Bharat Jayram Venkat. At the Limits of Cure. Critical Global Health: Evidence, Efficacy, Ethnography Series. Durham: Duke University Press, 2021. xiv + 287 pp. $27.95 (paper), ISBN 978-1-4780-1472-0.
Reviewed by Gourav Krishna Nandi (Yale University)
Published on H-Sci-Med-Tech (October, 2022)
Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)
At the Limits of Cure, by Bharat Jayram Venkat, is a compelling narrative of the changing ontology of cure surrounding tuberculosis. Spanning over a hundred years, this book traces the notion of healing and being cured in the late nineteenth century to ways of imagining cure and living with disease in the early twenty-first century. To achieve this methodologically difficult analysis, Venkat expertly weaves archival methods of the historian and ethnographic fieldwork of the anthropologist to tell a powerful story that intersects colonial and postcolonial medicine with knowledge production from the bacteriological revolution to postwar antibiotics and sheds light on the quotidian experiences of patients living with tuberculosis. At the same time, Venkat shows that as physicians developed newer tools and metrics to represent symptoms, illness, and the possibility of cure, everyday practices associated with cure as a category changed over the decades. The singular focus on tuberculosis is useful, especially as the book meanders through a number of dispersed stories to interweave an interesting narrative. The book is divided into five chapters, each of which is partially situated in time and addresses a number of periodized themes. Venkat begins every chapter with a story from a myth or literature or with a highly visualized vignette, which serve as a thematic focus for the questions that he asks throughout the chapter.
However, the particular focus on tuberculosis and the discrete situatedness of the stories leaves a number of questions unanswered for the historian of medicine. The stakeholders of the stories—the patient, physicians, and the state, both colonial and postcolonial—can sometimes appear as universal and non-porous categories, given a particular period. Furthermore, while the story of Dr. David Chowry Muthu, the physician who owned and ran sanatoriums first in England and later in Madras, is compelling, how can we situate his story within the milieu of late nineteenth-century practitioners? Similarly, while chronicity and HIV are alluded to, in what ways can the history of tuberculosis shed light on people living with other illnesses that may have a different history of cure? These questions, however, do not in any way detract from what is a powerful and original narrative in the study of health and illness in South Asia. I believe this book deserves to be in syllabi of both history of medicine and medical anthropology courses.
The first chapter begins with miasmatic notions associated with symptoms of consumption in the late nineteenth century and methods of healing and cure that were pursued by patients and physicians. Situated mainly in colonial South Asia, therapeutic approaches to tuberculosis, even decades after the discovery of the tubercle bacilli, were based on the power of the environment. Treatments were centered within the sanatorium, a colonial medical institution that existed in opposition to the “unhygienic” cityscape in nineteenth-century India. During this period, cure also transformed from healing with the help of nature to a hunt for microbes. This hunt for microbes also transformed the ontology of diseases—if diseases were caused by microbes, surely eliminating them could end diseases. Disease was reduced to its novel causal agents, bacteria, and the notion of cure was transformed into an achievable goal—one was merely waiting for science to develop.
In chapter 2, the book explores the geographies of cure in the late nineteenth and early twentieth centuries and, in doing so, sheds light on the structures of racialized geographies and bodies. Moving the site of analysis from the sanatorium to ships and prisons, the chapter shows that tuberculosis was often addressed as a geographically and racially determinant condition. Whether the patient was European or Indian often shaped "where" their cure was perceived to be located. As the archival records show, the same places could be curative for one person and pathogenic for another. Furthermore, this chapter illuminates the encounter between colonial bureaucracy and the diseased body. If one contracted tuberculosis during a military expedition, was it the responsibility of the state or the patient? What did it mean for the state to be responsible for a disabled employee? Using the archives of an Irish soldier in the British army, Venkat presents the quotidian life of a tuberculosis patient, providing a rather rare glimpse into the life of a patient as well as the lifecycle of tuberculosis, located at the intersections of colonial bureaucracy, relapsing symptoms, geography, and climate. Furthermore, with the onset of capitalist management of time, disease also came to represent a body that was incapable of doing work. In a world that was increasingly run on the labor of colonized bodies, able-bodiedness was intricately intertwined with the notion of being cured. Cure, for the colonial state, came to represent a state of being that was marked by the capacity for labor and production.
Chapter 3 examines the process of establishing scientific and medical discoveries and, using the divergent examples of Robert Koch and the Madras randomized trials, explores the nature of evidence in medicine. While the theatrics and communication of Koch and Louis Pastuer have received significant attention in the historiography of medicine, Venkat’s originality lies in focusing on how they shaped the promise of cure. Furthermore, in the case of the Madras antibiotics trials of the 1950s, cure also decentered the sanatorium from the script of tuberculosis treatment. Antibiotics not only made the promise of cure possible but also, unlike the sanatorium, made cure accessible to poor and working-class patients. At the same time, with the development of new medical imaging and radiological techniques, cure came to be represented by new markers that shaped the choreography of healing and treatment.
Chapters 4 and 5 are centered on rich ethnographic portraits of the quotidian lives of people living with tuberculosis today and the diverse ways they are searching for cure. Chapter 4 focuses on the paradoxes and false dichotomy between being cured and being healthy. How does a patient navigate the symptoms of tuberculosis that reappear months, or sometimes years, after they were declared cured? Was bacteria inside their bodies all along? Or as the book asks, “what does it mean to cure if you can be cured repeatedly?” (p. 167). As the author follows their interlocutors through the cycle of health and illness, tuberculosis seems to present the portrait of a chronic disease.
Chapter 5 ends with a rather somber look on the waning impact of antibiotics, with the prevalence of antibiotic-resistant bacteria. Here, the interviews with Drs. Zarir Udwadia and Anuj Bhatnagar not only bring back sanitorium-style treatment but also bring the state back into the story—this time in the encounter between the dissenting physician and the persecutory postcolonial state. While a move toward sanatorium-style treatment remains an academically interesting problem, a future without antibiotics, which were available to millions of patients regardless of class background, represents a morally frightening situation.
At the same time, there are a number of missed opportunities to further enrich these narratives and tie them with wider events and discourses. For example, in chapter 2, we see the intersections of cure and disability with the history of eugenic thought, which, while it is briefly addressed, could have been explored in more detail. One can conjecture that in this narrative, the ontology of cure might be missing its eugenic history. A number of themes on the nature of time also shaped the meanings of cure, and while they appear throughout the narrative, they could have been brought together to form a broader argument. As Venkat shows, the ontology of cure is explicitly based on particular understandings of time and biomedical futures, and it is perhaps worth asking, how do patients, situated in their complicated cosmologies, make sense of time while living with illnesses? Lastly, tuberculosis as a chronic disease is a theme that would interest a number of historians of late twentieth-century health. Chronicity also opens the door to the intersection of disease and class, which could address questions about the meaning of disease for people whose everyday lives are inseparable from illnesses and for whom clinical encounters are not anomalies but part of everyday life.
Overall, we hear powerful voices from patients, physicians, civil servants, and social workers in Venkat's narratives. Reading as a historian, this book is a great reminder of the power of ethnographic narratives and a great example of how to give richer voices to historical actors and make them more alive. Venkat compellingly shows the embodied experience of contracting and living with tuberculosis. As we are coming to a new stage in the global pandemic, this book can contribute to important conversation about our own approaches to cure, while noting that the concept of cure has been changing over the decades, shaped by contemporaneous technologies and political systems and used by historical actors in diverse positions of power toward their own ends.
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Citation:
Gourav Krishna Nandi. Review of Venkat, Bharat Jayram, At the Limits of Cure.
H-Sci-Med-Tech, H-Net Reviews.
October, 2022.
URL: http://www.h-net.org/reviews/showrev.php?id=57705
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