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Response to Review of Discovering Tuberculosis: A Global History, 1900 to the Present

I am grateful for the chance to respond to Dr. Vivkek Neelakatnan’s review of my book. It is a respectful, thoughtful, and critically engaged review. I agree with many of his comments; I also welcome the criticisms. I do hope that my comments below reflect my admiration and gratitude for the time and care Neelakantan took to reflect on my book. 

As with other reviews, Neelakantan does not engage with significant portions of the book, preferring to focus on the middle of the 20th century. He writes: ‘McMillen’s aim has been to investigate the missed opportunities of tuberculosis control, especially during the 1950s when multi-drug resistance emerged’. It’s true that I do discuss the 1950s; it’s also true that it’s a critically important decade. But of the book’s 12 chapters only two – one on the global spread of the BCG vaccine and another on resistance to BCG in India – are directly concerned with the 1950s. Other chapters, to be sure, touch on the decade, but they range considerably beyond. For example, the two that deal most directly with drug resistance are really much more focused on the 1960s and 1970s. The first section of the book, on race and TB, is concerned with the period from roughly 1900 to 1945, while the final section of the book is on the 1980s to the present. In other words, Neelakantan’s review is mainly concerned with part two of the book (which is, certainly, the longest section) and then with only a few chapters.

Neelakantan writes, perceptively and accurately, of one of my central goals: ‘The book does not focus on individuals but on institutional structures which enable and constrain decisions and actions of individuals and organisations in TB control’. But he then never focuses on the structure that the first third of the book interrogates: racism. Nor does he spend much time on the final section of the book on HIV/AIDS and TB. I point all of this out not to chide Neelakantan, but to make clear to readers of the review and my comments that the book is about much more than the 1950s. But I also point it out to ask a more general, though in this context unanswerable, question: Why have Neelakantan and others skimmed over critical portions of the book?

There are a series of critiques in the review that I think raise good questions. But, respectfully, they are either questions I was not interested in pursuing or they are questions that don’t seem answerable from the source material I was working in. I would have liked to hear more from Neelakantan about the ‘tenuous link’ I make between decolonization and tuberculosis control in Kenya. I agree that I don’t make much of decolonization, but do wonder what might have been different had I ‘critically interrogate[d] how independence ushered in a new hope for tuberculosis control for Kenya between the late 1950s and 1970s.’ Neelakantan’s comments suggest there’s a story to be told that links decolonization and TB control. I wonder what it is? Further, Neelakantan asks: ‘The monograph does not examine the differences between the Medical Research Council (MRC) and the WHO that impeded commitment to fund TB research in Kenya and South India, or whether a reduction for TB funding in Africa and South India by the early 1960s was symptomatic of the larger Cold War anxiety of post-colonial states jealously guarding their political sovereignty in public health from superpower intervention?’ It’s true. I don’t consider these matters. But this critique feels like a wish for a different book rather than a critique of the book in hand. The Cold War and its influence on TB funding: is there evidence somewhere of a link? Perhaps. Likewise, Neelakantan notes that ‘A good deal more could be said in the monograph about the political landscape of international health during the 20th century, and the way in which the rediscovery of TB during the long 20th century helps historians in understanding the transition from international to global public health, particularly with reference to the Stop TB Campaign.’ As with his critique of my handling of decolonization and the Cold War Neelakantan does not suggest what more could be said that would satisfy him. It’s possible he’s referring to themes discussed in Theodore Brown, Marcos Cueto, and Elizabeth Fee’s article ‘The World Health Organization and the Transition from ‘International’ to ‘Global’ Public Health’ (1a) in which they analyze changes in global health from the 1970s through the 1990s. But it’s not clear. That said, I would be happy to learn how better to position my work so as to have influence over the Stop TB Campaign.

Again, Neelakantan raises many good questions. My overriding interest in this response is to take them seriously while also not appearing defensive. If I have not adequately answered them it is for two reasons: either the source material would not permit me to do so or they are not, to my mind, germane to my arguments. That said, it does seem that Neelakantan has at least partially formulated answers to some of his questions; the language used to ask the questions themselves suggest as much And it is possible that they might reveal serious shortcomings of my approach. I thought a lot about decolonization in Kenya and wondered many times what its affects might have been. I found it had little impact. This does not mean, as I write in the book, that decolonization was not a critically important event. What I was trying to argue was that medicine and politics and so forth had been so cordoned off from one another that TB had become merely a technical matter – which of course in reality it never was and never will be. Many historians have written about disease eradication campaigns and the Cold War, focusing especially on malaria and smallpox. They make clear the connections between control of these diseases and the Cold War aims of the United States and Russia. TB is a different story and while I was cognizant of the connections between malaria, smallpox, and the Cold War I was not interested in, or able to, force TB in to the same narrative structure. Neelakantan’s remarks suggest that both decolonization and the Cold War had an impact on the history of TB control that I do not adequately address. This is certainly possible.

By way of conclusion, let me make clear to readers that Discovering Tuberculosis is about more than the 1950s. My discussion of race, TB, and virgin soil in East Africa, South Africa, and among American Indians is critical to the overall claims of the book. So, too, are the chapters on the TB/HIV co-pandemic since the 1980s. These portions of the book must be considered in more detail in order to grapple with the history of TB control across the 20th century.

My thanks again to Dr. Vivek Neelakantan and to Reviews in History for reviewing my book and allowing me the chance to respond.

Notes

  1. Theodore Brown, Marcos Cueto, and Elizabeth Fee, ‘The World Health Organization and the Transition from ‘International’ to ‘Global’ Public Health’, American Journal of Public Health, 96, 1 (January 2006), 62–72.Back to (1)