Tuberculosis, the state and international intervention in India, 1914–82
By Niels Brimnes
A study of tuberculosis control in India in a short 20th century is more than just a study in disease control. The nature of TB – ever-present but hardly visible, ‘chronic’ but infectious, and intimately connected to issues of poverty – makes it particularly suitable for analyses of the shifting features of the state and of the nature and impact of international health interventions during India’s transition. As the country moved from being ruled by colonial authorities with limited capacity and will to intervene against disease to a post-colonial state with a modernist ideology and ambitions to develop through state regulation and intervention, TB control strategies changed profoundly. This study also offers an excellent perspective on major social and political developments in modern India.
Although probably prevalent in India for centuries, TB was not discovered as a major health problem in India until the 20th century. In 1909 the Director of the Indian Medical Service, Sir Pardey Lukis, noted that it was spreading at an “alarming rate in all the larger cities of India”, and he suggested that the causes of the disease be investigated and arrangements made both for its prevention and treatment. Similarly the 1914 All-India Sanitary Conference, held in Lucknow, passed a resolution recording that TB demanded “serious attention and special methods for dealing with it”. In the following decades TB continued to command attention. In 1930 the public health commissioner declared: “There is little doubt that the population of the large towns, and especially of the larger industrial urban areas are very severely infected.” Three years later the Commissioner identified TB as “certainly one of the of the main health problems in India, ranking next to malaria in this respect. In fact, it may be regarded as an epidemic disease.”
The authoritative report of the Bhore Committee – established in 1943 to lay out the guidelines for a future health service in India – noted that there were 2.5 million cases of TB in India and that the disease caused 500 000 deaths every year. By mid-century, it was recognised that only malaria claimed more deaths. The control strategy advocated by the Committee in many ways summarised the way colonial authorities had approached the disease. Recognising that a strategy based on expensive sanatoria or hospitalisation was not feasible in India, it placed “an organised domiciliary service” centred on approximately 200 TB clinics in the forefront of its proposed control programme. Supplemented by educational efforts, limited care and supervision was all colonial India could offer.
Shortly after independence, the context of TB control changed dramatically. Within a relatively short period of time the Indian health authorities obtained what had been denied to their colonial predecessors: two specific biomedical remedies against the disease. These potential ‘magic bullets’ were BCG vaccination and domiciliary chemotherapy. BCG vaccination was introduced in 1948 by the International Tuberculosis Campaign, a Scandinavian vaccination initiative, and mass vaccination conducted from 1951 through massive campaigns supported by the WHO and UNICEF. Antibiotic drugs effective against TB were discovered from the 1940s and in the following decades it was established – largely through trials conducted in India with assistance from the British Medical Research Council and the WHO – that these drugs were effective even if administered on a domiciliary basis. These findings made large-scale chemotherapy against TB realistic in India, and they became instrumental in developing the DOTS programme, which today is the centrepiece of WHO efforts to combat the disease worldwide.
In 1959 a National Tuberculosis Institute was established in Bangalore to design an integrated TB control programme. This ran from the early 1960s to the early 1990s, but faced considerable obstacles and difficulties. In the 1990s a new programme – the Revised National Tuberculosis Control Programme – started operating. Although this was more successful than its predecessor, TB remains a major problem in India. According to figures available from the Institute’s website, TB in 2005 caused 330 000 deaths in India. During the swine flu panic in 2009, the magazine Frontline remarked with sobriety that the greatest killer in India was not the new scare, but an old acquaintance: pulmonary TB. In India, TB has indeed been a disease that refused to go away.
Utilising material located in India, Britain, the USA, Switzerland and Scandinavia, this project will seek to answer questions relating to the history of medicine, the state and international organisations. Among other things, it will ask how TB was discovered as a major health problem in India, and how colonial efforts to control the disease developed. It will ask why the ‘magic bullets’ of the immediate post-independence period did not succeed in eliminating the TB problem. It will ask how the state and the state’s ability to intervene in Indian society changed over time, and particularly how and to what extent the post-colonial state constituted a break with its colonial predecessor when it came to the implementation of disease control measures. And it will ask how the relationship between India and international health organisation, mainly the WHO and UNICEF, evolved. Finally, it is my hope that the project will show how the histories of disease control, decolonisation and globalisation in the 20th century are thoroughly intertwined and constitute a challenging, but also highly rewarding, field of investigation.
Dr Niels Brimnes is Associate Professor in Asian History, Institute of History and Area Studies, Aarhus University, Denmark.