Tuberculosis, Care, and Subjectivity at the Margins of Rajasthan

A review of Troubling Breath: Tuberculosis, Care and Subjectivity at the Margins of Rajasthan by Andrew McDowell.

The dissertation is a timely and valuable contribution to medical anthropology and South Asian studies, as tuberculosis (TB) illness remains a pressing concern in the region. In his dissertation, Andrew McDowell sets out to investigate TB “care” and TB patients’ engagements with diverse modes of care and subjectivities as they unfold at the intersections of local and global, state and citizen, family and individual, body and mind. The dissertation delves into the questions of care as it is projected by state and global agencies, and as local and everyday practices. The work is based on 14 months of extensive fieldwork in rural Rajasthan, in the village of Ambawati, where McDowell closely followed everyday lives of the TB patients and other villagers. He also conducted fieldwork among various governmental, private, informal, and religious institutions, and with actors who are engaged in TB care locally, regionally, and globally. McDowell’s engagement with a multiplicity of actors and local knowledge systems, as well as his attention to minute details, enables him to provide a rich and overarching picture of TB care and afflicted lives in a rural setting in India.

The insightful title of the dissertation hints of the central inquiry of the work – the experience of TB as an illness that troubles one’s breath and relations, putting subjectivities at stake. Following the well-established medical anthropology tradition, McDowell asks what really matters for TB patients in Ambawati at the time of affliction, when life, already precarious, is put at even higher risk? He mostly engages with male patients, which leads him to draw conclusions about familial relations, the role of fathers in the family, and what TB puts at stake for the afflicted families. His accounts elucidate the ways people choose different institutions, and what happens when they come into contact with those institutions. He shows how community and kinship relations, and collective aspirations, come into the picture of affliction.

Likewise, the dissertation usefully makes connections between local and global care by pulling together the analyses of the Indian National tuberculosis program, its global origins and claims, and local failures. Being in the margins, Ambawati residents are failed by the state, in that they do not receive adequate care. However, McDowell remains truthful to his informants, and makes an attempt to demonstrate that efforts are made to provide care by the state workers. This latter aspect is an important insight in the context of a number of writings that tend to quickly write-off or even disregard state care by attributing overarching powers to neoliberalism.

Social composition and transformation of the village are important for understanding the ways in which TB and its care shape the lives of the village and the ways in which Ambawati residents forge claims to the state. Apart from being situated in the region where TB is widespread, Ambawati village is particular in its social structure, where sanskritisation of indigenous communities has been present since 40 years ago, when Meenas have claimed Rawat status. Using caste strategically is a common practice in the village, and McDowell elucidates this with empirical passages on how villagers encounter the state.

The chapters in the dissertation are organized into two parts that engage respectively with “care” and subjectivity, and which are introduced by a prologue. In the prologue to Chapters 1-3, McDowell introduces the structure and governmental mechanism of the Revised National TB Control Program (RNTCP), a program designed to provide free TB treatment for the patients in India and thus facilitate the country’s developmental achievements nationally and globally.

Chapter 1, “The Hospital: Global TB as practiced, accounted and reported and not,” explores the ways in which the governmental TB program discourse is framed globally and the ways it is implemented locally. McDowell ethnographically traces the global ”success” of the program that is validated through statistics and numbers, and his informant’s encounters with the program as he seeks care in a TB hospital. The argument made is that the RNTCP works as a neoliberal mode of biopolitics, haunted by postcolonial nation-state aspirations. Statistical blindness here masks the insufficiencies of care – “transparency is an effective way of secrecy” of the program that disguises those who remain without care or receive it by conforming to corruption (p. 70).

In Chapter 2, “On care communities: Community-based care in a context of direct observation,” McDowell shifts the focus to the local actors in Ambawati as they engage in community-based care. The chapter traces the way TB affliction manifests, is received, and dealt with by the patients, step by step. This is illustrated by an account about Siddhart and his family, who seek care by trying out various health, religious, and political practitioners in order to address the affliction in a utilitarian way (p. 96). Stigma, attached to those who are ill, is connected to the public health sector, which is noticeably non-homogenous (p. 110). While some of the local health workers provide services with superior efforts, even by breaching formal rules in order to assure a better care, others maintain their distance, enticing and reproducing the stigmatization of the patients by the community. By discussing these multiple actors together in one chapter, McDowell argues that community-based care is complex and needs to be rethought by contextualizing it in the existing relationships between and among practitioners and families.

Chapter 3, “Relief, rotation and resistance: Ersatz practitioners, pharmacopeias and patient care in Rural Rajasthan’s storefront clinics,” focuses on unlicensed biomedical practitioners known as “Bengali doctors” and their patients in rural Rajasthan. While rejecting an interpretation of ersatz medical practice as mimicry of ‘real’ doctors, McDowell reads their activity as one that co-produces and takes part in the market of care, effective “hi-fi” pharmaceuticals, the democratization of access to pharmaceuticals, debt, and relief. The desirable outcome for those who are weak and ill in Ambawati is “relief” (p. 137); but it is exactly this practice that alarmingly generates local ecologies of resistant bacteria and resistant bodies in India (p. 141). Providing relief rather than effectively treating illnesses, Bengali doctors share with the patients an understanding of body as a rotation system that combines notions of body inspired by the Classical Ayurvedic philosophy as well as notions of body as a tool of labor and production. The attentiveness, flexibility, and market interest in “hi fi” pharmaceuticals and steroids by such doctors lead them to prosperity and a clientele who prefer to access health through the private market, rather than the state. However, it is not only resistance to the state, but also caste relations and politics of dignity, MacDowell suggests, that play a role in the patients’ choices between the state and the Bengali doctors (p. 163).

Chapter 4, “Authentic forms of poverty:  Subjectivity, assessment, experience and suffering in the context of state care,” brings the reader to the second part of the dissertation that deals with relationality and subjectivities. Through ethnographic accounts that describe the ways in which villagers make strategic claims to poverty by filling in the BPL forms and reselling the grains, McDowell interrogates subjectivity from a Foucaultian perspective, and asks how one can understand subjectivities of the poor in the Indian context, where poverty has become a historical and rigid governmental category. He suggests that subjectivity is a product of the interplay between the governmental definitions and the social and ethical forms of co-presence and sharing. Poverty here is relational, and must be understood as a precariousness through which people steer by making ethical decisions.

The final chapter of the dissertation, entitled “Waiting to exhale: Breath, ecology, violence and care of the self,” interprets breath as an analytical category that gives insights into the subjectivities, life, body and mind relationship. The chapter insightfully draws on the classical Indian philosophical knowledge systems, including Ayurveda, considering local sadhu’s tales and tantric tradition, as well as local people’s narratives of illnesses and injuries brought by clouds. These accounts of local knowledge show that breath and breathing are productive concepts to think about the relation of self and body to the cosmological order, environment, and mind at the same time. McDowell yet again comes into dialogue with Michel Foucault’s perspective on cultivation of self and care of self: rather than developing a political subjectivity, people in Ambawati cultivate a complex relational self in connection to the ecological environment and local moral worlds (p. 241). McDowell uses the concept of “biomoral” to address breath as a substance, interrelated with the ecology and partaking in the relational self-making. As the Governmental RNTCP ignores breath and avoids “sharing it” with the TB patients, its care is death.

In the conclusion, McDowell considers ancestry rituals, performed after the passing away of the elderly males, that open the window for an inquiry of kinship and relations between fathers and sons. The ghosts and their voices that seek to be represented and connect the past with the present raise questions about structure and agency, so longstanding but yet so relevant for the current anthropological analyses on the insurgent world (p. 257). Resistance in Ambawati is not as forthright and recognizable as a conscious action for Aihwa Ong, Jean Comaroff, and Michael Taussig, but may be described as “getting by” and making sense of a precarious world (pp. 259-260).

The dissertation delves into many relevant questions about state and citizenship, care, illness, and body in contemporary India, and the lives of those who are situated in the margins, but who are also interconnected with the global forces. This type of work is of utmost relevance not only for readers in medical anthropology, development, and healthcare systems, but for larger audiences within South Asian studies, a field within which state care and subjectivity are addressed only by a handful of authors. The dissertation also sheds the light on rural settings in India, in this way reminding us of the importance of rural areas in a time when India is reinventing itself through largely urban representations. Finally, McDowell contributes not only to the academic debates and theories – he also remains temperately critical of various modes of care available in the rural India, which likewise makes his work useful for health and development policy makers.

Emilija Zabiliute
Department of Cross-Cultural and Regional Studies
University of Copenhagen
Fjq214@hum.ku.dk, emilija.zabiliute@gmail.com

Primary Sources

Fourteen months of fieldwork among TB patients, governmental, religious and ersatz health institutions and practitioners; governmental offices in rural Rajasthan, India.

Dissertation Information

Harvard University. 2014. 294pp. Primary Advisors: Arthur Kleinman and Byron Good.

Image: Photograph by author.

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