Critical Global Health: Evidence, Efficacy, EthnographyDurham: Duke University Press, 2021. xiv, 287 pp. (Graphs, figures, B&W photos, illustrations.) US$27.95, paper. ISBN 9781478014720.
Bharat Venkat’s book, At the Limits of Cure, whispers a secret that terrifies modern biomedicine in the early twenty-first century: that there may be no cure for tuberculosis (TB). And more than that, that the concept of cure itself is a slippery and unreliable object of desire, with implications far beyond tuberculosis. To breathe such a secret into wider circulation is to suggest several kinds of limits at once: that there is a limit to biomedicine’s ability to contain infection through isolation in sanitaria, or to cure with drugs, irrespective of context. It is to suggest that TB is less a question of personal failure than one of material, historical, and political economic context: that is, of structural immiseration—that medicine’s self-image of progress must be rethought in the face of antibiotic resistance and that cure might best be thought of not in relation to treatment failure or incurability, but in relation to a more unstable notion of “limit.”
How then to conceive of limits? For example, the limits of biomedicine (to heal), or the limits of the state (to govern), or the limits of science (to know)? I read this book from a perspective situated in post-apartheid South Africa, which has one of the heaviest burdens of TB in the world, and where the history of TB is inextricably bound with forced labour migration from rural areas around southern Africa to gold and coal mines on the Rand over the nineteenth and twentieth centuries. The colonial (and post-colonial) points of intersection (and divergence) between Venkat’s account of the history of TB in India and that of South Africa are powerfully instructive for how modern biomedicine has relied on a global network of institutions, values, techniques, and concepts, to produce knowledge, experimental sites, and extractive labour regimes. We should also ask, therefore, about the limits of comparison—of historical context, of metaphor, and of concepts of body, society, history, and myth that make these analytical moves possible. More importantly, the limits of cure (and what Venkat calls “curative reason”) demand that we link these histories to better imagine alternative ways of dealing with diseases like TB. This is one way to understand the past in the present, looping histories of violence, and the waxing and waning of health and disease.
Each of these limits are centrally at stake in this brilliant book. The approach of the book is part ethnography, part historiography, and part philosophy of medicine. We learn of the history of tuberculosis in India, in its colonial and post-colonial guises, the attempts to develop vaccines and public health programs, and the interconnections between European science and Indian clinical trials. But we’re also treated to a literary analysis of how myth and narrative have been at the heart of all efforts to grapple with TB—not only in Ayurvedic texts, but especially recent pharmaceutical approaches that frame relapse and reinfection as personal failures of discipline or lifestyle. The book flows between ethnographic descriptions, historical archives, and literary examinations of films, classical texts, and popular media, to show how the concept of cure has crystallized during the course of the last 150 years around a set of evidentiary standards, public health commitments, and cosmologies of the body, each of which is less stable and secure than public health institutions would like to admit.
What Venkat aims at, rather brilliantly, is a “critique of curative reason.” The diagnosis is devastating: for biomedicine not to reckon with the limits of the concept of cure is, as Venkat argues in an earlier essay, “to risk falling into a naive empiricism or, what is perhaps worse, a cruel optimism” (“Of Cures and Curses: Toward a Critique of Curative Reason,” Public Culture 30, no. 2 [2018]: 277–822). The critique delivers the insight that cure, for biomedicine, is imagined to be an endpoint, as singular; whereas a reading of cure from, say, an early twentieth century Ayurvedic text, which takes the myth of the moon god Chandran as the central motif, suggests that cure is not absolute—that it is dynamic, multiple, looping, consisting of ”endings lacking finality” (Venkat, Bharat Jayram, “Cures,” Public Culture 28, no. 2 [2016]: 475–497). Venkat’s project, in this book and in related essays, is “to conceive of other possibilities of cure, ones in which we are left without tidy endings. Ones in which, for example, we wax and wane but are not necessarily marked as incurable or chronically ill” (281).
The book’s structure is partly chronological in its history of TB and efforts to combat it in India; but it is also poetic in the way the chapters draw together historiography and descriptive narrative, personal stories and analysis of myth, global exchanges, and national and local specificities. The book is rich, dense, and delicately crafted—a real pleasure to read. My one small quibble, which betrays my interest and location, is its tight focus on India. It excels in its fine-grained attention to archival sources and careful exegesis of clinical trials and mythic texts, and it shows, powerfully, the close knitting of European anxieties and histories with Indian efforts to combat TB. I would have liked a little more analysis of how these histories articulate with southern Africa, where similar colonial anxieties have been at stake, and where metropolitan science and medicine have been equally dependent on colonial visions of an experimental laboratory and a rich source of labour power and natural resources.
At the Limits of Cure is tragically timely precisely because biomedicine and global health are still invested in pharmaceutically and bacteriologically-premised conceptions of cure for TB, even while a new clinical category is now emerging that contains an implicit acknowledgement of the limits of cure. “Post-tuberculosis” has had clinical standards defined, in 2021, and two world symposia, in 2019 and 2023, and is now an object of intense knowledge production and global health politics. Post-TB discourse implicitly acknowledges the limits of cure, even while it holds out the promise of health. Venkat’s critique of curative reason helps to bring squarely into view the question of how else we might imagine cure, and thus, health. It is essential reading for clinicians, public health officials, historians, and medical anthropologists.
Thomas Cousins
University of Oxford, Oxford