McDowell, Andrew. Breathless: tuberculosis, inequality, and care in rural India. 272 pp., bibliogr. Stanford: University Press, 2023. $28.00 (paper)

Tuberculosis (TB) claimed the lives of 1.6 million people globally in 2021, 480,000 of them (i.e., nearly a third) in India. The reasons for this shocking statistic are mired in the inequalities generated by poverty, colonialism, and caste. As McDowell explains, ‘TB is not merely a biological phenomenon influenced by inequality … inequality is TB's condition of biological possibility’ (p. 8). Susan Sontag's Illness as Metaphor (Farrar, Straus & Giroux, 1978) famously deals with TB in Europe and the Americas, where only 5 per cent of deaths now occur. We need more epistemologically and ontologically informed work in those parts of the world where TB remains a living scourge. Breathless opens a window onto one such place. The book is based on long-term periods of ethnographic fieldwork among Dalit and Rawat, Meghwal Salvi-caste Adivasi farmers in Ambawati, the pseudonym for a scattered village of some 1,500 people in southeast Rajasthan. In epidemiological terms Ambawati is something of a TB ‘hotspot’. With his in-depth, linguistically sophisticated knowledge of Ambawatians’ life experiences, McDowell provides a useful corrective to global health arguments that TB is simply a matter of pharmaceuticals, standardized treatments, and control. The conceptual scaffolding McDowell uses – ‘atmospheric entanglements’ – reflects TB as a phenomenon enmeshed with multiple human and non-human realities. The seven relevant atmospheric constituents chosen – breath, dust, air, mud, clouds, forests, ghosts – help to frame, while sometimes overwhelming with theory, the human stories that bind these different elements together. The first substantive chapter, ‘Breath’, argues for the importance of breath as much more than a biomechanical means through which bodies live. It presents the story of Siddarth Singh's suspected TB, and three kinds of breath – ‘strength breath’ (dam), ‘life-breath’ (praan) and the tantric invocations carried on ‘respiration-breath’ (sans) – through which his family make sense of and attempt to deal with Singh's condition. The second chapter, ‘Dust’, takes us to a desolate health clinic where Suresh and other nurses contend with the all-pervasive dust that damages both lungs and machines intended to revolutionize the diagnosis of TB. In the chapter on ‘Air’, Khem Singh leaves school in order to attend to the ‘atmospheric care’ (M. Vine, ‘Beyond touch: cultivating caring atmospheres in arid America’, Journal for the Anthropology of North America 22: 1, 2019) of his ailing father. It also reflects on how ‘air’ in Ambawati can be used, particularly by outsiders, as a euphemism for ‘caste’. ‘Mud’ is invoked as both a representation and cause of truncated development and stalled aspirations. Daulat Singh, his family, and the Caucasian anthropologist extricate themselves from Ambawati's mud to visit a TB hospital for treatment during the monsoon. The ‘mud’ metaphor also alludes to assuage sticky institutional inertia with bribes and the way caste pollution, like death, infiltrates the disinfected, mud-free environs of the hospital. Subsequent chapters – ‘Clouds’, ‘Forests’, and ‘Afterlife’ – also contain some fascinating ethnographic material. Cirrus-like yellow clouds called ‘gawada’ have the ability to cause internal knots that block breathing in the morally and/or physically frail. The idea of ‘cloud-initiated breathlessness’ demonstrates the close relationship between notions of body permeability and unusual body–environment entanglements in South Asia. ‘Forests’ introduces us to Devi Singh, a forest resident suffering from multiple drug-resistant TB (MDR-TB). The forest metaphorically helps explain how unfair it is for global health to assume that MDR-TB is the result of patient negligence or biopolitical resistance rather than a tangled, forest-like thicket of factors such as the simultaneous use of different forms of treatment. There is also an encouraging story about the district TB officer validating Devi Singh's MDR-TB treatment by calling it ‘government employment’ and his need to rest as ‘official duty’. The ‘Afterlife’ chapter summons Rai Singh Rawat and his ilk – those who have died of TB in Ambawati but continue to animate its atmospheres as ghosts. The book is extremely well-referenced with unobtrusive footnotes. Despite its rich array of sources, though, there are other literatures that could have been drawn upon, particularly across disciplinary and geographical boundaries where ‘atmosphere’ and ‘breath’ are having cognate moments. Consider, for example, books and articles like Anderson's ‘Affective atmospheres’ (Emotion, Space and Society 2: 2, 2009), Lande's ‘Breathing like a soldier’ (The Sociological Review 55: s1, 2007), Berndtson's Phenomenological ontology of breathing (Routledge, 2023) and his co-edited Atmospheres of breathing (SUNY Press, 2018), as well as Markovic's Atmospheric history of smoking in modern Britain (Bloomsbury, 2025). The latter connects, abstrusely, with the tendu leaves used for bidi (leaf cigarette) rolling that are an important source of income in Ambawati (p. 27) – and a potential source of breathlessness of a different sort. One might also expect, in a book weaving environmental and medical themes together, to have reference to a classic such as Zimmermann's The jungle and the aroma of meats: an ecological theme in Hindu medicine (University of California Press, 1987). Such omissions highlight the breathtaking opportunities for further research collaborations, not to mention action, across land, sea, and air. McDowell won the American Institute of Indian Studies’ Joseph W. Elder Indian Social Sciences prize in 2023 for an earlier, pre-publication version Atmospheric entanglements: caste, contagion, and care in rural India. One wonders whether the word ‘atmospheric’ really adds anything substantive that ‘environmental’ (in its broader senses) would not? But it is the human stories of entanglement that are among the most compelling aspects of this book; they deserve a more than anthropological readership.