The making of imperial tuberculosis

In the fin de siècle, TB became the central public health concern of metropolitan France, while colonial administrators effectively ignored the disease. Although long-term trends showed a slow but clear decline in TB mortality rates (from 3.89 per 10,000 in 1887 to 2.91 in 1914, across twenty-six cities), in 1898, the Academy of Medicine, government commissions, and various popular movements raised the issue as a central problem of French society – the war on tuberculosis (la lutte contre la tuberculose).Footnote ¹⁵ David Barnes has argued that TB became a way for the French bourgeoisie to express fears over national decline, the threat posed by unhygienic working classes, the shifting of moral norms, and the rise of vices such as alcoholism and syphilis. Defeating TB would mean defending prosperity, national security, and bourgeois morality.Footnote ¹⁶ The country’s obsession with TB waxed and waned. It reached a peak in the early 1900s, subsided, and surfaced again during the First World War, propelled by high TB rates among the enlisted, as well as by the American Rockefeller Foundation’s mission to France. By the 1920s, France had established organizations such as the Comité National de Défense contre la Tuberculose (Committee for National Defence against Tuberculosis; CNDT), educational programmes, dispensaries, and sanatoria, all committed to improving social hygiene and preventing TB.Footnote ¹⁷

In the French colonies, however, TB remained largely absent from the official mind. Epidemiological studies of TB were rare in the decades before the First World War. Discussions were often limited to general studies of ‘diseases in warm climates’, often in doctoral dissertations of aspiring tropical physicians, or in publications by doctors working in hospitals in Dakar or Saigon, based on individual case studies observed in their clinical practice.Footnote ¹⁸ In annual medical reports to the governments of French West Africa (l’Afrique Occidentale Française; AOF) and Indochina, TB rarely occupied more than a paragraph. In the AOF, TB was simply reported as being ‘frequent and widespread’ in all regions of the colony – but not destructive enough to warrant administrative action.Footnote ¹⁹ In Indochina, administrators often categorized TB as a ‘sporadic disease’, the least important of three categories, which also included ‘epidemic’ (smallpox) and ‘endemic’ (malaria).Footnote ²⁰ Remarkably, unlike experts in the US and South Africa, for example, most French scientists before the 1900s not only rejected ‘virgin soil’ theories, which emphasized European contact as the source of TB infections, but believed that the tropical environment could, in some cases, even protect against TB.Footnote ²¹

In one of the first pan-imperial surveys of the problem, published in 1905, the director-general of the Colonial Health Service, Alexandre Kermorgant, observed that, as in the metropole, TB in the colonies appeared to multiply with ‘agglomeration’ (population density) and with ‘civilization’, by which he meant urbanization and European contact.Footnote ²² Yet he categorically rejected the idea of TB’s European origins, emphasizing that TB had been in the French colonies ‘since time immemorial’.Footnote ²³ Hospitals in Hanoi admitted patients from distant provinces of Annam, Cochinchina, and Tonkin, where they could not have had extensive contact with Europeans. Records of TB cases dated back to missionary reports from the 1860s, when colonization had only just begun. References to local names provided further evidence of the disease’s ancient provenance in both Indochina and West Africa. Experts reported that TB had traditional indigenous names: it was called ‘Lo Beng’ in Cambodia, ‘Binh ho Lao’ in Annam, for example.Footnote ²⁴

Rather than blaming the corruptive effects of social and moral ills, doctors in the colonies focused on environmental and racial determinants, which gave tropical TB a different character from its metropolitan equivalent. Some doctors argued that blacks and ‘orientals’ carried ‘a sort of natural immunity against tuberculosis’.Footnote ²⁵ In Indochina, Alphonse Voillot believed that the ‘yellow races’ suffered less from the disease ‘in spite of their ancient contact with Europeans’.Footnote ²⁶ Doctors noted that, even in high-affliction regions of Indochina, TB among ‘orientals’ was milder, with ‘a slow evolution’, ‘dry’, without coughing or sputum, and that symptoms were more likely to include ‘diarrhoea and intestinal problems’.Footnote ²⁷ Other experts, however, speculated that Africans were more, rather than less, susceptible to TB.Footnote ²⁸ Either way, tropical doctors agreed that race played a central role in TB susceptibility.

Still others emphasized environmental determinants: in their view, cleaner air and a warm, dry tropical climate could lower affliction rates. Algeria, in particular, was known for its healthy air, with some doctors calling the country’s climate the patibulum vitae, the life-giving cross.Footnote ²⁹ Some doctors even suggested that malaria acclimatized Africans’ organs against certain forms of morbidity, including TB. ‘Tuberculosis and the malarial miasma are like two pans of a scale, if one rises then the other must lower’, wrote Dr Boudin in 1857.Footnote ³⁰ These views persisted into the early twentieth century, reappearing in reports at the 1904 tuberculosis conference speculating that malaria might be responsible for the low rates of TB among Malagasies and Somalis.Footnote ³¹ Over time, however, doctors who showed that malaria could, in fact, accelerate and worsen TB, contested these environmentalist claims.Footnote ³²

Colonial doctors concluded that, if colonial TB was indeed a perennial problem determined by environmental and racial factors, then ‘all prophylactic measures would prove illusory’.Footnote ³³ Administrative action remained rare in both the AOF and Indochina. In 1900 and 1904, the Ministry of the Colonies mandated that hospitals and sanitary services across the colonies must take precautions against contagion: military establishments were required to regularly disinfect the premises and aerate buildings, while hospitals were required to isolate consumptives from other patients. Yet, even here, local officials acknowledged that budgetary resources were insufficient for complying with all the demands, and implored that, at minimum, doctors should change shirts and wash their hands after seeing patients with TB.Footnote ³⁴ In the pre-war years, neither medical nor administrative elites made the case to take TB in the colonies seriously. In the early 1900s, in part thanks to the efforts of the Pastorian Albert Calmette, this view began to change.

Calmette became involved in the anti-TB movement in the late 1890s, when working at the Pasteur Institute in Lille, an industrial town, where TB was a particularly acute problem, and where he ‘could observe, every day, the inutility or insufficiency of the poorly coordinated efforts of public welfare institutions and of private charity’.Footnote ³⁵ Unlike other social hygienists, Calmette focused exclusively on contagion. He elaborated on this principle in several high-profile studies, most notably in a 713-page magnum opus titled The role of microbial infection in human and animal tuberculosis. After spending several hundred pages on the morphology, cultivation, life cycle, chemical composition, and infection mechanisms of the tubercle microbe, he proceeded to demolish the ecological public health approach of the day. Listing popular arguments that grounded TB infections in ‘ignorance’, ‘alcoholism’, ‘misery’, and ‘insufficient nutrition’, Calmette concluded that

Calmette believed that the broad social campaign against TB was misguided, focusing too much on the environmental conditions of potential victims and not enough on eradicating the microbe itself. Instead, he argued that ‘it is hard to imagine the limitation and then extinction [of the tubercle microbe] otherwise than by the vaccination of all men and susceptible animals’.Footnote ³⁷

Calmette had many allies in the colonies, where his own career had begun, and where he had mentored a generation of young Pastorians. From 1912 onwards, his methodological conviction of the primacy of contagion, and a new technological tool at his disposal – the tuberculin skin test – enabled him to reorient the scholarly consensus on the importance of TB in the colonies. A series of epidemiological studies, which used the resources of the expansive Pastorian network and took the entire empire as the scale of analysis, constructed TB as an acute, pan-imperial problem, with roots in the colonizing process itself. In what follows, I argue that Calmette-era epidemiologies worked as epidemiological devices, which constructed an imperial geography of TB, undermined the fatalist implications of previous studies, and made an argument for Pastorian medical intervention.Footnote ³⁸ We will see that Calmette’s data was limited by similar factors to those of previous studies (for example, a focus on select urban areas) and did not paint a dramatically different picture of TB spread, but the technical innovations he used allowed him to dismiss previous studies and impress the novelty of his conclusions on medical administrators.Footnote ³⁹

Calmette first turned his attention towards the colonies in 1910, when he and Camille Guérin managed to cultivate a non-virulent strain of the tubercle bacterium, and a vaccine appeared to be within their grasp. At that point in time, the French doctors Mantoux and von Pirquet, using Robert Koch’s research, had developed a new tool for diagnosing TB infection even in people who were not symptomatic. This was a major innovation in an age when even symptomatic TB was often confused with other diseases such as pneumonia or lung cancer. The test involved injecting matter extracted from dead tubercle microbes – tuberculin – and then observing the subject’s reactions. A red patch developing at the site of injection within 48–72 hours indicated that the subject had TB antibodies.Footnote ⁴⁰ Calmette furnished his collaborators with free tuberculin developed at the Pasteur Institute in Lille, and Pastorians and doctors in the colonies, sensing an opportunity for furthering their careers, eagerly went along with the plan.Footnote ⁴¹ The results were published in the Annales de l’Institut Pasteur in 1912, and became the basis for a number of future studies, cited as the beginning of a new epoch by both colonial administrators and later researchers alike.Footnote ⁴²

The tuberculin skin test allowed Pastorians both to dismiss prior studies for their lack of technical sophistication, and to emphasize the importance of fighting a disease that, on the surface, seemed less immediately dangerous than malaria or yellow fever. As Marcel Léger argued in his overview of TB studies in West Africa,

Tuberculin tests could detect latent carriers of TB, and, equally importantly, Pastorians considered them to be sufficiently precise. Calmette suggested that the ‘great precision’ of the tuberculin test would enable the charting of the spread of the disease and the development of a ‘tuberculosis index of a particular ethnic group, locality or even an entire country’.Footnote ⁴⁴ To that end, the only studies he considered relevant were those that utilized tuberculin, such as those done in the in Kalmyk steppes in Russia, or a few studies attempted at around the same time by other Pastorians.Footnote ⁴⁵

Yet, for all the claims to technical precision, Calmette’s statistics were not much more detailed than those collected by Kermorgant ten years earlier, nor did they show a fundamentally different picture of TB epidemiology. Calmette’s collaborators could indeed break down the communities they studied by age (children under one year, children aged between one and fifteen, children older than fifteen), and by ethnic group (white, Wolof, Maure, Bambara), rather than extrapolating from mortality rates or simply reporting the disease as ‘rare’, ‘present’, or ‘dominant’, as Kermorgant’s study had done.Footnote ⁴⁶ But Calmette’s study was far from a village-by-village accounting of TB rates. His reach was limited by the extent of his network of collaborators: Pastorians based in laboratories in major cities such as Dakar or Saigon, with little access to the less-travelled areas of West Africa and Indochina. In Indochina, Calmette had data from all five colonies, but, even there, most of the tuberculin tests were performed in Hué, Saigon, and Phnom-Penh, with only a few tests done in rural regions. In the AOF, the vast majority of his data came from the colonies of Senegal and Guinea (3,000 tests). Outside colonial capitals, his research remained as impressionistic as prior studies.

Calmette still drew novel conclusions. He argued that TB was ‘extremely rare among the indigenous populations of the black race, in areas where Europeans have only recently penetrated; but the proportion of contaminated subjects grows with the intensity of commercial exchange and foreign immigration’.Footnote ⁴⁷ The Pastorian further asserted that in certain areas TB infection was more likely to develop into symptomatic illness, and such illness would have graver consequences than in regions where TB was ‘more widespread and more ancient’.Footnote ⁴⁸ Further, since infants in the colonies ‘never [drank]’ cow’s milk, the infection could not come from bovine TB.Footnote ⁴⁹ This, Calmette concluded, meant that ‘Europeans … constitute[d] the primary means of infection’, and were responsible for the development of ‘serious forms’ of the disease among colonized populations.Footnote ⁵⁰ Questions of nutrition, climate, racial specificity, and other environmental-biological factors, which previous researchers had used to explain the variability of TB mortality rates in the colonies, were completely irrelevant to Calmette; he focused on infection, which he asserted came from Europeans. The solution therefore had to be bacteriological, one that could halt the spread of the infection both from Europeans to colonized subjects, and from those with a latent infection to those with symptomatic illness: in short, the ‘methods of vaccination’ he was researching with Guérin.Footnote ⁵¹

After 1900, experts in other colonial empires, too, began to term TB a ‘disease of civilization’, noticing its prevalence in mines that made extensive use of indigenous labour, in urban agglomerations, and in the military. The Irish pathologist Lyle Cummins, working in the Royal Army Medical Corps, studied Sudanese troops in the 1910s, and South African mine workers in the 1920s, concluding that the ‘virgin soils’ of Africa were responsible for higher mortality rates. In British India after the First World War, officials cited the study of Dr Arthur Lankester, which showed dramatic increases in TB rates in most urban areas, and in industrial areas in particular. German experts called increasing TB rates in Africa ‘the price paid for civilization’.Footnote ⁵²

Many of these studies referenced Calmette’s research, but there were also significant differences. In South Africa, virgin soil theories led to fatalistic conclusions that TB could not be mitigated by active interventions, and that improvements would take decades, if not centuries. Many experts focusing on Africa and the United States remained committed to theories of racial specificity even in the 1930s, arguing that factors ‘deeply fixed in the blood of each race’ were far more important than acquired immunity and prior contact.Footnote ⁵³ Neither interventionism nor fatalism necessarily followed from virgin soil theories; they were responses deriving in part from political necessity, methodological conviction, and the ability to make a case to policy-makers. In Calmette’s case, his Pastorian pedigree, the ability to marshal technological innovations, and the alignment of his solutions with policy-makers’ anxieties all contributed to the success of his logic.

BCG in colonial politics and global science

The French Ministry of the Colonies returned to public health problems in the interwar years, prompted by metropolitan concerns over birth rates, changing gender roles, and wartime injuries, and by the conviction that colonial subjects, particularly Africans, were untainted by civilization and therefore exceptionally virile.Footnote ⁵⁴ While many commentators interpreted this latter claim as yet another sign of danger to the French race, a significant number of experts saw it instead as an opportunity to regenerate the French nation through intermarriage and settler colonialism.Footnote ⁵⁵ Researchers called for a renewed focus on preventive and social hygiene, ‘the improvement of both the quality and quantity of the races’.Footnote ⁵⁶ Ultimately, though, colonial pronatalism was more economic and military than social or moral: ‘all of our colonial problems, from the economic development of our overseas colonies … to the recruitment of indigenous troops depends directly on achieving high population densities in our colonies’.Footnote ⁵⁷ For the Minister of the Colonies, Édouard Daladier, the population problem was primarily a labour problem.

At the same time, colonial officials were under pressure to demonstrate the humanitarian role of imperialism with new urgency. For anti-colonial activists, conditions of hygiene in particular became representative of the hypocritical promises of the civilizing mission, echoing Pastorian concerns about the European sources of TB. One African intellectual writing in Le Cri des Nègres argued that the trifecta of TB, alcoholism, and syphilis, the ‘defects of “civilized metropoles”’, had led to demographic decline in Africa, thereby proving that colonized societies under French rule were ‘in a worse state than when they were left to their “barbarous instincts”’.Footnote ⁵⁸ The ‘archaic hygienic conditions of life that civilization has left them’ led African intellectuals in Paris to conclude that ‘it is a cynical lie to say that Negroes are incapable of self-governance and that they need the tutelage of European metropoles to prevent them from falling back into barbarity’.Footnote ⁵⁹

Improving hygiene therefore remained the core strategy for demonstrating imperial humanitarianism. In 1924, Daladier attempted a massive expansion of the colonial health system, refocusing it ‘on demographic and social questions’.Footnote ⁶⁰ The minister sought to expand the Assistance Médicale Indigène (AMI), a health service for subject populations of the AOF and Indochina, founded in 1905, which he argued had remained essentially powerless.Footnote ⁶¹ Daladier’s second goal was orienting colonial medical services more towards social hygiene, through popular education, training of midwives and construction of maternity wards, improvement of sanitation and potable water in the cities, and finally prevention of infectious diseases, particularly those that tended to threaten infants and expectant mothers.Footnote ⁶²

Daladier’s reforms, which aimed to standardize and expand preventive medicine across the colonies, created conflicting demands on colonial officials. Development budgets were meagre before the First World War, and remained so under Daladier as well. Large-scale investments to transform the colonies in France’s image were not going to be forthcoming, and political transformations were going to be equally limited. Daladier’s medical reforms remained similarly constrained. Imperial officials focused primarily on reorienting existing institutions and capitalizing on modest technical improvements. In 1924, the Governor-General of the AOF, Jules Carde, ordered the AMI to push staff towards indigenous maternity services, hoping that in addition to delivering babies and administering care, midwives and nurses would also impart hygienic education to new mothers – yet these reforms were limited to a tiny number of hospitals and involved no new resources.Footnote ⁶³

The Pasteur Institute provided both the rationale and the technology for Daladier’s reforms in such a constrained setting. Pastorians were already collaborating with colonial governments on a number of preventive endeavours: they produced smallpox and rabies vaccines, and they performed analyses of potable water in cities like Dakar or Saigon, lending force to the ministry’s focus on technical improvements. TB vaccination was one such example of a relatively cheap technical fix that could be integrated into Daladier’s reform plan.

Calmette’s enthusiasm for the colonial mission, however, has to be seen equally in the context of widespread scepticism in the global scientific community. In 1924, Calmette and Guérin publicized their work on an experimental vaccine, the Bacillus Calmette-Guérin (BCG). Based on two human trials on 667 infants, Calmette and Guérin claimed that the vaccine was both safe and efficacious.Footnote ⁶⁴ This, however, quickly became a controversial claim. The Pastorians’ enthusiasm for a vaccine-based solution was at odds with rising confidence in social hygiene, spearheaded by the Rockefeller Foundation, international bodies such as the LNHO, and a number of high-profile statisticians in Denmark, the UK, Poland, and elsewhere.

By 1920, the Rockefeller Foundation mission to France had built up a system of charities, dispensaries, and education programmes, reinforcing principles of social hygiene in French physicians and the lay population alike.Footnote ⁶⁵ Evidence from the United States suggested that social hygiene was indeed effective. Rockefeller propaganda materials cited, in particular, the rapid fall of TB mortality in New York after reforms undertaken by the newly formed city Health Board in the early 1900s.Footnote ⁶⁶ Statistics showing that mortality rates in New York in 1913 were half (1.92 per 10,000) those in Paris (3.79) migrated from Rockefeller publications to prestigious general interest journals such as Revue des Deux Mondes.Footnote ⁶⁷ Mortality rates in France did indeed decline, though not as rapidly as in the United States, the Netherlands, or Germany. A growing number of medical experts believed that improving demographics confirmed that the ‘war on tuberculosis’ would take place principally in the domain of social medicine.Footnote ⁶⁸ Calmette seemed to be addressing a problem that already had a reliable solution, thereby making the perceived risks of vaccination unjustifiable. As one article asserted, the ‘white plague’ would ‘not be cured by drugs, but by hygiene, a particular way of life, by following simple precautions’.Footnote ⁶⁹

From the start, Calmette and Guérin saw their campaign to prove the safety and efficacy of BCG as a global task. They distributed samples of the vaccines to interested parties around the world and called upon the international scientific community to experiment with BCG and confirm their claims. Yet these calls could also backfire. In France, a small but vocal coterie of physicians and veterinarians led by Joseph Lignières challenged Calmette, and suggested that environmental factors might render BCG pathogenic, and that adverse reactions might undermine public trust in physicians.Footnote ⁷⁰ More concerning were attacks by statisticians and social hygienists from the UK, Sweden, and the United States, among others, who criticized Calmette’s cavalier use of statistics, which were intended to confirm the efficacy of the vaccine but did not meet emerging norms of randomized trials. Critics such as Arvid Wallgren at the Gothenburg Children’s Hospital, or Major Greenwood at the London School of Hygiene, did not so much accuse BCG of being actively harmful, but simply noted that the lack of rigour in Calmette’s use of statistics made it impossible to prove that it was effective.Footnote ⁷¹ A well-publicized incident in Lübeck in 1929–30, where 72 infants who had been vaccinated with BCG died over the course of a few months owing to contamination in the production process, further accelerated criticisms, and the Netherlands, Belgium, Poland, Switzerland, and Germany all discontinued the use of BCG for a shorter or longer period as the situation unfolded.Footnote ⁷²

Calmette hoped that the LNHO, a new organization, could confirm the efficacy and safety of BCG and silence critics, but the organization’s verdict turned out to be as ambivalent as those of Calmette’s critics. The head of the agency, Ludwik Rajchman, a Polish bacteriologist and committed socialist, wanted the agency to focus on the large-scale study of complex health systems, which ‘no single administration … can undertake’.Footnote ⁷³ This meant gathering data on global epidemiology, the effects of nutrition on health, infant mortality, and rural hygiene – all factors that were social and therefore malleable by human action.Footnote ⁷⁴ It is hardly surprising, then, that TB, the quintessential social disease, generated considerable interest within the LNHO. As the LNHO investigated global TB rates as part of its epidemiological mandate, Yves M. Biraud, a representative of the LNHO, corresponded with Calmette, who had served as a member of its predecessor, the Provisional Health Committee, in 1922–23, discussing the possibilities and limitations of national statistics, and ways of standardizing data collection.Footnote ⁷⁵ Under Calmette’s sponsorship, the LNHO discussed BCG at a series of conferences held at the Pasteur Institute in Paris in October 1928, and in Berlin in 1929, and finally proclaimed BCG ‘a harmless vaccine’, ‘incapable of producing virulent tuberculosis lesions’, concluding that it was potentially, although not conclusively, effective.Footnote ⁷⁶ Though Calmette interpreted the report as a clear endorsement of the Health Organization, it did little to close the controversy, as the LNHO report echoed concerns about the reliability of the Pastorian’s statistics, and argued that only randomized controlled trials could conclusively prove that the vaccine worked.Footnote ⁷⁷ The controversy caused much anxiety for Calmette: his letters to Charles Nicolle abound with assurances of the vaccine’s safety, frustration over the public’s lack of confidence in him, and confessions of health issues resulting from the dispute. ‘This ordeal in Lübeck is making me sick’, he wrote in 1930, and complained of ‘suffering from cardiac troubles since this miserable affair’.Footnote ⁷⁸

As early as 1924, Calmette had enrolled the Ministry of the Colonies to sponsor BCG trials. Daladier sent out circulars to governments-general in Madagascar, Indochina, and West and Equatorial Africa, ordering them to collaborate with the Pastorians.Footnote ⁷⁹ The minister was convinced by the thesis of European contact, noting in his circulars both the ‘particular exposure’ of colonial troops to contagion during their stays in France, and the vulnerability of populations living on ‘virgin soil’.Footnote ⁸⁰ Second, Daladier was concerned about ‘other problems of colonial demography’, namely infant mortality and population density.Footnote ⁸¹ At the same time, Calmette wrote to his Pastorian collaborators in Tunis, Dakar, and elsewhere, convincing them to spearhead vaccination campaigns and collect data that would help his crusade to legitimize BCG in Europe.Footnote ⁸² The fact that Pasteur Institutes assumed the cost for producing vaccine made the proposition even more appealing to the ministry.

In the interwar decades, Pastorians in Algeria, Tunisia, West Africa, and Indochina produced the BCG vaccine and distributed it to local populations. Although these programmes were supposed to be trials, both Pastorians and colonial officials soon began to describe BCG as a proven and efficacious vaccine. From 1929 onwards, the Ministry of the Colonies began referring to BCG as a reliable vaccine, citing evidence from the 1924 trials, although these were still highly contested in European metropoles.Footnote ⁸³ In some colonies, the experimental nature of BCG was effaced much faster. In 1925, doctors in Cholon and Phnom-Penh were already discussing the ‘importance of convincing, first of all, the indigenous milieux of the safety of this procedure as well as its prophylactic importance’.Footnote ⁸⁴ In meetings of health councils, bacteriologists did occasionally emphasize the ‘uncertain efficacy’ of the procedure, but ultimately concluded that it remained ‘the only applicable [method] in our arsenal, given the state of things’, and the problem of efficacy quickly disappeared in official popularizations, replaced with references to ‘encouraging results’ in official correspondence.Footnote ⁸⁵

The colonies – where Pastorians and officials worked closely together, where independent oversight was lacking, and where administrative pressure to report ‘humanitarian’ benefits was stronger – helped Pastorians defend BCG in Europe and in organizations such as the LNHO. As Clifford Rosenberg has documented, Algeria became the site for the first randomized control trial to meet LNHO criteria, a project that lasted until the mid 1950s.Footnote ⁸⁶ Defending BCG in front of bodies ranging from the Royal Society to the LNHO, Calmette cited simian testing in Guinea, adult vaccinations in the AOF, and mass infant vaccinations in Mauritius, North Africa, Madagascar, and Indochina, alongside statistics from other European countries, as supporting evidence for the vaccine’s safety and efficacy.Footnote ⁸⁷

Throughout the 1920s, colonial uses of BCG provided Calmette with firepower for defence against his scientific opponents in France, the UK, the LNHO, and elsewhere. Yet, while colonial politics helped him in his scientific struggles, the science of BCG in turn shaped colonial politics beyond questions of public health. As officials and scientists began to pay attention to TB in the colonies, other actors, who did not support BCG, entered the colonial debate. We will now turn to colonial Indochina, and investigate how Vietnamese and French social hygienists used the TB threat to demand social rights, and how the BCG vaccine was used as a technopolitical weapon against such demands.

The technopolitics of BCG in colonial Indochina

The most expansive BCG campaigns took place in Indochina. With the exception of the North African colonies, Indochina had the best-developed health system in the empire, with a medical school in Hanoi, several Pasteur Institutes, and infrastructure that, while far from perfect, nevertheless allowed the AMI to access some of the more remote areas of the colony.Footnote ⁸⁸ The French reported high vaccination numbers. By 1928, the Pasteur Institute was distributing more than 60,000 doses a year to maternity hospitals in twelve cities; by 1931, the number had increased to more than 100,000. From 1929 the government-general made the ‘war against tuberculosis’ a part of the institute’s mission and a separate line item in the colonial budget.Footnote ⁸⁹ Indeed, Laurence Monnais has used BCG vaccination as an example of the colony marching ahead of the metropole in providing preventive health care and responding to local needs.Footnote ⁹⁰ Yet a closer look suggests that there was, in fact, much debate over the proper means of combating TB in Indochina, and that the consensus that emerged between colonial officials and Pastorians had more to do with BCG’s political usefulness than its humanitarian potential.

As Calmette and others made the case that TB was an imperial problem, other actors in France and Indochina were taking an interest in the issue. In the interwar years, the CNDT attempted to expand to Indochina, organize stamp sales, fund dispensaries and sanatoria, and provide public education. Their hygienist concerns intersected with those of Vietnamese doctors and local notables, who used the vocabulary of social hygiene to discuss controversial political issues around labour and public expression. For administrators, political radicalism posed the greatest threat to French rule during the interwar years. Intellectuals such as Nguy$${{\rm{\tilde \hat e}}}$$n An Ninh, Tr$${{\rm{}}}$$n Huy Li$${{\rm{\hat }}}$$u, and Bùi Quang Chiêu founded newspapers and journals such as La Cloche Fêlée or Đông Pháp Th $$\`o '$$i Báo, as well as revolutionary groups such as the Young Annamites and the Secret Society of Nguy$${{\rm{\tilde \hat e}}}$$n An Ninh. As various incidents – the arrest of Nguyen An Ninh, the Yen Bay rebellion, to name but two – escalated and led to mass boycotts and strikes, French officials clamped down on associational life, believing it to be a road to radicalization.Footnote ⁹¹ Repression peaked in 1930–31, when French forces responded to peasant riots by machine-gunning protests from the air, burning down ‘communist’ villages, and executing those suspected of seditious activity.Footnote ⁹²

Meanwhile, workplace rights rose to the top of both Vietnamese and French concerns. By 1928, the labour force on French plantations had ballooned to nearly 100,000 labourers, a small fraction of the expanding Vietnamese population, but economically significant nonetheless. Colonial health officers noted that the establishment of hévéa (rubber) plantations by companies like Michelin had caused unprecedented epidemics of malaria.Footnote ⁹³ Responding to episodes of mass worker desertion, such as at the Mimot plantation where 300 workers left their posts in reaction to mistreatment, the French government sent out experts to study the conditions of labour and life in rubber plantations. These studies became the basis of official and popular exposés that uncovered unsanitary housing conditions, routinely violent managers, starvation, and forced hiring.

Vietnamese workers quickly learned how to take up the language of social hygiene in making claims against their employers. In the late 1920s, mandarins like Bui Bang Doan inspected plantations and chronicled instances of abuse, and Vietnamese council members criticized the French medical system for only catering to rich city-dwellers. Vietnamese doctors and activists increasingly articulated concerns over epidemic disease, labour conditions, and the inadequate medical response as specifically anti-Vietnamese in nature.Footnote ⁹⁴ In 1927, the government-general set up a Department of Labour and issued a series of decrees that reformed labour law, established retirement funds, and strengthened public health provisions.Footnote ⁹⁵ As usual, these laws looked better on paper than in practice. Around the country, however, more and more Vietnamese came to see health as a political issue. Through the work of indigenous midwives, the establishment of local medical schools, and public education campaigns, sanitationist ideas, particularly about the questions of infant care, spread among young Vietnamese, creating further enthusiasm for social hygiene.Footnote ⁹⁶

The arrival of the CNDT in 1926 brought questions of social hygiene and TB prevention into the centre of Indochinese politics. The construction of new dispensaries and sanatoria was largely financed through the sale of stamps, as in France. As the society’s finances lagged behind its expanding reach, representatives of the CNDT wrote to officials and medical experts in Indochina, encouraging them to join the ‘defence against the social danger’ and become a part of the charitable network.Footnote ⁹⁷ Indochinese administrators initially rejected the idea, since it involved creating non-governmental Franco-Vietnamese associations. The first proposal of Senator André Honnorat was returned with a note saying ‘This does not concern local affairs and deals with an issue not immediately useful to the Annamite people.’Footnote ⁹⁸

The reluctance of the Government-General, however, was superseded by pressure from both above and below. The CNDT’s proposal aligned perfectly with the Ministry of Colonies’ new emphasis on social hygiene, leading the minister to pen a strongly worded reminder to the Indochinese governor-general about the ‘capital demographic importance’ of the TB problem.Footnote ⁹⁹ Meanwhile, CNDT propaganda began to spread in Vietnam, largely through Camille Guérin’s efforts to raise awareness about the role that childhood infection played in the development of TB, and to highlight the importance of proper prophylaxis and maternal care. These publication stressed the cost of TB to ‘the social capital’, the importance of better living and working conditions, and the need for collective action to combat the disease – the hygienist aspects of TB prevention, largely copied directly from metropolitan French examples.Footnote ¹⁰⁰ Such brochures were quickly translated into Vietnamese and distributed in schools and hospitals in Saigon, Cholon, and elsewhere.Footnote ¹⁰¹ Soon, a corps of Vietnamese doctors and officials began expressing support for extending anti-TB prophylaxis, constructing dispensaries, and organizing anti-TB social movements in Indochina itself. Joining forces with French doctors and medical officers, these activists founded a number of associations dedicated to selling TB stamps and building a movement for social hygiene: by 1930, these included the Central Committee for Mutual Aid, the Anti-Tuberculosis League of Tonkin (LAT), the masonic Fraternité Tonkinoise, the Pierre Pasquier Dispensary, the Anti-Tuberculosis League of Cochinchina, and the League of the Friends of Annam.Footnote ¹⁰²

Vietnamese doctors used even marginal cases of infection to lobby for the expansion of workers’ rights and the improvement of working conditions. In 1939, Dr Hoang Mong Luong filed a report with the Resident of Annam, demanding greater attention to TB among the giáo su’ (secondary school teachers) in a township near Hué. The number of recorded cases turned out to be very low – ten over three years among a population of 215 teachers – but, as Luong argued, the social danger posed by the disease was much greater. Infected teachers could spread TB in the classroom before developing symptoms, but, crucially, the rise in confirmed cases signified ‘deplorable hygienic conditions in which our giáo su’ live: lack of physical exercise, poor nutrition and probably overworking’.Footnote ¹⁰³ To combat TB, Luong suggested a number of measures ranging from the clinical – regular check-ups and X-rays for suspected cases – to the social: limiting the number of students per teacher to fifty, reduction of working hours, raising wages to ‘improve nutrition’, and organizing a free ‘centre of vacation for tired teachers, whether at a beach or a hill station’.Footnote ¹⁰⁴ The language of social hygiene enabled Vietnamese doctors to pivot medical discussion towards the politics of labour.

In response, French officials and experts used the rhetorical force of BCG to undercut social hygiene, and to restrict the scope of TB prevention to vaccination. BCG was both cheap and did not endanger French control over questions of labour and associational life. This dynamic played out in exemplary fashion in the meetings of a 1932 committee to study the use of TB stamp sales.Footnote ¹⁰⁵ Most French members in the committee suggested modest initiatives, ranging from expansion of BCG vaccination to the construction of a few new dispensaries. One member, Dr Bourgin, however, joined two Vietnamese experts, Dr Lan, and Dr Cua, in proposing a thorough overhaul of the TB prevention system. The proposal focused on three pillars: ‘protect – instruct – cure’, again drawing from the CNDT’s hygienist lexicon. Lan and Cua outlined a nine-year plan for radically expanding TB facilities, constructing new isolation wards within existing hospitals, producing popular educational and propagandistic films, building seaside resorts for Vietnamese children, buying mobile dispensary units, and, in the last stage, constructing seaside and high-altitude sanatoria for adult Vietnamese patients. This effort would have required a vast expansion of state funding for TB prevention: the estimated budget, as one councillor noted, was over 360,000 piasters, nearly ten times the money raised by the sale of stamps, creating immediate opposition among administrators.Footnote ¹⁰⁶

There were other, political, reasons for the French to resist such proposals. Vietnamese hygienists’ plans would have further empowered voluntary associations and Vietnamese labour. In order to secure the trust of the population, experts such as Tr$${{\rm{}}}$$n Hàm Nghi$${{\rm{\hat }}}$$p argued that it was crucial to staff the new dispensaries with ‘Annamite nurses, women of excellent general education, high technical skill and exceptional moral values’.Footnote ¹⁰⁷ Others suggested training Indochinese doctors in every province and equipping them with a mobile sanitary unit, to improve anti-TB propaganda.Footnote ¹⁰⁸ Finally, Bourgin and others recommended using money from the sale of stamps to construct ‘larger and more hygienic housing’ for the Vietnamese in cities like Saigon, Hanoi, and Hué.Footnote ¹⁰⁹ While always couched in the language of social hygiene, the recommendations of Vietnamese doctors and their French allies sought to increase the power and social standing of Vietnamese professionals, address the social injustices in the domains of labour and housing, and direct more power to voluntary associations.

In response to the political problems raised by the CNDT’s social hygiene model of TB prevention, the government used research on BCG to limit the scope of medical intervention. Officials argued that the use of the ‘progressive’ BCG was sufficient to protect against TB, therefore obviating the need for further reforms and for the expansion of associative life. When the LAT applied to the government to approve the society’s constitution, the Resident Superior ordered a medical expert to offer his opinion on the mission of the association. The local director of health broadly disapproved of the wide mandate of the society by leaning on Calmette’s contagionist thesis. He noted that, unlike in France, where people worked in factories, working conditions in Indochina had little impact on the spread of TB. Plantations had fresh air and plenty of space, making contagion more difficult: ‘Workers are less affected since they lead an active life in open air and they live in paillottes open to all kinds of bad weather; agricultural workers are even less affected for similar reasons.’Footnote ¹¹⁰ In this rendition, the low quality of Vietnamese housing and the harsh conditions of the indigénat became virtues, instead of contributing factors to disease.

The real problem, the doctor argued, was infant mortality, which could be solved with BCG: ‘the war against tuberculosis has its only weapon in the form of anti-tuberculosis vaccination with BCG; other means, without meaning to neglect them, have only a secondary importance. In fact, with the exception of vaccination, no other prophylactic measure can take hold among this carefree population completely ignorant of the laws of hygiene.’Footnote ¹¹¹ Here, the doctor combined the scientific rhetoric of contagion, moralist language about the Vietnamese constitution, and a technical insistence on the reliability of BCG. He convinced the administration to curtail the permitted range of activities of the LAT, limiting its ability to purchase real estate and to publish educational material, and placing it under close police surveillance for years to come.Footnote ¹¹²

Officials similarly used BCG to limit action in the committee for distributing the anti-TB stamp funds. Administrators were reminded that BCG was the colony’s ‘first line of defence’ and provided gratis by the Pasteur Institute. Anti-TB stamps were to be used to further fund the TB laboratories of the Pasteur Institute. As the president of the ad hoc committee argued: ‘In order not to disperse our efforts, we ought to focus them on BCG, because BCG represents the future.’Footnote ¹¹³ Eventually, the ambitious proposals of Vietnamese doctors were all rejected, with a single concession to provide more public propaganda, but only if it was limited to advertising the benefits of BCG.Footnote ¹¹⁴

Some Vietnamese and French doctors in Indochina remained committed to social hygiene. In Cholon, city officials showed enthusiasm for préventoriums, social assistance funds, and studies of schoolchildren’s housing. Debates at the Far Eastern Association for Tropical Medicine, and at venues such as the Bandoeng Conference emphasized the importance of the social conditions of life; these were in turn amplified by similar calls within the International Labour Organization and the League of Nations.Footnote ¹¹⁵ Yet officials in Paris, Hanoi, and elsewhere in the colonies, supported by Pastorian expertise, pushed to expand BCG and to limit other kinds of interventions – dispensaries, vacations, improved nutrition, limiting working hours, and expanded public education – even as they lacked evidence of the vaccine’s actual impact. Calmette himself admitted that, in places like Indochina, the lack of état-civil made determining the variance of death rates between vaccinated and non-vaccinated patients effectively impossible.Footnote ¹¹⁶ Official reports admitted that, while tuberculin skin tests confirmed the general presence of TB around Indochina, the statistics were not sufficient to observe changes in infection rates over time.Footnote ¹¹⁷ In defending his research to an international public, Calmette used high vaccination numbers from Indochina to argue that the vaccine was trusted and safe, and animal testing in Guinea to argue for its efficacy, while his collaborators in Algiers, which did have an état-civil, began to prepare a trial to properly test its effectiveness.Footnote ¹¹⁸

Ultimately, changes in TB morbidity could not be determined, and it is telling that officials did not try to find out. Instead, they cited the very inability to produce comparative statistics as a reason for continuing BCG vaccinations, which colonial health experts saw as ‘subject to incontestable proofs’.Footnote ¹¹⁹ For administrators, the political power of BCG to counter Franco-Vietnamese demands for social reform sufficed. After the Second World War, as the geographical and political contours of the French empire changed, organizations such as the World Health Organization and the United Nations put new emphasis on rural health, and as antibiotics, such as streptomycin, created new, powerful means to combat TB, the technopolitical importance of BCG disappeared.Footnote ¹²⁰

Administrators elsewhere also embraced BCG as a political alternative to reform.Footnote ¹²¹ Pastorians themselves observed this. In 1936, Dr Morin, the director-general of the Indochinese Pasteur Institutes noted that British and Japanese officials were taking an interest in BCG: ‘because they consider it impossible to fight against tuberculosis by improving the living conditions of coolies, [the British and the Japanese] are taking an active interest in BCG vaccination’.Footnote ¹²² For precisely the same reason, so did the French. Although Calmette’s epidemiology had opened up a path for debating labour and associational politics under the rubric of social hygiene, the technopolitics of BCG vaccination blocked this avenue.