of modern medicine, arguing that improvements in socioeconomic status, not medical science, explained the decline of tuberculosis. Yet McKeown’s discussion of decline is deeply misleading. While tuberculosis did decline in western Europe and North America, it never declined on a global scale. One-third of the world’s population has been exposed to tuberculosis and millions die each year. This persistence of tuberculosis requires a new history of the disease, one focused on the recent past that offers lessons for the present. Christian McMillen offers valuable contributions to this goal, especially his arguments about attention and efficacy.
Despite its title, Discovering Tuberculosis, the book spends just a few sentences on Robert Koch and the discovery of the disease. Instead, it is a book about rediscovery, about how each new generation of doctors, researchers, and health officials “discovered” tuberculosis and its possible remedies, while remaining unaware that their insights had already appeared, repeatedly. From the recurring discovery of tuberculosis among American Indians in the early-twentieth century, to the ongoing rediscovery of the myriad challenges of co-morbid AIDS and tuberculosis, physicians have exhibited “remarkable historical amnesia” (174). McMillen does not pull his punches: “Discovering what is old and calling it new is at a minimum inefficient and at worst regressive” (12).
How and why does this happen? Tuberculosis has been a dominant feature of the medical landscape since the nineteenth century. No one in medicine or public health could have been unaware of its challenges. Forgetfulness must have a specific appeal. In Rationalizing Epidemics, I offered a cynical account of the psychology of progressive era campaigns against Indian tuberculosis: “By forgetting, or never even knowing, that past efforts had failed, officials of the progressive era could maintain their enthusiasm for old programs of sanitation and health education. If such efforts against tuberculosis merely ran on a treadmill to nowhere, then this cycle of ignorance and rediscovery prevented government officials from getting bored of the scenery.” Have similar mechanisms been at work in the failed vaccine and antibiotic programs of the late-twentieth century?
McMillen’s analyses of efficacy, meanwhile, revise and extend McKeown’s classic arguments. Even as McKeown critiqued medicine, he told a success story: tuberculosis had declined in England and Wales. McMillen, taking a global perspective, shows that there has not been a decline worth celebrating. McKeown argued that medicine had achieved power over tuberculosis, but it arrived on the scene too late to play a lead role in the decline. McMillen demonstrates that even when physicians and health officials had this power where tuberculosis persisted, they failed to use it successfully: “the period of greatest scientific progress and most robust institutional engagement in the fight against TB was also the time when the disease became more and more difficult to control” (70). This is a history not of medical powerlessness, but of unfilled promises, of control programs that could have been effective, but failed nonetheless.
The narrative of failure forces McMillen to grapple with a difficult problem. He could cast blame widely, from the directors of the World Health Organization to the community health workers who directly observe therapy. But he explicitly avoids doing so: he has empathy for the tuberculosis campaigners and the obstacles they faced. McMillen directs the reader’s attention to the social, economic, and political obstacles that have contributed to the failure of so many programs — the social determinants of treatment access and outcome. While this might be the charitable thing to do, is it the right analytic stance? If we, as a global population, are ever to succeed against tuberculosis, individuals and institutions will need to take responsibility for controlling the disease. We need to hold them accountable for success, without blaming them for failure. We need to master the lessons of the history that McMillen tells so well. If we do, then perhaps some day there will no longer be tuberculosis to be rediscovered.
David Jones, trained as a psychiatrist and historian of medicine, is the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard University. His first book, Rationalizing Epidemics, examined the histories of smallpox, tuberculosis, and the explanations of health inequalities experienced by American Indians. He is now at work on a history of heart disease and cardiac therapeutics in India.