Decolonizing International Health: India and Southeast Asia, 1930-65 (Cambridge Imperial and Post-Colonial Studies)

Decolonizing International Health India and Southeast Asia, 1930–65

Sunil S. Amrith

Cambridge Imperial and Post-Colonial Studies Series General Editors: Megan Vaughan, King’s College, Cambridge and Richard Drayton, Corpus Christi College, Cambridge This informative series covers the broad span of modern imperial history while also exploring the recent developments in former colonial states where residues of empire can still be found. The books provide in-depth examinations of empires as competing and complementary power structures encouraging the reader to reconsider their understanding of international and world history during recent centuries. Titles include: Sunil S. Amrith DECOLONIZING INTERNATIONAL HEALTH India and Southeast Asia, 1930–65 Tony Ballantyne ORIENTALISM AND RACE Aryanism in the British Empire Anthony J. Barker SLAVERY AND ANTI-SLAVERY IN MAURITIUS, 1810–33 The Conflict between Economic Expansion and Humanitarian Reform under British Rule Robert J. Blyth THE EMPIRE OF THE RAJ Eastern Africa and the Middle East, 1858–1947 Roy Bridges (editor) IMPERIALISM, DECOLONIZATION AND AFRICA Studies Presented to John Hargreaves T. J. Crib (editor) IMAGINED COMMONWEALTH Cambridge Essays on Commonwealth and International Literature in English Ronald Hyam BRITAIN’S IMPERIAL CENTURY, 1815–1914: A STUDY OF EMPIRE AND EXPANSION Third Edition Robin Jeffrey POLITICS, WOMEN AND WELL-BEING How Kerala became a ‘Model’ Gerold Krozewski MONEY AND THE END OF EMPIRE British International Economic Policy and the Colonies, 1947–58 Ged Martin BRITAIN AND THE ORIGINS OF CANADIAN CONFEDERATION, 1837–67

W. David McIntyre BACKGROUND TO THE ANZUS PACT Policy-Makers, Strategy and Diplomacy, 1945–55 Francine McKenzie REDEFINING THE BONDS OF COMMONWEALTH 1939–1948 The Politics of Preference John Singleton and Paul Robertson ECONOMIC RELATIONS BETWEEN BRITAIN AND AUSTRALASIA 1945–1970

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Decolonizing International Health India and Southeast Asia, 1930–65 Sunil S. Amrith

© Sunil S. Amrith 2006 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2006 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN 13: 978–1–4039–8593–4 hardback ISBN 10: 1–4039–8593–6 hardback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Amrith, Sunil S., 1979– Decolonizing international health : India and Southeast Asia, 1930–65 / Sunil S. Amrith. p. cm. – (Cambridge imperial and post-colonial studies series) Includes bibliographical references and index. ISBN 1–4039–8593–6 1. Public health–India–History–20th cent. 2. Postcolonialism–India. 3. Public health–Southeast Asia–20th cent. 4. Postcolonialism–Southeast Asia. I. Title. II. Series. RA529.A47 2006 362.10954–dc22

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For My Parents

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Contents List of Tables and Figures

ix

Acknowledgements

x

List of Abbreviations

xiii

Introduction The problem The argument

1 4 11

Chapter 1 Depression and the Internationalization of Public Health The limits of colonial medicine The internationalization of public health Two visions of rural hygiene Bandung, 1937 The ‘modernist’ challenge Conclusion

21 22 26 29 36 42 46

Chapter 2 War and the Rise of Disease Control DDT and disease control Building expertise Planning for the health of the world A new international health organization Conclusion: The ghosts of Bengal

47 48 50 56 63 69

Chapter 3 The Political Culture of International Health Health and the United Nations Envisioning Asia’s health Crisis and sovereignty Public health and the Cold War The birth of technical assistance Rights and technologies of health The argument for public health Conclusion

72 73 76 79 83 85 87 90 98

vii

viii Contents

Chapter 4 Building A New Utopia Projects and policies Health and nationalism A post-colonial discourse? Journeys to health Seeds of doubt

99 100 103 106 108 116

Chapter 5 The Techno-politics of Public Health Human and non-human obstacles Poverty and politics The return of community Rationality and resistance ‘A form of quackery’ Conclusion: the ambiguities of success

121 122 127 130 135 137 146

Chapter 6 The Limits of Disease Control Curing tuberculosis in Madras and Bangalore Problems of policy Dangerous journeys The end of eradication Eradication and evolution The triumph of population control Conclusion: dispersion and ‘medical pluralism’

149 150 156 161 165 170 171 175

Conclusion The effects of health policy Faith and doubt Enduring utopias

179 185 187 190

Notes

192

Bibliography

231

Index

255

List of Tables and Figures Tables 3.1 WHO Income, 1949–57 5.1 WHO/Indian Government BCG Vaccination Campaign in Madras State, 1954–55 C.1 Infant Mortality Rates, 1945–65

91 141 181

Figures 1.1 A Mantri’s House Visit 2.1 Singapore is Sprayed with DDT, 1945 C.1 Estimates of World Population, 1920–60

ix

31 54 181

Acknowledgements I acknowledge, gratefully, financial support from: The Ellen MacArthur Fund of the Cambridge Faculty of History; The Cambridge Commonwealth Trust; Universities UK; Christ’s College, Cambridge and Trinity College, Cambridge. Additional funding for the extensive travel needed to undertake the research came from the Centre for History and Economics; Christ’s College; The Ellen MacArthur and Holland Rose Funds of the Cambridge Faculty of History; the Smuts Memorial Fund of the University of Cambridge, and a Grant-in-Aid from the Rockefeller Archive Centre. Archivists and librarians on three continents have facilitated this research in many ways. I would particularly like to thank the staff of: The Cambridge University Library; The National Archives of the UK; The British Library (and newspaper library); The London School of Economics library; The London School of Hygiene and Tropical Medicine library and archives; The Bodleian Library; The National Archives of India, Delhi; The National Medical Library of India; the library of the All-India Institute of Medical Sciences; the Planning Commission library, Delhi; The Nehru Memorial Archives and Library; the Southeast Asian Regional Office of the World Health Organization, Delhi; The Tamil Nadu State Archives, Chennai; The Hindu’s library in Chennai; The National Archives of Singapore; The National University Library and Medical Library, Singapore; the archives of the International Labour Organization, Geneva and Yale University Library, New Haven. I am particularly grateful to Mrs Murthy at the National Tuberculosis Institute, Bangalore; Carole Modis and Ineke Deserno at the World Health Organization library and archives, respectively; Mme Pejovic at the League of Nations Archives, and Darwin Stapleton, Thomas Rosenbaum and Erwin Levold at the Rockefeller Archive Centre in Tarrytown, New York. I have accumulated a trail of personal and intellectual debts in researching and writing this book, and I can only begin to acknowledge them here. For helpful discussions, advice and support I would like to thank Sabina Alkire, D. Banerji, Susan Bayly, Jens Boel, the late Raj Chandavarkar, Susan Daruvala, Angus Deaton, Shane Doyle, Richard Drayton, B. Eswar, Andrew Hardy, Mark Harrison, John Iliffe, Sriya Iyer, K.S. Jomo, Pratap Bhanu Mehta, Angela Meijer, Thandika x

Acknowledgements xi

Mkandawire, V.R. Muraleedharan, Lion Murard, Thelma Narayan, Francesca Orsini, M.S.S. Pandian, N. Ram, the late C.V. Ramakrishnan, Mohan Rao, David Reynolds, Ralf Richter, Charles Rosenberg, Leo Saldhana, Amartya Sen, Glenda Sluga, Richard Smith, Helen Tilley, Frank Trentmann, Hans Van de Ven, Michael Worboys and Patrick Zylberman. I am grateful to seminar audiences at Cambridge, Manchester, Warwick, and Goettingen for their comments on earlier versions of this material. For their expert comments on draft chapters, I would particularly like to thank Alison Bashford, J. Devika and Simon Szreter. I have benefited enormously from Lincoln Chen’s perspectives as a practitioner of international public health. Sugata Bose was the external examiner of the Ph.D. dissertation on which this work is based; I am grateful for his incisive comments and for his continuing support. An anonymous reviewer for Palgrave helped immensely in the final stages with constructive criticisms of the manuscript. I am especially grateful to those who have guided me through several years in Cambridge. Christopher Bayly’s support and counsel have made many things possible and I am grateful for his continuing generosity and inspiration. Martin Daunton has always been a source of ideas and encouragement and has opened many new avenues for me. The work owes much to all I have learned from Tim Harper; I am grateful for his kindness over the years. Megan Vaughan has been unfailingly supportive, as an examiner of the original thesis, as a series editor, and as a colleague; her own work has provoked many of the ideas here. I am grateful, finally, to the Master and Fellows of Trinity College for providing a congenial environment in which to complete this book. John Lonsdale’s lectures and supervisions on African history when I was an undergraduate remain a highlight of my academic career to date, without his inspiration I doubt I would have embarked on research. The sudden death of Raj Chandavarkar, as this book was going to press, was a terrible blow. Raj did so much when I was a student to draw me to Indian history, and since my arrival as a fellow at Trinity he had been a wonderful colleague and friend; memories of his kindness – and his wicked sense of humour! – will stay with all who knew him. Most of all, I would like to thank Emma Rothschild, who supervised the original thesis from which this book developed: I could not imagine a better or a more generous supervisor. Emma always allowed me complete freedom to follow my own path with this research, while sharing her unerring instinct for finding good stories in unpromising places.

xii Acknowledgements

I have continued to benefit from her wisdom in the process of writing this book. The example of her own work has been an inspiration throughout. For this, and much else, I am very grateful to her. Needless to say, any shortcomings that remain despite all this good advice are entirely my own responsibility. I would like to thank Michael Strang and all at Palgrave for making the process of publication so painless; their friendly efficiency has been much appreciated by this first-time author. One of the pleasures of having completed this book is the chance to acknowledge the support and kindness of some wonderful friends. I would particularly like to thank Sharad Chari, Ai Lin Chua, Tracy Dennison, Abdul Fakhri, Mike Finn, Mark Frost, Nilima Gulrajani, Sarah Hodges, Ananya Jahanara Kabir, Inga Huld Markan, Magnus Marsden, William O’Reilly, Shomikho Raha, Nate Roberts, Florian Schui, Rhiannon Stephens, Rosie Vaughan and Rupa Viswanath. I do not know quite how to thank my family in India (and elsewhere), and John, Barbara and Rachel in England. All of them have helped in ways they may not realize. Above all, I am grateful to my sister Megha, my parents, Jay and Shantha, and my wife Ruth for their love and support.

List of Abbreviations AIIMS BCG DDT FAO IESHR ILO INH IOR LN LNHO NAI NAS NMML NPC NTI OR RAC TNA TNSA UN UNESCO UNICEF UNRRA WHO

All-India Institute of Medical Sciences, Delhi Bacille Calmette-Guérin Dichloro-diphenyl-trichloroethane Food and Agriculture Organization Indian Economic and Social History Review International Labour Organization Isoniazid (anti-tuberculosis drug) India Office Records, British Library, London League of Nations League of Nations Health Organization National Archives of India, Delhi National Archives of Singapore Nehru Memorial Museum and Library, Delhi National Planning Committee National Tuberculosis Institute, Bangalore Official Records of the World Health Organization Rockefeller Archive Centre, Tarrytown, New York The National Archives of the UK (Public Record Office) Tamil Nadu State Archives, Chennai United Nations United Nations Educational, Scientific and Cultural Organization United Nations Children’s Fund United Nations Relief and Rehabilitation Administration World Health Organization

xiii

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Introduction

In the middle decades of the twentieth century, Asia was at the heart of international efforts to create a new utopia: a world free from disease. This is a political, intellectual and social history of those efforts, from the late-colonial era through the first generation after independence. The work is positioned at the boundary between international history, the history of Asian nationalism and decolonization, and the history of post-colonial public health and medicine. These fields come together in my focus on international institutions as a site for the exchange of ideas and policies on disease, welfare and development. The book focuses primarily on India, but suggests that debates and interventions in the field of public health were pan-Asian, sometimes even global, as a result of the intellectual, personal and technological connections forged through international health institutions. As a result, the story takes us from Delhi to Djakarta, Rangoon and Zagreb. The starting point for my analysis is the observation that the problem of Asia’s health emerged, during the inter-war years, in an increasingly transnational arena of debate and exchange. The 1930s saw the rise of a new language and a new set of connections bringing together local experiments in public health scattered from China to India, most of them decidedly on the fringes of state policy. Writing in 1936, Dr A.S. Haynes, a former British administrator in Malaya, who had just completed a tour of Southeast Asia on behalf of the League of Nations, observed that ‘From Bombay to Batavia, from Hanoi and Manila to Colombo, there is no more familiar cry in the newspapers of every country than Rural Reconstruction’. Having inspected medical and sanitary facilities across the continent, Haynes was convinced that ‘among large sections of the rural population in these lands there is occurring a gradual awakening; with the perception 1

2 Decolonizing International Health

of the possibility of improved conditions of life is the growing desire to attain them’. Indeed, he concluded that ‘no longer does all the peasantry live as in the words of the Malay proverb, seperti katak dibawah tempurong – like a frog under a coconut shell, in a tiny world of its own’.1 Haynes’ comments reflected the convergence and contention, in the aftermath of the Depression, of international, colonial, and nationalist ideas about health, focusing particularly on questions of nutrition and rural welfare. The Second World War transformed a sense of the possible with the revolutionary new technologies of disease control that it produced. The insecticide DDT (dichloro-diphenyl-trichloroethane) and antibiotic drugs made it possible to imagine that the control of infectious disease might be a realistic prospect in large parts of the world. Such was the power of the new technology, the images of aircraft trailing plumes of DDT in their wake, that the localized, ‘ecological’ methods of public health advocated by the rural hygienists of the 1930s seemed, to many, outdated. The promise of a world without disease led directly to the establishment of the World Health Organization (WHO) as one of a number of agencies constituting the United Nations (UN) after 1945. Perhaps the most fundamental shift occurring during the war was the emergence of the notion that health was a responsibility of government and a right of citizenship. This was radically different from earlier approaches to public health in the colonized world, where colonial states had never been more than ‘fire fighters’, preventing epidemics and ensuring the productivity of labour. Health, the WHO constitution declared, was a ‘fundamental human right’. The foundation of the WHO coincided with the culmination of anticolonial struggles in India, Indonesia, Burma and Indochina. Looking beyond the immediate crises of war, mass migration and Partition, each of the newly independent countries made plans to develop staterun health services for their populations. In a very short space of time, to possess a health service had become a universal element of the functions of a state; any state. Asian states were not slow in calling in the help of the WHO and other international agencies to assist in the forbidding task of extending health services to the excluded and the dispossessed. Health became part of the broader promise that gripped large parts of the world after 1945: the promise of ‘development’. The WHO, working through and with national governments, set out to transform the world. South and Southeast Asia constituted by far the largest arena for its interventions. Subject to the pressures of the Cold

Introduction 3

War, working with straitened resources, and fighting the charge that public health work would intensify the ‘population explosion’, the WHO found its strength in technology. Moving away from discussions about the social and economic roots of ill health and the structure of health services, the WHO offered targeted interventions as a simple tool of ‘technical assistance’, allowing countries to maximize economic productivity. Starting from myriad ‘pilot projects’ and demonstration sites, the WHO envisaged the ceaseless expansion of its campaigns, using BCG vaccination against tuberculosis, penicillin against the disfiguring yaws, and DDT against malaria. In the minds of the WHO’s medical consultants, travelling from Indonesia to Nepal, inspecting malaria spray teams and venereal disease treatment centres, these disparate attempts to activate new forms of technical expertise assumed the ordered form of a pan-Asian ‘policy’. The techno-centric campaigns against infectious disease engendered much optimism, and an ever-greater sense of ambition in the 1950s. The commencement of a global malaria eradication programme in 1955 encapsulated the sense of mission that emerged not only from international debates, but also from countless local experiments, tied together by the discourse and the practices of international public health. The technology of the 1950s was genuinely effective, and, for many, liberating. The impact of these campaigns upon rates of mortality across the Third World was, in the words of one contemporary observer, ‘amazing’.2 Yet the onward march of technological medicine was never unchallenged. The techno-politics of public health encountered resistance at every turn, belying the notion that the international health campaigns represented a planned triumph of technology over nature. The degree to which internationally administered programmes relied on local agency and improvisation in practice proved uncomfortable for the planners. However effective the biomedical and chemical technologies at their disposal, the architects of disease control confronted constant practical obstacles, requiring constant adjustments to the plans: broken down trucks, interrupted supplies, harsh terrain, and the irruption of politics into the domain of technical endeavours. The questions international public health sought to surmount using technology – questions of poverty, of the limits of state control – asserted themselves unbidden. By the early 1960s, the whole project of disease control and eradication faced serious challenges. The problems inherent in the technocentric campaigns of the 1950s grew to the extent that malaria

4 Decolonizing International Health

eradication slipped out of the WHO’s grasp: insecticide resistance developed; technology could not surmount the fact that much of Asia possessed little in the way of rural health services to detect and report cases of malaria. Similarly, attempts to introduce powerful drugs to treat tuberculosis proved unworkable when the WHO and national health administrations confronted the limits of their control over patients’ bodies and their movements. The earlier charge, that public health would contribute less to ‘development’ than would the control of population growth, became increasingly strident in the 1960s. With the emergence of simple contraceptive technologies, population control began to supplant public health on the international agenda, in Asia above all. This, then, is the basic narrative of this book: it is a story of the origins, rise and decline of a set of ideas about health, illness, and their management on a mass scale, in a regional arena shaped by the crisis and collapse of European imperialism.

The problem International health and international organizations The history of international health can be told as part of a broader story about the rise of international organizations. According to this narrative, recently constructed by the historian Akira Iriye, the increasingly complex manifestations of international organization, both intergovernmental and non-governmental, are a significant trend in the history of the twentieth century.3 Iriye’s work is at the forefront of a move beyond the traditional focus of international history on questions of diplomacy and high politics.4 The ‘new’ international history has begun to take more seriously the importance of cultural exchange and cultural politics; the history of ideas (such as the idea of economic development), and the roles played by non-state actors.5 Technical and scientific matters have always lent themselves especially well to international cooperation, and the field of medicine provides an early and conspicuous example of this exchange. The formal internationalization of medicine can be traced back to professionalization, standardization, and centralization of medical knowledge during the ‘long’ nineteenth century.6 The internationalization of medicine coincided with a gradual shift in medical perception, from a local, ‘classificatory’ view of illness resulting from systems and humours out of balance, to a more circumstantial view of epidemics as singular, limited events.7

Introduction 5

As Charles Rosenberg has argued, however, the collective recognition of epidemics is a gradual and often reluctant process.8 It took the dramatic cholera epidemics that swept Europe between 1830 and 1847 to provoke concerted efforts at inter-governmental cooperation in public health. There was initially much hesitation when it came to concerted action: conflicting commercial interests and different views of disease causation stood against international agreement on quarantine and disease control.9 Eventually, a series of 11 international sanitary conferences were convened, between 1851 and 1903, to coordinate international information and policies on quarantine regulations and the containment of outbreaks of disease. The conferences proceeded haltingly, finding it very difficult to reach agreement. At the sixth of the conferences, held in Rome in 1885, the Italian hosts remarked upon the ‘most complete anarchy’ which continued to reign ‘in quarantine matters’. Indicating the extent to which nineteenth century internationalism had progressed, the Italian memorandum expressed particular surprise that no sanitary convention had yet been agreed, since ‘our epoch is characterized by the vast number’ of international agreements which ‘embrace almost the entire universe’.10 The first International Sanitary Convention finally came into force in 1892. The sanitary convention led to the establishment of the permanent international health organization, charged with overseeing the implementation of the Conventions and undertaking epidemic surveillance: the Office International D’Hygiène Publique, in Paris.11 The move towards internationalization in public health was not simply an official one. The second half of the nineteenth century saw the growth of transnational voluntary activity in the field of public health, exemplified by the International Red Cross, founded in Geneva in 1863 by Henri Durant to send an army of ‘volunteers, motivated by Christian charity, into the battlefields, to make up for shortcomings of military medical organizations’.12 Numerous professional bodies, too, existed on an increasingly international plane. This multiplicity of national and international, public and private organizations is characteristic of international health in the first half of the twentieth century, a period that witnessed significant growth in the range of international institutions concerned with health and welfare. The period after the First World War saw a flourishing of international agreements that ‘embrace almost the entire universe’. The founding of the League of Nations in 1919 epitomized this trend towards internationalization. The Covenant of the League of Nations formed part of the Treaty of Versailles, with its origins in the internationalist

6 Decolonizing International Health

thought of the First World War. The United States government, however, did not ratify the Paris Peace Treaties, leaving the League of Nations compromised from the outset in its function as an organization for collective security.13 Nevertheless, the League of Nations took an early and active interest in ‘social’ questions. In 1920, a Committee on Social and General Questions began work, its concerns ranged from the condition of refugees to the opium trade, the ‘traffic in women and children’, and questions of economic management. The League had a direct involvement, too, in colonial questions. At the end of the First World War, the Ottoman and German colonial territories were assigned to the victorious allied powers as ‘mandates’, divided into three categories according to the ‘stage of development of the territory’. The League’s institution of Mandates heralded a new era of ‘trusteeship’, wherein ‘the well-being and development of such peoples form a sacred trust of civilization.’14 Within this broad context of an internationalization of responsibility for ‘social’ questions, public health naturally became one of the League’s responsibilities.15 The League of Nations Health Organization had its origins in the Epidemics Committee, established in 1918 to coordinate efforts against the epidemics of typhus sweeping Eastern Europe after the First World War. Under the leadership of the Polish physician and bacteriologist, Ludwik Rajchman, the League of Nations Health Organization, in collaboration with the Rockefeller Foundation, extended the boundaries of international health work.16 The League established an epidemiological surveillance station in Singapore, and convened expert commissions of enquiry on subjects ranging from tuberculosis and malaria to biological standardization. In the aftermath of the Depression, the League’s health committee became more radical, moving beyond narrow technical discussions to consider the deeper social and economic roots of illness.17 A defining feature of the League’s health organization was the relative autonomy it afforded to independent ‘experts’ in relation to government representatives. The League initially confined its interest to Europe, and particularly Eastern Europe, but I will argue in this book that Asia (and Africa) soon became important areas of concern for the organization. Throughout its life, the League of Nations Health Organization had a close working relationship – intellectual, institutional, and financial – with the Rockefeller Foundation, which expanded its own work in international health during the inter-war period.18 Following the early work of the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease from the southern states of the USA, the Foundation

Introduction 7

established its International Health Division in 1913. The health division played a role in war relief during the First World War, and proceeded to initiate research-driven public health campaigns in Europe, Latin America, South Asia, and China, targeting yellow fever, malaria, and tuberculosis, as well as developing medical education.19 From the late 1920s, the Foundation focused increasingly upon laboratory research, reflected, for example, in the Yellow Fever Commission’s efforts to trace the contours of the global distribution of the disease.20 The Foundation also established a series of rural health units, in 17 countries by the 1930s. Recent histories have gone beyond narrowly ‘instrumentalist’ or ‘idealist’ approaches to the Foundation’s health work, highlighting both the relative autonomy of the scientific networks it established, and the ways in which the Rockefeller Foundation’s initiatives were appropriated and adapted by a range of local actors. A prosopographical approach has proved particularly fruitful, highlighting the personal and intellectual connections forged by the Foundation’s networks that crossed both national and institutional boundaries.21 On one view, then, the establishment of the WHO under the auspices of the UN organization in 1946 (its constitution was ratified in 1948) might appear to mark the culmination of more than a century of internationalism in health. Certainly, this narrative was widely accepted at the time of the WHO’s inception. At the opening meeting of the WHO’s preparatory commission, Andrija Stampar, a Yugoslavian physician who had played a major role in promoting ideas of rural public health in the 1930s, submitted a lengthy memorandum that began with an historical narrative of the rise of international health, from the Sanitary Conferences of the nineteenth century to the League of Nations. Each stage, in his view, represented an extension of international responsibility, and an expansion of the power of international expertise.22 Colonial and post-colonial health The underlying model in much of the literature on internationalization is one of diffusion, with international organizations and transnational networks covering more and more of the world over the course of the twentieth century, gradually stretching to encompass Asia and Africa. Yet a very different narrative about the globalization of modern medicine emerges from the historiography of colonial medicine. This literature is founded upon a much more sceptical view of ‘science’ than that taken by the historians of internationalization.23

8 Decolonizing International Health

The starting point of this alternative narrative is that to speak of ‘global’ health is to speak of the expansion of Western medicine as an inherent element of imperialism, and thus also of a history of violence and domination which the liberal or humanitarian narrative of internationalism obscures. The expansion of ‘Western’ medicine was part of a centuries-long process of expansion of trade, migration, and communication. The earliest priority of imperial medicine was the health of European soldiers. Philip Curtin has shown the extent to which the tropical world was a ‘white man’s grave’ in the late eighteenth and early nineteenth centuries. The dramatic improvement in the health of Europeans in the tropics, over the course of the nineteenth century, owed much to the improvisations and empirical adaptations of military surgeons and sanitary engineers and often preceded the medical advances of the era.24 Colonial medicine was equally concerned with ensuring the reproduction of labour, focusing on the health of slaves and, later, ‘free’ plantation labourers.25 With the consolidation of imperial control in the nineteenth century, medicine became an increasingly important ideological justification for empire, and an essential part of the self-image of ‘civilizing’ imperialism. A central concern of this historiography on colonialism and medicine has been the question of how medicine related to colonial power over ‘native’ societies and economies, bodies (and souls). At the risk of generalizing about an increasingly diverse literature, the fundamental proposition of work on colonial medicine is that biomedicine was a constitutive element of colonial power. Modern medicine served both as a symbolic legitimation of colonial rule, and as a means for the colonial state to regulate and discipline the bodies of colonial subjects.26 David Arnold, in one of the pioneering works in this field, argued that the diffusion of western medical practices in India played an important role in the increasing regulation of colonial subjects by an expanding state.27 Medical discourse demonstrated the ‘superiority of Western science over the “inertia” and “prejudice” of the East’, thus ‘promoting the security and legitimacy of colonial rule, and concurrently eliminating or subordinating all rival systems of authority’.28 Writing about British colonial Africa, Megan Vaughan has argued that ‘medicine and its associated disciplines played an important part in constructing “the African” as an object of knowledge, and elaborated classification systems and practices which have to be seen as intrinsic to the operation of colonial power’.29 However, unlike histo-

Introduction 9

rians who see colonial medical discourse in monolithic terms, Vaughan illustrates its inherent limitations.30 She suggests that whilst colonial medical discourse constructed an image of an uncontrolled, pathological African sexuality, in practice, the impact of colonial medicine in colonial Nyasaland (now Malawi) was limited. Colonial medical officers were seldom willing to follow through on the implications of their constructions of ‘the African’.31 From the early twentieth century, there emerged a strand of thought which suggested that though diseased and dirty, ‘native’ bodies could ultimately be reformed into the bodies of hygienic citizens – a conversion no longer dependent on conversion to Christianity; the language of mission was secularized and turned towards the question of maternal and child health.32 Led by more self-consciously ‘progressive’ colonies like the Philippines under American rule, or the Dutch East Indies, colonial governments began to talk more about the health of indigenous populations. Often, as I will argue in these pages, the shift began on the fringes of the state, in the discussions and activities of an increasingly mobile group of nutritionists, reformers and nationalists which were then taken up, almost defensively, by colonial states. Some historians have seen this shift in terms of a more fundamental change in the nature of colonial rule, encapsulated by Michel Foucault’s notion of the ‘governmentalization of the state’.33 This was a process – which Foucault traced to the second half of the eighteenth century in Europe – whereby ‘the welfare of the population, the improvement of its condition, the increase of its wealth, longevity [and] health’ become the ‘ultimate end of government’.34 Although Foucault neglected resolutely the question of colonialism, historians have seen a process of governmentalization at work in Europe’s colonies, albeit in a way shaped by the racial divide between colonizer and colonized.35 As a result of the governmentalization of colonial states, argues Warwick Anderson, Native bodies were increasingly recognized not simply as the body of the Other, but more importantly perhaps, as the body of the worker, or the body of the future worker’s mother. These were bodies to be studied, surveyed, disciplined and, when necessary, reformed to ensure their efficiency as parts of the emerging world system.36 Across Asia, nationalist thinkers and activists responded to the governmentalization of colonial states through a process of appropriation and

10 Decolonizing International Health

translation. They turned the colonial discourse about the welfare of the population into claims of entitlement – Asian nationalists argued that they could care for the welfare of ‘their’ populations better than alien colonial governments.37 Into the 1930s, colonial states remained content to secure welfare through the small network of voluntary associations that had developed on the fringes of the state, from missionary organizations to cooperative societies.38 Yet such was the gulf between the tiny realm of ‘civil society’ and the mass of the population in most parts of Asia that many nationalists – and, by the 1940s, some colonial administrators too – believed that the ‘population’ could only be acted upon by the state.39 Not the least consequence of this was to make the capture and exercise of centralized state power an absolutely fundamental aspiration of maturing nationalist movements across South and Southeast Asia.40 At the moment when nationalists across Asia took over colonial states, a wide set of technologies for the government of the population were freely available for adoption and adaptation.41 Amongst these were new technologies to control mortality. International organizations like the WHO played a crucial role in circulating and legitimizing new techniques for the government of health and illness. The WHO acted on a scale above the nation, surveying and seeking to improve the health of the world (or, less ambitiously, of ‘Southeast Asia’ or the ‘Eastern Mediterranean’). Individual states were subject to certain ways of knowing (reporting to the WHO the ‘causes of death’ each month in standardized form),42 and intervening (following acceptable and legitimate policies of disease control). Does this represent a globalization of colonial governmentality? Randall Packard has argued that the ‘hegemony’ of the WHO in the international arena allowed the organization to incorporate large populations into its exercise of governmental power, turning them into more productive workers and opening their lands while securing their ‘hearts and minds’ against communism.43 I would suggest, however, that there is a danger in presenting the rise of colonial and post-colonial governmentality in too monolithic a fashion. It is possible to exaggerate the power of government (and, consequently, of international organizations) to transform or even to understand the ‘regularities’ governing the population. It is important to remember that for all of the rhetoric about the welfare of the population, colonial states neglected public health to a remarkable degree. Colonial public health was intrusive, but it was also fundamentally exclusive. It

Introduction 11

touched a tiny proportion of indigenous populations. Historians of India have written that a ‘critique of the colonial state [should] concentrate on its inaction, if not complete dereliction of responsibility in public health’ rather than on rare moments of intensive intervention, as during the plague epidemic of the 1890s.44 There is a fundamental tension here, and it recurs throughout this book; a tension between evidence of the governmentalization of colonial and post-colonial states, bolstered by international organizations, and the equally compelling evidence for the weakness, the absence, and the ineffectiveness of repeated interventions – colonial, national and international – to govern the health and welfare of large populations. More broadly, the juxtaposition of the international and colonial historiographies raises questions that motivate the analysis that follows: did the internationalization of public health emerge from the activities of a vanguard of cosmopolitan doctors, or from the inexorable process of governmentalization, itself a response to the challenge of governing growing populations increasingly integrated into the world economy? What role should we accord to ideas and imagination relative to ‘interests’ in explaining the development of international public health? What exactly is the relationship between colonial, national and international public health? In what sense was international public health post-colonial?

The argument Locating international health: ‘Southeast Asia’ The field of public health in mid-twentieth-century Asia was, irreducibly, both transnational and international. The problem of the health of the vast majority of Asia’s population emerged with greater urgency as a result of transnational (initially trans-colonial) debates between nutritionists and rural health officials, channelled through the primary international organization of the time, the League of Nations. The League’s reports, its statistics on health and universal standards, bolstered the arguments of nationalists and activists across Asia, who used this information to mount a critique of colonial neglect. Colonial states, in turn, were often goaded by the spotlight of the League of Nations into defending their records in the field of health and welfare, submitting lengthy reports that began to systematize ‘health policies’ that were, in reality, disparate and haphazard. A model of ideas moving from metropolitan core to colonial periphery does not capture the complexity of the ways in which ideas about

12 Decolonizing International Health

health moved through Asia in the 1930s. International public health first arrived in Asia with the visits of Eastern European physicians (from Europe’s own ‘periphery’) working for the League of Nations in China (on the margins of European imperial control in Asia), and funded by the Rockefeller Foundation. From there it spread through reports, tours of inspection, statements and published statistics that began to constitute a discourse on ‘public health in the Far East’. The Second World War cemented a shift, already underway in the 1930s, towards the notion that science, technology and expert knowledge ought to be employed by the State, supported by international organizations, to bring about a planned transformation of social and economic life in Asia and Africa. The WHO, on this view, emerged out of a widely shared faith that ‘modern’ methods of disease control, like strategies of economic management or progressive labour policies, could be standardized and implemented in a rational manner by a new generation of professional technocrats.45 Coinciding with the moment of decolonization for many Asian states, the new organizations established after 1945 were more consciously inter-national than the League of Nations, recognizing the primacy of the nation state as the appropriate agent for carrying out such policies. The central role of the WHO, from the 1940s onwards, was as a site for the formulation of goals and the establishment of the bounds of possibility in public health policy. The WHO was enthusiastically embraced by so many post-colonial governments because, to adapt Frederick Cooper’s characterization of international labour policy, the WHO ‘provided a forum at which the ideas of progressive … policy could be detached from their specifically colonial context, and slowly and subtly shifted from a discourse among colonial powers to a discourse among independent nations’.46 By disseminating universal norms (what sociologists have called the assumptions of ‘world society’) the WHO could govern what it meant to speak of ‘health policy’ (and, of course, what fell beyond the realm of ‘health policy’), to such an extent that modern public health meant something similar in states with widely different political cultures.47 India played a central role in shaping this growing consensus, and formed the nodal point in a network of expertise and policies that spanned Southeast Asia, but which touched some parts of the region more than others. This can be explained by the intersection of epidemiological, imaginative, and political geographies. First, India presented a uniquely complex and internationally important disease environment, both because of its size and its diversity. Now integrated

Introduction 13

within a state that claimed to put the welfare of the population above all else, India seemed an obvious place to begin to test the new technologies and the new policies, that had emerged out of the war. Poverty-stricken India seemed, to many, to encapsulate the range of conditions in what would come to be the under-developed world. India had, of course, long occupied a place in the European imagination as a pathogenic heart of darkness: source of the most malaria, the most cholera, the most plague. The openness of the post-colonial Indian state to international assistance in health, and to new technologies, made India an ideal ‘testing ground’ for new approaches to malaria, tuberculosis and smallpox prevention and control. At the same time, knowledge of prevailing health conditions in India was significantly better than for many other parts of Asia. A reasonably effective system of vital registration and a good bank of census data existed; more immediately, the comprehensive survey carried out by the Health Survey and Development Committee in 1944 presented a detailed picture of health conditions and medical facilities across the country.48 Such depth of information was manifestly absent in warravaged Southeast Asia (or, for that matter, China). India thus provided an ideal ground for ‘pilot projects’, demonstration areas, and other such concentrations of new technical expertise. Second, the relative stability of the post-colonial transition in India made the Indian state particularly amenable to working with new international organizations. Crucially, the non-revolutionary nature of the transfer of power in India meant that the ‘Keynesian’ assumptions that shaped international approaches to social policy after 1945 accorded closely with the assumptions of India’s new technocratic elite.49 Not for India the heavily militarized medicine based on mass mobilization that was taking shape in China, or Vietnam in the late 1940s.50 The Indian state placed more faith in planned expertise, and in advanced technology, to bring about gradual transformation. At the same time the retention by Indian nationalists of most of the institutions of the colonial state and bureaucracy, meant that an institutional basis for policy was in place, however ineffective and incomplete it might have been. Thus India, and Indians, played a greater role in shaping approaches to Asia’s health problems than did Indonesians or Burmese, their respective countries absorbed by more fundamental problems of constructing state authority amidst much violence and numerous revolts by ethnic and religious minorities. The comparison between India and Pakistan, which played a very limited role in shaping international approaches to public health, is instructive: constructing a

14 Decolonizing International Health

state, consolidating territorial boundaries, and negotiating the place of the military in political life proved much more pressing concerns in Pakistan.51 The relative dominance of India over the field of public health in the region owed much, too, to the fact that many more Indians (mainly upper caste Hindus) had been trained in biomedicine than their counterparts in the Dutch East Indies, or in British Burma.52 The biopolitics of international public health reconciled, to an extent, Indian aspirations for regional leadership with Southeast Asian fears of Indian ‘imperialism’; it also helped to reconcile a more general post-colonial fear of American dominance. Acting against infectious disease was something on which all could agree, and the blue flag of the United Nations made external assistance, and American largesse, more palatable. This was, at least in part, because despite being an inter-governmental organization, the WHO facilitated and allowed transnational connections to flourish, and it was often through these connections that assumptions, practices and policies concerning health were transmitted. Thus, I argue in the later part of the book that even after the cementing of Asia into nation-states, transnational (as opposed to intergovernmental or international) linkages remained important in structuring the field of public health. International public health was held together by a series of what I call ‘administrative pilgrimages’ – borrowing, here, from Benedict Anderson: journeys by a coterie of experts that were often intra-Asian journeys.53 Often, these were journeys by Indians to other parts of South and Southeast Asia, where they met other Indian doctors, nutritionists and technicians, to discuss a set of problems that resembled those of India itself. Yet these networks, or pilgrimages, were themselves shaped by pre-existing links – the British imperial links between India, Burma and Ceylon – and by international politics: Indian doctors were much in evidence in non-aligned Indonesia, and studiously avoided Pakistan. Within this regional arena, straddling the former British empire and non-aligned Asia, international organizations like the WHO were relatively free from the constraints of both colonial and communist rule. At the same time, direct American influence was qualified, despite massive aid, by the ambivalent positions taken by non-aligned countries in the Cold War. The WHO carved a space, between American hegemony and the aspiration of Asian nation-builders, for the practice of biopolitics. Modern public health in the Pacific region – in the Philippines, or even Japan – was more directly shaped by the United States; in Latin America, by pre-existing regional organizations that

Introduction 15

only reluctantly joined the WHO; and in Africa by a newly energetic, reforming colonialism. China and Indochina stood apart, forging a very different path to health and hygiene. This serves to explain why Southeast Asia, with India at its heart, constitutes the focus of this book. The region was central to the development of international health in an age of decolonization, the site of its most ambitious programmes, its greatest successes and its most disappointing failures. Many of the goals of international public health – malaria eradication, for instance – were global in scope, but they took on additional layers of meaning in this part of Southeast Asia. My argument is that a particular approach to problems of health, life and death, was forged in the intersection between the legacies of the British Empire and the imperatives of nation-building; between American hegemony and non-alignment; between medical expertise and quotidian politics in societies where the memory of mass anti-colonial mobilization was still fresh. This configuration of forces meant, in turn, that South and Southeast Asia assumed a centrality in global plans, as their most challenging site and their most enthusiastic constituency. This regional formation was, however, historically bounded. It began to fragment in the 1960s. After the fall of Sukarno, Indonesia moved closer to the orbit of an East Asian economy, centred on Japan; the slaughter of half a million ‘communists’ in 1965 took the gloss off the egalitarian discourse of the 1950s.54 Burma withdrew into hermetic isolation.55 And the Indian state scaled back its ambitions, faced with the fractious demands of mass democracy.56 As the final part of the book will argue, the 1960s also witnessed renewed scepticism about the fundamental premises of a world without disease, and about the ability of technology to transform the tropical world. The colonial inheritance Three main themes run through much of what follows. The first is that the relationship between colonial public health and post-colonial, internationalized public health was complex and unpredictable. On the one hand, post-colonial public health can be characterized by the self-conscious attempt by both international agencies and national governments to break from colonial precedents, assumptions, and interventions. On the other hand, the institutional, intellectual and epidemiological legacies of the colonial medical past continued to shape and constrain post-colonial debates and policies on public health.

16 Decolonizing International Health

The very limitations of the earlier colonial attempts at transformation necessitated a change in approach. The chief transformations in the colonial era, so far as health practices are concerned, took place in the small and restricted realm of bourgeois civil society: in the bedrooms and living rooms of the colonial middle classes. The agents of this attempted transformation were missionaries or social reformers more often than they were state officials. The end of the Second World War saw a rather abrupt shift, wherein public health came to be one of the services which any government, whatever its nature, was expected to take responsibility for. As a result, public health expanded outwards, to ‘the people’. In order to do so, it had to rely on the institutions of the post-colonial state, crucially bolstered by the technologies and techniques circulated around Asia by the new international organizations. But this entailed weaknesses as well as strengths. The fractured and halting process through which health came firmly within the realm of the state reflected many of the weaknesses of colonial approaches to public health; weaknesses that persisted in an era where public health was more ambitious than it had ever been. The engineers of the international health campaigns, that is to say, were constrained in the kind of power they could exercise. The rural hygienists of the 1930s had believed, like secular missionaries, in the power of conversion to new ways of being, new ways of inhabiting the body. The prospect of bringing this about on a large scale, as ‘policy’, was not promising. The technologies of the Second World War provided a way out of this dilemma; their use seemed not to require conversion in quite the same way. From then on, technology – antibiotics, DDT and vaccines, as well as aircraft, spray guns and motor vehicles – was both the main source of power for international public health, and its fundamental weakness. Technology and its discontents Technology, then, provides the second major theme of this work. Many scholars have suggested that the political culture of development after the Second World War was founded upon the use of conspicuous technology as an end in itself, and often as a means of exercising governmental power over the poor.57 I hope to show, in what follows, that the availability of effective technologies of disease control after the Second World War undoubtedly oriented the policies and goals of international public health in a particular direction, but that a simple equation of ‘dominance’ does not capture the nature of this process. Specific technologies allowed the architects of international public

Introduction 17

health to intervene intensively, and over huge areas of the world, but this intervention was on a very narrow front. DDT, antibiotics and vaccines gave the power to WHO teams of just three men to vaccinate thousands of people over vast areas. This dominance – to invoke Ranajit Guha’s famous dictum – could not pretend to ‘hegemony’, in the sense of internalizing itself in the form of new kinds of behaviour and subjectivity on the part of local people.58 The very attraction of a techno-centric approach to public health was that it appeared to detach the WHO from the need to intervene deeply, in matters of ‘culture’ or social transformation. This was the strength of technology, and also its weakness. Repeated efforts to ‘decolonize’ public health through technology – by moving away from colonial assumptions about the natives’ cultures and behaviours – remained incomplete, never fully achieved. In part, the power of biotechnology in the 1940s and 1950s lay in its ability to capture the imagination. Disease control was used, by international organizations and national governments, to create a series of associations between medical technology, economic development, family happiness and national ‘progress’ and security. Yet I suggest that these associations sometimes failed to ring true, in a context where material poverty and social inequality continued to condemn large numbers of people to suffering and illness that appeared, now, ‘unnecessary’ in the light of the unrealistic expectations raised by promises of a world without disease. The meanings of medical technology were neither stable nor monolithic. The uncertainties of biotechnology were, and are, particularly profound because of their direct impact upon the body. A key argument in the book is that the technologies of public health meant different things to, say, a WHO consultant in rural Madras, a locallytrained health ‘auxiliary’ wielding a spray gun of DDT, and the parents of a child who had reacted adversely to a vaccination. If, as Bourdieu argued, we ‘learn bodily’, the lessons delivered by contact with the biotechnologies were complicated.59 The dramatic success of yaws vaccination was ‘internalized’ very differently to the uncertain prophylaxis of the anti-tuberculosis BCG vaccine, when tuberculosis continued to exact a heavy toll even after hundreds of millions were vaccinated. Biotechnology in the 1950s was a source of excitement and frustration, hope and fear. It would be a mistake to underestimate the degree of faith involved in the whole enterprise of disease eradication, on the part of its architects and planners as much as of its beneficiaries (or its victims).

18 Decolonizing International Health

The boundaries of medicine The third theme running through the narrative concerns the boundaries of medicine. I suggest that the internal and external boundaries of ‘medicine’ were fluid throughout the international expansion of disease control. International public health – both a form of knowledge and a set of practices – stood astride numerous kinds of expertise. Often the authority of international public health came from its command of ‘medical’ authority – knowledge of diseases, and the techniques to cure or prevent them – but just as frequently, international public health distanced itself from clinical medicine (as, in a sense, public health has always done).60 At times, international public health strengthened its position relative to the medical profession with reference to the authority of political economy, or ‘development economics’ as it came to be known when applied to the Third World. Certain interventions might be less than optimal from a medic’s point of view, they could argue, but they would bring maximum utility to the greatest number. This latent conflict often revolved around questions of professionalization. What kinds of personnel would take the massive campaigns of international public health forward? Would they be doctors or ‘auxiliaries’, healers or technicians? At the same time, the WHO became the site for debates within public health itself. In particular, the story of international public health in the Asian arena highlights the constant tension between the perspective of ‘social medicine’ and what might be called the ‘magic bullet’ approach to public health. Social medicine highlighted the importance of social and economic conditions to the practice of public health, and to the explanation of patterns of disease.61 ‘Social medicine’ included a diverse body of thought, but its currents were united, Patrick Zylberman suggests, by their ‘sharp criticism of a clinical, technical, specialized medicine and of the administrative policing of health’.62 The ‘magic bullet’ approach, on the other hand, focused upon the advances in technology made possible by germ theories of disease. Proponents of this school of thought, like the Rockefeller Foundation’s Fred L. Soper, believed that since specific diseases were a result of specific causative organisms (the tubercle bacillus, or the malaria parasite, for example), public health ought to focus upon narrowly attacking those ‘specific’ causes.63 The contention, sometimes the contradiction, of the two approaches to public health is a theme that recurs throughout this book. My approach to sources has been eclectic. This was dictated partly by the nature of the subject and partly, alas, by the continuing unavail-

Introduction 19

ability of certain kinds of archival material, even 40 or 50 years after the events in question.64 In the end, many of the sources are international ones. This is partly because so many ‘local’ sources I examined – books, pamphlets and newspapers in English and in Indian languages, as well as quite a few interviews – pointed back to the chambers of the United Nations, the WHO, as the ultimate authority deciding policies governing the health of millions. It is also because, over the period in question, English emerged, overwhelmingly, as the language of international public health. We can see in the field of health the broader process which Sudipta Kaviraj describes, of a growing gulf between vernacular political discourse and the Anglophone world of government and expertise.65 In my approach to these sources I have tried, perhaps in vain, to follow the sterling example of Rudolf Mrázek: probing speeches, letters, diaries and photographs for ‘unseemly technology trivia’, while searching the ‘dry technical texts of the period … for their poetry’.66 The cyclostyled ‘grey literature’ typewritten on scratchy yellow paper that inhabits many of the footnotes herein is indeed loquacious, it tells stories, both comic and tragic, of adventure and of terrible failure; of expectation, faith and frustration. The book proceeds in broadly chronological sequence, with some degree of overlap as from chapter to chapter the perspective changes, from the level of policy debates to the village clinic and back again. Chapter 1 opens the discussion with an account of the internationalization of public health in response to the global economic depression of the 1930s, and the concomitant crises of colonialism. Chapter 2 moves to a discussion of the transformations brought by the Second World War: new technologies of disease control and new expectations of the responsibilities of national and international government. Chapter 3 describes the constitution of the field of international health after 1945, centred upon the development of the WHO. The chapter seeks to explain why, by the early 1950s, the WHO had opted to focus its efforts on large, techno-centric campaigns of disease control and eradication, seemingly leaving behind the ‘rural hygiene’ of the 1930s. Chapter 4 moves from debates to practices, exploring the ways in which international public health was in fact built up from myriad local ‘pilot projects’ and experiments scattered across Asia. The chapter explores the confident visions of a world without disease provoked by the early practical experiences, visions at once technocratic and romantic. The sense of ambition culminated in the declaration of a global malaria eradication programme in 1955. Chapter 5 provides a

20 Decolonizing International Health

parallel narrative to chapter four, suggesting that the techno-politics of disease eradication in Asia confronted a range of obstacles from the start: the reliance of carefully planned campaigns on improvisation and local agency proved uncomfortable for their architects. Perhaps more importantly, the chapter suggests that the utopian visions sometimes failed to convince, provoking critiques. The final chapter (Chapter 6) examines the decline of disease control in the 1960s. New technologies to treat chronic diseases like tuberculosis required a degree of medical and administrative control that neither the WHO nor national governments possessed; at the same time, the centrepiece malaria eradication campaign fragmented in the face of resistant mosquitoes and absent medical infrastructures.

1 Depression and the Internationalization of Public Health

This chapter is concerned with the constitution of an international discourse of public health in the 1930s, a discourse that wove previously fragmented experiments in medicine and sanitation across Asia into a more unified set of ideas and practices. While colonial public health efforts remained fragmented and touched a very small proportion of Asia’s populations, the language of rural public health brought together a somewhat unlikely range of visions on the fringes of colonial policy. Rural hygiene came to unite a range of aspirations, from Mahatma Gandhi’s quest for bodily and hygienic reform, to the attempts of a Rockefeller Foundation official to transform the health of a village in the Dutch East Indies. Rural hygiene was built upon new scientific knowledge, above all the knowledge of nutrition, and advances in understanding of vitamins and deficiency diseases. It brought together a set of techniques of public health, pioneered in locales across both Asia and Eastern Europe – health centres, experimental projects and institutes of medical research – in response to an overwhelming problem posed by the worldwide depression: the problem of agrarian decline, (and the potential for political unrest in its wake). I argue in this chapter that the new international discourse of public health often, though not always, stood removed from what we might call ‘policy’. Where public health specialists writing in the 1930s took a critical view of the impact of commercialization on rural Asia, colonial states and their local collaborators intensified their commitment to industrial and agricultural development in the aftermath of the depression. Consequently, the reception, translation and appropriation by Asian nationalists of the new discourse of international health varied along the lines of internal divisions, between – to simplify – ‘modernists’ 21

22 Decolonizing International Health

and communitarians. Modernists across Asia and beyond wondered if the universal standards set by the League of Nations did not, in fact, support their vision of an activist, state-centred transformation of society and economy; quite contrary both to Gandhi’s rural idyll and to colonial indifference. The constitution of the field of international public health, which I describe in this chapter, provided a new language that translated and transformed both the nature and the scale of the problems of public health. From the reports and conferences of the 1930s and, not least, the personal voyages of a number of cosmopolitan doctors, there emerged a new problem, on a new scale: the health of ‘Asia’, or even the world.

The limits of colonial medicine As suggested earlier, recent historical work has emphasized the importance of medical discourse in establishing colonial authority. By claiming access to a unique truth about the human body, colonial medicine often led to a devaluation of indigenous knowledge, and the authorization of new modes of intervention in the lives (and on the bodies) of colonial subjects. But colonial medical discourse had complex relations with practice. The desire to know, to classify and to quantify did not correspond to the will or the ability to intervene.1 In general, only when key aspects of colonial rule were threatened did concerted state intervention came forth. That is to say, colonial states only mobilized their medical police at moments of crisis and emergency, and particularly in response to epidemic disease; there is a reason why so much of the literature on medicine and colonialism, particularly in the South Asian context, has focused on particular epidemics. On the whole, colonial medical police was characterized by its absence, its weakness, and its neglect. Hugh Tinker’s meticulous work in the early 1950s made the point very clear. He showed the inadequacy of personnel, infrastructure and resources in the public health system of British India and Burma: just 56 health officers, for example, in all of the municipalities of Madras Presidency; only four serving all of rural Burma.2 The main problem, in Tinker’s view, was that public health was the responsibility of local government in India, and that local governments lacked the will and the capacity to discharge their obligations. He listed countless examples of the ‘ephemeral’ nature of commitment to public health: In 1930 the Satara District Board would only sanction measures to check a cholera epidemic two months after the outbreak of the

Depression and the Internationalization of Public Health 23

disease. Schemes for village water supplies in Bombay dragged on for years without completion. The organization of village sanitation was often put on ‘for the benefit of the public health staff’ only; as soon as they departed the system would lapse.3 Statistics, he pointed out, ‘only … demonstrate the feeble resources available’. In countless cases, ‘the attempt to provide a service merely revealed the existence of vast problems previously only half suspected’. As a result, ‘local authorities at best could only select the most pressing cases for relief; at worst the slender local funds were dissipated in tiny sporadic ventures from which no permanent benefit was derived’.4 Indian nationalists were not slow to recognize the level of colonial neglect. Public health was, by the early twentieth century, a subject of extensive popular discussion. With the revolution in printing technology that swept India in the second half of the nineteenth century, there was an increase in popular writing about health and illness, targeted at a new middle class reading public, and often at Indian women. Debates over ‘western’ ideas about the body, about diseases and their treatment, particularly in relation to indigenous traditions of thought about these subjects, featured prominently in the press. The output of vernacular literature on health flourished, particularly in Tamil and Bengali. Particular hygienic practices gained an inextricable association with being modern, with escaping ‘backwardness’ and ‘superstition’. With the growth in the number, and the confidence, of medically trained Indians, the critique of colonial neglect intensified. Thus Nil Rattan Sircar, a prominent member of the Indian Medical Association, told the annual meeting of the organization, in 1928, that India’s ‘medical backwardness’ was a consequence of imperial neglect: An alien trusteeship of a people’s life and fortune is almost a contradiction in terms. For among the governing factors in all sanitary reforms and movements are the social and economic conditions of life, the environment, material as well as moral, and above all the psychology of the people – and an alien administration, out of touch with these living realities, will either run counter to them and be brought up against a dead wall of irremovable and irremediable social facts or … grow timid and fight shy of all social legislation, even in the best interests of the people’s lives and health.5 The relatively large number of Indians trained in western medicine – unparalleled in other parts of colonial Asia – allowed for a new level of

24 Decolonizing International Health

debate, which scrutinized colonial public health efforts, while staking a claim that Indian medical officials might be better placed to improve the health of the Indian population. In some cases, this led Indian doctors, like Ram Nath Chopra of the Indian medical service, to argue for recognition of the ‘rationality’ of indigenous systems of medicine.6 Others, like T.M. Nair, of the Madras Legislative Council in the early twentieth century, wholeheartedly embraced ‘western’ therapeutics, but criticized the colonial government for its inaction, and its failure to invest enough in public health.7 Demographic evidence supports the case that colonial public health interventions in South Asia were very limited. Indeed, there is something of a consensus in recent literature that the gradual decline in mortality in British India from the 1920s was due to factors other than the effects of public health policies and medical interventions. Ira Klein has made a powerful case that the significant decline in mortality in the late colonial era owed very little to public health policies and advances in medical technology, and still less to any improvements in incomes or nutrition. He argues, rather, that the mortality decline came about as a result of ‘biological immunization’: the reduced lethality of infectious diseases after a generation of particularly intensive exposure.8 Sumit Guha, too, suggests that neither nutritional improvement nor public health policies can account for the mortality decline, but emphasizes not ‘biological immunization’ but climatic factors. He argues that the Indian population experienced an increased life expectancy after the 1920s because ‘the weather gods enabled it to maintain a stable level of moderate malnutrition rather than alternately plunge between adequate nutrition and severe malnutrition’.9 This is not to say that there did not exist a steadily growing medical infrastructure in South and Southeast Asia by the 1920s. The argument of this chapter is that the forms of expertise and technical knowledge emerging from myriad localized ‘experiments’ played a key role in the internationalization of public health in the 1930s, which in turn allowed various localized techniques to be woven together into a singular expertise on rural public health in Asia. At times, colonial states financed and controlled the expansion of medical infrastructure in Asia, but missionary institutions also played an important role in establishing particular institutions – hospitals, schools – in which sanitary experiments could flourish. In South and Southeast Asia, however, they lacked the cultural sway that came with mass conversion to Christianity in colonial Africa.10 The real impact of missionary medicine often lay in its activation of internal debates

Depression and the Internationalization of Public Health 25

within colonized societies: Maneesha Lal’s work on the hygienic discourses of Indian nationalist women, for example, shows how a number of upper-caste social reformers appropriated (and transformed, sometimes refuting) the missionary critique of Indian hygienic practices.11 The disciplinary institutions of industrial capital, too, played their role in the expansion of medical surveillance and intervention, above all on the mines and plantations of colonial Southeast Asia, where tens of thousands of Indian and Chinese labourers lived and died.12 The expansion of medical research and the establishment of medical institutions in the tropical colonies gained support from networks of international scientific research and philanthropy, which expanded into Asia during the inter-war years. The Pasteur Institutes exemplified the new scientific networks which, by the 1920s, crossed imperial and colonial borders.13 In French Indochina, as Andrew Hardy has shown, the Pasteur Institute played a significant role in mapping the epidemiology of malaria.14 But no network had the reach of the Rockefeller Foundation by the 1920s. The Foundation, established in 1909, first intervened in public health activities through the work of its Sanitary Commission for the Eradication of Hookworm Disease in the US Deep South. With the opening of the Panama Canal in 1914, General William Gorgas, Surgeon-General of the US Army, urged the Rockefeller Foundation to support efforts to eradicate yellow fever.15 Following relief efforts during the First World War, the Foundation expanded its health work further overseas, initiating, in 1917, a tuberculosis control and education project in France.16 Despite the US government walking away from the League of Nations, the Rockefeller Foundation took an early interest in the League’s Health Organization: between 30 and 40 per cent of the League’s health budget came from the Rockefeller Foundation.17 The health division went on to launch research-driven public health campaigns in Europe, Latin America, South Asia, and China, targeting yellow fever, malaria, and tuberculosis, as well as developing medical education.18 A number of the ideas and practices from the transnational medical networks of the 1920s came together in unlikely ways as parts of a significant shift in the nature and scope of public health across Asia in the 1930s. Historians have hitherto failed to recognize that this shift was global, not colonial, in nature. That is to say, international developments, channelled through the League of Nations, activated a new level of debate on public health in individual Asian colonies, while at the same time, a range of localized ‘experiments’ in nutrition and

26 Decolonizing International Health

sanitation across Asia were themselves constitutive of a newly recognized international expertise in public health.

The internationalization of public health The Depression played a catalytic role in launching rural public health onto the global agenda, bringing together colonial and metropolitan concerns. It was the republican government of Spain that persuaded the League of Nations to call a conference on rural hygiene in Europe, in 1931, expressing a widely shared concern about the exploitation of rural economic distress by the far right and the far left. The following decade witnessed an accelerated global circulation of a set of techniques, institutions and discourses, many of which had emerged earlier in Eastern Europe. The lands of Eastern Europe were an early focus of the Rockefeller Foundation’s activities in the 1920s. The Foundation had established schools of public health in Warsaw, Zagreb and Budapest, Prague and Bucharest by 1930. The Rockefeller approach to Eastern Europe came out of its experience in the US Deep South, which had convinced them that only the State, supported by philanthropic funds, could effect a transformation of public health in ‘backward’ agricultural areas. The American approach gained a number of admirers throughout Europe, including the French social medic Jacques Parisot, and the Croat Andrija Stampar.19 At the Zagreb School of Public Health, Stampar pioneered an approach to rural medicine based on mass education, agricultural extension projects and the techniques of the cooperative movement. Stampar was close to Stepan Radic, head of the Croatian Peasant Party, and was expelled from the Yugoslav Ministry of Health in 1931, accused of being a socialist.20 A socialist he was, but his vision of public health was much closer to the educative social medicine of the Rockefeller Foundation and the rural hygiene of the League of Nations than to Soviet medicine, which was resolutely committed not to rural but industrial health, at a time when Stalin was visiting the terror of collectivization upon the Soviet countryside.21 Thus, in 1933 Stampar accepted an invitation by the League of Nations to travel to nationalist China as a consultant on rural public health. He stayed for three years, travelling from the four northwestern provinces to Szechuan and Fukien.22 After three years travelling through China, Stampar was convinced that ‘successful health work is not possible where the standard of living falls below the level of tolerable existence’.23 Stampar found the ideas

Depression and the Internationalization of Public Health 27

of social medicine confirmed by his own observations in China: the prevalence of disease in China was due, above all, to ‘bad water-supply, unhygienic housing conditions, [the] ignorance and poverty of the population’. The best health policy, he argued, would be to ‘raise the standard of living of the people and to increase their resources’. Education would be central to this project. Stampar pointed out that ‘unless the farmer can read pamphlets, and is given a rudimentary scientific attitude, it is very difficult to reach him by propaganda’. Even more important was ‘the removal of social grievances, such as the sense of exploitation by the landlord’. Ultimately, public health was dependent upon the ‘cooperation of the people, and this will only be given by a population which is reasonably optimistic about the future, and which is willing to give at least qualified acceptance [to] the social order’.24 Upon his departure, the Chinese government presented Stampar with a testimonial, on a ‘wonderful silk and coloured paper’, extolling his contribution to China’s ‘rural reconstruction’, but the government proved more than a little reluctant to implement Stampar’s proposals for wide-ranging agrarian reform.25 Nevertheless, the very fact of an Eastern European physician going to China with the League of Nations, taking with him techniques he had perfected in Yugoslavia with American philanthropic support, suggests an expansion in the international scale of public health by the early 1930s; an acceleration in the transmission of ideas and practices across colonial and international frontiers. The onset of the Depression also served to increase the international visibility of arguments relating ill health to poverty and under-consumption. The League of Nations played a catalytic role, from the early 1930s, as a forum for debate, and as a body which could lend significant legitimacy to new ideas about health. The League’s Health Organization was itself in an unusually activist mood by the early 1930s. The early 1930s saw an increasingly close relationship between the League and the International Labour Organization (ILO). Pressure from workers’ delegations to the ILO, combined with the sympathetic attitude of its new director, Harold Butler, led the ILO to work closely with the League’s Health Organization on the issues of public health made visible by the economic shock of the Depression. The League’s Health Organization’s own director, the Polish doctor Ludwik Rajchman, exhibited an increasing radicalism in his desire to see the League Health Organization tackle broader socio-economic questions.26 In September 1932, the League expressed this growing concern in a report on ‘The Economic Depression and Public Health’. The report

28 Decolonizing International Health

pointed out the problems associated with aggregate poverty statistics, suggesting ways of measuring the quantity and the effects of morbidity and malnutrition.27 From the early 1930s, then, the League began to embrace broader socio-medical concerns.28 The ‘marriage of health and agriculture’, which the League of Nations championed, focused on the question of nutrition. Developments in the scientific knowledge of vitamins provided a language that could draw together Europe and the colonies, ‘core’ and ‘periphery’, economics, geopolitics, and the government of the individual human body. The explicitly comparative framework of nutritional discourse was open to application to colonial problems. A significant amount of the ‘new knowledge of nutrition’ emerged from colonial laboratories. Perhaps the best known of the new nutritional studies were John Boyd Orr’s contrast of the diets and health of the Maasai and Kikuyu, and Robert McCarrison’s experiments contrasting the health and vigour of rats fed with Punjabi diets with the malnutrition experienced by their counterparts fed on the rice-based diet of the ‘Bengalis and Tamils’.29 McCarrison made the comparison between metropolitan and colonial bodies quite explicit: in a series of vivid posters, he contrasted the plump rats with glossy coats fed on Sikh diets, with the stunted creatures fed on the typical diet of the ‘poorer classes’ in Britain.30 There was an immediate interest within India in the new knowledge aired at and circulated by the League of Nations. Not only had a number of Indian medical officials been involved directly with the League – W.R. Aykroyd served as its Health Secretary after 1930 – but the new knowledge of nutrition served as a stimulus to work that was already flourishing in India.31 There was no direct link, however, between the colonial and international debates on health and nutrition and any concerted action on the part of colonial states. The global economic depression hit the colonial empires hard after 1929. The evaporation of credit put great strain on rural economies in South and Southeast Asia. The interlinked colonial economies of the Indian Ocean began to turn inwards, and all of the major empires experienced an upsurge in political unrest and nationalist activity, from the Indonesian Communist Party’s attempted insurrection in 1926–7, brutally crushed, to the Saya San Rebellion in Burma, and Gandhi’s mass campaign of Civil Disobedience. In the main, colonial states in Asia responded with retrenchment and repression. The Dutch authorities in the East Indies turned away from their ‘ethical policy’ of the early twentieth century which had encouraged associational life, and towards a repressive austerity. One historian of

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Indonesia has described the period after 1927 as the ‘most conservative and repressive phase of [the Dutch regime’s] twentieth century history’.32 By the mid-1930s, there were fewer than 400 Indonesian doctors in the entire archipelago. The colonial state, under pressure from falling revenues and Dutch business interests, supported isolated hygiene projects, often administered by voluntary and charitable organizations: the Muhmadiyya, Protestant and Catholic missions.33 But, as will be shown, the neglect of the colonial state did not in any way restrain the ambitions of some hygienists on the fringes of the state, notably those of a Rockefeller Foundation official working in one of the Indies’ model hygienic sites. In British India, countless reports from provincial public health officials stressed the need for austerity in the light of the Depression; now was hardly the time for an expansion in the public health services. The Surgeon-General of Madras Presidency, Major-General Sprawson, wrote to Delhi that ‘during the last year the world depression has forced on us retrenchment to an extent that not only restricts expansion, but would actually in some respects narrow our activities.’34 The inspector of civil hospitals in the United Provinces was even more pessimistic in his assessment. ‘No real advance in medical relief was made during this year’, he wrote in 1933, ‘indeed, the net increase since 1918 has been only 9 dispensaries…. In spite of an apparent increase in popularity of our dispensaries, the actual individual patient must be receiving less efficient treatment than in 1914.’35

Two visions of rural hygiene The Indies and the world It was on the fringes of the state that the discourse of nutrition and social medicine flourished. In the view of the protagonists of rural hygiene, much more ambitious than colonial states running on a shoestring, public health was nothing less than an alternative to communism. A manifestation of ‘biopolitics’, rural hygiene put the welfare of the rural population, the quality of the race, ahead of economic accumulation.36 It provided space for unlikely intellectual alliances between colonial officials, scientists and Asian nationalists. The experiments of Dr J.L. Hydrick exemplify the transformation of local expertise into a global discourse of health. A Rockefeller Foundation officer sent to advise the Dutch colonial government on rural public health, Hydrick was, from 1924, in charge of an experimental health centre at Poerwokerto, in Java. Hydrick wove his experiences into

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a manifesto for the new gospel of rural hygiene, published in 1936 in Dutch and English (the English title was Intensive Rural Hygiene Work in Netherlands India), and soon translated into French. The context for his experiments in Java was a Dutch colonial state committed to austerity, and intensely worried about political unrest.37 We can nevertheless detect in Hydrick’s social medicine a palliative for the disease of socialism. Hydrick’s aims for rural hygiene were nothing less than the internalization by Javanese villagers of new bodily practices and dispositions; his task, to use Michel Foucault’s oft-quoted phrase, lay in the ‘conduct of conduct’.38 The aim was to ‘awaken in the people a permanent interest in hygiene and to stimulate them to adopt habits and to carry out measures which will help them secure health and remain healthy’. An appreciative colonial health minister wrote of Hydrick’s miraculous techniques, ‘so planned that they quietly and gradually penetrate and become a part of normal village life’.39 The rationale for deploying the subtle power of persuasion to shape individual and communal conduct, lay in the very weakness of the colonial state in large parts of rural Java. ‘There would be no objection whatever to the use of coercion’, Hydrick declared, ‘if its use could secure permanent results’. Yet that would require ‘a large personnel to enforce all the rules and regulations and this makes it far too expensive’. He concluded, not without reason, that ‘If it were possible to secure results at a reasonable cost by coercion then conditions in all countries would be much better than they actually now are’.40 Hydrick chose to rely, instead, on the persuasive powers of specially-trained mantris, or hygiene nurses. The mantri would, in his own bodily conduct and hygienic practices, mould the behaviour of those around him. The successful mantri had to meet rigorous criteria. He was to be ‘polite and modest and no circumstances will excuse rudeness or misuse of authority’, on the other hand he could not be ‘too shy’, as this would ‘not inspire confidence’. The list of virtues continues, rapturously: He must possess an inexhaustible patience, because he will be obliged to talk daily to many people about things which they do not understand. A monotonous voice practically disqualifies an applicant … efforts for improvement of his technic [sic.] must never cease. … The manner in which the mantri approaches the house and calls to the people to see if anyone is at home; the way in which he enters the house and finally gets all the members of the family

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together; his method of leading the conversation; where he sits; his manner of talking; his skill in keeping the interest of all members of the family; his patience; his answers to questions which are asked; his ability to make people talk, etc., are all points of the technic for which a long and thorough training is necessary.41

Figure 1.1

A Mantri’s House Visit

Source: J.L. Hydrick, Intensive Rural Hygiene Work in Netherlands India (Batavia Centrum, 1937), insert.

To be a mantri was a craft, a cultivated set of dispositions and practices. Simply trained mantris were always to be preferred to haughty nurses, according to Hydrick, since ‘the people felt at once that the nurse was of much higher rank and the nurse was unwilling to speak in simple language. They used large words and technical words which they had learned during their training in the hospital, so that the people could not understand their explanations’.42 Hydrick’s vision was of a village in which the conduct of the residents was shaped to ensure a maximum of health and hygiene, from the pit latrines, regularly inspected, to the coconut wire toothbrushes which all would use. Inherent in Hydrick’s project was the unrealized – perhaps

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unrealizable – intention that all the Indies would, in time, come to resemble Poerwokerto. This was not a question of state policy; rather it was the mobilization of new technologies of government to solve a particular social problem which had posed itself to scientists, experts and administrators in the 1930s: the problem of rural hygiene. Through the League of Nations, the Rockefeller Foundation and other transnational networks, the local techniques of Hydrick and his counterparts across the region began to coalesce into a set of ideas and prescriptions gaining ethical force, as a body of knowledge and practice: ‘international public health’. The ways in which very different political and ethical concerns could come together to define a discourse of ‘rural hygiene’ is evident from the rather unlikely juxtaposition of Hydrick’s utopia with another micro-site of hygienic transformation: Gandhi’s ashram. What is most striking is that despite their very different political motivations and moral visions, an American public health advisor to the Dutch colonial government and the preeminent Indian nationalist leader could speak within the same discourse of rural hygiene. ‘Green Leaves’ When Gandhi invited a number of village workers to his ashram for a communal meal in 1934, it was by way of inducting them into a new consciousness of the importance of diet and health. Though he was himself on a self-imposed diet of uncooked nuts, seeds and fruit, Gandhi – an ‘experienced cook’ – prepared a meal for the 98 workers, at a carefully-calculated 6 pice per head. He explained to the workers the process of cooking, and the ingredients: ‘Before the dough [for the rotis] was kneaded’, he told them, ‘it was treated with linseed oil. This rendered it both soft and crisp’. In addition, ‘as we must have some greens and raw vegetables’ – the ‘must’ was both a moral and a nutritive injunction – Gandhi prepared ‘tomatoes and two chatnis … Koth fruit is known for both its aperient and astringent properties and jaggery goes well with it to make a delicious chatni’.43 Healthy and nutritive food was but the beginning of the transformation Gandhi envisaged. A transformation in bodily practice would herald, in his idiosyncratic vision, a growth in national consciousness and – in a further step – an improvement of the Indian ‘race’. Declared Gandhi: If we would be national instead of provincial we would have to have an interchange of habits as to food, simplify our tastes and produce

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healthy dishes all can take with impunity …. Volunteers will have to learn the art of cooking and for this purpose they will have also to study the values of different foods and evolve common dishes easily and cheaply prepared.44 Gandhi made a direct link between the weakness of the body induced by an excess of polished rice in the diet and national weakness. Indeed, he concluded that ‘we need every ounce of the bran of wheat and rice if we are to become efficient instruments of production’, (a rather ‘unGandhian’ turn of phrase), ‘not to be beaten on this earth by any race, and yet without the necessity of entering into killing competition or literally killing one another’.45 If ahimsa and bodily self-government were at the heart of Gandhi’s vision of a new nutritionally-based public health, he nevertheless nourished it with the authority of modern science. Gandhi embraced the science of nutrition wholeheartedly, quite aside from his suspicion of biomedicine. Gandhi’s writings on nutrition are full of references to the latest research on the subject: he referred, for example, to Robert McCarrison’s experiments with rats; to The Newer Knowledge of Nutrition by E.V. McCollum; and to home-grown texts such as Balanced Diets, by H.V. Tilak of the Bombay Presidency Baby and Health Week Association.46 He carried on a public correspondence with both Robert McCarrison and W.R. Aykroyd, successive directors of the Nutrition Research Laboratory in Coonoor.47 On one occasion, Gandhi invoked a speech by Aykroyd, in which he had argued that ‘well-balanced diet need not cost more than Rs. 4 per month’. Gandhi reported Aykroyd as having told a meeting in Bangalore that The dietary requirements of an adult man per day were 16 oz. of soya bean, two oz, of arhar dal, an oz of jaggery, four oz each of spinach and amaranth, an oz each of potatoes and colacacia, 1.5 oz of cocoanut oil and six oz of buttermilk – all costing about 2 annas.48 Gandhi gave pride of place – because of its authority and its universality – to the League of Nations Health Committee’s seminal findings on the Physiological Bases of Human Nutrition in 1936; a summary of the report immediately appeared in the pages of Harijan, one of Gandhi’s main outlets of publication.49 In his search for a diet that would bring national vigour and vitality, Gandhi turned to the scientific authority of the League of Nations, and its claim to have discovered universal minimum standards.

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Translated into specifically Indian terms (as, for example, in Gandhi’s argument that the Indian digestive tract was adapted to a vegetarian diet) those international standards would go towards increasing national vigour and vitality. Underlying his experiments with food and hygiene was a critique of the economic impact of colonial rule on rural India. Not only did polished rice weaken the vitality of the Indian ‘race’, it was an example of the (economic and moral) impoverishment of India’s villages through mechanization: If rice can be pounded in the villages after the old fashion the wages will fill the pockets of the rice pounding sisters and the rice eating millions will get some sustenance from the unpolished rice instead of pure starch which the polished rice provides. Human greed, which takes no count of the health or the wealth of the people who come under its heels, is responsible for the hideous rice-mills one sees in all the rice-producing tracts.50 In an article entitled ‘Green Leaves’, Gandhi declared that ‘since the economic reorganization of the villages has been commenced with food reform, it is necessary to find out the simplest and cheapest foods that would enable villagers to regain lost health.’ Gandhi’s critique culminated in the redefinition of his Constructive Programme in 1940: ‘it is impossible for unhealthy people to win swaraj (self-rule)’, Gandhi declared, ‘therefore we should no longer be guilty of the neglect of the health of our people’. Gandhi suggested, tying nutrition to sanitation, that ‘if rural reconstruction were not to include rural sanitation, our villages would remain the muck-heaps they are today … it needs a heroic effort to eradicate age-long insanitation’.51 Strikingly, however, it was not Gandhi but his occasional correspondent, British nutritionist W.R. Aykroyd, who used the language of nutrition to develop a systematic critique of the deleterious impact of colonial capitalism on health, particularly in the aftermath of the Depression. Aykroyd’s pioneering research had shown that the preponderance of highly milled rice in the south Indian diet led to a range of nutritional deficiencies, as a result of the lack of proteins and of ‘protective foods’, and a particular lack of leafy vegetables and proteins. Aykroyd himself was amongst the foremost international ‘experts’, a member of the League of Nations committee which had provided great legitimacy to the new discourse of nutrition, in reports that were cited around the world by health reformers with very different agendas. This demonstrates, again, what a number of historians have argued: the

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traffic of ideas and expertise between metropole and colony was not simply in one direction;52 in this case, knowledge gained in a colonial laboratory in south India allowed Aykroyd to make authoritative interventions in setting the international agenda. It also suggests that ‘colonial medicine’ was internally differentiated, with leading colonial scientists like Aykroyd taking a rather different view of health and illness in India, and their underlying causes, to certain policymakers in London and Delhi. Aykroyd with his colleagues at Coonoor, G. Krishnan, R. Passmore and A.R. Sundararajan, presented a speculative but detailed explanation for the apparent shift to highly polished rice in the south Indian diet. The most immediate cause, they argued, was in the spread of rice mills, which had ‘appeared even in areas remote from large towns’.53 Contrary to the image of large factories, however, they suggested that ‘it is the spread of the small mill, often worked by a group of 5 individuals or less, which so impressed our correspondents’. These mills operated machines modelled on the American-made Engleberg huller & polisher, which had been ‘copied and modified in Indian foundries’, to the point where they were widespread ‘in villages of 2000 people or less’.54 Underlying this technological shift were social and economic transformations: chief among them was the development of transport and improvement of roads (‘the ubiquitous motor-bus’, they wrote, ‘has loosened the bonds which attach the villager to his own plot of ground and traditional manner of life’). Cheap electric power accelerated the change.55 Aykroyd’s committee heard much evidence from a range of ‘experts’: political and social leaders, invariably drawn from the middle class elite, but nevertheless representing a range of political opinions. Many of the experts argued that villagers’ fondness for mechanizations stemmed from innate ‘laziness’.56 Yet Aykroyd and his colleagues suggested, rather, that a reduction in the domestic burden of home pounding was welcome for ‘many village women, exhausted by malnutrition, ill health and continuous child-bearing’.57 In examining the rapid decline of the ‘healthy’ habit of pounding rice at home for domestic consumption, the committee published the lengthy testimony they had received from Pattabhi Sitaramayya, a Gandhian Congressman from the Telugu-speaking region of Madras Presidency. The Congressman’s report on the ‘rice problem’ in the Godavari and Krishna deltas traced causation back to inequalities in the distribution of land. ‘Home produced rice’, he pointed out, ‘means home storage of paddy’. Yet the majority of small landowners possessed less than three acres. Heavy levels of debt meant that

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immediately after the harvest, farmers were compelled to sell the paddy, only to live on more credit until the next harvest: ‘in effect’, Sitaramayya concluded, ‘the villager has no paddy to pound.’ Wage labourers were in a worse position still, lacking the ‘spacious accommodation’ needed to pound paddy at home, if indeed there were any paddy to be had.58 Aykroyd and colleagues concluded that paddy therefore ‘becomes an article of commerce’, lamenting that with the proceeds of paddy sales villagers would buy (less nutritious) machine-milled rice, often imported from Burma or Siam. Aykroyd’s critique focused on the negative impact of the regional colonial economy, involving the import of rice by the densely-settled parts of eastern India (and southern China) in exchange for the export of labour and skills to the frontier lands of Burma, Malaya and Ceylon.59 During the Depression, the price of rice fell more sharply even than that of other commodities, and cheap, poor quality imported rice continued to flood south India.60 Throughout the report on the ‘Rice Problem’, critiques of the colonial state and economy are left implicit, with Aykroyd simply warning that though the commercialization of rice production had advanced furthest in Madras ‘it is quite conceivable that in 20 years’ time the practice may be as rare in Bengal and elsewhere in India as in Madras’. He concluded, carefully, that ‘it is therefore important to decide what attitude should now be adopted towards the penetration of the mill into areas in which domestic methods of preparing rice for consumption are still followed by the majority of the population’.61 The strong implication, however, was that this development should not be ‘allowed’; that government nutritional policy ought to restrain the spread of capitalism into the Indian countryside. It was only during the Second World War that Aykroyd argued, more explicitly, for concerted state intervention in the production and distribution of food.62

Bandung, 1937 The League of Nations gave voice to the new technical knowledge, the new discourses on health and nutrition emerging on the fringes of colonial states and within nationalist movements in Asia. It was with a view to understanding the complexity and diversity of Asia’s health problems, and formulating a concerted international response to them, that a group of three League of Nations consultants set out on a journey across the continent in 1936. The team consisted of: A.S. Haynes, formerly Colonial Secretary of the Federated Malay States;

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C.D. De Langen, formerly Dean of the Batavia Faculty of Medicine, and E.J. Pampana, a Venezuelan malariologist who was Secretary of the League of Nations’ Malaria Commission. Between April and August of 1936, the three men toured India, Burma, Siam, Malaya, Indo-China, the Philippines, the Netherlands East Indies, and Ceylon.63 They sought to identify the different approaches to public health that were on display for their consideration across imperial frontiers; and they sought a language with which to discuss these changes. The diaries of the journey, during which the three men covered 45,000 kilometres, paint an expansive picture of public health. They focused on precisely those local sites of transformation exemplified by Hydrick’s health centre and Gandhi’s experiments. Bombay was one of the first stops on the tour, and one of their first diary entries gives a revealing glimpse of what the commission saw: April 10 [1936]: Bombay Health visitors’ school; Presidency Infant Welfare Society; The National Baby and Health Week Association; David Sassoon’s industrial school, nutritional experiments on the boys. Two days later, the commission went by ‘motor to villages under the activity of the “Deccan Agricultural Association”’, stopping at the ‘village of Shivpur’ to examine the ‘activity of an unqualified lady social worker’ before proceeding to inspect ‘villages under the activities of local cooperative societies’.64 The League’s consultants focused on a range of institutions managed by voluntary bodies, and saw, in their ambitious attempts at hygienic transformation, a vision of the future. The particular significance of the League’s increasing interest in problems of public health across Asia lay in its ability to bring together a range of unrelated sites; the comparative, classifying perspective of the League’s consultants allowed them to see, in all of their inspections, a broader set of forces at work. Haynes, for one, could barely contain his enthusiasm on the voyage home. Writing on board the S.S. ‘Maloja’, traversing the Red Sea, he wrote to the Private Secretary of the Viceroy of India, thanking him for receiving the commission, and summarizing his impressions of his visit: The countries we have visited are almost entirely agricultural … in each country, ‘rural reconstruction’ is prominent in the papers, and is on everyone’s lips. It is perhaps somewhat strange that this

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should occur simultaneously in all the countries concerned and that it should be so recent and so comparatively sudden. But it is indisputable that a reorientation of governmental policies is taking place and that the needs of the distant and inarticulate peasant are being weighed in the council chambers … where his voice has been little heard. The letter concludes with Haynes expressing excitement about the upcoming League of Nations Conference on Rural Hygiene in Bandung: ‘there has been no such meeting of Eastern Nations before’.65 The August 1937 League of Nations Conference on Rural Hygiene in the Far East included representatives from across South and Southeast Asia, perhaps the first such formal dialogue on questions of health and welfare which was at once inter-imperial, and international. The conference was attended by representatives from each of the British territories in Asia, including separate representation of individual provinces in British India, and the Indian princely states; French Indo-China; Japan (despite its withdrawal from the League after the Manchurian invasion, and, indeed, after the outbreak of the Sino-Japanese war); the Netherlands Indies; the Philippines, China and Siam.66 The meeting gave much scope, too, to a range of ‘experts’ not directly linked to colonial or national states, including both W.R. Aykroyd and J.L. Hydrick, whom we have already encountered. The conference on the problems of rural life met in the heart of Asia’s most consciously ‘modernist’ city: Bandung; the ‘Paris of the East’, boasting many examples of modernist architecture, and the home of the Technische Hogeschool, one of Asia’s first technical colleges (where the young Sukarno trained as an architect).67 This irony was not inappropriate, perhaps, given the later tensions that would emerge between visions of rural hygiene and those of modernist development. The discussions at the Bandung conference established a complex narrative of the spread of modern (‘western’) medicine in south and Southeast Asia, moving beyond the triumphalist colonial narratives so prevalent at the time. The conference report argued that colonial medicine in Asia was such that ‘the first representative of preventive medicine to become known to tropical populations was the vaccinator, whose ministrations, except in the case of epidemics, are not likely to strike the individual’s imagination’.68 Furthermore, vaccinations almost inevitably ‘imply a coercive element’. There is an implicit reference, here, to the widespread resistance to vaccination witnessed in the early years of colonial rule. ‘The sanitary inspector, the anti-mosquito

Depression and the Internationalization of Public Health 39

squad, and lastly, the medical officers of health’ followed the vaccinator. Whatever their merits, ‘from the population’s point of view’ such health workers ‘do not possess the merit of easing suffering’.69 The committee thus suggested that if ‘a friendly attitude towards public health is to be induced in rural districts’, then curative medicine needed to feature heavily in the initial approach, as this would ‘enable the population to benefit by, and to appreciate, the advantages of certain forms of treatment. This is a very simple matter, since diseases such as yaws … yield rapidly to medical treatment’.70 The fundamental problem, however, was one of poverty. In this connection, the new nutritional thought was never far from the forefront of discussion. In particular, the Bandung conference focused on the ‘problem’ of rice ‘throughout the east’. The conference proceedings echoed the views presented earlier, of nationalists like Gandhi, colonial scientists like Aykroyd, and reformers like Hydrick. The conference resolution on the rice problem is worth quoting at length: The Conference emphasizes the fact that the degree of milling to which rice is subjected is of vital importance in connection with the problem of nutrition throughout the East. In many countries, the poorer classes consume foods other than rice in small quantities, and it is very difficult, for economic reasons, to increase the amount of supplementary foods in the diet. … It deplores the tendency of urban and rural populations in the East to consume highly-milled rice. It strongly recommends that Governments should make a thorough investigation of the nutritional, commercial, economic and psychological aspects of the problem, attention being given to the possibility of checking the spread of mechanical rice mills in rural areas … with a view to conserving the healthy habit of consuming home-pounded rice.71 Unease with the processes of colonial development is evident here. Influenced by the likes of Aykroyd, the League of Nations saw that restraining the advance of mechanization might be necessary to ‘conserve … healthy habits’. As important as nutrition was the problem of malaria, and here, too, the potential tension between health and (colonial) wealth was all too evident. Going back to the 1920s, the League of Nations committee on malaria had long taken a social approach to the problem, arguing that a focus on the problems of poverty and the environment, rather than a medicalized focus on the vector of transmission, was the most sensible

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approach to the problem of malaria in Eastern Europe.72 The 1937 conference’s consideration of the problem of malaria illustrates the concern of this new international public health with the relationship between health, poverty, and agricultural development. Some of the blame for the devastation caused by malaria lay squarely upon the efforts of colonial capitalism to transform the countryside across Asia, which had deleterious effects on public health. The 1937 conference issued a resolution declaring that: The amount of engineer-made malaria … is appalling. Specifically, the conference draws attention to malaria due to improper siting and housing; indiscriminate aggregation of labourers; uncontrolled jungle clearing … obstruction of natural drainage by road, railway and canal embankments with culverts too few and too high; impounding of water without regard to leakages, seepages and raised water-table levels; irrigation without drainage.73 Despite this growing recognition of common factors underlying the causes and consequences of malaria, the League’s experts stated emphatically that ‘the problems which it raises cannot be dealt with – or settled – without intimate knowledge of local conditions. Any attempt to proceed on standardized lines would be disastrous’.74 The conclusion of the commission’s discussion of malaria encapsulates the growth of international social medicine in Asia: It must be admitted that, except for a few quinine tablets distributed here and there, the health conditions of, say, a peasant living with his family in a hut in the middle of a marshy plain … have received very little attention. … Malaria is a health and social problem; it must be attacked simultaneously from both these angles. While, on the one hand, marked economic progress may depend on the success of anti-malarial measures, these, on the other hand, will be facilitated by an adequate diet, healthier dwellings, more widespread education – in a word, by rural reconstruction.75 This was the perspective of concerned scientists, disillusioned with the neglect of their findings in the operation of the colonial state and economy. More expansively, the views expressed on malaria and nutrition alike at the Bandung conference reflected the aspirations of those who saw in rural public health a panacea to ‘extremism’, and even a path to national consciousness.76

Depression and the Internationalization of Public Health 41

These developments marked the culmination, in many ways, of myriad local level interventions and experiments, devised at different times by scientists and social reformers. The Bandung meeting expressed, in an authoritative way and on the international stage, the kinds of ideas which motivated, amongst others, the Central Cooperative Anti-Malaria Society of Bengal, established by Dr G.C. Chatterjee in 1912, and which had, by the 1930s, 2,000 similar bodies affiliated to it: local-level initiatives carried out by elite reformers. Through the missionary fervour of the societies, one admiring British official declared, ‘the illiterate, suspicious and apathetic peasant could be moved to action’. Yet the income of this valiant society, ‘from the endowments collected and invested by Dr Chatterjee’, was ‘small in comparison with the task before it’.77 To some extent, these international discussions of nutrition and health in the wake of global depression influenced colonial states. The government of the Dutch East Indies was furthest advanced in this, making a display of their commitment to widening and implementing the kinds of reforms Hydrick had advocated (although the extent of measures actually taken is debatable).78 British colonial governments, too, indicated their increasing interest in public health. The ‘model colony’ of Ceylon saw an expansion of maternal and child welfare services.79 Reflecting the influence of rural hygiene and nutritional thinking on colonial officials, one 1935 report on public health in India, (which later shaped British colonial thinking on the African Survey), argued that: No preventive campaign against malaria, against tuberculosis or against leprosy, no maternity relief or child welfare activities, are likely to achieve any great success unless those responsible recognize the vital importance of this factor of defective nutrition and from the very start give it their most serious consideration…The first essentials for the prevention of disease are a higher standard of health, a better physique, and a greater power of resistance to infection.80 Yet such views coexisted with a deepening colonial pessimism about their ability to affect the conditions of health in tropical Asia. As David Arnold has argued, colonial officials faced a ‘growing awareness of the complex and vulnerable nature of the Indian environment and the cultural and political difficulties involved in trying to effect any change’.81 The missionaries of rural hygiene put their faith in a wholesale transformation of rural society and economy; however, colonial administrators were in search of a quicker, cheaper solution. In the words of a

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colonial public health official in British Burma, writing at the time of the 1937 Bandung conference: ‘In rural areas the amount of ground to be covered renders anti-mosquito measures impracticable save at prohibitive cost’, instead he suggested that ‘the problem can best be attacked by the wide and systematic distribution of quinine’.82 Referring explicitly to the findings of the League of Nations, British health officials conceded that ‘adequate diet, healthier dwellings, more widespread education are all needed if anti-malarial measures are to be fully effective’.83 Yet those were hardly realistic aspirations for a colonial state running on a tight budget. Instead, British colonial authorities argued that ‘it would be difficult to over-estimate the importance from an economic aspect of a successful campaign against the disease’.84 If rural reconstruction was too expensive, at least ‘the provision of anti-malarial drugs’ could be given ‘an important place amongst the essential social services directed towards building up of national health and efficiency’.85 The logic was clear: if a cost-effective intervention against malaria could be found, ‘there could hardly be a more important contribution in present circumstances to the prosperity and well-being of tropical countries than an effective attack upon the disease.’86 The underlying question was one which would emerge and reemerge over the decades to come, and which later chapters will continue to consider: was public health a means to an end, or an end in itself? The language of rural reconstruction and nutritional reform privileged public health as the end of a widespread social, cultural and economic transformation in rural life, including – if necessary – restraints upon the expansion of colonial capitalism. Colonial states, by contrast, saw public health as a means of reducing economic inefficiency and waste; as such, public health interventions had to be cheap and widespread, rather than intensive and localized. Even the distribution of quinine was extravagant, in the eyes of the colonial state: the authorities made prisoners in Rangoon Central Jail manufacture quinine tablets for the whole of the Asian empire, as a way of cutting costs.87

The ‘modernist’ challenge On the view of so many present at Bandung, ‘policy’ implicitly and explicitly meant restraining the expansion of industrial capitalism into rural areas, quite the opposite of the classic colonial use of public health as a means of ‘clearing the bush’, allowing for ever more inten-

Depression and the Internationalization of Public Health 43

sive exploitation of the countryside. The apparent crisis of global capitalism, a sense of which was pervasive in the 1930s, might have given confidence to the proponents of rural reconstruction. However, the timing for such an approach to the conjoined questions of public health, agricultural development and colonialism was not propitious. The focus of public health reformers on the body and the environment, exemplified at the 1937 Bandung conference, came at just the moment when, in British India and elsewhere in the region, colonial states began to foster Asian industrialization. As C.J. Baker concluded in his exhaustive study of the south Indian rural economy, ‘the advance of state intervention in the economy was founded on a fear of public disorder and a despairing realization of the extent of agrarian decline.’88 Far from halting the spread of commercial agriculture, as the proponents of nutritional reform advocated, the new alliance between the colonial state and dominant elements in the Indian economy sought to develop indigenous agrarian capitalism. In the thinking and practice of the colonial state, the developmental plans had no real hygienic component beyond ensuring the efficiency and productivity of labour.89 But elements within Asian national movements, above all in India, harnessed the new global vogue of planning to a far more sweeping vision of state intervention to transform economy and society.90 No less than enthusiasts for rural reconstruction and individual bodily and diet reform, proponents of modernism drew on the legitimating force of the League of Nations’ universal standards and statistics, in support of their very different vision. For Gandhians the ability to control scientifically the body’s minimum needs was part and parcel of a project of bodily self-abnegation; for a number of nutritional scientists and public health officials, nutritional knowledge suggested the need to discipline or control the expansion of colonial capitalism into the Asian countryside. For the modernists, however, nutritional control was to be one arm in a much more systematic regulation of social and economic life, from the regulation of reproduction and ‘racial quality’ to the regulation of the commanding heights of the economy. The theme of rural reconstruction struck a sympathetic chord with a range of political imaginations in the 1930s; but so too did the high modernism of the New Deal, the steel and concrete of the Tennessee Valley Authority, not to mention the images of Magnitogorsk. This was a widespread tendency across Asia. Although the Indonesian nationalist movement might have lacked anything resembling the concerted commitment to planning on the part of some Indian nationalists,

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Rudolf Mrázek’s brilliant work has demonstrated that the allure of modernism, of smooth roads and gleaming machines, was seductive to the engineers of Sukarno’s generation.91 Nowhere in the colonial world was an important strand of nationalism more committed to modernism of this kind than in the India of the 1930s. Even as Gandhi elaborated on his hygienic village utopia, the left wing of the Congress Party made the case for science and socialism; the establishment of the Congress Socialist Party in 1934 gave the left an institutional platform within the nationalist movement. Following sweeping provincial election victories in 1937, the Congress established their National Planning Committee [NPC], its membership divided between experts from the Congress left and a number of industrialists. The flourishing of international nutritional thought in the 1930s found a ready audience amongst the NPC, but from it they drew very different lessons. Drawing on League of Nations studies on the deficiencies of the Indian diet, the NPC decried the vicious circle of poverty and under-nutrition leaving the Indian poor with ‘inadequate safeguards against the rigours of nature or ravages of disease to resist which they are very poorly equipped’.92 The nutritional thought of the League of Nations committees focused on the nutritional deficiencies of individual bodies – a state of individual lack which was statistically widespread within particular populations: the poor, the unemployed and above all the peasantry. In the eyes of the NPC, the qualitative issues of individual nutrition linked more closely with the mass spectre of Malthusian catastrophe. Increasing food production, as much as redistributing its consumption, was at the heart of the NPC’s vision. Going much further than the reformers who wished to spread the gospel of hygiene, the NPC declared that: ‘all social customs, religious taboos and injunctions which now stand in the way of the husbandry of soil resources and efficient utilization of available food resources have now to be abjured to mitigate the effects of chronic food shortage and poverty’.93 This was but a first step. If Gandhi saw in ‘diet reform’ a path to the improvement of the Indian race, one meal at a time, the NPC took the notion of racial improvement much further. In their view, nutrition and sanitation were but elements in a thoroughgoing, planned transformation of India, directed by the foremost experts in the land. The NPC set out its aims in the most expansive terms: In the interests of social economy, family happiness, and national planning, family planning and a limitation of children are essential;

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and the State should adopt a policy to encourage this. It is desirable to lay stress on self-control, as well as to spread knowledge of cheap and safe methods of birth control … A eugenic programme should include the sterilization of persons suffering from transmissible diseases of a serious nature, such as insanity or epilepsy.94 A combination of legislation and the very latest technologies of government (birth control clinics, schemes of social insurance) would relieve India from the ‘terrible waste of life spilling on all sides’.95 This ‘waste’ flowed from a range of ills. Some had been dear to social reformers in India for more than a generation: child marriage above all, as well as all manner of ‘superstitions’. Although the nutritional thought of the 1930s touched on concerns about India’s growing population, the emphasis on nutrition and sanitation worked, in many cases, against the popular claims of eugenicists. Gandhi and Aykroyd alike argued that a change in food habits, rather than selective breeding, would transform the health and vitality of the Indian ‘race’. The NPC, on the other hand, linked the two strands of thought according to its own, modernist vision of national development. The NPC’s epistemology of planning brought the hygienic/ nutritional nexus of diet studies, pilot schemes and rural reconstruction projects together with other networks of civic and voluntary activism which had flourished across Asia in the inter-war years, such as the birth control movement and the science of eugenics.96 Both would find expression in the state – which the modernists had firmly in their sights – and in case of conflicting imperatives, decisions would be made on ‘scientific’ grounds. It may not be going too far to view the thinking of the Indian NPC as an instance of the nutritional and sanitary utopia of the League of Nations ‘seen like a state’.97 However, as we will see, the institutional structures which the European colonial empires bequeathed to their successors across Asia were hardly propitious. To use the language of political science, the ‘state capacity’ to implement schemes as ambitious as the NPC’s simply did not exist. The constraints of resources (if not the constraints of imagination) which had led British colonial officials to look to cheap quinine as a solution to the malaria problem in the empire would confront their successors in a major way. In Asia, it was only within the Japanese empire in the Northeast, perhaps, that the more ambitious hygienic ideas of the 1920s and 1930s found expression in concerted state policy. Unlike the British or the Dutch, the Japanese instituted an ‘organized, architectonic colonialism

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in which the planner and the administrator was the model’.98 The Japanese exercised a level of sanitary control over Korea and Taiwan which the most enthusiastic hygienists in the British Empire could only dream of.99

Conclusion The League of Nations brought together a number of forces – techniques, types of expertise, practical experiences – on the margins of state power, which together seemed to address the pressing problems of the day: the relationship between health, consumption and economic development, particularly agricultural development. Among the key contributors to the League’s debates were colonial scientists who were able to use their prior experiences in order to shape international debates on hygiene and nutrition. Equally, the League of Nations’ embrace of nutritional and social medical concerns lent legitimacy – through reports, declarations, statistics and investigations – to ambitious experiments carried out by nationalist reformers and colonial officials alike This process was underway, however, at the precise moment when national/colonial states were developing within hardened boundaries, and where the state emerged more firmly committed to colonial industrialization. The story of the 1930s was one of internationally circulating norms taken up by nationalist intellectuals in colonial states; following chapters will consider what would happen when the scope and nature of internationalism changed, when colonial states became post-colonial. On the eve of the Second World War, the field of international public health was poised between the minimal and the maximal state, between liberal-individual and social governmentality.100 The coming together of these strands of thought shaped the future of public health at the colonial, national and international levels in the years to come. But first we turn our attention to the Second World War. War and consequent decolonization led to the realization of a very different configuration of forces, technologies and ideas in South and Southeast Asia after 1945, and the meanings and potentialities of public health stood transformed.

2 War and the Rise of Disease Control

The Second World War marked a watershed in the practice of public health. The impact of the war on the field of public health was such that we can see a fundamental paradigm shift; a change in the way public health was conceived, discussed, and acted upon. Technological transformation played a central role in engendering a new sense of the possible. The wartime discovery of the insecticide DDT and a range of pharmaceutical technologies made effective, cheap disease control more feasible than it had been previously. The experience of wartime relief operations put these technologies into practice, in ways that came to shape their civilian use in the post-war era. The previous chapter argued that the internationalization of public health between the wars brought together a range of practices and aspirations, often on the fringes of the state. The proponents of rural reconstruction in the inter-war years often had an uneasy relationship with the progress of capitalist development in Asia and Africa. This chapter argues that the nature of internationalism in public health changed completely by the end of the war, and is particularly concerned with two sets of questions. Why, firstly, did the modernist vision of public health prevail over the rural romanticism so prevalent in the 1930s? Why did a vision of public health centred on technology come to supplant the more expansive notions of rural public health? I suggest, in the first part of the chapter, that this shift owed much to the global circulation of DDT, a technology that required much less ‘incorporation’ than anything that had gone before, leading to a new sense of the possibilities for disease control in unpropitious circumstances. Secondly, the chapter is concerned with the kinds of States, national and international, that emerged from the war. What was the process whereby health emerged as a ‘right’? How was this related to changing 47

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capacities of states to provide the conditions of health? What underlies the shift from an international public health composed of loose networks of experts and voluntary groups to a post-war set of connections based on the notion that States, of whatever kind, were responsible for the health and welfare of their populations?1

DDT and disease control The Second World War expanded the frontiers of international medicine. The war precipitated a technological revolution, and necessitated massive campaigns of medical relief. Public health was mobilized and motorized to an unprecedented extent. It is difficult to over-state the importance of the military medicine of the Second World War to the future of international health: in the realms technology and organization, the war saw significant developments.2 Above all, the experience of the war held out the prospect of a world free from disease. The symbolic and practical power of this possibility was immense. Nothing symbolized the transformations of the Second World War more clearly than the arrival of DDT, a new technology created and mobilized during the war. The war revived and energized a model of transnational public health that had begun to fall from favour amidst the discussions of social medicine and rural hygiene in and around the League of Nations, including its conference on Rural Hygiene in the Far East. DDT was a new tool, but in fact the Rockefeller Foundation had pioneered the method of vector eradication in Latin America in the 1930s.3 Fred Lowe Soper was particularly influential in developing and advocating this method of public health.4 Soper had made his career with the Rockefeller Foundation in the 1920s and 1930s, pioneering the techniques of vector eradication using what he called ‘search and destroy’ methods in the Amazon rainforest, in his successful campaign against yellow fever.5 Soper was instrumental in persuading the Egyptian government to embrace DDT in the midst of the devastating malaria epidemic of 1943–44. As his visit to Cairo coincided with the onset of the epidemic, Soper was in a position to advise the Egyptian government on its response, despite British opposition.6 By 1944, Soper was advising the Egyptian government to use DDT rather than pyrethrum (then the most popular insecticide) in the vector eradication campaign in Southern Egypt. Teams of malaria workers sprayed a DDT-kerosene mixture on trains and houses, ‘an innovation later copied around the world’.7 Within five years, Soper would be at the

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forefront of the World Health Organization’s attempt to eradicate malaria worldwide. The Swiss chemist Paul Müller, employed by the Geigy corporation, had discovered DDT to be toxic against insect vectors of disease in 1941, and after further trials in Britain and the United States, the British Ministry of Supply began to manufacture DDT on a priority basis in April 1943.8 Like pyrethrum, hitherto the insecticide of choice, DDT worked by interrupting the breeding cycle at the point when plasmodium spores were concentrated in the bodies of female mosquitoes. Unlike pyrethrum, DDT was long lasting. Experiments with the new insecticide suggested that a single spraying of the walls and ceilings of a house would protect it for a considerable period. Entire areas could now be ‘secured’ from malaria through the massive aerial spraying of DDT. The first concerted campaign using DDT began in December 1943, when the insecticide was used to arrest an epidemic of typhus – an insect-borne disease – in Sicily. At the height of the campaign, 75,000 people were being sprayed each day, despite the fact that Allied authorities had little knowledge of the toxicity of the chemical.9 From March 1944 onwards, Allied forces used DDT in the Central Mediterranean theatre against malarial mosquitoes.10 Towards the end of the malaria season in 1944, Allied armies brought DDT into widespread use in Southeast Asia.11 The advent of DDT revolutionized malaria control. The methods hitherto used – ‘gigantic drainage projects, widespread larvicidal operations and systematic daily spraying with pyrethrum insecticide’ – paled in comparison with DDT.12 Military medical officials suggested that ‘unlike the anti-mosquito measures previously employed, DDT ground spraying, if properly exploited, had immense potentialities in that such spraying could be easily and rapidly organized under diverse conditions’.13 The impact of the technological revolution in insect control emerges clearly from a report by the British War Office’s Director of Hygiene during a tour of Southeast Asia. He suggested, emphatically, that the extensive drainage works being carried out were redundant after the advent of DDT and the intensified use of mepacrine, a synthetic anti-malarial drug: ‘If all 1000 men employed in keeping the Manipur drains in order, were used in the distribution of DDT, I am convinced much better results would be obtained’.14 The war put a premium on ‘temporary measures’.15 Before long, DDT almost completely replaced the ‘anti-larval measures, which had hitherto formed the backbone of the entire malaria control scheme’.16 This transformation ‘could be effected all the more readily, because control through

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DDT did not require prolonged training of personnel and the slow building up of the ponderous organization essential for anti-larval measures’.17 Building on these early experiments and improvisations, the use of DDT was extensive by 1945.18 The aerial spraying in preparation for the Lombardy Plains offensive of 1945 required 50,000 gallons of DDT solution, as well as 30 tons of Paris Green.19 Further east, the aerial spraying of Rangoon with DDT was complete within three days of the Allied reoccupation. By the end of June 1945, Liberator aircraft had sprayed an area of 68 miles around the city.20 A naval medical report on malaria control work in Rangoon between May and July 1945 described the ‘mopping up operations’ after the end of the aerial spraying. Clouds of DDT covered the side streets of Rangoon, which archival photographs show strewn with detritus and replete with stagnant ponds: The Fordson truck was driven slowly up and down those streets with a six foot jet of oil [mixed with DDT] directed into the drains from a knapsack sprayer on the back. At first the power sprayer was used with spray guns, and a fine spray shot out of each side of the truck. This was not found sufficient to deal with the large numbers of culicines and a more powerful spray was used … All streets from China Street to Thompson Street, and north from Strand Road to Montgomery Street were dealt with in this fashion.21 Some of the most dramatic successes with DDT came not on the battlefield, but in Ceylon, headquarters of the Southeast Asia Command. DDT sprayings were initiated in military camps at Trincomalee and Kandy in February 1945, and death rates from malaria showed a great reduction which was all the more remarkable for coming in the midst of an epidemic of malaria in surrounding areas which led to widespread mortality and morbidity in the civilian population.22

Building expertise The story of Wilfred Chellapah, a malaria worker from Malaya who worked on some of the earliest trials of aerial spraying with DDT in Orissa in 1943, brings out the excitement, and terror, of the introduction of DDT.23 Chellapah’s narrative also shows the ways in which the implementation of the new technology built upon kinds of technical knowledge built up on a local level during the inter-war years, includ-

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ing his own. Having graduated from a course in public sanitation in Singapore in 1939, Chellapah obtained a job as a malaria assistant in Ceylon, from where his family originated. Stationed in Kandy, Chellapah was responsible for anti-malaria activities in the plantations of the region. ‘Two of us covered the whole area’ around Kandy, he recalled, ‘we had motorbikes, and later cars’. The methods Chellapah employed typified the environmental approach to malaria control which was common in urban areas and plantations in the inter-war years. He would go to estates, and teach the workers ‘how to construct temporary drains to drain away marshy areas … how to efficiently carry out oiling’ and ‘how to deal with stagnant pools’. In each estate, Chellapah would conduct a survey, using a map to mark out ‘all the water courses, streams, rivers’. He would then ‘ma[ke] a sketch map, following it and marking the places where draining was needed’. Without a job after the end of his contract on the estates, Chellapah received a telegram in late 1943 from J.W. Sharp, a senior medical officer in Southeast Asia Command, asking him to come to a hotel in Kandy. At the secret encounter, Sharp asked Chellapah to join the experimental DDT project as his personal assistant. Within days, Chellapah was at an RAF base in Orissa, near Cuttack, where military scientists were carrying out tests of the aerial spraying of DDT.24 Chellapah’s duties as a civilian malaria assistant covered ‘two villages, three and six miles from the camp’, to which he had to ‘cycle every morning, and collect all the dead insects’. Chellapah recalled the atmosphere of desperation to find an effective insecticide to replace pyrethrum, which was in short supply. Chellapah’s daily reports ‘helped them to work out that the DDT was a success’; there was great optimism about the miracle of DDT. Chellapah’s oral testimony brings out a significant undercurrent of violence in the experiments with DDT. The war gave rise to DDT, and thereafter the insecticide remained inscribed with the circumstances of its introduction: military necessity, and an urgency that pushed aside caution. ‘Lots of birds were dying’, Chellapah recalled, ‘… the villagers eat insects too, and some of the garden insects were affected by DDT’. On his return from Orissa to Ceylon, ‘they put me in an enclosed room which had been sprayed with DDT, and would release, say, 200 mosquitoes into the room, and I would have to collect their bodies. The fumes affected me’. More frightening still was an episode that Chellapah witnessed: ‘two Singhalese workmen were brought into the office and there was a naval officer [who] soaked DDT solution in cotton wool and with a razor blade he made a slit on that man’s arm’

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and bandaged it. The second workman, who served ‘as a control’, had cotton wool soaked in pure kerosene oil rubbed into his wound. ‘Within a few minutes’, the men ‘fell on the ground and had all sorts of tremors’ and convulsions; Chellapah’s own tremors lasted for five years. Chellapah might not have been an expert, in the sense of carrying scientific authority, but his body of practical knowledge, accumulated at a local level on the plantations of Ceylon, was mobilized in order to make DDT work. The new insecticide was an exciting, sometimes frightening, technology; the abruptness with which it supplanted earlier forms of malaria control belies the fact that its utilization initially depended on knowledge and practice of malaria-control demonstrations and projects from the 1930s and early 1940s. From military bases and ‘theatres of war’, DDT gradually reached civilian populations by 1945. The residents of Kanara district in Bombay Presidency were amongst the first beneficiaries, under the leadership of D.K. Viswanathan, the province’s director of anti-malaria services. The memoirs of Viswanathan, one of India’s foremost malariologists, highlight this process of mobilizing existing technical knowledge in service of the new technology. Viswanathan had spent his early career as a malaria officer on the tea plantations of Assam. In late 1942, he was relieved of his military duties to take up the directorship of the Bombay malaria organization, based in Kanara district; the Viceroy, Linlithgow, decreed that Bombay ought to have a permanent anti-malaria organization when the governor of the Province, Sir Roger Lumley, came down with a nasty bout of malaria after a tiger shoot!25 Viswanathan and his colleague Ramachandra Rao conducted intensive local experiments on mosquitoes over the course of 1943 and 1944; it was ‘a most thrilling period in our technical pursuits’. These ‘experiments’, however, ‘were attended with poor results’; indeed, ‘in one village there was a greatly enhanced prevalence of malaria after a programme of pyrethrum spraying’. The experiments proceeded by trial and error. Each new technology called forth a new set of problems which, in turn, needed new technical solutions.26 The malaria workers cleared streams and water courses of ‘marginal vegetation’ and mosquito breeding stopped in those locales, only to flourish in the terraced rice fields. Trials of new synthetic anti-malarials ‘were none too successful, for the sole reason that we could not get the public to take a sustained interest’.27 Nevertheless, with each setback ‘we were able to find a reason for our failures, determine a remedy for them and actually prove the beneficent results of our painstaking investigations’.28

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And then there came DDT. The ‘painstaking investigations’ of two years proved ‘wholly unnecessary with the wartime discovery of DDT’.29 This is a turning point in Viswanathan’s narrative, which is a story of a gradual, linear progression towards the eradication of malaria, parallel to the unfolding of his own career. Yet even Viswanathan points out the importance of what had gone before: We … venture to doubt if we would have had the daring to propose a service of such great magnitude as to serve about a million population if we did not have the benefit of worship at the altar of science, of patient investigations into the habits of the mosquito, careful reasoning for our earlier failures, planning newer methods of worship in the light of this reasoning and having science grace our fresh attempts with patent results.30 Viswanathan argued that the detailed knowledge of local ecology built up by his centre in Kanara provided them with the ability to implement DDT quickly. Furthermore, earlier technical expertise provided ‘technical personnel with a confidence with which to embark on control procedures’.31 It would not be long, however, before proponents of DDT forgot these ‘messy’, improvised origins. The success of DDT, Viswanathan wrote ‘has given rise to the impression that pre-control surveys of the relevant epidemiological features were no longer necessary and that spraying service could be undertaken in any and every malarious area.’ 32 The reasons for this confidence are evident from Viswanathan’s narrative itself. Viswanathan was ‘thrilled’ with the results of the early results of DDT – the first civilian home in India was sprayed on July 1, 1945 – DDT was a ‘wonder drug’, and before long, Viswanathan had canvassed enough support to launch an intensive programme of DDT spraying from his base in Kanara district. The anti-malaria campaigns using DDT heralded a transformation in international public health. Technological medicine had been conspicuously absent from many of the discussions of the League of Nations’ Health Committees.33 Now the technological advances of the war – which involved new biological agents, and new means of using them – placed the ‘magic bullet’ at the heart of international medicine. The localized, permanent measures of malaria control work in the inter-war years declined under the pressures of war, despite the fact that they were, in many ways, essential to the mobilization of DDT. By

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Figure 2.1

Singapore is Sprayed with DDT, 1945

Source: West, T.F. and G.A. Campbell, DDT and Newer Persistent Insecticides (London: Chapman & Hall, 1950), Frontispiece [Crown Copyright]

1945, the size and scope of these health campaigns dwarfed all that had gone before. However, the apparent success of DDT rested on a paradox. The urgent need to control infectious diseases on the battlefield led to a significant amount of improvisation; at the same time, much faith was placed in the seemingly limitless power of the new medical technology, making the health campaigns appear to be a planned, concerted ‘victory’ over nature. Timothy Mitchell, writing of the early use of DDT during the Egyptian malaria epidemic of 1942–44, captures this paradox particularly well: The chain of events that took DDT from the Peet-Grady chamber to the field was a process of borrowing, translations, and things invented for one purpose taken over by other forces, all modulated by US-British rivalry over Egypt, the needs of war, the accidents and ambitions of [Fred L. Soper’s] Rockefeller career, and the impact of sugarcane production and irrigation works.34

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Despite not knowing exactly how DDT worked as an insecticide, Allied medical authorities put it into immediate use.35 In fact, as Frank Snowden has shown, the dramatic successes against malaria in Italy resulted not merely from the use of DDT, but from the supplementation of DDT with older, more localized measures of public health and environmental sanitation. That DDT could be so effective, he suggests, was because Sicilians were ‘already medicalized’, after generations of anti-malarial work. As much as to DDT, success in the anti-malarial campaign was down to ‘literacy, the familiarity of the population with quinine, the widespread understanding of the mosquito theory of transmission…and the availability of trained and experienced health personnel’.36 Furthermore, the use of DDT coincided with a reconstruction of rural health centres, a renewal of swamp drainage and works of sanitation, and massive public investment by the United Nations Relief and Rehabilitation Administration (UNRRA) in providing employment, public works, and nutritional supplementation to vulnerable groups.37 All of this leads Snowden to conclude that, in focusing purely on the miraculous results of DDT, international health authorities had ‘drawn misleading lessons from the Italian triumph’.38 DDT was far from the only new medical technology to emerge out of the war. Major advances in sulpha drugs, X-ray technology and synthetic anti-malarial agents each played a significant role. As Mark Harrison has shown in his recent book on Allied military medicine, transformations in the nature of medical organization, and an increase in the mobility of medical facilities made the new technologies more effective.39 The transformations in international medicine resulted in the amalgamation of military and civilian medicine during the campaigns of humanitarian relief mounted towards the end of the war. A turning point in the relief efforts came in November 1943, with the establishment of the UNRRA. Directed by Herbert Lehman, the Democratic governor of New York, UNRRA’s first task was to coordinate food supplies for liberated areas in Southern and Eastern Europe. The history of UNRRA was one of immediate, emergency measures. From the beginning, an early document by the medical sub-committee stated that ‘health work will necessarily constitute one of the primary and fundamental responsibilities of UNRRA. The relief and rehabilitation programme must aim toward the maximum of health security.’ The priority of UNRRA’s work was to provide a level of relief sufficient to avert ‘disease and unrest’. 40 The organization’s planners defined food requirements narrowly and, in theory, ‘scientifically’.41 UNRRA drew on the advances of nutritional research

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in the 1930s, considered in the previous chapter, not to change the habits of whole populations, but to forestall social unrest.42 The meaning of nutrition shifted, under the pressures of war, into a simple question of supply: James Gillespie has shown that UNRRA’s approach to the health of children in liberated Europe focused on the distribution of milk supplies, which ‘soon became a universal panacea’. To a significant extent, this approach was determined by the availability of plentiful supplies of powdered milk.43 Similarly, health itself became a question of the supply of tangible goods. ‘Health’ was the ‘15,000 vials of penicillin, 600 bottles of isotonic solution of sodium chloride for use with penicillin, 10 tons of DDT, 9,987 gallons of velsicol for use with DDT and 39 long tons of contributed clothing’ sent to China, for example.44 UNRRA provided over $117 million worth of medical supplies – 4 per cent of the entire supply programme – with China as the largest beneficiary, followed by Poland and Yugoslavia. Over 80 per cent of the medical supplies came from the United States.45 The experiences of UNRRA showed what could be done with the new technologies, channelled through a more global organization; it provided a formative experience for medical officers used to working on a very local level with next to no money.

Planning for the health of the world New medical and chemical technologies were given meaning and ethical force by the concurrent circulation of new technologies of government: social insurance, planned health services, new techniques of economic management, and a newly revived language of political rights. The publication, in 1942, of William Beveridge’s Report on Social Insurance and Allied Services was a watershed in the history of welfare provision, not only in Britain, but also throughout the world.46 Beveridge declared his report, an ‘attack upon five great evils’: Upon the physical Want … upon Disease which often causes Want and brings many other troubles in its train, upon Ignorance which no democracy can afford among its citizens, upon Squalor which arises mainly through the haphazard distribution of industry and population, and upon Idleness which destroys wealth and corrupts men.47 A National Health Service was at the centre of Beveridge’s proposals for a universal welfare state.48 From South Africa to the West Indies,

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reports emerged planning for a future of expanded welfare provision, in which public health would play an important role.49 This ‘universalization’ of the welfare state was a process that was strengthened by the institutionalization of these new ideas about welfare at an international level, in the new organizations that emerged in the midst of the war. I will consider these international organizations later in this chapter, but turn first to an exercise in planning for the health of the most important part of the British Empire: India. The Bhore Committee The initial motivation for re-thinking the future of welfare in India arose from simple necessity. The resignation of the provincial Congress ministries in 1939, in protest at the Viceroy’s declaration of war on India’s behalf and without consultation, left the British casting around for allies. The outbreak of the Quit India movement in August 1942 left the colonial state facing the greatest threat to its authority since 1857. In this context, and even whilst suppressing the Quit India movement brutally, with all the force at their disposal, the government of India turned to plans for post-war reconstruction to make a display of their concern for the ‘national welfare’, and to assuage key sections of the Indian elite.50 This was a period, as Benjamin Zachariah has shown recently, when fundamental assumptions of imperial governance were undergoing a shift: the laissez faire budget balancing of the past gave way to an interventionist colonial state.51 Our main concern is with the plans for India’s public health services, but health planning took place alongside a range of other plans for ‘post-war reconstruction’ in industry, agriculture and social security. The plans for India’s health service also coincided with the publication of the so-called Bombay Plan by a number of leading industrialists: an economic plan which used socialist language carefully to ‘preserve what was essential in capitalism’.52 The Viceroy appointed the Health Survey and Development Committee in early 1944, under the chairmanship of Sir Joseph Bhore. On the surface, the Bhore Committee – as it was known – exhibited a somewhat predictable membership, similar to countless colonial commissions of inquiry in preceding years. Bhore himself was the quintessential Indian member of the Civil Service. He entered the ICS in 1902, having taken a degree at University College London. Married to Margaret Stott, Bhore served as high commissioner for India in London in the early 1920s, and subsequently entered the Governor-General’s Executive Council, a carefully-selected body of advisors and collaborators. Bhore’s

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credentials led him to represent India at the Silver Jubilee celebrations in London in 1935. Over the course of his public service, Bhore served in departments of agriculture and lands, labour and industry. Also on the committee was the Diwan Bahadur Dr A. Lakshmanaswami Mudaliar, who would later occupy a leading position in the World Health Organization. A gynaecologist by training, he was, at the time of the Bhore survey, the vice-chancellor of Madras University and, again, a reliable collaborator for the colonial state. Most of the practical work of the committee fell on the able shoulders of K.C.K.E. Raja, a medical statistician at the All-India Institute of Public Health in Calcutta; Raja would proceed to become Director-General of Health Services in independent India.53 But all was not as it seemed. The circumstances of the war brought together, within the Bhore Committee, a combination of conservative Indian civil servants and progressive international doctors, at least one of whom was openly communist in his views. Perhaps as a result of this unlikely meeting of minds, the committee was – for an ‘official’ body – unusually open to new ideas. The thinking of the Bhore Committee owed much to its discussions with a group of international consultants, who toured India in late 1944 on a trip sponsored by the Rockefeller Foundation.54 The British members of the international committee were hardly conventional choices: John Ryle, the first ever professor of Social Medicine at the University of Oxford and a communist, and Janet Vaughan, also of Oxford, who had played a central role in organizing the blood bank during the Blitz.55 Joining them were doctors from Australia, Canada and the United States. Perhaps the most selfconsciously radical member of the international committee was Henry E. Sigerist. Born in Paris, and educated in medicine at Zurich University, Sigerist arrived in the United States in 1931, taking up the directorship of the Institute for the History of Medicine at the Johns Hopkins School of Public Health in 1932. Sigerist’s diaries and correspondence provide a clear indication of the sense of opportunity and the flourishing of communication engendered by the global networks planning for the future of public health. Sigerist’s wartime interest in India resulted from his chance friendship with a young Indian doctor named Kamala Ghosh. Ghosh had written to Sigerist at Johns Hopkins in early 1941, introducing herself as ‘an Indian (Hindu) woman doctor’ who had been ‘working for 8 years in India, as a member of the Women’s Medical Service, being in charge of small (45–65 bed) hospitals for women and children in different parts of the country’.56 Ghosh, the daughter of a former Justice of

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the Calcutta High Court,57 happened to be in the United States on leave. She was moved to contact Sigerist, she wrote, ‘because, reading your book on “Socialized Medicine” a few weeks ago, all the problems in public health and education that I have been facing, were presented in an entirely new aspect and became suddenly capable of solution’.58 Sigerist invited Ghosh to visit him at Johns Hopkins, which she did, and in their subsequent correspondence, she expressed a desire to return to India to play a part in medical relief and planning for the future. Unable to secure a passage home on an ordinary ship, Ghosh took the position of medical officer on an oil tanker: a radio broadcast about her heroic journey described her as a ‘small, dynamic charming woman, under thirty, she insists that she is first and foremost a doctor and refuses to say anything about her adventures’.59 On board the oil tanker, traversing the North Atlantic, Ghosh wrote to Sigerist again: ‘I have been reading some books on the Chinese industrial cooperatives, and a surgeon’s book on the experiences of the Republican medical services during the Spanish War, and also have your little “Medicine and Human Welfare” with me to dip into for a tonic at low moments’.60 A more evocative idyll of social medicine in the 1940s would be hard to find. Tragically, Kamala Ghosh died at sea. Enemy fire destroyed the tanker. ‘It is really terrible’, Sigerist wrote, ‘I am more upset than I can tell’.61 The following year, Sigerist received an invitation from the Government of India to join the tour of international experts studying India’s health problems and advising the Health Survey and Development Committee. Noting that his fellow international experts included John Ryle, Sigerist concluded that ‘I think the choice is interesting. It shows that liberal forces are involved’.62 In Sigerist’s mind, this was a symptom of the flourishing of progressive and radical thinking about health in the 1940s, which – more than anyone – his late friend Kamala Ghosh epitomized. ‘I think Kamala Ghosh prepared the ground’, he wrote in his diary.63 Sigerist’s path to involvement in India suggests that the outcome of the Bhore Committee’s discussions cannot be explained wholly by the workings of techno-politics: a set of unintended outcomes flowing directly from the consolidation of new discourses and new kinds of expertise. Imagination, even emotion, played an important part. The most influential of the international consultants, and the only one who was formally a member of the Bhore Committee, John Grant represented the American variant of social medicine.64 A career Rockefeller officer, and the son of a missionary, Grant spent much of

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the 1930s in China. During the war, Grant headed the All-India Institute of Hygiene and Public Health in Calcutta. Despite his extensive experience in public health in poor rural areas, Grant later told an audience in New York, ‘India shocked me’. ‘I knew the Asiatic countries, and all of them had features way ahead of India. Medically it is the most backward country in the world’.65 Grant had pioneered rural health centres and health education in China, and had been involved with the establishment of the Rockefeller Foundation’s model health centre in Singur, Bengal. Where Sigerist brought to the committee a detailed knowledge of (and great enthusiasm for) Soviet industrial medicine, Grant brought the expertise of the 1930s which the previous chapter considered: a focus on the problems of rural areas, and the relationship between health and agriculture.66 The committee’s ‘ideas of India’ harked back to the 1930s. In the committee’s analysis, India’s poverty was at the root of the problems of public health. The Bhore Report, finally published in 1946, expressed its interest in widening the ‘conception of disease … by the inclusion of social, economic and environmental factors which play an equally important part in the production of sickness’. The committee went on to associate public health firmly with plans for economic development, suggesting that ‘unemployment and poverty produce their adverse effect on health through the operation of such factors as inadequate nutrition, unsatisfactory housing and clothing and lack of proper medical care during periods of illness.’67 The report channelled the language of rural reconstruction, suggesting health was a moral as much as a technical endeavour. Grant had been closely involved with rural public health in the 1930s, and it was also an endeavour of interest to various members of the ICS.68 The committee drew on the wealth of nutritional knowledge from the surveys of the 1930s to emphasize the point so widely made before the war, that poor nutrition was at the root of many of India’s health problems. In suggesting the need for a cadre of simply trained health workers to serve India’s rural masses, the Bhore Committee went back to the concerns of the League of Nations Conference on Rural Hygiene. The workers would receive simplified medical training, and be left in charge of medical statistics, water purification, and the ‘spray killing of mosquitoes’. In keeping with the transformative, almost missionary, aims of social medicine, the Committee declared that a ‘social outlook should be developed in every health worker’. The ‘woman who, through lack of knowledge of mothercraft, feeds, bathes, clothes, or nurses her baby improperly, the tuberculosis patient who, through

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ignorance, disseminates infection by indiscriminate spitting or coughing’, each of them required the ‘technical knowledge and skill that the doctor, the nurse and the social worker can make available to them’. However, they also needed ‘understanding and sympathy, tact and patience’.69 Interestingly, and like a number of rural hygienists in the 1930s, the Bhore Committee turned itself against the use of birth control, and here the voice of the conservative civil servant spoke clearly: ‘Conduct divorced from responsibility injures the individual and the community’. Worse still, in their view, and ‘fraught with serious consequences to the national welfare’, was the fact that ‘contraceptive practices are … more likely to be used by the more successful and intelligent sections of the community than by those who are improvident and mentally weak’.70 Up to this point, the findings of the Bhore Committee are familiar in terms of the language of the 1930s. But the Bhore Committee proceeded to signal a crucial shift in perspective in its insistence that public health was a fundamental responsibility of the state, rather than for social reformers and voluntary organizations. This was exactly what the Congress’ National Planning Committee had argued in 1939, but now the recommendation came from an official commission of inquiry. The Bhore Committee was implicitly critical of the prior neglect of public health by the colonial state (even though the report began with a conventional narrative of the beneficent medical progress which British rule brought to India), the more so in their confidential correspondence with the government. A memorandum by the British advisors to the committee declared that ‘the Provinces … are jealous of an autonomy in respect of public health, medical relief and medical education, which they are not as yet strong enough in personnel or material resources to wield’. Similarly, they were critical of the prevalent attitudes of the civil service: ‘there is a too widespread attitude of apathy of defeatism: i) because the problems are so vast; ii) because the political situation is so difficult and uncertain and iii) because of the frequently reiterated lament that “India is a poor country”’.71 In making its case for a national health service, the Bhore Committee cast its net wide, examining, in detail, plans for post-war health services in Britain, the United States, Canada, Australia and New Zealand, as well as making frequent reference to Henry Sigerist’s admiring account of the development of Soviet health services in the 1930s.72 This was a significant departure from the perspectives of the 1930s, which had suggested the need for a completely different approach to health in poor agricultural (and, of course, colonial) countries to those of advanced

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industrial societies. Based upon this comparative view, the Bhore Commission suggested that ‘the comprehensive conception of what a community health service should undertake has led to the development of modern health administration, in which the State makes itself responsible for the establishment and maintenance of the different organizations required for providing the community with health protection’.73 At the centre of the Bhore Committee’s proposals for the Indian health services was their ‘Three Million Plan’, a national network of district health centres linked to more specialized centres of medical care in larger urban areas.74 Perhaps the most significant strategic move on the part of the Bhore Commission was to make the case for the economic benefits of public health. Where the League of Nations’ discussions had expressed unease with the consequences of economic development and commercialization in agriculture, the Bhore Committee tied their plans for health closely to the legitimating language of planned development. The committee’s advisors accused the finance department of the Government of India of indifference to public health. They spoke of a …failure on the part of the Finance Departments to realise a) that health is one of the greatest economies and b) that disease is one of the most expensive and wasteful of a nation’s enemies. Famine, chronic malnutrition, malaria, plague, cholera, typhoid, the dysenteries, leprosy and tuberculosis do not only entail high expenditure for relief: they also mean a devitalized population, unable to work efficiently or advance with the times.75 Indeed, Vaughan and colleagues concluded that ‘it seemed to us that the education of the civil servant and the legislator in regard to health as a national and economic asset was even more urgently needed in India than elsewhere in the world’.76 The British advisors went further than the Bhore Committee’s final report in advocating a public health targeted towards national efficiency: The building of hospitals and multiplication of doctors still has priority in the public mind, but for erroneously conceived humanistic reasons. … more effective measures for malaria-control alone would probably save more lives and render more people efficient than the work of all the hospitals and practitioners put together.77 The Bhore Committee ultimately proved unwilling to abandon a conception of public health centred on hospitals – it was on their recommenda-

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tion that the government built India’s most glittering institute of advanced medicine, the All-India Institute of Medical Sciences, in 1956. Yet the argument for prioritizing effective (and cheap) malaria control was prescient, suggesting exactly the arguments that prevailed in the 1950s. The Bhore Committee said many things, its arguments and recommendations were not necessarily internally consistent, yet ultimately their argument for the economic value of public health was the one which made the deepest impression on the shape of future debates on health. As suggested in the previous chapter, colonial states had on many occasions made the argument that ill health weakened the vitality of workers; less familiar was the concomitant argument that this necessitated state action. The argument about health and economic efficiency is one reason why the Congress leadership, when it emerged from prison at the end of the war, was so ready to accept the findings of the Bhore Report. Although the Congress’ National Planning Committee did not meet after 1940, its reports emerged only in 1947, by which time the editors had taken account of the Bhore Report, and cited it on almost every page.78 There were, of course, differences between Bhore and the Congress. The Bhore Committee advocated a health service funded by central taxation, along the lines of the British National Health Service; the Congress preferred a system of contributory health insurance. The Congress Health Committee viewed birth control with much more favour than the Bhore Committee, hoping initially that population control would form an integral part of the public health programme. Finally, anxieties about a specifically Indian modernity meant the Congress had to pay lip service to India’s indigenous medical traditions, though this seldom translated into direct support for Ayurveda or Unani (as opposed to a desire to control their practice). The Bhore Committee was quite direct in its support of ‘modern’ medicine: The committee noted with approbation the move towards abolishing indigenous systems of medicine in Japan and the Soviet Union.79 The question of the place of indigenous medicine within the post-colonial state remained unresolved, periodically emerging as a matter of debate but seldom leading to any substantive changes in the status quo.

A new international health organization Even as the architects of India’s new health service cast their net wide in looking for models and for intellectual inspiration for their plans, efforts were underway to institutionalize the global convergence in thinking about public health and welfare.

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The war witnessed an upsurge in the production of pamphlet literature on health conditions around the world: awareness increased of the interconnected nature of health problems.80 The increasingly international framework for the discussion of public health reached well beyond a small group of international experts. One of the Bhore Committee’s international advisors, for example, received a letter from the Nagpur Municipal Voters Association highlighting, in a curious way, the international significance of their city’s health problems: … We have read how you have seen ‘the tragic, the sad and the terrible’ prevailing in our country. But we would like to request you to visit our city which enjoys the reputation of the highest death rate in the whole world. We have started our Association for the last ten years for this very purpose and have agitated over a number of health problems urgently required to be tackled by the Government. The problems of our town have now assumed an international importance since we are the worst affected spot in the whole world.81 Associated with this newly comparative perspective on the problems of public health was the notion that an international body ought to oversee the new responsibilities of governments in the field of health, and to decree which ‘spots’ were ‘worse’ than others. The problem was that although public health was a conspicuously international issue during the war, the international health organizations of the inter-war years, the League of Nations’ Health Organization and the Office International D’Hygiène Publique, were effectively dead. The League retained a skeletal administration, whilst the German Occupation severely compromised the Paris Office. The head of the League of Nations’ Eastern Bureau in Singapore, Dr C.L. Park, had fled on the floor of a seaplane to Batavia in February 1942, leaving the League’s files and equipment behind.82 UNRRA, when established in November 1943, took over much of the epidemiological intelligence work of both organizations. In the meantime, as James Gillespie has recently shown, other international organizations began to take up questions of public health.83 The ILO was the only organization associated with the League of Nations that survived the war intact. The ILO, exiled to Montreal during the war, began to formulate wide-ranging proposals for social security in a post-war world. The acting director, Edward Phelan, an Irishman who had made a career at the ILO after attending its found-

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ing conference as a member of the British delegation, called for a recognition of the ‘unity of all social risks’. The ‘Social Mandate’ of the ILO pointed towards a post-war world in which universal medical services would be funded by compulsory insurance.84 The ILO’s proposals provoked the immediate ire of the American Medical Association and the US insurance industry.85 Nevertheless, the ILO was an important forum for the legitimation and circulation of new governmental technologies of social and medical insurance on an international level. Also concerned with questions of health, in this case nutrition, was the first of the new United Nations agencies: the Food and Agriculture Organization (FAO), created at a conference in Hot Springs, Virginia, in 1943.86 With John Boyd Orr as its founding director general, and W.R. Aykroyd as the head of its nutrition section, the FAO showed an early interest in the links between health and nutrition, following from the work of the League of Nations in the 1930s.87 The presence of Aykroyd, amongst others, suggests the continuity of thought linking the new organization with the debates of the 1930s. The Hot Springs Conference passed a resolution declaring that it was ‘deeply impressed by the dominant role played by adequate food in the reduction of sickness and death rates and the maintenance of health’. The resolution recognized that ‘malnutrition is responsible for widespread impairment of human efficiency and for an enormous amount of ill health and disease’.88 Aykroyd wrote in a memorandum, upon his return to India, that ‘it was not primarily a health conference … nevertheless, the relation between proper food and health was one of the basic ideas underlying the deliberations’. The meeting had not, however, gone so far as the League of Nations had in the 1930s, in its call to ‘marry health and agriculture’.89 In the years after the war, the creation of separate international bodies concerned with agriculture and with health would have important consequences in dissociating ‘public health’ from its earlier conjunction with nutritional thought. Given the central place of health in wartime relief and post-war planning, the question of designing an international institution to replace the League of Nations Health Organization became increasingly urgent. One of the first, and boldest, proposals came from Ludwik Rajchman, the Polish doctor who had been director of the League’s Health Organization from 1921 to 1938, and particularly involved with work on rural health in China. Rajchman (1881–1965) was a Polish Jew, politically ‘on the extreme left’, yet an ally of Chiang Kai Shek (through his close friendship with T.V. Soong, Chiang’s brother-in-law and foreign minister). After being forced out of the League of Nations

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in 1939 by the deeply conservative French director, Avenol, whose efforts to appease the Axis powers extended to a ‘purge’ of the League, Rajchman focused his energies into gaining American aid for the Polish resistance, and helping T.V. Soong in his efforts to gain American support in China.90 Rajchman’s proposal on the future of international health was widely circulated. He submitted a memorandum to the British foreign office in late July or August 1943, and published his paper ‘A United Nations Health Service. Why Not?’ in the journal Free World in September 1943.91 The internationalization of health, Rajchman suggested, was a symptom of a ‘century of common people’ which ‘was born with the break up of mighty empires in 1918’.92 International health, in this analysis, was an inherently democratic phenomenon, but it had not established lasting roots in the inter-war years. Writing from obvious personal disappointment, Rajchman lamented the League of Nations Health Organization’s ‘slump into oblivious suspension’ at the start of the War. The problem, in Rajchman’s analysis, was one of representation. The League ‘lacked a solid foundation of organized support from the “consumers of health”’. This striking invocation of ‘consumers of health’ – a locution very much in advance of its time – referred to ‘the common people’, or the beneficiaries of public health. ‘However wholehearted, support of the “administrators of health” was not sufficient, and as an appendage to a political body, the Health Organization had to suffer the fate of its principal’. The new United Nations Health Service thus needed stronger foundations, and greater autonomy. Citing the ‘vested interests’ of organized labour and employers’ federations as an important explanation for the ILO’s survival, Rajchman suggested that a similar system of direct, ‘organized representation’ be considered for his UN Health Service. He proposed that social security organizations, local governments, and central governments be represented: the medical profession was notably absent from his plans.93 With representation would come taxation, and this was one of Rajchman’s most innovative proposals. ‘The support of the electorate should be tangible’, he argued, and ‘adequate machinery for the election of delegates’ needed to be formulated. This support would be underscored by a ‘health tax levied in each participating country’. Rajchman suggested that the tax should be ‘assessed at a fraction of 1% of annual appropriations for public health and social medicine on the budgets of the three constituents: Local Governments … Social Security Agencies, and National Governments.’ ‘Imagine’, he suggested ‘a

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penny added to each water bill in civilized communities everywhere. An infinitesimal charge, but millions in dollars for constructive health projects throughout the world’. The other theme in Rajchman’s proposals concerned global inequalities in health. This built directly upon the realization of the deeply unequal provision of health services in different parts of the world: The task is considerable: thus, for example, Great Britain for 46 million people has 62,000 doctors and 110,000 nurses; Japan for 100 million has 50,000 doctors. But India for 400 millions has only 42,000 doctors and 4,500 nurses while China for 460 million, just 9,000 doctors and 2,000 nurses. The 350 million Europeans, 130 [million] North Americans, 100 million Arabs, and 200 million Latin Americans stand between the two extremes. Here we have the clearest example of the discussion of the provision of public health with the world as the scale of comparison. Perhaps Rajchman’s most dramatic proposal was that ‘under whatever name, Colonial Empires, particularly in the Pacific Area and in Africa, would be administered multi-nationally. Health and medicine were used to “open up” new, to maintain, and develop old areas; An United Nations Public Health and Medical Service can effectively perform these functions’. Interestingly, Rajchmann did not express any particular sympathy for nationalist arguments about the colonial neglect of public health; he argued, rather, that the UN would use health as a tool of economic exploitation just as effectively as its colonial predecessors. In the first instance, ‘a Special Joint Commission (USA, British, French, Dutch, Spanish, Portugese and independent experts) should take over forthwith all existing National Services under the United Nations’ authority’. The initial response to Rajchman’s proposals at the British Foreign Office was positive, even enthusiastic. A handwritten note appended to Rajchman’s draft states that: This is an interesting example of the ‘functional’ approach to the question of international co-operation, which has found much recent support (Cf. Prof Mitrany’s ‘A Working Peace System’, which Chatham House has just published). The idea is, roughly, to bypass problems of national sovereignty, formal alliances, federal constitutions, etc. by a series of ad hoc organizations on the basis of the ILO to perform definite functional services (in health, nutrition, etc.) on

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an international basis. Such organizations would develop naturally from the immediate needs of reconstruction.94 Another Foreign Office official, the noted internationalist Philip NoelBaker, wrote to a colleague that under Rajchman’s direction, the League’s Health Organization had ‘a marvellous record of practical work, in spite of the fact that they were constantly hampered by lack of funds and other difficulties’. He concluded that ‘Rajchmann’s paper is very ambitious, and, in my view, none the worse for that’.95 It was decided, however, that the Foreign Office ‘should not be committed to any expression of opinion on Dr Rajchman’s plan until the Ministry of Health gives their views’.96 By October 1943, the consensus at the Ministry of Health, having considered Rajchman’s draft, was decidedly antagonistic.97 Melville MacKenzie, in his detailed critique of the plan, shared Rajchman’s concern with the question of representation, but reached different conclusions, suggesting that the League of Nations Health Organization had been undermined by the fact that ‘members of the Health Committee did not sit as representatives of their Governments, but as experts only’.98 Contrary to Rajchman’s view, MacKenzie suggested that an international health organization was inherently unrepresentative. ‘It must be constantly remembered: a fact that is too often forgotten, that an international body does not feel so direct a responsibility to an elected public body as is the case with Officers of a National Health Service or of a Local Authority’. MacKenzie concluded that ‘impracticable idealism in administrative medicine or even what may be regarded as extreme medico-social views, may in the end defeat their own object and do irreparable damage to the cause of international collaboration.’99 The growing consensus within the British government was to treat the UNRRA as the basis for any permanent international health organization after the war. Of great importance was the fact that the constitution of UNRRA ‘commits the American Government on its own initiative and Russia to international collaboration in medical work and this might be very difficult to obtain at a later date with a new organization’.100 By the following year, the British government saw that the best way to retain American support would be to plan for UNRRA to evolve into an ‘international health commission which would be associated with, or a constituent body of, the proposed Economic and Social Council’ of the United Nations.101 The birth of a new international health organization, in the aftermath of war and

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in the midst of decolonization, will form the subject of the next chapter.

Conclusion: The ghosts of Bengal This chapter has considered the activation, by the Second World War, of new medical technologies, and the new governmental technologies that gave them force. It was far from being a smooth process; the fractures and contradictions inherent in the developments described in this chapter would have a profound influence on public health after the war. Events in Bengal, gripped by devastating famine in 1943–44, exemplified these contradictions. The Bengal Famine showed, first, that the grand declaration of international responsibility for health, indeed for life, rang hollow as long as the interest of imperial rule took precedence over the welfare of the population. Events in Bengal showed that the demands of sovereignty were well capable of prevailing over the imperatives of biopolitics into the mid-twentieth century and beyond, particularly in an imperial context.102 In response to a relatively mild request on the part of the colonial government of India for relief supplies for Bengal from UNRRA, the British government in London panicked. The India Office in London wrote indignantly to the Foreign Office, claiming that: ‘In a matter of this sort on which HMG obviously have views and which affects a good many issues of foreign policy and supply it would have been proper for the Government of India to have consulted us before they took any such action’.103 The main problem, for the British government, was the potential embarrassment that would follow from UNRRA’s intervention in India. The Secretary of State for India put it concisely in a telegram to the Governor-General: If UNRRA operated in India in the sphere of supply and public health they would no doubt wish to send supervisors or inspectors whose operations would presumably be concentrated on Bengal and you must expect undesirable attention to be directed, e.g. on the breakdown of administration there.104 The British government quickly brushed off the Indian proposal. Officials were instructed to respond to parliamentary questions on the matter by pointing out that ‘food grains have been sent to India to the full extent which the shipping resources of the United Nations permit’,

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and that ‘India has … large external balances with which to purchase her import requirements, including relief supplies’.105 The pressure that London brought to bear meant that the Government of India quickly desisted.106 The glaring gap between the rhetoric of UNRRA as harbinger of international responsibility for welfare, and the tragedy of Bengal, did not go unnoticed. With characteristic force and eloquence, Jawaharlal Nehru, writing his Discovery of India from Ahmadnagar jail, made the connection between the tragedy of Bengal and the global discourse of the Four Freedoms. ‘Famine came, ghastly, staggering, horrible beyond words’, Nehru wrote. Men, women, and children ‘dropped down dead before the palaces of Calcutta, their corpses lay in the mud-huts of Bengal’s innumerable villages’. The horrors of the famine stood in the sharpest contrast to the language of the Atlantic Charter. Nehru pointed, scathingly, to ‘President Roosevelt’s Four Freedoms. The Freedom from Want. Yet rich England, and richer America paid little heed to the hunger of the body that was killing millions in India, as they had paid little heed to the fiery thirst of the spirit that is consuming the people of India’.107 By relating the famine to the language of the Four Freedoms, as well as the ‘thirst’ of Indian nationalism, Nehru begins to make a link between famine, social crisis, and a lack of political freedom. The Bengal Famine undermined, perhaps fatally undermined, the imperial claim to be working for the national welfare. It strengthened the nationalist argument that only a new international order of nation-states could make good on the promises of health and wealth for all which had spread so rapidly around the globe during the war. Thus, Nehru suggested that whilst the ‘hundreds of millions of Asia and Africa … welcome all attempts at world cooperation and the establishment of an international order’ they nevertheless ‘wonder and suspect if this may not be another device for continuing the old domination’.108 The fundamental question about any new form of international organization was: ‘does it hold forth the promise of an early liquidation of poverty and illiteracy, and bring better living conditions?’.109 In the inter-war years, internationalism was often strengthened by the networks of colonial rule – scientific, intellectual, institutional – building on a thin layer of voluntary associations established in the image of their Victorian counterparts in the metropolis; in the post-war era, internationalism would be tied to the voluntary association of post-colonial states. The Bengal Famine was not the only cause for this shift, but it played a contributing role.

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The second fundamental contradiction exposed by the Bengal Famine, in the light of the great ambitions for health in the post-war world, was the potential gulf between the newly assumed responsibilities of governments and their capacities. Even more sharply than the investigations of commissions like the Bhore Committee, the inquiry into the causes of the Bengal Famine highlighted how shallow and incomplete was the expansion of modern medicine before the war. ‘The calamity of famine fell on a population with low physical reserves’, the commission found, ‘and circumstances were favourable for a flare-up of epidemic disease. The association between health conditions in normal times and the high famine mortality must be underlined.’110 Thus one of the causes of the very high levels of mortality from the famine lay in the existing weaknesses of Bengal’s medical infrastructure – and Bengal was relatively advanced when compared with other parts of south and southeast Asia: If a public health organization is to be capable of meeting emergencies, it must reach a certain degree of efficiency in normal times. In Bengal the public health services were insufficient to meet the normal needs of the population and the level of efficiency was low …Clearly, one sanitary inspector, even with the help of a health assistant, a medicine carrier and a few temporarily employed vaccinators, cannot deal adequately with the health problems of a population which may exceed 200,000 and inhabit an area of over 150 square miles.111 There is a hint here of why the prospect of a technological fix, through the civilian use of DDT and other new technologies, proved so seductive after the war.

3 The Political Culture of International Health

This chapter examines the reconstitution of the field of international public health, in the light of transformations brought by the Second World War. It begins with the establishment of the World Health Organization in 1946, and culminates with the debates surrounding the relationship of public health to population growth in the mid1950s. Within this period, there was a fundamental shift in the way that international public health was thought about, discussed, and acted upon. The decade after 1945 saw the establishment of a bureaucratic and political field of ‘development’ policy, within which international health had to find its place. At stake was nothing less than the definition of the relationship of health, medicine, hygiene, and economic development. Previous constellations of ideas unravelled, and re-formed.1 In the 1930s, the discourse of rural hygiene had brought together questions of poverty, agricultural development, land ownership and health; now health was identified with ‘economic, social and cultural rights’, and as a form of ‘technical assistance for economic development’. Asia played a central role in these debates, both because of its epidemiological centrality as a ‘source’ of epidemic disease, and because of the politics of decolonization. The transformations, both technological and ideological, brought by the Second World War dented the environmental determinism of tropical medicine. The boundaries of the debate remained relatively fluid until the late 1940s. However, the international context – the unresolved legacies of the Second World War and decolonization, as well as the intensifying Cold War – narrowed the boundaries of possibility. Given the uncertainty and tension of international relations, the new international agencies as well as national governments chose to concentrate on the piecemeal extension of their short-term emergency measures. Broadly 72

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based debates on international social and economic policy narrowed to focus almost exclusively upon economic development as the overriding goal of international cooperation. In this context, the champions of international health had to defend the utility of public health against the neo-Malthusian argument that, by aiding population growth, international health was a fetter on economic development.

Health and the United Nations The United Nations (UN) organization played the central role in the internationalization of responsibility for welfare after 1945. The UN charter was signed by 50 countries at the San Francisco conference of 1945, based on the proposals drawn up by the ‘Great Powers’ at Dumbarton Oaks in late 1944. From the outset, the new organization was to have an Economic and Social Council, reflecting the expanded conception of security emerging after the war, extending the idea of security from States to individuals, and from the realm of military security to economic and social security.2 Expanding on the League of Nations’ concern with ‘social’ questions, the Economic and Social Council of the UN was to oversee the work of a number of specialized agencies.3 The first of these, the Food and Agriculture Organization (FAO), was established towards the end of 1943. By 1946, it had been joined by the UN Educational, Social and Cultural Organization (UNESCO), the United Nations Children’s Fund (UNICEF), and the World Health Organization (WHO). Shaped by the values and the political language emerging from both anti-fascist and anti-colonial struggles, the UN enshrined a new international order founded on democracy. The massive inequalities that remained, in the new order, would be remedied by the all-encompassing notion of ‘development’, aided and assisted by the UN’s new agencies. The WHO was the central arena for many of the debates on health after the war.4 The debates on the future of international health during the war, considered in the previous chapter, culminated in the establishment of the WHO between 1946 and 1948. Given the controversy that had surrounded Ludwik Rajchman’s proposal of 1943,5 British and American policymakers had hoped to keep the question of an international health organization off the agenda at the San Francisco conference of 1945.6 Hugh Cumming, director of the Pan-American Sanitary Board was told by the State Department that ‘the question would not be brought up at San Francisco’. Cumming had gained the impression from American planners that ‘health was not considered important

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enough to be a separate subject’, but would be incorporated into a ‘conglomerate mass’ known as a ‘commission on education, labour, and social welfare’.7 However, Chinese and Brazilian delegates at San Francisco, Szeming Sze and Paula Souza, oblivious to their AngloAmerican counterparts’ prior discussions, called for a conference to be convened to design a new international health organization. The British and American delegates could not, for fear of embarrassment, openly oppose such a proposal, and thus it passed unanimously.8 Much of the debate during the initial discussions on the WHO revolved around the extent to which the new international health organization would develop the more interventionist, even radical, angle of the League of Nations’ approach in the 1930s. Despite disagreements over the extent of the new organization’s powers, and over the question of how far it would endorse social medicine, a level of consensus did emerge.9 Although the American delegation sought to limit the powers of the organization, the US Surgeon-General, Thomas Parran, concurred that the WHO ought to ‘co-operate with other international organizations … in developing standards of human dietary requirements, working conditions, housing or other factors which may affect physical or mental health’.10 How ambitious a task the WHO set itself emerges from the preamble to its constitution. The wording owed much to Andrija Stampar, the radical Yugoslavian social medic who (as I showed earlier) took his ideas of rural hygiene to China and beyond with the League of Nations and the Rockefeller Foundation. Stampar was a key member of the WHO’s preparatory committee, and succeeded in defining the organization’s mission (the ‘world’s health’) thus: The right to health is one of the fundamental rights to which every human being, without distinction of race, sex, language or religion, is entitled. Health is not only the absence of infirmity or disease but also a state of physical fitness and mental and social well-being. Health is an essential factor in the attainment of security and well-being for individuals and nations.11 This declaration, which appears almost verbatim in the final Constitution of the WHO, encapsulates the ways in which health emerged as part of the language of human rights, security and development, out of the upheavals of war. In 1948, the year the WHO Constitution was finalized, the Universal Declaration of Human Rights made a parallel

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commitment, that ‘everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services’.12 The WHO’s Constitution was signed at the International Health Conference, held in New York in June 1946, which was attended by all 51 members of the UN, 13 non-members, and representatives of ten other organizations interested in health, including UNESCO, the FAO, and the Rockefeller Foundation. All states, with the exception of Britain and China, made their signatures conditional upon domestic ratification.13 It would be a further two years before the required minimum of 26 signatures appeared and the WHO formally came into force. When its constitution was finally ratified in 1948, the WHO had 55 member states, including colonial territories that were given ‘associate membership’ upon the application of their colonial rulers. All member states were represented in the World Health Assembly, the main legislative body of WHO, by up to three delegates ‘technically qualified in health’ and ‘preferably representing the national health administration of the member state’.14 An Executive Board oversaw the implementation of the Assembly’s decisions. The daily running of the organization was the responsibility of the Secretariat, dominated by medical professionals, based at the WHO headquarters in Geneva.15 Brock Chisholm, the Canadian psychiatrist and former deputy-director of health in the Canadian government, took office as the first DirectorGeneral. At the start, the staff of the WHO was nearly 200 strong, including ‘a small nucleus of ex-League, UNRRA and Paris Office employees, with previous international experience.’16 Notably, the WHO opted for a decentralized structure, with six regional offices, each with a degree of autonomy unparalleled within the United Nations system.17 On the verge of independence from colonial rule and anxious to take their place on the international stage, the newly post-colonial states of South and Southeast Asia would play a central role in the organization’s debates and activities. The establishment of the WHO coincided with the moment of independence in South Asia, and the new international health organization received the enthusiastic support of Asia’s new leaders.18 In particular, the WHO’s ‘Southeast Asian’ regional office, which included the two most populous Asian nations – India and Indonesia, as well as Afghanistan, Burma, Thailand and Ceylon – was a focus of the new organization’s work, and will provide the focus for this chapter, and indeed the rest of the book.19

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Envisioning Asia’s health How would the new international system give effect to the ambitions of the wartime planners for a new order of welfare for all? How would aspirations for the enactment of health as a right of citizenship, rather than the object of charitable relief, take effect? How could the new technologies governing life – from the statistical technologies of social insurance to the biochemical technologies of vaccines and insecticides – be implemented in large, poor Asian countries on the verge of independence from colonial rule? A number of discussions in 1947 revolved around the idea that Asia posed a particular, and unified, set of problems with respect to the government of welfare; a set of commonalities and regularities in the sphere of political economy, governed by climate, resources, population and – as a residual category – ‘culture’. Implicit in these discussions was a quest to define the scope of action open to post-colonial Asian states. But this was done in such a way as to privilege the welfare of the greatest number over questions of sovereignty. While consensus emerged that public health was a fundamental duty of government, it was also suggested that the space of government might stretch beyond the limits of particular national sovereignties. The prior decision to organize the WHO on regional lines gave a ready-made, though always contested, arena for the formulation and implementation of policies for Asia. Asian governments and the new international organizations alike saw a set of deeper regularities governing the conditions of life and health across Asia. The conception of ‘Asia’ as an administrative category for the government of life and welfare drew on a range of disciplines, many of them colonial disciplines. The first was tropical geography and tropical medicine. ‘Asia’ found its unity, on this view, in patterns of climate and disease ecology. In the words of a WHO expert, writing in 1947: The Central and South-Eastern parts of Asia, together with Indonesia, i.e. the ‘Monsoon Asia’ of geographers, should be considered as one epidemiological area. It would include the endemic foci of cholera and territories most readily infectible [sic.] by that disease … it is free from yellow fever but is severely affected by malaria, by flea-borne and miteborne rickettsioses and by the ubiquitous smallpox. Most of the area suffers from the food deficiencies of the rice eaters, from a high tuberculosis morbidity and mortality in its cities and the extension of the prevalence of that disease in the rural districts.20

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The leaders and administrators of post-colonial states reinforced this view of ‘Asia’, as possessing a certain unity, but their focus was less on the disease environment and more on the ontological fact of Asia’s poverty. Indeed, a focus on Asia’s poverty undermined the power of tropical nature as an explanation for the region’s disease patterns. Jawaharlal Nehru suggested, at the anti-colonial Asian Relations Conference of 1947, that ‘backwardness’ was the essential problem that united Asia; across the region, he said, ‘standards of life are appallingly low’.21 There was an unfortunate commonality in that ‘most of the Asian countries suffered from extreme backwardness in respect of health’. A committee at the Asian Relations Conference explained the persistently high mortality and morbidity across Asia in terms of material deprivation: ‘the reason for infant mortality and lower vitality’, they argued, ‘is also largely economic. It was stated that in Ceylon twofifths of the population did not obtain sufficient energy from their diet’.22 The social welfare committee of the Asian Relations Conference discussed the continent’s problems in singular terms. The high levels of mortality and morbidity in ‘Asia’ were due to a veritable catalogue of ills: ‘an extreme inadequacy of existing health services’; ‘unhygienic environmental conditions’; a ‘lack of education and certain social practices which have had an adverse impact on the physical and mental health of the people’. Above all, illness was due to poverty.23 This definition of the problem of public health as part of a broader nexus of poverty and under-development had clear implications. The new international organizations and post-colonial Asian governments held the view that concerted policies of public health might form part of a broader series of interventions to bring about agrarian transformation and industrial development. A number of modernizing colonial administrators, and some British and American doctors, concurred with this view. 24 The perceived similarities in the underlying conditions producing health and illness in Asia led to a number of solutions which took ‘Asia’ as their targets of intervention. Discussions at the International Labour Organization (ILO) turned specifically to the question of policy, arguing that ‘even a cursory survey of existing conditions in the rural areas of Asiatic countries points to the conclusion’ that its health problems ‘should, in fact, be treated as one and indivisible’.25 The ILO’s first meeting in Asia, also held in Delhi in 1947, concluded that common problems afforded common solutions;26 Asia’s health problem was singular, but also alterable

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through public policy. Taking a holistic view of public health, the ILO recommended to its Asian members that Collective provisions must first be made for such elementary measures as the removal of refuse and night soil, a water supply protected from contamination, the prevention of malaria by the oiling of stagnant ponds … the cementing or asphalting of village roads which now turn into puddles or rivulets in the rainy season, the ventilation of huts or houses to allow the smoke to escape and the air to enter, the destruction of rats and vermin, and so forth.27 Taking into account the ‘community structure, health conditions and the general lack of health facilities in rural Asia’, the ILO was strongly in favour of a ‘public medical care service’. The subsequent discussion of the precise organization of health services across Asia ends with a strong presumption in favour of centralization and universalization. Public health, on this view, was part of a wider move towards a centralized welfare state: ‘a stage in the evolution from poor relief via social assistance to a system under which the beneficiary emerges from the status of a recipient of charity … and becomes a citizen entitled to medical care as of right’.28 The question, then, was how the ‘right’ to health could be given effect. The discussions emanating from both the Asian Relations Conference and the ILO meeting in Delhi reflected, or coincided with, an argument from within medical thought that challenged the ‘naturalness’ of Asia’s disease patterns. The pioneering social medic John Ryle, of Oxford University, had argued against the determinism of tropical medicine in a series of lectures given in 1947. He suggested that students in Britain were ‘misled’ by talk of the ‘tropical diseases’ that continued to devastate the lives of the populations in Asia and Africa. ‘Cholera, malaria, plague … these great endemic diseases of backward populations still prevail in India, China and Africa’, he argued, as once they had prevailed in Europe. ‘Nearly all of them’, Ryle argued, ‘are pre-eminently “social” diseases and due to alterable social causes.’29 Clear in all of this was a desire to establish international health work on a basis other than that of emergency charitable relief, and to use a conception of Asia’s ‘natural’ poverty to justify a coordinated Asian policy. Yet by the second half of 1947, immediate crises intervened, again, to undermine the realization of these grand plans for the government of health, none greater than the aftermath of the Partition of the Indian subcontinent in August 1947.

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Crisis and sovereignty India lay at the centre of the ‘new Asia’; in August 1947 it was divided into the new states of India and Pakistan in what Lord Mountbatten was pleased to call the ‘greatest administrative operation in history’. The human tragedy of Partition soon overwhelmed everything before it.30 In this context, medical policy could not but take the form of ad hoc interventions, piecemeal extension of wartime emergency relief extended to refugees and to women and children.31 Thus Janet D. Corwin, a nursing officer of the Rockefeller Foundation who went to India to help the Indian Government and the WHO develop plans for a comprehensive national nursing service, confronted the far more immediate horrors of Partition. ‘The need for people with medical training is so great’, she wrote, ‘that I have been helping out, first in Irwin hospital and then in one of the refugee camps’. She continued: I have never seen such concentrated tragedy in my life. So many people have been hacked up and shot at, one sees women with arms cut off and heads cut open and even little babies of four or five months … There is no human word for it, and I do not see how human beings can do such things to fellow countrymen, even if they are of a different religion.32 The Kurukshetra relief camp was the largest in India, with over 100,000 inhabitants by 1949. Mass vaccination against smallpox and inoculation against cholera became urgent priorities. Inevitably, epidemics followed closely in the wake of the concentrations of human misery that were the refugee camps.33 In the east, the hospitals of divided Bengal felt the strain acutely, and were ill equipped to deal with it.34 The Bhore Committee report had outlined the desperate shortcomings in India’s medical infrastructure; these weaknesses were shown in sharp relief by the demands of Partition. An article in Calcutta’s Statesman newspaper contained a lurid indictment, simply entitled ‘Hospitals’. Fever and isolation hospitals are even worse than others, for distinguished visitors are rare, and dissuaded by suggestions of danger; in fact the stench might be adequate deterrent, for often excreta lie upon the floor and filth everywhere. Outside one cholera ward a doctor found a whole pile of blankets covered with faeces; on asking what was being done with them he was told that they were to be

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issued to incoming patients. A cholera patient should be prevented from the smallest exertion; in practice, drinking water is sometimes placed by his bed in buckets, and help in getting a drink can only be obtained by bribing an attendant.35 Making direct reference to the commitments of the time, on the lips of politicians and constitution-makers everywhere, the Statesman proceeded to declare that ‘responsibility, however, rests squarely on the shoulders of Governments … the remedy lies with Governments, and the public is entitled to insist that Governments act’.36 It would not have been hard to conclude, though, that the aspirations of the fledgling WHO seemed a very long way indeed from realization. Questions of welfare and public health quickly retreated before more pressing issues of sovereignty asserting themselves across Asia – in the Indian constituent assembly, as within the provisional government of Indonesia, fighting a rearguard action by the Dutch, and the cabinet of the beleaguered government of Burma, facing insurgencies on three fronts.37 The discussions of the Indian Constituent Assembly, for one, hardly touched on the question of public health at all. In striking contrast with the centrality of health to earlier nationalist discourse, by the time the Constituent Assembly embarked on its discussions, almost every mention of ‘health’ was in connection with the ‘health of the body politic’; with ‘healthy’ and opposed to ‘unhealthy’ criticism of the state; with ‘healthy’ national sentiment.38 The Bhore Committee’s plans for the transformation of India’s public health were an early victim of the overwhelming interest in consolidating state power and preserving national unity. Arguments for public health within India’s constituent assembly were plaintive, almost desperate. Renuka Ray of West Bengal, in a rare reference to public health at the assembly, attempted to twist the language of a ‘healthy body politic’ to raise the question of public health care. She argued that ‘if we are to progress and prosper I suggest that in the matter of the two nation-building services of education and public health there should be some provision in the Constitution of the type that is there in the Chinese Constitution’. The latter, she suggested, specified minimum levels of state expenditure in each of those fields.39 The new state rapidly found itself having to secure and enforce its own boundaries – using force to secure the accession of the princely states of Hyderabad and Junagadh to the union, and at war with Pakistan over Kashmir within months of the transfer of power. The architect of the Indian Constitution, the conservative ‘iron man’,

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Sardar Vallabhbhai Patel, argued for a substantial retention of large parts of the colonial coercive and administrative apparatus. This meant, amongst other things, retaining the decentralized, fractured structure of the public health services. Public health, as a relatively ‘inessential’ subject, remained the responsibility of provincial government, without the funding to match.40 Providing for public health, in the final version of the Constitution of India, was one of the directive ‘principles of governance’ which was ‘non-justiceable’, that is to say, it was not binding. The new state focused on consolidating its hold over territory, and it increasingly focused on a goal around which there was much consensus: industrialization.41 In this context, India’s interest in the new international bodies shifted away from an engagement with fundamental questions regarding the organization and the responsibilities of the state. Rather, the new international bodies now faced demands for immediate and effective action. Inaugurating the first session of the Southeast Asian regional committee of WHO, held in Delhi in 1948, Jawaharlal Nehru stated that ‘India attaches the greatest importance to the work of the WHO, more especially from the point of view of South-east Asia, which was very backward in health conditions’. Suggesting that in the past, ‘world organizations directed their activities more towards the problems of Europe or America’, Nehru drew on the fear of epidemic diseases in order to justify priority for Asia in the new organization’s work. He claimed that ‘It is well known today … that one cannot isolate any part of the world and make one part of it healthy and leave other parts unhealthy, because infection spreads. The world must be tackled as a whole, and in doing so backward areas must be tackled first.’42 Here Nehru returns to a familiar language of emergency, through the invocation of epidemic disease, to make the case for international assistance to India. It is a significantly different language, and line of reasoning, to the conceptions of health aired at the Asian Relations Conference on the eve of Partition. It was a call for action, delivered with the urgency of a statesman who felt he had more pressing concerns of his own. A regional imagination continued to shape Nehru’s view of international cooperation, but it was a region clearly divided by national boundaries. As Nehru remarked at another international meeting in 1948: ‘you represent the South-East Asia region. Now, India is curiously situated from the geographical point of view as well as from many other points of view. It belongs to South-East Asia, it belongs to South Asia, it also belongs to West Asia….’43 From the point of view of health

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and welfare, it was the ‘South-East Asian’ identity which the Indian state privileged as primary. The notion persisted that ‘Southeast Asia’ had a certain unity, shaped by the tropical environment, by shared poverty, and by pathogenic conditions. But the new emphasis on state sovereignty, at the same time, undermined the notion that ‘Asia’ as a space of biopolitical intervention should transcend the sovereignties of nation-states. As the political commentator Werner Levi observed in 1952, India’s championing of ‘Southeast Asian’ interests within international bodies substituted for ‘an Asian organization’, and was ‘more acceptable to most Asian nations’ who had seen earlier, and now defunct, proposals of an Asian Union as a veiled form of Indian imperialism.44 Wrote Levi: The UN and other international agencies afford the best opportunity for the common interests of India and other Asian countries to find practical expression. The agencies are used for much consultations and the coordination of policy. A system of multilateral relations has developed there which is unspectacular but which has been politically more important than the widely advertised Asian conferences.45 The ‘multilateral’ as opposed to the transnational focus of public health interventions marked a significant shift away from the early aspirations for a new global health organization; but it was a shift that was always halting, and never complete. The first such ‘coordinated policy’ in the field of public health, treating the Asian arena as a whole, was dramatic indeed. It took the form of a mass vaccination campaign against tuberculosis, using BCG, launched in 1947; it became the largest vaccination campaign ever undertaken. The massive population movements and widespread social crises of the Second World War highlighted, and exacerbated, the extent of tuberculosis infection, particularly in the occupied territories of Central and Eastern Europe. The United Nations Relief and Rehabilitation Administration (UNRRA) brought this to light when it conducted surveys showing the incidence of tuberculosis wherever it mounted relief operations, often using newly available X-ray technology.46 In the immediate aftermath of the war, an emergency humanitarian mission by Danish Red Cross doctors to Poland found that amidst ‘frightful misery and illness’, local authorities ‘had no facilities for handling’ tuberculosis cases ‘and were able to do nothing.’47 An

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unprecedented decision was taken to launch mass BCG vaccination campaigns in Poland and Yugoslavia, drawing on the Danes’ extensive previous experience of this technique, as the only feasible way of stemming the spread of the disease.48 By the middle of 1948, Italy, Greece and Czechoslovakia had asked for the Danish Red Cross to assist with similar BCG campaigns, and assistance was given by the Swedish and Norwegian Red Cross societies, making it a jointly run Scandinavian programme.48 The Scandinavian Red Cross societies were able to turn for support to another temporary humanitarian relief agency of the UN, the International Children’s Emergency Fund, and through UNICEF to the WHO. The involvement of UNICEF in this so-called ‘Joint Enterprise’ saw its expansion beyond Europe, to North Africa, the Middle East, India and Pakistan, and Ecuador.50 Debates from the time show that the Red Cross societies felt ill-prepared for this expansion into the tropics.51 The image of an emergency global vaccination campaign gave an identity to the new UN organizations’ activities.52 Aircraft, medical technology, and dramatic speed came to characterize the public image of the WHO. Even before the advent of the international tuberculosis campaign, the WHO’s Interim Commission had been tested by the outbreak of a cholera epidemic in Egypt.53 Here, too, the focus was on rapid, military-style public health measures, on a trans-continental scale. The political scientist Charles Ascher saw the WHO’s intervention in Egypt as a harbinger of its later reliance on ‘impact’ programmes: ‘by transoceanic telephone WHO summoned US Army planes from Asia and Soviet planes from Moscow with life-saving serum’.54 In the field of malaria control, the WHO elevated the wartime experience of DDT campaigns into a model for the future. An expert committee of malariologists at the WHO declared in 1948 that ‘it is now possible to attain a degree of practical malaria control, and even of malaria eradication, impossible 15 years ago’.55

Public health and the Cold War The onset of the Cold War intensified the need for a new basis for public health – a basis not overtly political, and also one that moved away from an onerous specification of responsibilities of individual states. The Truman Doctrine of March 1947 committed the United States to the defence of ‘freedom’ everywhere, followed in 1948 by the institution of the Marshall Plan, a massive injection of funds to assist

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western European recovery. The following year, Harry Truman announced the so-called ‘Point Four’ plan. In ‘Point Four’ of his inaugural address, on 20 January 1949, President Truman set forth a ‘bold new programme for making the benefits of our scientific advances and industrial progress available for the improvement and growth of underdeveloped areas’.56 A memorandum on the ‘objectives and nature of the Point IV Program’ stated clearly that ‘technical assistance is now raised to a major role among the instruments for the accomplishment of existing objectives’. These ‘objectives’ included ensuring a regular supply of raw materials from the ‘under-developed’ world;57 securing expanding world markets for US manufactured goods, and the desire for ‘good will’ in ‘areas of strategic economic or military importance’, and, of course, to ‘contain’ communist expansion.58 Others have considered in detail the effects of the Cold War on international public health, and readers are directed to those works for a fuller discussion.59 Socrates Litsios concludes, in his careful study, that The urgency to reconstruct war-torn countries was used covertly to keep the UN system on an ‘emergency’ status throughout the Cold War. The focus on ‘urgent’ problems and the need for relatively quick results naturally led to a fragmentation of global assistance … the Cold War undermined the possibility of addressing politically sensitive issues, such as rural indebtedness and iniquitous land tenure systems.60 That is to say that, combined with the immediate political and humanitarian crises confronting Asia’s new post-colonial states in the late 1940s, the pressures of the Cold War dampened the discussions about health in terms of broad-based social transformation that had characterized the Asian Relations Conference, or the ILO meeting of 1947. The global commitment to public health that had circulated so widely during and after the Second World War was mobilized, in the new context of the Cold War, to serve a range of different agendas; but in order for this to happen, health had first to assume much narrower definitions. Asian nations welcomed aid for public health, both because it appeared less politically sensitive in such fields, and because, as I have already suggested, most Asian states were unwilling to spend large amounts of their own resources on health. The Americans, too, realized that the increasingly depoliticized field of public health held great potential for garnering ‘good will’.61

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On both sides, the involvement of the UN in the administration of the new programmes helped to obscure the unequal relations underpinning the system of foreign aid. The UN agencies, for their part, viewed the US commitment to ‘technical assistance’ as a great boon, a source of funds at a time when funds were scarce. In the field of health, the withdrawal of the USSR from the WHO in 1949 (until 1957), along with many of its eastern European satellite states, left the field open for American initiatives. Ironically, given the pioneering role played by eastern European public health experts in the internationalization of health before 1939, their voices were almost wholly absent from international debates on health in the 1950s. The venerable Andrija Stampar, from Tito’s resolutely non-aligned Yugoslavia, was a rare exception.

The birth of technical assistance The practices and institutions of ‘technical assistance’ attempted to resolve some of the contradictions in the new politics of international public health. In the process, the arguments for health shifted decisively from the terrain of rights and entitlement to one dominated by the primacy of economic expertise. In early 1949, the United States’ delegation to the UN’s Economic and Social Council proposed a resolution calling for a ‘comprehensive plan for an expanded co-operative programme of technical assistance for economic development through the United Nations … paying due attention to questions of a social nature which directly condition economic development’.62 It was a proposal that received the ready support not only of Asian governments, but also of the UN’s specialized agencies, which saw in technical assistance a means for their own consolidation. The UN’s definitional statement on ‘Technical Assistance for Economic Development’, published in 1949, set out very clearly the fundamental characteristics of the new politics of technical assistance. Technical assistance would be based upon the exchange and implementation of technology. Its ultimate goal was to bring about ‘economic development’, which involved ‘in particular … an increase in productivity’.63 Such development could only be brought about through the ‘full use of the scientific and technical advances that have already so changed the economies of more highly-developed areas’. The key role of the UN, in this analysis, was to ‘assist under-developed countries to take advantage of modern techniques’.64 The underdeveloped countries were ‘likely to fall farther and farther behind’

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unless ‘deliberate and effective measures’ were taken ‘to bring to them the benefits of modern science and technology’ – including, of course, the technology of disease control.65 Development would require ‘adjustments’ and ‘far-reaching changes’ in governance, in the ‘attitudes and habits of the people’; it would require ‘political courage’ and ‘administrative competence’ of governments to minimize the ‘stresses’ of industrialization.66 The new emphasis on technical assistance, and the subordination of most social goals to that of economic growth, found a sympathetic echo within the new post-colonial states of Asia. By the end of the 1940s, the immediate crises of the post-war era were giving way to a period of consolidation and state-building. Technical assistance represented the international expression of the vogue for national planning, widespread across post-colonial Asia and above all in India. Planning, as Partha Chatterjee has argued, pretended to the ‘technical evaluation of alternative policies and determination of choices on scientific grounds’ by experts detached from the political process.67 This serves well as a characterization of technical assistance. Across the region, there was a fundamental consensus on the primacy of what economists have called a ‘commodity-centred approach’ to development.68 Economic growth alone would paper over the conflicts and contradictions within the ‘modern’ sector of Asia’s new states: growth to fund militarization, growth to forestall communist advance, growth to reduce poverty, growth to cement national bonds, growth to win domestic capitalists over to the cause of state direction. Thus the political economist Francine Frankel wrote of India’s first five-year plan that ‘all programmes included in the plan were justified by reference to a single yardstick: the economic goal of increasing production’.69 On this view, health was important to the Indian Planning Commission largely because ‘in the calculation of the country’s resources for economic development the health of the people must be reckoned an important factor’.70 The Planning Commission declared explicitly that public health was but an instrument in the goal of development: ‘the large incidence of sickness among those engaged in productive work … determines the choice of the specific measures to be included in the health programme’.71 This was an instrumental argument for public health. At the same time, planning – and so technical assistance – would serve as a palliative, easing the ‘unnecessary costs’ of industrialization. The availability of international technical assistance funds to do undertake such tasks was particularly attractive because it fit within the depoliticized frame-

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work of planning. Thus malaria control projects using DDT, organized and funded by the new international bodies (and by American aid) could have a significant, even dramatic, impact on the problems of rural public health in agrarian Asia.72 But they did so in a way that avoided raising questions of a ‘political’ nature; questions to do with land ownership, economic inequality and the bases of social power. Technical assistance often presented itself as an exercise of global cooperative endeavour – translated in Burma as a route to the Buddhist-socialist utopia of Pyidawtha, a ‘pleasant and happy land’ of self-help or, in India, in Gandhian terms of ‘community development’. Yet technical assistance projects studiously avoided raising the question of corresponding changes in structures of ownership or decisionmaking.73 Technical assistance had an important role to play, then, at a time when in India as elsewhere in South and Southeast Asia, postcolonial states sought to ‘incorporate within the framework of [their] rule not a representative mechanism solely operated by individual agents in civil society, but entire structures of pre-capitalist community taken in their existent forms’.74

Rights and technologies of health Perhaps the most significant political effect of the absorption of public health into the framework of technical assistance was the decline of any conception of health in terms of rights. An early, if short-lived, possibility was that human rights would provide the over-arching framework for the UN’s social policy. A striking example of this potential path can be seen in Carol Anderson’s recent work, which shows the ways in which the international ‘right to health’ took on a very real meaning for African-American leaders for a brief period in the mid-1940s. Anderson argues that, unlike the more limited discourse of civil rights, human rights ‘especially as articulated by the United Nations … had the language and philosophical power to address not only the political and legal inequality that African-Americans endured, but also the education, health care, housing, and employment needs that haunted the black community’.75 Thus, when the National Negro Congress petitioned the United Nations in mid-1946, an important part of their argument was to highlight the systematic inequalities between the health of black and white Americans: the infant mortality rate in black communities was almost double that of white Southerners; ten times as many blacks as whites died of tuberculosis and malaria.76 A petition of this kind, submitted just at the time when

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the WHO’s constitution was being finalized in New York, suggested the possibility of an explicitly political approach to international health. Had this kind of human rights activism had a longer life, it is conceivable that the WHO might have been a very different institution, with a more interventionist role in exposing inequalities in health, and holding governments to account. This would, certainly, have resonated with the views of a John Ryle, or an Andrija Stampar (Ryle had written in 1948 of the ‘duty of physicians everywhere … to assume leadership in the struggle for improvement of conditions’).77 The politics of the Cold War, however, quickly closed off this avenue of approach. Anderson argues that the anti-communist hysteria of the late 1940s and early 1950s ‘systematically eliminated human rights as a viable option for the mainstream African-American leadership’;78 the same could be said for the United Nations. The first blow came when, under strong pressure from the State Department, Eleanor Roosevelt – chair of the UN’s Commission on Human Rights – set herself firmly against allowing the Commission to consider petitions from individuals and organizations.79 One of the main points of contention was whether a category of ‘economic and social rights’ (including the right to health), ought to be included within the covenant and, if so, how they were to be enforced. It is in this context that technical assistance increasingly appeared as a substitute for rights. As part of its tortuous attempts to define the scope of economic and social rights, the UN’s Commission on Human Rights invited written submissions from the directors of the specialized agencies. The response of the WHO is particularly revealing, in that it shifted considerably within the space of a few months. Initially, the organization’s position on rights was ambiguous. The DirectorGeneral’s initial submission to the UN, in February 1951, seemed to question the need for a covenant to secure the right to health, since ‘it is clear that the whole programme approved by the World Health Assembly represents a concerted effort on the part of Member States to ensure the right to health’.80 On this view, the work of the WHO, whatever form it took, was sufficient. However, if there was indeed going to be an international covenant on social and economic rights, the WHO thought that ‘the enjoyment of the highest obtainable standard of health’ ought to be among those rights. The organization was specific in spelling out certain measures of governmental responsibility for the ‘right to health’. These measures were expansive. They included governmental responsibility ‘to improve nutrition, housing, sanitation, recreation, economic and working con-

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ditions and other aspects of environmental hygiene’.81 However, the WHO concurred with the Commission on Human Rights that petitions from ‘individuals and non-governmental organization’ should not be received. This was a vision of the ‘right to health’ being implemented through technical means, by experts. Even this stance, however, proved too much for the American member of the WHO’s Executive Board, Henry Van Zile Hyde. He wrote to Chisholm stressing that ‘guaranteeing economic and social rights in an enforceable covenant is considerably different from a declaration of objectives’. He suggested that ‘no matter how great the desire of governments to provide such rights, some are not, unfortunately, in a position to guarantee them’. Hyde hoped that the WHO would ‘call the attention of the Commission … to the problems inherent in attempting to draft enforceable rights for health services’.82 By the middle of 1951, the WHO’s Director-General had decided that it would be better if the article on the right to health in the draft covenant ‘omitted … detailed undertakings’, and ‘stated only the principle of the right to health’.83 This was, perhaps, a result of the subtle American pressure on the WHO not to go too far.84 However, the arguments used by Chisholm suggest, also, that the WHO began to worry that a covenant on human rights would undermine rather than strengthen its own authority. There is alarm in the Director-General’s statement to the Executive Board that, potentially, ‘the proposed Human Rights Committee’, rather than WHO, would have the authority ‘to mediate in a complaint by a government … regarding the provision of medical services’ in another member state. Having a very loosely worded ‘right to health’ provision, with no concrete specifications or means of implementation would thus ‘give less justification for detailed discussion of technical questions by these non-technical UN organs’.85 Technical questions were the province of the specialized agency, and the coordinating Technical Assistance Board, alone. ‘The introduction of non-technical elements into the decisions of [the Technical Assistance Board] would certainly appear undesirable’.86 This is one of the clearest indications in the historical record of the gradual process of depoliticization of development through technical assistance.87 The instrument of ‘technical assistance’ became the focus of attention; the ultimate ends (improved living standards, reduced suffering from illness) would take care of themselves; the means (technical assistance) would be the focus of the discussion.

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By the early 1950s if not even earlier, the WHO saw its future as tied to the framework of technical assistance, in which it would provide the health ‘input’. However, the field of technical assistance entailed struggles of its own. Even in the midst of negotiations for a covenant on social and economic rights, the WHO found itself having to justify its role within the technical assistance administration. In effect, once it was accepted that public health was an instrument directed towards the ultimate goal of ‘development’ through capital accumulation – rather than stressing that health was an intrinsic right – health projects were open to the charge that they hindered rather than advanced that goal. Above all, public health had to defend its position against the neo-Malthusian assault of the theorists of population explosion.

The argument for public health During all these ups and downs in economic life which have thrown now a hundred thousand, now a hundred million into poverty, misery and disease, there exists one basic factor in society, one fundamental value on which in the end we have to build as the only basis of society. That factor is the human being – the working, creating, hoping and struggling human being. Therefore it seems to me that the Second World Health Assembly might profitably be, ‘Let not the economist make us forget the human being’. Karl Evang88 From the logic of technical assistance came a plethora of demands on the new international organizations for concrete action (for ‘projects’). These demands stretched their fragile infrastructures to the limit. Karl Evang, a Norwegian public health specialist who had been with WHO from the outset put it in these terms: We are public health people, not representatives of Treasury departments. We know that action is needed, and we know that we cannot convince anybody unless we take action. To take action you have to be an operating agency – to go out into the field and do the work; and we are being invited to do so by very eager and anxious regional offices throughout the world.89 Yet the WHO manifestly lacked the resources needed to undertake such action. The WHO was a chronically impoverished institution. Its emergency relief work, like the anti-tuberculosis vaccination campaign,

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had depended upon voluntary contributions. It was precisely the ‘sporadic charity’ that so many during the war had excoriated as outmoded and inefficient. The WHO’s regular budget – drawn from the compulsory contributions of member states, assessed according to their ‘ability to pay’ – was severely limited. In 1949, in its first full year as a functioning organization, the WHO received just $3.6 million from its member states. It thus came as a significant boost to the WHO when the UN’s Economic and Social Council and the General Assembly voted, in June 1950, to establish an Expanded Programme of Technical Assistance of US$20 million.90 Over the next decade, funds from the Expanded Programme of Technical Assistance contributed almost as much to the WHO as its regular budget, as illustrated by Table 3.1. The need for resources helps to explain why the debates surrounding the role of public health within the administration of technical assistance were so important to the survival of international health. Consequently, the process through which international public health tried to make a place for itself at the heart of the institutional (and intellectual) framework of technical assistance shaped the conditions of possibility for public health policy for a generation. Public health could draw on its own intellectual history in order to give primacy to the authority of economic criteria and economic knowledge. Chapter 1 argued that, from the time of the 1930s’ depression if not long before, debates about public health in Asia were inextricably linked to questions of economic development, particularly rural development. For many at the time, malnutrition, endemic and epidemic disease were the (unacceptable) price of unrestrained capitalist development in the Table 3.1

1949 1950 1951 1952 1953 1954 1955 1956 1957

WHO Income, 1949–1957

Contributions from member states

Technical assistance funds

Total income

3,693,604 4,164,925 5,516,096 6,943,486 7,566,598 7,580,165 7,889,113 8,524,767 11,517,988

– – 2,899,069 4,997,233 4,604,064 4,253,435 5,142,903 6,121,044 6,180,663

5,136,893 6,280,427 10,905,332 13,683,999 13,598,382 12,868,945 14,412,719 16,053,189 18,425,093

Source: Constructed from WHO, First Ten Years of the World Health Organization (Geneva, 1958), pp. 522–23.

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countryside. Yet at the same time, there grew a resolutely modernist version of the narrative linking health and development: the Congress National Planning Committee in the 1930s, for example, worried about public health partly because it acted as a fetter on industrialization. Recall, too, that the Bhore Committee’s expert advisers, during the Second World War, had made the argument for the economic importance of public health. As Janet Vaughan had written in 1945: ‘it seemed to us that the education of the civil servant and the legislator in regard to health as a national and economic asset was even more urgently needed in India than elsewhere in the world’.91 The ultimate authority in the field of international public health lay, by the early 1950s, with economists, and economists had clear ideas about what kinds of public health intervention counted as ‘useful’. The fundamental question concerned the value of public health. We have seen that technical assistance defined its goal as ‘economic development’, and ‘in particular … an increase in productivity’.92 How would international public health interventions contribute to this end? The new generation of development economists, working within the UN, offered ambiguous answers to this question. One of the formative documents defining development was the UN’s report on Measures for the Economic Development of Under-Developed Countries, authored by a committee which included the likes of W. Arthur Lewis and T.W. Schultz, and D.R. Gadgil, the Indian director of the Gokhale Institute of Economics and Politics. Discussing the question of how to ‘increase productivity’, the authors of the report conclude: In our opinion, most under-developed countries are in the situation that investment in people is likely to prove as productive, in the purely material sense, as any investment in material resources … this is most obvious in two spheres, the sphere of public health, and the sphere of education.93 A focus on productivity and capital accumulation, then, did not necessarily shut out investment in public health, but its scope was to be very clearly defined: ‘Not all expenditure on public health increases productivity. What is most productive is expenditure which reduces the incidence of debilitating diseases, such as malaria, yaws, hookworm, sleeping sickness or bilharzias, and expenditure for the improvement of diets, which increases the capacity to work’.94 On this view, rapid, technical public health campaigns – campaigns of disease eradication – were a desirable form of ‘technical assistance

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for economic development’, but the economic orthodoxy of the 1950s had much less room for the prescriptions of social medicine, particularly in its 1930s’ incarnation of ‘rural hygiene’, based upon the values of rural reconstruction (see Chapter 1). The model of the ‘dual economy’, starkly divided between the ‘modern’ and ‘traditional’ sectors, was a commonplace of development thought and of the thinking of the United Nations, which found eloquent expression in the work of W.A. Lewis. Rural areas of Asia and Africa, Lewis believed, belonged to ‘another planet’ compared with the few ‘modern towns, with the finest architecture’; there was a gulf between the mass of the population and the few ‘trousered natives … speaking western languages and glorying in Beethoven, Mill, Marx or Einstein’.95 The cardinal aim of development, in Lewis’s view, would be to move people from the ‘economic darkness’ of the traditional sector towards the urban capitalist economy. Contrary to the rhetoric of reforming, rural public health for the ‘masses’, the UN’s group of economic experts suggested that: ‘large numbers of people who cannot keep up with progress have to have their expectations of a comfortable life frustrated’.96 To defend its work (and its funding) in the terms of the economists, the WHO deployed the arguments of Charles Edward-Amery Winslow, an eminent American public health pioneer and social medic. In a widely circulated pamphlet, The Cost of Sickness, the Price of Health, and in an important speech to the World Health Assembly in 1952, Winslow made the case for the ‘economic value of public health’. ‘In the case of mosquito-borne diseases’, Winslow argued, ‘the economic returns due to control measures are, of course, particularly striking.’97 Preventable disease was economic ‘waste’, inhibiting production and productivity. In countries such as China, Egypt and India, where the average expectation of life at birth is in the neighbourhood of 30 years, only 54 out of every 100 children born ever reach the age of 15 and enter the period of maximum economic productivity…. Reduction in the death rate in the under-developed areas will mean an increase in human resources available for production in proportion to the population.98 Extending this argument, Winslow invoked earlier attempts to explicitly quantify the economic benefits of health. He cited the work of Colonel J. Sinton, a veteran British colonial malariologist who had

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calculated that ‘malaria in India involves an economic loss of £80,000,000 a year’.99 This is a clear case of older arguments being translated into the terms of technical assistance. Sinton’s original work had made an argument against rapid rural development;100 by the early 1950s, Winslow used these statistics to argue that public health would facilitate just such development. In his attempts to quantify the benefits of health, Winslow received cautious support from the pioneering Swedish development economist Gunnar Myrdal. Myrdal conceded that ‘the economic value of health and the price of health, have been given comparatively little thought’ in economics; ‘our very large literature on capital, depreciation, and interest has never taken … [the concept of “personal capital”] very seriously.’ But he warned that ‘the economic value of preventing premature death, to take the simplest case, depends entirely upon whether such an economic development is under way which ensures productive work for the greater number of people we thus keep alive.’101 By allusion, by implication, the defenders of public health battled against a counter-argument that gathered force in the early 1950s: the argument that by ‘keeping more people alive’, international public health was contributing to the looming ‘population explosion’. At its most lurid, the argument was that public health work was saving people from ‘dying from malaria so that they could die more slowly of starvation’. Indeed the neo-Malthusian publicist William Vogt went so far as to call malaria a ‘blessing in disguise’. 102 The racial anxieties underlying this argument were clear: the spectre of proliferating dark masses threatening the security and prosperity of the West. Yet the idea that the relationship between public health and development was double-edged received much intellectual support both within and outside Asia, not least from the young discipline of demography.103 If the economists focused on the use of productive investment to transform resources, demographers had another angle on the value of public health: their implicit, and then increasingly explicit, conclusion was that, by accelerating population growth, international health might pose a grave danger to development. A number of historians have suggested that the theory of ‘demographic transition’ underwent a significant shift in the 1940s, from the view that a reduction in fertility rates would be a long-term consequence of economic development, to a view which saw planned interventions to reduce fertility as a prerequisite for development, failing which all of the calculations of economists were idle. As early as 1944, Frank Notestein, head of the

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Office of Population Research at Princeton University, and pioneer of the post-war discipline of demography, suggested that population was the determinant (rather than dependant) variable; that without a reduction in population growth, ‘modernization’ would have perverse effects.104 The very conspicuous success of the new technologies of disease control pioneered during the war was at the root of the new population panic.105 Countless Indian observers shared these concerns, worrying about the impact of population growth on ‘national discipline’ and national development: Gyan Chand, the Patna University economist, and Radhakamal Mukherjee, amongst others. The modernizers within the Congress Party had been interested in, even obsessed by, the question of population growth from at least the 1930s.106 Indeed, the use of Asia’s commonality to justify a common health programme on the grounds of its shared epidemiological patterns was double-edged; for there already existed a rich vein of thought associating the ‘Orient’/’Far East’/’Asiatic lands’ with over-breeding, impoverished masses. The UN’s 1952 Report on the World Social Situation resurrected this idea of Asia as inherently over-populated. One point of commonality uniting the region, the report argued, was Asia’s ‘thick’ population. Asia, the report pointed out, ‘is the most densely populated continental area of the world, and South and Southeast Asia is still more densely populated than Asia as a whole’.107 The picture of ‘Southeast Asia’ given in the UN’s Preliminary Report draws on the colonial discourse of Asia as a ‘land of famine’, naturally poor.108 Asia was characterized, the UN report argued, by an ‘all-prevailing poverty of most of the people’. The report argued that ‘every other social deficiency is minor’ compared with Asia’s poverty. To ascribe this crushing poverty to ‘any one cause alone’ would be ‘to oversimplify the issue’, but the pressure of population clearly loomed large in this reckoning.109 The latent conflict between public health and population growth came to a head in the 1952 World Health Assembly, when a senior official of the UN’s FAO made the charge quite explicitly, not to say crudely. Opening the meeting as a guest speaker, Sir Herbert Broadley – Deputy-Director of the FAO – put the charge against the WHO quite starkly: ‘the more successful you are in reaching your goal’, he told WHO delegates, ‘the more difficult FAO’s task becomes … more mouths demand more food. Where birthrates continue to advance, as is the case in many countries …[and] where death rates and human mortality are halved … we cannot just sit back and let nature take its course. If we do, nature’s course will be a very desperate one.’110

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This charge drew two main lines of response. The first came from the Indian government, with the support of other Asian states. They suggested that concerns about population growth attendant on successful public heath work provided the justification for the expansion of the realm of public health (and of the remit of the WHO) to include questions of population (and, quite explicitly, population control). The Indian government was strongly in support of the population problem being medicalized, and delegated to the WHO. The Indian health minister Rajkumari Amrit Kaur – a devout Christian, a close associate of Gandhi’s, and a member of one of India’s fading princely families – had written to Brock Chisholm in early 1952, stating that: The means that are now available for reducing sickness and mortality and for prolonging life make it all the more necessary for Governments, particularly in countries which are over-populated or in which the population is nearing saturation, to promote measures for family limitation so as to make some adjustment between the number of people and the resources that are available to them.111 In the Indian nationalist imagination, the need for population control complemented, rather than contradicted, the need for public health: poverty, they argued, ‘condemns [the Indian people] to poor nutrition and inadequate safeguards against … the ravages of disease’; overpopulation exacerbated, perhaps even caused, this poverty.112 In constant tension with an elite fear of India’s ‘teeming millions’ stood a romantic celebration of the masses.113 This troubled ambivalence within the nationalist vision of population and well-being left a contradictory legacy for the post-colonial state and its approach to health and population. The planners’ imagination had recognized, since the 1930s, that ‘over-population’ would be against the interests of ‘social economy and family happiness’, as they had put it; yet this had always to be reconciled with the promises made to India’s new citizens that the state would care for their health. There could be no question of denying the population the benefits of new medical technologies to which India was now rightly entitled, as a sovereign modern nation, particularly under a system of representative government. The post-colonial imagination of health and population was considerably more conflicted than that of some American demographers who, increasingly, posited a stark choice. Thus the Indian government persuaded the WHO to fund a ‘pilot project’ in population control, the first of its kind. Under the direction

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of Dr Abraham Stone, a small team of investigators began an experiment into the workings of the ‘rhythm method’ of contraception at two sites: the residential area of Lodi in Delhi, and the village of Ramnagaram in Karnataka (then still part of Madras State).114 The Indian authorities optimistically believed that the rhythm method would be in accordance with ‘Indian traditions of self-control and … Gandhian thought’. The project represented an unprecedented effort to penetrate the domestic sphere, in quite intimate ways. Stone devised a seemingly ingenious system to guide ‘uneducated’ couples in the mysteries of the rhythm method. Each couple received coloured beads to map the reproductive cycle: green beads signalled ‘safe’ days, black ones signalled days of abstinence. Inevitably, reports surfaced of women believing that the beads themselves possessed ‘magical’ contraceptive qualities. And then things began to fall apart: An elaborately planned and ambitious investigation, from which definite and substantial results were clearly expected, was slowly found to dwindle in scope and possibilities. As the inquiry progressed, increasing numbers of couples fell out or were dropped as unsuitable … by miscellaneous processes of erosion, a respectably sized mountain slowly shrank to the dimensions of a mound.115 The WHO, born in the circumstances of post-war crisis, poorly funded and fragile, was hardly in a position to undertake interventions that depended on deep social and cultural knowledge, not to mention power. This is a theme that the second half of the book will develop at length. For the moment, it will suffice to note that, apart from the practical difficulties faced by the Indian pilot project, an important reason why the WHO did not widen its remit to consider questions of population in the 1950s was due to fierce opposition from Catholic member states. The Belgian delegate to the 1952 World Health Assembly, for example, said that ‘the problem of over-population in several regions of the world was primarily of an economic and social character, and only secondarily a medical problem … from the purely medical standpoint, population problems do not require any particular action on the part of WHO at the present time’.116 The Irish delegate went further, threatening that ‘some governments may be forced into a position where they had to withdraw from WHO’.117 This is a salutary reminder that hold of secular developmentalism on the world (anything goes, as long as it maximizes growth and, hopefully, welfare) was far from complete. Perhaps ironically, the Catholic position at WHO supported a ‘human-rights’-derived position

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in opposition to the instrumentalist view then taking hold, holding up the (Christian) argument for the ultimate sanctity of each human life.118 Faced with the threat of internal disintegration at the very time when its legitimacy was under attack from prophets of population explosion, the WHO retreated almost entirely from the population debate, not to intervene in the field again until the later 1960s. In a revealing letter, the Director-General, Brock Chisholm wrote to a colleague in the United States public health service that ‘after exploring every possibility I could think of finding ways to take active measures from this headquarters about population problems, it seems there is no probability of our being able to do anything about it in the near future.’119

Conclusion What the WHO could do was to concentrate on its dramatic campaigns of disease control, using cheap and effective technology. As Charles Winslow put it to the World Health Assembly in 1952: From the standpoint of community psychology, the World Health Organization has been wise in choosing for major emphasis during the past two years simple and efficient procedures, such as spraying with DDT, immunization with BCG, and treatment of syphilis and yaws with penicillin, which make it possible to obtain dramatic and immediate results at a minimum cost.120 Notwithstanding the institution’s expansive declaration that health was ‘not only the absence of infirmity or disease but also a state of physical fitness and mental and social well-being’, the WHO moved firmly towards treating public health as a series of campaigns against specific ‘causes of death’. In a situation where funding was scarce, the availability of cheap medical technology, particularly DDT, strengthened the hand of those within the WHO that adopted a narrow biomedical approach to public health, which advocated military-style campaigns using medical technology to eradicate major disease. The philosophical underpinning of this approach consisted of what Stephen Kunitz has called ‘causal necessity’: because a disease like malaria, or tuberculosis, could not occur in the absence of a specific cause (the tubercle bacillus, or the malaria parasite), international health work would focus on those causes, and on those causes alone.121 The following chapters will consider some of the complexities and contradictions of this approach in practice.

4 Building a New Utopia

On paper – and the plans filled reams of thin, now greying, cyclostyled sheets – technical assistance was a finely honed machine, its component parts functioning in close synchronization. The two chapters that follow suggest that the operation of technical assistance projects was, in fact, much messier and often far removed from the discussions in the chambers of the world’s parliament of health. The extent of commitment to public health on the part of post-colonial states and international institutions determined the bounds of the possible. It was in debates at an international and a transnational level that ‘technical assistance’ emerged as the dominant framework for public health policy. It was in the WHO’s expert committees that the decisions were taken to launch ‘campaigns’ against the ‘big four’ diseases. Yet technical assistance was implemented ‘in the field’, or ‘on the ground’. These metaphors recur in contemporary discussions, highlighting, perhaps, the gap between the plans for a world without disease and the ‘muddier’ social, economic and political conditions shaping the production of health and illness. It was shown, earlier, that South and Southeast Asia assumed a particular centrality in discussions and plans for the new international public health after the Second World War. It was from these contradictions, encountered at every turn, that the practices of ‘actually existing’ international health were formed. This chapter and the one that follows (Chapter 5) provide overlapping narratives of the same chronological period: the ‘long’ 1950s. Their sequence nevertheless indicates a shift. This chapter examines the vast aspirations for disease control and eradication unleashed by the early ‘technical assistance’ projects in south and Southeast Asia, focusing on how this vision of a world without disease emerged from, 99

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whilst in turn shaping practice. The level of ambition grew once the initial projects were well-established in the early 1950s, with the expansion of ‘pilot projects’ into ever-larger, interlinked schemes. Between 1949 and 1955, the WHO established and supported pilot projects in malaria control across Asia. Over 60 countries around the world were conducting spraying campaigns with DDT by 1960. Other ‘campaigns’ were almost as extensive. Hundreds of thousands of people were treated for yaws with penicillin in Indonesia and Thailand. Between 1948 and 1960, teams directed by WHO vaccinated almost 100 million people in Asia with BCG, most of them under 20 years old. Despite the centrality of technology to the vision of a world without disease, the new utopia envisaged contained seeds of older ones. Despite the ostensible privileging of technical over moral or social solutions, the earlier aspirations for public health as a form of moral and bodily self-government remained in view. The year 1955 was, in many ways, the high point, the year in which the WHO launched a programme to eradicate malaria from the face of the earth. But the debates surrounding malaria eradication also indicate that beneath the apparent confidence (arrogance, in the view of some post-colonial scholars) underlying disease eradication were fears of many kinds. A closer look at the evidence suggests that the fears and uncertainties were present from the start. Utopian visions persisted well beyond 1955, indeed until the early 1960s it seemed that the malaria eradication programme might well succeed. However, the chapter after this one argues that the innumerable ‘problems’, ‘obstacles’ and ‘difficulties’ confronting the Asian campaigns of disease control and eradication were an inherent feature of the techno-politics of the post-war era, from its inception.

Projects and policies As was shown earlier, discussions of public health during and after the Second World War challenged the discourse of tropical medicine by suggesting that the health problems of colonial Asia (and Africa) were not insurmountable. The likes of John Ryle, and the early leaders of the WHO, suggested that the high incidence of illness in the tropical colonies, soon to be independent, was as much due to social, economic and political factors as to environmental ones. Belief in the primacy of economic transformation and faith in technology came together to undermine the pessimistic certainties of tropical medicine. As the pressures of state-building and the Cold War impeded these visions of

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wide-ranging hygienic reform, technology still offered the agents of the new international health a way to effect change, without the corresponding need to intervene in fraught questions of social and economic transformation. The WHO and Asian governments mobilized the new technologies in a series of ‘pilot projects’, which took the form of intensive experiments in carefully circumscribed areas. The WHO began its ‘field operations’ in 1949. Among its first initiatives were malaria demonstration projects in rural areas: initially, four in India, one in Thailand and one in Afghanistan. Adapting Timothy Mitchell’s formulation, we might say that the projects constituted a ‘concentration and reorganization of knowledge rather than an introduction of expertise where none had been in use before’.1 In fact the malaria control projects were built upon earlier experiments, universalizing them as ‘policy’. D.K. Viswanathan’s work in Kanara district in Bombay state, for example, along with the experiments with insect control in Sardinia and in Greece, was a crucial foundation on which malaria control using DDT was generalized, partly through the work of the WHO’s Expert Committee on Malaria.2 The Indian projects were located in the Himalayan Terai, the Jeypore Hills, in Malnad (in Mysore) and in Ernad (Malabar district) in the foothills of the Western Ghats. Initial results were dramatic. In the Terai, within a year of spraying, ‘examination of blood-smears of 3,000 infants has revealed a reduction in malaria endemicity from 60 per cent to nil in the sprayed villages’.3 This represented a striking transformation indeed, in a region which, David Arnold has shown, was once ‘almost defined by death. This tract was considered so deadly as to be impassable for Indians and Europeans alike through a large part of the year’.4 In Malnad, too, ‘complete disappearance of the vector has resulted in general improvement of local conditions’.5 In Thailand, a malaria control project began with WHO support in Chiang Mai province, and here the WHO was able to boast, again within a year, of ‘a striking improvement in general health conditions’.6 In each case, the WHO deemed the ‘extension’ of the work to be imminent: pilot projects would spread the new technical expertise far and wide. The early attempts to treat yaws showed similar success. India, again, was the first to receive a demonstration team, in this case in Simla. The ‘dramatic response’ of yaws to antibiotics (‘for the first time…available free of charge to the people of the area’) was ‘rapidly publicized’.7 Within a year, tens of thousands of injections had been delivered by pilot projects in Indonesia and Thailand.

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Looking across Asia as a whole, the WHO’s activities in the 1950s resembled a network with a number of nodal points (‘pilot projects’, ‘demonstration sites’, ‘projects’), between which experts, supplies and fleets of vans moved, constantly. By the mid-1950s, on the eve of the malaria eradication campaign, the organization was responsible for eight projects in Afghanistan; ten in Burma; 11 in Ceylon; 15 in India; ten in Indonesia, and nine in Thailand. 8 The projects encompassed everything from malaria control and demonstration projects using DDT to pilot projects in nursing education and the establishment of statistical infrastructures.9 Numerous kinds of expertise came together within the framework of ‘technical assistance’, from drug and insecticide manufacture to nursing. Despite their very limited number and their localized nature, such projects succeeded in orienting ‘health policy’ in the region towards focusing on specific diseases, and specific ‘campaigns’ of treatment. There was a remarkable similarity in the health policies adopted by polities as different as those of India, Indonesia and Burma, each framed within a broader, ‘Southeast Asian’ approach to health. Each accepted the WHO’s definition of priorities, and its definition of ‘health’ in terms of clearly distinguishable causes of death. Thus, at a major national conference in 1952, the Burmese government spoke avidly of an ‘Anti-Big Four Campaign’, the ‘big four’ being the four diseases targeted by the WHO expert committees for international action: malaria, tuberculosis, venereal diseases and leprosy.10 Across South and Southeast Asia, each state had a malaria control organization; each undertook campaigns of mass vaccination with BCG, and each followed the lead of the WHO even though in none of the three political cultures was public health anything like a priority in government spending and public policy.11 The absolute amount spent by the WHO in South and Southeast Asia was very small, and insufficient to explain the extent of the WHO’s ability to shape the international agenda. One commentator, writing in 1952, estimated that it worked out to one-seventh of a cent per capita in Asia. ‘Expressed in these terms’, he said ‘the programme seems hopelessly inadequate – or might it be that this method of measuring the work of WHO is wrong?’12 In the case of India, Roger Jeffery has estimated that, in the period 1950–1959, external aid accounted for an average of 14 per cent of the total expenditure on health.13 Of this, the UN (WHO and UNICEF, the latter concentrating on providing material supplies) accounted for only 15 per cent, most of the remainder coming from US bilateral aid to India, channelled in particular

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through the Public Law 480 programme.14 Yet Jeffery’s careful calculations suggest that the US funds were largely used to purchase ‘material supplies’ like DDT, whilst the WHO provided ‘technical advisers’. He concludes, in an exhaustive study of the internal workings of India’s health bureaucracy that ‘WHO’s “non-political” status has meant that its advice has had more weight than that of other donors’.15

Health and nationalism In part, the WHO was able to wield influence over the bounds of discussion on health policy because its campaigns were readily absorbed into narratives of progressive national development. To mark ‘World Health Day’ on April 7 1953, one of India’s leading English-language daily newspapers, The Hindu, dedicated an editorial to the work of the WHO, arguing that ‘there cannot be any progress in the social and economic conditions unless there is a marked increase in the level of public health’. Focusing on the contribution of the WHO’s work to India’s, and Southeast Asia’s, development, The Hindu argued that In India anti-malarial campaigns, undertaken with WHO assistance, have been successful. There has been an increase in the population of the Terai region and the area under cultivation has gone up 40 thousand acres. Equally striking successes are claimed in the eradication of malaria in some of the most deadly hotbeds of the disease in Burma. In the battle against tuberculosis the WHO helps in the retraining of doctors, nurses, home visitors and X-ray technicians. … That highly infectious disease, yaws, is widespread in many Asian countries, like Indonesia and Siam, and, by a suitable use of penicillin and preventive measures, substantial gains have been recorded in the fight against the scourge. Plants for manufacturing penicillin and DDT, two of what one may call the fundamental drugs of the modern world, are being set up in India with WHO assistance.16 This was the language ‘battles’ and ‘campaigns’, with a clear focus on technology (and technicians). The editorial then draws a direct link between international health and ‘nation-building’. Far from imposing itself upon governments, the WHO’s ‘assistance is given only when asked for by governments concerned and its aim is to afford opportunities for such administrations to help themselves’. The newspaper succeeded in giving priority to public health as a form of technical assistance: ‘While there may be some argument regarding the usefulness

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and efficacy of other types of technical assistance extended to underdeveloped countries’, the editors argued, ‘there cannot be two opinions about the humanitarian and nation-building activities of bodies like the WHO’. That the WHO’s work is considered ‘nation-building’ by India’s leading English-language nationalist newspaper, is striking. The editorial concludes with a ringing call to arms: ‘Health and prosperity are inseparable and in the battle against disease, there can be no neutrals’. Everywhere across the region, the images and narratives of nationalism played a central role in making ‘policy’ out of myriad isolated ‘pilot projects’ and ‘demonstrations’ which the WHO took to India, and elsewhere in Southeast Asia, as a first step in reorienting the discourse and practice of public health. The rapid spread of malaria control projects through India received dramatic affirmation, in ways that made it possible to imagine a singular ‘campaign’ against disease, linking the local, national and international planes. In 1954, India’s national malaria control programme was formally launched, funded and orchestrated by the WHO and the American Economic Cooperation Administration.17 Some manifestations of this modernist representation of public health projects tended towards dramatic display. Ritual performance linked international public health campaigns with the state, and with nation-building. Writing on the occasion of ‘World Health Day’ in 1955, celebrated on April 7th – an occasion commemorated around the world – a major Indian newspaper reported that ‘the Ahmedabad Corporation has undertaken mass DDT spraying on 7,000 tenements in the working class area in observance of the World Health Week’. In Shillong, in India’s northeast, ‘hundreds of students paraded the streets carrying posters exhorting people to observe the World Health Day’. Hyderabad, too, witnessed a ‘procession of medical men, women and nurses carrying placards, “Lead Healthy Lives and Keep Your Surroundings Clean” which went round the city marked the celebrations in Hyderabad’. Going yet further, ‘two planes of the Indian Air Force dropped leaflets on health on Hyderabad and Secunderabad’.18 In the latter case, the commemoration of international public health was wedded to a dramatic assertion of the state’s presence, through its Air Force planes, just seven years after Hyderabad was subject to forcible incorporation into independent India by ‘police action’. In the Republic of Indonesia, too, early pilot projects in malaria control (26 spraying programmes in all by 1955) were associated with the assertion of state power, and in particular with the state-sponsored scheme of transmigrasi – the transfer of population from Java to the

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outer islands.19 ‘Some thousands of families have been rehabilitated in the new transmigration areas in West Java and South Sumatra’, wrote the Indian malariologist Jaswant Singh, on assignment with the WHO, ‘this became possible only after malaria control had been achieved’. The Indonesian demonstrations of malaria control were concerned, too, with moulding hygienic citizens; the Indonesian government’s ‘policy’, Jaswant Singh declared, was to ‘create in [the people] a desire for living under hygienic conditions … a sense of responsibility and the will to carry out simple measures through their own efforts’.20 Yet the agglomeration of malaria control teams in India and Indonesia (as also in Burma, Thailand and Ceylon) were part of a much broader regional, even global, network of similar teams. The crucial point about the public health campaigns of the 1950s is that they were organized at once nationally and transnationally. WHO-sponsored projects were integral parts of ‘national’ policy, at the same time as all of the malaria control projects, and all of the BCG vaccination projects across Asia constituted unities of their own. The WHO was both an international and a transnational institution; it was both a professional body advising member governments and the site of networks of malariologists, DDT sprayers, insect-collectors and vaccinators. The supply of material goods for technical assistance illustrates, in itself, the intersection of national spaces and transnational networks. Amongst the earliest priorities of technical assistance was to equip the larger Asian countries with the supplies to construct DDT and penicillin factories of their own, producing these goods within protected national economies. Under an agreement between the Government of India, WHO and UNICEF, signed in July 1951, construction began on a penicillin factory at Pimpri, near Pune; the factory, Hindustan Antibiotics Limited, began production in 1955.21 Yet from the outset, supplies produced or procured by States were not enough to put the plans into action. The Indian pharmaceutical industry continued to be dominated by the private sector (both large Indian firms and foreign firms) in the 1950s.22 As late as 1956, Nehru felt the need to write to the Chief Ministers of India’s States, suggesting it was ‘not necessary … nor desirable’ for state governments to buy ‘foreign made penicillin’; ‘our production of penicillin is considerable and can meet all demands made of it’, he promised.23 Nehru’s pleas notwithstanding, technical assistance activated a ceaseless flow of things along the networks of foreign aid and international assistance: Fordson vans, DDT spray guns, vaccines, petrol and refrigerators.24 Yet in some Asian states, not even imported supplies for malaria eradication were exempt from customs duty.25

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These supplies were often ‘gifts’ from the American Economic Cooperation Administration. Even in the era of the 1955 Afro-Asian Conference in Bandung – the high point of the attempt by some Asian leaders not to allow the Cold War to erode their sovereignty – American supplies remained at the heart of national-transnational public health campaigns, because they were directed towards an end higher than that of sovereignty: the welfare of the population.26

A post-colonial discourse? In their public celebration and commemoration in Asia, the new international health projects appeared as an inherently post-colonial enterprise. Access to the latest international expertise and the latest international technologies, denied to them under colonial rule, was a democratic right claimed by Asian nations. But the architects of technical assistance, too, envisaged their task in opposition to the epidemiological and epistemological legacies of colonial medicine. In one of the first comprehensive reports to emerge from a technical assistance mission, the WHO representatives on a UN mission to ‘plan Burma’s social services’ declared that ‘mass’ diseases ought to be treated with ‘population-wide measures and not individual ones’.27 The basic premise of the new international public health was to minimize contact with individual bodies by working, wherever possible, upon ‘the environment’. In a report that seems to have been written deliberately to create an effect of radicalism and novelty, the WHO consultants used an unusually blunt, even shocking, logic in discussing the most prevalent of health risks: those faced by mothers and infants. Since birth is a physiological act it is not per se dangerous. Major pathological risks to the child come after it is born, when it is faced with its new environment. In the control of this environment lies the main opportunity for reducing infantile mortality. The risk to the mother is not the natural act of birth but her state of health…. That is not primarily an obstetrical problem but rather one of the control of the prevalent disease; once again, the environment is implicated, and it is not too much to say that the control of malaria will do more to lessen maternal mortality than any other measure.28 With this statement, international health consultants speaking within the discourse of international public health sought to establish their authority in relation to the legacy of colonial medicine, and they

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sought particularly to displace ‘culture’ from the heart of colonial medical knowledge. In a quest for universality, the techniques of international public health attempted to abstract from the problems of ‘culture’ that had so concerned colonial medical officials, missionaries and social reformers.29 The discourse of international public health was a self-conscious exercise in homogenization, flattening the ‘rule of difference’ that governed the perception of colonial medicine. Moving onto another ostensibly ‘medical’ problem, the international consultants in Burma suggested that the authorities ought not to treat venereal disease through ‘the control of individual cases’. Such an approach was only possible, they argued, ‘where there is a high degree of administrative control of the population, where there is a moderate incidence, where the dangers of venereal disease are appreciated by the public, and where machinery exists for seeking out the contact and bringing him or her to a treatment centre’.30 The implication was that in the condition of an ‘under-developed’, once colonized country, the ‘high degree of administrative control’ simply did not exist. ‘Colonial’ categories of perception, however, persisted, in interesting ways. In order for the project of mass disease control to succeed, population groups had to be identified in a finely differentiated way – ostensibly according to their differential susceptibility to infection.31 Here, then, the categories of the colonial and then the post-colonial ‘ethnographic state’ came into play in governing the path of disease control projects, in shaping the perception of technical assistants as to ‘problem’ areas, likely hotbeds of resistance or recalcitrance.32 Thus one of the first WHO malaria control projects, in Malabar, could not but fall back on understanding its subject population in terms of ‘moreevolved castes’ and ‘very under-developed hill tribes … who should be considered pagans’; industrious Syrian Christian communities claiming nature’s bounty in Lockean fashion and ‘very primitive aboriginal tribes’.33 Yet in the discourse of technical assistance, the object was no longer to reform the primitive and discipline the savage; ‘ethnographic’ differences were of interest for purely ‘technical’ reasons. Each community, so defined, built their walls of different materials, replastered them at different times, and so posed different challenges to DDT spraying teams.34 Essentially, the notion of the irreconcilable ‘difference’ of colonial populations prevailed, but its significance shifted. In the colonial era there existed a clear distinction between the government of the welfare of advanced populations in liberal metropolitan societies, and the government of ‘primitive’ peoples, in whose case coercive measures and

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administrative interventions were easily justified.35 In the immediate post-colonial era, the dichotomy remained (between the ‘West and the rest’), but it now had different implications. Third World societies were precisely those resistant to penetration by the medical apparatus, and therefore the arena where the discourse of international public health could claim authority. Medicine was for societies that could afford it; simple, effective technology was the panacea for those that could not. Thus, technical assistance challenged the autonomy of ‘medical’ expertise as the ultimate authority, in the specific conditions (themselves defined by political economy, demography and geography) of the Third World. By orienting the goals of public health towards the control, and then the eradication, of specific diseases, the architects of technical assistance privileged particular kinds of knowledge, types of expertise, whilst devaluing others. Although technical assistance was constructed upon myriad local experiments, it played down the importance of locality in the practice of public health. If, as Michel Foucault argued, the ‘status of the doctor is generally a rather special one … he is hardly ever an undifferentiated or interchangeable person’, the practice of technical assistance sought to challenge this unique claim to the ‘right to make medical statements, and to claim for them the power to overcome suffering and death’.36 The WHO criticized clinicians’ ‘great concern for retaining so-called professional standards’, suggesting that these ‘professional standards’ were meaningless in the conditions of the Third World, ‘preserved from contact with the problems of the population at large’.37

Journeys to health The (partially post-colonial) discourse of international health undoubtedly served as a link between ‘all the various activities, relations, subject positions, sites, forms of authorization’ that made up the ‘specific practice’ of technical assistance, dispersed across myriad pilot projects, documents, reports and missions of inquiry.38 Yet, perhaps above all of this, international health policy was built on imagination, even faith. If we ask what connected myriad disparate ‘pilot projects’, the answer lies often in the minds of individual public health officials; the WHO consultants whose personal journeys, crossing south and southeast Asia, linked myriad small projects into a larger whole. The venerable Indian malariologist, D.K. Viswanathan, was one such official. Over the course of 1956 and 1957, Viswanathan travelled

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extensively throughout the Southeast Asian region, inspecting projects, assessing their workings, speaking to health officials, compiling his impressions. The diaries of his journeys indicate the importance of what – borrowing from Benedict Anderson – we might call ‘administrative pilgrimages’ in making ‘health policy’ a tangible, transnational reality.39 From headquarters to ‘field’, from pilot project to pilot project and from country to country, the pilgrimages of a new corps of international health officials cemented the reality of ‘health policy’. The impression conveyed by Viswanathan’s itinerary is one of constant movement. He was conveyed by air, by truck and by boat, to inspect his domain. The following extract from his diary of a tour through Burma in February 1957 is worth quoting at length: 5.2.57 08.00 to 19.00 Myitkyina to Kya Gyi Kuin and back – 136 miles by road with Drs. Ohn Pe, Sambasivan and Lal. Saw a spray squad at work under a malaria inspector and a supervisor. Met a mid-wife in charge of a sub-unit (at Pin Paw) attached to Mogaung health unit which was also visited. Met Dr. Mukherjee, Medical Officer in charge of Mogaung hospital, lady health visitor and midwife of health unit. Saw two leprosy cases in two villages, Pamti and Pilan Kataung on the way, along with the leprosy inspector… 6.2.57 08.30 to 16.00 Myitkyina to Myothit and on to Bhamo by road – 108 miles. Met Dr. Das Gupta, a lady health visitor and four midwives at Myo Thit health unit. Met two malaria inspectors and malaria assistants of Bhamo on the way, and Dr. Basu, Dr. Mazumdar and Dr. Paul of the Civil Hospital in Bhamo. 7.2.57 07.00 to 19.00 Bhamo – Lashio by road – 200 miles with Dr. Ohn Pe, Dr. Gurubaksh Singh and Dr. Sambasivan. Met Dr. Tin Sein, malaria medical officer, Shan States at Namkhen on the way with a malaria inspector. Saw a squad at work under another malaria inspector and a supervisor at Nampheka40 These projects, scattered and localized, constituted the essence of international health policy in the 1950s. Viswanathan’s journey through Burma followed an earlier tour through Ceylon in October 1956 – travelling hundreds of miles, inspecting bridge construction, land clearance projects, leprosy colonies and DDT spray teams – and visits to Afghanistan, Nepal and sites across India.41 The journeys were, in

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effect, a set of links connecting the nodes of international health policy. The number of Indian doctors and administrators Viswanathan encountered in Burma, and across the Southeast Asian region is itself striking. Here we see the intersection of the new international connections made possible by the United Nations, and older networks of colonial medicine: up to and beyond Burma’s administrative separation from India in 1936, a good number of Burma’s trained medical personnel were Indian, whether through the Indian Medical Service or in private practice. In the post-war era, Indian medical personnel continued to be recruited directly into service by the Burmese government, even as the Burmese denounced Indian neo-colonialism. Long after the exodus of the majority of Burma’s Indian population and the Burmese government’s attempts to minimize its dependence on its neighbour, Indian doctors, consultants and inspectors continued to play the central role in advising and establishing the country’s health services. A contemporary report suggested that ‘most Burmese government doctors have resigned to take up more remunerative private practice. Unable to fill these vacant posts locally, the Burmese government sent a mission to recruit doctors in India … 600 applied for the 280 positions advertised.’42 We can only speculate that better pay or conditions might have attracted Indians to Burma, despite powerful memories of the exodus of Indians from the country in 1942, and despite the fact that India itself faced serious shortages of trained medical personnel. At the same time, through the institutions of the British Commonwealth (the Colombo Plan), Burmese technicians went directly to India for training.43 And through the networks of the United Nations, Indian consultants toured Burma to advise on policy. Transnational connections in the service of biopolitics could, still, transcend the boundaries of national sovereignty. The connections forged by the new international organizations across Southeast Asia were personal as much as discursive, and as often haphazard as planned. Given the gulf between aspiration and the capacity to effect change (‘policy’), much was left to the discretion of the technical assistants themselves. At the furthest reaches of the ‘new’ Asia, where state power was weakest, the international advisers had the greatest discretion, and at times resembled the colonial district officials of old, the men on the spot who ‘knew their natives’. Here the international medical consultant could appear as swashbuckling conqueror of disease, as in the case of Dr Luigi Mara, an Italian WHO consultant who came to be known as ‘Dr Malaria’, chasing

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nomadic Kurdish populations through the borderlands of Iraq in order to spray their tents with DDT.44 In Cambodia – newly independent from France – public health was as romantic, if more leisurely, a pursuit. With only a handful of qualified Cambodian doctors at independence, international consultants had free reign. This is made abundantly clear in the diary accounts of Dr Arthur E. Brown, a British public health specialist who had trained at the London School of Hygiene and served with the UNRRA at the end of the war, and who served as the first WHO consultant to Cambodia. There was, Brown wrote in his diary, ‘a fairy tale quality about the whole situation which a glass or two of good French wine did nothing to dissipate’. Early on in his time in Cambodia, Arthur Brown convened a lunch of a ‘convivial group of UN experts’. They met at the Petit Tricotin, in the centre of Phnom Penh, ‘a pleasant place to eat out in the fresh air, in whatever section took one’s fancy. It was popular, too … frequented by “taxi girls”, but they were discreet and on the whole attractive’. The composition of the group, which gathered in these fine surroundings, evokes much better than any official report a tangible sense of ‘technical assistance’: M. Franz, a stocky Belgian, had just arrived to get a UNESCOassisted programme under way. His field was Community Development. Mr Andrew Gilmour, a lanky Scot who had spent many years in Malaya, and had been Financial Secretary in Singapore, was the new UN Financial Adviser to the government … Finally there was the WHO contingent: two Belgian lady doctors, and a Dutch nurse involved in the Maternal and Child Health and nursing training, and myself, whose task was to help the government with planning and running its health programmes. We all spoke French … more or less!45 On paper, technical assistance was a finely oiled machine with its component parts contributing to the end of ‘development’. In practice, the details were worked out on the ground, ‘over a good meal, a couple of bottles of Beaujolais’. Like a good colonial official, Arthur Brown wrote unselfconsciously that the ‘… smiling brown-skinned Cambodian lived his lazy happy life, getting the essentials of life with minimum effort. Even his women seem satisfied and good tempered …it takes reforming Europeans to spoil all this what with missionaries, commercial travellers, insurance agents, emancipators of women, and people like me’.46 Brown toured his domain, escorted by the Cambodian Minister of

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Health, in a convoy of black government Citroens, ‘escorted by police motorcycles and wailing sirens’. On one occasion, the entourage mounted eight elephants, and ‘with his Excellency [the local governor] leading the way, we went in procession through the town, cheered on by the population’. It was, Brown declared proudly (ironically?) a ‘United Nations occasion’.47 Tales of international medical heroism, not unlike the ‘Jungle Doctor’ narratives of missionary medicine in Africa that Megan Vaughan has analysed, circulated widely in the 1950s, largely for a western audience.48 The dominant impression from these accounts, though, is how few international consultants there were. The whole project rested on the ability to train a new kind of personnel, the ‘new men’ of technical assistance. If, on the frontiers, ‘Dr Malaria’ could make things happen, in the heartlands of South and Southeast Asia, much depended on the small army of local vaccinators, nurses, truck drivers, and X-ray technicians that staffed the massive international campaigns of disease eradication. These technicians would be the ‘new men’ of international public health, imbued with an ethos of depoliticized, technically competent service. Technology was at the heart of the international health campaigns of the 1950s, and this technology needed to be embodied in an army of men (almost entirely men, they were) with the dispositions to operate the new technology.49 As we have seen, the architects of the international health campaigns held up technology as a way of transcending the constraints of ‘culture’ and society; it was down to the army of technicians to put that technology to work. In one of the earliest technical assistance reports from Burma, (cited earlier in this chapter), the Fordist logic underlying the new practices of public health emerged explicitly. The fundamental premise was this: ‘If any complex procedure, whether it be making a motor car or poisoning a germ or insect without poisoning the human being near it is examined, apparently skilled operations can be seen to be composed of a series of unskilled ones’.50 The logic of technical assistance was that ‘the greater the degree of job-breakdown, the more the skill is concentrated at the centre, and the more it is diluted at the periphery.’ This was the principle underlying the public health approach of the mass campaign: These principles are applied in preventive medicine in the current anti-malaria campaigns involving Asian populations numbering millions; they are applied in curative medicine in the same way in

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the current anti-syphilis and anti-yaws campaigns also involving millions. They can also be applied in Burma to the current health problems of the scattered rural peoples.51 The fundamental task of the new agents of international public health lay in the mastery of technology; developing the dexterity to read film slides rapidly, the movements of the hand needed to vaccinate rapidly and accurately.52 Thus, declared one report: One film reader can read 100 to 300 pictures per hour if assisted by a secretary. One radiographer can take 150 to 500 pictures per day of seven hours work. One trained laboratory technician can handle 50 specimens a day including culture. One home visitor on a bicycle can visit a maximum of 100 houses per month. One registry clerk can handle 200–300 persons per day if the work is well organized. One tuberculin-tester can test or read 500–1000 per day if the work is well organized.53 This new generation of medical technicians appear here as so many cogs in the well-oiled machine of technical assistance. The masculinity at the heart of technical assistance was marked. In the photographs, and in almost all of the field reports in the archives, the local characters are overwhelmingly male. Technical assistance was a deeply gendered approach to international policy. The technicians who carried it out were men, supervised by a sole white (often Scandinavian) female nurse, even as women and children were chief amongst the intended beneficiaries of their interventions. Although large amounts continued to be spent by international agencies on the education of local nurses, during the mass campaigns of disease control, male medical auxiliaries played the greater role.54 Technical assistance, after all, was part of what James Ferguson calls a ‘masculine version of modernity based on a hard, metallic, masculine industrialism’55 – this modernity was based, too, on hard, metallic cans of DDT, and physically fit men to carry them. Perhaps the quintessential ‘health technicians’ of the international health campaigns were the DDT sprayers in malaria demonstration teams. Dr Luigi Mara, the Italian malariologist who would later be

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immortalized as ‘Dr Malaria’, conveys the daily routine of the spray-men: The field assistants (squad leaders) were responsible for: a) weighing the DDT for the day’s work; b) cleaning the pumps and keeping them in good conditions; c) preparing the suspensions from the concentrate in the field; d) measuring the area sprayed and recording in a book all the details about the number and nature of the structures, number of persons living in them, owners’ names, etc.; and e) submitting in the evening a report on the day’s work.56 The field assistants appear, here, as the main characters in the drama of public health sweeping across South and Southeast Asia: they served as the ‘eyes and ears’ of the campaigns. Throughout his journeys through south and Southeast Asia, D.K. Viswanathan, the eminent malariologist, highlighted the importance of the spraymen, the supervisors and the insect collectors. His reports are constantly calculating their capacity, constantly determining how far and how fast they can go. ‘Each sprayman can spray a minimum of six houses per day to begin with’, he suggested, ‘but after a couple of rounds of experience in spraying, he can easily do nine houses, or a total surface of 2250m2 per day and still later even 3000m2’.57 The expansion of the malaria control programme in Indonesia, as elsewhere in the region, was conceived graphically in terms of men and machines. Viswanathan’s report contains an elaborate table entitled ‘Projection of National Malaria Control in Indonesia in 1956–7’, detailing, for each province, the number of spraymen, insect collectors, supervisors and mantris required, together with the kilograms of DDT and the ‘trucks or other transport’: ‘3 station wagons, 11 trucks, 16 jeeps, 10 trailers, 825 bicycles’ for West Java.58 Viswanathan was particularly pleased to see ‘the insistence by the national and WHO malariologists on meticulous compliance with the drill of spraying procedures in every detail. While this might appear to stifle “initiative” on the part of the regional staff, strict compliance with the drill is necessary, lest incorrect spraying techniques masquerade as “initiative”.’59 The new generation of malaria technicians were to be the agents of transformation, but they were not to take too much ‘initiative’; their bodily reflexes were to be trained in such a way that initiative would not be necessary. Yet for all of the attempts to ensure that the health workers were technicians, and nothing more, older expectations of

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their social role persisted well into the era of international public health. In a set of instructions to trainee spraymen on Burma’s malaria eradication campaigns – the instructions themselves adapted from a Mexican manual for malaria workers – there remained the expectation that the technicians would also function as agents of modernity.60 They would function as rational, self-governing citizens whose example would serve as a beacon for the illiterate rural masses. Similarly, in an address to a newly trained cohort of community development workers – many of them would staff UN-sponsored technical assistance projects in public health and other fields – Jawaharlal Nehru asserted the specifically post-colonial, nationalist character of the endeavour, with reference to the freedom struggle. ‘Thirty years ago’, he declared, ‘it was possible for one man to bring out that “elemental force” from the Indian people … the question now is how to regenerate that “elemental force” and the urge to do things’, and how to harness it to the much more quotidian task of development.61 Somewhat uncharacteristically, for a firm believer in the ‘scientific temper’, Nehru pleaded with the new agents of development to ‘search your hearts to find out whether you are going back to your States with the feeling of a crusader or a missionary.’62 This harked back to an earlier aspiration of Nehru and his fellow modernists during the late 1930s. In their plans for the health services of post-independence India, the Congress Party’s National Planning Committee declared that India’s young health workers needed to project ‘missionary spirit’. ‘By example and persuasion’, the Congress report declared, ‘they will spread the gospel of healthy living, communal and personal, and thus take other villagers a step or two away from their age-long prejudices and superstition on the road to better living’.63 Nehru, in 1952, appealed to the administrators of ‘projects’ – in health, sanitation, agricultural development and housing – to ‘not … be afraid of using untrained people, wherever you can, provided you think they have some energy and enthusiasm’.64 It seemed that the physically fit, self-governing, dedicated individuals like the malaria sprayers would serve as agents of a new Indian/Asian modernity, the ‘new men’ of the new approach to health and development. The Prime Minister himself, however, had a prescient awareness of what was to happen: ‘with all the good [bureaucracies] do’, he noted, ‘they have a certain deadening influence on anything that is spontaneous or vital’.65 The new men of the international health campaign resemble, at times, the army of labourers in Kafka’s parable ‘The Great Wall of

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China’: impelled by enthusiasm and commitment, driven from place to place, project to project, lest they realize how forbidding the task is before them. ‘One is forced to conclude’, Kafka’s narrator declares, ‘that the command deliberately chose the system of piecemeal construction’, partly ‘in order to encourage the men of lower rank, whose mental capacity far outstripped their seemingly petty task’. The arduous labour of construction for ‘months or even years’ in ‘some uninhabited mountain region hundreds of miles from their homes’ would be work ‘to which no end could be seen even in the longest lifetime’ – so, many felt, would the work of medical personnel permanently assigned to rural areas. However, the ‘piecemeal system’ – or the mass campaign – allowed for a rallying of forces, a periodic injection of enthusiasm. Sent away after the completion of ‘a section’, the foot soldiers’ journeys showed them visions of ‘completed sections of the wall towering up here and there’ and ‘the cheers of new armies of labour streaming up from the depths of the provinces’. And ‘on all the roads they met with cheering, flags, banners; never before had they seen how vast and rich and fair and lovely their country was.66

Seeds of doubt As one reads again various accounts of the long struggle against malaria, now flowing so dramatically in man’s favour, it appears that there has been no steady triumphal march. Rather, as suggested by Conant’s simile, the happenings resemble those of modern warfare: advance objectives wished for, reconnoitred, attacked, boldly seized, precariously held, and painstakingly consolidated.67 Paul F. Russell (1955) This chapter has suggested a close connection between the aspirations for a world free from infectious disease and a democratic modernism, channelled, in part, through the United Nations and its roving consultants. This modernism built upon belief in the universal effectiveness of new technology, and conviction that the technology would allow public health to expand to ‘the people’, beyond the confines placed on it by the exclusions of colonial medicine. The architects of the new international public health believed not only that technology could subdue nature – in the sense both of microbes, and the ‘natural’ poverty of much of Asia – but that the use of technology would mould a new generation of workers, technically competent and devoted to serving the cause of development with enthusiasm.

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The declaration of a global programme to eradicate malaria reflected, in many ways, the unease beneath the technological optimism that this chapter has tried to convey. On the one hand, malaria eradication was the natural, even inevitable, outcome of the logic of technical assistance: the logic of pilot projects expanding throughout the land, the confidence underpinning the mobilization of new technologies. On the other hand, the attempt to formalize and globalize, as ‘policy’, the interconnections between the proliferating local projects, was a response to the fact that all was not as it seemed. Beneath the surface of technological confidence were all manner of fears, and obstacles both human and ‘natural’. Paul Russell, perhaps the most optimistic of the malariologists, himself possessed by an unshakeable faith in eradication (which some have ascribed to his background; he was the son of a missionary), encapsulated this contradiction: ‘boldly seized, precariously held’. The WHO’s formal recognition that its ultimate aim was the complete eradication of malaria came during the World Health Assembly of 1955.68 Here we see encapsulated the technological confidence that this chapter has attempted to convey in its smallest manifestations. However, much of the urgency underlying the move towards formalizing the goal of international health in terms of eradication arose from the sense of panic experienced by malariologists at the prospect that mosquitoes might prove resistant to the assault by DDT.69 Malaria projects using DDT were at the heart of the WHO’s struggle for legitimacy and funding within the politics of technical assistance.70 Malaria eradication proved an objective that could easily be understood, something that proved important in the competition for funds and, as importantly, in projecting a particular image of international public health. A dramatic and seemingly effective public health intervention, malaria control (and then eradication) helped to strengthen the WHO in the competition for funds, and for a place within the set of interventions that made up ‘technical assistance’. Malaria control fit particularly well with the framework of technical assistance: it was based on the simple, mass application of technology towards an end that could be justified in terms of its tangible contribution to ‘economic development’. It is thus unsurprising that increasing evidence of insecticide and drug-resistant mosquitoes provoked a sense of alarm amongst policymakers within the WHO in general, and the Expert Committee on Malaria in particular. By 1952, studies began to show the fragility of one of the most publicized successes of DDT: the anti-malaria cam-

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paign in Greece. A WHO report suggested that, despite massive spraying, first houseflies and eventually malarial mosquitoes showed resistance to DDT.71 The fear of developing resistance is clear from reports on malaria control in the Asian region. A 1953 report by WHO states, at first that ‘none of the governments reported that the anopheline mosquitoes in their countries had developed resistance to the insecticides’; this is immediately qualified, however, by the admission that ‘in Burma, Ceylon, Indonesia, and the Philippines, there were impressions (unconfirmed scientifically) that culicines have developed a certain amount of resistance to DDT’.72 ‘To heed the warning from Greece’, declared Emilio Pampana – the Venezuelan malariologist and member of the WHO’s Expert Committee on Malaria – in 1955, ‘means to plan the programme in such a way that house-spraying could be safely discontinued before insecticide resistance develops’.73 What was needed was a ‘new pattern of planning’, envisaged in terms of ‘huge areas, of total coverage, of great thoroughness of control … its implementation will require more funds, more trained personnel, greater efficiency of operations, and better systems of epidemiological surveillance than are necessary now.’74 Pampana’s was the opening article in a special issue of the WHO Bulletin, designed to make the case for an urgent acceleration of the worldwide malaria programme. Critical perspectives were not absent from the debates on malaria eradication. Within the WHO organization itself, many recognized that malaria eradication may not be a universally appropriate policy. A confidential memorandum prepared for the Director-General, Candau, before his tour of Southeast Asia in late 1954, raised questions about the effectiveness of the WHO’s strategy of malaria demonstration projects. In India, ‘control areas are widely scattered’, and in Thailand, ‘the campaign appears to be poorly carried out and inadequately supervised’. The authors of the memorandum raised serious doubts: it would be ‘most difficult’, they wrote, ‘to attain an end-point of transmission that might give the possibility of eventually discontinuing the spraying’. Yet, the report lamented that eradication was being pushed forward, influenced by a large influx of ‘aid, unassociated with high level malariological advice, and complicated by the urgency of spending available money’.75 Amongst the strongest dissenting voices at the 1955 World Health Assembly was that of the Liberian delegate, Dr Togba, the sole African represented in the discussions. ‘Much was said about DDT’, he agreed, but he ‘wondered whether enough research had really been done on

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the use of that insecticide … in his own country, it had been found that DDT decomposed very rapidly, and was therefore of little use as a residual insecticide’. Indeed, experience in Liberia had shown that an alternative insecticide, dieldrin, was far more effective, yet ‘it has also been found that for large-scale use it was prohibitively expensive’.76 This underscored the fact that cost played as much of a role as efficacy in the decision to intensify the worldwide use of DDT. Dr Togba was cautious about the possibility of mass anti-malarial campaigns. Largescale malaria control ‘may present no great difficulties in a relatively well-developed country like Venezuela, or an island like Ceylon’, he conceded, ‘but the magnitude of the task of spraying residual insecticides in every village of Liberia, in the face of bad communications and adverse weather conditions, could hardly be imagined unless it had been experienced’. He concluded, presciently, that ‘it would be illadvised to arouse the hopes of governments and run the risk of censure when results failed to come up to expectations’.77 These criticisms did little to dent the confident exhortations of Paul Russell, the pioneering American malariologist whose career with the Rockefeller Foundation had taken him from India in the 1920s to the WHO’s Expert Committee on malaria in the 1950s. Russell expressed ‘surprise’ at the criticisms of DDT, gently implying that such doubts were based on ingratitude, since ‘the finest insecticide discovered in the twentieth century was available … and, if used energetically, it would certainly eradicate malaria’.78 In pushing through his proposal, Russell evoked a sense of urgency, of unique opportunity: Already four or five of the fifty-odd major malaria-carrying anopheline species had developed different kinds of resistance to DDT in certain areas … Since there was not at present any satisfactory substitute method of attacking malaria, it was very important to eradicate the disease before the vector anophelines became resistant to the insecticide. It was not known exactly how many years the insects would remain sufficiently susceptible to DDT to allow of malaria eradication; the minimum appeared to be six or seven years and the maximum ten.79 For reasons analysed at length by others, the proponents of malaria eradication prevailed.80 The contribution of this chapter to an already extensive literature on the malaria eradication programme might lie in the suggestion that to understand malaria eradication we need to look well beyond the level of ‘policy’, and focus on the logic, planned and

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un-planned, of techno-politics, which built eradication ‘from the ground up’. The malaria eradication campaign proceeded apace after 1955, with the multiplication of spraying teams, the cementing of networks both national and transnational. The campaign was well supported by American funds.81 Yet the fear of resistance always lurked in the shadows. A document submitted to the Third Asian Malaria Conference, held in Delhi in March 1959, was eloquent in its attestation to the logic of expansion. In sparse, note-like prose, the report reviewed, country by country, the progress of malaria eradication. In Burma, 2,468,000 houses had been sprayed by 1958, and in malariometric surveys of children, only 0.4 per cent tested positive for malaria parasites; in addition, 8.3 kilograms of chloroquine was employed to treat ‘fever cases’. At the bottom of the page, under the heading ‘field operations’, the report noted quietly that ‘increased tolerance to DDT’ was found in the A. sundaicus species, though it remained ‘susceptible’ to dieldrin. 82 The Indian anti-malaria campaign was ‘the world’s biggest’. In 1958, a total of 8,704 malaria squads were in operation – a dramatic indication of the expansion of malaria control from a few pilot projects – and 438 million houses had been sprayed. Again, ‘field operations’ showed that of the nine ‘recognized vector species’ in India, ‘resistance to DDT has appeared only in A. sephensi, and resistance to dieldrin in A. culicifacies.83 And thus, in the immaculate prose of technical assistance, the report continues, detailing numbers, targets, ‘obstacles’ and ‘problems’, never losing its optimism: ‘only’ a few species were resistant, a change of insecticide would suffice to do the job; an adjustment here, and adjustment there, and the plans would be realized. The next chapter will return to the beginning, so to speak, in order to examine these countless adjustments, and the apparent contradiction between techno-centric optimism and the proliferating obstacles in its way.

5 The Techno-politics of Public Health

Beneath the confident visions of technology freeing the world from infectious disease, many architects of the international campaigns were concerned that all was not well. Plans there were in abundance and, it seemed, they had achieved results to justify belief. However, this chapter will show that inherent in the process of techno-politics was a tendency for practical obstacles to proliferate in the face of expertise, provoking more plans, more projects and constant adjustments. Timothy Mitchell argues that it is characteristic of technical assistance, in health as in other fields, that ‘failures and adjustments’ were overlooked, because ‘techno-science had to conceal its extra-scientific origins’. He suggests, and this chapter confirms, that ‘fundamental difficulties were presented as minor issues of the improper implementation of the plans, unexpected complications’ or ‘bureaucratic delays’.1 The first part of this chapter examines the constant adjustments necessary for the mass campaigns of disease control to function: mosquitoes acquired resistance to DDT very early on, and pilot projects showed worrying results. The need to reconcile these experiences with the optimistic narrative of ceaseless expansion – from pilot project to global eradication – led to a great concern with acting as rapidly and as intensively as possible. Yet the problems multiplied: broken down trucks, monsoon rains and interrupted supplies of vaccine. Above all, there was the ‘problem’ of human agency. Auxiliary health workers, malaria sprayers and vaccinators were poorly paid and insecure in their jobs, leading to the need for more and more ‘supervision’, complaints about their ‘inefficiency’. The vision of health workers as disciplined technicians remained far from realization. Underlying these problems was the fact that the depoliticization of technical assistance was always incomplete. Despite its effects as an 121

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‘anti-politics machine’, to use James Ferguson’s felicitous phrase, technical assistance was always threatened by the world of politics spilling over into its domain, and it was threatened by the most fundamental problem that it was, itself, designed to solve: poverty.2 Thus at the margins of the discourse of technical assistance, it was clear that inequality of land ownership, poor urban housing, and rapid population movements all contributed to an enduring experience of frequent illness for large numbers of people, despite the success of campaigns against specific diseases. The constant subversion of plans, by human and non-human forces, produced ill-defined and poorly articulated fears of ‘resistance’ among the architects of international public health. Planners believed that only dramatic and visible success would engender confidence among the public (or, perhaps, that only dramatic success would cause the public to share the planners’ own confidence). Yet I suggest that the mixed – though often enthusiastic – responses to the health interventions of the 1950s might be explained, rather, by what was unseen and unspoken by the technical assistants. The chapter ends with an account of an unusual episode: in 1955–56, the international campaign of BCG vaccination was openly challenged in the political arena by C. Rajagopalachari, a conservative South Indian politician and veteran of the nationalist movement. In this (exceptional) instance, he was able to exploit the silences in the discourse of international public health to mount a thorough, if short-lived, critique of its fundamental assumptions.

Human and non-human obstacles Today, we are simply doubling, blindly, the use of those same methods for killing mosquitoes which, for years, we’ve been told to use. We have very limited knowledge about the insects we want to destroy. … A good illustration of their cleverness and adaptability is the fact that within a given season, just one kind of mosquito can display fifteen different ways of attacking man. Sometimes they make a headlong dive …3 Phanishvarnath Renu, Maila Anchal Soon after the WHO had declared a global campaign to eradicate malaria, Jaswant Singh, an eminent Indian malariologist, toured Indonesia on behalf of the organization. His findings were not encouraging. Far from demonstrating the universal efficacy of DDT, the WHO’s pilot project in Tjilatjap, Java – from which the national eradi-

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cation campaign arose – showed results that were far from optimistic. Singh summarized them with concision: 1. DDT indoor residual spraying at a dose of 2 gm/m2 failed to produce the desired control. 2. Spleen rates in 1954 were higher than in 1952 in certain localities after a satisfactory fall in 1953. 3. A significant infant parasite rate and the sporozoite positive sundaicus were still found in the area.4 Moving, in his tour, from Tjilatjap to the town of Semarang, Singh encountered similar problems, which originated, partly, in the very success of DDT in supplanting earlier, sanitary attempts at malaria control.5 Drainage and clean weeding used to receive greater attention before 1950. DDT spraying programme was started in 1953 with satisfactory result for a period of two years. Since then increasing densities of A. sundaicus have been reported. At the same time, malaria morbidity, spleen and parasite rates have shown an increase. Singh cited numerous local studies that had shown that local mosquitoes had acquired resistance to DDT. Later the same afternoon, he was taken to visit ‘village type huts in the city of Semarang which had already been sprayed four times … occupants looked sickly and gave a history of repeated attacks of malaria. DDT had proved ineffective’.6 The following year a confidential report, circulated within the WHO, pointed to fundamental problems inherent in the use of DDT. ‘Malaria control today is essentially based on the interruption of transmission by residual insecticides’, the report declared, yet there was increasing evidence of the ‘inactivation’ of DDT due to ‘chemical degradation of DDT to DDE by dehydrochlorination owing to the presence in the soil of various mineral salts and particularly of iron oxides’. The problem was particularly acute given that ‘in many malaria stricken areas of the tropics the majority of houses have mud walls’. Yet in the discourse of technical assistance, this was simply an obstacle that could now be foreseen and circumvented: Inactivation of DDT is no longer an unknown factor: we know that it occurs by sorption and how to foresee it with reasonable accuracy … A major problem still remains to be solved: How to prevent sorption.7

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The emphasis, in public statements and field reports alike, was on the need for speed.8 Jawaharlal Nehru, addressing an Asian malaria conference in Delhi, in 1959, put the challenge in more universal terms: ‘In this, as in other matters which affect us underdeveloped countries’, he declared, ‘the pace, the speed of advance, become all the more important. … If you don’t go fast enough, the others will’. ‘The others’ in this case referred to all manner of natural forces, from evolving anopheles mosquitoes to the ‘iron laws’ of human population growth. Yet Nehru himself suggested, at odds with the discourse of technical assistance, that non-human actors might shape the outcome of events: ‘In many of these regions of Asia, maybe elsewhere, malaria has been a more powerful determinant in the course of human history than people imagine’; the implication was that it might still prove to be so.9 If technical assistance turned the ‘natural’ obstacles to disease control into problems of logistics, the practice of techno-politics, too, proved troublesome. As one astute commentator put it, ‘the killing of mosquitoes or spiroschetes depends just as much in a mass campaign upon the provision of petrol, tyre-patches and drivers’ salaries as upon an exact judgement of the dose of DDT or penicillin’.10 Thus in Burma, ‘difficult terrain, poor communication, small villages and the long distances to be traversed’ made the spraying campaigns ‘somewhat difficult’. 11 Fearing the development of resistance to DDT, the WHO’s malaria experts conceded that ‘it has not been possible to obtain simultaneous coverage of all malarious areas, chiefly because of the inaccessibility of certain localities for local reasons’.12 By the end of the 1950s, after nearly a decade of spraying, the WHO concluded that ‘about two million people are still inhabiting endemic areas which, owing to their “inaccessibility”, have not so far been sprayed even once’.13 ‘Inaccessibility’ was a matrix of many things: terrain and transportation, the limits of human agency, and the politics of insurgency on Burma’s frontiers. Writing in similar terms of Indonesia, D.K. Viswanathan phrased it delicately, in terms of ‘gaps’ between ‘the Centre’s schemes and provincial implementation’: The number of squads is not always related to the quantum of work. Insect collectors are not employed in many provinces. Malaria mantris who are well trained are not utilized for supervising spraying operations in many provinces. In some provinces the full quota

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of transport has not yet been made available, and even insecticides are not always received in time.14 This provides a clear illustration of the profusion of obstacles in the way of the functioning of technical assistance: lack of staff, who in turn were insecure and of low status, ill-equipped with bicycles and vans (themselves prone to break down) and ‘even insecticides’, the very technology they were employed to mobilize. As a result of countless practical difficulties, Viswanathan concluded, on a tour of Indonesia, that the proportion of houses successfully sprayed was too low ‘to warrant hopes for successful control, let alone eradication’.15 The pan-Asian campaign of BCG vaccination, too, encountered ‘obstacles’ to its smooth functioning, at every turn.16 In the words of Kirsten Hansen, a ‘BCG nurse’ sent to oversee the fieldwork of the mass vaccination drive in Ceylon, ‘improvisation was the order of the day.’17 Conditions were difficult. The fleet of Fordson vans supplied by UNICEF were not all that reliable. ‘Torrential rains and subsequent floods during this period also caused material interference with the programmes’, her report continued. In particular, ‘the frequent breakdown of vans, due to adverse communications, and the great distances which usually had to be covered before repair facilities were available, whittled down the working periods of the teams.’18 In the Eastern Province of the Ceylon, ‘difficult terrain’ and the need for ‘long journeys on foot, sometimes through virgin forest’, meant that ‘however carefully the programmes were planned … [there was] a target shortfall of at least 40%’.19 Perhaps the greatest frustration, however, came from the disused cinema projector: ‘the expensive cinema equipment given by UNICEF has only been used on a few occasions when unofficial help was available to screen films. No cinema operator has been appointed in spite of repeated appeals made both personally and in writing.’ This was particularly trying, as ‘in Ceylon … cinema publicity is invariably followed by an increased attendance at work centres’. The WHO nurse was convinced that ‘had it been possible to use the cinema apparatus on a planned programme basis, productivity would undoubtedly have increased’, but the sad sight of the unused cinema projector ‘is a source of constant disappointment to all the staff’.20 If the mass campaigns can be seen as medical technology in motion, it becomes clear that there were obstacles in the path. Above all, it was the technical assistants that shaped the workings of technical assistance. The archival reports are full of references to problems of ‘personnel’. The ‘problem’ was essentially that the hundreds

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and thousands of health workers, truck drivers, vaccinators and X-ray operators who staffed the most ambitious health interventions of the 1950s were neither faceless technicians in a Fordist production line of health, nor the self-subjecting agents of modernity that the more romantic observers of the drama of public health wanted them to be. Neither technology nor enthusiasm was enough, in the end, to make it work. Low rates of pay and job insecurity were problems that vaccinators and technicians faced, almost universally across South and Southeast Asia. A WHO nurse writing from Indonesia observed that Lay vaccinators are recruited locally at a very low pay. As long as they are working in their home towns and can live with their families, they can manage, but when the team moves onto the next place, the problem starts. They get no extra allowance and their pay hardly covers the cost of board and lodging.21 The positions of both the mantri and the lay worker were far from secure. WHO nurses observed that their poorly educated ‘lay’ counterparts ‘rarely dare approach a person in a higher official position than himself’;22 ‘with a strong minded doctor in charge, the mantri is handicapped’.23 The insecurity of the field staff, and the consequent difficulties of recruitment, featured heavily in the discussions of the Indian Government’s Central Committee on Health Policy in the mid-1950s. Health ministers from a number of States pointed out that the field staff on the BCG project were ‘not members of a permanent and pensionable service’. Furthermore, the vaccinators and field staff had ‘run into trouble because of active opposition from qualified practitioners’.24 The WHO officers working with the BCG teams in the field produced a similar assessment. ‘Sustaining the interest of the field staff’ in their ‘repetitive, and always arduous’ work was increasingly difficult, a WHO public health nurse wrote, as their ‘future possibilities…do not seem to have been even vaguely defined’.25 Another commentator put it in stronger terms, when he argued that ‘their work is monotonous and they live a hard life away from their families. Good work is seldom appreciated, nor is bad work punished, and although the campaign has been going for more than 10 years, they are still “temporary”, with little hope of promotion.’26 The constant practical difficulties faced by the programmes of disease eradication in the 1950s arose, then, from the impossibility of control-

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ling the complex human and environmental factors involved in shaping the conditions of public health – from the efficiency of spraymen to the weather. But the problems grew also out of the fact that technical assistance constantly confronted the messy ‘political’ issues it had attempted to submerge.

Poverty and politics The international health campaigns of the 1950s were founded on the assumption that poverty was amongst the ‘natural’ conditions that the new medical technologies of the age could circumvent. Questions of poverty, like questions of politics, were ‘parametric’, listed along with annual rainfall and topography at the beginning of each technical assistance report.27 Campaigns were organized on a territorial basis, each centred on a pilot project or a training centre – the most important of them staffed by international consultants. The boundaries of these regions were assumed fixed, usually according to geographical or epidemiological features (Burma’s hill zones, Ceylon’s ‘dry’, ‘intermediate’ and ‘wet’ zones), or, as in India, according to the lines of provincial boundaries.28 Yet the population of South and Southeast Asia in the 1950s was anything but stable. If the borders between nation-states were increasingly rigid, the boundaries of regions were constantly in flux.29 The 1950s saw a significant and continuing movement of population across the borders of India’s partition. Civil and political conflict spurred the frequent movement of population in Burma and Indonesia, to say nothing of the tens of thousands of Asian Muslims who made the pilgrimage to Mecca each year.30 Not only were the pathogenic targets of the international health campaigns constantly slipping out of control, so, too, were human victims, or ‘vectors’, of infection. The plans for disease eradication assumed populations to reside within static regions, densely or sparsely populated, hypo- or hyper-endemic with malaria. They assumed, furthermore, that the space of claimed sovereignty would also constitute the space of national disease control programmes. Yet as Agnese Lockwood, an American political scientist, observed in Burma at the time: The whole programme … is seriously jeopardized by the inaccessibility of insurgent-held regions. To be effective, a programme must cover the infested areas and their population 100 per cent. Not only

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do mosquitoes fly from one place to another but, even more serious, they gradually develop resistance to insecticides. At the present time, a race is developing in Burma between the vector resistance and the government’s ability to make the entire country accessible to malaria spray teams.31 There was a constant ‘threat of infection across borders with India, Pakistan, China, Laos, and Thailand’.32 Although the malaria control programme was conceived as a transnational initiative, the WHO planners ultimately assumed a series of ‘homogeneous’ national spaces that did not exist. At the end of the 1950s, Edmund Leach concluded that the Burmese state’s ‘claims regarding territorial suzerainty were optimistic in the extreme’. Leach argued that ‘the authority exercised by the central government over the Independent Sovereign State of Burma over its outlying regions in the year 1959’ was in some senses ‘a fiction’. Nor did the sharp dichotomy between the densely populated Valleys of Burma and the ‘isolated’ Highland societies prove an adequate representation of Burmese society.33 Even anecdotal evidence from the time suggests that people, including sick people, were very mobile, presenting a picture of ‘population’ very different from the one established in the documents on malaria and tuberculosis control in Burma. Ludu U Hla, Burmese journalist and folklorist, collected, in the 1950s, a series of life histories, narratives of his fellow prisoners in Rangoon central jail – each was a story of movement, from the Karen lands to lower Burma, from Rangoon to the Tamil Nadu countryside and back again; and, almost universally, from the country to the city.34 The complex role of population movements, and the poverty underpinning them, in shaping patterns of disease emerged from a report by the senior WHO officer, Dr F. Loven, who had traversed Burma, from Palaung villages in the highlands to Rangoon and Mandalay. 35 The problem of tuberculosis, Loven wrote in his report to headquarters, ‘is to a great extent a social one’. He highlighted the ‘density of population and the nutritional status, occupations, accommodation, economic position, social life and habits of the people’. The ongoing insurrections in the country ‘create more poverty amongst the people and cause restlessness, migration and a mixture of the population; because of these insurrections, the townships, district-headquarters and cities in Burma are over-crowded with evacuees.’ 36 WHO surveys of tuberculosis infection rates were completely unable to reach this fluid population, bound as they

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were by administrative categories that emphasized the need for fixity. 37 Inflation was rife, ‘the calories taken in are derived mainly from cheap starch’, leading to ‘grave nutritional deficiencies amongst the Burmese people’. Indeed, a survey by an Indian WHO nutritional consultant Radhakrishna Rao showed that 72 per cent of those he examined were ‘undernourished’. 38 With urbanization and poverty came the dark, damp corners ideal for the transmission of tuberculosis: The houses in which the general mass of population live are very poor, ill ventilated and badly illuminated. Several families usually live together and one open case of tuberculosis amongst them is enough to transmit the infection. The common spoon used at the table, the common drinking cup, the common cheroot (cigar) and the spitting habit contribute towards the common end.39 Implicit in this discussion was the suggestion that BCG vaccination could achieve little in these conditions, where infection spread rapidly and where poverty and malnutrition weakened powers of bodily resistance. Loven’s report, typewritten and filed away, provides an example of the ways in which technical assistance could contain a critique of itself. Loven’s report highlighted the importance of population movements, themselves impelled by ongoing Karen and Communist insurgencies on the frontier, in producing the poverty and overcrowding at the root of the tuberculosis epidemic. Yet according to the rules governing the discourse of technical assistance, ‘political’ and ‘other’ factors were simply logistical conditions, like the state of the roads. It is striking how infrequently the prose of technical assistance makes any reference to political violence, to the revolutionary movements challenging the authority of the state not only in Burma, but also in Indonesia. ‘Unrest’, at most, was given as a reason why teams could not ‘reach’ their targets.40 Loven’s attempts to construct a compelling narrative of causation carried little authority within the ‘library, or documentary field’ of technical assistance. Anecdotal, and based on observation, it lacked the translatability of statistics. Here Loven had indeed, in Foucault’s terms, ‘gradually ceased to be himself the locus of the registering and interpretation of information … beside him, outside him, there have appeared masses of documentation, instruments of correlation, and techniques of analysis which … modify his position as an observing subject’.41

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The return of community The discourse of technical assistance was similarly reticent on the subject of rural poverty. Indeed, I suggested earlier that the discourse and the practices of technical assistance arose, in part, out of the geopolitical and financial need to occlude questions of rural reform and land distribution; that, indeed, was one of its conditions of possibility.42 It is for this reason that descriptive accounts of health, (often, imaginative ones), produced from outside the discourse of technical assistance, expose the jarring silences within it. I have already, in this chapter, cited the words of Phanishvarnath ‘Renu’, a pioneer of modern Hindi literature, whose 1954 novel Maila Anchal provides an insightful commentary on questions of health, of life and death, in rural India at the time. The novel’s protagonist, a young and idealistic doctor, is in many ways the very opposite of a technical consultant; he longs for absorption into the village community, for an erasure of his status as an outsider and an expert. The doctor was a government official, an outsider. He wasn’t really part of the village … It was the doctor’s own fault. Right from the start he had kept aloof from the villagers. His relations had been only with the patients and their diseases. He had never made an effort to mingle in village life. But lately, he was starting to enjoy life in the village, and the people there. He loved the village. Why didn’t anybody throw dye at him? He wanted to be drenched in coloured dye and mud and cow dung!43 Yet the doctor nevertheless participated in the global flow of ideas and information about public health, by using DDT, and by publishing his work in medical journals circulating in India and beyond. The narrator situates the doctor’s aspirations within the utopian vision of a world without disease: ‘[The doctor] wanted to serve mankind, to find the causes of diseases that destroyed human life, to invent a new medicine that would wipe out bacteria, and leave all of mankind healthy and strong. … His name would be mentioned in medical colleges all over the world’.44 Ultimately, the fictional doctor finds his vision shattered by the realities of rural poverty. In a climactic passage of despair, the doctor finds himself confronted with failure: The doctor was awed by the poverty and helplessness of these folk. What great acceptance must sustain them! … What good did it do

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for those who felt pity for them to make up long lists of vitamins and distribute them? … People who came here trying to alert the villagers to the dangers of malaria by showing slides and writing preventive procedures on wall posters with pictures of mosquitoes might as well be from another planet! …It was considered a luxury to use even bitter-smelling oils to repel mosquitoes; getting people to use DDT or mosquito nets was out of the question. … It must be the life-giving black soil of the fields that keep the people alive. Moist and fertile, overflowing with crops … wasn’t this earth their mother? But soon, they might lose the right even to set foot on the soil! Before laws could even be enacted, men were busy devising ways to by-pass them. … A man with no land was no man at all; he was but a beast!45 On this view, the most advanced medical technologies would be unable to confront the deeply entrenched inequalities of the village community, and thus the fundamental conditions shaping the life chances (and life expectancies) of its inhabitants.46 Like Dr Loven’s recognition of political violence and forced migration as a factor in the spread of tuberculosis in Burma, the problem of rural poverty and landlessness did, at the margins, enter the discourse of international public health. At the World Health Assembly of 1954, Andrija Stampar once again raised the issue of rural public health. ‘I hope’, he declared, that ‘we may resume the studies [on rural public health] which were initiated and organized by the Health Organization of the League of Nations some twenty years ago, although a considerable period has elapsed since the problems of rural health were on the agenda’. Despite all the technological advances of the past few years, he suggested, ‘if the world is considered as a whole’, the question of rural public health ‘has lost nothing of its acuteness’.47 Yet, as Socrates Litsios has recently pointed out, Stampar’s report coincided almost exactly with the decision to launch the global malaria eradication campaign, to which questions of rural poverty and even rural health services were considered irrelevant.48 It would thus be a mistake to suggest too categorically that the discourse of technical assistance was closed to considerations of rural poverty. As I suggested earlier, the boundaries of ‘technical assistance’ were permeable, though it was nevertheless governed by a set of regularities (structured by the end of economic growth, liable to discount non-’technical’ solutions to the problems it generated). On one level, national and international networks of technical assistance retained an

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interest in sponsoring (if not appropriating) much more local approaches to the problems of public health, rooted in the perspectives of the 1930s and informed by the enthusiasms of the rural reconstruction movement. The Government of India’s Community Development Programmes were the quintessential example of this attempt, in the 1950s, to re-activate the approaches to rural public health of the 1930s. Modelled, at least rhetorically, on Gandhi’s constructive programme, Community Development sought to foster development by relying on the agency of the self-governing village community, channelled through the institution of the panchayat. The Community Development Programme stressed the principles of cooperation and ‘self-help’, and at one level recognized the ‘social obstacles’ in the way of agricultural development: unequal land holdings, the unavailability of credit to poor families.49 The Community Development Project was initially financed by American assistance, and met with approval for its emphasis on class conciliation and for its gradualism. A UN mission to investigate community development in South and Southeast Asia appeared to encourage the incorporation of the broader social, even moral, emphasis of community development into the UN’s own ‘technical assistance’. Yet on this view, ‘culture’ is merely one more factor to be added to the list of constraints and conditions amenable to technical transformation: Religion, folklore, customs, patterns of human relations and all those factors affecting attitudes which we describe as culture, clearly have a bearing on the success of community programmes. We have already referred in passing to certain of them as causing resistance to change or obstacles to improvement. … 50 Nevertheless, the UN consultants (one of whom was John B. Grant, the Rockefeller official who had pioneered social medicine across Asia) praised the likes of the Firka Development Scheme in Madras, a selfconsciously Gandhian project in rural reconstruction. The health activities of the scheme were modelled on Gandhi’s enthusiasm for nutrition and sanitary reform: it ‘emphasized balanced diet, supply of clean drinking water, promotion of preventive measures as well as curative measures of ordinary ailments by “natural methods and simple remedies with suitable village herbs and drugs”’.51 To allow the final statement (on indigenous remedies) to pass without commenting on the need for medicine to proceed on ‘scientific’ lines was most unusual for the language of technical assistance. At many points

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during their inspection of community projects in India, Ceylon and the Philippines, the commission did acknowledge that ‘land reform is an imperative need in such countries and that community projects are well suited to implementing certain important requirements for land reform.’52 Needless to say, these remained but pious aspirations. If the community development approach to agrarian poverty (and rural public health) provided an alternative, in the 1950s, to the technocentric internationalist approach, it had many problems of its own. Francine Frankel, in her unsurpassed study of India’s development apparatus in the 1950s concluded, of the community development programmes, that: The dominant landed castes were successful in manipulating the majority of subsistence cultivators and landless workers fragmented by vertical factional structures to capture the village institutions. They increased their access to scarce development resources and strengthened their position as strategic intermediaries, linking local markets and power structures to the state and national economic and political systems.53 Confirmation of this position comes from a somewhat unlikely source, in the studies undertaken by the Visva Bharati society, the rural uplift organization founded by Rabindranath Tagore. Deeply committed to the establishment of health cooperatives in rural Bengal, the society might be the last to despair of the potential for such local solutions to the problems of health, but it nevertheless concluded that not much could be done by the local health cooperatives in the absence of the ‘general economic development of the country’. The entitlements of local farmers to the conditions for good health, ‘is largely determined by economic factors over which they have hardly any direct control’. The authors of the Visva Bharati report concluded that ‘the national interest would be served better by paying more attention to vulnerable groups’ – such as the ‘untouchable’ Bayen villagers whose landlessness was so acute as to preclude the opportunity to grow (and thus consume) the fresh vegetables so essential to health.54 Throughout South and Southeast Asia, contemporary sources point to the deeply entrenched inequalities in rural society, which continued to work against the effectiveness of locally based approaches to public health, while also inhibiting the smooth operation of mass campaigns of disease control.55 If local conditions shaped, constrained and diverted global intentions, so too did forces operating at the national

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and international levels shape the conditions of possibility for local agency in the production of health and illness. Only in a few cases do we see evidence of an alternative approach to public health asserting itself in South Asia, an approach at odds with the depoliticization inherent in the international campaigns against infectious disease. Kerala presents a history quite different from that of much of South Asia; one in which the ‘universal’ campaigns of disease control and eradication were matched by a sustained, and deeply politicized, effort to build up local institutions.56 Health, in mid-twentieth century Kerala, was championed as a ‘people’s right’, in a way almost without parallel in the region.57 The declaration that health was a ‘fundamental right’, institutionalized with the foundation of the WHO after the Second World War, took on ethical force and political meaning in Kerala, where a political culture of social reform had taken root in the nineteenth century, particularly in the princely states of Travancore and Cochin.58 The mobilization of a well-organized communist movement, first within and later outside the Congress Party, led to a level of political competition unusual in post-colonial India. This led, particularly around the time of the (short-lived) Communist victory in the 1957 elections, to a heightened awareness among the poor that ‘health services were their right and not a boon conferred upon them’.59 In the words of one observer, ‘In Kerala, if a Primary Health Centre were unmanned for a few days, there would be a massive demonstration at the nearest collectorate led by local leftists, who would demand to be given what they knew they were entitled to’.60 Doctors working in primary health care centres in Kerala at the time recall numerous instances when the very poorest would make extensive use of dispensaries, demanding ‘soochi’ (injections) or ‘micchar’ (‘mixture’, or medicine), and expecting a medical presence at all deliveries.61 The specific configuration of political society in mid-twentieth century Kerala served to turn national and international promises of health and welfare into claims of entitlement. The contrast even with the (relatively progressive) neighbouring states of Tamil Nadu and Karnataka was stark.62 Local politics, including the politics of unequal social relations, had an impact on the mass campaigns of technical assistance; to the planners, they appeared as so many ‘obstacles’ in their way. The process of depoliticization, however, was never complete. Yet I have also tried to suggest here that it would be a mistake to juxtapose the techno-centric international campaigns of disease control against an idealized, even

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mythical notion of ‘local’ agency in public health. When they did succeed in surmounting the ‘obstacles’ in their path, the international health campaigns were often better able to reach the poorest and most disadvantaged than were haphazard, if fashionable, schemes of ‘community development’.

Rationality and resistance I have focused thus far in this chapter on the practical obstacles confronting technical assistance, and on the enduring role of poverty and social inequality in shaping the conditions of health, even in the age of technological ‘magic bullets’. However, there was also an underlying, epistemological problem: a problem of understanding. From the start, the mass campaigns tried to avoid contact with local populations to the greatest extent possible. This suggests that the proponents of disease eradication doubted their own abilities to make a convincing case for their work in terms that large numbers of people would understand. The proponents of international health took for granted many of the assumptions of modernization theory, as much as did economists, demographers and sociologists. Planners of health, too, held to a narrative that linked poverty and under-development with pre-rational, superstitious modes of thought – the transition to rationality would accompany the process of urbanization, industrialization and the diffusion of education.63 However, in order to persuade less-than-fully-rational people to accept vaccination or house sprayings in the first place, the results of health work had to be tangible. The proponents of technical assistance conceived of the problem in terms of a gap between faith and reason, and their challenge was to make their work as visible (and thus as able to stimulate belief) as possible. Everywhere, the language used to describe popular receptions of international health work was the language of faith and belief. ‘The Indonesians love injections’, wrote one WHO consultant, deliberately using the language of trusting emotion and suggesting childlike enthusiasm, ‘and are quite willing to file up for hours in order to get one’.64 The documentary archive of technical assistance makes repeated reference to the ‘miraculous’ transformations that result from the mass campaigns. Indeed, Charles Winslow expressed this view clearly even in 1952: ‘From the standpoint of community psychology’, he declared, it was important to focus on those interventions that ‘make it possible to obtain dramatic and immediate results’.65 The WHO planners were not very different, in

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this sense, to the British colonial administrators who explained the widespread acceptance of anti-syphilis drugs in Nyasaland and Zambia with reference to Africans’ ‘belief in magic’.66 The problem came when the results were neither dramatic nor immediate, as was the case with BCG vaccination against tuberculosis. In the case of yaws, ‘when the skin ulcers … disappear after on injection of penicillin, people are easily persuaded’. However it was ‘more difficult to convince superstitious and illiterate people that a small injection in a child’s arm will prevent its suffering from tuberculosis later in life’.67 Paradoxically, the perceived problem here is that the ‘superstitious and illiterate’ people do not believe enough; their blind faith fails them at the crucial moment, the moment of vaccination. As long as they simply used the practices of biomedicine without ‘believing’ in it, there was the prospect that they might not accept something, unseen, which might benefit them in later life.68 For all of the pretensions to confine technical assistance to technical questions, the concern with belief, with converting large numbers of people to new and modern ways of seeing, was never eclipsed. The debate over faith and rationality could, of course, afford a different interpretation. For Pramoedya Ananta Toer, pioneer of modern Indonesian literature, the advance of mass campaigns for the treatment of yaws into the Javanese countryside in the late-colonial and early post-independence era was a form of liberation from a childhood ‘enslavement by fear, ignorance and illness’. Writing to his daughter many years later, Pramoedya used the yaws campaign as a demonstration that ‘knowledge and science, which depended not on mantra or intrigue, but on proven fact, could not be held back forever, and gradually came to be accepted by the public body.’69 On this view, the ‘public body’ embraced the yaws eradication campaigns because penicillin worked. The WHO was less willing, perhaps less able, to consider the possibility that different reactions to different kinds of interventions lay not in the degree to which they could overcome superstition, but to the very different experiences their ‘targets’ might have of them: yaws virtually disappeared after the 1950s, tuberculosis most certainly did not. The problem, perhaps, lay less in any disjunction between superstition and rationality than in the problem of translating the WHO’s notion of ‘health’. The problem, Rene Dubos suggested a few years later, was that ‘health’ as the WHO conceived of it, ‘is a disembodied concept’. Unlike disease and illness, talk of health ‘stimulates no emotional response and inspires only dull official speeches and allegorical

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paintings, which do not touch the heart because they are only an inhuman and fleshless abstraction’.70 The language of international health was not a quotidian language that appealed to ‘common sense’ ideas about health.71 Indeed, pain was almost wholly absent from the conceptual world of technical assistance. There was no room, in the language of ‘output’, ‘targets’ for these uncertainties of the body. The ‘closed’ language of technical assistance was unable to accommodate pain or suffering, and it was particularly unsuited to recognizing that the technical assistance itself could be a source of pain and suffering: ‘adverse reactions’ from vaccinations, ‘side effects’ from drug treatments, were hardly recorded, let alone acknowledged.72 Yet these silences in the documentary archive of technical assistance were dependent on international health workers’ own conceptions (or misconceptions) of local attitudes to pain. Thus one doctor explained the lack of overt resistance to BCG despite ‘complications’ following vaccination by arguing that ‘people in Indonesia do not go to the doctor easily and … they obviously felt that the little we had produced in the way of ulcers or abscesses were not worth mentioning’.73 When opposition to BCG vaccination became a political issue in India in 1955–56 (as will be discussed), the socialist Hari Vishnu Kamath stood up in the Indian parliament and complained that the mass vaccination campaign was ‘absolutely callous. There was no disinfection, or sterilization, there was no precaution taken against contamination’.74 People continued to suffer pain, even as mobile teams moved through the land with spray cans of DDT, and vials of freeze-dried vaccine.75 To believe that medical technology would prevail over the diseases of poverty, the ‘tropical’ diseases, required a good deal of faith, as international health planners themselves admitted in unguarded moments. The use of BCG vaccination against tuberculosis was particularly controversial, with many doctors in Britain continuing to dispute its efficacy into the 1950s. ‘BCG vaccination’, wrote Karen Hansen from Ceylon, ‘has been taken on faith’. She then repeated this, for emphasis and effect: ‘it has been taken on faith’.76

‘A form of quackery’ It was by combining an intimately familiar language of pain with the language of technical assistance that C. Rajagopalachari, the veteran south Indian nationalist, mounted one of the most public critiques of an international health campaign. In a widely circulated pamphlet entitled BCG Vaccination: Why I Oppose It, Rajagopalachari attacked the international

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BCG campaign: ‘this … mass campaign lacks true scientific basis and is no more than a form of quackery’.77 Rajagopalachari’s pamphlet contain extracts from letters which he had been sent from across Madras State, and beyond, detailing episodes in which BCG vaccination had apparently proved harmful.78 These are stories of pain and loss. Six year old Vasantha, from Coimbatore, ‘lost her eyesight’, her father wrote, when ‘without my consent the authorities vaccinated my child in the school’. The children of a C.J. Sundararajan ‘developed boils all over the body three days after the BCG vaccination’, he wrote, ‘for three months they suffered terribly’. The young daughter of a M.S. Fakir, a beedi worker in Majid Mark Factory, Coimbatore had her ‘eyesight affected’ by BCG and was in deteriorating health. To take just one more example, of several, a Michael Anthony, of Poona, wrote Rajagopalachari a ‘doleful angry letter … about the foreign “World Health Experts” in whose presence he was vaccinated’, after which he developed a serious illness which cost him his job.79 These accounts of illness and suffering are a long way from the ‘disembodied’ stories which, Warwick Anderson has rightly pointed out, characterizes most histories of international health.80 Exploiting the silence within the discourse of technical assistance on the question of pain, Rajagopalachari was able to challenge its claims to truth. In so doing, Rajagopalachari used the language of the body alongside an explicitly ‘scientific’ critique of the international health campaign, a critique that used the language of technical assistance itself.81 This was tied to a more general critique of the post-colonial state in India, its intrusiveness and its reliance on ‘big’ science.82 He objected particularly strongly to the ‘propaganda’ employed by the WHO-led international campaign in India. In the eyes of international health workers, propaganda was necessary to dispel the fears of the native population; in Rajagopalachari’s view, it was the propaganda itself that was at the root of fear: One of the worst incidents of a mass campaign is the ceaseless effort by men whose words carry weight, to rouse a dread of the disease in the vast majority of people. Fear considerably reduces the power of resistance among those who have hitherto coped with dormant infection. Another general consequence of the campaign is the neglect of other measures such as would go-far [sic.] towards real control of tuberculosis.83 This was to suggest, then, that the language of fear and emergency employed by the international agencies not only made the inconclusive benefits of BCG appear unquestionable, it also closed off other,

The Techno-politics of Public Health 139

longer-term, policy alternatives. Countless posters and publications by the international agencies showed that ‘so many lakhs of children have been immunized this year against Tuberculosis [etc.]’, when ‘any one who remembers the nature of the very limited claims put forward on behalf of BCG vaccination can discover that the public propaganda in this respect is misleading’. The international health campaigns made extensive use of statistics to show the benefits of their work; Rajagopalachari claimed that these were ‘not real statistics but only inferentially deduced conclusions’. Indeed, Rajagopalachari went yet further, and claimed that the international campaigns were removed from the principles of modern science. Scientists and experts were bound to disagree, Rajagopalachari suggested, but policy decisions ought not to be in their hands alone ‘when on the basis of a theory, men’s persons are touched for good or evil’.84 Here Rajagopalachari mobilized a much older discourse of anti-vaccination, with a long history in India and in Europe alike. By claiming that public health interventions like BCG vaccination were simply a form of ‘technical assistance’, the architects of the international health campaigns tried to exclude the questions that had long surrounded vaccination qua vaccination. Rajagopalachari brought back the fundamental concern about ‘touching the person’ that lay at the root of a very different discourse of health and healing.85 International public health had staked out for itself a field of authority distinct from that of clinical medicine; though the claims of biomedicine to authoritative knowledge were essential to the legitimacy of the international health agencies, they were, at the same time, sceptical of the applicability of ‘advanced’ medicine in ‘under-developed’ countries.86 Rajagopalachari, however, drew on medical authority to challenge the planners of the international BCG campaign.87 Citing evidence from diverse medical literature questioning the efficacy of BCG, Rajagopalachari decried the fact that ‘Indian children are being offered for mass experimentation on the same plan as was put in operation among the people in the war-ravaged areas and uncivilized dependent communities’. This striking turn of phrase immediately draws a distinction between what is suitable for citizens of sovereign states and subjects in ‘dependent communities’. The logic of planning and technical assistance suggested that medicine was unaffordable to the poor of the formerly colonized parts of the world, and that a cheap set of public health technologies would bring a greater amount of welfare to a greater number. Rajagopalachari, by contrast, draws a direct link between political self-government and citizens’ sovereignty over their bodies (their right, so to speak, not to

140 Decolonizing International Health

be ‘experimented’ upon). Rajagopalachari’s argument is not, however, that all medicine is colonial with respect to the body, or that biomedicine is colonial by virtue of its ‘western’ provenance. The heart of Rajagopalachari’s critique is that India’s former position of subordination under British rule had established a double standard in the postcolonial period: wealthy nations would have advanced medicine, the ‘underdeveloped’ would have cost-effective magic bullets. At the same time, Rajagopalachari addressed his critique of technical to a different constituency than that usually addressed by planning documents and pamphlets: Rajagopalachari’s ‘Asia’ was not the Asia of bureaucrats and development planners constructed by the new international organizations, but a Tamil-speaking Asia, stretching from southern India to Ceylon and beyond. For a time, Rajagopalachari’s critique caused some concern to the authorities. In Madras State, the numbers of people accepting vaccination dropped suddenly. The impact of Rajagopalachari’s statements emerges quietly in the official record, in a short paragraph in the Madras state government’s annual report for 1955. The state ministry of health noted that: When the mass campaign was started in November 1954, the response was excellent and the scheme was a great success. Unfortunately in May 1955, anti-propadanda started in this State seriously and affected the smooth working of the campaign from June 1955. Vigorous efforts have, however, been taken by Government for countering the propaganda and the set back created is being slowly overcome and the position is gradually improving. It is hoped that the fears created in the minds of the public will soon die out and that the campaign will go on in full swing.88 The most that is said is that Rajagopalachari’s ‘anti-propaganda’ interfered with the ‘smooth running’ of the campaign. With both Rajagopalachari and the Madras Government/WHO talking the language of ‘fears’, it is likely that many people would have thought it advisable to steer clear of BCG vaccination stations. Perhaps the clearest sense we have of this ‘resistance’ to an international health campaign lies in a reconstruction of the course of the campaign in 1955. By any standards, June 1955 marks a dramatic falling off of the vaccination campaign: within a few days, the campaign went from testing between 40 and 90 per cent of each population to less than 5 per cent (see Table 5.1).89 The total numbers of vaccinations delivered in each

The Techno-politics of Public Health 141 Table 5.1 WHO/Indian Government BCG Vaccination Campaign in Madras State, 1954–55 Place

Period

Population Total tested

Coimbatore (urban)

15 to 20 Nov, 1954

197,755 210,814

Coimbatore (rural)

29 Nov to 25 Dec, 1954

Kozhikode (urban)

Percentage of population tested

Percentage positive

Total vaccinated

107

60

73,215

300,000 230,077

76

50

95,328

3 to 15 Jan 1955

158,724 107,214

67

73

25,556

Kozhikode (rural)

24 to 29 Jan 1955

118,820

54,583

45

56

22,195

Mangalore (urban)

7 to 12 Feb 1955

117,083

95,781

82

69

26,757

Mangalore (rural)

14 to 19 Feb 1955

49,000

36,499

74

58

13,238

Udipi (urban)

15 to 19 Feb 1955

21,254

21,474

101

58

8,191

Udipi (rural)

21 to 25 Feb 1955

42,500

31,089

73

53

12,883

Kalikavu, South Malabar

22 to 27 Feb 1955

50,000

38,989

78

55

15,046

Salem (urban)

28 Feb to 5 Mar 1955

202,335 179,463

89

60

60,751

Salem (rural)

14 to 26 Mar 1955

50

26,869

Cochin (urban)

28 Mar to 2 Apr 1955

67,395 29,881

20,011

67

76

4,215

Ootacamund 4 to 9 Apr (urban) 1955

41,370

37,428

90

45

17,958

Coonoor (urban)

18 to 22 Apr 1955

23,902

22,346

93

46

10,021

Nilgiris (rural)

Do.

51

29,378

Tiruchirappalli (urban)

18 to 30 Apr 1955

218,921 108,304

47

70

28,130

Tiruchirapalli (rural)

16 to 26 May 1955

150,000

57,246

38

61

17,488

Tanjore (urban)

28 May to 3 Jun 1955

100,000

31,507

32

64

6,087

69,062

142 Decolonizing International Health Table 5.1 WHO/Indian Government BCG Vaccination Campaign in Madras State, 1954–55 – continued Place

Period

Population Total tested

Tanjore (rural)

7 to 12 Jun 1955

75,000

5,885

Madurai (urban)

27 Jun to 15 Jul 1955

361,781

35,784

Madurai (rural)

18 to 22 Jul ‘55

Tirunelveli (urban)

8 to 22 Aug 1955

73,470

417

Palayamkottai (urban)

Do.

40,010

Melapalayam (urban)

–

Tirunelveli (rural)

16 to 26 Aug 1955

Vinudhunagar (urban)

Percentage of population tested

Percentage positive

Total vaccinated

8

53

1,796

10

66

7,783

60

1,575