Untimely Morbidities: Tuberculosis, HIV, India by Bharat Jayram Venkat A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Anthropology and the Designated Emphasis in Critical Theory in the Graduate Division of the University of California, Berkeley Committee in charge: Professor Lawrence Cohen, Chair Professor Stefania Pandolfo Professor Xin Liu Professor Pheng Cheah Spring 2014 Untimely Morbidities: Tuberculosis, HIV, India © 2014 By Bharat Jayram Venkat Abstract Untimely Morbidities: Tuberculosis, HIV, India by Bharat Jayram Venkat Doctor of Philosophy in Anthropology University of California, Berkeley Professor Lawrence Cohen, Chair This dissertation traces specific figurations of tuberculosis and HIV in India, stretching from the late nineteenth century, with the inception of germ theory, into the present moment. I consider how tuberculosis and HIV are related, as co-infections but also as conditions that have produced a certain set of analogous institutional arrangements and modes of response in India. In recent years, there have been more new cases of tuberculosis in India than anywhere else in the world. The emergence of HIV in India has only exacerbated this problem. In contrast to the primarily historicist accounts of tuberculosis in Europe and the United States, this dissertation focuses on the ways in which disease and the body can be rendered untimely. I contend that historicism is only one means of approaching the past and ask about what it might mean to approach these conditions in a non-historicist manner. I argue that an examination of the untimeliness of these conditions forces a rethinking of diagnosis, cure, sign and symptom, as well as received notions of certainty and causality. This dissertation begins in the waning years of the nineteenth century by discussing the life and work of a Tamil Christian tuberculosis specialist named David Chowry Muthu. I draw upon Muthu’s extensive medical and metaphysical writings to think about how tuberculosis was diagnosed and treated in the late nineteenth and early twentieth centuries, which was the period immediately following Robert Koch’s proclamation that tuberculosis was caused by bacteria. Muthu’s ideas about causality put him into direct contention with Koch and his students. Muthu’s professional life unfolded in the gap between the proclamation of a bacterial cause of disease and the development of a specific treatment in the form of antibiotics. I consider the possibilities for treating tuberculosis during this gap in relation to the Indian nationalist movement, focusing on Jawaharlal Nehru’s account of his wife Kamala’s death in the Discovery of India, as well as on the correspondences between Nehru and Gandhi on the role of environment in treating tuberculosis. A pivotal episode in the development of a specific cure for tuberculosis was the 1950s Madras Study, which demonstrated the efficacy of home-based antibiotic treatment for tuberculosis. The Madras Study is often recognized as the death knell of the sanatorium movement. I reflect on the Madras Study in order to trace the emergence of mass chemotherapy for tuberculosis. I argue that this specific cure brought with it new figurations of anxiety: treatment failure, the non- 1 adherent patient and drug resistance. I locate the Madras Study within a broader history of specific cures for tuberculosis. I consider how the evidential grounds for what constituted a cure changed with the development of the randomized controlled trial, as well as how previous forms of research and treatment were retroactively denounced as lacking proper grounds. I turn form cures for tuberculosis to the recent development of a “functional cure” for HIV, to consider what we might make of the paradox that HIV has been cured but remains uncurable. I move from the question of cures to the temporally prior problem of diagnosis. Taking inspiration from the Victorian anthropologist Edward Burnett Tylor, I trace the persistence of old diagnostic technologies like x-rays and sputum microscopy into the present moment. I focus in particular on the uncertainty and indeterminacy that suffuse acts of diagnostic semeiosis, as part of a system in which many patients are continuously referred elsewhere or deferred to some point in the future. I examine diagnosis as a process that equally applies to non-human animals, turning to bacterial interplay between bovine, sloth bears and humans. In thinking through the lethality of certain forms of bacterial exchange in the encounters between species, I question more optimistic visions of interspecies relationships premised on companionship and liberal notions of tolerance. In the final sections, I consider the relationship between chronic, curable and terminal conditions. Specifically, I examine the ways in which HIV reshapes the time of the body. I demonstrate how the time of the body is split from itself, as clinicians separate chronological and biological or developmental age in assessing the deleterious impact of HIV and antiretroviral drugs. Working through the figure of natural history, I consider how clinicians chart both the movement of bacterial and human bodies through time, rendering certain kinds of bodies untimely. If the end point of such timelines is death, I argue that such deaths can have very different meanings, as I demonstrate through cases in which HIV-positive patients in South India seem to be asking to die. Despite the hopes that have surrounded all cures for tuberculosis and HIV, these conditions continue to shape the lives and deaths of people in India, as well as many others around the world. I end by asking what kinds of temporal conditions we might expect to see in the near future. 2 For my patti, Muthulakshmi, whose passing was truly untimely For my thatha, T.R.P. Kesan, and my chitti, Sudha, who gave me a home i CONTENTS Introduction: Historical Conditions 2 Two Conditions Historicism and its Others An Overview The Black Doctor 14 A Gap The Zenana and the Germ Formaldehyde and Fresh Air Air and Soil A Model Colony A Protean Disease Mutant Microbial Matter On the Causes of Evil Conclusion: an Alternative Science An Elegy for Kamala 56 Cures 62 Endings lacking Finality Ending 1: A Brownish Transparent Liquid Ending 2: Streptomycin Ending 3: At Home in the Postcolony Berlin, Again 84 ii Survivals 87 In a Time, but not of it Shadows Stains A Poisonous Gift Lethal Exchanges 106 The Dangers of Milk A Final Performance The Ages of the Body 113 Natural Histories Too Small Too Soon Fatalities 126 Heteronomy She’ll never Recover The Spirit of the Juggernaut Dead Elephants and Women on the Battlefield An Unusual Injection A Good Explanation Conclusions 143 Bibliography 146 iii Acknowledgements This work is the product of innumerous wrong turns. I have been fortunate to have many teachers who have helped me to chart these meanderings in order to produce a semblance of order. I would like to thank Lawrence Cohen, Stefania Pandolfo, Liu Xin, Pheng Cheah, Val Daniel, Nick Dirks, Partha Chatterjee, S. Bharathy, Sam Sudanandha, Janaki Bhakle, Marcia Ochoa, Saba Mahmood, Miyako Inoue, Paula Ebron, Barb Voss, Purnima Mankekar, Lynn Meskell, Liisa Malkki and Jim Ferguson. Many parts of this work have been improved in the context of conferences, thanks to the insightful comments of Bhrigupati Singh, William Mazzarella, Naisargi Dave, Charles Hallisey, Hannah Landecker, Harris Solomon, Sharika Thirangama, Anjali Arondekar, Blake Wentworth, Barney Bate, Kaori Hatsumi, Peggy Trawick, Clara Han, Dennis McGilvray and A.R. Venkatachalapathy. I have also had the support of good friends and colleagues, some of whom have read and commented on sections of this dissertation, and all of whom have shown me how to care and be cared for: Janelle Lamoreaux, Mareike Winchell, Ruth Goldstein, Laurence Tessier, Maiko Morimoto, Mara Green, Andy Hao, Krystal Strong, Leticia Cesarino, Bruno Reinhardt, Jeremy Soh, Lyle Fearnley, Patricia Kubala, Neftalem Araia, Dolly Kikon, Nina Aron, Aisha Ghani, Dwai Banerjee, Aniruddhan Vasudevan, Greer Waldrop, Hamsa Subramaniam, Pooja Bhatia, Emily Chua, Irene Yoon, Sophia Powers, Martin Lin, Jessica Ruffin, Margherita Trento, Vivek Divan, Abigail Ellman, Jayasri Pandian, Meena Pandian, Shanta Pandian, Rishi Srinivasan, Amy Rosenthal, Amy Lee, Amanda Lowe, Shamala Gallagher, Jyothi Chandra, Michael Baumgaertner, Katie Bollbach and Meir Alkon. Jonathan Yamakami, you have the most careful eyes of anyone I have ever known. I cannot thank you enough for your patience and your support in reading so many drafts and putting up with so much nonsense. Caroline Park, thank you for keeping my body and soul together for the last seven years, for playing house with me, for reading my work, and for the many warm meals. Thank you to my parents, Venkat Subramanian and Mythili Venkat, for your love and for supporting my decision to pursue an anthropological vocation. Thank you to my grandfather, T.R.P. Kesan, for reading each and every page of this work and refusing to mince words. Thank you also to my aunts, Sudha, Kala and Meena. This work would not have been possible if not for generous support from the Wenner- Gren Foundation, the Social Science Research Council, the Charlotte Newcombe Foundation, the University of California, the Designated Emphasis in Critical Theory at the University of California, Berkeley, and numerous Foreign Language Area Studies fellowships. Finally, and most importantly, I give my endless thanks to all of those doctors, scientists, patients, public health experts, activists and many others, both in India and elsewhere, for providing me insight into life and disease. iv Unhappily, time seems more normative than place. Lyn Hejinian 2001:11 The belief that time is morally destructive is the basis of the myth of the four Ages . In the Hindu view, human beings caught up in the process of time are inherently, naturally inclined to fall prey to evil. The pure creatures of the original Golden Age are not a part of time at all; for them, karma doesn’t exist; they are beyond good and evil.