Abstract
India has often been seen as a land of tuberculosis, which continues to pose vexing challenges to the entire issue of public health. Tuberculosis has essentially been identified as an incurable and deadly disease, which affected largely the poverty-stricken masses of the Indian society. In the present monograph, the incidence of tuberculosis in twentieth-century India has been discussed from the point of view of the contemporary and the past possibly setting the stage for a discussion on the history of the disease and how it was comprehended by colonial, national and international agencies. In colonial India, tuberculosis had posed a severe threat to mankind and there had been various initiatives by both the state and the non-state agencies to eradicate the face of this disease. The narrative is mainly based on an analysis of eight decades of discussions, surveys, vaccinations and drug distributions which had all formed a part of the official disease control programme. There is also a short discussion of the somewhat promising results in respect to the eradication of the disease, drawn from the reports of the last two decades. Interestingly, the history of tuberculosis control in India has been analysed in terms of four interconnected contexts, possibly to draw the attention of the students of history and medicine, health policymakers and scholars interested in developments in post-colonial India. In the 1950s, the introduction of the Bacillus Calmette-Guerin (BCG) met with severe oppositions from the medical specialists in Madras, who favoured a form of domiciliary chemotherapy with antibiotic drugs, which later was integrated into the WHO’s global directly observed treatment policy. By the 1960s, the national efforts to eradicate tuberculosis was acclaimed in the developing world as the model and the results of the Chingleput trial seriously questioned the validity of the BCG vaccination.
It has been argued that history of tuberculosis was replete with contradictions, casting gaps between prevention and cure, those of contagionism and environmentalism, clinical medicine and public health and also between ‘vertical’ and ‘horizontal’ control strategies. The very definition of tuberculosis went through processes of framing and reframing over a period of several decades. Yet, the most interesting fact is that the understanding of the nature of this disease was often influenced by the thought processes prevailing in the colonial and the post-colonial state systems. In fact, the colonial authorities in the later period sensibly felt the need to control the disease, which was largely dictated in terms of governmental obligation towards a subject and alien population. The post-colonial public health initiatives, as has been argued, were largely influenced by the pace of developments, which went under the rubric of de-colonisation. The approaches in both the colonial and the beginning of the post-colonial period had been informed by transnational perceptions involving Western missionaries, Western doctors and European health personnel. The majority of them were of Scandinavian descent and they remained involved with the administration of BCG vaccine and antibiotic treatment in the years following the Indian independence.
Significantly, the entire narrative on tuberculosis leads to a more deeper understanding of Indian identity, which emerged from the cultural encounter with modernity. In fact, there had been a great deal of debates as to whether tuberculosis in India was identical with the form of the disease which had spread in the West. There were many influenced by Gandhi, who believed that there was an element of Indianness when came to defining the disease and it was too often opposed to the articulation of modernity in the Indian situation. Yet, post-colonial India was drawn into modernism and the search for scientific and industrialised modernity clearly proved that Western models were to be accepted with the least bit of opposition.
The post-colonial situation was essentially dominated by two forms of medical strategies, one being the BCG vaccination campaign, which represented the high modernists elements, the very replica of an authoritarian and regulatory form of governmentality, the other being domiciliary chemotherapy, symbolising the liberal version of the state system. However, high modernist ideology, it has been rightly argued, had failed to transform the lives of the Indian patients into a ‘self-governing’ subject. This actually had forced many social theorists to re-examine the issue of modernity in South Asia. The author needs to be complimented for his candid admission that though there is no dearth of information on tuberculosis and its eradication, the present account has been largely a state-centric one, the emphasis being less on non-state charitable institutions and private practitioners who operated outside the state surveillance. The other major limitation that has been pointed out is that it is an account that only represents the views of the English-speaking elite, who formed the majority among the medical scientists in India. In view of such limitations, the interesting side of the doctor–patient narrative has been found to be missing. The version of the poor and the illiterate hardly ever finds mention in the history of tuberculosis control in India. In colonial India, the explanation of the incidence of tuberculosis was hardly part of a single discourse; rather it oscillated between theories of race and those of climate. The medical scientists who believed in the race theory felt that populations or races which had no history of exposure to tuberculosis were the easy victims of the disease, since they lacked a proper immunity system. However, those who believed that climate was the most important factor based their arguments on how temperature affected the living conditions of the people. However, there was yet another approach which interpreted tuberculosis as a ‘social disease’, something that was linked to indigence and overcrowding. There were also attempts to explain the incidence of tuberculosis from the point of view of malnutrition. In other words, such attempts sought to prove that tuberculosis was a disease of development and urbanisation.
Interestingly, throughout the colonial period, the incidence of tuberculosis was always underplayed and was rarely seen as something very alarming in terms of public health. The statistical evidence seemed to have convinced the colonial officials that the prevalence of such diseases was more in urban localities and the figures were much lower in the countryside. By the time the British had decided to leave India, there was also the implicit belief that as India became more urbanised and industrialised, the figures for tuberculosis would be on the rise. The old racial assumptions as held by the Dutch medical missionary Christian Frimodt-Moller publicised the opinion that coloured races had lesser immunity which was in consonance to the thinking of the European middle classes settled in India. In fact, such ideas had encouraged Mark Harrison and Michael Worboys to publicise the ‘racial turn’ in the writing of tuberculosis of the 1930s. However, some of the Indian researchers also seemed to have been influenced by the very thought that tuberculosis was caused by the customs and behaviour of the Indians. Y.G. Shirkhande of the King Edward Sanatorium of the United Provinces essentially favoured a gender perspective when it came to defining the disease and linked it with pardah, child marriage and early pregnancy. This was possibly dictated by figures which showed that tuberculosis affected women more than men. Nonetheless, despite an overwhelming belief that tubercular lung disease could be cured by Western medical methods, the formation of the Tuberculosis Association of India in the 1930s led to the idea that tuberculosis was also a social problem and that educational activities had to be promoted to remove much of the misconceptions related to this disease. However, all this seem to be quite different from what Gandhi believed so far as the eradication of tuberculosis was concerned. Interestingly, as the author had pointed out, Gandhi did not remain strongly opposed to Western medicine throughout his life. In some cases, he felt that Western medicine was needed for ensuring better health standards for Indian mothers and infants though he was very sceptical of the way in which vaccine was prepared, because to him it hurt religious sentiments. Yet it was his writings that generated a great deal of debate in India whether Western medicine would prove to be the curative for all health problems in India. But Gandhi’s assumptions represented some bit of a hotchpotch amalgamation of resistance and acceptance vis-à-vis Western medical efforts, possibly explicating the fact as why it found less acceptance among the new ruling classes in post-independent India.
The author needs to be complimented for making the assertions that relocation of resources to deal with the problem of tuberculosis was paltry, blurring the distinctions of the initiatives of both the colonial and post-colonial state. In the last years of the colonial period, as has been earlier reiterated, despite the debate in the official circles, there was little action, the same being for the post-colonial state. The points that have been made very strongly in the monograph is that the Indian state should have spent more of its budget on health and that international aid agencies should have been more concerned with the problem of tuberculosis. In fact, there was hardly much admission by both Indian doctors and WHO policymakers that every fifth Indian could be a carrier of tuberculosis. The author has found problems with the approach of the post-colonial state, which went too much into social planning without much concerted action at the grassroots level. The issue here is often something that is related to a paradox between thought and action, leading to deficiencies and delays. It is highly doubtful whether the tall assertions made by the proponents of domiciliary chemotherapy were successful in bringing down figures related to the disease. The problem that has been identified for the real lack of understanding of tuberculosis and the possible methods to eradicate it is something which is related to modernity. The problem with high modernism that has been singled out by the author remains something which is multidimensional in the context of post-colonial India while it demonstrates to some extent the assertions of James C. Scott that high modernism was nothing but a display of authoritarian power of a muscular state. The other consequences of it were related to the differences in the perceptions of the bureaucracy, the differences between central and state planning, the increasing distance between thought and delivering the services and the continuing lack of financial resources. The author is more inclined to accept the recommendation of Gandhi and the Bhore Committee which he believes were both Indian as well as modern in the field of health and should have been incorporated within the high modernist medical interventionism by the Nehru government. Perhaps, it was the contradiction between the colonists and the nationalists and the divide within the Indian elites in the post-colonial situation that remained responsible for half-hearted approach towards the eradication of tuberculosis, something which has been brilliantly narrated in the pages of the monograph.