In the fifteen years following World War II more was done to combat tuberculosis than at any other time in world history. On every continent, hundreds of millions received the BCG (Bacillus Calmette Guérin) vaccine and millions more benefited from newly discovered antibiotics. TB research and attempts to control the disease knit together disparate populations and places as a network of experts and a matrix of ideas spread out across the globe linking the world through a common vaccine, a battery of antibiotics, and a knowledge network.Footnote ¹ Medicine became internationalized as organizations like the WHO and UNICEF began to see diseases as global problems and not solely the concern of individual countries.Footnote ²

India, where TB was rampant, was of particular interest. Shortly after independence, in November 1948, it became the first developing country to enter into an agreement with the “International Tuberculosis Campaign” (ITC), a vaccination initiative run by Scandinavian Red Cross societies, supervised by the WHO, and funded by UNICEF.Footnote ³ For three years the ITC ran a BCG demonstration project in India. In 1951, just as the BCG campaign was set to expand across the country, and the ITC's work was drawing to a close, ITC Director Johannes Holm wrote: “India is in a key position as regards BCG vaccination in the Far East. If a mass campaign could be successfully carried out there, neighboring lands would realize that campaigns were possible in their countries too. On the other hand, if a mass campaign failed in India, it would be most unlikely that other countries in that part of the world would embark on mass campaigns for many years to come.”Footnote ⁴ The WHO and UNICEF had so little experience with mass campaigns in developing countries that they dreamt up the imaginary Southeast Asian country of “Hypothesia,” and designed mock plans for a mass campaign there.Footnote ⁵ Elsewhere, the doctor who carried out the WHO's first African TB survey in 1953 wondered in amazement at “how much the Organization and the world in general would profit scientifically and practically from such work in the ‘terra incognita’ of Africa.”Footnote ⁶ The postwar rush to develop mass-vaccination campaigns in most of the developing world was thus a vast global experiment carried out by an organization with little experience in the work at hand.

The campaign can be looked at in conjunction with other mass campaigns, like that against malaria. Hubris and hope characterized both, as did a fascination with technological solutions. Those working in the world of disease control were optimistic that TB could finally be confronted and defeated. And while the push for eradication of TB was never adopted as actual policy, as it was for malaria, there were those who began to see that the technology available to control TB could actually eradicate the disease, especially after it was decided that the BCG vaccine was efficacious, and antibiotics were discovered. Only six years after the events described here, Fred Soper—famous for his efforts to eradicate malaria—declared that TB could be wiped off the face of the earth. When people finally accepted that TB “was no longer a social and economic but rather a public health and medical administrative problem” it could be done away with.Footnote ⁷ Others, like Carroll Palmer of the U.S. Public Health Service and chief of the WHO's TB Research Centre, and James Perkins, President of the National Tuberculosis Association, were not as convinced as Soper that social and economic aspects of TB were unimportant, but they, too, talked about eradication. Perkins challenged the WHO at an international symposium on TB to take on the task of tackling the disease, just as it was doing with malaria.Footnote ⁸ Though some, contra Soper, continued to see TB as a social disease, most shared a commitment to finding a technological solution that would bypass social and economic forces, and almost everyone agreed that such a solution was within their grasp. Social medicine had little chance in the face of the growing power of biomedicine.Footnote ⁹

The BCG vaccine was one such solution. For many years, because of concerns over safety and efficacy, BCG had been controversial. It was not until the late 1940s that it was found to be at a minimum safe and in some trials—most notably among American Indians—effective.Footnote ¹⁰ But BCG had never been used in the developing world on the scale contemplated in India. The British had been leery of using it in the colonies and only agreed to do so, in East Africa and British Guiana, for example, after the publication of the American Indian results.Footnote ¹¹ Lingering fears about the vaccine's safety, doubts about its efficacy, and uncertainty that a mass-vaccination strategy was right for India plagued the program from the beginning. These doubts and fears, some well considered and others ill conceived, became the bases for a robust, and highly critical Indian response to the mass campaign. While there was also opposition elsewhere—in Iraq, Vietnam, and Mexico—the anti-BCG movement in India became more significant than any of these. It lasted longer and reduced significantly the number of vaccinations given.Footnote ¹²

By framing our case study as an example of medical modernization and medical nationalism, we join historians Randall Packard, Sunil Amrith, Sanjoy Bhattacharya, and others who have investigated similar topics. While “modernization” has become notorious for its multiple meanings,Footnote ¹³ we use it here to refer to a constellation of ideas and institutions that had their full fruition in the 1950s and 1960s, which worked to transform societies perceived to be bound by religion or tradition into ones that were secular, rational, scientific, and progressive. We employ the word as did planners, doctors, bureaucrats, and others involved in modernization through medicine.Footnote ¹⁴ Medical modernization was to be accomplished through central, bureaucratically managed planning. But the mass BCG-vaccination campaign did not attempt, as some would argue for modernization more generally, to harness the power of the state and the power of technology to forcibly reorient traditional societies into modern ones.Footnote ¹⁵ BCG vaccination was not aimed at restructuring traditional into modern life, and yet it infiltrated daily life as a conduit for modernity. The mass campaign worked, not necessarily purposefully or consciously, to reorient peoples' relationship to medicine in ways that juxtaposed the old with the new. Walsh McDermott, a prominent expert on TB and international health, noted in the first International Lectureship given at the National Institute of Health in 1963 that biomedical research and interventions were crucial to what he called “planned modernization.”Footnote ¹⁶ For McDermott, and others, “purposeful modernization,” was “the major social movement of our times.”Footnote ¹⁷ Biomedicine was at the heart of the movement.

The vaccination campaign provoked an eruption of medical nationalism because it was, very obviously, an example of one hallmark of modernization in postcolonial areas: the application of outside knowledge via outside experts to solve an indigenous problem. The argument that the BCG campaign was flawed because it was foreign was persistent and important, if never unambiguous. Those who opposed mass BCG vaccination with nationalist rhetoric did so because they felt that the Indian state had, by accepting a dubious and cheap remedy, betrayed the nation and the values that had been invested in the struggle for independence.

Ours is a detailed look at an early postcolonial response to a large-scale medical intervention. All case studies are unique in their own way; the personalities involved here are peculiar to India. But the larger issues are transcendent: debates over the suitability of large-scale vaccination campaigns, fears over experiments on children, state intervention in daily life, and the emergence of a supra-national order embodied in the WHO and UNICEF. The events related here are responses to a development that encompassed the entire world.

THE CONTROVERSIAL BCG VACCINE AND THE PROBLEM of VACCINATION

By introducing mass-vaccination with BCG, the Indian authorities and the Scandinavian experts chose a controversial remedy. Used on humans since 1921, BCG was the first vaccine based on attenuated live bacteria. Some experts feared that the vaccine could cause the disease, or at least invigorate a “dormant” infection in the body—doubts amplified by a tragedy in Lübeck, Germany, in 1930 when seventy-six infants died after vaccination. (Later investigations concluded that unattenuated tuberculosis bacteria had been injected by mistake, and cleared the vaccine.Footnote ¹⁸) From about 1940 most experts agreed that BCG was safe, but uncertainties regarding its efficacy lingered into the postwar period. By the late 1940s, France, Spain, Eastern Europe, and Russia had adopted BCG to various degrees, but it was in the Scandinavian countries where the vaccine was most widely used.Footnote ¹⁹ Skepticism prevailed in Britain and the United States. Doubt was cast on BCG's efficacy, and it was seen as a prophylactic suitable only for heavily exposed groups—nurses and relatives of infected individuals, and, on a large scale, American Indians, people in war ravaged areas, and the poverty-stricken masses in developing countries.Footnote ²⁰

The Indian anti-BCG movement was neither anti-Western nor anti-science in any simple sense. To the contrary, its leaders were steeped in Western bio-medical science, and they routinely cited the medical community's lingering doubts about BCG's efficacy as a way to bolster their cause. Rather than being anti-science, the anti-BCG movement was a reaction to what some thought was a second-rate solution to a serious problem—a cheap, potentially unsound vaccine in lieu of substantial infrastructural changes that would appreciably improve health and thus tackle the causes of TB.

This set of critiques—particularly that BCG did nothing to address the root causes of rampant TB, but was merely a technological fix—presages the debates that began in earnest in the mid-1970s and continue to this day over the efficacy of horizontal versus vertical health care interventions, and the testing of drugs in the developing world.Footnote ²¹ The public battle over BCG in the late 1940s and early 1950s highlighted two very different approaches: those in favor of BCG argued that something had to be done immediately, and that vaccination was the most efficient approach. Those opposed claimed that improving quality of life was the best solution.Footnote ²²

The anti-BCG forces that emerged in India were neither the first nor last eruption of anti-vaccination sentiment in the country, but rarely have such sentiments generated such a well-articulated and ideologically informed counter-campaign. Resistance to smallpox vaccination, for example, appears to have been only local and episodic.Footnote ²³ In postcolonial India, particularly in the 1970s, compulsory vaccination sparked resistance linked to larger political debates, but according to Sanjoy Bhattacharya it was relatively easy to isolate.Footnote ²⁴ In one of the best-known studies of resistance to vaccination, Paul Greenough charts only local and spontaneous resistance, and suggests that in the final stages of the smallpox eradication drive resistance to vaccination was never allowed to become significant.Footnote ²⁵

The history of vaccination in India is quite rich but so too is its history worldwide. Take a brief look at Africa: We find ample documentation (but a small historiography) from as early as the beginning of the twentieth century of vaccination campaigns there perceived as both coercive acts of the state and miracles of modern medicine, and indeed the two can be in tension in the same place.Footnote ²⁶ The author of the WHO's first African TB survey, conducted in 1953, worried that this past history had soured people on vaccines and that any mass campaign would have to overcome enduring fears.Footnote ²⁷ Likewise, there is evidence that more recent campaigns have been fiercely resisted, feared, or re-imagined based, in part, on past experiences with vaccination.Footnote ²⁸

WHY INDIA

Good timing brought about a sea change in India's TB-control strategy in the late 1940s: political independence and new possibilities for assistance in international health put India on the path to a major assault on the disease. During the first half of the twentieth century, Indian and British public health authorities gradually identified TB as a major health concern in India. By mid-century there were an estimated 2.5 million active cases of TB and half a million deaths annually.Footnote ²⁹ Before 1947 TB control was based on educating the public in hygiene and treatment through dispensaries, while the number of sanatoria was vastly insufficient.Footnote ³⁰ When the BCG vaccine appeared in the late 1940s, the Indian government found it appealing because it promised to reduce TB incidence by up to 80 percent.Footnote ³¹ It was also cheap. In a May 1948 press note announcing the mass campaign, the Government of India explained that such a scheme would “be a cheap and effective method of reducing the incidence of tuberculosis which is assuming epidemic proportions at the present moment in the country.”Footnote ³² As a technological solution to the TB problem, BCG not only promised to circumvent the social dimensions of the disease, but it also appealed to the modernist pretensions of Nehru's India—pretensions that insured a technological fix was at a minimum appealing.

With the emergence of organizations designed to promote international health, BCG had now become a realistic option. With support from the WHO the Government of India established a BCG laboratory at the King Institute in Guindy, just outside Madras, which began producing vaccine in August 1948. The first BCG vaccinations in India followed in Madanapalle, a rural location a few hundred miles away.Footnote ³³ In November India became the first non-European country to enter into an agreement with the ITC, which marked the beginning of a two and a half-year-long, countrywide demonstration campaign. Controversy quickly followed.

A. V. RAMAN'S CRUSADE AGAINST BCG

The BCG campaign was set to begin in Madras in early 1949. It was challenged immediately. Former sanitary engineer A. V. Raman began publishing one critical editorial after another in his monthly magazine Peoples' Health. Over the next two years, ITC international staff and the authorities in Madras faced crippling counter-propaganda from Raman and his supporters.Footnote ³⁴

Raman was already a vocal critic of the government. In the November 1948 issue of People's Health, before ITC personnel had even set foot in India and possibly before the agreement between the ITC and the Government of India was signed, Raman attacked the Union Government's general health policy.Footnote ³⁵ He accused the government of favoring “technical” solutions, arguing that it ought to give priority to sanitary reforms: clean drinking water, proper housing, and sewage. Among the “technical” solutions he vilified was BCG:

BCG vaccination was nothing but a cheap and inferior pseudo-solution, or, as Raman phrased it, “If in this way we devise what are triumphantly devised to be short cuts through which to eradicate diseases, we would be deluding ourselves and deluding the public. Cheap things are not always good or safe. Cheap things are mostly nasty.”Footnote ³⁷

The formal inauguration of the ITC's campaign in Madras was planned for 15 February 1949, but as the date approached Raman's opposition to BCG vaccination emerged in newspapers throughout India.Footnote ³⁸ On 4 February he addressed a scientific society in Madras, and targeted BCG and invoked the uncertainties surrounding it: “I strongly protest in the name of India … against our boys and girls being made a sort of cannon-fodder and treated like guinea-pigs for the sake of experimentation.”Footnote ³⁹ By referring to articles critical of BCG from scientific journals in Britain and the United States, Raman adroitly exploited the existing disagreements over the vaccine's safety and efficacy, a tactic particularly visible in a lengthy piece he published on 14 February in the important regional newspaper the Hindu. Finally, he doubted the good results claimed for BCG in the Scandinavian countries.Footnote ⁴⁰ Raman ended his article by quoting the Swedish Professor Arvid Wallgren—a renowned TB specialist and a member of the ITC's Coordinating Committee—to the effect that Sweden would not do trials with BCG because it would be too risky to leave any children as an unvaccinated control group. Instead, such tests had to be undertaken in areas “…where BCG vaccination was not prevalent and looked on with suspicion.”Footnote ⁴¹ While Wallgren's statement supported Sweden's strong belief in BCG, Raman misrepresented him. He linked Wallgren's comments about a Scandinavian trial to the fact that BCG trials had been conducted on American Indians in the United States, and concluded that Indian children were intended to be guinea pigs for a dubious vaccine: “The research workers in BCG had conducted experiments on guinea-pigs, calves and on American Indians. What the research workers are now after is to get a wider field for conducting their experiments! … I am driven by the irresistible conclusion that the authorities are exposing the people of this country to be utilised by research workers for their benefit. Guinea pig experiment is no good; man is necessary.”Footnote ⁴² With its allusions to ill-conceived foreign schemes, Raman's rhetoric was compelling in a country that had recently won independence. P. V. Benjamin, TB adviser to the Union Government, had to urge people to treat the foreign experts with more dignity. They were, as he put it, “on a mission of mercy.”Footnote ⁴³

People's Health continued its campaign by bringing to its readers the latest information on BCG, made possible by fast transmission of medical information to southern India.Footnote ⁴⁴ Particularly important was research conducted by Carroll Palmer. Palmer had overseen the final report on the American Indian BCG trials, and ran the WHO's Copenhagen-based Tuberculosis Research Office. Especially valuable ammunition in the fight against BCG was Palmer's admission that, “Strict scientific proof of the effectiveness of BCG vaccination in the control of human tuberculosis is not available.” To this Raman readily added that Palmer's “opinion cannot be brushed aside as ‘uninformed criticism’ nor [can] the expert advisers of the Ministries of Health, Provincial and Central, continue to assert that BCG vaccination has transcended the stages of experimentation.”Footnote ⁴⁵ The uncertainties that continued to surround BCG among medical scientists allowed Raman to suggest that BCG was still in the experimental stage. By deploying expert opinion to support such a claim, Raman hoped to convince his readers that the vaccine should not be introduced in India except for limited and controlled experiments.

Raman used his extensive references to the scientific literature to position himself as a believer in Western scientific medicine. As early as 1946, he considered ill advised the demands from various quarters of the nationalist movement that India design its future heath system according to indigenous traditions like Ayurveda. Raman critiqued modern medicine, yet he warned against “rushing to the other extreme.” He advised, “A great deal of spectacular progress is being achieved by modern systems of research today, which we can ill afford to ignore. The path of wisdom would therefore lie in our keeping in step with the latest developments of modern thought without necessarily fouling our own nest. …”Footnote ⁴⁶ Raman also wrote approvingly about streptomycin, the newly discovered anti-TB drug.Footnote ⁴⁷ Clearly, he could not simply be dismissed as an irrational critic of Western medicine.

Raman's anti-BCG campaign overshadowed the program's formal inauguration. Instead of celebrating the beginning of a new era in TB control, the speeches and addresses from the Indian medical authorities became defenses of the campaign.Footnote ⁴⁸ Staunchly supporting the scientific merits of BCG, the speakers nonetheless admitted that it had to be part of a broader effort. Thus P. V. Benjamin agreed that better housing and general sanitation would be the ideal way to tackle TB in India, but he also argued, “As our resources are limited, it will take many years before we could carry all these out. It is because of the consciousness of our limitations that we are advocating the BCG vaccination.”Footnote ⁴⁹

While Raman's critique took both Indian and Scandinavian TB workers by surprise, his position was based on well-known arguments in the public debate over health in late colonial India. In his rejection of BCG, Raman took inspiration from the Bhore Committee and Gandhi: “In view of the above considerations, we wish to make our position beyond doubt. We would give the first and foremost priority to the improvement of the nutritional and environmental conditions. The Bhore Committee has said so. Long before the Bhore Committee, Mahatmaji has said so. The fact, however, is that there is hardly a single Health Minister in any Province today, who is troubled by the disparity between official policies and Mahatmaji's teachings.”Footnote ⁵⁰

The Bhore Committee, established in 1943 under the chairmanship of Sir Joseph Bhore, made recommendations for the postwar development of the health field in India. Having consulted with some of the world's renowned advocates of social medicine, the Committee's report was deeply influenced by this doctrine.Footnote ⁵¹ Adopting a broad, inclusive definition of health as “that positive state of well-being in which mind and body are able to function to their fullest capacity,” the Committee considered environmental hygiene essential: “Without these our towns and villages will continue to be factories of disease, which will help to maintain undiminished demands on the curative side of the medical services.”Footnote ⁵² But the Committee knew resources were limited. In the communiqué that led to its establishment, the Committee had been advised to plan boldly, not extravagantly, and its recommendations noted that financial limitations could not be overcome immediately.Footnote ⁵³ The disagreement between Raman and Benjamin in February 1949 echoed the predicament of the Bhore Committee: Raman desired ambitious long-term environmental and social engineering schemes; Benjamin referred to short-term economic realities.

The Committee eschewed technological fixes. It warned that the “new health order” could not be achieved through “a bottle of medicine or a surgical operation,” and declared, “There is no magical wand to wave these changes into being overnight.”Footnote ⁵⁴ Although BCG was a well-known prophylactic at the time, the report took no notice of it, focusing instead on isolation and treatment of patients. Financial constraints meant that priority went to the development of an organized domiciliary TB service, supplemented by clinics and hospitals.Footnote ⁵⁵

Raman and the Bhore Committee not only agreed on how to tackle TB; they also shared views on the role of the state. The Committee unambiguously endorsed the “idea that the State should assume full responsibility for all measures curative and preventive, which are necessary for safeguarding the health of the nation….”Footnote ⁵⁶ Raman agreed, and writing about the futility in seeking parental consent before vaccination, he declared, “It should not be forgotten that the State is the parent of the country, parens patriae, and that it is bound to accept full responsibility in the matter without shifting it on to uninformed and ignorant parents of our college boys and girls.”Footnote ⁵⁷ Thus Raman reminded his audience of the expectation, prevalent in the years immediately before independence, that India would develop a “welfare” state that intervened in its citizens' lives in ways much more ambitious than the injection of a questionable vaccine.Footnote ⁵⁸

Raman also looked to Gandhi. Gandhi was positioned in direct opposition to the current health regime, a regime personified by the adamantly pro-BCG Union Health Minister Rajkumari Amrit Kaur. Raman's November 1949 People's Health editorial referred to Gandhi's famous remark about Western medicine as “the essence of black magic,” and then challenged the minister: “Come, come Rajkumari don't these words form themselves again on your memory, well? India was made the scene of a mass-vaccination campaign, almost immediately after his death.” According to Raman, Gandhi had realized “that diseases can be eradicated by improving the living conditions of man, not by injecting products of Western vivisection.”Footnote ⁵⁹

The figure of Gandhi was an enormously powerful rhetorical reference. Raman must have been enticed to invoke Gandhi's straightforward condemnation of Western medicine as part of his rhetoric against BCG. However, neither man was simply opposed to Western medicine.Footnote ⁶⁰ While Gandhi often criticized it as inadequate and immoral, he was also eager to position himself as a believer in science, if this was understood as a method of enquiry. In 1921, after having reiterated his statement about Western medicine as black magic, Gandhi wrote: “Having said this much I would like to pay tribute to the spirit of research that fires the modern scientist. My quarrel is not against that spirit. My complaint is against the direction that this spirit has taken.”Footnote ⁶¹ Gandhi did not entirely reject Western medicine, but rather identified specific practices that he found particularly objectionable. Chief among these was vaccination, a “savage custom” and a “sacrilege,” “tantamount to partaking of beef.”Footnote ⁶²

Gandhi in fact endorsed certain elements of Western medicine, such as sanitation, which he repeatedly described as a science.Footnote ⁶³ On one occasion in 1929 Gandhi positioned vaccination and sanitation in direct opposition to each other. Arguing that he rejected vaccination on religious grounds he admonished: “But those who do not get themselves vaccinated ought to know and follow the rules of sanitation… .”Footnote ⁶⁴ It was precisely this opposition that Raman latched on to—though without its religious associations—when he emphasized that India needed sanitary measures and not vaccination schemes.

When Raman invoked the Bhore Committee he gave his support to the doctrine of social medicine and hoped for a powerful and interventionist state, and he used Gandhi to bolster his claim that vaccination was a particularly problematic medical technology. Combining these two well-established positions allowed Raman to offer a forceful argument against vaccination and in favor of sanitation as the TB-control strategy for India.

While Raman and others continued to argue against BCG in People's Health up to 1951, it was in the spring of 1949 that the opposition was most energetic and visible. The Scandinavian experts in the ITC noticed the opposition against BCG in Madras. From New Delhi, Svend K. Svendsen, the ITC's chief medical officer in India, reported how the anti-BCG campaign had begun unexpectedly and how Raman had managed “to fill most of India's newspapers with counter propaganda, particularly in Madras and Bombay.” And while Svendsen remained hopeful about the success of the campaign, he cautioned, “We must not, however, expect that BCG in the near future will run triumphantly through the Indian masses. It will take a lot of hard work.”Footnote ⁶⁵ In other locations the campaign seems to have gone on with no extensive opposition. The problems in Madras did not prompt any soul-searching within the ITC, nor was Rajkumari Amrit Kaur shaken. In an April speech she unconditionally supported BCG and assured the public of the benevolent intentions of the Western countries.Footnote ⁶⁶

But Raman's protests caused the Government of Madras to postpone mass vaccination. Following the controversy in February 1949, politicians' and bureaucrats' early enthusiasm for BCG waned. In June the provincial government informed the Union Government that, considering the significance of the opposition, it preferred to train only one team instead of three as originally planned; when opposition died out more teams could be trained.Footnote ⁶⁷ That autumn, when Benjamin wrote to the minister for public health in the Government of Madras, Dr. Rajan, and asked whether the province was interested in participating in the next phase of the BCG program, the provincial government opted out of the Union Government's plans to intensify vaccinations.Footnote ⁶⁸ For Madras, this phase would mean training another ten vaccination teams. This proposal did not, Rajan informed the authorities in New Delhi, have the interest of the Government of Madras.Footnote ⁶⁹ The internal memorandum behind Rajan's rejection of the plan (written by an “additional secretary” in the Public Health Department) directly referenced the opposition radiating from the pages of People's Health: “It will be seen that, progressively, B.C.G. vaccination is being sought to be made a common garden affair like vaccination against small-pox, and as though the efficacy of B.C.G. vaccination and freedom of danger therefrom [sic] are established facts! Actually, an anti-B.C.G. campaign is raging throughout the world and in Madras; in the last month's issue of ‘People's Health,’ the arguments against B.C.G. have been clearly marshalled in an article.”Footnote ⁷⁰ With Madras turning its back on BCG, and Raman's resistance at its height, the campaign was in trouble. At the same time, because logistical difficulties and ambition were outweighing commitment to the campaign, the WHO's Indian representative characterized the campaign as a “flop” and the results so far as “extremely disappointing.”Footnote ⁷¹

In early 1950 another attempt was made to convince Madras that it should join the intensified campaign; the ITC's regional director wrote specifically to offer assistance to the Madras authorities. The provincial government remained adamant and declined the appeal. Explaining, “The time is not yet ripe for any mass B.C.G. Vaccination before public apprehension have been allayed,” it also promised, “Additional provision for more teams will be made if it [is] found that the results have been satisfactory and the considerable public opposition obtaining in this state has been overcome.”Footnote ⁷²

Thus, by the time the preliminary stage of BCG vaccination ended and the ITC was gone, and the “real” campaign—mass vaccination supervised and supported directly by WHO and UNICEF—began, India had already confronted one protest movement that had been effective, if only temporarily. Now, however, the intensified campaign to carry out vaccinations across the entire country appeared unstoppable. In the general “Draft Plan of Operation” for 1952 and 1953, the Union Government declared that it would carry out a campaign to vaccinate India's entire population of children and young adults.Footnote ⁷³ The new international health regime and the Government of India put an unprecedented amount of resources into assuring the campaign's success. It all threatened to come apart once again.Footnote ⁷⁴

RAJAJI AND RESISTANCE

For a time, opposition was a not a concern. Well into the WHO's mass campaign, in the spring of 1955, Halfdan Mahler, the WHO senior officer, wrote a lengthy report on the program's ups and downs. He noted various successes, and a number of setbacks such as the indifference of doctors (he noted, “BCG is a word by which medical directors threaten unruly doctors in the departments”), and the lack of interest in public health demonstrated by certain sectors of the government. But toward his report's conclusion Mahler declared, “No really dangerous country-wide opposition has ever appeared so far towards the BCG vaccination. The press, radio, cinemas and the campaign's own publicity units have all contributed in consolidating BCG's popularity.”Footnote ⁷⁵ He did acknowledge what he perceived to be peoples' suspicions of outsiders, and the unprecedented nature of such a public health campaign, and a year earlier, in April 1954, he had reported on pockets of anti-BCG campaigning in Orissa, where BCG was known as “Birth Control Government-guarantee.”Footnote ⁷⁶ Mahler knew that it was critical to win over both villagers and city dwellers by educating them about the safety of BCG and the dangers of TB. He told how the hostility of one village in Madhya Pradesh had changed to openness when a team replaced scolds and threats with smiles and jokes, and he wrote that the “BCG team had learned an embarrassing but fruitful lesson—To tell everybody once more that this is the biggest show on earth.”Footnote ⁷⁷ Mahler believed from the beginning that the BCG campaign was creating a new public health consciousness among rural and urban Indians as well as doctors.Footnote ⁷⁸

Despite evidence of resistance, no one worried about the program's ultimate success. Even the campaign in Madras got off to a good start. Raman's voice had been silenced: likely due to financial constraints and lack of energy he stopped publishing People's Health in 1951.Footnote ⁷⁹ Dr. Sangham Lal, director of Medical Services for Madras State and once a staunch opponent of the vaccination campaign, had been converted to the cause and officially launched the program.Footnote ⁸⁰ When the WHO/UNICEF mass campaign began in Coimbatore in November 1954, Mahler thought it a smashing success: “This explosive inauguration of the campaign caught the anti-propagandists asleep on their previous laurels, and some last minute efforts by them had no effect whatsoever.” When he wrote this in January 1955, Mahler had good reason to be optimistic: “30 million people [had been] tuberculosis indoctrinated through the campaign's health education units.”Footnote ⁸¹ There were challenges, but Mahler considered one of them well on the way toward being met: people were coming around to the value of BCG. Mahler was pleased that people with little or no experience with vaccination were responding favorably to what then was the largest vaccine effort in world history (the smallpox campaign was still nascent, and most large-scale public health interventions had been responses to crises rather than sustained efforts).Footnote ⁸²

But then it all threatened to come apart. In August, the Indian Express reported that, according to the Madras minister of health, the BCG teams were creating “mass hysteria” wherever they went.Footnote ⁸³ A month later, the New York Times reported that the program in South India was in jeopardy.Footnote ⁸⁴ A mass-resistance movement had erupted. By September, UNICEF's field agent had to write, “The effect of the anti-propaganda is not to be underestimated, and it will influence the test-totals of the Indian BCG-Campaign.”Footnote ⁸⁵

Resistance radiated outward from the epicenter of resistance in Madras, and across many parts of India the numbers of tuberculin tests plummeted from highs above 90 percent to, in some cases, as low as 0 percent.Footnote ⁸⁶ One doctor reported from Uttar Pradesh in the far north that the Madras resistance had “created a panic in the minds of the general public.” Tensions were so high that he warned, “There will be a public beating on the arrival of the [BCG] party.”Footnote ⁸⁷ In Andhra Pradesh, UNICEF's BCG field nurse wrote that while the mass campaign had been lax in getting educational materials into the hands of local people, the opposition had been active, and successful. Anti-BCG pamphlets were in every house in Chittoor.Footnote ⁸⁸

Across the Bay of Bengal, in Rangoon, Burma, the Reddy Young Men's Association requested copies of the movement's Bible, B.C.G. Vaccination: Why I Oppose It.Footnote ⁸⁹ In Chittoor, Andhra State, the field nurse reported that about half the parents of school-aged children requested that they be exempted from vaccination, and the other half were outraged that their children were vaccinated without parental consent.Footnote ⁹⁰ Still further north, in Punjab, one man wrote of the BCG doctors and their LMS degrees—“License for Murder and Slaughter.”Footnote ⁹¹ And, finally, the resistance fanned the flames of the anti-vaccination movement in England, where M. Beddow-Bayly, one of the movement's stalwarts, already on record as being against BCG, took great pleasure at the massive Madras opposition to it.Footnote ⁹²

The man most responsible for the Madras resistance was Chakravarti Rajagopalachari, the first Indian governor general, and head of the Government of Madras in 1937–39 and again in 1952–1954. He was one of the founders of modern India, and the man whom Gandhi called the “keeper of my conscience.” Well known as Rajaji, he was an old friend of Raman's and they frequently socialized, spending most evenings together during this period.Footnote ⁹³ This was also the time in Rajaji's career—mid-1955, in the wake of being forced to resign his post as head of the Madras government—that marked the beginning of his outsider status. He was a Tamil Brahman and a member of the South Indian elite, and during his first spell as the leader of the Madras government he had promoted the north Indian Hindi language. He now found himself at odds with the Dravidian movement and its anti-Brahman rhetoric. His replacement in 1954 by the non-Brahman, Tamil-speaking Kamaraj Nadar was probably an attempt to popularize the Congress.Footnote ⁹⁴ Also during this period Rajagopalachari came to disagree with the policies and practices of the Union Government in New Delhi and developed increasingly anti-statist views.Footnote ⁹⁵ His protest against BCG was in part a protest against the modern Indian state. Looked at in this way, Rajaji picked the perfect target—a more powerful symbol of Nehru's modernist pretensions would have been hard to find. The immunization plan was a scheme devised largely by outsiders and the central government, which would require Indians to submit to a medical practice that many found objectionable.Footnote ⁹⁶

Rajaji successfully tapped into a popular, deep vein of suspicion, resentment, and nationalism that had been brewing since Raman's earlier protests. His suspicion of BCG, however, began before 1955. In May 1952 he requested a note on BCG from government servants. Upon receiving it he wrote to Rajkumari Amrit Kaur and told her that he could not support the proposed mass-vaccination campaign. He noted, “The atmosphere is not favourable for plunging into a mass campaign” and admitted that he took “the previous anti-propaganda into account in judging policy.”Footnote ⁹⁷ Thus he had been skeptical about BCG from at least 1952, but only after resigning as chief minister was he free to voice his opposition in public.

Like Raman before him, Rajaji and his supporters opposed BCG for many reasons. They practiced medical nationalism, they were angry over what appeared to be experimentation on children, and they continued to worry about BCG's safety and efficacy and to profoundly doubt that a single technological solution would solve India's entrenched TB problem. Some of the opposition was characterized by distrust and disdain of expert outsiders, and an allegiance to Ayurvedic over allopathic medicine. Outside experts, many believed, did not understand conditions in India. Rajaji embodied this spirit, and as one of his many correspondents put it: “The sage of the East … refuses to bow to the West and the Westernized.”Footnote ⁹⁸ But the anti-BCG forces did not take a facile stance against Western medicine; their characterization by WHO doctor P. Mohamed Ali as “medical Rip Van Winkles” was not apt.Footnote ⁹⁹ In fact, Rajaji and his supporters did not reject outsiders, or even cast off the opinions of British or American TB specialists—they readily harnessed outsider's views, but only when they meshed with their own.

The people with whom Rajaji corresponded, and Rajaji himself, were anything but medical Rip Van Winkles when it came to BCG. They had a firm grasp of the global literature on the BCG vaccine, and knew it was controversial. For example, when the British Medical Journal published its skeptical assessment of BCG in April 1955, those opposed to the vaccine in India seized on it. Two months after the article's publication, N. K. Iyengar, a woman from Calcutta, published a letter to the editor in the Statesman citing it as support for the anti-BCG movement.Footnote ¹⁰⁰ Rajaji and his supporters did not object to Western medicine, but rather cleverly used it against itself to show the uncertainty surrounding BCG. N. K. Iyengar and others used the doubts raised by the British Medical Journal to express her worry over the “serious danger” India would face if “blind adoption” of BCG proceeded and Rajaji's warnings went unheeded. If “advanced countries” were hesitant about BCG, then, she wondered, why should India accept it?Footnote ¹⁰¹

Rajaji and supporters opposed what they perceived to be foreign experts in league with a national government bent on imposing its will on Indian bodies. A member of the Bahawalpur State Relief Committee in New Delhi wrote to him in September and characterized India's medical profession as trapped in “mental slavery” to the West; the government was “fast becoming a terror-creating machinery.”Footnote ¹⁰² A correspondent from Madras, who freely quoted from giants of Western medicine, made his outrage clear when he wrote, referring to indiscriminate BCG use, that the campaign had gone too far: “The Britishers would never have done it even in Kenya.”Footnote ¹⁰³ When one man learned that Rajaji favored a legislative solution to BCG's introduction into India, he wrote of his vehement opposition: if the legislature gets involved then mandatory vaccination was all but assured—“no amount of public protest will be heeded.”Footnote ¹⁰⁴ Frustrated that their concerns were, according to one correspondent, “set aside as the blabberings of an ignoramus,” Rajaji's supporters couched their protests in as rational and well-supported a way as possible, and they did not come across as reactionaries or anti-modern cranks.Footnote ¹⁰⁵ Debates over BCG became a contest over who could better marshal scientific authority—Rajaji and his supporters, or the Government of India, WHO, and UNICEF.

In the spring of 1952, while still chief minister, Rajaji wrote reassuringly to Rajkumari Amit Kaur, “I am a believer in modern medicine and scientific methods and particularly the great results derived from Pasteur's discoveries.” But his faith in Western medical science had its limits, and in the same letter he first voiced his uneasiness with BCG.Footnote ¹⁰⁶ Kaur was disheartened by what she perceived to be Rajaji's irrational opposition to BCG, especially given her conviction that science supported the vaccine. Of course, she wrote, improving living conditions, isolating carriers, and providing adequate treatment were essential to combating TB. But in 1952 India was unable to implement adequate TB-control measures. A vaccine was the best hope. The rest of the world had accepted BCG, and she wondered why Rajaji had not. She wished he would change his mind, for Madras was missing what the rest of India was benefiting from. “I can only hope,” she wrote to him, “that the example of the rest of India will in due course make the people of Madras demand vaccination.”Footnote ¹⁰⁷ She could certainly hope.

When Rajaji began to challenge BCG publicly, he continued to claim that his criticism was thoroughly scientific; he expressed no doubt about technological solutions in general. Indeed, he advocated the use of antibiotic “wonder drugs,” which, it bears note, at the time were much more experimental than BCG. Referring to promising results with INH (another name for the TB antibiotic Isoniazid), he could not understand why the INH program was limited, while vaccinations continued on a mass scale.Footnote ¹⁰⁸ At one meeting, according to the Hindu, Rajaji not only “narrated the vast progress that had been made in the science of tuberculosis treatment,” he went to great lengths to assure the audience that he was a firm believer in smallpox vaccination.Footnote ¹⁰⁹ He quoted Francis Bacon, whom he saw as a key figure in the development that had led to the “remarkable success of modern science,” and declared that his opposition was not “emotional” but based on “what might be called scientific reasons.”Footnote ¹¹⁰ He labeled BCG “quackery.” In a key passage from B.C.G. Vaccination: Why I Oppose It, his widely distributed, much admired and much reviled pamphlet, he forcefully laid out his position, claiming that proper science was on his side:

Rajaji demonstrated his knowledge of Western medicine by peppering his pamphlet liberally with quotes from renowned international medical journals.

Rajaji's attack on BCG demanded a response from the campaign's supporters, and in a volley of editorials and articles published primarily in the widely circulated Hindu, a very public debate ensued. The first to come to the aid of P. V. Benjamin in defending the scientific basis of BCG was Dr. K. S. Ranganathan, director of the national BCG laboratory in Guindy just outside Madras, and a supporter of the BCG campaign from the beginning.Footnote ¹¹² In mid-June 1955 Ranganathan called the opposition “a relic of the past” and claimed, erroneously, that the efficacy of BCG had been established through proof “that was irrefutable and statistically sound.”Footnote ¹¹³ In early July, J. Frimodt-Moller, the respected superintendent of the Arogyavaram Sanatoria, described BCG as “one of the latest gifts of medical science to mankind for effective protection against the disease.”Footnote ¹¹⁴ Three weeks later Frimodt-Moller again addressed the issue, but this time more cautiously. While convinced that BCG was harmless, he admitted that it would take some time before the efficacy of BCG could be established.Footnote ¹¹⁵ Rajaji immediately seized on this equivocation, and he quoted Frimodt-Moller to suggest, “The BCG campaign in India was really an experimentation on an unjustifiably large scale rather than a prophylactic measure of proved value.”Footnote ¹¹⁶ Frimodt-Moller, now forced to publicly clarify his position, published a statement in the Hindu on 3 August. While admitting that it would take time to produce sufficient data to determine the degree of immunity conferred by BCG, he asserted, “This need not hold us back from applying B.C.G. as a general measure in this country. We have sufficient evidence from experiments in animals as well as from observations in human beings to know that B.C.G. affords considerable immunity.”Footnote ¹¹⁷

Rajaji's pamphlet circulated all across India, and it was also read by people in Burma, England, Canada, and likely elsewhere. It was so successful at galvanizing opinion against BCG, and so adroit at using Western medical research to buttress the case against the vaccine, that the government was compelled to respond in kind. The Government of Madras in mid-August published The Truth about B.C.G. Why Government Have Launched a Mass Campaign, which took issue specifically with Rajaji's misuse of the evidence and experts. Rajaji's claim that he based his opposition “on the definite pronouncements of most eminent and illustrious medical men of the civilized world” galled the campaign's supporters.Footnote ¹¹⁸ The government's pamphlet highlighted this sentence to show that the eminent medical men referred to by Rajaji, such as Frimodt-Moller, actually supported BCG.Footnote ¹¹⁹ “Whoever may be the ‘most eminent and illustrious medical men of the civilised world’ who endorse the views of Rajaji,” the pamphlet trumpeted, “Dr. Frimodt-Moller is not one of them.”Footnote ¹²⁰

Rajaji's arsenal, like Raman's before him, included Carroll Palmer. At a meeting in October 1955 Rajaji praised Palmer as the “Shri Krishna' of the ‘BCG Gita.” Rajaji claimed Palmer opposed BCG.Footnote ¹²¹ But The Truth about B.C.G., as well as Palmer himself, countered this claim.Footnote ¹²² Throughout his pamphlet and in his correspondence Rajaji turned doubts about the efficacy of BCG into hard held opinions that it was worthless, and in this way he willfully distorted Palmer's work. Palmer rebutted, writing that to summarize his work as anti-BCG “is obviously to distort and misquote my views.”Footnote ¹²³ Rajaji readily invoked the experts of modern medical science: when he agreed with them they were reliable; when he did not he was dismissive. For Rajaji, and Raman before him, to say nothing of those in support of BCG like P. V. Benjamin, it was not a question of belief in expert knowledge, but rather which experts to believe in.

While Rajaji relied on Western medicine to criticize the mass campaign, his position on Indian versus Western medicine was poorly developed. This could not be said of his followers, some of whom supported him because they considered the mass campaign, and the government's support of it, a reproach to Ayurvedic medicine. From the earliest days of the mass campaign, Ayurvedic and naturopathic practitioners and supporters had spoken out against BCG; the Delhi Naturopathic Association, for example, wrote a resolution condemning it.Footnote ¹²⁴ Many of Ayurveda's supporters did not simply reject Western medicine; it was more that they wanted Ayurvedic medicine to be taken seriously.Footnote ¹²⁵ There were those like A. B. Parisad, president of the Institute of Ayurvedic Studies and Research in Calcutta, who thought it acceptable to incorporate the best of Western medicine into Ayurveda. What concerned him was that the “central and provincial governments are after integration and seduced by strange voices from abroad.”Footnote ¹²⁶ Some complained the government's commitment to Ayurvedic medicine was thin, and Rajkumari Amrit Kaur was accused of discounting Indian in favor of Western medicine.Footnote ¹²⁷

But there were things that people found still more alarming. What most angered Rajaji and his supporters was that they perceived the campaign to be a vast experiment on children. They may have also been drawn to this issue because it had such rhetorical power. The campaign was directed at the young, and as one correspondent put it, some considered Rajaji “the saviour of our helpless children.” Rajaji told Rajkumari Amrit Kaur that the BCG campaign was “bacteriological warfare against children.”Footnote ¹²⁸ The Madras minister of health decried the climate of fear that Rajaji's pamphlet and public pronouncements were creating.Footnote ¹²⁹

The fear was unwarranted, however, and by the 1950s doubts about BCG's safety had largely disappeared. Nonetheless, they proved easy to rekindle. Rajaji's pamphlet not only contained countless citations to medical literature; it was also filled with parents’ and local health officials' tales of BCG-induced health problems. Rajaji used these letters to his advantage, in ways that did not square with the facts.

Except in two cases, the letters Rajaji included in his pamphlet presented accounts that no one had verified. Stories about children going blind or being stricken with TB after vaccination were offered as a powerful injunction against BCG. But their inclusion also warranted investigations into their veracity. Two of the fifteen letters Rajaji quoted were accompanied by follow-up materials, medical reports that made clear that the blame put on BCG was misplaced. Why Rajaji included these contradictions of the parents' claims is unknown, since they weakened his position and undermined the veracity of the other thirteen cases. And in fact four more cases of alleged BCG-induced illness in Rajaji's papers are absent from the pamphlet. All four were investigated at Rajaji's urging, and in each case the illnesses were found to be unrelated to BCG. One of the children had never even been vaccinated!Footnote ¹³⁰ Just as with the scientific materials, Rajaji used his evidence from parents selectively. He quoted at length from a letter written to him by a man in New Delhi whose son had suffered what appeared to be an adverse reaction to BCG. The man was angry, yet in his original letter he supported the goals of the BCG program. After describing his family's experience the man wrote, “I may add here also that I have no reason whatsoever to doubt the intentions or the bonafides of the Government. The interest of the public at large is always supreme in the eyes of the Government and it is for this reason only that a large sum is being spent over the scheme in quite good faith.” These comments were explicitly edited out of the pamphlet, slashed through by either Raraji or someone else.Footnote ¹³¹ Rajaji tapped into a general uneasiness about vaccines and outsiders with needles and created a link in the minds of the public between sick children and BCG. He did this by means of his pamphlet, and, in at least one case, by urging a sick child's father to contact all the major Indian newspapers, which the father did, only to learn subsequently that his son's poor health was unrelated to BCG.Footnote ¹³²

Despite the doubtful veracity of these stories, Rajaji included them in his pamphlet to highlight what may have been at the root of the entire protest: Rajaji and his supporters did not believe India should be a laboratory. And they were especially alarmed by the possibility that the campaign—novel, untested, invasive, and of outside origin—might be harming children. But in truth, the WHO did consider India a laboratory of sorts, and Rajaji was warranted in writing: “I cannot resist the feeling that the mass campaign in India is a vast empirical experiment in the supposed interest of scientific progress and that Indian children are being offered for experimentation on the same plan as was put in operation among the people in war ravaged areas and uncivilized dependent communities.”Footnote ¹³³

An explicit WHO goal was to use India as a test case for the mass campaign. Rajaji and others, however, were dismayed that the WHO appeared to be focused on a technological fix for what was so obviously a problem of poverty. This strain of criticism emerged out of the perception on the part of Rajaji and his supporters—strongly echoing Raman's earlier critique—that the WHO considered BCG to be a panacea. Rajaji was concerned that BCG would be presented as a cure-all and that efforts to improve Indian lives would take a backseat to experimental measures like BCG. Many who wrote to Rajaji expressed themselves along these lines. S. R. Srinivasa Raghavan's remarks are emblematic of this: “It is high time that our ‘Experts’ felt more humble about themselves… . Our essential disease as a society in this world is poverty and not the multifarious ailments that result from poverty. I hope you will understand me when I say that there is no point in compelling man to live in slums and unhealthy quarters with no wherewithal to buy his needs, making him contract all the diseases in the medical dictionary and suddenly discover that a mass B.C.G. campaign is manna for him.”Footnote ¹³⁴

This criticism was apt in that BCG was not a solution for the conditions that gave rise to TB. But the WHO also recognized this. Johannes Holm, who was now heading the TB section of the WHO, recognized this central fact in October 1955 in his speech “Tuberculosis—A Problem of Different Races.” TB was the same everywhere, he argued; it was the conditions in which people lived that were different.Footnote ¹³⁵ The tension between people like Rajaji and those like Holm was that the latter thought that it was their responsibility to intervene, and now they had a technological means by which to fulfill that responsibility. Rajkumari Amrit Kaur had a similar view. She found Rajaji's intransigence exasperating, and said that all she could do was “plead with you to refrain from misleading the public.” She told him that if the government did not offer BCG, in a country where raising living standards could only be a long-term prospect, they “would be guilty of criminal negligence.”Footnote ¹³⁶