Hope, Doubt, Paradox

Tuberculosis is a condition of paradoxes, a condition interweaved with stories of neglect, rediscovery, misconceptions (about why tuberculosis takes hold in some populations more than others, for example), and failures. As Christian McMillen beautifully demonstrates in Discovering Tuberculosis, this is not a novel situation. Tuberculosis and its framings, interventions, and responses, it seems, have always been fraught with paradoxes. This standpoint could be explored from numerous perspectives including, as McMillen examines, the absence of historical consciousness in TB-control arenas; problems controlling tuberculosis at the very moments when anti-tuberculosis efforts gain momentum and attention; and the ways in which biomedical standardization multiplies and increases tuberculosis, despite a relative, albeit misguided (e.g. neglecting HIV/TB and preventative therapies), proliferation of resources marshaled against its demise in the twenty-first century.

The enduring significance of hope and doubt in driving the paradoxes (and failures) of (eliminating) tuberculosis (and TB/HIV) is particularly compelling. Hand-in-hand with despair, skepticism, and optimism, hope and doubt not only shape, but also are integral to, biosocialities of tuberculosis. For example, they have a lot of influence in driving the often large-scale rollouts of experimentation, therapeutics, and their export. Sadly, these practices usually proceed without reliable or sufficient consideration of evidence regarding how things like vaccines, antibiotics, and standardized protocols might actually take hold and take on meaning in what McMillen appropriately refers to as the “real world.”

Let’s take hope. Hope for an effective vaccine. Hope for cures. And, if you are someone like me, hope that those with the social and financial capital necessary to halt and reverse such global health atrocities will acknowledge the tremendous human costs of historical amnesia. Hope (and faith, sometimes blinded by the hegemonic status of biomedicine) has a long and deep history as a driving force in experimentation and intervention. Taking seriously the long view that an historical analysis can provide, it is clear that when it comes to TB control and treatment hope and optimism walk hand-in-hand. But when accompanied by haste and blind faith, even the most well-intended (vaccine) trials and (antibiotic) treatments might translate hope into hubris. In the not-at-all-new world of TB control, hope that is not anchored to the real world leads to hubris, which leads to failure, and thus to a paradox of tuberculosis. What the world (people living with tuberculosis, their families and communities, their caretakers, and so on) really needs are hope-driven experimentation and intervention that start from the ground up, not the top down. Could real-world human beings who are considered from the perspectives of their daily lives be a vaccine against and cure for amnesia-driven global public health hubris?

What about doubt? When it comes to tuberculosis and TB/HIV, doubt tends to walk hand-in-hand with skepticism and despair. Regarding public health this is not necessarily a bad thing. When we are skeptical or have doubts about ethics and efficacy, for example, it can mean that we are taking the lives of real-world people (past and present) seriously and thoughtfully. However, as is the case with hope, doubts about how best to prevent and cure tuberculosis and TB/HIV can work against the most well-intentioned efforts, especially when they are propelled without sufficient knowledge about or attention to the real worlds in which they will be introduced. Sometimes, as has been the case with tuberculosis, the outcome is myopic and reductionist, treating, framing and responding to tuberculosis as if it is uniform (leaving preventative therapies for latent cases and TB/HIV out of global TB efforts) or static. This, too, leads to paradoxical failures of tuberculosis.

Don’t get me wrong. Like McMillen my viewpoints are not intended to simply criticize and dismiss the hard work and well-intentioned efforts of those who have and continue to work against conditions such as tuberculosis. We need biomedical techniques and technologies. We need nuanced and self-aware public health institutions and practices that see beyond questions of cost-effectiveness. But as long as the labors of global public health remain unanchored in the real world — past and present — hubris will paradoxically undermine the potential of hope and doubt in driving ethical and efficacious interventions. I’m optimistic this scenario is possible, but doubtful that it will ever come to be without a long view of history that is anchored in the real world.

Erin Koch is Associate Professor of Anthropology and Co-Director of the Health, Society, and Populations Program at the University of Kentucky. Her research and teaching interests include infectious disease, human-microbe biosocialities, global health discourses and practices, and biomedical sciences and technologies.

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