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Awakenings

2016-05-25 05:00:19

By Bharat Jayram Venkat

Tuberculosis is curable.

Figure 1: Propaganda materials rehearsing the curability oftuberculosis are produced by a variety of institutional actors acrossIndia. From left to right: poster from Christian Medical College,Vellore (accessed via US National Library of Medicine); logo fromGovernment of India’s Revised National Tuberculosis ControlProgramme (RNTCP); and poster from a series developed by theIndian Development Foundation, an NGO.

But what if it isn’t?

Figure 2: Clippings from Indian newspaper reports on theemergence of totally drug-resistant strains of tuberculosis in India.

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What would it mean to awaken to a post-antibiotic future, to a world inwhich the promise of cure has come undone? In December of 2011, atwo-page letter appearing in the journal Clinical Infectious Diseasesthreatened to rouse even the deepest of sleepers from their reverie. In theletter, Dr. Zarir Udwadia and his team at Mumbai’s P.D. Hinduja Hospitalannounced that they had identified the first cases of totally drug-resistanttuberculosis in India.

“You write a good article, four to five people will ask you for reprints and itdies its natural death,” Udwadia told me when I met him in his clinic in thesummer of 2015. “But this,” he said, referring to his letter, “this just tookoff. Suddenly, drug resistant TB was on everyone’s radar. The papersdidn’t stop. It appeared on the front page of the Times of India. It ended upon the BBC, the Lancet, the British Medical Journal, Time Magazine. Haveyou seen that Time Magazine cover?” Udwadia stood up and began riflingthrough a drawer. “Somewhere here…” He pulled the magazine outtriumphantly and laid it in front of me. “There we are! One of our patients,”he explained, pointing to the cover. “It’s quite haunting.”

Figure 3: Time Magazine cover from March 2013. Photo of Indiantuberculosis patient taken by James Nacthwey.

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The photograph in question draws in close to a man’s face. He looksaway from the camera, his eyes wide open. His hair falls like straw ontohis forehead, and one hand holds in place a gingham cloth wound tightlyaround his mouth (pulmonary tuberculosis patients are often warned tocover their mouths to avoid infecting others). Quarantined behind theyellow prison bars of the word CONTAGION, the man in the photograph isgraphically figured as a threat – as a carrier of an incurable bacterial strainthat “threatens us all.”

Indeed, the idea of India as an exporter of disease is nothing new. As farback as the 1860s, commercial interests clashed with epidemic fears indebates about the mandatory inspection and quarantine of ships settingsail from India. More recently, we can hear this threat reverberate in the quarrel between the Indian National Center for Disease Control and The Lancet over the naming of a highly-mobile “superbug” after the city ofNew Delhi. With regard to tuberculosis specifically, we might consider the case of an Indian woman who was found to be carrying an extensivelydrug-resistant strain of the disease while visiting relatives across theUnited States in 2015. The fact that resistance spills over geopoliticalborders means that an India after antibiotics might easily cascade into apost-antibiotic world.

Similar to the promise of cure, the threat of resistance opens up anuncertain temporality of anticipation and trepidation, of speculative futuresthat may or may not come to pass. Such futures have been long in themaking. In particular, the history of drug resistance in India stretches backto the country’s first antibiotic trials in 1950s Madras (now Chennai).These trials produced a subset of drug-resistant patients, but the story thatcarried the day was that a combination of antibiotics provided on anout-patient basis constituted a self-sufficient mode of therapeuticintervention. Those minor voices that preached forbearance failed todampen the enthusiasm surrounding this new class of drugs. A diseasethat had plagued humanity since antiquity might finally, it was thought, beput to rest.

***

Udwadia first encountered resistance at the Parsee General Hospital inMumbai. It was the early ‘90s, and the patient was an 18-year-old mansuffering from hemophilia, hepatitis B and drug-resistant tuberculosis. “Wethrew everything possible at him,” Udwadia told me. Despite his bestefforts, the patient died from exsanguinating hemoptysis: coughing upblood. Prior to the consolidation of antibiotic treatment, the bloody coughwas a widely-recognized sign of tuberculosis.

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Figure 4: In the 1961 Tamil film Paalum Pazhamum (Milk & Fruit),a devoted wife, nurse and research assistant played by SarojaDevi coughs up blood onto her husband’s white shirt, causing himto put aside his cancer research in order to focus on finding a curefor tuberculosis.

As Udwadia reminded me, it had also been “the usual cause of death”among tuberculosis sufferers. In the wake of resistance, historical signs ofthe fatality of tuberculosis were returning. In both symptom and symbol, anIndia after antibiotics might well begin to resemble an India before antibiotics.

I asked Udwadia whether, at the time, anyone had been talking aboutdrug-resistant tuberculosis in India. “It wasn’t seen as a big problem,” heresponded. “Which makes you wonder, doesn’t it? Whether the treatmentwe’ve been getting today has in a sense contributed to this. It didn’tsuddenly just come out of nowhere. It was always there, but it was notrecognized. What I think really stirred things up is when we gave thismoniker of TDR – total drug resistance – to four patients we saw rollinginto this very room. These patients were resistant to all the drugs that ourlab could test”.

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Figure 5: Table enumerating the many drugs to which the patientsdescribed in the letter to Clinical Infectious Diseases wereresistant.

Udwadia’s letter rattled a hornet’s nest in the Ministry of Health, whichdispatched a fact-finding mission to Mumbai. In their report, the teamnoted that many of these antibiotics lacked standardized resistance testsand that TDR was not a recognized classification. According to Udwadia,government officials demanded that he rescind the letter. He refused.

“A lot of good came from that simple two-page article,” Udwadia insisted.In spite of their initial recalcitrance, he explained, the government investedgreater funds into the national tuberculosis program. “The governmentwoke up,” Udwadia told me. “More importantly, people began talkingabout drug resistance. I began to believe in the redemptive power of thewritten word.”

The sociologist Michael Löwy draws attention to a sentence from an earlydraft of Walter Benjamin’s theses on history: “This concept [of thepresent] creates a connection between the writing of history and politicsthat is identical to the theological connection between remembrance andredemption” (Löwy 2005:40). For Udwadia, the word awakens and theword redeems, acquiring a kind of messianic power to bring recognition toresistance. Might his letter constitute, in Benjamin’s terms, the writing ofhistory, a history of failed treatments and subsequent microbialtransformations? In awakening to the recognition that resistance “wasalways there,” might it become possible to redeem the past in service ofthe future? What, then, might therapeutic intervention look like in an Indiaafter antibiotics?

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***

“Back to the sanatorium era!” Udwadia exclaimed with a flourish. Thiswas the title of a talk that Udwadia gave on the lecture circuit. “And attimes, it feels like that. That there are no drugs left,” he told me.

In India, finding hospital beds for drug-resistant patients has becomeincreasingly difficult. A week before coming to Mumbai, I had spoken withDr. Anuj Bhatnagar, a senior physician at the sprawling Rajan BabuHospital on the outskirts of Delhi. Constructed in the 1930s tocommemorate George V’s coronation as Emperor of India, this formersanatorium has become one of the largest tuberculosis treatment facilitiesin the country. Although imperial decoration has been replaced withsuitably nationalist iconography, the hospital still retains elements of itsoriginal open-air architecture.

Figure 6: Photo of TB patients admitted to Rajan Babu Hospital inDelhi (Source: AFP Photo/Chandan Khanna)

A former TB patient himself, Bhatnagar had recently co-authored a paperthat asked whether drug-resistant patients should be treated on anin-patient basis. “Despite the fact that the sanatorium era is over” – hequickly corrected himself – “or deemed to be over, the fact is that a hugegroup of patients require admission.” In recent years, he added, theadmission rates had been quite high. “The patients are havingcomplications from medicines, or from the more severe forms oftuberculosis,” he explained. Bhatnagar told me that he had warned

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government officials that the national program – premised on out-patient,antibiotic therapy – would “either cure a TB patient or turn him into adrug-resistant case. And that,” he said, “is ultimately what hashappened.”

In the most extreme of eschatological visions, a nightmarish future hasalready taken root in the here and now, but we have failed to recognize it.A critical threshold has been transgressed beyond which lies a return tothe dark ages of the pre-antibiotic era.

Figure 7: “We are on the brink . . . If TDR spreads, we will go backto the Dark Ages.”

Put simply, the future is past. By contrast, for those who hold to a faith inthe technological outmaneuvering of nature, the near future still allows forrecalibration. The relation between human and microbe might once againbe set right. The limit to the antibiotic era may have been reached, but ithas not been exceeded. Rather than a rupture with the past, such visionsare suffused by an intensification of a techno-optimistic strain in Indianpolitical thought that can be traced from Nehru to Modi.

More commonly, the speculative futures that emerged throughout myconversations in India espoused a kind of weak eschatology ortechno-pragmatism. The antibiotic era might be over, but antibiotics may

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still have a role to play in the days to come. Such visions diagnose a breakwith a techno-optimistic past, although not necessarily a break withtechnology itself. The critical difference between this moment and anearlier one – a time in which Nehruvian dreams of science for the peopleupheld antibiotics as a magic bullet – is that these drugs are no longerdeemed to be adequate in and of themselves. The dream of antibiotic curehas spawned the nightmare of resistance, and now is the time ofawakening. Here, we might think about awakening in a second sense, an awakening of slumbering potentialities, of forms of dying (coughing blood)and modes of therapeutic practice (sanatorium admission) that had by andlarge been consigned to the past. At the end-of-days of the antibiotic era,remnants of this past are being revived in response to the threat ofresistance.

***

What then might be the role of antibiotics in a post-antibiotic era?

In 2012, the FDA approved the use of bedaquiline, the first new anti-TBdrug in forty years. “We’ve seen dramatic results in patients who havereceived it,” Udwadia told me. Yet, he insisted that bedaquiline was notenough. “When there’s a complete no-hoper, with no chance, resistant toeverything else except for this one drug, bedaquiline won’t work. It’s notas if it’s a wonder drug on its own. We need a whole new regime, and weare a long way off from that.”

“So the drug in and of itself is not useful…?” I began to ask.

“Any new drug on its own will be doomed to failure and will go the way ofprevious drugs. Any new drug.”

“So for the very worst-off of the patients, who have such extensiveresistance, it’s not going to work . . .”

“On its own, no.”

For those patients who have already exhausted the available drugs,bedaquiline was an insufficient response. Many also feared that resistancewould develop against this new drug as well.

Back in Delhi, Bhatnagar expressed to me that he shared this fear. “Wehad this fear that the moment a new TB drug was introduced into themarket, and into unrestricted use, you will have resistance developing verysoon. That’s why the government has very clearly said, no, this will not belicensed for private use in India. If you use bedaquiline with other drugsthat are failing, then obviously, you will lose bedaquiline too. If you ask me,

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if you use bedaquiline without finding the right combination, you’ll startseeing patients with resistance to it within 2-3 years. I’m afraid of that.”

Bhatnagar had identified a fork in the road: if such combinations could befound, and if bedaquiline use could be strictly controlled, then it mightprove an effective addition to the therapeutic armamentarium. If not, thenbedaquiline would only spur on the development of further resistance. Aswas the case in the antibiotic trials of the 1950s, it was once againimportant to find effective combinations to avoid, or at least slow down, thedevelopment of resistance. With each new advance, the same questionsseemed to recirculate.

***

One future that Bhatnagar did not anticipate was eradication. I asked himabout a recent draft document circulated by the international STOP TBinitiative that promoted eradication of the disease.

Bhatnagar lightly chided me for my question. “Do you remember thehistory of the development of the BCG vaccine?” Developed in the earlydecades of the twentieth century and rolled-out in one of the largestvaccination campaigns in history, the Bacillus Calmette–Guérin (BCG)vaccine has been found to offer minimal protection against tuberculosis.

“Now I will develop a vaccine and TB will be eradicated,” Bhatnagar said,playfully mocking his scientific forbearers.

“BCG, antibiotics,” I added.

“There’s always been this talk,” he responded. “BCG, streptomycin, thenrifampicin, then fluoroquinolone,” he said, rehearsing generations oftherapeutic ambition. “This talk continues.”

Historically, eradication campaigns have depended on the production anddistribution of effective vaccines (see Jeremy Greene’s earlier post in thisseries). Whereas cure has been understood to operate at the level of theindividual, eradication depends upon the aggregation of individualinterventions in order to produce a population-level effect that is greaterthan the sum of its parts. In fact, eradication should render the question ofcure irrelevant. Yet, through the promissory force of antibiotics, cure anderadication had been sutured together in the therapeutic imagination.

I continued to push. “But do you see an end point? Do you see somethinglike eradication ever happening?”

“To be very frank,” he said, “no.”

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“We are still,” he reminded me, “a significant number of years away fromdeveloping a vaccine. We are still a significant time away from developinga prophylactic medicine. We are still unable to test a regimen that is shortenough for compliance to improve. If someone says, ‘this is a magicbullet,’ I’m sorry, but I would not accept that.”

Back in Mumbai, I posed the same question about eradication to Dr.Udwadia.

“I think eradication is a catchy global mantra that sounds good inGeneva,” he said, “where they never see any TB anyway. It’s a mantrathat doesn’t translate to the real world.”

Yet, dreams of eradication continue to circulate in India alongside thepromise of cure. In December of 2014, at a press event in Mumbai, theBollywood actor Amitabh Bachchan revealed that he had been treated fortuberculosis during the filming of his popular quiz show Kaun BanegaCrorepati. “I used to wake up feeling weak,” he noted. “Today, I amstanding in front of you completely cured.”

In his new role as brand ambassador for India’s anti-TB campaign,Bachchan underscored the affinity between cure and eradication.Tuberculosis, he explained, is a “curable disease and we must spare noeffort to take our country towards the target of zero TB deaths.”

Figure 8: As India’s anti-TB brand ambassador, Bachchan starredin two television advertisements produced by the marketingmasters at Ogilvy & Mather, the communications firm behind the“Incredible India” campaign. In one ad, this former “angry youngman” of Bollywood assumed the role of an auto driver who hijacksa man and woman on their way to the movies, taking them instead

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to the hospital. She has been coughing for over two weeks, shemight have TB, he warns, but don’t worry: with treatment, she toocan be cured. These short clips conclude with the pithy tagline “TBharega, desh jeethega” – tuberculosis will lose, the country willwin.

Bachchan went on to contrast the therapeutic poverty of the pre-antibioticpast with the resplendent efficacy of the present. “Earlier, TB patientsused to be sent to sanatoriums,” he explained. “Nowadays there are goodmedicines. There is nothing more that you need to do apart from takingmedicines on time.” As the line between the pre-antibiotic era and thepresent blurs, Bachchan’s speech represents a recommitment to thepromise of cure. Yet, we might wonder whether such a promise threatensto restore us to our sleep, to a dreamworld in which the therapeutic formsof the past remain dormant and antibiotics retain their efficacy.

Bharat Jayram Venkat is a postdoctoral researcher in the Program inGlobal Health at Princeton University. He is currently at work on a bookmanuscript, India after Antibiotics: Tuberculosis at the Limits of Cure, anethnographic and historical study of tuberculosis treatment in India from1860 to the present. Beginning in the fall of 2016, he will be AssistantProfessor of Anthropology at the University of Oregon.

AMA citationVenkat B. Awakenings. Somatosphere. 2016. Available at:http://somatosphere.net/?p=12333. Accessed May 25, 2016.

APA citationVenkat, Bharat Jayram. (2016). Awakenings. Retrieved May 25, 2016,from Somatosphere Web site: http://somatosphere.net/?p=12333

Chicago citationVenkat, Bharat Jayram. 2016. Awakenings. Somatosphere.http://somatosphere.net/?p=12333 (accessed May 25, 2016).

Harvard citationVenkat, B 2016, Awakenings, Somatosphere. Retrieved May 25, 2016,from <http://somatosphere.net/?p=12333>

MLA citationVenkat, Bharat Jayram. "Awakenings." 24 May. 2016. Somatosphere.Accessed 25 May. 2016.<http://somatosphere.net/?p=12333>

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