And not one of these things nor one of these persons is ever quite to be duplicated, nor replaced, nor has it ever quite had precedent: but each is a new and communicably tender life, wounded in every breath, and almost as hardly killed as easily wounded: sustaining for a while, without defense, the enormous assaults of the universe.
—James Agee, Let Us Now Praise Famous Men
GAJANANDIBAI RAWAT1 OPERATES ONE of rural India’s ubiquitous tea stands. A homemade terracotta shingle roof supported by six roughhewn posts, it squats between a pond and a road at the edge of a village called Ambawati. On a cloudless February day in 2012, five or six men and I were gathered there. We were drinking tea and avoiding the midday heat. All was peaceful, almost languid, until Gajanandibai turned a mechanical bellows to kindle the flame under her aluminum kettle. Just then the hot Rajasthani wind blew from the west, engulfing the tea drinkers in sparks and smoke. The sudden atmospheric assault sprang us into action. We coughed and sputtered and searched our clothes for sparks. Most of the men had only one or two sets of clothes, and sparks could burn small holes in cotton or polyester garments. One man instructed Gajanandibai to be more careful as we all fanned the smoky air. Soon things settled back to normal, but Kalyan Singh Rawat kept coughing. He had recently been diagnosed with tuberculosis after finding specks of blood in his phlegm.
Years later, our intense reaction to this everyday occurrence still surprises me. We had responded, collectively and each in our own way, to air and the connections it created to people and the world. Our actions—coughing, patting, fanning, admonishing—worked on bodies and atmospheres to return the sleepy tea stand to its peaceful state. Yet they were temporary. The wind would blow again. Gajanandibai’s fire would occasionally send out smoke and embers. Kalyan Singh would cough more bacteria into the air. Rain would even fall, turning the slip of land to mud. Atmospheres are both the context in which life is lived and the effect of that living. They are the center of this book.
Ambawati is a community of about 1,500 Dalit and Adivasi farmers in Rajasthan’s southeastern corner. It sits nearly midway between New Delhi and Mumbai, is about a four-hour bus ride from Udaipur, and has historically been associated with the nearby small town and erstwhile feudal lordship of Sagwai. For most residents, Ambawati is simply home, but it is also a place where social inequality and public health intersect with TB treatment in rural India. As Adivasis or indigenous people, Gajanandibai and her customer Kalyan Singh were among some of this relatively poor state’s most socially and economically marginalized residents.2 So were their Dalit neighbors, who caste discrimination has historically excluded from participation in many aspects of public life. As people in Ambawati shared their lives and experiences with me, I began to see TB and inequality as diffuse yet intertwined parts of everyday life there. The paired phenomena moved through Ambawati’s social worlds and bodies as atmospheric entanglements, much as the sparked-filled gusts did that day in the tea stall. Furthermore, the entanglement of TB and inequality in Ambawati is as buffeted by health and development policy decisions made in New Delhi or Geneva as it is by lung-irritating dust kicked up by the western wind.3
This book engages the lives of people like Kalyan Singh and his neighbors to consider how people in an out-of-the-way place live with inequality and infectious disease. It shows that TB is inseparably entangled with social and climatic atmospheres. To do so, it reframes how public health and anthropology understand life with TB. Most dominant narratives of TB in public health and anthropology consider TB from the perspective of a pharmaceutically driven disease-control program or as an abject form of suffering connected to social marginalization and poverty.4 TB, however, is far more entangled with life and its effects are more diffuse than these narratives can imagine.5 People in Ambawati know this well.
Indeed, practices of living with TB in Ambawati subsume and evade these frames. Everyday actions at Ambawati’s tea stall, its clinic, and its bedsides and in its fields and forest suggest that life with TB is a complex and moral entanglement with the world of others. Though public health systems tend to reduce TB to a deadly rod-shaped microbe seen under a microscope, Ambawatian action insists on the irreducibility of life with TB to a microbe. TB is a deeply social experience that draws meaning from existing ways of living as it shapes and is shaped by them. It does not override all other aspects of the human experience or reduce human bodies to hosts for microbes. Instead, TB reveals the lifelines and fault lines in social worlds and pharmaceutically organized interventions that attempt to kill bacteria without addressing disease.
The stories of suffering in this book often emerge from a mismatch between health system and Ambawatian ways of imagining TB care and social life. In Ambawati, TB is deeply enmeshed in forms of social living like kinship, lineage, neighborliness, caste, and ritual, as well as broader themes of Indian political life like development, affirmative action, and the fickle pastoral state. It cannot be understood outside these frames. Indeed, powerful accounts of TB-related death or financial devastation often come from public health’s powerful insistence on treating TB through pharmaceuticals alone without concern for the social, economic, affective, and climatic atmosphere in which it occurs.6 By arguing, alongside Ambawatians, that TB is an atmospheric illness, I contend that both social inequality and biological reality matter.
At the same time, TB infuses but does not wholly capture life. When someone is exposed to TB, or sick with TB, or a TB caregiver, or a TB orphan, that is life with TB, but life with TB is not about continually attending to bacilli or constantly being trapped in the mire of inequality. Joyous stories of life snatched from the mouth of death describe neighbors and family members moving through spaces and networks to provide care and achieve healing. These are moments in which care for TB is a multidirectional atmospheric care for bodies in space that attends to suffering and the world in which it exists. As an atmospheric illness, TB infuses life in ways that both are constrained by and exceed social and biological explanations. TB is simply a part of the atmosphere, be that atmosphere desperate, jovial, or mundane.
Atmospheric entanglements are complex ecologies. They enmesh human and nonhuman actors, affects, meanings, and places in sometimes fleeting and sometimes persistent webs of connection.7 They are a constant condition of life, but they only sometimes elicit a response. As they did in the moment at the tea stand, atmospheric entanglements can snap together and fall apart, bringing worlds and lives into being and shattering them. TB, with its capacity to trouble breath, as well as individual and social lives, gathers together a knot of meanings and material things in Ambawati that invoke atmospheric responses from those afflicted by TB bacteria, their community, and occasionally the public health system. Tuberculosis’s combination of lungs, microbes, fear, air, breath, care, pharmaceuticals, ideas about contagion, public health policy, and social relations connects people and things in a living atmosphere of disease, but it also shapes atmospheres of living. Thus, TB’s atmospheric entanglements are useful lenses on the dynamically iterative relationship between biological and social life that influences the distribution and experience of disease. They create what medical anthropologists have called situated biologies.8 A situated biology might foreground how breath, so necessary as a part of life, is made particular to times, places, and people through its entanglement with subjectivity, the body, politics, practice, and even climate. Atmospheric entanglements also help us think about situated biologies across scales that include microbial genetics, muddy roads, lungs, and state- and global-population health initiatives.
Though located in Rajasthan, Ambawati is rather different from the images of deserts, palaces, and land-owning warrior kings that the name might bring to mind.9 The village spreads across a stretch of flat fertile land at the edge of a large forest and ridge of hills. Most people are small-scale farmers with between a quarter and five hectares of arable land and little money in the bank. Their crops of wheat, corn, soybeans, lentils, and occasionally medicinal plants depend on rain and water pumped from deep stone wells. If yields are good, most families can grow enough food to eat for the year and manage their annual expenses, but money is always tight. The Rajasthan government considers about half the families in the village to be below the poverty line and provides subsidized grain and kerosene when it is available.10 When crops and rains fail, many families send a member or two off to work in the city as street hawkers of snacks or as construction workers. Bigger families nearly always have one person working outside the community.11
Ambawati also deviates from the Gandhian and typical anthropological image of an interdependent cluster of homes belonging to groups of people who, as interconnected occupational castes, constitute a fully enclosed economy.12 Though poverty limits residents’ purchasing power, Ambawati is connected to global grain markets and local markets of goods and services. Moreover, it is not spatially unified. Ambawati is one of south Rajasthan’s scattered villages.13 Extending over more than three square kilometers, the village comprises six named hamlets, clusters of between fifteen and thirty mud and stone houses. All but two of these clusters are home to a single extended family each. Categories of neighbor and cousin often overlap.
Ambawatians identify themselves as members of only three castes—Rawat, Meghwal, and Salvi. Members of the Rawat collective, who figure prominently in this book, make up a two-thirds majority in Ambawati. As descendants of people once known to rulers and census takers as Meenas or Bhil-Meenas, and associated with less rigidly Hindu forms of social organization and the forest, Ambawati’s Rawats could take this identity and assert the political status of officially categorized indigenous people. For most of the time that I have known members of this collective, however, nearly all abjured any reference to indigeneity.14 Instead, they worked hard to assert a status as the dominant caste, which they were in numbers, by forging historical and practical connections to Rajasthan’s famous kingly Rajputs.15 These practices were not always accepted by others, and contestations around caste status were pervasive.16 This is particularly important because TB was often entangled with the poverty and marginality that their collective identity politics aimed to eschew. Their Meghwal and Salvi neighbors number a few hundred and also carry a collective history of marginalization due to caste.17 Most own very little land, but some have been relatively successful in accessing low-level public employment through India’s reservation system.18 In Ambawati, the majority of Meghwal and Salvi residents prefer to identify with the political category of scheduled caste, but scholars of caste in India would term them Dalit, a Marathi-origin word meaning “crushed” that describes those crushed or oppressed by practices of caste.19
Regardless of caste affiliation, residents of Ambawati are uniformly marginalized by caste and poverty. Nonetheless, people get by until a catastrophe like TB pushes them to the brink of destruction. In that sense, Ambawati serves as an example of how political and social inequality initiatives in contemporary India have left rural communities, and those marginalized by caste, out of the national story of growth and progress. It is also an ideal place from which to identify what falls outside public health’s vision of TB.
The burden of a global TB epidemic weighs heavily on Ambawati. Though Kalyan Singh was the only person sick with TB at the tea stall that day, seven of his neighbors were also in treatment. Several more were sick but had not yet been diagnosed, and others never would be—dying without a diagnosis. These Ambawatians made up only a small portion of the estimated two million Indians sick with TB that year, but in 2012 rates of TB in Ambawati were about two and a half times as high as India’s national average.20 TB is a social fact of life here. It also shapes life: bodily, social, and atmospheric.
Tuberculosis in Ambawati is a statistical, experiential, and biomedical phenomenon, but these aspects of the disease cannot be separated. In biomedicine, TB is an airborne infectious disease caused by mycobacteria that can afflict most parts of the body. Sometimes the body can suppress them, but sometimes they multiply and spread.21 TB is particularly dangerous and contagious when it lodges in the lungs. There, it can metabolize tissue, reproduce, make breathing difficult, and be expectorated back into the world on coughs and breath. Epidemiologists suggest that, if untreated, a person with active pulmonary TB can infect between ten and fifteen others with whom they have close contact in a year. These are often family members, neighbors, and coworkers who inhale bacteria coughed or breathed out by people experiencing the disease’s symptoms. Tuberculosis makes shared air and shared atmosphere a problem.22
People afflicted by TB lose weight, experience morning and evening fevers and night sweats, cough, have difficulty breathing, and sometimes even cough up blood. Many in Ambawati experience pulmonary forms of TB in this way. They report struggling to breathe, difficulty adapting to changes in weather, weight loss, chest pain, fever, and sadness. It is a slow, debilitating disease that, if left untreated, is deadly. When lodged in other parts of the body, TB can cause infertility, joint pain, and even neurological changes. However, TB’s affliction moves beyond the bodies of people who harbor active bacilli. For those affected by TB through its presence in the body of another, TB is experienced as leaving school, seeking medical and other interventions, spending hard-earned savings, taking on extra work to recuperate lost income, providing care at home, mourning, and collecting medicines from Ambawati’s clinic. Biomedicine consolidates this diversity of experiences as “TB” when the rod-shaped bacilli are present in slides or bacterial cultures and manages them with six months of pharmaceuticals.
Robert Koch, a Nobel Prize–winning German bacteriologist, identified the mycobacterium that causes the disease in 1882 and paved the way for its treatment by antibiotics in 1947. He famously called TB a social disease.23 Indeed, social relations pattern how people interact, whose breath one breathes, who one might go to for help in times of sickness, and how care might be organized or financed. In that sense, a social disease is a kind of anthropological truism. All diseases are social. That this one should be deemed social by the very person who established its biological cause, however, is telling. The anthropologist Erin Koch argues that TB in particular is a threshold from which one might proceed into social and biological worlds and ways of knowing. As a threshold, Koch writes, TB “is the arena in which material, relational, and historical aspects are intertwined, framing the biosocial aspects of this classic ‘social disease’ as ultimately unstable and reconfigurable.”24 In this view, TB is a tangled knot in which technological, biological, cultural, and historical factors surface or submerge, but within most accounts of TB “the social” is never specified. What “the social” might indicate in narratives of TB as a “social disease” is central to interpreting its atmospheric entanglements.
Public health often views the social aspect of TB as related to care-seeking patterns, health beliefs and practices, adherence to drug regimens, and intersubjective stigma.25 In these literatures, the social is social inequality that interacts with biological processes to shape illness outcomes by limiting available information or access to prompt and effective treatment. For anthropologists, however, the social is larger and further reaching. Paul Farmer, one of the first medical anthropologists to insist that TB is an indicator of a dysfunctional twentieth-century political and economic order, argues that TB is a pathology of unequal access to economic and epistemic power.26 Critical medical anthropologists often follow Farmer to point out that tuberculosis is ubiquitous at global scale, afflicting about 10.5 million people each year, but not uniformly distributed.27 Eighty-six percent of people sickened by TB in 2022 lived in South and East Asia (45 percent), Africa (23 percent), and the western Pacific (18 percent).28 Only 5 percent of people afflicted by the disease lived in Europe and the Americas. Such a staggeringly unequal distribution, anthropologists suggest, highlights TB’s connection to racism, colonialism, and neoliberal projects of economic adjustment. For them, TB is not merely a biological phenomenon influenced by inequality. Instead, inequality is TB’s condition of biological possibility.
The social for TB can also describe ways of organizing people and knowledge. Randall Packard’s analysis of the interaction between TB and twentieth-century-apartheid South Africa’s racialized political economy shows how processes of capital accumulation proliferated the disease among laboring Black South Africans and structured what white clinicians and public health workers thought they knew about TB.29 TB’s relationship to societies and ways of knowing organized around inequality becomes even more startling when we remember that TB is, in all but the rarest cases, a treatable disease and has been for more than seventy years. Indeed, anthropologists and historians have shown that infrastructural development combined with pharmaceutical treatment for TB led to the disease’s near eradication in Europe and its settler colonies but left it a major cause of death, despite available pharmaceutical treatments, in countries deemed less developed or in development.30
Finally, TB and the social is of interest to anthropologists because for the last century it has been a locus (and problem) of liberal governance. In settings as diverse as Nepal, Zambia, and Canada, anthropologists have shown that the state positions TB treatment as part of a social contract, both to shore up its power and to train modern productive citizens.31 This impulse to standardize and train citizens through biomedical interventions for TB has grown since global health embraced TB control in the late 1990s, but it has a long history.32 In his masterful ethnography of TB in colonial and postcolonial South Asia, Bharat Venkat has suggested that TB as a social disease authorized techniques of governance that manage access to cure and mobility on the grounds of social identity and social network.33 Thus, Venkat shows that TB governance reinforces social and political differences.
Determinations of what the social might be and why it might matter for TB frame what TB is. They also guide representations of those dealing with it. In all three views of “the social,” the individual and collective aspects of TB create a multi-scalar entanglement. The social can abide in global processes, like capitalism, that drive class inequality. For instance, the social is the many blind spots created by presumptions about patients in TB science.34 It is also the political work that the liberal state does through TB treatment provided to citizens. As a threshold to multiple forms of the social and political, TB becomes a lens on subjectivity. Anthropologists use the concept subjectivity to describe complex, iterative, and simultaneous experiences both of being an embodied actor—with desires and choices that feel as if they originate from one’s self and that orient action in a world of meaning and power—and of being shaped by power so that one’s desires, perspectives, tastes, and even bodily attunements might be the consolidation of a series of circumstances and positions in relation to others and to power.35
In that sense, subjectivity in Ambawati is deeply connected to these multiple social manifestations of TB. First, Ambawatian selves and subjectivities are entangled with global economies that marginalize the rural poor in Asia and orient habits, possibilities, and desires there. Second, they are shaped by public health policies that imagine people as culture-bearing subjects whose “cultures” or “beliefs” guide a reflexive self to make choices that allow it to resist or submit to TB treatment.36 Third, they exist and act in webs of kinship, caste, and governance that categorize individuals in relation to others and to politics. For example, Kalyan Singh shaped his subjectivity in relation to TB and the TB bacteria in his body through actions related to accessing care, taking medicine, sharing narratives of suffering, and submitting samples to diagnostic assemblages. He is an actor and his choices affect the world and sometimes even the material reality of TB bacteria. Similarly, his life and actions are shaped by the TB bacteria that make him cough, require intervention, evade simplistic diagnostic technology, and bring him into contact with uncomfortable regimes of power. Kalyan Singh’s choices, ideas, experiences, and individual meanings are not wholly subsumed by the bacilli and the bacilli and relational webs they create are not wholly determined by his action. As in Kalyan Singh’s experience, the subject (and subjectivity) of TB in this book is a dynamic, iterative one that operates in and is the effect of atmospheres. People make choices within atmospheres, but they must do so within an entanglement of circumstances and meanings that extend far past what any one person or even social assemblage might know.
By approaching TB as an atmospheric illness, we can account for the ways that TB substantiates the larger planetary systems of inequality that engulf Ambawati, while leaving space for the deeply situated contours of that experience in particular entanglements of meanings and bodies. It also allows us to see how meaning and everyday practices of being together move TB between people who have something in common, even if it is simply having been in the same place and time. Ultimately, this book argues that a high-TB-incidence site in rural India is an ideal location to study the embodiment of social and economic inequality through disease and to engage new ways of thinking about TB and the social as atmospheric.
1. Throughout this book I have adopted pseudonyms for everyone. I chose names that seemed to best fit the person’s social identity and age. Similarly, Ambawati, Sagwai, and Sadri are pseudonyms for real places. I do this to protect people’s identities, particularly health workers who might be easily associated with a particular health institution.
2. “Indigeneity” is a complicated term in South Asia, and I use it here with considerable caution. I follow André Béteille in using “indigeneity” to indicate marginality (2006). Béteille and many others—like Baviskar (2006); Chakrabarty (2006); Gooch (2006); Hardiman (2007); and Moodie (2015)—argue that “indigeneity” in South Asia indicates a political form with a set of fantasies about connection to the environment, history, and mobility. For me it is a way of talking about economic and social marginalization and a particular position of social, economic, and environmental difference in the eyes of the broader Indian society and the state.
3. Michael Hathaway has shown that wind is a particularly meaningful metaphor for development and ideological change when considering environmentalist movements in China (2013). I wish to show that other materials and their metaphors do similar work in Ambawati too.
4. For histories of the programmatic management of TB globally, see McMillen (2015). For India, see Amrith (2006) and Brimnes (2016).
5. TB often enters ethnography as an aside or as contextual information. A surprising number of ethnographies of South Asia report interlocutors sick or dying from TB. See Das (2015); Trawick (2017); Piliavsky (2021); and Saria (2021) for a few recent examples. In literature, Aman Sethi’s A Free Man (2011) profiles the life of a TB-afflicted laborer in Delhi, and TB appears in Katherine Boo’s Behind the Beautiful Forevers (2012).
6. For more on the development of this perspective in South Asia, see Brimnes (2016); Harper (2014); Seeberg (2014); and Ecks and Harper (2013). For a important critique of this transition in India, see Banerji (1999).
7. I am particularly inspired here by Nancy (2002); Paxson (2008); Bubandt (2014); Nading (2014); Tsing (2015); Kirksey (2015); Tsing, Mathews, and Bubandt (2019); and many others.
8. According to Margaret Lock and Vinh-Kim Nguyen, “Local biologies refers to the way in which biological and social processes are inseparably entangled over time, resulting in human biological difference” that become “artifacts—snapshots frozen in time of ceaseless biosocial differentiation [in which] individual bodies represent a microcosm of these ceaseless interactions” (2018, 90). The concept of local biology has been fruitfully extended to many facets of medical anthropology (Nading 2017). In conversations about TB, it has been used to understand multiple-drug-resistant TB (Lock and Nguyen 2018), to study the situated laboratory practices that fit TB into categories and localize them (Koch 2011), and to engage the epistemic entanglement of HIV and TB (Engelmann and Kehr 2015).
9. For ethnographies that engage some of these aspects of life in Rajasthan, see Snodgrass (2006); Gold and Gujar (2002); Piliavsky (2021); and Carstairs (1958, 1983).
10. For more on India’s poverty line and the public distribution system, see Béteille (2003); Gupta and Sharma (2006); and U. Rao (2018). For a detailed study on the politics of development interventions in India, see Sharma (2008).
11. In this sense Ambawati is representative of Dipankar Gupta’s Indian village of small landholdings and circulation to and from the city (2005b).
12. Charles Metcalfe is reported, though perhaps erroneously, to have first termed Indian villages “little republics” in a report to the United Kingdom’s House of Commons in 1832. Regardless of origin, the term has been intellectually powerful. For a brief account on these perspectives among colonial administrators, see Srinivas and Shah (1960) For classical studies on these forms of village life, see Wiser, Wiser, and Wadley (2000); Marriott (1955); and Srinivas (1976). One might also consult Marx (1853) on the Indian village or M. K. Gandhi’s Village Swaraj (1962).
13. For other accounts of life in scattered villages like these, see Unnithan-Kumar (1997) and Kumar (1984), among others.
14. Many have become loosely associated with a political movement called the Kshatriya Rawat Rajput Parishad that is affiliated with the Hindu right-wing Bharatiya Janata Party (BJP; Indian People’s Party). This has often led to an alignment with Hindutva values concerning kinship and cosmology, as well as a more neoliberalized view of citizenship. It inflects forms of subjectivity that privilege ritual hierarchy over indigeneity as a source of identity and social value. This is ironic, given that investment in asserting Hinduism indigeneity in India. For more on this, see Sundar (2002). For more on flexible identities in southeast Rajasthan, see Unnithan-Kumar (1997).
15. Srinivas (1959). For a longitudinal view of a similar process occurring a few hundred kilometers north, see Carstairs (1983).
16. There is a massive literature on contestation around caste hierarchy. For some examples, see Srinivas (1952); Cohn (1987); Bandyopadhyay (2004); Chatterjee (2004); and Lee (2021a).
17. New movements like the Meghvansh Andolan have encouraged or remembered solidarities between Meghwal and Salvi groups. For a longer narrative about the complexity of a larger Chamar community to which Meghwals and Salvis in Ambawati once belonged, see Rawat (2011). See also Snodgrass (2006) for a nuanced ethnography of the shifts in social identity in south Rajasthan over the last forty years. The Dalit author and activist Kusum Meghwal has also written of her experience in this community (2019).
18. For more on the successes and failures of these reservation politics, see Jaffrelot (2003); Moodie (2015); and Ciotti (2010).
19. For more, see A. Rao (2009) and Teltumbde (2017).
20. RNTCP 2013.
21. For an important anthropological critique of biomedicine’s categorization of latent and active TB, see Koch (2011).
22. Indeed, the theme for the International Union Against TB and Lung Disease’s 2013 annual conference (the largest annual gathering of TB scientists) was Shared Air, Safe Air. Despite the theme and presentation titles related to it, there was little talk of shared air at the event. There was much concern for pharmaceuticals, though (International Union Against TB and Lung Disease 2013).
23. Feldberg 1995.
24. Koch 2013, 310.
25. For more on public health narratives of social determinants and health seeking, see Craig, Joly, and Zumla (2014); Craig et al. (2017); and Chikovore et al. (2015). For more on social determinants and TB treatment, see Munro et al. (2007) for a systematic review. See Jaggarajamma (2007) and Deshmukh et al. (2018) for Indian examples. For more on stigma, see Daftary (2012); Sommerland et al. (2017); or Craig et al. (2017). For examples of anthropologists who have engaged this conversation, see Rubel and Garro (1992) and Nichter (1994).
26. Farmer 1999.
27. McDonald and Harper 2019; Gandy and Zumla 2003; Kehr 2016.
28. WHO 2022.
29. Packard 1989. For more on TB’s epistemological entanglements, see Engelmann and Kehr (2015) and Farmer (1999).
30. McMillen 2015.
31. Harper 2014; Hunleth 2017; Stevenson 2014.
32. See Porter and Ogden (1997); Engel (2015); and McMillen (2015).
33. Venkat 2021.
34. Keshavjee 2014.
35. For more on subjectivity, see Foucault (1982, 1990, 2009); Aretxaga (1997); Fischer (2003); Biehl, Good, and Kleinman (2007); Good et al. (2008); and Pandolfo (2018).
36. For an analysis of “belief” or “cultural belief” as set up in opposition to biomedicine, see Good (1993) and Farmer (1997).
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