Global Health and Transnational History

It is hardly necessary to note that Christian McMillen has written an enormously important book. The history of tuberculosis control — outside the West and after 1950 — has so far been severely neglected by historians. We know so much about sanatoria and social reform in nineteenth-century western countries, and frustratingly little about the biomedical remedies more recently applied to much larger populations in Asia and Africa. Discovering Tuberculosis goes a long way to fill that gap.

In at least two ways, the book is bold and courageous. By taking the history right up to the present, McMillen enters the uncertain and still developing field of contemporary health policy, ripe as it is with scientific and political tension. “Our stories end,” he writes towards the end of the book, but not this one. The history of tuberculosis control cannot easily be wrapped up. The historian has left his comfort zone, and rather than deciding on the significance of what happened, McMillen needs to reflect on this uncertainty in his brief conclusion.

Also, the book is genuinely transnational. McMillen brings the reader to Kenya, to South Africa, to India, to Indian reservations in the US, and of course to London, Paris, and Geneva, where organizations such as the British Medical Research Council, The International Union Against Tuberculosis, and the WHO had their headquarters. The remarkable ease with which McMillen is able to move from one place to the other, to approach the global network of TB experts from a variety of entry points — one might say that he is treading the paths of the likes of Johannes Holm, Wallace Fox, and Karel Styblo — is one of the major achievements of the book.

The transnational perspective really works when it reveals the connections between the MRC in London and its activities in Madras and Nairobi. And when Johannes Holm turns up as being in charge of BCG vaccination in India in one chapter, while in another he speaks about the shortcomings of chemotherapy in Africa as leader of the IUAT. We understand the nature and the dynamics of the expert networks that made up international health in the 1950s and 60s, when results from a trial in one area are used or — just as often — neglected in another. The fact that McMillen’s history is set in so many locations also enables him to expose with particular force what is perhaps the most severe flaw in modern TB control: that drug resistance was known and debated in Kenya — among other places — in the 1950s, but was neglected in Geneva for decades and came back with a vengeance to create the contemporary global mess known as multidrug-resistant (MDR) TB.

Yet, such achievements of the transnational perspective do not come without costs, and since I have made different — and more conventional — choices in my own writings about TB control, I take the opportunity to ask what might be lost when the historian casts off his or her geographical moorings. McMillen has a chapter on resistance to the BCG vaccine in India in the 1950s (which is based on research McMillen and I did together in very fruitful cooperation). While this is certainly an interesting episode in the history of global TB control and deserves a chapter in the book, do we miss a fuller Indian context of this episode? This is a question worth asking. In a similar vein, I was struck by McMillen’s bold assertion that decolonization was of minor importance to the efforts to develop TB control in Kenya. Could this really be? McMillen is clearly (and rightly) puzzled not to find any references to this substantial political change in the writings of those involved in TB control. But maybe he did not look from the right angle? 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? Put in a different way, I suspect that one of the losses of the transnational perspective — exciting and revealing as it might be — is a solid understanding of the more durable state and public health structures in places like India and Kenya. Even if the transnational is currently in vogue, national structures and their development over time might still be important.

Alas, you cannot accommodate all contexts into one account. I am thrilled that McMillen has produced such a bold account that takes us virtually around the globe. The history of tuberculosis control deserved such a book. Now it has got it.


Niels Brimnes is Associate Professor at the Department of History, Aarhus University. He has written articles on TB control and BCG vaccination and expects to publish Languished Hopes: Tuberculosis, the State and International Assistance in Twentieth-Century India with Orient Blackswan in 2016.