Decolonizing International Health - India and Southeast Asia 1930-65 - Amrith (2006)

Decolonizing International
Health
India and Southeast Asia, 1930–65
Sunil S. Amrith
Cambridge Imperial and Post-Colonial Studies Series
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Sunil S. Amrith
DECOLONIZING INTERNATIONAL HEALTH
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
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THE EMPIRE OF THE RAJ
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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
Sunil S. Amrith
© Sunil S. Amrith 2006
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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 2006046405
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15 14 13 12 11 10 09 08 07 06
Printed and bound in Great Britain by
Antony Rowe Ltd, Chippenham and Eastbourne
For My Parents
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Contents
List of Tables and Figures ix
Acknowledgements x
List of Abbreviations xiii
Introduction 1
The problem 4
The argument 11
Chapter 1 Depression and the Internationalization of

Public Health 21
The limits of colonial medicine 22
The internationalization of public health 26
Two visions of rural hygiene 29
Bandung, 1937 36
The ‘modernist’ challenge 42
Conclusion 46
Chapter 2 War and the Rise of Disease Control 47

DDT and disease control 48
Building expertise 50
Planning for the health of the world 56
A new international health organization 63
Conclusion: The ghosts of Bengal 69
Chapter 3 The Political Culture of International Health 72

Health and the United Nations 73
Envisioning Asia’s health 76
Crisis and sovereignty 79
Public health and the Cold War 83
The birth of technical assistance 85
Rights and technologies of health 87
The argument for public health 90
Conclusion 98
vii
viii Contents
Chapter 4 Building A New Utopia 99

Projects and policies 100
Health and nationalism 103
A post-colonial discourse? 106
Journeys to health 108
Seeds of doubt 116
Chapter 5 The Techno-politics of Public Health 121

Human and non-human obstacles 122
Poverty and politics 127
The return of community 130
Rationality and resistance 135
‘A form of quackery’ 137
Conclusion: the ambiguities of success 146
Chapter 6 The Limits of Disease Control 149

Curing tuberculosis in Madras and Bangalore 150
Problems of policy 156
Dangerous journeys 161
The end of eradication 165
Eradication and evolution 170
The triumph of population control 171
Conclusion: dispersion and ‘medical pluralism’ 175
Conclusion 179
The effects of health policy 185
Faith and doubt 187
Enduring utopias 190
Notes 192
Bibliography 231
Index 255
List of Tables and Figures
Tables
3.1 WHO Income, 1949–57 91

5.1 WHO/Indian Government BCG Vaccination Campaign
in Madras State, 1954–55 141
C.1 Infant Mortality Rates, 1945–65 181
Figures
1.1 A Mantri’s House Visit 31

2.1 Singapore is Sprayed with DDT, 1945 54
C.1 Estimates of World Population, 1920–60 181
ix
Acknowledgements
I acknowledge, gratefully, financial support from: The Ellen MacArthur

Fund of the Cambridge Faculty of History; The Cambridge Common-
wealth 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 Interna-
tional 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 acknow-
ledge 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 prac-
titioner 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 gen-
erosity 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 grate-
ful for his kindness over the years. Megan Vaughan has been unfail-
ingly 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 com-
plete 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 All-India Institute of Medical Sciences, Delhi

BCG Bacille Calmette-Guérin
DDT Dichloro-diphenyl-trichloroethane
FAO Food and Agriculture Organization
IESHR Indian Economic and Social History Review
ILO International Labour Organization
INH Isoniazid (anti-tuberculosis drug)
IOR India Office Records, British Library, London
LN League of Nations
LNHO League of Nations Health Organization
NAI National Archives of India, Delhi
NAS National Archives of Singapore
NMML Nehru Memorial Museum and Library, Delhi
NPC National Planning Committee
NTI National Tuberculosis Institute, Bangalore
OR Official Records of the World Health Organization
RAC Rockefeller Archive Centre, Tarrytown, New York
TNA The National Archives of the UK (Public Record Office)
TNSA Tamil Nadu State Archives, Chennai
UN United Nations
UNESCO United Nations Educational, Scientific and Cultural
Organization
UNICEF United Nations Children’s Fund
UNRRA United Nations Relief and Rehabilitation Administration
WHO 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 peas-
antry 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 anti-
biotic 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 govern-
ment 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 anti-
colonial 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 state-
run health services for their populations. In a very short space of time,
to possess a health service had become a universal element of the func-
tions 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 for-
bidding task of extending health services to the excluded and the dis-
possessed. 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 dis-
parate 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 mortal-
ity across the Third World was, in the words of one contemporary
observer, ‘amazing’.2
Yet the onward march of technological medicine was never unchal-
lenged. 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 eradica-
tion faced serious challenges. The problems inherent in the techno-
centric campaigns of the 1950s grew to the extent that malaria
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 increas-
ingly complex manifestations of international organization, both inter-
governmental 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 ques-
tions 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 espe-
cially well to international cooperation, and the field of medicine pro-
vides an early and conspicuous example of this exchange. The formal
internationalization of medicine can be traced back to professionaliza-
tion, 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 dra-
matic 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 con-
ferences were convened, between 1851 and 1903, to coordinate inter-
national information and policies on quarantine regulations and the
containment of outbreaks of disease. The conferences proceeded halt-
ingly, 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 interna-
tionalism had progressed, the Italian memorandum expressed particu-
lar 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 con-
vention 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 charac-
teristic 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 interna-
tional agreements that ‘embrace almost the entire universe’. The found-
ing 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
thought of the First World War. The United States government, how-
ever, 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 cate-
gories 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 divi-

sion played a role in war relief during the First World War, and pro-
ceeded 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 fruit-
ful, 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 aus-
pices 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 inter-
national 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 internationaliza-
tion is one of diffusion, with international organizations and trans-
national 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 medi-
cine. This literature is founded upon a much more sceptical view of
‘science’ than that taken by the historians of internationalization.23
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 vio-
lence 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 nine-
teenth centuries. The dramatic improvement in the health of Euro-
peans 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 lit-
erature, 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 prac-
tices in India played an important role in the increasing regulation of
colonial subjects by an expanding state.27 Medical discourse demon-
strated the ‘superiority of Western science over the “inertia” and “prej-
udice” 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 elabo-
rated 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 implica-
tions 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 conver-
sion no longer dependent on conversion to Christianity; the language
of mission was secularized and turned towards the question of mater-
nal 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 govern-

mentalization of colonial states through a process of appropriation and
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 deve-
loped 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 aspira-
tion 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 cir-
culating 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 (follow-
ing acceptable and legitimate policies of disease control). Does this rep-
resent 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 exer-
cise 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, con-
sequently, of international organizations) to transform or even to under-
stand 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 organiza-
tions, 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 inte-
grated 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, irre-
ducibly, 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 periph-
ery does not capture the complexity of the ways in which ideas about
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 know-
ledge 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 organiza-
tions 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 dis-
course 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 tech-
nologies 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 imagina-
tion 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 techno-
logies, 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 war-
ravaged 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 institu-
tional 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
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 cement-
ing of Asia into nation-states, transnational (as opposed to inter-
governmental or international) linkages remained important in struc-
turing 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 jour-
neys 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 rela-
tively 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 coun-
tries 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 deve-
lopment 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 cen-
trality 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 iso-
lation.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 fun-
damental 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.
The very limitations of the earlier colonial attempts at transforma-

tion 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 bed-
rooms 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 organiza-
tions. 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 pro-
vided a way out of this dilemma; their use seemed not to require con-
version 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 gov-
ernmental 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 inter-
national 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 mono-
lithic. 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 locally-
trained 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 prophy-
laxis of the anti-tuberculosis BCG vaccine, when tuberculosis con-
tinued 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).
The boundaries of medicine

The third theme running through the narrative concerns the bound-
aries 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 tech-
niques 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 refer-
ence to the authority of political economy, or ‘development econom-
ics’ 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 great-
est 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 medi-
cine’ included a diverse body of thought, but its currents were united,
Patrick Zylberman suggests, by their ‘sharp criticism of a clinical, tech-
nical, 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 nar-
rowly 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 interna-
tional 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 inter-
national public health. We can see in the field of health the broader
process which Sudipta Kaviraj describes, of a growing gulf between ver-
nacular 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 search-
ing 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 international-
ization 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
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 some-
times 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 dis-

course 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 colo-
nial 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 vita-
mins 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 depres-
sion. 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
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 import-

ance of medical discourse in establishing colonial authority. By claim-
ing access to a unique truth about the human body, colonial medicine
often led to a devaluation of indigenous knowledge, and the authoriza-
tion 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 part-
icularly 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 inade-
quacy 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 techno-
logy 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 contra-

diction 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
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 some-
thing 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 lethal-
ity of infectious diseases after a generation of particularly intensive
exposure.8 Sumit Guha, too, suggests that neither nutritional improve-
ment 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 alter-
nately 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
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 prac-
tices.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 epidem-
iology 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 dev-
elopments, 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
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 tech-
niques, 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
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 rela-
tionship 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 ques-
tions.26 In September 1932, the League expressed this growing concern
in a report on ‘The Economic Depression and Public Health’. The report
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. Develop-
ments 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 crea-
tures 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 interna-
tional 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 natio-
nalist 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 repres-
sion. 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
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 orga-
nizations: 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 ser-
vices. The Surgeon-General of Madras Presidency, Major-General
Sprawson, wrote to Delhi that ‘during the last year the world depres-
sion 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 shoe-
string, public health was nothing less than an alternative to commu-
nism. A manifestation of ‘biopolitics’, rural hygiene put the welfare of
the rural population, the quality of the race, ahead of economic accu-
mulation.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 Founda-
tion 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
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 social-
ism. Hydrick’s aims for rural hygiene were nothing less than the
internalization by Javanese villagers of new bodily practices and dis-
positions; 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 perma-
nent 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 pen-
etrate 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 expen-
sive’. 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
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
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 par-
ticular 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 juxta-
position of Hydrick’s utopia with another micro-site of hygienic trans-
formation: 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 pre-
eminent 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 nutri-
tive 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 transforma-
tion 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
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 ‘un-
Gandhian’ 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 Asso-
ciation.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 universal-
ity – 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.
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 colo-
nial 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 nutri-
tion 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 correspon-
dent, 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 prepon-
derance 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 ‘pro-
tective 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
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 inter-
ventions in setting the international agenda. It also suggests that ‘colo-
nial 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 explana-
tion 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 individ-
uals or less, which so impressed our correspondents’. These mills oper-
ated 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 acceler-
ated 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 mech-
anizations 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
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 accom-
modation’ 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 nega-
tive 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 colo-
nial 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 consump-
tion 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 con-
certed 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;
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 per-
spective 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
should occur simultaneously in all the countries concerned and that

it should be so recent and so comparatively sudden. But it is indis-
putable 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 con-
ference was attended by representatives from each of the British territo-
ries 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 exam-
ples 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 refer-
ence, here, to the widespread resistance to vaccination witnessed in the
early years of colonial rule. ‘The sanitary inspector, the anti-mosquito
squad, and lastly, the medical officers of health’ followed the vaccina-
tor. 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 con-
nection, 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 thor-
ough 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 ‘con-
serve … 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
approach to the problem of malaria in Eastern Europe.72 The 1937 con-

ference’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 encap-
sulates 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 facil-
itated 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 nutri-
tion 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
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 initia-
tives carried out by elite reformers. Through the missionary fervour of
the societies, one admiring British official declared, ‘the illiterate, sus-
picious 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 ser-
vices.79 Reflecting the influence of rural hygiene and nutritional think-
ing 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 cul-
tural and political difficulties involved in trying to effect any change’.81
The missionaries of rural hygiene put their faith in a wholesale trans-
formation of rural society and economy; however, colonial administra-
tors were in search of a quicker, cheaper solution. In the words of a
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 pro-
hibitive 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 colo-
nial state running on a tight budget. Instead, British colonial author-
ities 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 prov-
ision 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 prosper-
ity and well-being of tropical countries than an effective attack upon
the disease.’86
The underlying question was one which would emerge and re-
emerge over the decades to come, and which later chapters will con-
tinue 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 manufac-
ture 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-
sive exploitation of the countryside. The apparent crisis of global cap-

italism, 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 ques-
tions 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 agricul-
ture, 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 national-
ist movement might have lacked anything resembling the concerted
commitment to planning on the part of some Indian nationalists,
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 national-
ism 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 move-
ment. 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 nutri-
tional 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 pro-
duction, 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 trans-
formation 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;
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 gov-

ernment (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 sani-
tation 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 develop-
ment. The NPC’s epistemology of planning brought the hygienic/
nutritional nexus of diet studies, pilot schemes and rural reconstruc-
tion 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 ambi-
tious 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
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 – tech-

niques, 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 eco-
nomic 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 inter-
national debates on hygiene and nutrition. Equally, the League of
Nations’ embrace of nutritional and social medical concerns lent
legitimacy – through reports, declarations, statistics and investiga-
tions – 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 indus-
trialization. The story of the 1930s was one of internationally circulat-
ing 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 aspi-
rations, often on the fringes of the state. The proponents of rural recon-
struction 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 sup-
plant 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 ‘incorpora-
tion’ 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
capacities of states to provide the conditions of health? What underlies

the shift from an international public health composed of loose net-
works 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 medi-

cine. 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 organiza-
tion, the war saw significant developments.2 Above all, the experience
of the war held out the prospect of a world free from disease. The sym-
bolic 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 pio-
neered 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 eradica-
tion 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
War and the Rise of Disease Control 49
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 plas-
modium 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 author-
ities 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 opera-
tions 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 condi-
tions’.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 syn-
thetic 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 com-
pletely replaced the ‘anti-larval measures, which had hitherto formed
the backbone of the entire malaria control scheme’.16 This transforma-
tion ‘could be effected all the more readily, because control through
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 spray-
ing. 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 introduc-
tion 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-
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’
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 malar-
iologists, highlight this process of mobilizing existing technical know-
ledge 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 inten-
sive local experiments on mosquitoes over the course of 1943 and 1944;
it was ‘a most thrilling period in our technical pursuits’. These ‘exper-
iments’, however, ‘were attended with poor results’; indeed, ‘in one
village there was a greatly enhanced prevalence of malaria after a pro-
gramme 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 mos-
quito breeding stopped in those locales, only to flourish in the terraced
rice fields. Trials of new synthetic anti-malarials ‘were none too success-
ful, for the sole reason that we could not get the public to take a sus-
tained 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
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 popula-
tion if we did not have the benefit of worship at the altar of science,
of patient investigations into the habits of the mosquito, careful rea-
soning 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 imple-
ment 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 malar-
ious 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 con-
spicuously 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
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 techno-
logy, 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
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 supplementa-
tion 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 reconstruc-
tion 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 cam-
paigns 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 Demo-
cratic 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 rehab-
ilitation programme must aim toward the maximum of health secu-
rity.’ 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
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 avail-
ability 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 vels-
icol 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 pro-
vided 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,
reports emerged planning for a future of expanded welfare provision,

in which public health would play an important role.49 This ‘universal-
ization’ of the welfare state was a process that was strengthened by the
institutionalization of these new ideas about welfare at an interna-
tional 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 Com-
mittee in early 1944, under the chairmanship of Sir Joseph Bhore. On
the surface, the Bhore Committee – as it was known – exhibited a some-
what 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
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 Organ-
ization. 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 com-
mittee 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 self-
consciously 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 corre-
spondence 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 friend-
ship 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 differ-
ent parts of the country’.56 Ghosh, the daughter of a former Justice of
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 co-
operatives, 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 Gov-
ernment of India to join the tour of international experts studying
India’s health problems and advising the Health Survey and Dev-
elopment Committee. Noting that his fellow international experts
included John Ryle, Sigerist concluded that ‘I think the choice is inter-
esting. It shows that liberal forces are involved’.62 In Sigerist’s mind,
this was a symptom of the flourishing of progressive and radical think-
ing 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
the 1930s in China. During the war, Grant headed the All-India
Institute of Hygiene and Public Health in Calcutta. Despite his exten-
sive experience in public health in poor rural areas, Grant later told an
audience in New York, ‘India shocked me’. ‘I knew the Asiatic coun-
tries, 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, suggest-
ing 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
ignorance, disseminates infection by indiscriminate spitting or cough-

ing’, 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 ‘contra-
ceptive 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 pro-
ceeded 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 pre-
valent 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 sug-
gested the need for a completely different approach to health in poor
agricultural (and, of course, colonial) countries to those of advanced
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 pro-
tection’.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 commercializa-
tion in agriculture, the Bhore Committee tied their plans for health
closely to the legitimating language of planned development. The com-
mittee’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 dysen-
teries, 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 pri-

ority 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 concep-

tion of public health centred on hospitals – it was on their recommenda-
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 recom-
mendations 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 vital-
ity 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 Com-
mittee 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 tradi-
tions, 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.
The war witnessed an upsurge in the production of pamphlet litera-

ture on health conditions around the world: awareness increased of the
interconnected nature of health problems.80 The increasingly interna-
tional 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 ter-
rible’ 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 organiza-
tions of the inter-war years, the League of Nations’ Health Organ-
ization 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 inter-
national 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-
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 ser-
vices 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 sick-
ness 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 rela-
tion between proper food and health was one of the basic ideas under-
lying 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 inter-
national 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
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 representa-
tion. 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 sur-
vival, 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 gov-
ernments 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 elec-
tion 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
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 inequali-
ties 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 func-
tions’. Interestingly, Rajchmann did not express any particular sympa-
thy 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 constitu-
tions, etc. by a series of ad hoc organizations on the basis of the ILO
to perform definite functional services (in health, nutrition, etc.) on
an international basis. Such organizations would develop naturally

from the immediate needs of reconstruction.94
Another Foreign Office official, the noted internationalist Philip Noel-

Baker, 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 Organ-
ization 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 unrepresen-
tative. ‘It must be constantly remembered: a fact that is too often
forgotten, that an international body does not feel so direct a respon-
sibility 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
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 frac-
tures 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 prevail-
ing 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 govern-
ment, 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’,
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 con-
suming 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 estab-
lished 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.
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 respons-
ibilities 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 con-
ditions in normal times and the high famine mortality must be under-
lined.’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 emergen-

cies, 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 mid-
1950s. 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 bureau-
cratic and political field of ‘development’ policy, within which interna-
tional health had to find its place. At stake was nothing less than the
definition of the relationship of health, medicine, hygiene, and eco-
nomic 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 owner-
ship 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 uncer-
tainty 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
The Political Culture of International Health 73
based debates on international social and economic policy narrowed to

focus almost exclusively upon economic development as the over-
riding goal of international cooperation. In this context, the champ-
ions 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 secu-
rity 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 estab-
lishment 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 interna-
tional health organization off the agenda at the San Francisco confer-
ence 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
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 Anglo-
American 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 dis-
agreements 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 inter-
national 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 Con-

stitution 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
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 ‘associ-
ate 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 Director-
General. 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 organiza-
tion’s debates and activities. The establishment of the WHO coincided
with the moment of independence in South Asia, and the new interna-
tional 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
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 gov-
ernment of welfare; a set of commonalities and regularities in the
sphere of political economy, governed by climate, resources, popula-
tion and – as a residual category – ‘culture’. Implicit in these discus-
sions 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 gov-
ernment 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 mite-
borne rickettsioses and by the ubiquitous smallpox. Most of the area
suffers from the food deficiencies of the rice eaters, from a high tuber-
culosis morbidity and mortality in its cities and the extension of the
prevalence of that disease in the rural districts.20
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 mate-
rial deprivation: ‘the reason for infant mortality and lower vitality’,
they argued, ‘is also largely economic. It was stated that in Ceylon two-
fifths of the population did not obtain sufficient energy from their
diet’.22
The social welfare committee of the Asian Relations Conference dis-
cussed 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 prac-
tices 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 implica-
tions. 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 simi-
larities 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
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 mea-

sures as the removal of refuse and night soil, a water supply pro-
tected 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 central-
ized 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 Con-
ference and the ILO meeting in Delhi reflected, or coincided with, an
argument from within medical thought that challenged the ‘natural-
ness’ 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 stu-
dents in Britain were ‘misled’ by talk of the ‘tropical diseases’ that con-
tinued 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 gov-
ernment of health, none greater than the aftermath of the Partition of
the Indian subcontinent in August 1947.
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 inocula-
tion 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 infrastruc-
ture; 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 distin-
guished 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
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 pro-
ceeded 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 con-
trast 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’,
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 govern-
ment, 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 regard-
ing the organization and the responsibilities of the state. Rather, the
new international bodies now faced demands for immediate and effec-
tive 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 emer-
gency, through the invocation of epidemic disease, to make the case
for international assistance to India. It is a significantly different lan-
guage, 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 interna-
tional 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
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 opportu-

nity for the common interests of India and other Asian countries to
find practical expression. The agencies are used for much consulta-
tions and the coordination of policy. A system of multilateral rela-
tions 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, treat-
ing 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
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 stem-
ming 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 Inter-
national 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 out-
break 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 interven-
tion in Egypt as a harbinger of its later reliance on ‘impact’ pro-
grammes: ‘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
western European recovery. The following year, Harry Truman

announced the so-called ‘Point Four’ plan. In ‘Point Four’ of his inau-
gural 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 under-
developed 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 inter-
national 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
On both sides, the involvement of the UN in the administration of

the new programmes helped to obscure the unequal relations under-
pinning 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 inter-
national 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 deci-
sively 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 resolu-
tion 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 imple-
mentation of technology. Its ultimate goal was to bring about ‘eco-
nomic 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 under-
developed countries were ‘likely to fall farther and farther behind’
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 ‘atti-
tudes 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 rep-
resented the international expression of the vogue for national plan-
ning, 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 develop-
ment.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 pallia-
tive, 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-
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 ques-
tion of corresponding changes in structures of ownership or decision-
making.73 Technical assistance had an important role to play, then, at a
time when in India as elsewhere in South and Southeast Asia, post-
colonial 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 poten-
tial 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 en-
dured, 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 impor-
tant part of their argument was to highlight the systematic inequal-
ities 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
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 con-
ceivable 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 Director-
General’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-
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, unfortu-
nately, 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 prin-
ciple 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 under-
mine 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.
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 strug-
gles 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 depart-

ments. 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,
had depended upon voluntary contributions. It was precisely the ‘spo-

radic charity’ that so many during the war had excoriated as outmoded
and inefficient. The WHO’s regular budget – drawn from the compul-
sory contributions of member states, assessed according to their ‘ability
to pay’ – was severely limited. In 1949, in its first full year as a func-
tioning 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 assis-
tance 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 WHO Income, 1949–1957
Contributions from Technical assistance Total

member states funds income
1949 3,693,604 – 5,136,893

1950 4,164,925 – 6,280,427
1951 5,516,096 2,899,069 10,905,332
1952 6,943,486 4,997,233 13,683,999
1953 7,566,598 4,604,064 13,598,382
1954 7,580,165 4,253,435 12,868,945
1955 7,889,113 5,142,903 14,412,719
1956 8,524,767 6,121,044 16,053,189
1957 11,517,988 6,180,663 18,425,093
Source: Constructed from WHO, First Ten Years of the World Health Organization (Geneva,
1958), pp. 522–23.
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 impor-
tance 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 develop-
ment’, 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 neces-

sarily shut out investment in public health, but its scope was to be very
clearly defined: ‘Not all expenditure on public health increases produc-
tivity. 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
for economic development’, but the economic orthodoxy of the 1950s

had much less room for the prescriptions of social medicine, part-
icularly 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 think-
ing 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 ex-

plicitly quantify the economic benefits of health. He cited the work
of Colonel J. Sinton, a veteran British colonial malariologist who had
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 pio-
neering Swedish development economist Gunnar Myrdal. Myrdal con-
ceded 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 explo-
sion’. 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 fert-
ility rates would be a long-term consequence of economic develop-
ment, 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
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 dis-
cipline’ and national development: Gyan Chand, the Patna University
economist, and Radhakamal Mukherjee, amongst others. The modern-
izers 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 associat-
ing the ‘Orient’/’Far East’/’Asiatic lands’ with over-breeding, impover-
ished 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 popu-
lated 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 colo-
nial 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
This charge drew two main lines of response. The first came from the
Indian government, with the support of other Asian states. They sug-
gested 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 mortal-
ity and for prolonging life make it all the more necessary for Gov-
ernments, 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’; over-
population exacerbated, perhaps even caused, this poverty.112 In con-
stant 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 popula-
tion and well-being left a contradictory legacy for the post-colonial
state and its approach to health and population. The planners’ imag-
ination 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 represen-
tative government. The post-colonial imagination of health and popu-
lation 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
of Dr Abraham Stone, a small team of investigators began an experi-

ment 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 pro-
gressed, 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 develop-
mentalism 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
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, strength-
ened 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 compo-
nent 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 com-
mitment to public health on the part of post-colonial states and inter-
national 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, high-
lighting, 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 discus-
sions 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 over-
lapping 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
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 solu-
tions, 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 indi-
cate 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’, ‘obsta-
cles’ 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 pres-
sures of state-building and the Cold War impeded these visions of
Building a New Utopia 101
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 ex-
periments in carefully circumscribed areas. The WHO began its ‘field
operations’ in 1949. Among its first initiatives were malaria demonstra-
tion 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 reorgan-
ization 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 transfor-
mation 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.
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 encom-
passed everything from malaria control and demonstration projects
using DDT to pilot projects in nursing education and the establish-
ment 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 dis-
eases 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 fol-
lowed 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 mea-
suring 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 remain-
der coming from US bilateral aid to India, channelled in particular
through the Public Law 480 programme.14 Yet Jeffery’s careful calcula-
tions 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 dis-
cussion 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 eco-
nomic 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 thou-
sand 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 preven-
tive 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 opportuni-
ties for such administrations to help themselves’. The newspaper suc-
ceeded in giving priority to public health as a form of technical
assistance: ‘While there may be some argument regarding the usefulness
and efficacy of other types of technical assistance extended to under-

developed 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 editor-
ial 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 pro-
jects’ and ‘demonstrations’ which the WHO took to India, and else-
where 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 for-
mally 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 Cor-
poration 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 Sur-
roundings 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
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 malar-
iologists, 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 pen-
icillin factory at Pimpri, near Pune; the factory, Hindustan Antibiotics
Limited, began production in 1955.21 Yet from the outset, supplies pro-
duced 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 desir-
able’ for state governments to buy ‘foreign made penicillin’; ‘our produc-
tion of penicillin is considerable and can meet all demands made of it’,
he promised.23 Nehru’s pleas notwithstanding, technical assistance activ-
ated 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
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 tech-
nical assistance, too, envisaged their task in opposition to the epidem-
iological 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 deliber-
ately to create an effect of radicalism and novelty, the WHO consul-
tants 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
sought particularly to displace ‘culture’ from the heart of colonial

medical knowledge. In a quest for universality, the techniques of inter-
national 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, popu-
lation groups had to be identified in a finely differentiated way – osten-
sibly according to their differential susceptibility to infection.31 Here,
then, the categories of the colonial and then the post-colonial ‘ethno-
graphic 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 ‘more-
evolved 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; ‘ethno-
graphic’ differences were of interest for purely ‘technical’ reasons. Each
community, so defined, built their walls of different materials, re-
plastered 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 gov-
ernment of ‘primitive’ peoples, in whose case coercive measures and
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 tech-
nology was the panacea for those that could not. Thus, technical assis-
tance 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 orient-
ing 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 suf-
fering and death’.36 The WHO criticized clinicians’ ‘great concern for
retaining so-called professional standards’, suggesting that these ‘pro-
fessional 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 undoubt-

edly 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
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 ‘administra-
tive 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 inter-

national 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
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 con-
nections 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 person-
nel were Indian, whether through the Indian Medical Service or in
private practice. In the post-war era, Indian medical personnel contin-
ued 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 con-
temporary 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 adver-
tised.’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 Common-
wealth (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 connec-
tions 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 dis-
trict officials of old, the men on the spot who ‘knew their natives’.
Here the international medical consultant could appear as swashbuck-
ling conqueror of disease, as in the case of Dr Luigi Mara, an Italian
WHO consultant who came to be known as ‘Dr Malaria’, chasing
nomadic Kurdish populations through the borderlands of Iraq in

order to spray their tents with DDT.44 In Cambodia – newly indepen-
dent from France – public health was as romantic, if more leisurely, a
pursuit. With only a handful of qualified Cambodian doctors at inde-
pendence, 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 con-
vened 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 UNESCO-

assisted programme under way. His field was Community Develop-
ment. 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 com-
ponent 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 trav-
ellers, insurance agents, emancipators of women, and people like me’.46
Brown toured his domain, escorted by the Cambodian Minister of
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 depo-
liticized, 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 tran-
scending 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 con-
centrated 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
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 indus-
trialism’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
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 record-
ing 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 import-
ance of the spraymen, the supervisors and the insect collectors. His
reports are constantly calculating their capacity, constantly determin-
ing 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 elabo-
rate 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 masquer-
ade 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
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 tech-
nical 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 “ele-
mental 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
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 con-
struction’, 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 life-
time’ – so, many felt, would the work of medical personnel perma-
nently 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 consul-
tants. 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.
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 con-
tradiction: ‘boldly seized, precariously held’.
The WHO’s formal recognition that its ultimate aim was the com-
plete 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 formal-
izing 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 assis-
tance.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 interna-
tional 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 techno-
logy 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 policy-
makers 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-
paign in Greece. A WHO report suggested that, despite massive spray-

ing, first houseflies and eventually malarial mosquitoes showed resis-
tance 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 insect-
icides’; this is immediately qualified, however, by the admission that
‘in Burma, Ceylon, Indonesia, and the Philippines, there were impres-
sions (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 Com-
mittee on Malaria – in 1955, ‘means to plan the programme in such a
way that house-spraying could be safely discontinued before insect-
icide 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 cam-
paign 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 malar-
iological 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
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. Large-
scale 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 insect-
icides 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 ill-
advised 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 anophe-

line species had developed different kinds of resistance to DDT in
certain areas … Since there was not at present any satisfactory sub-
stitute method of attacking malaria, it was very important to eradi-
cate 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
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 Con-
ference, 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 malario-
metric 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 cam-
paign 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 con-
tinues, 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 contradic-
tion 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, unex-
pected complications’ or ‘bureaucratic delays’.1
The first part of this chapter examines the constant adjustments nec-
essary for the mass campaigns of disease control to function: mosqui-
toes 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
‘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 funda-
mental 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 popula-
tion 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 dra-
matic 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 conserv-
ative South Indian politician and veteran of the nationalist movement. In
this (exceptional) instance, he was able to exploit the silences in the dis-
course 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 encour-
aging. Far from demonstrating the universal efficacy of DDT, the
WHO’s pilot project in Tjilatjap, Java – from which the national eradi-
The Techno-politics of Public Health 123
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 satisfac-
tory result for a period of two years. Since then increasing densities
of A. sundaicus have been reported. At the same time, malaria mor-
bidity, spleen and parasite rates have shown an increase.
Singh cited numerous local studies that had shown that local mosqui-
toes 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
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 ‘some-
what 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 con-
cluded 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 prov-
incial 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 spray-
ing operations in many provinces. In some provinces the full quota
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 count-
less 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 break-
down 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 jour-
neys 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 prob-
lems of ‘personnel’. The ‘problem’ was essentially that the hundreds
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 fami-
lies, 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’ counter-
parts ‘rarely dare approach a person in a higher official position than
himself’;22 ‘with a strong minded doctor in charge, the mantri is handi-
capped’.23
The insecurity of the field staff, and the consequent difficulties of
recruitment, featured heavily in the discussions of the Indian Gov-
ernment’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 pen-
sionable service’. Furthermore, the vaccinators and field staff had ‘run
into trouble because of active opposition from qualified practition-
ers’.24 The WHO officers working with the BCG teams in the field pro-
duced 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-
ling the complex human and environmental factors involved in

shaping the conditions of public health – from the efficiency of spray-
men 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 tech-
nical 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 bound-
aries of these regions were assumed fixed, usually according to geo-
graphical 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 increas-
ingly 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, fur-
thermore, 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 inaccess-

ibility of insurgent-held regions. To be effective, a programme must
cover the infested areas and their population 100 per cent. Not only
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 histo-
ries, 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 town-
ships, 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
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 move-
ments, themselves impelled by ongoing Karen and Communist insur-
gencies on the frontier, in producing the poverty and overcrowding at
the root of the tuberculosis epidemic. Yet according to the rules gov-
erning 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 chal-
lenging 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, instru-
ments of correlation, and techniques of analysis which … modify his
position as an observing subject’.41
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 possi-
bility.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 real-
ities 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
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 migra-
tion 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 consider-
able 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 dis-
course 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 regu-
larities (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
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 reconstruc-
tion 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 Develop-
ment Programme stressed the principles of cooperation and ‘self-help’,
and at one level recognized the ‘social obstacles’ in the way of agricul-
tural 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 com-
munity development in South and Southeast Asia appeared to encour-
age 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 self-
consciously Gandhian project in rural reconstruction. The health activ-
ities 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
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 techno-
centric 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
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-twen-
tieth 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 com-
munist 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 exten-
sive use of dispensaries, demanding ‘soochi’ (injections) or ‘micchar’
(‘mixture’, or medicine), and expecting a medical presence at all deliv-
eries.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 plan-
ners, 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
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 con-
fronting 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 pro-
ponents 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, industrial-
ization 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 assist-
ance 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 emo-
tion and suggesting childlike enthusiasm, ‘and are quite willing to file
up for hours in order to get one’.64 The documentary archive of tech-
nical assistance makes repeated reference to the ‘miraculous’ trans-
formations that result from the mass campaigns. Indeed, Charles
Winslow expressed this view clearly even in 1952: ‘From the stand-
point 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
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 injec-
tion 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 ‘believ-
ing’ in it, there was the prospect that they might not accept some-
thing, 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 dif-
ferent 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 demonstra-
tion that ‘knowledge and science, which depended not on mantra or
intrigue, but on proven fact, could not be held back forever, and gradu-
ally came to be accepted by the public body.’69 On this view, the
‘public body’ embraced the yaws eradication campaigns because peni-
cillin worked. The WHO was less willing, perhaps less able, to consider
the possibility that different reactions to different kinds of interven-
tions 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 super-
stition 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 emo-
tional response and inspires only dull official speeches and allegorical
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 tech-
nical 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 ‘complica-
tions’ 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 vacc-
ination 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 particu-
larly 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 lan-

guage of technical assistance that C. Rajagopalachari, the veteran south
Indian nationalist, mounted one of the most public critiques of an inter-
national health campaign. In a widely circulated pamphlet entitled BCG
Vaccination: Why I Oppose It, Rajagopalachari attacked the international
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 ‘dis-
embodied’ 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 particu-
larly strongly to the ‘propaganda’ employed by the WHO-led interna-
tional 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 inconclu-
sive benefits of BCG appear unquestionable, it also closed off other,
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 sug-
gested, 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 vaccina-
tion. 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 author-
ity distinct from that of clinical medicine; though the claims of bio-
medicine to authoritative knowledge were essential to the legitimacy of
the international health agencies, they were, at the same time, scept-
ical 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 oper-
ation 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 medi-
cine 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
be ‘experimented’ upon). Rajagopalachari’s argument is not, however,

that all medicine is colonial with respect to the body, or that biomed-
icine is colonial by virtue of its ‘western’ provenance. The heart of
Rajagopalachari’s critique is that India’s former position of subordina-
tion under British rule had established a double standard in the post-
colonial 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 organiza-
tions, 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 vaccina-
tion 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 seri-
ously 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’ inter-

fered with the ‘smooth running’ of the campaign. With both
Rajagopalachari and the Madras Government/WHO talking the lan-
guage of ‘fears’, it is likely that many people would have thought it
advisable to steer clear of BCG vaccination stations. Perhaps the clear-
est sense we have of this ‘resistance’ to an international health cam-
paign lies in a reconstruction of the course of the campaign in 1955.
By any standards, June 1955 marks a dramatic falling off of the vacci-
nation 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
Table 5.1 WHO/Indian Government BCG Vaccination Campaign in

Madras State, 1954–55
Place Period Population Total Percentage Percentage Total

tested of population positive vaccinated
tested
Coimbatore 15 to 20 Nov, 197,755 210,814 107 60 73,215

(urban) 1954
Coimbatore 29 Nov to 300,000 230,077 76 50 95,328
(rural) 25 Dec, 1954
Kozhikode 3 to 15 Jan 158,724 107,214 67 73 25,556
(urban) 1955
Kozhikode 24 to 29 Jan 118,820 54,583 45 56 22,195
(rural) 1955
Mangalore 7 to 12 Feb 117,083 95,781 82 69 26,757
(urban) 1955
Mangalore 14 to 19 Feb 49,000 36,499 74 58 13,238
(rural) 1955
Udipi 15 to 19 Feb 21,254 21,474 101 58 8,191
(urban) 1955
Udipi 21 to 25 Feb 42,500 31,089 73 53 12,883
(rural) 1955
Kalikavu, 22 to 27 Feb 50,000 38,989 78 55 15,046
South 1955
Malabar
Salem 28 Feb to 202,335 179,463 89 60 60,751
(urban) 5 Mar 1955
Salem 14 to 26 Mar 67,395 50 26,869
(rural) 1955
Cochin 28 Mar to 29,881 20,011 67 76 4,215
(urban) 2 Apr 1955
Ootacamund 4 to 9 Apr 41,370 37,428 90 45 17,958
(urban) 1955
Coonoor 18 to 22 Apr 23,902 22,346 93 46 10,021
(urban) 1955
Nilgiris Do. 69,062 51 29,378
(rural)
Tiruchi- 18 to 30 Apr 218,921 108,304 47 70 28,130
rappalli 1955
(urban)
Tiruchi- 16 to 26 May 150,000 57,246 38 61 17,488
rapalli 1955
(rural)
Tanjore 28 May to 100,000 31,507 32 64 6,087
(urban) 3 Jun 1955
Table 5.1 WHO/Indian Government BCG Vaccination Campaign in

Madras State, 1954–55 – continued
Place Period Population Total Percentage Percentage Total

tested of population positive vaccinated
tested
Tanjore 7 to 12 Jun 75,000 5,885 8 53 1,796

(rural) 1955
Madurai 27 Jun to 361,781 35,784 10 66 7,783
(urban) 15 Jul 1955
Madurai 18 to 22 Jul 6,188 60 1,575
(rural) ‘55
Tirunelveli 8 to 22 Aug 73,470 417 <1 73 80
(urban) 1955
Palayam- Do. 40,010 786 2 70 113
kottai
(urban)
Melapa- – 37,653 194 2 71 33
layam
(urban)
Tirunelveli 16 to 26 Aug 702 23 533
(rural) 1955
Vinud- 5 to 10 Sep 46,309 4,161 9 65 839
hunagar 1955
(urban)
Vellore 12 to 17 Sep 106,024 2,123 2 63 522
(urban) 1955
Vellore 20 to 23 Sep 744 64 140
(rural) 1955
Cuddalore 12 to 22 Sep 69,084 4,244 6 57 1,093
(urban) 1955
Cuddalore 20 Sep to 42 61 8
(rural) 29 Oct 1955
South 17 to 29 Oct 25,126 56 8,760
Kanara 1955
(rural)
Mangalore, 31 Oct to 28,387 53 10,295
Kasargod, 26 Nov 1955
Karkal
Source: Reconstructed from Report on the Health Conditions in Madras State 1955 [Tamil Nadu State
Archives Library, Chennai]
locality plummeted from tens of thousands to a few hundred, or fewer.

Yet, this ‘resistance’ seemed to fade with a whimper. There are virtually
no press reports about any resistance to vaccination. By the following
year, the ministry of health reports no ‘obstacles’ or complications in
the running of the campaign;90 neither do WHO sources contain any

references to organized resistance. Oral history bore no further fruits.
The many people I spoke with, who had lived in various parts of
Madras State in the 1950s had no recollection of any widespread ‘resis-
tance’ to BCG vaccination, although many remembered being vacc-
inated. There does, however, appear to be increased anxiousness about
‘propaganda’, when the Government’s report for 1959 declares that:
Four hundred and eight cinema shows were exhibited, 143 meetings
held and 898 talks delivered. 142,662 leaflets were also freely dis-
tributed to the public. The BCG team participated in the exhibition
conducted by the Salem Municipality and was awarded ‘Gold Medal’
for having demonstrated valuable exhibits on BCG Vaccination
campaign.91
The overall impression is that the powerful support of the State and
WHO for BCG vaccination gradually re-established a level of public
confidence, and a dissipation of anxiety.
However, the response to Rajagopalachari’s denunciations was not
confined to India. If anything, they had a greater impact amongst the
Tamil-speaking population of Ceylon. In Ceylon at this time, the Tamil-
speaking population was a minority in an increasingly precarious polit-
ical position, given the rising political strength of Solomon Bandaranaike
on a Sinhalese nationalist platform. The impact of an eminent, Tamil-
speaking Indian politician speaking out against BCG was more immedi-
ate. There was also a further way in which political critique in India, and
‘resistance’ to vaccination in Ceylon, were connected. The international
organizations imagined ‘Asia’ as a whole, an Asia that together cele-
brated ‘World Health Day’ on April 7th each year. But this could also
mean that a critique, by an Indian, of the international campaign would
have immediate resonance beyond India’s shores. The awareness of the
global reach of public health in the 1950s could equally work against the
progress of the international campaigns.
Rajagopalachari’s criticisms of the international BCG vaccination
campaign began to be published in 1955, in both the English and the
Tamil language press in India. This happened to coincide with the
beginnings of the WHO’s ‘attack’ on the Tamil-speaking Eastern
Province of Ceylon, which the WHO had already envisaged as a
‘problem’ area due to its ‘inaccessibility’ (the minority population of
the area, as much as its topography, lay behind this perception).92 The
Director of Ceylon’s health services, Dr D. Kahawita, referred, tersely,
to the impact of Rajagopalachari’s critique in his annual report for
1955: there were ‘severe repercussions’, he wrote, as a result of ‘propa-

ganda in India, fortunately not from medical authoritative sources,
decrying [BCG] as dangerous and valueless’.93
A slightly clearer sense of the impact of Rajagopalachari’s ‘propaganda’
can be discerned from the report of the WHO’s nurse in Ceylon, Kirsten
Hansen. She describes it thus, in her account of the BCG campaign:
For the first time in the mass BCG campaign, and – unfortunately –
in this of all areas, there was a blast of counter-propaganda origi-
nating from C.R. Rajagopalachari’s attacks on BCG published in the
Tamil periodical Kalki, published in India. The Eastern Province
population is almost entirely Tamil-speaking, and this particular
magazine has a very wide circulation in the province. The counter-
propaganda, especially as it originated from a person of C.R.
Rajagopalachari’s eminence and international stature, had a consid-
erable effect on the population, and materially hindered the
progress of the campaign in the province.94
It is striking that Hansen makes particular reference to ‘this of all

areas’, suggesting the trepidation with which the international health
agencies viewed their potential power in areas with ethnic or cultural
minorities. Through transnational networks of publishing and commu-
nication, the views of Rajagopalachari reached Ceylon; it was not only
Rajagopalachari’s ‘eminence and international stature’ but the fact that
he was a Tamil leader that gave such resonance to his criticisms in the
Eastern Province of Ceylon.
How are we to interpret the ‘resistance’ of which Kirsten Hansen speaks?
One indication, which she herself used, was to compare the ‘response rate’
for vaccinations in the Eastern Province with those for other parts of
Ceylon.95 The ‘productivity per team’ in the Eastern Province was sign-
ificantly lower than the others. Yet, what a curiously disembodied picture
of ‘resistance’ this conjures up. ‘Resistance’, here, is a machine that fails to
function as it should, not a set of individual responses made up of fear,
suspicion, resentment and uncertainty. The only indication in Ceylon’s
English-language press that I was able to access, of what this ‘resistance’
might have meant comes in a small item on the front page of the newspa-
per on July 30 1955, which stated, simply, that
The BCG Team at Palyagala was today obstructed in a school by

some members of the public.
The incident occurred when some girls fainted while inoculations
were being given. Police were called in.96
It is important not to overstate, or to romanticize, the significance of

the ‘resistance’ informed by Rajagopalachari’s statements on BCG. It
can, in part, be ascribed to the specific uncertainties surrounding BCG
rather than a reaction to the broader culture of techno-centric public
health. Indeed, concerns about BCG’s effectiveness proved to be well-
founded.97 Rajagopalachari’s argument was not anti-vaccination tout
court, but against BCG vaccination in particular. ‘I am not against
modern “western” therapy or modern science’, he declared emphati-
cally. BCG, in his view, did not fulfil the requirements of proof that the
‘modern’ scientific tradition itself insisted upon.98 Furthermore,
responses to Rajagopalachari’s interventions were largely confined to
Tamil-speaking Madras State (and Tamil-speaking Ceylon), where there
was an earlier history of resistance to BCG vaccination, during the
Scandinavian Red Cross campaign of 1948;99 and where a particularly
assertive regional nationalism was ascendant, giving credence to his
broader critique of the post-colonial Indian state.100
Indeed, in other circumstances at the same time, the story of vacc-
ination in South and Southeast Asia continued to be told as one of
progress. In the midst of Renu’s Maila Anchal, published just the year
before Rajagopalachari’s statements on BCG, and despite the novel’s
scepticism over the promise of a new dawn of health and hygiene,
there is a scene that presents vaccination as the quintessential triumph
of science over superstition. Kalicharan the newly converted socialist
cadre helps the doctor force vaccination upon a reluctant village.
Kalicharan’s men surrounded the bazaar. The doctor was ready and
waiting under the mango tree, with all his equipment spread out on
a table. Kalicharan caught hold of the people, one by one, and
brought them over. The lady teacher rubbed a spot on each one’s
arm with cotton soaked in alcohol, and the doctor gave each an
injection. The tahsildar wrote down their names. The marketplace
was like a madhouse! Even if you got away, where could you run?
There were So-so-list Party sepoys on all four sides!101
The result, in the narrative, is for the good of all:
The doctor was not a man – he was a god!

In all the Tatma, Poliya, Kurma Chatri and Raidas quarters, only five
people passed away. In one house or another, one or two might be
sick. But the doctor was like a god!
Day and night, he never stopped to rest for even a moment. The
lady teacher was like a goddess, and Kalicharan was a hero, too!102
The line between science and superstition, gods, heroes and villains,
was a fluid one throughout the international campaigns to eradicate
infectious disease in the 1950s.
Throughout the 1950s, international public health was greeted by a
sense of ambivalence, provoking a spectrum of responses that did not
fit easily within the simple categories of disease eradication campaigns
– ‘acceptance’ and ‘resistance’. Nor is it enough to posit a dichotomy
between national/international campaigns and ‘local responses’, as it
appears in some recent histories of medicine. International health cam-
paigns, I have argued here, were dependent, from the start, on local
agents, both human and ‘natural’ – vaccinators and spraymen,
monsoon rains and political insurgents.
Conclusion: the ambiguities of success
Insofar as we have what Rajagopalachari might call ‘real statistics’ on

the mass campaigns of the 1950s, the picture that emerges is one of
overwhelming success. Ceylon, one of the first countries to receive
WHO support for malaria control, presents a particularly dramatic
picture. As a result of an anti-malarial DDT campaign with fewer than
1,000 workers, the general mortality rate on the island fell by more
than a third in less than five years.103 Ceylon was, in many ways, an
exceptional case: a relatively small island, and one with a more deve-
loped health infrastructure than most of its neighbours. Yet in India,
too, the statistics – however unreliable – tell an astonishing story. The
number of recorded cases of malaria fell from 75 million in 1951 to
just 50,000 in 1961, a massive and unprecedented diminution.
Going beyond the malaria campaign, the WHO campaign against
yaws, in which Indonesia and Thailand saw particularly large-scale
intervention, was dramatically successful. It was estimated that there
were over 20 million cases of yaws world wide in c. 1950, over half of
which were in Asia: by 1955, the WHO was giving 100,000 injections a
month in Indonesia, and had treated over a million cases in Thailand.
Given that a single injection of penicillin would cure the disease,
making painful lesions disappear, this was a particularly ‘popular’
intervention.104 The case of tuberculosis was more ambiguous: by the
early 1960s, the WHO had vaccinated almost 100 million people in
Asia with BCG, most of them under 20 years old. Whilst it was gener-
ally accepted that BCG protected young children from particularly
virulent strains of infection, the long-term protective effects were in
doubt.105
The techno-centric international campaigns of the 1950s, though

they neglected questions of distribution and inequality, were poten-
tially more ‘democratic’ than more locally based projects in being able
to offer ‘health’ to the very poorest. Fred Soper, the pioneer of disease
eradication, could make a case for the eradication approach based on
the values of equity and democracy. In disease control programmes, he
argued, ‘one may disregard the rights of the minority, of those living in
sparsely settled areas of difficult access’. Eradication, however ‘cannot
sacrifice the minority’, it ‘cannot be made available to part of the
people; protection of all the population becomes the only acceptable
… standard’.106
Despite this evident and quite remarkable success, however, the
disease control campaigns of the 1950s felt fragile, as has been shown
throughout this chapter. The aggregate statistics, like the confident
images of unchallenged technological mastery, papered over the many
cracks that had begun to appear within the campaigns. The power of
the campaigns, I have suggested in the last two chapters, was very
limited: it was based on genuinely effective technology, and on the
hope that this technology could work regardless of social, economic,
and institutional circumstances.107 As a result of the many improvisa-
tions and adaptations of health workers, the technologies had a
significant impact on levels of illness across South and Southeast Asia.
This was a long way, however, from the image of a planned, infallible
campaign. As has been suggested in this chapter, the WHO’s basis of
knowledge about the diseases it was ‘attacking’ was limited, based, in
its own words, on ‘near mythology’. Workers in the field and experts
in Geneva did not know exactly how DDT was having its effects, so
scanty was the basis of their knowledge. This is perhaps one reason
why the early, isolated, reports of insecticide resistance caused such
panic, setting in motion the urgent push towards eradication. The fact
was that international health workers did not know if widespread drug
resistance was around the corner, if their Fordson vans would last
through the month, if their plans could survive the Monsoons.
The practice of international health in the 1950s, in which malaria
played a particularly prominent role, appears to stem from what James
C. Scott has called the ‘ideology of high modernism’; a ‘strong …
muscle-bound, version of the self-confidence about scientific and techni-
cal progress’. Scott contrasts this ‘ideology’ of science with ‘real’ science;
the former was ‘uncritical, un-sceptical, and thus unscientifically
optimistic’, and expressed itself in ‘remarkably visual aesthetic terms’.108
By looking at malaria control alongside a range of other international
health interventions across Asia in the 1950s and, in particular, by

looking at the thoughts and sentiments of some of those involved in car-
rying out the health campaigns, I would suggest that we need to think
about ‘smaller’ histories of international health and technical assistance.
This chapter has suggested that when looked at too closely, the mod-
ernist image fragments into so many broken-down vans, fears of ‘resis-
tance’, recalcitrant mosquitoes, and plans gone wrong. To discuss the
international health campaigns of the 1950s in terms of ‘hegemony’ is to
reflect their self-projection more than their reality.109
By the early 1960s, moreover, it became evident that the indis-
putable successes of the mass campaigns of disease control might not
last.
6
The Limits of Disease Control
This chapter explores the crisis and eventual decline of interconnected

public health initiatives in the Asian arena, spanning the period
between the late 1950s and the mid-1960s. Many of the difficulties of
the mass campaigns of the 1950s arose from the uncertainties, of pre-
vention, both practical and epistemological. The gaps between the seen
and the unseen – the ‘small injection’ and ‘disease later in life’; the
disappearance and reappearance of anopheles mosquitoes – caused
problems for planners, health workers and patients alike. This led to a
renewed attempt to put into practice yet newer and better technologies
that might bring about the finality of cure.
The first part of this chapter examines a shift in the approach to
the problem of tuberculosis control in Asia from the late 1950s, when
technological innovation seemed, once again, to provide a solution
to intractable and expensive problems. Given the uncertainties sur-
rounding BCG vaccination, the prospect of being able to cure hun-
dreds of thousands of tuberculosis patients in the Third World was
attractive to national and international health officials. The WHO
instituted the use of new anti-tuberculosis drugs in Asia as (yet
another) pilot project, this time in Madras. However, unlike in prev-
ious pilot projects, the experiment with anti-tuberculosis drugs took
the form of a full clinical trial, and the importance of proper
‘medical’ expertise was thus greater than in many other health cam-
paigns. Where mass vaccination campaigns were consciously
designed to minimize contact between health workers and their
‘targets’, long-term chemotherapy required intimate and intensive
contact with patients in their homes. Changing technologies,
I suggest, presented new fields of social life requiring medical surveil-
lance and intervention. This only served to expose the limits of the
149
planners’, and the doctors’ power over domestic and social space, and
their power over nature.
In the second part of the chapter, I show that it seemed to many, by
the 1960s, that ‘nature’ might have the last word after all. A resurgent
environmentalist discourse of the filthy, implacable tropical envi-
ronment cast doubt on optimistic techno-utopias. The international
public health community acknowledged that the ‘causes of death’ in
the Third World were more complex than the campaigns against par-
ticular diseases had once assumed. The importance of nutrition in
shaping patterns of illness gained renewed recognition.
Perhaps most significant, malaria eradication, at the very heart of the
new utopia, fragmented and then collapsed in the face of all the prob-
lems outlined in the previous chapter: natural resistance to insecticides
(and anti-malarial drugs), difficulties with staff and with equipment,
and because of a lack of medical infrastructure. By the mid-1960s, the
position of international public health relative to the newly vocal
enthusiasts for population control was distinctly fragile. This was, at
least in part, because the arguments for a new international public
health, outlined in previous chapters, had failed to convince. The
enduring irony is that, in terms of reducing the burden of illness and
death in the Third World, they had, despite all the problems, been
tremendously successful.
Curing tuberculosis in Madras and Bangalore
In the late 1950s, and for a decade afterwards, urban South India
served as a global laboratory of sorts for medical and social research on
the treatment of tuberculosis. The need for a new approach to tubercu-
losis control seemed clear in South and Southeast Asia. In India alone
there were an estimated 2.5 million active cases of tuberculosis and
500,000 deaths every year, while there were only 23,000 hospital and
sanatorium beds available for the clinical treatment of the disease.
As we have seen, prevention through BCG had provoked not only
political opposition, but also great medical uncertainty.1 Antibiotics
discovered in the 1940s and early 1950s, including streptomycin and
isoniazid, had proved effective against tuberculosis, and were used
widely in the West by the 1950s. Policymakers at the WHO hoped that
the introduction of these drugs to the Third World would pave the way
for a ‘cheap and effective chemotherapy that could be applied on a
mass scale … under domiciliary conditions’; that is, in patients’
homes.2
The Limits of Disease Control 151
Between 1956 and 1959, the WHO and the Indian government jointly
established two projects to investigate the impact of anti-tuberculosis
chemotherapy on poor patients in southern India. The first project, in
Madras, was a trial of newly available anti-tuberculosis drugs in circum-
stances of urban poverty, in the form of a controlled medical exper-
iment. The British Medical Research Council collaborated in the project,
and provided its first director, Wallace Fox.3 The second project, based at
the National Tuberculosis Institute (NTI) in Bangalore, approached the
problem of introducing new medical technology from another angle.
Using detailed social surveys and interview-based research, investigators
at the NTI aimed to construct a sociological picture of the urban tubercu-
losis problem, and the potential social constraints to the implementation
of mass chemotherapy.
The events in question lie at the intersection of the history of bio-
medicine, and international history. On the one hand, the Madras
study was designed according to a logic internal to clinical medicine, it
was, indeed, one of the first clinical trials in the Third World;
the ‘stakes’, in a sense, were defined by the medical field, and were
designed to contribute to increasingly vigorous debates about
chemotherapy in Europe and the United States.4 Yet the Madras and
Bangalore studies of tuberculosis chemotherapy were also founded
upon a series of assumptions and associations shaped by the discourse
of international development and the practices of technical assistance.
The ultimate end of the Indian studies was to transform global policy.
To initiate the project, the Madras Tuberculosis Chemotherapy
Centre asked a major state-run clinic to refer its tuberculosis patients to
the centre to determine whether they were suitable subjects for the
trial. Each patient who registered with the centre was randomly allo-
cated to either 12 months sanatorium treatment, or treatment at
home. The patients in the study all lived within a few kilometres of the
chemotherapy centre, which was located in the Egmore neighbour-
hood of Madras, along the banks of the Cooum River. One contempo-
rary census report complained that the river banks were a ‘fertile
ground’ for the growth of slums, noting that ‘it is rather disquieting to
note that slum dwellers who constitute a little above a fifth of the city’s
population should be confronted with the problems of promiscuity,
susceptibility and high fatality to diseases and woefully poor health
conditions’.5 The patients in the study were from some of the poorest
districts in Madras.
The Madras Centre carried out a detailed investigation of the social
and economic circumstances of the tuberculosis patients selected for
the study, gathering data on a range of factors which had long been
crucial in determining the outcome of tuberculosis cases: nutritional
status, living and working conditions, and economic circumstances.
The aim of the investigation was to reconsider these ‘environmental’
factors ‘when an effective combination of anti-microbial drugs is being
administered’.6 At the same time, the patients assigned to sanatorium
treatment (while receiving an identical regimen of medication) found
themselves in an environment reflecting all of the traditional remedies
for tuberculosis prior to the antibiotic era: ‘airy, well-ventilated wards
… in the country’, balanced diets according to the recommendations
of nutritional experts, and complete rest from physical activity.7
Unsurprisingly, the investigation of patients’ diets at home revealed
that the vast majority were poorly nourished. The report described the
‘usual diet’ of patients as consisting of ‘a very light breakfast (often the
water in which the rice is cooked) and two fuller meals (sometimes
only one) … [which] consist of cooked rice’. ‘A small amount of green
vegetables and pulses; on some occasions, very small quantities of flesh
foods, predominantly fish, fats, and fruits are also eaten.’8 Patients
treated in the sanatorium, on the other hand, were fed on a diet
meeting all minimum nutrition requirements, and gained significantly
more weight over the course of treatment than did those treated at
home.9 The nutritional deficiencies in the diets of home-based tubercu-
losis patients were exacerbated by their early return to work. One
report noted, in particular, that: ‘Many housewives, because of their
family responsibilities, were unable to restrict their activity for very
long, if at all.’10
Thus, the work of the Madras Tuberculosis Centre illustrated starkly
the additional strains that poverty placed on tuberculosis patients.
However, the striking conclusion reached by the Madras study was
that these circumstances had little or no adverse impact on the
outcome of drug treatment. ‘Whereas the patients admitted to sana-
torium were treated under favourable conditions … the poverty-
stricken patients treated at home remained in their overcrowded
conditions and had much less rest [and] a poor diet.’ Yet, the results
of the study had shown that diet and overcrowding played ‘little, if
any, part’ in preventing the ‘attainment of bacteriological quiescence
at the end of the year in patients receiving standard combined
chemotherapy’. The investigators suggested that ‘successful treatment
of patients in their homes in developing countries need not await an
increase in the standard of living’ [emphasis added]; ‘Treatment of
patients on a mass scale can begin as soon as adequate supplies of
medicaments are available, and as soon as the necessary supervision

of patients can be organized.’11
The finding that domiciliary chemotherapy could be a viable option
even in unpropitious circumstances had a significant impact upon the
way in which tuberculosis was conceived as a public health problem.
The ability to treat each individual case with drugs transformed tuber-
culosis into a problem of individual patients, rather than the preven-
tive vaccination of whole populations. The studies published by the
Madras chemotherapy centre, and disseminated internationally
through the widely circulated Bulletin of the WHO, brought a number
of issues to the forefront of the international debate on tuberculosis:
questions about the ‘acceptability’ of the new drug regimen to patients,
and the likely ‘compliance’ of patients with long-term drug therapy.
The NTI in Bangalore, established in 1959 by the Indian Ministry of
Health and WHO, played a defining role in investigating the issue of
‘compliance’, and did so using innovative methods. The NTI was (and
still is) housed in the palace of ‘Avalon’, a rambling property set within
several acres of gardens adjacent to the royal palace in Bangalore, and
was formally inaugurated by Nehru in 1960. Notably, the NTI con-
tained a sociological section, which was ‘one of the first institutional-
ized experiments in the collaboration of these two branches [social and
medical] of science in under-developed countries’.12 Stig Andersen, a
Danish sociologist sent by WHO, led this section along with Debabar
Banerji, a young Indian doctor who had ‘train[ed] himself as a sociolo-
gist’.13 Like Dr Ramakrishnan in Madras, D. Banerji was not attracted to
clinical medicine or laboratory research, and found his vocation in
public health whilst working as a government physician in Western
Tibet and the Himalayas in the mid-1950s.14 In the midst of his spell at
the NTI, Banerji spent time at Cornell University gaining a Masters in
cultural anthropology, which reinforced his inclination to take a social
approach to public health.15
In its first years, the NTI pioneered the use of a very different
approach to the collection of information about the tuberculosis
problem in India, based on personal interviews with patients, and
based upon patients’ experiences and perceptions of illness. ‘In
justifiable enthusiasm over mastering the more precise measurements
of the epidemiological surveys’, an early NTI report argued, implicitly
criticizing the basis of knowledge generated by the mass campaigns of
the 1950s, ‘tuberculosis research workers have sometimes lost sight of
the true problem of tuberculosis’. The real problem, they suggested, lay
in the ‘suffering, discomfort, or economic dislocation brought about by
the tubercle bacillus destroying human lung tissue’.16 The report

conceded that ‘a sociological approach to a public health problem is a
relatively new field of investigations’, and that ‘when symptom ques-
tioning [of individual patients] has been used in the past, it has more
often than not been considered a less desirable alternative to investiga-
tions using more precise diagnostic means’. In tuberculosis control, in
particular, ‘the relatively objective tuberculin test, X-ray examination
and bacteriological examinations have completely dominated the
field’.17
The NTI’s decision to pay greater heed to the subjective experience of
illness seemed to be vindicated by the first major research findings of
the sociological unit. The study suggested that the majority of those
with active tuberculosis were not only aware of the problem, but
sought assistance from government health centres, dispensaries and
hospitals.18 The sociologist Stig Andersen argued that the main impli-
cation of these discoveries was that: ‘The first obligation of a tuberculo-
sis programme [is] to take care of those cases which are now standing
at the very door-step of health services, seeking assistance.’ Andersen
suggested that ‘once this part of the patient population has been taken
reasonably adequate care of, a substantial proportion of the remaining
patients will be attracted by the improved services’.19
The significance of domiciliary chemotherapy went beyond its
potential to cure tuberculosis. Chemotherapy had the potential to
increase individuals’ sense of security by giving ‘people who now feel
ill’ the confidence that ‘they will be taken care of as well as medical
technology can currently manage’, and ‘people who fear that they or
their dear ones might become ill’ the sense that ‘should catastrophe
strike’, that it could, and would, be cured.20 Stig Andersen argued that
the security offered by chemotherapy played a far greater role than
narrow health education in securing patients’ support for the new
directions being taken by tuberculosis policies. ‘The Indian villager’,
Andersen wrote pointedly in a report to Geneva, ‘does not need to be
told in words about the tuberculosis problem, but needs a service to
deal with a problem which … is only far too well known to him’.21
The greatest contemporary interest in the work of the sociological
section undoubtedly lay in its findings on the subject of whether or
not patients could be trusted to take their anti-tuberculosis drugs over
the course of 12 months, and what the reasons were for cases of
patient ‘default’. A report from NTI ruefully remarked that there
seemed to be great disappointment that it had not devised ‘some magic
formula through which a majority of patients could be induced to take
drugs regularly for the required period of time’.22 Contrary to expecta-

tions, the NTI’s detailed investigation of ‘defaulting’ patients based,
again, on in-depth interviews with the patients and their families,
portrayed ‘non-compliance’ as far more complex than a question of
‘ignorant’ or unreliable patients refusing to cooperate with their own
treatment. The institution’s researchers found that: ‘Taking drugs for a
long time depends on the patient’s motivation to do so, in the midst of
conflicting motivations and in a life of other worries, which in many
or most cases appear far more important to the patient than worry over
his disease.’
Yet the NTI also concluded that the ‘slippery slope of sloppy treat-
ment organization rather than the ignorant patient’ was responsible
for a significant part of the problem of ‘default’.23 A number of the
‘defaulters’ in the Bangalore study that failed to complete 12 months
of treatment had ‘pretended to live in the city and gave the addresses
of relatives’. ‘These relatives collected pills for them and had the pills
sent to the patients, and this arrangement had failed before the end of
the 12 months.’ Other reasons given for not completing treatment
included:
‘Lost card, thought I could not then get pills’

‘Health visitor behaved very rudely’
‘Was advised special diet I could not afford, therefore thought it was
no use taking pills’.24
The study thus concluded that ‘organizational and administrative

measures’ could have averted a number of the ‘defaults’. It was
emphatically declared that, contrary to a widespread belief, ‘it is not
true that relief of symptoms usually, or even often, leads to default.’
‘That patients discontinue treatment as soon as they feel better has
been reported so often that it is now widely believed always to be true.’
Finally, the studies of the NTI found (again, contrary to expectation)
that ‘irregularity in drug taking does not seem correlated with the eco-
nomic, social, educational or other status of the patient and his family.
The composition of the defaulter group is virtually the same as that of
the regular group, not only in age and sex, but also in respect of status
in family, religion, [and] caste.’25
The direct implication of these findings was that the effectiveness of
anti-tuberculosis drugs was dependent on a sophisticated treatment
organization, with the ability to respond to the myriad individuals’
circumstances. This was a finding with uncomfortable implications for
the administration of international public health, which had, for a

generation, moved in precisely the opposite direction: towards simplifi-
cation and homogenization. In contrast with the clinical trials in
Madras, the conclusions reached by the NTI suggested that, far from
being a ‘magic bullet’ for tuberculosis, the success of chemotherapy
was dependent on the improvement of socio-economic conditions,
and the expansion of health services to provide even coverage across
the region, and country. It was noted that all too often, ‘defaulting’
patients had in fact moved to another district, which was not supplied
with drugs, and lacked a tuberculosis programme.26
Problems of policy
Interpreting the results of the research conducted in Madras and

Bangalore was a matter of great practical importance. The NTI, respon-
sible for the social research in Bangalore, was at the centre of India’s
nascent ‘national tuberculosis programme’. Based on the recommenda-
tions of the NTI, the Indian Ministry of Health issued guidelines in
1963 to all state governments outlining the basis for District Tuber-
culosis Programmes for each of India’s 380 districts, beginning with a
‘pilot’ programme in ten districts with an overall population of
12 million. The Indian Government recognized from the start that the
two fundamental issues would be the adequate ‘provision for a con-
stant supply of drugs by the health services’, and ‘regular intake of
drugs by patients’ (the failure of which would ‘render the best drug
combination ineffective’).27
The implications of the south Indian research, as we have seen, went
beyond India. The research was conceived, carried out, and interpreted
within the broader context of the internationalization of responsibility
for health after the Second World War. At issue was nothing less than
the future of global tuberculosis policy. The insertion of the Madras and
Bangalore studies into international policy debates was underpinned by
an underlying tension between the potential universality of the Indian
(social) scientific research, and the particular circumstances of its produc-
tion: that is, the carefully controlled environment of a medical trial, and
the specific social and economic conditions of Bangalore. The generaliza-
tion of the results of the south Indian research depended on the imag-
ination of a singular ‘Third World’, united in its epidemiological and
social characteristics. It was dependent, too, on the existence of an inter-
national health organization of the size and scope of the WHO. By the
end of the 1950s, the WHO had initiated parallel projects in ‘crowded
slums’ in Tunis and Nairobi, modelled on Madras.28 The WHO’s key role,
then, was in ‘universalizing’ the particular research from Madras.29 In the
process of universalization, its significance was transformed.
The fundamental problem emerging from the Madras chemotherapy
study lay in the relationship between the methodology of the scientific
trial, and social and economic conditions. In the words of one British
journalist’s account of the Madras study, it was an open question
whether ‘ … in the conditions which exist in an Indian city, with its
crowded and often unstable population and its low level of literacy, an
experiment in social medicine could really be carried out with
sufficient exactness to ensure the validity of the results’.30 ‘Validity’
entailed replicability. Could the results of the Madras project be trans-
lated into standardized policy interventions across the Third World?
This question was of the foremost importance for the WHO.
In a number of ways, the Madras study was very far from ‘realistic’,
in terms of being representative of the conditions that would con-
front the implementation of a large-scale public health intervention
using chemotherapy against tuberculosis. For a start, the patients who
took part in the Madras study were very carefully selected. Only those
families deemed to be ‘cooperative’ after detailed preliminary inter-
views, were accepted into the programme. 31 Given this measure of
pre-selection, the most troubling issue, of patient compliance, was
largely circumvented in the Madras trial.
Furthermore, ample resources allowed the Madras Centre to exercise
a particularly high level of social control over the daily lives of the
patients in the study, to the point of being highly intrusive. All
manner of methods were employed to determine the regularity with
which patients being treated at home consumed their medication, and
this despite the patients having been carefully selected for being
‘cooperative’. Urine tests were carried out routinely, on ‘completely
unexpected visits’ to the patients’ homes.32 Dr C.V. Ramakrishnan
recalls how patients in the study were ‘educated, advised, and I would
say, in this particular study, even indoctrinated, to some extent, that
if they miss a treatment, they will pay dearly for it’. Dr Ramakrishnan
tells the story of spending most of his holiday in the town of
Coimbatore trying to locate a ‘wastrel and drunkard’ who had
dropped out of the treatment study, and bringing him back to
Madras.33
This tension between scientific research carried out by highly com-
mitted researchers like Dr Ramakrishnan, and the practicalities of public
policy, was present from the early stages of the research in Madras. The
conflict focused on the balance between the necessary complexity of

such a trial, and the need for results that could be put into practice as
policy. The tensions are brought out particularly starkly in a letter to
Wallace Fox, the British director of the Madras project, from Johannes
Holm, the WHO’s chief adviser on tuberculosis in Geneva, written in
1957. Holm claimed that ‘I am more and more convinced that our
views on these problems differ a great deal; in fact we seem to have basi-
cally different views on the objectives of the Madras projects’. Holm was
of the impression that Wallace Fox and his team wanted to
… do everything possible for each one of your patients, including

those who have deteriorated after the treatment in the trial to which
they have been allocated; that is those patients who, for the purposes
of the trial, can be described as failures and thereafter can be of little
or no scientific interest. I realize that this is from humanitarian or, if
you prefer it, clinical considerations and feelings.34
For Holm, however:
The objectives of the project as I see them – and I think WHO in

general – are somewhat different. They are to study the effect, in
terms of rendering infectious patients non-infectious and keeping
them so, of treatment that is inexpensive and which consists of self-
administration of drugs with no close clinical supervision by experts
and with no complicated laboratory tests.35
From the point of view of wanting treatment to be as cheap and rapid

as possible, Holm suggested that he did not understand Wallace Fox’s
‘scientific reasons for insisting on such low doses of INH [isoniazid],
which are considered insufficient by most people today’. ‘I would not
be too afraid of complications if the treatment was highly effective.’36
Yet, the results of the Madras trial stated unequivocally that multiple
drug combinations were far more effective than a single-drug
regimen.37 This disagreement over the question of whether to rely
heavily on high doses of isoniazid (the cheapest of the available drugs),
would come back to haunt the WHO in later years. Holm concluded
his letter to Fox with the warning that: ‘I fully realise that in a
scientific trial you sometimes have to use complicated methods and
examinations … [but] I am afraid, I have already told you personally,
that by making the trial too complicated the purpose of the study will
be defeated.’38
The exchange between Wallace Fox and Johannes Holm shows,

tangibly, the clash between biomedicine and technical assistance in
terms of their priorities, and the professional dispositions that under-
pinned them. They illustrate the potential disjunction between the
commitment of the physician to cure each patient, and the demands
on international public health officials to cure the greatest number at
the lowest cost. Because the chemotherapy trials had been conceived
with international policy implications in mind, the main question
concerned the relationship between scientific research and practical
intervention.
For some participants in the debate, the results of the Indian research
served to underscore the complex rage of interventions needed to
address the problem of tuberculosis in poor countries. In the midst
of an important WHO policy debate in 1962, one Dr Abu Shamma
suggested that:
He was much interested in the trend to encourage ambulatory treat-

ment on a house-to-house basis since in most of the developing
countries hospital beds were in scarce supply … [but a policy of drug
treatment] needed some strengthening through accompanying
social measures. He had in mind that UNICEF might help by supply-
ing dried milk and vitamins or additional feeding of some kind to
patients under domiciliary treatment, in order to raise their resis-
tance to the disease…. Secondly, UNICEF and WHO might join in
urging governments to improve housing conditions for such cases
so that the patient might have his own room and thus lessen the
danger of infection to others, and to subsidise the family to some
extent whilst the breadwinner was unable to work.39
Dr Abu Shamma’s views suggest the range of factors that needed to

be considered in formulating a sustainable tuberculosis policy, in the
light of the information gathered in India: questions of cost (the
limited ‘budget assigned to national health services’); nutritional
status (‘in order to raise resistance to the disease’); social security, and
living conditions all needed to be considered. However, this broad
‘ecological’ view of health, and health policy, was eclipsed over the
course of a number of policy debates and official publications issued
between 1962 and 1965, in favour of the more familiar view of ‘causal
necessity’.40 That is to say, in favour of using ‘specific means…to
attack the ubiquitous tubercle bacilli directly – through highly potent
drugs’; means which rendered the ‘natural evolution of the disease,
and … such environmental factors as nutrition, housing, sanitation

and social security’ irrelevant.41
A series of articles in the WHO Chronicle declared that the ‘astound-
ing’ findings from India transformed the WHO’s tuberculosis strategy
into one based on chemotherapy: ‘The Tuberculosis Chemotherapy
Centre in Madras [has] shown that, given the drugs and time,
nothing else was really necessary for the treatment of advanced
tuberculosis.’42 Notably, it was decided that drug treatment could be
implemented ‘without the need’ for ‘accompanying social mea-
sures’;43 and in ‘practically any epidemiological or socio-economic
conditions’.44
In 1964, a report of the WHO’s Expert Committee on Tuberculosis
set out clearly the main thrust of international strategy thenceforth:
national programmes based on simplified technology would be imple-
mented through existing health infrastructures.45 The WHO experts
employed a synthesis of the Madras and Bangalore studies, whatever
their mutual contradictions, to justify the dismantling of mobile X-ray
centres, and the transformation of tuberculosis hospitals into multi-
purpose health centres and general hospitals. The Expert Committee
directive from 1964 also recommended the simplification of the infor-
mational base for tuberculosis control: active ‘case-finding’ was given
far less emphasis, and this is reflected in the significant decline in the
number of countries reporting any kind of tuberculosis statistics to the
WHO by the end of the decade, and into the 1970s.46
The strategy of limiting international tuberculosis policy to the ques-
tion of drugs, with less attention (even on a rhetorical level) to the
social nature of the disease, arose from the interaction of the exigencies
of cost-effectiveness with the shift to the individual level in analysing
and understanding tuberculosis (that is to say, the belief that each case
could be treated). Yet, as a disease linked inextricably with social prac-
tice, the ‘control’ of tuberculosis called for a degree of medical control
and surveillance which neither the Indian health infrastructure nor the
WHO, was able to provide. Undoubtedly implicit in the work of the
NTI in Bangalore and the clinical trials in Madras, was an effort to
reform the attitudes, the subjectivities of poor tuberculosis patients,
and to create rational, compliant patients. This required a level of
social control that could only, if at all, be achieved within the ‘unreal-
istic’ conditions of a scientific experiment. In the end, the focus shifted
towards achieving a basic minimum ‘target’ for the number of patients
treated, and even these targets were allowed to lapse. The strategy,
from the mid-1960s, was that, since the treatment for tuberculosis had
been ‘simplified and standardized’, it could be delivered through exist-

ing health services, however rudimentary they might be.
The overall impact, in a recent review by two contemporary WHO
tuberculosis specialists, was that ‘dismantling of specialized services and
delegation to general services was not accompanied by any extra re-
sources’. Indeed, they suggest that ‘no significant impact on tuberculosis
indicators could be achieved in the less-developed countries’.47
Dangerous journeys
From the outset, it was amply clear that drugs themselves were far from
enough to ensure that tuberculosis chemotherapy would succeed as a
strategy. The artificiality of the medical experiment which had given
rise to those conclusions became clear in the course of efforts to imple-
ment anti-tuberculosis chemotherapy in other parts of India, beyond
the purview of the WHO and the Indian and British Medical Research
Councils. ‘Paradoxical though it may appear’ said Miss K. Das, a nurse
at a Delhi Tuberculosis Centre, ‘the success of antibiotics in the treat-
ment of tuberculosis has increased and complicated the connected socio-
economic problems’.48 Das pointed out what the Madras study had itself
uncovered, even whilst dismissing it as irrelevant to the success of
treatment: a poor tuberculosis patient, she said, ‘usually has the burden
of a big family, is ill clad, ill fed and almost at the verge of starvation’.
For those not fortunate enough to be covered by the fully-funded
chemotherapy trials in Madras, or the WHO-supported social research
programme in Bangalore, affording the drugs was almost impossible.
Das found that 84 per cent of patients under treatment ‘are unable to
afford antibiotics for themselves’. Only very few were ‘provided with
antibiotics by [a] contributory health scheme, [the] Employees’ State
Insurance Corporation, and other schemes’.49 Nutritional supplemen-
tation from ‘outside agencies’ was indeed welcome, but the ‘flow of
such help is not steady, and after a time, the need of patients remains
unmet, due to lack of continuous programme and funds’.50
Despite the efforts of the NTI social research to uncover some of the
social and psychological consequences of domiciliary treatment of
tuberculosis, it was left to ‘social workers’ to point out the depths of
pain and suffering that chemotherapy entailed. Many patients ‘who feel
exhausted due to the disease’, and are under advice to ‘take rest’,
‘cannot get it in a crowded home’. The situation was particularly bad for
‘a daughter-in-law in the family’: ‘the patient may feel embarrassed to
have any extra care for herself … at times the heartless and frustrated
in-laws go on nagging the female TB patient for bringing in the ailment

and ruining the life of her husband’.51 Women who were given food ‘by
an outside agency’ said they felt particular ‘shame’: ‘I am nothing short
of a demon or demoness’, one woman told the psychiatrist, ‘when
I take milk, butter and eggs, and my children subsist on chapattis and
salt’.52
The conclusion that chemotherapy could be universally effective was
founded, in essence, on the assumption that, firstly, most patients
would make the rational choice to seek and complete courses of
chemotherapy.53 Secondly, and crucially, it assumed that the requisite
level of ‘medical supervision’, however minimal, was in place, with
deep social reach. The ‘problem’ of ensuring that tuberculosis patients
took their drugs was, in fact, largely a question of how deeply the
medical apparatus of surveillance and supervision was able to penetrate
the urban environment. Stig Andersen and D. Banerji concluded that a
programme of drug therapy against tuberculosis could
… only be properly dealt with through an all-embracing national

programme in which all infectious cases diagnosed are registered in
geographically organized case indexes and transferred from one to
another as the need arises …[if] a patient is diagnosed in one area
and then treated in another or moves during the treatment period.54
Furthermore, as Andersen and Banerji pointed out:
… in the search for the basic reasons for patients’ not taking drugs,
common sense should not be forgotten. Except under very special
circumstances of mass hysteria, it has never been demonstrated that
a large group of people can be persuaded, without force, to adopt a
new habit from which they never deviate.55
The inevitable frustrations of the task did, in some circumstances, lead

health workers to place the responsibility for treatment failures on the
‘ignorance’ or obstruction of the patients themselves. A WHO nurse in
India wrote in 1963 that ‘perhaps even as many as a third of patients
were resistant to all forms of persuasion, and should be identified as
soon as possible’. This ‘wilful non-co-operation’ was only treatable
through institutional ‘supervision and discipline’.56
Yet, it is precisely this level of social control, and ‘discipline’ that was
lacking. The NTI found that the very chaos of the urban landscape and
the fluidity of population rendered any hope of tight control over
patients taking drugs at home very difficult. Writing of the patients

who were lost to the study because their ‘houses could not be found’,
the investigators at the NTI pointed out that:
in many cities in India, and presumably in several other countries, an

address is not necessarily adequately described in terms of a street and
a number. One needs description in terms of landmarks, distances
and directions from these, perhaps in terms of names of inhabitants
of neighbouring houses, for example, those of shop owners.57
While there seemed to be scope for ‘improvement in address-taking’,

the NTI researchers concluded that ‘it would seem unlikely that this
problem can be solved until the whole street-naming and house-
numbering system has been improved’.58 That is to say, a degree of
control over tuberculosis patients taking chemotherapy could not be
achieved until the map of south India’s cities had been rendered more
‘legible’ to bureaucrats and medical policymakers.59 These problems
were, in a sense, a symptom of the social change and massive urban
influx of the 1950s and 1960s.60 The Indian anthropologist M.N.
Srinivas, in an essay on Bangalore, speaks of the post-independence
transformation of the city’s cantonment area, with ‘wide roads…big
trees and flowering shrubs’ giving way to ‘long narrow lanes in which
houses cling to each other, the neighbourhood being palpable, noisy
and conflict ridden’. The influx of migrants from neighbouring states
led to ‘slums on the outskirts of the cantonment … [and] parts which
look like they have been transplanted from a small Tamil town’.61
The lanes through which the WHO had to pursue recalcitrant
patients were difficult to navigate, if they were marked on the map at
all. As one of the early social surveys of Bangalore made clear:
… the area lying to the south of Nagarthapet up to Narasimharaja

Road, from Avenue Road up to the United Mission High School com-
pound is the most congested one … In the cantonment the area
between Timmaiah Road and Broadway Road … the area between
Commercial Street and Russel Market are mostly congested. In the
above areas, there are no sufficient open places between houses. The
streets with the houses on both the sides are very narrow. Dust and
dirt surround these houses. Sanitation is very poor in these localities.62
This was not a problem confined to South India. As the strategy of

using anti-tuberculosis chemotherapy was extended, gradually,
beyond its testing ground in South India, and incorporated into tech-
nical assistance programmes, the problems of Bangalore multiplied.63
Michel Foucault observed, in the case of eighteenth century Europe,
that for a process of outpatient treatment (the shift towards a ‘domes-
tic form of hospitalization’) to work, there needed to be a ‘medical
corps dispersed throughout the social body, and able to offer treat-
ment for free or as cheaply as possible’. 64 As a WHO technical assis-
tance mission to Rangoon quickly realized in 1964, however, it was
precisely this level of dispersion of medical care within society that
was missing.65 The old problem of inadequate health services came,
once again, to hinder efforts at disease control. Paradoxically, this
was the very problem that the WHO and its partners had attempted
to circumvent through mass campaigns of disease control that were
independent of local health services. Efforts were made to map out
the landscape of Rangoon in terms of the distribution of health ser-
vices, depicting, in stark visual form, the limits of control. For, in the
case of long-term drug therapy, surveillance and ‘control’, as the
Bangalore studies showed, was at a premium.
In this and many other more detailed maps, Mr Thorup, the WHO
consultant in Burma pondered the impenetrability of areas of
Rangoon, where the reach of the ‘medical gaze’ did not reach, where
the streets – if they were there at all – had no names. He made a
detailed ‘Survey of Ethnic Composition, Economic Status, Type of
Residence and Accessibility of Rangoon Area’.66 The survey found
that the townships of Htaukkyant, Saik-kyi and Dalla, their residents
‘Burmese only’, ‘poor’ in economic status, were filled with ‘primitive
housing/congested’, and were of ‘very poor’ accessibility to the
medical apparatus, both national and international, charged with
curing tuberculosis with drugs.67
At the very moment when medical technology offered the promise
of circumventing the environment, the power of the environment to
shape patterns of health, illness and treatment came sharply into
view. Journeys, in Bangalore and Rangoon alike, were deeply
hazardous ones from the epidemiological point of view. Indeed,
the revolution in chemotherapy did little to weaken the hold of
earlier conceptions of disease and contagion, which, if anything,
were stronger by the early 1960s – a generation after the announce-
ment of international aspirations to vanquish disease – than in the
1940s.
Several commentators, both administrative and medical, continued
to hold to an almost miasmic theory of disease; contagion comes from
the filth of the environment, which is the ultimate ‘menace to public

health’. In the words of a 1961 census report on Madras City:
One has to go round Kotwal market in George Town and its sur-
rounding areas to see how much the locality is in need of sanitation
… the sewage and sullage tend to settle down, causing a perpetual
stench that pervades the entire neighbourhood, pollutes nearby
wells in houses and constitutes a menace to public health and the
aesthetic susceptibilities of the people.68
This description dates from the early 1960s, exactly the time when the
Madras chemotherapy studies appeared to show that environment was
irrelevant to the successful treatment of tuberculosis. The implication
here is that even the treatment of every tuberculosis case, would not
dent the underlying epidemiological picture. One of the striking fea-
tures of the official report on Madras, from which the statement above
is drawn, is its timeless nature. The descriptions of pathogenic urban
squalor move rapidly across time and space: contemporary accounts
from the early 1960s are juxtaposed with extracts from colonial reports
of the early twentieth century, suggesting that nothing much had
changed.69
As was suggested in an earlier chapter, ‘Asia’ was treated as a single
category for the administration of public health policies. Observers in
the international organizations, and many of their counterparts in
national governments, saw Asia in terms of a set of shared problems
and shared conditions, all of them amenable to technological interven-
tion. However, an older discourse on ‘Asia’, focusing on the almost
insurmountable problems of ‘filth’ and the tropical environment, had
not disappeared.70 This focus upon the pathogenic dangers of the
urban environment spanned from India to Burma and Indonesia.
Colonial and post-colonial, national and international medical dis-
courses were amalgamated in a way that challenged, unwittingly, the
optimistic narrative of progress in international public health.
The end of eradication
Nowhere did the ‘return of nature’ seem more devastating than in the
field of malaria control. The ‘attack’ phase of the global malaria erad-
ication campaign reached its zenith in 1960–61, at which point no
fewer than 66 countries were part of the programme. In India, site of
the largest national malaria eradication programme, 150,000 people
were employed in malaria eradication work by 1961. By that year,

malaria cases accounted for less than one per cent of all hospital
admissions, an astonishing diminution in the burden of malaria.71 By
1963, the WHO claimed that of the 147 territories that it initially
declared to be ‘malarious’, 45 had ‘wholly or partially eradicated
malaria’.72
Yet an increasing number of reports, first anecdotal and then formal,
made reference to ‘problem areas’, where all was not going according
to plan. In February 1962, at a conference of the Royal Society of
Tropical Medicine and Hygiene, a number of malariologists expressed
their unease with the problems encountered by the malaria eradication
campaign. M.J. Colbourne, a British malariologist working for the
WHO in Southeast Asia, suggested that ‘not a few campaigns have
stated with a good prospect of successful malaria eradication, but have
come near to disaster, usually due to failures of organization’.73
He went on to suggest that ‘it appears that resistance is seriously inter-
fering with progress in several countries’, while in other places, ‘there
are vectors whose period in contact with a sprayed surface is so short
that it is doubtful whether it is possible for a lethal dose to be picked
up’.74 Colbourne pointed out that, across the region, it was only
in Taiwan that malaria had been almost eradicated, and that Taiwan
presented a very specific set of conditions:
The case-finding mechanism most suitable for Taiwan was deve-

loped from local experience. The campaign has the advantage of a
well-developed rural health services which served as a framework for
operations, a well-developed national administrative service, and a
well-trained and enthusiastic staff in adequate numbers. It must be
admitted that the vector, A. minimus minimus, is very susceptible to
attack with residual insecticides.75
This hardly suggested a campaign easily replicable elsewhere. Col-

bourne’s observations found support among the audience at the Royal
Society. Sir Gordon Covell, a veteran malariologist with experience in
South Asia, highlighted the ‘magnitude of the problem of malaria on
the Indian sub-continent’, and reminded the audience that Pakistan’s
failure to commence large-scale DDT spraying put India at risk of
‘re-infection’ on its frontiers.76 Others like John McArthur, a health
official in British Malaya, suggested that his experience showed that
‘malaria eradication is a local problem, depending on the conditions,
and on the habits of the local vector’. Blanketing the world with DDT,
he argued, ‘seemed to me an unscientific approach, to reject the

findings of research and to apply instead a measure found to be effec-
tive in some other parts of the world’.77 He looked back, that is to say,
to the approaches to malaria control that characterized myriad local
experiments in South and Southeast Asia in the 1930s.
The sceptics were still, in the early 1960s, ‘heretics’ of a kind.78
However the turning of the tide became fully clear in Sri Lanka, long a
‘model’ for malaria control. So successful was the initial campaign of
DDT spraying in Ceylon that spraying had virtually ceased by the mid-
1950s. Following a brief resurgence of malaria in 1956, the government
called in international assistance to resume large-scale spraying opera-
tions.79 The success was fragile. The Sri Lankan medical infrastructure
was better developed than many of its neighbours’, and health workers
continued to collect samples of blood regularly, to test for malaria
infection. Yet it emerged that the majority of samples had come from
regions of relatively low risk for malaria infection; in the regions where
malaria had been hyper-endemic, the basis for medical surveillance
was far less secure.80 F.R.S. Kellett, a WHO official wrote that he feared
the ‘situation had been smouldering for a longer time than originally
realised’.81 A full-scale epidemic finally broke out in 1968 and was dev-
astating, because earlier successes in preventing malaria transmission
had led to a loss of immunity among the population. In a short space
of time, the number of malaria cases in Sri Lanka jumped from perhaps
a few hundred to half a million.
Perhaps more important than natural resistance to DDT were prob-
lems of a very similar nature to those confronting the WHO’s tuber-
culosis control efforts: a lack of medical infrastructure, and the virtual
impossibility of medical surveillance. In India, as elsewhere in South
and Southeast Asia, medical power was very widely dispersed, medical
police almost non-existent. Yet an active programme of ‘case-finding’
constituted a crucial stage in malaria eradication. After the initial cam-
paign of intensive spraying, to eliminate the anopheles vector, malaria
control teams needed to find all infected persons in an area and treat
them with anti-malarial drugs so that the human reservoir of plas-
modia would be eliminated before the mosquitoes could return.82 As
with the detection of tuberculosis, malaria surveillance could be
‘active’ or ‘passive’, the former involving regular house visits by
malaria workers, the latter ‘requires all people suffering from fever to
report to various individuals, voluntary and paid, who have been given
instruction on how to take blood films and administer anti-malarial
drugs’.83
The ‘active case finding’ in India was the responsibility of surveil-

lance officers, each paid three rupees a day, equivalent to a wage for
unskilled or semi-skilled labour. The work was ‘even more tedious and
repetitive than the job of the sprayman’, and there was evidence that
teams routinely avoided villages far from the main roads, and ‘con-
cealed their delinquency by taking an excess of blood samples from
families more easily reached’.84 Passive case finding by hospitals was no
more promising. Gordon Harrison observed a public health system
inadequate to the task, with tales of hospitals forgetting to order micro-
scope slides, and doctors ignoring the ‘routine’ tasks of surveillance:
‘what struck the visitors as probably symptomatic of similar failures
elsewhere was not so much the technician’s forgetfulness as the
doctors’ unconcern’. Such was the state of rural health services that ‘by
the time a reasonably prompt report came that a particular individual
was infected, he might have left his village or because of a false or
ambiguous identification at the local clinic have become untrace-
able’.85 We see here exactly the same powerlessness on the part of the
medical administration as also characterized the attempts to treat
tuberculosis.
In 1961, there were fewer than 100,000 cases of malaria in India.
Between 1961 and 1965, the number of cases jumped to 150,000, and
then doubled again within a few years. The Indian government itself
concluded, in an investigation into the resurgence of malaria in the
country, that:
We can see that in those States where the rural health services are
well developed, such as Mysore and Kerala, reversions have not
occurred, and the maintenance is kept under good control even in
areas previously hyperendemic. In other words, the map of reverted
areas can be super-imposed on those with delays or imperfections in
the development of the rural health sector.86
Yet the complexity of the problem emerges from the fact that careful
investigations in the 1980s suggested that the resurgence of malaria in
India was due less to the ineffectiveness of DDT than to shortages of it.
V.P. Sharma and K.N. Mehrotra argued, in 1986, that the cessation of
free supplies of DDT from the US government in 1963 (in the aftermath
of Rachel Carson’s Silent Spring); shortages of foreign exchange, and
inefficiencies in domestic production left several States with shortfalls
of DDT at crucial moments in the ‘attack’ on malaria. ‘Although insect-
icide resistance did pose a problem’, they argued, the ‘resurgence of
malaria could not be contained … mainly because of want of insecti-

cides rather than their failure’.87 This reminds us, once again, that the
technologies of disease control were genuinely effective; that there was
always debate, as there still is, over whether the ‘obstacles’ and ‘set-
backs’ of techno-politics could and should be met with the ever-more
intensive use of technology.
The mounting frustrations of international public health by the early
1960s provoked some within the WHO to question the very basis on
which the organization had intervened in Asia and beyond from the
late-1940s. Karl Evang, one of the first presidents of the World Health
Assembly, a veteran Norwegian public health specialist, and amongst
the most reflexive practitioners of international public health, was par-
ticularly eloquent in his analysis during the 1963 World Health
Assembly. He argued that malaria eradication had, for a time, ‘captured
the imagination not only of the hundreds of millions suffering from
the disease but also of the economists and politicians’. For as long as
malaria eradication was funded by voluntary donations, an ‘advertising
method’ was needed – with all the hyperbole and drama this entailed.
With the removal of large-scale American support, however, ‘such
methods were no longer possible’. Evang declared that it might be nec-
essary ‘at a later stage’ to ‘drop’ the notion of eradication altogether; at
the very least it needed re-definition.88
The problem confronting the WHO, however, was of a much more
fundamental nature, and that was to do with the ‘relationship between
the specialist organs of the malaria eradication machinery and the
rural health services of the countries concerned’. Evang suggested,
reflecting on the mixed experiences of international public health in
the 1950s and early 1960s, that there were clear limits to how far a
‘mass campaign’ approach could go. His analysis is worth quoting at
length, so much does it touch on issues that have been at the core of
this book:
With the first group [of diseases], which included malaria, smallpox,
cholera, plague and yaws, very good primary and secondary results
could be obtained without involving the local population: all that
was asked of them was cooperation with vaccination and spraying
teams.
The second group, however, which included tuberculosis, leprosy,

diseases of mothers and children … could only be fought if the local
population was completely involved from the outset. The most
difficult thing of all was asked of them: to change their daily habits
concerning food, irrigation and other matters.89
The ‘second’ group of diseases, Evang argued, could not be tackled

‘unless rural health services were developed’. Despite the conspicuous
success against the ‘first’ group of diseases, ‘diseases in the second
group had spread’. Evang suggested that this threatened to become a
‘terrifying situation for the local population’, and, worse, ‘one that
would undermine their trust in the health services’. Evang suggested
that the time might have come to reverse, completely, the WHO’s
order of priorities: ‘no programme for the eradication of any disease
should be introduced in any country until the integrated basic health
service existed’.90
Few within the WHO were as openly critical as Evang of the state of
affairs that prevailed by the mid-1960s.91 Yet Evang’s criticisms
reflected, without necessarily being influenced by, a more general trend
within public health thinking about the complexity of the ‘epidemio-
logical transition’.
Eradication and evolution
In the practice of public health there remained great uncertainty about

the potential for further progress in using technology to transform the
relationship between pathogens and humanity. While practitioners
debated the future of disease control, the failures and frustrations of
the mass campaigns of disease control provoked an ecological critique
of the entire philosophy of disease eradication, a critique as uncompro-
mizing as earlier celebrations of the concept. When the biologist
Rachel Carson published her findings on DDT’s capacity to cause
lasting ecological damage, she captured the imagination of a genera-
tion in the United States and Western Europe. She recognized that
technology itself posed grave dangers to human health in the short
and the long-term. Hers was but the most prominent of a number of
ecologically informed critiques of the techno-centric approach to
development, which the malaria eradication programme seemed to
encapsulate.
Perhaps the most thoroughgoing critique of the whole philosophy of
disease eradication came from the microbiologist Rene Dubos, of the
Rockefeller University. In his opus Man Adapting, of 1965, Dubos
pointed to the ‘rapid occurrence of mutations endowing the parasites
with resistance to any kind of drug that is widely used … we are
engaged in an endless cycle of synthesizing at an ever-increasing cost

more and more insecticides to which vectors become progressively
more resistant’.92 There was a fundamental error, he suggested, in the
idea that ‘malaria’ could be eradicated, since
Malaria is not a single disease, but a huge congeries of diseases,

occupying a large number of ecological provinces each with its par-
ticular conditions. The multiplicity of problems comprised under
the single word malaria makes it therefore hazardous to conclude
that a given procedure that has been effective in a particular area
will necessarily prove effective in another.93
Dubos went on to argue that ‘the biological truth is that elimination of

one particular agent makes the ground available for another or even
usually for several other kinds of pathogens’, a fact illustrated by the
fact that ‘non-specific’ infections caused by malnutrition ‘dominates
the pathogenic picture in a large part of the underprivileged world
today’.94
Epidemiological research began to confirm Dubos’s suggestion that
the prevention of mortality from certain widespread diseases would
not necessarily lead to lessened morbidity. By the 1960s, then, public
health specialists increasingly accepted that the leading cause of mor-
bidity and mortality in the Third World was not the ‘named’ diseases
which had shaped the vast campaigns of disease control after 1945, as
the ‘pneumonia-diarrhoea complex’, which could be caused by a
number of pathogens, and which depended on the nutritional status of
the individual.95
The triumph of population control
If one line of argument criticized disease control for not being success-
ful enough, another suggested that it had been too successful. The eco-
logical critique of disease eradication pointed to the wily resilience of
pathogens in overcoming insecticides and chemotherapy alike. This
accorded with the experience of health workers and administrators
who confronted the challenges of the ‘tropical’ environment. Yet
others had, from the 1940s, seen in the perceived success of disease
control campaigns a profound threat, in its facilitation of rapid popu-
lation growth. I argued (in Chapter 3, above) that international public
health had, from the start, to defend itself against the charge that it
would herald a population explosion. The decision to adopt mass
campaigns like that of malaria eradication was, in large part, shaped

by their promise to deliver dramatic success at low cost, and thus to
support the argument that they facilitated rather than hindered eco-
nomic development, to an extent that outweighed the economic
drain of a fast-growing population. So long as the ‘romance’ of disease
eradication remained strong, the WHO managed to maintain support
and funding for its massive programmes. When their façade began to
fragment, when frustrations and obstacles mounted, the champions of
population control were waiting in the wings, now armed with new
technologies of their own.
The history of international efforts to control population has
produced a vast literature spanning history, demography and anthro-
pology.96 Throughout the 1950s, coincident with the apogee of faith in
disease eradication, American private foundations and a number of
other non-governmental groups assembled a vast infrastructure of
research and training in population studies. Like international public
health, population control grew out of myriad pilot projects, local
experiments and technological changes; population control developed
as a ‘powerful submerged programme waiting to burst into action’. Yet
the ‘insidious, diffuse and incontestable atmosphere of public oppro-
brium’ surrounding birth control in the United States meant that,
unlike public health, the infrastructure of population control was built
up on the margins of official ‘policy’.97 For a number of reasons, the
ground was prepared by the early 1960s for the official adoption of
population control: Ansley Coale and Edgar Hoover gave the argument
for population control the seemingly incontestable authority of eco-
nomic science in their influential 1958 publication Population Growth
and Economic Development. Furthermore, in late 1961, the new Kennedy
administration showed itself more open than its predecessor to the
prospect of intervening directly to limit population growth in the
Third World. Above all, it seemed now that fertility, as much as mor-
tality could be transformed through technology: new tools were avail-
able, as cheap and almost as easy to distribute as antibiotics or DDT:
the Intra-Uterine Contraceptive Device (IUCD) and then the contra-
ceptive pill.
Thus, as Paul Demeny has argued, ‘the beginnings of large-scale
family planning programmes in the developing world are a story of the
1960s’. In 1965, Lyndon Johnson, convinced by his economic advisers
and by the growing acceptability of contraceptive technology, declared
before the United Nations that less than $5 invested in population
control was worth more than $100 invested in economic develop-
ment.98 By the mid-1960s, population policy became a ‘sector’; by the

late 1960s, the UN had established a separate Fund for Population
Activities (UNFPA), and the World Bank began to intervene in the
field. Most importantly, from the perspective of the history of public
health, funding for population control was often diverted straight from
funding for public health.99
The new technology, and the new funding catalysed interest in pop-
ulation control across Asia, where there had long been a constituency
of administrators and activists interested in birth control and who per-
ceived population growth as a threat to national welfare (and, on some
views, to women’s health).100 Mohan Rao has shown with great clarity
how the agenda of population control in India came to ‘dominate con-
cerns in the field of health and contoured the directions of health
policy’. A major shift came, Rao argues, when a UN advisory mission
convinced the Indian government, in 1964, that the IUCD could be
used on a massive scale, thus overcoming the problems faced thus far
in the proven unpopularity of the ‘rhythm’ method, and the dangers
attendant on surgical methods. The central government undertook to
fund population control activities in the states (even as they refused to
cover the costs of their public health apparatuses), and from 1966,
family planning was created as a separate ministerial responsibility,
granted almost as much in funding as the entire public health service
of India.101 Matt Connelly, using recently opened archives, has
explained this shift with reference to the power struggles within the
Indian administration, with enthusiasts for family planning within the
Planning Commission prevailing over the beleaguered Ministry of
Health.102
But part of the reason why population control was able to sweep
aside the demands of international public health so comprehensively
in the 1960s lies in the very language in which international public
health justified itself. I have argued (in Chapter 3) that by claiming the
language of economic development and the quantification of the value
of human life, the WHO and its supporters temporarily succeeded in
attracting support for public health. Yet, as Gordon Harrison – himself
a participant in the global drama of public health – noted poignantly,
reflecting on the failure of malaria eradication, this recourse to the
language of economic rationality was double-edged:
If the model predicts that fighting disease pays, then the exercise
can seem as harmless as it ought to seem superfluous. But suppose
the fight is found not to pay. As the whole point of running a
cost-benefit model is to sway governments presumed to be respon-

sive to that kind of argument, would they not be under as strong
pressure to forgo malaria control when the model lights turn red
as to proceed when they are green?103
The underlying implications, he suggested, went to the heart of the

debate about valuing human life that motivated the foundation of the
WHO in 1946. ‘It used to be argued’, Harrison lamented, ‘that develop-
ment was a good thing because it benefited people; now we seem to be
on the point of agreeing that people are a good thing so far as they
benefit development’.104 The shift from public health to population
control, a shift latent in the 1950s and manifest in the 1960s, was at
least in part a product of this emphasis on the instruments over the
fundamental values of development.105 The logic that underpinned
arguments for population control rested upon a negative, rather than a
positive, valuation of human life – a birth averted is money saved.106
By the late 1960s, the WHO’s smallpox eradication programme
emerged as the sole ‘showpiece’ for international health, partly because
the USSR had adopted it as a project to champion after re-entering
the WHO in 1957 after almost a decade’s absence. The programme
intensified in 1967, when the US government decided to support it as a
gesture, at a time when the vast majority of their foreign aid funds for
‘health’ were being channelled to population control.107 The smallpox
eradication programme, it is well known, became the WHO’s one great
‘success story’, and it is the campaign with which the organization
remains most closely associated. Smallpox, however, had a number of
unique features that made it amenable to eradication whilst avoiding
the frustrations that had beset malaria or tuberculosis policies. First, in
stark contrast to malaria, the disease had no animal reservoir, and no
long-term human carriers; the characteristic rash made it easy to iden-
tify infectious people, quite unlike the ‘silent’ tuberculosis. Finally,
the vaccine, unlike BCG, was proven to be highly effective, and heat-
stable. It was, in short, ‘unique in relation to human infections’.108
In other ways, too, the smallpox eradication campaign of the late
1960s and 1970s was a very different entity to the campaigns against
malaria, tuberculosis and yaws considered in this book. Harish
Naraindas has argued that in the early 1970s, smallpox was ‘recast
from a deity into a demon’, a force of evil to be vanquished by the
needle, an ‘instrument of God (science/technology) in the battle
against the demon’. The language of good and evil was of a fundamen-
tally different order to the language of development underpinning the
campaigns of the 1950s, suggesting implicitly that this language, this

method of reasoning, had failed. Smallpox eradication provided a way
to recapture an element of drama, of legitimacy and purpose, when the
frustrations of the techno-politics of the 1950s threatened to under-
mine the very mission of international public health. Few, if any, inter-
national health workers spoke of the new utopia of a world without
disease. They focused, instead, on the more realizable goal of a world
without the demon smallpox. Writes Naraindas:
Its seemingly inherent legitimacy (marked by the visibility of the

disease and the ‘fear’ of leaving one marked for ever?) makes persua-
sion, ruse and excess both legitimate and ‘understandable’ tools.
…In the bargain the state, and super-states like the WHO, not only
legitimate and renew their contract but consecrate themselves.109
If we were to extend – too far, perhaps – Naraindas’s metaphor of

smallpox eradication as a ‘grand act of ritual purging’, it appears that
by focusing that intently on the goal of eradicating the demon small-
pox, by using all means (including force), the WHO expurgated the
sense of failure that hung over its entire mission after the mid-1960s.
Conclusion: dispersion and ‘medical pluralism’
Speaking to a WHO conference in Brazzaville in 1968, the WHO tuber-

culosis specialist and future Director-General, Halfdan Mahler, sug-
gested that tuberculosis control policies in the future needed to
recognize that ‘the technology for controlling tuberculosis’ had been
‘standardized and simplified to such an extent’ that the problem lay
merely ‘in setting up an effective … sales organization with standardized
consumer goods’.110
Reflecting, briefly, on the legacies of the myriad interventions that
this book has attempted to examine, it seems that Mahler’s statement
touches upon an important element of truth. Mass campaigns of
disease control did not work as they were meant to, but they had a
number of unintended consequences that continue to shape exper-
iences of illness and therapeutics today. I have argued, throughout the
book, that repeated attempts to reform or to shape the behaviours of
populations, first their sanitary and nutritional habits, and later their
responses to the offer of medical technology, were incompletely suc-
cessful. To ensure that tuberculosis patients visited health clinics
weekly to consume drugs; that primary health workers reported ‘fever’
cases and tested them for malaria; that ‘voluntary’ vaccinations were
accepted, was a fraught and ultimately frustrating process. Yet new
technologies, nevertheless, were appropriated, adopted, and internal-
ized by very large numbers of people.
Recent anthropological research has shown, clearly, that ‘self-care
with modern pharmaceuticals’ is the dominant form of therapy in
large parts of Asia and Africa today. Research in many different set-
tings, including in South and Southeast Asia, suggests that belief in the
power of pharmaceuticals, and particularly injections, plays an impor-
tant part in shaping people’s therapeutic practices. Susan Reynolds
Whyte and colleagues write of a ‘popular belief that health can be
obtained and maintained through the consumption of commodities,
medicines’.111
Though the introduction of western medicine long pre-dates the
international campaigns of disease control, the mass campaigns of
the 1950s did, as we have argued, reach a far greater proportion of the
populations of South and Southeast Asia than anything that had gone
before. To that extent, the appropriation of modern medical technolo-
gies in daily life may well be a consequence of the experience of the
mass campaigns of the 1950s. In an article exploring the ‘popularity of
injections in the Third World’, H.V. Wyatt suggested that this was
indeed the case. He argues that the WHO’s (and, in Africa, colonial
governments’) yaws eradication campaigns, with their ‘massive use of
injections’, served to ‘establish the injection as the pre-eminent
therapy in places as widespread as Ghana, Brazil and Ceylon’.112 Their
attraction was due to the dramatic and immediate effects of these
specific therapies in relieving symptoms. A similar argument might be
made about certain kinds of chemotherapy against malaria, which
large numbers of people were exposed to in the later phases of the
malaria eradication programme. Thus Whyte et al suggest that ‘efficacy
provides evidence that changes the culture of health’. In the process,
the use of medical technology was routinized, internalized as a stan-
dard, even ritual, response to feelings of illness.113
This was an outcome that might be explained, at least in part, by the
very process this book has tried to describe. Planners and administra-
tors of national and international health programmes experienced a
gradual loss of control: control over patients, over practitioners, over
health workers, over the environment, and over the very technologies
that gave them power. The last two chapters, in particular, have
suggested that each of these elements of international public health
circulated in an increasingly ungoverned fashion over the course of the
1950s and early 1960s. The control of vaccinations, of treatments and

prophylactics was initially designed to remain carefully within the
control of a hierarchy of experts, reaching from the WHO headquarters
in Geneva to the village malaria surveillance team or tuberculosis
clinic.
These medical technologies ‘were not supposed to become common
commodities’, but the effort to control them was ‘doomed to failure’.
For
As the value and power of injections became established within the

growing biomedical health care system, health workers themselves
began to sell them in order to supplement their salaries. Lay specialists
(and needlemen) carried forward the process of commodification.114
The very weakness of local health infrastructures meant that pharma-

ceutical technologies have circulated in an unregulated way.115 ‘Malaria
doctors’ dispensed not only anti-malarials, but also all manner of other
drugs.116 Powerful anti-tuberculosis agents became available from
private providers, from grocery shops and ‘medical stores’ to private
clinics and ayurvedic practitioners.117 Rarely if ever were patients able
to afford to complete their courses of treatment, leading, inevitably, to
the spread of drug-resistant pathogens.
The production and marketing of pharmaceuticals, throughout the
Third World, became an increasingly lucrative commercial enterprise,
and this is a process we will understand only dimly.118 The restraints
organizations like WHO and national governments exercised upon the
global pharmaceutical industry began to fragment in the late 1960s.119
It was not least as a result of the powerlessness of the organization to
secure the supplies needed to implement its policies that the Director-
General, Halfdan Mahler, embraced a more strident rhetoric in the
1970s, arguing that ‘a huge medical industry has grown up with pow-
erful vested interests of its own. Like the sorcerer’s apprentice, we have
lost control, social control over health technology’.120 The WHO’s
radical attempts to ensure that poor countries had access to generic
versions of ‘essential drugs’ did not, ultimately, prove effective in the
face of the pharmaceutical industry’s power.121
On one view, voluntary self-medication with drugs provides people
with a degree of control over their own health. Certainly, thinking of
people as ‘consumers’ of, say, anti-tuberculosis drugs rather than
‘patients’ (or, worse, ‘targets’) gives them considerably more agency.122
In the view of medical anthropologists who have studied the effects of
the commoditization of medicines in recent decades, it remains the

case that ‘money, however little, can be a crucial mode of empower-
ment in the struggle for health. It allows people to make an exchange,
to choose a commodity without being dependent on an inconvenient,
patronizing and demeaning formal health care system’.123 Yet the dom-
inant picture is a bleak one. As mutant pathogens necessitate the use of
increasingly powerful, and expensive, pharmaceutical agents, so more
and more people have been killed by a lack of access to increasingly
expensive drugs, or by the consumption of incomplete courses of
(sometimes suspect) medicines.124 Yet the belief in drugs prevails. As
Mark Nichter put it in his study of medical practices in South India
and Sri Lanka:
The false consciousness generated by health commodification serves

to undermine the impetus to participate in ecological-environmental
based popular health movements in a context where they are of
crucial and immediate importance.125
It may be going only slightly too far to see this as one of the longer-
term legacies of the WHO’s choice – a choice I have tried, in this book,
to explain – to see health primarily in terms of things.
Conclusion
The period under consideration in this book, the 1930s to the

mid-1960s, saw rapid declines in overall levels of mortality around the
world, and particularly in the Third World. On this there is general
consensus amongst demographers. The most dramatic reductions in
mortality were seen in the 15 years between 1945 and 1960. A sample
of 18 ‘under-developed’ countries showed that whereas the period
from 1935–39 had brought a 6.3 per cent decline in mortality rates
compared with the previous five-year period; the percentage declines
in mortality over subsequent five-year periods, respectively, were
15.2 per cent for 1945–49, and 20.1 per cent for 1950–54.1 In the case
of India, official estimates of infant mortality show that the rate fell
from 182 per 1,000 in the period 1941–50, to 146 per 1,000 in the
following decade.2 In sub-Saharan Africa, too, 1950 has been identified
as the starting point for a rapid growth of population founded, above
all, on the intensification of mortality decline.3
The most rapid rates of mortality decline began in the aftermath of
the Second World War, coinciding with the most intensive phase of
the international campaigns against infectious diseases in Asia and
Latin America, and the growth of colonial public health efforts in sub-
Saharan Africa. Commentators at the time saw a direct causal connec-
tion between the two phenomena, not least commentators within the
UN itself. Soon after the commencement of a worldwide programme of
‘technical assistance for economic development’, the UN’s Preliminary
Report on the World Social Situation spelled out the implications of the
early experiments in international health after the Second World War:
Against disease the general advance has been substantial in recent

years, and, in some of the less developed areas, it has been dramatic,
179
with death rates dropping as much as 50 per cent in a few years’

time. The extension of modern methods of mass-disease control,
which can eliminate such scourges at relatively little cost, accounts
in good part for these successes.4
This reflected a widespread perception in the 1950s that international

health campaigns were universally effective; that they could work
regardless of local conditions.
The unprecedented power of relatively cheap medical technology
convinced many observers that health could be greatly improved
without waiting for economic development. The demographer George
Stolnitz described the increasing dissociation of health from economic
development in an influential 1955 paper in the journal Population
Studies, where he argued that ‘the primary role of international rather
than national health agencies, the use of antibiotics, the development
of cheap yet effective methods for combating malaria’. Each of these
developments was ‘a mid-century innovation’, and each challenged
the ‘emphasis on overall socio-economic conditions as determinants of
survival levels.’5 The new vaccines and chemotherapeutic drugs,
an early WHO report declared, ‘gave doctors the means of attacking,
selectively, the specific causes of disease.’6
Kingsley Davis, one of the most eminent population theorists after
the Second World War, painted an even more unequivocal picture.7 It
was commonly believed, Davis wrote in the American Economic Review
in 1956, that ‘the fundamental cause of declining death rates was
considered to be economic development’. If employed as ‘an interpre-
tation of Western history’, Davis suggested, such a view ‘seems
essentially correct’. However, ‘when it is applied to contemporary
under-developed areas, it is wrong; for the truth is that these areas do
not need to become economically developed to reduce their death
rates drastically’.8
The case of Ceylon provided perhaps the most dramatic illustration
of this point. In just five years, between 1945 and 1950, the mortality
rate in Ceylon had fallen by 24 per cent. This outcome Davis attrib-
uted in large part to the WHO-sponsored DDT-spraying campaign
across the island, which began in 1946. Based on this and other exam-
ples, Davis argued that ‘the great reduction of mortality in under-
developed areas since 1940 has been brought about mainly by the
discovery of new methods of disease treatment’, and by the ‘diffusion’
of these technologies ‘through international organizations’. This mor-
tality decline ‘did not depend on general economic development or
Conclusion 181
Figure C.1 Estimates of World Population, 1920–60 (’000,000s)
2600
2100
World
1600 Africa
Americas
1100 Asia
600
100
1920 1930 1939 1950 1954 1960
Source: compiled from UN, Demographic Yearbook, various years, 1948–62
Table C.1 Infant Mortality Rates, 1945–65 (rate per 1,000)
1945–49 1950 1952 1953 1954 1955 1956 1957 1958 1959 1960
Burma1 303.9 240.3 239.2 230.6 198.6 177.6 166.8 164.3 147.6 130.3 148.6
Ceylon 110.5 77.0 78.4 71.2 72.0 71.5 66.5 67.5 64.5 57.5 56.8
India2 132.7 118.9 115.9 117.8 109.4 99.9 102.2 99.4 100.2 87.0 86.5
Indonesia3 – 95.2 82.5 89.4 107.4 100.4 99.6 99.6 83.5 84.1 –
Philippines 114.7 101.5 101.6 105.3 94.2 84.3 83.9 93.0 80.0 72.4 73.1
Singapore 98.7 69.4 70.0 67.1 56.0 49.6 42.5 41.1 43.4 35.8 34.8
Thailand 82.2 63.8 62.8 64.9 63.5 56.1 55.2 62.2 54.1 47.1 48.7
Vietnam – 48.8 – – 48.8 42.3 46.6 33.4 35.4 32.2 36.3
Notes:
1
Burmese Figures include urban areas only.
2
Data for a changing group of states and territories over the period.
3
Data for a changing group of regencies over the period. UN report declares that for Indonesia, these are
‘estimated rates’: ‘source unknown’.
Source: UN, Demographic Yearbook, various years, 1948–62.
social modernization’, nor did it depend on ‘training local medical

personnel’ (although, if the argument of this book is correct, it
depended a great deal on the training of local medical auxiliaries and
technicians). Ultimately, and despite ‘lip service paid to the necessity
of general economic improvement and community welfare’ in public
health textbooks, ‘the truth is that many scourges can be stamped out
with none of this’; Davis added, for effect, that this could be achieved
‘just like diseases in cattle can be eliminated’.9 The conclusion of
Davis’s argument, in keeping with his widely disseminated views on
over-population, was that international disease control was producing

an unsustainable level of population growth, something that was
likely to end in Malthusian disaster. The champions of international
health, we have seen, turned the argument around, and suggested
that improvements in health – using cheap and universally applicable
technology – were a necessary prerequisite for economic development.
But what appeared as an indisputable ‘secular’ trend to Kingsley Davis
seemed very different indeed in the eyes of the young Pramoedya
Ananta Toer, the great novelist of modern Indonesia. In a short story,
‘My Kampung’, published in 1952 – as the mass vaccination programmes
and malaria spraying teams were underway in Indonesia – Pramoedya
painted a picture not of progress but of an ever-present threat of illness
and death. His words mock the promises of governments and interna-
tional organizations; they question what it really meant to speak of a
‘right to health’.
The story appears in a collection of tales and sketches set in the
Djakarta of the late 1940s and early 1950s, its characters are Djakarta’s
labouring poor. The subtitle to the collection, ‘Caricatures of
Circumstances and Their Human Beings’ is strongly suggestive of the
tone of the stories, with their atmosphere of futility and despair.10 ‘My
Kampung’ begins with a caricatured image of filth and pestilence, so
characteristic of the colonial discourse on the tropical environment.
Pramoedya evokes the grotesque and the corporeal, even as his tone
alternates between resignation and sarcasm. The story begins: ‘Friend,
you’ve heard the name of my Kampung, haven’t you? Kebun Djahe
Kober, five hundred metres in a straight line from the palace. And you
also know, don’t you? Its gutters are covered in shit of the kampung res-
idents’ (p. 77). Distancing himself, immediately, from the presumed
revulsion of the reader at the opening description of the kampung, the
narrator declares: ‘This is not a situation that ought to be admired or
condemned’ (p. 77).
The narrator declares that not even a ‘small guerrilla squad’ –
writing, here, in the aftermath of Indonesia’s bloody war of indepen-
dence – would suffer the mortality of this kampung, ‘with its stink and
condition’, where ‘people die one after another’ (p. 78).
There follows a sordid catalogue of the many residents of the nar-
rator’s alley, one of seven in the kampung, who had suffered ‘cheap’
deaths. There is the case of the man who dies from ‘chronic venereal
disease’; the mother who kills her favourite child with an overdose
of worm medicine; the print setter who dies of lead poisoning, and
the Chinese shop owner who flees on a ship to ‘die in [his] own
Conclusion 183
country’, leaving his wife to die in the Kampung. And then there are
the countless victims of tuberculosis: ‘T.B. did not surprise anyone in
my kampung anymore; it was something routine’ (p. 83). In keeping
with the tone of tragedy, bordering on farce, the narrator makes no
attempt to pass judgement on the situation. Instead, he implicitly
mocks the discourse of hygiene and public health: ‘If killing with
weapons is punished by the government, killing because of igno-
rance and poverty is not prohibited in my kampung, even if the
killing is of one’s own child. It is a routine situation and perhaps
quite understandable’ (p. 82).
If this portrait of the kampung Kebun Djahe Kober appears to mock
the promises of a new era of health and hygiene, the effect was entirely
intentional. It is the conclusion of ‘My Kampung’ that makes it such
an explicit, and interesting, commentary on the global discourse of
public health. ‘You too, friend, can come to my kampung sometime’,
the narrator says, ‘finding it is not hard at all’ (p. 84). The kampung,
after all, is a stone’s throw from the Palace: ‘five hundred metres in a
straight line towards the southwest, there my kampung stands in all its
glory, defying the doctors and the technical professionals’ (p. 84). And
then this striking point is repeated once more: ‘the kampung’s located
so near the palace where everyone’s health, and every little detail is
guaranteed’ (p. 84).
Thus, even after a generation of disease control and eradication pro-
grammes, when the trends that Davis and others identified were clear,
Frantz Fanon could write, in 1965, that
The colonized person, who in this respect is like the men in under-
developed countries or the disinherited in all parts of the world, per-
ceives life not as a flowering or a development of an essential
productiveness, but as a permanent struggle against an omnipresent
death. This ever-menacing death is experienced as endemic famine,
unemployment, a high death rate, and inferiority complex and the
absence of any hope for the future.11
Here, in the juxtaposition of the plunging mortality statistics and

the continuing experience, of so many, of illness and (technically)
‘preventable’ death lies the most fundamental paradox that has
informed this book. New technologies, channelled to governments
through international organizations committed to providing the ‘right
to health’ saved hundreds of thousands of lives, yet poverty continued,
quite literally, to kill.
The explanation for this gulf lies, partly, in the nature of the changes
brought about by the mass campaigns of disease control. The demo-
grapher Samuel Preston estimated that at most 30 per cent of the
overall reduction in mortality in the Third World between the 1930s
and the 1960s was due to ‘measurable aspects of social and economic
development, such as income, literacy and nutrition’. The remaining
70 per cent he ascribed to ‘exogenous…factors such as anti-malarial
programmes, immunization and other vertical governmental and inter-
national programmes’.12 Essentially, the international campaigns of
public health, built on so many local experiments, had a massive
impact on the incidence of certain kinds of diseases, but not others.
By the mid-1960s, there was a significant slowing in the rate of mor-
tality decline. Explanations for this deceleration of mortality decline,
while absolute levels of mortality were still relatively high, have
focused both on the dramatic success of the campaigns of the 1950s,
and on their supposed failings. Samuel Preston illustrates the case for
the success of the disease-specific ‘mass campaigns’ of the 1950s by
suggesting that, given the dissociation between life expectancy and
economic level due to the internationalization of disease control pro-
grammes, ‘one would expect to observe certain differences in the struc-
ture of mortality by cause of death…. In particular, diseases most
closely associated with standards of living, and the least amenable to
attack by specific medical and public health measures, ought to be rela-
tively more prominent in the later population’. This situation, Preston
argues, did indeed prevail in developing countries in the mid-1960s.13
Even as the dramatic successes of the campaigns against ‘named’ dis-
eases were being celebrated, public health specialists were pointing out
that ‘non-specific’ diarrhoeal diseases were in fact the biggest killers in
Asia and Africa.14 These ‘non-specific’ infections proved much less
amenable to control with technological ‘magic bullets’. This was part
of the explanation for the apparent paradox that, even as international
health campaigns appeared to be successful, the huge toll of ill health
on Third World countries remained clear for all to see, as indeed it
does to this day.
A second explanation for the slowing in mortality decline after the
early 1960s, however, has to do with changes in the international cam-
paigns themselves. It has been argued that, at the very point when
efforts to eradicate malaria, for example, should have been intensified,
international and governmental support for the initiative flagged. As
was shown in Chapter 6, evidence of increasing drug resistance, and
numerous practical difficulties faced by malaria eradication teams were
Conclusion 185
increasingly reported by the mid-1960s. By the late 1960s, malaria had

begun to re-appear in a major way. In the case of tuberculosis control,
too, potentially valuable technological breakthroughs – the advent of
home-based chemotherapy to cure the disease – led to official apathy
and a reduction in funding, based on the mistaken belief that with
effective technology at hand, the problem of tuberculosis was effec-
tively solved.15 The fact that such international health programmes
operated with ‘sharply reduced intensity’ from the mid- to late-1960s,
Preston argues, is the major explanation for the ‘sluggish’ mortality
decline after 1965.16
Others have argued, however, that the very success of the mass cam-
paigns of the 1950s contained the explanation for the eventual
reverses; the attempt to use technology to subdue nature was, on this
view, unsustainable, and bound, ultimately, to fail. Thus, the massive
use of DDT during the malaria eradication programme produced drug
resistant mosquitoes; the unsupervised distribution of anti-tuberculosis
drugs led to the development of resistant strains.17
The effects of health policy
For a demographer like Samuel Preston, explaining the conditions of

possibility for the dramatic mortality decline of the mid-twentieth
century, it is sufficient to say that ‘universal values assured that health
breakthroughs in any country would spread rapidly to all others’.18 This
book, however, has tried to show that this process of ‘universalization’
was a complex and contingent historical phenomenon.
The transformations that demographers identify are related, in
myriad ways, to the changing ideas of international officials (colonial
administrators, theorists of social medicine, nurses, and UN policy-
makers), to their changing perception of diseases and environments,
and the ways of acting upon those diseases and environments. To the
extent that the decline in mortality was a direct consequence of the
‘health policy’ of the 1950s, its explanation must be found, in part, in
the debates which universalized public health, making the health of a
villager in India or Indonesia an ‘international problem’, to be dis-
cussed in Geneva and New York as much as in Delhi or Djakarta.
The history of the mortality revolution of the 1950s is also the history
of frustrated Scandinavian nurses waiting for supplies of vaccine; of
the enthusiasms of Indian malariologists and ‘DDT fiends’; of the
difficulties faced by poor tuberculous men and women in getting to the
local health clinic, every week, to consume antibiotics.
From the 1930s, an international movement grew up around ques-

tions of rural public health, concerned with taking modern tech-
niques of public health, and health education, to the masses of Asia
and Africa. The League of Nations Health Organization international-
ized this concern, allowing for a discussion, across imperial frontiers,
of ‘health policies’ that were being formulated, piecemeal, in different
locations. The rise of nationalist concern with public health gave
these debates a sharper edge, and the international forum of the
League allowed them a voice. The (almost) ‘universal’ values of this
period were the values of ‘rural reconstruction’, and, increasingly, of
equity, between city and country and between different regions of the
world. Rural romanticism was combined, here, with a heightened
understanding of the bodily effects of crushing poverty.
The Second World War was the source of the medical technologies
which allowed for the fight against infectious diseases to be intensified.
Just as importantly, however, the war gave rise to the institutions
which would shape ‘health policy’ after 1945, and shaped the dispos-
itions of a generation of public health workers around the world who
believed in the possibility of a world free from disease. Above all, and
building on the experience of the 1930s, the war made it possible to
see the ‘world’ as the main unit of analysis in public health.
The focus of this book has been on the way these debates were man-
ifested in the Asian arena, within which India was at the centre of
international policy debates, and interventions in health. As I have
argued throughout this book, international health, late-colonial
welfarism, and the institution of post-colonial developmental states
committed to the ‘right to health’, were all products of the same set of
ideas and historical processes, with their immediate origins in the after-
math of the 1930s Depression. The particular political conjuncture of
Asia in the 1950s – post-colonial states at the height of their con-
fidence, working with and via international organizations at the height
of their prestige and influence – was central to the formation of the
increasingly global political culture of health.
One of the recurrent themes in our discussion of the international-
ization of public health has been the relationship between knowledge
and intervention; and between description and prescription. From the
outset, participants in the world of international public health dis-
cussed the consequences of what they were doing: Was public health,
in the new technological era, independent of standards of living? Were
health technologies a major cause of population growth? Or did
health, by contrast, provide the key to economic development? Was
Conclusion 187
medical technology universal, thus making ‘culture’ and ‘society’

unimportant? In tension with the technological approach to public
health was an approach that attempted to change minds, and bodily
practices. Paradoxically, the more effective the medical technology
became, the more it was dependent on particular behaviours, such as
the regular, long-term consumption of anti-tuberculosis drugs.
Part of the problem for international health, by the end of the 1950s
and into the 1960s, was the weak and fragile way in which it could
exercise governmental power. What has emerged throughout this
study is the lack of control and power which international health poli-
cies were able to exercise over people (who would not take their drugs),
over nature (not all diseases were susceptible to technology, and some
grew resistant), and over post-colonial states (not as easily moulded to
the plans of technical assistants as they had hoped). The narrow power
which international organizations, and their national counterparts,
were able to exercise was a power based on spectacle, image, and
enthusiasm. It was unsustainable in the long-term.
Faith and doubt
The high point of the symbolic power of international health was

reached with the launching of the global malaria eradication pro-
gramme in 1955. It seemed that a new utopia was on the horizon. As
one Indian report enthused in the mid-1950s, internationally-sup-
ported public health campaigns had brought the ‘relief of human
illness and suffering [that] has changed the face of the country … a
new era of health and happiness is dawning for the people living in
erstwhile malarial tracts’.19 Yet, it has been suggested here that even at
the height of this apparent confidence, international health was beset
by numerous fears, and its progress was always fragile.
By the early 1960s, these fears were articulated increasingly widely.
Few commentators were more scathing in their criticisms of the tech-
nological approach to international health, and the idea of disease
eradication, than the American biologist Rene Dubos. Even at the
height of confidence in the ‘magic bullet’ of post-war biomedicine,
Dubos adhered to a strongly environmentalist view of health, arguing
that ‘while drugs and other specific therapeutic procedures are impor-
tant in restraining microbial agents, they rarely bring about lasting
control of a chronic infectious process. This demands in most cases a
reform of the conditions which have made the individual or the
societal body prey to the disease’.20 By the time Dubos wrote his opus,
Man Adapting, in the 1960s, his scepticism about the potential of inter-
national campaigns of disease control to bring about lasting results was
more widely shared. At a time when Rachel Carson’s seminal work,
Silent Spring drew attention, in the West at least, to the destructive eco-
logical effects of DDT, and when ‘environmental’ diseases were becom-
ing increasingly prominent in both the West and the Third World, it
might have begun to seem that techno-centric disease eradication was
a misguided folly.21
To the extent that Dubos did credit them with success in bringing
about a reduction in mortality in the 1950s, he saw the ultimate conse-
quences of the international health campaigns as profoundly threaten-
ing. Echoing a line of argument familiar amongst population theorists,
Dubos argued that the current rate of population growth in the world
could not long continue. The question, he suggested, was: ‘… will the
break come from the operation of natural growth-limiting factors …
from a biological catastrophe … from a technological accident, such as
nuclear warfare or wholesale poisoning by environmental pollution?’22
The only cause of optimism, in Dubos’s view, was that ‘several pro-
grams are presently under way in many parts of the world to bring the
population avalanche under some form of rational control’, suggesting
that these, rather than programmes of disease control, were what was
needed to bring ‘man’ into a more harmonious relationship with
nature. Dubos was no crude Malthusian, however, and did accept the
possibility that better health might, in itself, ‘change ways of life’, and
encourage people to ‘raise their sights beyond the dismal present’ –
that is to say, to limit the sizes of their families.23
But the fundamental problem, Dubos suggested, was the new ‘utop-
ianism’ which had infiltrated characterized public health in the 1940s;
the utopianism of the Andrija Stampars and John Ryles of that era, the
drafters of the WHO Constitution. The Beveridge Report of 1942, and
all of its global counterparts, from India to South Africa, reflected ‘the
utopian views of universal health through the eradication of disease
that were then and are still widely held all over the world’. The techno-
logical breakthroughs of the Second World War gave this new utop-
ianism a particular slant. Unlike the idyll of Hygiea, and other Victorian
visions of public health and hygiene, ‘the medical utopias of our times
… assume that the achievement and maintenance of health depend
not upon living in accordance with the laws of nature, but upon
medical care based on scientific bio-technology’. This was, ultimately, a
‘dangerous mirage’ for Dubos. The time might not be far off, Dubos
suggested, when there might arise an ‘anti-utopian movement directed
Conclusion 189
against scientific medicine’; a medical equivalent of H.G. Wells’

portrait of the Mind at the End of its Tether.24
From an historical perspective this is, of course, a familiar debate.
Gareth Stedman Jones has recently written about the faith, of the late
eighteenth century, that scientific and economic progress could
‘abolish poverty’. In the aftermath of the French Revolution, this
conception was assailed by a ‘conservative and anti-utopian transfor-
mation of political economy’, with Malthus’ population theory at its
heart. Malthus’ ideas, Stedman Jones suggests, ‘provided the main
bulwark against further attempts to enlarge the framework of collective
welfare provision for around a century’.25
The 1940s provided a historical moment when, once again, visions
of scientific and economic progress leading to an end to poverty were
widely shared; for the first time, these visions were extended beyond
the Western world. I have argued, here, that visions of a world free
from disease provided an important part of this international imagina-
tion of the future. For a brief period, a language of political and
scientific possibility did supplant a language of ‘natural forces’ when
talking about health and development. Against this conception was
ranged the persistently strong Malthusian tradition, which ‘sub-
ordinated all history, law and culture to an instinctual non-social and
ahistorical force’.26 In the Asian arena of the 1960s, it was decidedly
this latter tendency that prevailed.
By focusing on the positive value of individual lives, the discourse
of international public health, and the ‘right to health’ did, for a
brief period, offer an alternative to the instrumental approach to
health, population and development that prevailed. For a time, dis-
cussions of public health on a transnational scale focused on ‘the
human being – the working, creating, hoping and struggling human
being’.27 The social medicine of the 1930s and 1940s had been con-
cerned with discussion and persuasion; with mental as well as phys-
ical health; with political rights and the end of imperial rule.
Speaking to the WHO’s Regional Committee for Southeast Asia in
1954, Jawaharlal Nehru captured the spirit of idealism behind the
expansion of international health and welfare policies. Nehru sug-
gested, optimistically, that the WHO might do something about the
‘mental conflicts, the political events’ that ‘disturbed’ humanity. ‘If
the mind of the individual or of the group is disturbed’, he suggested,
‘it becomes difficult for the body to find equilibrium or any proper
balance’. Turning to the question of health and population policies,
their relative balance, Nehru declared that: ‘it amazes me how often
we forget the human being in our statistical conferences. We think in

terms of blocks and curves or other such figures, forgetting that all
these things represent individual men, women and children’. People,
he declared pointedly, ‘are not blocks, they are not some mechanical
gadgets that you can play about with and order about’. The makers of
international health policy should ‘treat people as individual human
beings who must be convinced, who must be made to understand
and must be won over to any cause we seek to further’.28
This language of citizenship and rights was overtaken – in India, at
the United Nations, and in most of the Third World – by a conception
of development whereby legitimacy stemmed not from the participa-
tion of citizens in social transformation, but from the ability of the
state and international organizations to provide for the well-being of
carefully defined ‘targets’ of policy.29 By this logic (‘providing more
well-being to more people at less cost’) it soon appeared that popula-
tion control might prove a much more efficient intervention than
public health.
Enduring utopias
This book has been concerned with describing and explaining an

episode in the international history of public health. To a large extent
the period from the 1930s to the 1960s is a bounded one; bounded by
assumptions and relationships that no longer exist.
Yet, Charles Rosenberg reminds us, current policy is, inevitably,
shaped by previous struggles for authority, definition and resources.
Policy, in Rosenberg’s terms, is ‘structured contingency’.30 Given the
history we have recounted here, it would be unrealistic to expect
that, in the present, the WHO could be other than a narrow technical
organization seeking technical solutions to social problems.
Yet within its own genesis, in its constitutional commitment to
the ‘right to health’, the Organization continues to hold out claims of
entitlement. Writes Pierre Bourdieu: ‘As soon as principles of universal
validity … are stated and officially professed there is no longer any
social situation in which they cannot serve at least as symbolic
weapons in the struggles of interest or as instruments of critique’.31 The
‘right to health’ is still available for use as a weapon in the contingent
and transient mobilization of population groups in the Third World on
the terrain that Partha Chatterjee calls ‘political society’, groups for
whom the ‘right to health’ is further than ever from realization.32
Doubtless the order of international public health has often served to
Conclusion 191
silence issues of inequality, distribution and class. Yet, organizations

like the WHO are still in a position where they are, returning to
Bourdieu’s words,
Capable of acting as a kind of umpire … ultimately less unfavour-

able to the interests of the dominated, and to what can be called
justice, than what is exalted, under the false colours of liberty and
liberalism, by the advocates of ‘laissez-faire’, in other words the
brutal and tyrannical exercise of economic force.33
In the increasingly acute struggle between the right to health of hun-

dreds of millions of people and the imperious demands of the global
pharmaceutical industry, the WHO might still have an important,
political, role to play.
Notes
Introduction
1 League of Nations Archives, Geneva (hereafter LNA), Box 6095, 8A, 26762
8855, Note Prepared by Dr Haynes [typescript], [n.d.? 1936].
2 K. Davis, ‘The Amazing Decline of Mortality in Underdeveloped Areas’,
American Economic Review, 46, 2 (1956), 305–18.
3 A. Iriye, Global Community: The Role of International Organizations in the
Making of the Contemporary World (Berkeley: University of California Press,
2002).
4 A. Iriye, Cultural Internationalism and World Order (Baltimore and London:
The Johns Hopkins University Press, 1997).
5 Examples of recent work which I have found particularly illuminating
include: M. Connelly, A Diplomatic Revolution: Algeria’s Fight for Independence,
and the Origins of the Post-Cold War Era (New York: Oxford University Press,
2002); M. Connelly, ‘Population Control is History: New Perspectives on the
International Campaign to Limit Population Growth’, Comparative Studies in
Society and History, 45 (2003), 122–47; D.C. Engerman, ‘The Romance of
Economic Development and New Histories of the Cold War’, Diplomatic
History, 28, 1 (2004), 23–54, and C. Anderson, Eyes Off the Prize: The United
Nations and the African American Struggle for Human Rights, 1944–1955
(Cambridge: Cambridge University Press, 2003).
6 C.A. Bayly, The Birth of the Modern World, 1780–1914 (Oxford: Blackwell,
2004), esp. pp. 320–22. Informal processes of medical exchange, of course,
can be traced back over millennia.
7 M. Foucault, The Birth of the Clinic: An Archaeology of Medical Perception,
trans. A. Sheridan (London: Tavistock, 1976), pp. 23–6. On the nature of
these transitions, see also C. Rosenberg, Explaining Epidemics and Other
Studies in the History of Medicine (Cambridge: Cambridge University Press,
1992), and James C. Riley, The Eighteenth-Century Campaign to Avoid Disease
(New York: St. Martin’s Press, 1987).
8 C. Rosenberg, Explaining Epidemics, pp. 293–304.
9 For a detailed history of the sanitary conferences, see N.M. Goodman,
International Health Organizations and Their Work (London, 1952).
10 Goodman, International Health, pp. 60–1.
11 Goodman, International Health, pp. 49–79.
12 J. Hutchinson, Champions of Charity: War and the Rise of the Red Cross
(Boulder, CO.: Westview Press, 1996), p. 347.
13 J.M. Cooper, Breaking the Heart of the World: Woodrow Wilson and the Fight
for the League of Nations (New York: Cambridge University Press, 2001).
14 Susan Pedersen ‘Settler Power: What Difference did the League of Nations
Make?’ Paper presented at conference on ‘Settler Colonialisms in the
Twentieth Century’, Harvard University, October 2002, p. 1. I am grateful
to Dr Pedersen for showing me the manuscript of her talk. See also
192
Notes 193
M.D. Callahan, Mandates and Empire: The League of Nations in Africa,

1914–1931 (Brighton: Sussex Academic Press, 1999).
15 M. Dubin, ‘The League of Nations Health Organization’, in P. Weindling
(ed.), International Health Organizations and Movements, 1919–1939
(Cambridge: Cambridge University Press, 1995), pp. 56–80.
16 M.A. Balinska, For The Good of Humanity: Ludwik Rajchman Medical
Statesman, trans. R. Howell (Budapest: Central European University Press,
1998).
17 P. Weindling, ‘Social Medicine at the League of Nations Health Organ-
ization and the International Labour Office Compared’, in P. Weindling
(ed.), International Health Organizations, pp. 134–53, p. 142.
18 For more on the Rockefeller Foundation, see Chapter 1 below. For a detailed
but rather narrow history see, J. Farley, To Cast Out Disease: A History of the
International Health Division of the Rockefeller Foundation (1913–1951)
(Oxford: Oxford University Press, 2004).
19 Farley J., To Cast Out Disease.
20 H. Bell, Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899–1940 (Oxford:
Oxford University Press, 1999), chapter six.
21 See, in particular, L. Murard and P. Zylberman, ‘L’Autre Guerre (1914–1918).
La Santé Publique En France Sous L’Oeil de l’Amérique’, Revue Historique 276
(1986), 367–98; L. Murard and P. Zylberman, ‘French Social Medicine on the
International Public Health Map in the 1930s’, in E. Rodriguez-Ocaña
(ed.), The Politics of the Healthy Life: An International Perspective (Sheffield:
European Association for the History of Medicine and Health Publications,
2002), pp. 197–218. The latest research emerging from work on the
Rockefeller Archives is available in the Rockefeller Research Reports, at http://
www.archive.rockefeller.edu/publications/resrep/rronlinemain.php [accessed
20 December 2005]. For a more conventionally ‘instrumentalist’ view, see
S. Hewa, Colonialism, Tropical Disease and Imperial Medicine: Rockefeller
Philanthropy in Sri Lanka (Lanham, MD: University Press of America, 1995).
22 See Chapter 2 for a fuller discussion and references.
23 M. Vaughan, Curing Their Ills: Colonial Power and African Illness (Cambridge:
Polity Press, 1991), p. 5.
24 P. Curtin, Death by Migration: Europe’s Encounter with the Tropical World in
the Nineteenth Century (Cambridge: Cambridge University Press, 1989).
25 On the concern of early colonial medicine with the bodies of slaves, see
Megan Vaughan, Creating the Creole Island: Slavery in Eighteenth-Century
Mauritius (Durham, N.C.: Duke University Press, 2005), chapter five; Megan
Vaughan, ‘Smallpox, Slavery and Revolution: 1792 on Ile de France’, Social
History of Medicine, 13 (2000), 411–28.
26 Key works in the field include: D. Arnold, Colonizing the Body: State Medicine
and Epidemic Disease in Nineteenth-Century India (Berkeley and Los Angeles:
University of California Press, 1993); G. Prakash, Another Reason: Science and
the Imagination of Modern India (Princeton: Princeton University Press, 1999);
W. Anderson, ‘Excremental Colonialism: Public Health and the Poetics of
Pollution’, Critical Inquiry 21 (Spring 1995), 640–69; M. Vaughan, Curing
Their Ills. Two historiographical reviews: S. Marks, ‘What is Colonial About
Colonial Medicine? And What has Happened to Imperialism and Health?’
Social History of Medicine, 10, 2 (1997) 205–9; W. Anderson, ‘Where is
194 Notes
the Postcolonial History of Medicine?’ Bulletin of the History of Medicine, 79, 3

(1998), 522–30.
27 Arnold, Colonizing the Body.
28 Arnold, Colonizing the Body, pp. 139–40; see also Prakash, Another Reason,
chapter 5.
29 Vaughan, Curing Their Ills, p. 8.
30 Cf. Anderson, ‘Excremental Colonialism’.
31 Vaughan, Curing Their Ills, esp. pp. 10–14.
32 W. Anderson, ‘The Third World Body’ in R. Cooter and J. Picktone (eds),
Medicine in the Twentieth Century (Amsterdam: Rodopi, 2000), pp. 235–45;
Vaughan, Curing Their Ills, p. 23.
33 Michel Foucault, ‘Governmentality’, in G. Burchill and C. Gordon (eds), The
Foucault Effect: Studies in Governmentality (London: Harvester Wheatsheaf,
1991).
34 Foucault argues that ‘population has its own regularities, its own rates
of deaths and diseases, its cycles of scarcity … the domain of population
involves a range of intrinsic aggregate effects, phenomena that are irreducible
to those of the family, such as epidemics, endemic levels of mortality,
ascending spirals of labour and wealth’. ‘Governmentality’, p. 100.
35 See, for example, D. Scott, ‘Colonial Governmentality’, Social Text, 43
(1995), 191–220; Prakash, Another Reason; Ann Laura Stoler, Race and the
Education of Desire: Foucault’s History of Sexuality and the Colonial Order of
Things (Durham: Duke University Press, 1995); Sarah Hodges, ‘Govern-
mentality, Population and the Reproductive Family in Modern India’,
Economic and Political Weekly, 13 March 2004
36 Anderson, ‘The Third World Body’.
37 This is the argument of Prakash, Another Reason, chapter five.
38 Cf. Carey Watt, Serving the Nation: Cultures of Service, Association and
Citizenship (New Delhi: Oxford University Press, 2005). See Benjamin
Zachariah, Developing India: An Intellectual and Social History (Delhi: Oxford
University Press, 2005), pp. 110–32, on the discourse of community
development and cooperation in late-colonial India.
39 On this process in general, see Partha Chatterjee, The Politics of the Governed:
Reflections on Popular Politics in Most of the World (New York: Columbia
University Press). See also, Sudipta Kaviraj, ‘On State Society and Discourse
in India’, in J. Manor (ed.), Rethinking Third World Politics (London/
New York: Longman, 1991), pp. 72–99; Sudipta Kaviraj, ‘In Search of Civil
Society’ in Kaviraj and S. Khilnani (eds), Civil Society: History and Possibilities
(Cambridge: Cambridge University Press, 2001), pp. 287–323.
40 For different views on this tendency, see Partha Chatterjee, Nationalist
Thought and the Colonial World: A Derivative Discourse? (London: Zed Books,
1986); Sugata Bose, ‘Instruments and Idioms of Colonial and National
Development: The Indian Experience in Comparative Perspective’, in
F. Cooper and R. Packard (eds), International Development and the Social
Sciences: Essays in the History and Politics of Knowledge (Berkeley and
Los Angeles: University of California Press, 1997), pp. 45–63. Bose suggests,
contra Chatterjee, that centralization was not an inevitable but a contingent
outcome. See also K. Sivaramakrishnan and Arun Agrawal (eds), Regional
Modernities: The Cultural Politics of Development in India (Delhi: Oxford
Notes 195
University Press, 2003). For a sensitive consideration of the state-centred

political culture of Indonesia, see Henk Schulte Nordholt, ‘A Genealogy
of Violence’, in F. Colombijn and Th. Lindblad (eds), Roots of Violence in
Indonesia (Leiden: KITLV Press, 1002), pp. 33–61; see also Benedict
Anderson, Spectre of Comparisons: Nationalism, Southeast Asia and the World
(London: Verso, 1998).
41 Partha Chatterjee, ‘Development Planning and the Indian State’, in
P. Chatterjee (ed.), State and Politics in India (Delhi: Oxford University Press,
1997), pp. 271–97.
42 Manual of the International Statistical Classification of Diseases, Injuries and
Causes of Death, 6th revision (Geneva: WHO, 1948).
43 Randall Packard, ‘Postcolonial Medicine’, in R. Cooter and J. Pickstone
(eds), Medicine in the Twentieth Century; and R. Packard, ‘Malaria Dreams:
Postwar Visions of Health and Development in the Third World’, Medical
Anthropology, 17 (1997), 279–96.
44 S. Bose and A. Jalal, Modern South Asia: History, Culture, Political Economy
(London/New York, 1998), p. 110. See also the indictment in M. Davis, Late
Victorian Holocausts: El Niño Famines and the Making of the Third World
(London: Verso, 1999).
45 F. Cooper, Decolonization and African Society: The Labor Question in British
and French Africa (Cambridge: Cambridge University Press, 1996), pp. 376–7.
46 Cooper, Decolonization, p. 382.
47 J.W. Meyer, J. Boli, G.M. Thomasa and F. Ramirez, ‘World Society and the
Nation State’, The American Journal of Sociology, 103, 1 (1997), 144–81.
48 See Chapter 2, below.
49 Kaviraj, ‘State, Society and Discourse’, p. 89.
50 On China, see H. Van de Ven, ‘War in the Making of Modern China’,
Modern Asian Studies, 30, 4 (1996), 737–56; J. Banister, China’s Changing
Population (Stanford: Stanford University Press, 1987); for a contemporary
account, see J.S. Horn, Away With All Pests: An English Surgeon in People’s
China, 1954–69 (New York: Monthly Review Press, 1969). On Vietnam, see
Andrew Hardy, ‘One Hundred Years of Malaria Control in Vietnam:
A Regional Retrospective’, Part 2, Mekong Malaria Forum, 6 (April 2000).
51 For the comparison, see Ayesha Jalal, Democracy and Authoritarianism in
South Asia: A Comparative and Historical Perspective (Cambridge: Cambridge
University Press, 1995), esp. chapter 1.
52 David Arnold, Science, Technology and Medicine in Colonial India, New
Cambridge History of India, 3, 5 (Cambridge: Cambridge University Press,
2000), chapter three.
53 Benedict Anderson, Imagined Communities: Reflections on the Origin and
Spread of Nationalism (London: Verso, 2nd ed., 1991).
54 See Benedict Anderson, Spectre of Comparisons, pp. 299–317; A. Vickers,
A History of Modern Indonesia (Cambridge: Cambridge University Press,
2003), pp. 169–98.
55 R.H. Taylor (ed.), Burma: Political Economy Under Military Rule (London:
Palgrave, 2001).
56 F. Frankel, India’s Political Economy: The Gradual Revolution, 1947–1977: The
Gradual Revolution (Princeton: Princeton University Press, 1978), chapters
five and six.
196 Notes
57 There is an extensive critical literature on the political culture of develop-

ment, and particularly on the role of science and technology within it. The
most important works include: J.C. Scott, Seeing Like a State: Why Certain
Schemes to Improve the Human Condition Have Failed (New Haven: Yale
University Press, 1998); A. Nandy, ‘Science as a Reason of State’ in A. Nandy
(ed.), Science, Hegemony and Violence: A Requiem for Modernity (Delhi: Oxford
University Press, 1988), pp. 1–26; J. Ferguson, The Anti-Politics Machine:
‘Development’, Depoliticization and Bureaucratic Power in Lesotho (Cambridge:
Cambridge University Press, 1990); A. Escobar, Enountering Development: The
Making and Unmaking of the Third World (Princeton: Princeton University
Press, 1995); A. Gupta, Postcolonial Developments: Agriculture in the Making of
Modern India (Durham NC & London: Duke University Press, 1998).
58 Ranajit Guha, Dominance Without Hegemony: History and Power in Colonial
India (Cambridge: Harvard University Press, 1998).
59 Pierre Bourdieu, Pascalian Meditations (Richard Nice, trans. Cambridge:
Polity, 2000), p. 140.
60 On the tension between public health and clinical medicine in the British
context, see Dorothy Porter, ‘Enemies of the Race: Biologism, Environ-
mentalism and Public Health in Edwardian England’, Victorian Studies, 34, 2
(1991), 159–78.
61 D. Porter and R. Porter, ‘What Was Social Medicine? An Historiographical
Essay’, Journal of Historical Sociology, 1, 1 (1988), 90–106.
62 P. Zylberman, ‘Fewer Parallels than Antitheses: Rene Sand and Andrija
Stampar on Social Medicine, 1919–1955’, Social History of Medicine, 17, 1
(2004) 77–93, p. 89.
63 A. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United
States Since 1880 (New York: Oxford University Press, 1987); F. Soper,
‘Problems to be Solved if the Eradication of Tuberculosis is to be Realized’,
American Journal of Public Health, 52, 5 (1961), 734–48.
64 My experiences of trying to locate post-colonial archival materials in India
shared many of the frustrations Vivek Chibber sets out in detail in his
Locked in Place: State-Building and Late Industrialization in India (Princeton:
Princeton University Press, 2003). I was able to access very few files on
public health at the National Archives of India, in Delhi. Most of the files
I requested ‘could not be located’; a few other folders were delivered to me,
complete with file numbers and titles, but were empty inside. Even in the
catalogue of holdings on the Ministry of Health, which is supposed to span
1946–1960, the latest file listed is from 1948. I am grateful to the archivist
at the NAI who endeavoured to find out what happened to the files, sadly
without success. Inquiries at the Directorate General of Health Services pro-
duced no further results. Nevertheless, I feel a reasonably complete picture
of internal debates within the Indian administration has been gained from
the unpublished proceedings of the Central Council on Health Policy,
which I found mimeographed (though not in a complete series) at the
National Medical Library, and the library of the All India Institute of
Medical Sciences. Other countries in the region refused to even grant me a
research visa; the jealousies of national sovereignty, and a pathological
post-colonial concern with official secrets, continue to stand in the way of
research in transnational history.
Notes 197
65 Kaviraj, ‘State, Society and Discourse’.

66 Rudolf Mrázek, Engineers of Happy Land: Technology and Nationalism in a
Colony (Princeton: Princeton University Press, 2002), p. xvi.
Chapter 1 Depression and the Internationalization of

Public Health
1 Cf. Vaughan, ‘Health and Hegemony’.
2 H. Tinker, The Foundations of Local Self-Government in India, Pakistan and
Burma (London: Pall Mall Press, 1954), p. 287.
3 Tinker, Foundations, p. 290.
4 Tinker, Foundations, p. 294.
5 K.S. Ray (ed.), The Problems of the Medical Profession in India (Calcutta:
All-India Medical Association, 1929), p. 5; parts of the same passage are
cited in Jeffery, The Politics of Health in India, p. 177.
6 See Arnold, Science, Technology and Medicine, pp. 182–3.
7 Nair declared that the Madras health department officials ‘do not under-
stand nor have they the capacity to understand how to deal with the
defects and yet you turn around and say that the people are dirty. The
Health department are inefficient and have no sanitary knowledge, and it is
the inefficiency of the Sanitary department that stands in the way of
improvement’. Cited in Arnold, Colonizing the Body, p. 279.
8 I. Klein, ‘Population growth and mortality in British India, Part II: The
demographic revolution’, The Indian Economic and Social History Review, 27,
1 (1990), 33–63.
9 S. Guha, Health and Population in South Asia: From the Earliest Times to the
Present (London: Hurst & Co., 2001), p. 86.
10 Cf. J. & J. Comaroff, Of Revelation and Revolution, 2 volumes (Chicago, 1991,
1997).
11 M. Lal, ‘The Ignorance of Women is the House of Illness’: Gender,
Nationalism and Health Reform in Colonial North India’, in M. Sutphen
and B. Andrews (eds), Medicine and Colonial Identity (London/New York:
Routledge, 2003), pp. 14–40.
12 R. Shlomowitz and L. Brennan, ‘Mortality and Indian labour in Malaya,
1877–1933’, IESHR, 29 (1992), 57–75.
13 See Weindling (ed.), International Health, especially the chapter by Anne-
Marie Moulin.
14 Andrew Hardy, ‘One Hundred Years of Malaria Control in Vietnam: a
regional retrospective’, Parts 1 & 2, Mekong Malaria Forum, 5 (Jan 2000), and
6 (April 2000).
15 On the history of the Rockefeller Foundation’s International Health
Division, see J. Farley, To Cast Out Disease: A History of the International
Health Division of the Rockefeller Foundation (1913–1951) (Oxford: Oxford
University Press, 2004).
16 L. Murard and P. Zylberman, ‘L’Autre Guerre’.
17 J. Farley, ‘The International Health Division of the Rockefeller Foundation:
the Russell Years’, in P. Weindling (ed.), International Health, pp. 203–21.
18 Farley, To Cast Out Disease.
198 Notes
19 Murard and Zylberman, ‘French Social Medicine’.

20 M. Grmek, ‘Life and Achievements of Andrija Stampar, Fighter for the
Promotion of Public Health’, in Grmek (ed.), Serving the Cause of Public Health:
Selected Papers of Andrija Stampar (Zagreb: Andrija Stampar School of Public
Health, 1966), pp. 13–51; Zylberman, ‘Fewer Parallels than Antitheses’.
21 Murard and Zylberman, ‘French Social Medicine’; Zylberman, ‘Fewer
Parallels than Antitheses’.
22 A. Stampar, ‘Health and Social Conditions in China’, Quarterly Bulletin of the
Health Organization of the League of Nations, 5 (1936), 1090–126.
23 Stampar, ‘Health and Social Conditions in China’, p. 1123.
24 Stampar, ‘Health and Social Conditions in China’, p. 1124.
25 M. Grmek, ‘The Life and Achievements of Andrija Stampar, Fighter for the
Promotion of Public Health’, in Serving the Cause of Public Health, pp. 13–51,
p. 39.
26 Weindling, ‘Social Medicine’.
27 ‘The Most Suitable Methods of Detecting Malnutrition Due to Economic
Depression’, Quarterly Bulletin of the Health Organization, 2, 1 (September 1932).
28 League of Nations, Report of the Health Organization for the Period, October
1932 to December 1933 (Geneva, 1934); E. Burnet, ‘General Principles
Governing the Prevention of Tuberculosis’, Quarterly Bulletin of the Health
Organization, 1 (1932), pp. 489–663.
29 J. Boyd Orr, and J.L. Gilks, Studies in Nutrition: The Physique and Health of
Two African Tribes (London, 1931).
30 Wellcome Contemporary Medical Archive Centre [CMAC], London, papers
of R. McCarrison, GC 205; R. McCarrison, Nutrition and Health being THE
CANTOR LECTURES delivered before the Royal Society of Arts, 1936 (London:
The McCarrison Society, n.d.).
31 David Arnold, ‘The “Discovery” of Malnutrition and Diet in Colonial India’,
The Indian Economic and Social History Review, 31, 1 (1994), 1–27.
32 M. Ricklefs, A History of Modern Indonesia Since c. 1200 (Basingstake:
Palgrave, 2001), p. 227.
33 P. Boomgaard, ‘The Welfare Services in Indonesia, 1900–1942’, Itinerario,
(1986), 57–82; Boomgaard, citing this evidence, reached a rather more opti-
mistic conclusion about the expanse of colonial health services. See also
D.A. Low, ‘Counterpart Experiences: Indian and Indonesian Nationalisms,
1920s–1950s’, Itinerario, 1 (1986), 117–44.
34 Triennial Report on the working of the Civil Hospitals and Dispensaries in
the Madras Presidency, 1929–1931; British Library, London, Asia, Pacific &
Africa Collection, India Office Records [hereafter IOR], V/24/679.
35 Annual Report of the Civil Hospitals and Dispensaries of the United
Provinces for the Year 1933 (Allahabad, 1934), IOR, V/24/716.
36 Cf. M. Foucault, Society Must Be Defended: Lectures at the College de France,
1975–76 (trans. David Macey, Penguin, 2003), lecture of 17 March 1976.
37 M. Ricklefs, History of Modern Indonesia Since c. 1200 (Basingstoke: Palgrave,
2001), chapter 16.
38 For a helpful exegesis on this concept, see Nikolas Rose, Powers of Freedom:
Reframing Political Thought (Cambridge, 1999), especially pp. 1–14.
39 J.L. Hydrick, Intensive Rural Hygiene Work and Public Health Education of the
Public Health Service of Netherlands India (Batavia-Centrum, Java, January
1937), pp. i–ii.
Notes 199
40 Hydrick, Intensive Rural Hygiene, p. 8.

41 Hydrick, Intensive Rural Hygiene, pp. 45–7.
42 Hydrick, Intensive Rural Hygiene, p. 48.
43 M.K. Gandhi, ‘A Talk to Village Workers’, extract from a talk given on
22 October 1935, in M.K. Gandhi, Diet and Diet Reform (Navajivan
Publishing House, Ahmedabad, 1949), pp. 31–3.
44 Gandhi, ‘National Food’, Harijan, 5/1/1934, in Diet and Diet Reform,
pp. 29–30.
45 Gandhi, ‘Waste into Wealth’, Harijan, 12/10/1935, in Diet and Diet Reform,
p. 51.
46 See, inter alia, ‘Dietetic Changes’, Harijan, 27/7/1935, in Diet and Diet
Reform, pp. 86–7; ‘Minimum Diet’, Harijan, 31/8/1935, in Diet and Diet
Reform, p. 30; ‘Polished v. Unpolished’, Harijan, 26/10/1934, in Diet and
Diet Reform, pp. 44–6. The work to which Gandhi referred appears to be
E.V. McCollum, The Newer Knowledge of Nutrition: The Use of Food for the
Preservation of Vitality and Health (New York: Macmillan, 1922).
47 Gandhi, ‘Unfired Foods’, Young India, 15/8/1929, in Diet and Diet Reform,
pp. 26–7.
48 Gandhi, ‘For Four Rupees A Month’, Harijan, 12/10/1935, in Diet and Diet
Reform, p. 31.
49 ‘Findings of the International Commission of Experts appointed by the
Health Committee of the League of Nations’, Harijan, 25 April 1936, repro-
duced in Diet and Diet Reform, p. 101. The original report was: League of
Nations, Report on the Physiological Bases of Nutrition, League of Nations
Document A.12 (a), 1936.
50 Gandhi, ‘Polished v. Unpolished’, in Diet and Diet Reform, pp. 44–6.
51 M.K. Gandhi, ‘Implications of Constructive Programme’ [1940], Collected
Works of Mahatma Gandhi, 72 (Delhi: Government of India, Publications
Division, 1958–78) p. 380.
52 See, for example, W. Anderson, ‘Introduction: Postcolonial Technoscience’,
Social Studies of Science 32, 5–6 (2002), 643–57.
53 W.R. Aykroyd, B.G. Krishnan, R. Passmore and A.R. Sundararajan (Coonoor
Nutrition Research Laboratory), Indian Medical Research Memoirs, No. 32,
The Rice Problem in India (January 1940), IOR, V/25/850/92, p. 64.
54 Aykroyd et al., Rice Problem, p. 64.
57 Aykroyd et al., Rice Problem, pp. 64–8.
58 Pattabhi Sitaramayya, in Aykroyd et al., Rice Problem, pp. 64–8.
59 C.J. Baker, ‘Economic Reorganization and the Slump in South and
Southeast Asia’, Comparative Studies in Society and History, 23, 3 (1981),
325–39.
60 Baker, ‘Economic Reorganization’.
62 Arnold, Science, Technology and Medicine, p. 201.
63 League of Nations, Intergovernmental Conference of Far-Eastern Countries on
Rural Hygiene: Report by the Preparatory Committee (Geneva, 1937) [III.
Health. 1937.III.3].
64 League of Nations Archives, Geneva [LNA], Box 6093, 8A, 15110, 8855,
Rural Hygiene: Conference in the Far East: Preparatory Measures.
200 Notes
65 LNA, Box 6093, 8A, 25509, 8855, Haynes to Private Secretary, Viceroy of
India, 22 August 1936.
66 League of Nations, Intergovernmental Conference on Rural Hygiene,
pp. 16–20.
67 J. Mackie, Bandung 1955: Non-Alignment and Afro-Asian Solidarity
(Singapore: Editions Didier Millet, 2005), pp. 24–5; on Indies modernism,
see Mrázek, Engineers.
68 League of Nations, Report by the Preparatory Committee, p. 13.
71 League of Nations, Intergovernmental Conference, p. 68.
72 See, for example, League of Nations, Malaria Commission: Report on its
Tour of Investigation in Certain European Countries in 1924 (Geneva, 1925),
C.H. 273.
76 Cf. LNA, Organization d’Hygiene, vol. 358, C.H./Conf.Hyg.Rural.Orient/
4, Note received by the Secretariat of the Conference from Dr Leonard
Shishlien Hsu, ‘Rural Reconstruction and Social Planning’.
77 E. Blunt (ed.), Social Service in India: An Introduction to Some Social and
Economic Problems of the Indian People (London: HMSO, 1939), pp. 382–3;
Central Co-operative Anti-Malaria Society, Annual Reports (Calcutta,
1927–43).
78 See League of Nations, Intergovernmental Conference of Far-Eastern
Countries on Rural Hygiene, Preparatory Papers: National Reports: Report of
the Netherlands Indies (Geneva, 1937), [III.Health.1937.III.15]; and
A.P. den Hartog, ‘Towards Improving Public Nutrition: Nutritional Policy
in Indonesia Before Independence’, in G.M. van Heteren, A. de Knecht-
van Eekelen, M.J.D. Poulissen (eds), Dutch Medicine in the Malay
Archipelago, 1816–1942 (Amsterdam: Rodopi, 1989), pp. 105–18.
79 M. Jones, ‘Infant and Maternal Health Services in Ceylon, 1900–1948:
Imperialism or Welfare?’ Social History of Medicine, 15, 2 (2002), 263–89.
For a critique of Jones’ overly sanguine assumptions about the
beneficence of colonial public health, see Maarten Bode’s review in
Wellcome History, 30 (2005), p. 20.
80 Cited in John Farley, Bilharzia: A History of Imperial Tropical Medicine
(Cambridge: Cambridge University Press, 1991), p. 176.
81 Arnold, Science, Technology and Medicine, p. 203.
82 Government of Burma, Public Health Department, G Circular No. 14 of
1936, Rangoon 29 June 1936. IOR, M/3/180: ‘Quinine: Question of
Production Within the Empire’.
83 Economic Advisory Council, Committee on Scientific Research,
5th Report: ‘Consumption and Supply of Cinchona Alkaloids in the
Empire’, January 1938, EAC (SC) 31 (Confidential), IOR, M/3/180:
‘Quinine: Question of Production Within the Empire’.
84 IOR, M/3/180: ‘Quinine’.
Notes 201
87 Quinine Policy for the Empire: Proposed Enquiry by the Economic

Advisory Council: Views of the Government of Burma, 19 December
1938, IOR, M/3/180: ‘Quinine: Question of Production Within the
Empire’.
88 Baker, An Indian Rural Economy: The Tamilnad Countryside, 1880–1955
(Oxford: Clarendon, 1984), p. 519.
89 D.A. Washbrook, ‘The Rhetoric of Democracy and Development in Late
Colonial India’, in S. Bose and A. Jalal (eds), Nationalism, Democracy and
Development: State and Politics in India (Oxford: Oxford University Press,
1997), pp. 36–49.
90 See also Zachariah, Developing India, chapter five.
91 Mrázek, Engineers of Happy Land.
92 National Planning Committee, Population: Report of the Sub-Committee
(Chair: Dr Radhakamal Mukherjee) K.T. Shah ed., Vohra & Co., 1947,
p. 8. Although the proceedings of the NPC were published in edited form
after the war, the discussions took place between 1938 and 1940.
93 NPC, Population, p. 127.
96 See Sarah Hodges, Contraception’s Voluntary Empire (forthcoming,
Ashgate).
97 James C. Scott, Seeing Like a State: Why Certain Schemes to Improve the
Human Condition Have Failed (Yale: Yale University Press, 1998).
98 Bruce Cumings, Korea’s Place in the Sun: A Modern History (New York:
W.W. Norton, 1997), p. 148.
99 Prasenjit Duara, Sovereignty and Authenticity: Manchukuo and the East Asian
Modern (Lanham: Rowman & Littlefield, 2003); Ming-Cheng M. Lo,
Doctors Within Borders: Profession, Ethnicity and Modernity in Colonial
Taiwan (Berkeley & LA, UC Press, 2002).
100 Following, here, James Vernon, ‘The Ethics of Hunger and the Assembly
of Society: The Techno-politics of the School Meal in Britain’, American
Historical Review, 110, 3 (2005), 693–725.
Chapter 2 War and the Rise of Disease Control

1 Chatterjee, The Politics of the Governed.
2 See Edmund Russell, War and Nature: Fighting Humans and Insects with
Chemicals from World War I to Silent Spring (New York: Cambridge
3 Farley, To Cast Out Disease, part II.
4 F.L. Soper, Ventures in World Health: The Memoirs of Fred Lowe Soper
(Washington, DC: Pan American Health Organization, 1977).
5 See R. Packard and P. Gadelha, ‘A Land Filled with Mosquitoes: Fred
L. Soper, the Rockefeller Foundation, and the Anopheles Gambiae
Invasion of Brazil’ Medical Anthropology, 17 (1997), 215–38.
6 See the excellent account of the Egyptian malaria epidemic in
N.E. Gallagher, Egypt’s Other Wars: Epidemics and the Politics of Public
Health (New York: Syracuse University Press, 1990).
202 Notes
7 Mitchell ‘Can the Mosquito Speak?’ p. 46; see also Gallagher, Egypt’s
Other Wars, p. 198.
8 National Archives of the UK [TNA]: Public Record Office [henceforth PRO].
AVIA 22/2056, Dichloro-diphenyl-trichloroethane (DDT): Production,
1943–44.
9 Frank Snowden, The Conquest of Malaria: Italy, 1900–1962 (New Haven:
Yale University Press, 2006), p. 199.
10 F.A.E. Crew, The Army Medical Services: Campaigns Volume III: Sicily, Italy,
Greece (London: HMSO, 1959), pp. 587–93.
11 B.L. Raina (ed.), Official History of the Indian Armed Forces in the Second
World War, 1939–45, Vol. I: Medical Services: Preventive Medicine (Nutrition,
Malaria Control and Prevention of Diseases), (Combined Inter-Services
Historical Section, India & Pakistan, 1961).
12 Raina (ed.), Indian Armed Forces, p. 324.
14 TNA, PRO. War Office (WO) 222/2152, Director of Hygiene Tour of Far
East, 1944–1945: December 1944 to January, 1945. Maj Gen T.
Richardson. [Emphasis in original].
15 TNA, PRO. WO 222/2152.
18 TNA, PRO. WO 222/2152 Director of Hygiene Tour of Far East,
1944–1945, December 1944 to January, 1945: Maj Gen T. Richardson.
19 Harrison, Medicine and Victory, p. 145.
21 TNA, PRO. WO 203/3359. Interim Report: Mobile Malaria and Hygiene
Unit No. 4, May to July 1945, Rangoon.
22 Raina (ed.), Indian Armed Forces, pp. 332–33.
23 National Archives of Singapore, Oral History Collection, Mr. Wilfred T.
Chellapah, interviewed on 7 November 1983 by Daniel Chew. Accession
number: 000353. All quotations are from my transcription of the
interview tapes, reels 9–10.
25 D.K. Viswanathan, The Conquest of Malaria in India: An Indo-American
Co-operative Effort (Bombay, 1958), p. 26.
26 Viswanathan, Malaria, pp. 28–9.
27 Viswanathan, Malaria, pp. 31–2.
28 Viswanathan, Malaria, p. 34.
33 See Chapter 1, above.
34 Mitchell, ‘Can the Mosquito Speak?’ p. 47.
36 Snowden, The Conquest of Malaria, p. 202.
37 Snowden, The Conquest of Malaria, pp. 206–7.
38 Snowden, The Conquest of Malaria, p. 212.
39 M. Harrison, Medicine and Victory: British Military Medicine in the Second
World War (Oxford: Oxford University Press, 2004).
Notes 203
40 UNRRA Papers, British Library of Political and Economic Science

(LSE), Committee for Coordination in the Far East (44), 11,
28 September 1944 ‘Relief Requirements for Certain Areas in the Far
East’, quoting a report by the British War Cabinet’s Official Com-
mittee on Supply Questions in Liberated and Conquered Areas
SLAO/ER (44) 16. All subsequent references to this collection are
abbreviated as ‘UNRRA’.
41 On the Dietary Scales for the Far East see UNRRA, CCFE (44), 11,
29 September 1944: Appendix A.
42 UNRRA. TAG/ FE (45) 16, Australia 16, 24 April 1945. UNRRA, Subcommittee
on Agriculture in the Far East, ‘Some Recommended Substitute and Other
Food Policies in the Far East’, F.W. South (UK), Chairman.
43 J. Gillespie, ‘International Organizations and the Problem of Child
Health, 1945–1960’, Dynamis, 23 (2003), 115–42, p. 126.
44 UNRRA, Far East Committee: Documents. CCFE (45)/18, 18 July 1945
[RESTRICTED].
45 UNRRA: History of the United Nations Relief and Rehabilitation
Administration, under the direction of G. Woodbridge, 3 vols. (New York:
Columbia University Press, 1950), Vol. 1, pp. 434–37.
46 B. Abel-Smith, ‘The Beveridge Report: Its Origins and Outcomes’. In
John Hills et al. (eds), Beveridge and Social Security (Oxford: Clarendon
Press, 1994), pp. 10–22; J. Hills, J. Ditch and H. Glennester (eds) Beveridge
and Social Security: An International Retrospective (Oxford: Clarendon Press,
1994).
47 Report on Social Insurance and Allies Services, Report by Sir William
Beveridge (London: HMSO, 1942) [CMND 6404], p. 170.
48 C. Webster, National Health Service: A Political History (Oxford: Oxford
49 T.S. Smiley, Welfare and Planning in the West Indies (Oxford: Clarendon
Press, 1946); W. Arthur Lewis, ‘On Planning in Backward Countries’, in
The Principles of Economic Planning: A Study Prepared for the Fabian Society
(London: Dennis Dobson, and Allen & Unwin, 1949).
50 G. Pandey (ed.), The Indian Nation in 1942 (Calcutta: Centre for Studies in
Social Sciences, 1988).
51 Zachariah, Developing India, pp. 30–43.
52 See, for example, Sir Purshotamdas Thakurdas, J.R.D. Tata, G.D. Birla,
et al., A plan of economic development for India (Bombay: S. Ramu,
1944–45), and the rival plan put forward by the Labour movement:
B.N. Banerjee, G.D. Parikh, V.M. Tarkunde, members of the Post-War
Reconstruction Committee of the Indian Federation of Labour, People’s
Plan for Economic Development of India (Delhi, 1944). On the Bombay
Plan, see Chibber, Locked in Place, pp. 88–110.
53 Raja found Mudaliar’s affectations particularly wearing: Amongst other
things, Mudaliar ‘categorically refused to attend meetings after the
middle of May on the ground that it will be too hot to travel.’ Rockefeller
Archive Centre, Pocantico Hills, New York [Henceforth, RAC], records of
the Rockefeller Foundation [RF], Record Group [RG] 2: General
Correspondence – 1945, 464. Box 306, Folder 2075: K.C.K.E. Raja to
J.B. Grant, 24 December 1944.
54 RAC, RF, RG 2, 1945, Series 464. Box 306, Folder 2076.
204 Notes
55 John Ryle, Changing Disciplines: Lectures on the History, Method, and

Motives of Social Pathology (London: Oxford University Press, 1948), p. 85.
On Ryle, see Dorothy Porter’s work: Dorothy Porter, ‘Social Medicine and
the New Society: Medicine and Scientific Humanism in mid-Twentieth
Century Britain’, Journal of Historical Sociology, 9, 2 (June 1996),
pp. 168–87; D. Porter, ‘John Ryle: Doctor of Revolution?’ in D. Porter and
R. Porter (eds), Doctors, Politics and Society: Historical Essays (Amsterdam:
Rodopi, 1993), pp. 229–47. See also D. Porter, ‘Enemies of the Race:
Biologism, Environmentalism, and Public Health in Edwardian England’,
Victorian Studies, 34, 2 (1991), 159–78, on late-Victorian debates on
preventive medicine, from which Ryle emerged.
56 Sterling Memorial Library, Yale University. Henry E. Sigerist Papers
(No. 788), Box 5, folder 176: ‘Kamala Ghosh 1941–43’. Ghosh to Sigerist,
March 23, 1941.
57 ‘Indian Woman Doctor’s Courage’, London 13 January 1943. Typescript
of Broadcast, Sigerist Papers, Box 5, Folder 176: Kamala Ghosh.
58 Ghosh to Sigerist, March 23, 1941, Sigerist Papers, Box 5, folder 176.
59 ‘Indian Woman Doctor’s Courage’, 13 January 1943, Sigerist Papers, Box
5, folder 176.
60 Sigerist Papers, Box 5, Folder 176: Ghosh to Sigerist, October 19, 1942.
61 Sigerist Papers, Box 5, Folder 176: Sigerist to Charlotte Silverman, US
Department of Labor, June 15 1943.
62 Diary entries for 16 August 1944, and October 7, 1944, in Henry
E. Sigerist, Autobiographical Writings, [selected and translated by
Nora Sigerist Beeson], (Montreal: McGill University Press, 1966), p. 188,
p. 190.
63 Diary entry, 16 August 1944, in Sigerist, Autobiographical Writings, p. 188.
64 J.B. Grant ‘Public Health as a Social Service’, Science and Culture, 6, 5
(1940), 296–300.
65 Vellore Christian Medical College (North American Board), Luncheon
Meeting, December 11 1945, New York City: John B. Grant’s address.
RAC, RF, RG 2 – 1945, 464, Box 307, Folder 2083.
66 Sigerist, Socialized Medicine in the Soviet Union (New York, 1937).
67 Government of India, Report of the Health Survey and Development
Committee, 4 vols (New Delhi, 1946) [henceforth Bhore Report], Vol. 1,
p. 17.
68 On the enthusiasm of various ICS officers for rural reconstruction, see
Zachariah, Developing India, pp. 110–55.
69 Bhore Report, Vol. 2, p. 32.
70 RAC, RF, RG 2 – 1945, 464, Box 306, Folder 1078, ‘Bhore Committee
Reports, 3’, pp. 14–16.
71 Wellcome Contemporary Medical Archive Centre, London [Henceforth
CMAC], Janet Vaughan Papers, GC 186/6. Memorandum by the British
delegation [typescript], 20/1/1945.
72 H. Sigerist, Socialised Medicine in the Soviet Union (New York, 1937).
73 Bhore Report, Vol. 1, p. 21.
74 Bhore Report, Vol. 2, chapter 3.
75 Memorandum by British delegation, 20/1/45, CMAC, GC 186/6.
76 CMAC, GC 186/6, underlined in original.
Notes 205
77 CMAC, GC 186/6.
78 National Planning Committee, National Health: Report of the Sub-
Committee, Chair: S.S. Sokhey, K.T. Shah (ed.) (Bombay: Vohra & Co.,
1947).
79 RAC, RF, RG 2 – 1945, 464. Box 306, Folder 2076, ‘India – Bhore
Committee Reports, 1’, p. 3; see also RAC, RF, RG 12 – John B. Grant
Diaries, 1944–45 (Vol. 1). July 1944, Grand Hotel, Simla.
80 See, for example, Gyan Chand, Problem of Population (Oxford Pamphlets
on Indian Affairs, number 19: Oxford University Press, 1944); Oriental
and India Office Collection, British Library, London (OIOC), T. 43122;
S. Sze, China’s Health Problems (1st ed. Washington D.C.: China Medical
Association, 1943).
81 Nagpur Municipal Voters Association to Dalrymple-Champneys,
26 November 1944. CMAC, GC/139/H.2, Papers of Sir Weldon
Dalrymple-Champneys.
82 L. Manderson, ‘Wireless Wars in the Eastern Arena: Surveillance, Disease
Prevention and the Work of the Eastern Bureau of the League of Nations
Health Organization, 1925–1942’, in P. Weindling (ed.), International
Health Organizations and Movements, 1918–1939 (Cambridge: Cambridge
University Press, 1995), pp. 109–33.
83 J. Gillespie, ‘Social Medicine, Social Security and International Health,
1940–60’, in E. Rodriguez-Ocana (ed.), The Politics of the Healthy Life,
pp. 219–39.
84 ILO, Social Security: Principles and Problems Arising Out of the War
(Montreal: 1944).
85 J. Gillespie, ‘Social Security and International Health’, p. 221.
86 TNA, PRO. FO 93/1/251, ‘Final Act: United Nations Conference on Food
and Agriculture’, June 3, 1943.
87 J. Gillespie, ‘International Organizations and the Problem of Child
Health, 1945–1960’, Dynamis, 23, 115–42, p. 130.
88 Final Act of the United Nations Conference on Food and Agriculture,
Resolution 3, ‘Improvement of National Diets’, 1943.
89 IOR. V/25/840/72. Memorandum on the United Nations Conference
on Food and Agriculture, May 18 to June 3, 1943, with reference to
its findings on the subject of Food and Health by Dr W.R. Aykroyd,
Director, Nutrition Research, Indian Research Fund Association,
Coonoor.
90 This information comes from M.A. Balinska, For the Good of Humanity:
Ludwik Rajchman Medical Statesman, trans. R. Howell (Budapest: Central
91 TNA, PRO. FO 370/804.
92 This and subsequent quotations are from: L. Rajchman, ‘Why Not
An United Nations Public Health Service?’ Typescript enclosure in:
TNA, PRO. CO 859/66/14. Medical: Proposed International Health
Organization.
93 Gillespie, ‘Social Security and International Health’, focuses on this
aspect of Rajchman’s plans.
94 TNA, PRO. FO 370/804. Marginal notes attached to typescript of
Rajchman’s draft. The reference is to D. Mitrany, A Working Peace System:
206 Notes
An Argument for the Functional Development of International Organization

(London: RIIA, 1943).
95 TNA, PRO. FO 370/804. P. Noel-Baker to R. Law, 6 August 1943.
96 TNA, PRO. FO 370/804.
97 TNA, PRO. CO 859/66/14. ‘International Health Organization: Note on
the First Meeting of the Informal Medical Committee’, 19 October 1943.
98 TNA, PRO. CO 859/66/14. M. MacKenzie, ‘Critical Review of the Work of
the Office, and the Health Organization of the League of Nations’.
Confidential Note, 21 September 1943. All quotations are from this
document.
99 TNA, PRO. CO 859 66/14. MacKenzie, ‘Critical Review’
100 TNA, PRO. CO 859 66/14. MacKenzie, ‘Critical Review’.
101 TNA, PRO. CO 859 66/14.
102 The distinction drawn from discussion in M. Foucault, Society Must Be
Defended.
103 TNA, PRO. FO 371/40575. India Office to E.L. Hall-Patch, FO, 1 May
1944.
104 TNA, PRO. FO 371/40575. Draft Telegram, Secretary of State to Governor
General [no date].
105 TNA, PRO. FO 371/40575. ‘Notes for Supplementary Questions’ [typescript:
no author, no date].
106 TNA, PRO. FO 371/40575. India Office to E.L. Hall-Patch, FO, 1 May
1944.
107 J. Nehru, Discovery of India (Delhi: Jawaharlal Nehru Memorial
Fund/Oxford University Press, [1946] 2003), p. 17.
108 Nehru, Discovery of India, pp. 546–47.
109 Nehru, Discovery of India, p. 546.
110 Famine Inquiry Commission, Report on Bengal (Government of India,
1945), p. 116.
111 Report on Bengal, pp. 132–3.
Chapter 3 The Political Culture of International Health

1 Cf. B. Latour, The Pasteurization of France, trans. A. Sheridan and J. Law,
(Cambridge, Mass.: Harvard University Press, 1988), p. 137.
2 E. Rothschild, ‘What is Security?’ Daedalus, 124 (1995), 53–98.
3 United Nations Official Records, Economic & Social Council, Session 1–2
(1946).
4 The best institutional and political history of the WHO is J. Siddiqi,
World Health and World Politics: The WHO and the UN System (London:
Hurst, 1995).
6 League of Nations Archives (LNA), Geneva Box 6150, Group 8A, 41755/
41755: Post-War (1939–1945) Problems. H. Cumming to R. Gautier, June 1
1945; S. Sze, The Origins of the World Health Organization: A Personal Memoir,
1945–1948 (Boca Raton, Florida, 1983), p. 1.
7 League of Nations Archives [LNA], Geneva. Box 6150, Group 8A,
41755/41755, Cumming to Gautier, June 1 1945.
Notes 207
8 Documents on the United Nations Conference on International Organization,

San Francisco, 1945, Vol. III, p. 632.
9 Official Records of the World Health Organization, No. 1 [OR, 1], ‘Minutes of
the Technical Preparatory Committee for the International Health
Conference’, Paris, 18 March to 5 April, 1946 [hereafter, ‘Preparatory
Committee, Minutes’], p. 11.
10 Preparatory Committee, Minutes, Annex 7, p. 46.
11 Preparatory Committee, Minutes, Annex 10, p. 61.
12 Universal Declaration of Human Rights, UN General Assembly
Resolution 217A (III) of 10 December, 1948.
13 Official Records of the World Health Organization, 2: Proceedings and Final
Acts of the International Health Conference (New York, June 19 to July 22,
1946).
14 Goodman, International Health, p. 155; Brock Chisholm, ‘International
Health’, American Journal of Public Health, 41, 12, December 1951,
1460–63.
15 K. Lee, Historical Dictionary of the World Health Organization (Lanham,
MD.: Scarecrow Press, 1998) pp. 5–7; TNA, PRO. FO 371/59613,
‘Arrangements for the World Health Conference, 1946’.
16 Goodman, International Health, p. 164.
17 The regional offices were: South-east Asia (SEARO); Western Pacific
(WPRO); Africa (AFRO); Europe (EURO); the Americas (PASO), and the
Eastern Mediterranean (EMRO).
18 National Archives of India. Ministry of Health files. F. 9-4/47–PH (II), Part
I. Report by C. Mani, IMS, India’s Representative to the Interim
Commission of the WHO, November 1946.
19 On the controversies surrounding the boundaries of the WHO’s admin-
istrative regions, see Siddiqi, World Health, pp. 60–76. Here, too, the
politics of decolonization played a role: Pakistan opted not to join the
‘Southeast Asian’ region, the obvious choice, but the predominantly
Muslim ‘Eastern Mediterranean’ region, to avoid its health administra-
tion being influenced by India.
20 World Health Organization Archives, Geneva. First Generation Files
[hereafter WHO.1]: 452-1-5. ‘Delimitation of Regional Health Areas on
an Epidemiological Basis’, Third Session of the Interim Commission of
the WHO, 31 March 1947.
21 Asian Relations: Report of the Proceedings and Documentation of the First
Asian Relations Conference, New Delhi, March–April 1947 (New Delhi: Asian
Relations Organization, 1948).
22 ‘Report on Social Services’, in Asian Relations, pp. 183–5.
23 K.C.K.E. Raja, Health Problems of India, Pamphlet from the Asian
Relations Conference (Indian Council of World Affairs, 1947) [Nehru
Memorial Library collection].
24 On British colonial views on post-war development in their African
territories, see F. Cooper, Decolonization and African Society; J. Lewis,
Empire State Building: War and Welfare in Kenya, 1925–52 (Oxford:
James Currey, 2000); T.N. Harper, The End of Empire and the Making of
Malaya (Cambridge: CUP, 1999).
25 ILO, Problems of Social Security, p. 74. My emphases.
208 Notes
26 ILO Archives, Geneva. ‘Preparatory Asiatic Regional Conference’: RC 158-

1-100; RC 158-1-13; RC 158-1-7.
27 ILO, Problems of Social Security, p. 78.
28 ILO, Problems of Social Security, p. 111.
29 Ryle, Changing Disciplines, p. 9.
30 Only in recent years have the human consequences of Partition begun to
attract the attention of historians. See Joya Chatterji, ‘Rights or Charity?
Government and Refugees: The Debate over Relief and Rehabilitation in
West Bengal, 1947–1950’, in S. Kaul (ed.), Partition of Memory (Delhi:
Permanent Black Press, 2001); Urvashi Butalia, Other Side of Silence: Voices
from the Partition of India (Durham, N.C.: Duke University Press, 2000).
31 The UN children’s agency, UNICEF, for example, was designed as a tem-
porary, emergency operation. It was not until 1950 that, with the
support of the US government, it was made permanent, and the word
‘Emergency’ dropped from its title.
32 Rockefeller Archive Centre, Tarrytown, New York [RAC], Rockefeller
Foundation Archives [RF], Record Group 2 – 1947, Series 464 (Admin-
istrative), Box 384, folder 2590. Janet D. Corwin to G.K. Strode,
18 September 1947.
33 G. Borkar, Health in Independent India: A Decade of Progress (Delhi:
Government of India, 1961), pp. 11–12.
34 See the discussion at the end of Chapter 2, above.
35 The Statesman, 17 May 1948.
36 The Statesman, 17 May 1948.
37 On Burma, see H. Tinker, Union of Burma: A Study of the First Years of
Independence (London: Oxford University Press, 1957), on Indonesia, see
G. Kahin, Nationalism and Revolution in Indonesia (Ithaca: Cornell
38 See, for example, Constituent Assembly of India, Debates [henceforth
CAD], Vol. 8, Part 2b, 17 May 1949; Vol. 8, Part 5a, 20 May 1949.
39 R. Ray (West Bengal), CAD, Vol. 7, Part 5a, 9 November 1948.
40 K. Santhanam (Madras), CAD, Vol. 5, Part 3a, 20 August 1947.
41 See Chaterjee, ‘Development Planning’; Kaviraj, ‘State, Society and
Discourse’, and Engerman, ‘Romance of Development’.
42 TNA, PRO, DO 35/3764: World Health Organization – Regional
Organization. Enclosure: ‘Pandit Nehru Inaugurates WHO Regional com-
mittee session’, 7 October 1948.
43 Speech to the International Civil Aviation Organization, cited in W. Levi,
Free India in Asia (Minnesota, 1952), p. 53.
44 Levi, Free India, p. 42.
45 Levi, Free India, p. 61.
46 UNRRA: The History of the United Nations Relief and Rehabilitation
Administration, Volume II (prepared by staff under the direction of
George Woodbridge, Chief Historian of UNRRA). New York, 1950, p. 24.
47 International Tuberculosis Campaign, Final Report of the International
Tuberculosis Campaign: July 1, 1948–June 30, 1951. Copenhagen, 1951,
p. 13.
48 BCG, or Bacille Calmette-Guérin, is the vaccine against tuberculosis,
first isolated by French scientists from a strain of bovine tuberculosis,
Notes 209
cultured on potatoes. It was first used on humans in 1921, and grew in

popularity during the inter-war years, particularly in France, Spain,
Russia and – more than anywhere else – in the Scandinavian countries.
See J.B. MacDougall, Tuberculosis: A Global Study in Social Pathology
(WHO, Section of Tuberculosis). Edinburgh, 1949, pp. 390–5.
49 International Tuberculosis Campaign, p. 14.
50 International Tuberculosis Campaign, pp. 14–15.
51 WHO/UNICEF, ‘Joint Committee on Health Policy. Second Session,
Provisional Minutes.’ JC2/UNICEF/WHO/Min, p. 5 [WHO Print Archives,
Geneva]; WHO. JC2/UNICEF/WHO/Min, p. 3.
52 See, for example, UN, World War on Tuberculosis: What the United Nations
is Doing (New York: UN Department of Public Affairs, 1948) [British
Library of Political and Economic Science, London School of Economics
library, Pamphlets Collection].
53 A. Tawfiq Shousha, ‘Cholera Epidemic in Egypt (1947): A Preliminary
Report’, Bulletin of the World Health Organization, 1, 2 (1948), 368–9. For
an excellent historical analysis, see N.E. Gallagher, Egypt’s Other Wars:
Epidemics and the Politics of Public Health (New York: Syracuse University
Press, 1990), chapter seven.
54 C.E. Ascher, ‘Current Problems’, p. 29.
55 WHO, Report of the Expert Committee on Malaria: Second Session (Geneva,
1948), p. 216.
56 Cited in UN, Technical Assistance for Economic Development (New York,
1949), p. 9.
57 George C. Marshall, opening address at the Fourth International
Congress of Tropical Diseases and Malaria. PRO. FO 370/1535, Fourth
International Congress of Tropical Medicine and Malaria, Washington,
May 1948. On this point, see Packard, ‘Malaria Dreams’.
58 ‘Objectives and Nature of the Point IV Program’, March 19 1949, Foreign
Relations of the United States [FRUS], 1949, Volume I, ‘National Security
Affairs, Foreign Economic Policy’ (Washington D.C.: US Government
Printing Office, 1976), p. 783.
59 S. Litsios, ‘Malaria Control, Rural Development and the Post-War
Re-ordering of International Organizations’, Medical Anthropology,
14 (1997) 255–78; R. Packard, ‘Malaria Dreams’; J. Siddiqi, World Health;
H. Cleaver, ‘Malaria and the Political Economy of Public Health’,
International Journal of Health Services, 7, 4 (1977), 557–79.
60 Litsios, ‘Malaria Control’, p. 271.
61 Draft National Security Council Staff Study, ‘Proposed Transfer of the
Point IV Program from the Department of State to the Economic
Cooperation Administration’, July 18 1951. RESTRICTED. FRUS, 1951, I,
pp. 1653–56.
62 UN, Technical Assistance for Economic Development, p. 10. My emphases.
63 UN, Technical Assistance for Economic Development: Plan for an Expanded
Co-operative Programme Through the United Nations and the Specialized
Agencies (New York, 1949), p. 3.
64 UN, Technical Assistance, p. 3.
210 Notes
67 Chatterjee, ‘Development Planning’, p. 5.

68 S. Chakravarty, Development Planning: The Indian Experience (Delhi:
Oxford University Press, 1987), p. 7.
69 F. Frankel, India’s Political Economy, 1947–77: The Gradual Revolution
(Princeton: Princeton University Press, 1977), p. 85.
70 Government of India, Planning Commission, The First Five Year Plan: A
Draft Outline (New Delhi, 1951), p. 194.
71 First Five Year Plan, Draft Outline, p. 197. My emphasis.
72 For more on this, see Chapter 4, below.
73 Government of Burma, Pyidawtha: The New Burma: A Report from the
Government to the People of the Union of Burma on our Long-term Programme
for Economic and Social Development (Rangoon, Economic and Social
Board, 1954); Government of India, Jawaharlal Nehru on Community
Development (New Delhi, 1957).
74 Chatterjee, ‘Development Planning’, pp. 16–17.
75 Anderson, Eyes Off the Prize, p. 2.
76 Anderson, Eyes Off the Prize, p. 67, p. 80.
78 Anderson, Eyes Off the Prize, p. 5.
79 See A.W.B. Simpson, Human Rights and the End of Empire: Britain and the
Genesis of the European Convention (Oxford: Oxford University Press,
2001), pp. 480–86.
80 WHO.2, annotated copy of: WHO, Executive Board, ‘Co-operation With
the United Nations Commission on Human Rights’, EB8/49, 2 June
1951, p. 4.
81 The other five measures proposed were as follows: it was the respons-
ibility of contracting governments to reduce infant mortality and
provide for the healthy development of the child; to control epidemic,
endemic and other diseases; to improve the standard of medical teaching
and training in the health, medical and related professions; to enlighten
public opinion on problems of health; to foster activities in the field
of mental health, especially those affecting the harmony of human
relations. WHO.2, ‘Human Rights’, p. 6.
82 WHO.2 CC4-6/Human Rights, H. van Zile Hyde to B. Chisholm,
28 March 1951.
83 WHO.2, ‘Human Rights’, p. 16.
84 The WHO’s archives are haphazard and incomplete, making it difficult to
reach firm conclusions about certain internal debates. Most of the orga-
nization’s materials were destroyed in the mid-1950s, and what survives
from the early period is preserved on microfilm.
85 WHO.2, ‘Human Rights’, pp. 15–16.
86 WHO.2, ‘Human Rights’, p. 16, my emphases.
87 See J. Ferguson, The Anti-Politics Machine: ‘Development’, Depoliticization
and Bureaucratic Power in Lesotho (Cambridge: Cambridge University
Press, 1990).
88 Dr K. Evang, Chronicle of the World Health Organization, 3, 6 (June 1949),
p. 217.
89 Dr K. Evang, Chronicle of the World Health Organization, 2, 8–9 (Aug.–Sept.
1948), p. 200.
Notes 211
90 UN, Economic and Social Council, Resolution 222A (IX), para. 8; UNGA
Resolution 304 (IV).
91 See Chapter 2.
93 UN, Measures for the Economic Development of Under-Developed Countries
(New York, 1951), p. 52.
94 UN, Economic Development. This line of thought was formalized in the
theory of ‘human capital’ which T.W. Schultz was amongst the first to
use: T.W. Schultz, ‘Investment in Human Capital’, American Economic
Review, 51, 1 (1961), 1–17.
95 W.A. Lewis, ‘Economic Development with Unlimited Supplies of Labour’,
The Manchester School, 139–91, at pp. 147–8.
96 UN, Economic Development, p. 15, p. 93.
97 C.-E. A. Winslow, ‘The Economic Values of Preventive Medicine’,
Chronicle of the WHO, 1952, pp. 191–202, p. 192.
98 C.-E. A. Winslow, Cost of Sickness and the Price of Health (Geneva: WHO,
1952), p. 12.
99 Winslow, Cost of Sickness, p. 15.
100 J.A. Sinton, ‘What Malaria Costs India, Nationally, Socially and
Economically’, Records of the Malaria Survey of India, 5 (1935), pp. 223–64,
413–89; J.A. Sinton and Raja Ram, ‘Man-Made Malaria in India’, Indian
Medical Research Memoirs (1936), IOR, V/25/850/94.
101 Gunnar Myrdal, ‘Economic Aspects of Health’, Chronicle of the WHO,
1952, p. 203, p. 211.
102 Cited in S. Litsios, ‘Malaria Control’, p. 264.
103 On the intellectual history of demography, see D. Hodgson, ‘Demo-
graphy as Social Science and Policy Science’, Population and Development
Review, 9 (1983), 1–34; S. Szreter, ‘The Idea of Demographic Transition
and the Study of Fertility: A Critical Intellectual History’, Population and
Development Review, 19 (1993), 659–701; S. Greenhalgh, ‘The Social
Construction of Population Science: An Intellectual, Institutional and
Political History of Twentieth-Century Demography’, Comparative Studies
in Society and History, 31, 1 (1996), 26–66, and M. Connelly, ‘Population
Control is History: New Perspectives on the International Campaign to
Limit Population Growth’, Comparative Studies in Society and History, 45
(2003), 122–47.
104 F. Notestein, ‘Problems of Policy in Relation to Areas of Heavy
Population Pressure,’ in Demographic Studies of Selected Areas of Rapid
Growth: Proceedings of the Round Table on Population Problems. Twenty-
Second Annual Conference of the Milbank Memorial Fund, April 12–13, 1944
(New York: Milbank Memorial Fund, 1944), pp. 155–58.
105 Rockefeller Archive Centre, Tarrytown, New York [Hereafter, RAC],
Record Group [RG] 1.1, Series 600, Box 2, Folder 9, ‘Public Health and
Demography in the Far East, 1949’: M.C. Balfour, ‘Preliminary Note on
the Rockefeller Foundation Population Reconnaissance in the Far East’,
January 1949; F. Notestein, ‘Preliminary Reconnaissance on Public
Health and Demography in the Far East’, March 19, 1949. The impres-
sions were published in F.W. Notestein, I.B. Taeuber and M.C. Balfour,
Public Health and Demography in the Far East (1949). As early as 1944, an
212 Notes
ILO report on ‘Social Policy in Dependent Territories’ declared that

‘health policies in the tropics, even when successful in saving lives,
replaced one problem by a new one … the poverty of under-populated
areas was replaced by poverty resulting from overpopulation’. ILO, Social
Policy in Dependent Territories (Montreal: ILO, 1944), p. 10.
106 Gyan Chand, India’s Teeming Millions: A Contribution to the Study of the
Indian Population Problem (London: Allen & Unwin, 1939); Gyan Chand,
The Problem of Population (Oxford Pamphlets on Indian Affairs, Number
19: Oxford University Press, 1944) OIOC, T. 43122. See Chapter 1, above.
107 UN, Preliminary Report on the World Social Situation (New York, 1952),
p. 166.
108 Cf. M. Davis, Victorian Holocausts on the Victorian precedents for this
way of (de)valuing the lives of the Asian poor.
109 UN, Preliminary Report, p. 168.
110 Sir Herbert Broadley, Official Records of the World Health Organization [OR].
No. 42. Fifth World Health Assembly, Geneva, 5–22 May 1952, pp. 61–2.
111 WHO Archives, Second Generation files (WHO.2), GH/12, Rajkumari
Amrit Kaur to Brock Chisholm, 25 January 1952.
112 National Planning Committee, Population, p. 3.
113 D. Chakrabarty, ‘In the Name of Politics: Sovereignty, Democracy and
the Multitude in India’, Economic and Political Weekly, 23 July 2005.
114 WHO, Final Report on Pilot Studies in Family Planning (Geneva, 1954).
115 C.P. Blacker, ‘The Rhythm Method: Two Indian Experiments’ [unpub-
lished]: Wellcome Contemporary Medical Archives Centre [CMAC],
London. C.P. Blacker Papers, PP/CPB/H.1.
116 OR, no. 42, p. 232.
117 OR, no. 42, pp. 234–5.
118 I owe this point to Simon Szreter (pers. comm.).
119 WHO.1, GH/12, Brock Chisholm to Paul S. Henshaw, 21 January 1952.
120 Winslow, ‘Economic Values’, p. 193.
121 S. Kunitz, ‘Explanations and Ideologies’, p. 379.
Chapter 4 Building A New Utopia

2 See Chapter 2, above; D.K. Viswanathan and T. Ramachandra Rao, ‘Control
of Rural Malaria with DDT Indoor Residual Spraying in Kanara and Dharwar
Districts, Bombay province: First Year’s Results’, Indian Journal of
Malariology, 1 (1947), pp. 503–42; ‘Second Year’s Results’, Indian Journal of
Malariology, 2 (1948), pp. 157–210.
3 Chronicle of the WHO, 5,2 (February 1951), p. 44.
4 David Arnold, The Tropics and the Traveling Gaze: India, Landscape, and
Science 1800–1856 (Delhi: Permanent Black, 2005), p. 49.
8 Official Records of the World Health Organization, No. 44 [OR, 44], ‘Proposed
Programme and Budget Estimates for the Financial Year 1954’, pp. 259–73.
Notes 213
9 OR, 44.
10 Government of Burma, Pyidawtha, p. 109.
11 Cf. Meyer et al., ‘World Society’.
12 F.W. Clements, ‘The WHO in Southeast Asia and the Western Pacific’,
Pacific Affairs, 25, 4 (1952) p. 342.
13 Jeffery, The Politics of Health in India, p. 201.
14 Jeffery, The Politics of Health in India, p. 195. For broader considerations of
US economic aid to India in the 1950s, J. Merrill, Bread and the Ballot: The
United States and India’s Economic Development, 1947–1963 (Chapel Hill:
University of North Carolina Press, 1990).
15 Jeffery, The Politics of Health in India, p. 197.
16 ‘Campaign Against Disease: Tribute to the Work of WHO’, The Hindu, April
9, 1955.
17 On the intensified National Malaria Control Programme in India, see
Viswanathan, Conquest of Malaria in India; Government of India,
Directorate-General of Health Services, Annual Reports, various years.
18 ‘Campaign Against Disease: Tribute to the Work of WHO’, The Hindu,
April 9, 1955.
19 The programme of transmigration began in the colonial period, with
small-scale resettlement to the outer islands beginning in 1905. See
J.M. Hardjono, Transmigration in Indonesia (Kuala Lumpur: Oxford Univer-
sity Press, 1977).
20 Jaswant Singh ‘Malaria in Indonesia: Report on a Four Weeks’ Visit’,
July–August 1955. WHO. SEA/Mal/3, 31 Dec 1955 [Restricted].
21 Selected Works of Jawaharlal Nehru (Second Series), Vol. 33 (Delhi: Nehru
Memorial Fund, 2004), p. 213. Timothy Mitchell has suggested that perhaps
the ‘first international act’ of the new Egyptian government after Nasser’s
coup of August 1952 was to sign an agreement with WHO and UNICEF to
build a DDT factory at Kafr Zayat ‘that would produce two hundred tons a
year of finished DDT’. Mitchell, ‘Can the Mosquito Speak?’ p. 50.
22 P.L. Narayana, The Indian Pharmaceuticals Industry (Delhi: NCAER, 1984),
p. 38. In 1952, the public sector accounted for approximately 3 per cent of
pharmaceutical sales in India, with ‘foreign’ firms and ‘large Indian’ firms
accounting for over 30 per cent each, and ‘small’ Indian firms almost 20 per
cent.
23 Nehru, Letter to the Chief Ministers, 7 June 1956, Selected Works of
Jawaharlal Nehru (Second Series), Vol. 33 (Delhi: Nehru Memorial Fund,
2004), p. 213.
24 On the flow of imported commodities in the programmes, see, for example,
D.K. Viswanathan, ‘Report on Malaria in Indonesia’, WHO Print Archives,
WHO Library Geneva (WHO), Regional Office for South East Asia (SEA);
WHO. SEA/Mal/5, 17 October 1956 [Restricted], pp. 18–19; on the supplies
for the BCG campaign, an example is K. Hansen, ‘Report on Ceylon BCG
Campaign. May 1954–March 1956’, 30 April 1956 [Restricted]. SEA/TB/3.
25 Within the Southeast Asian region of WHO, Burma and Indonesia refused
to exempt malaria supplies from customs duty: Third Asian Malaria
Conference New Delhi, 16–21 March 1959, WHO. SEA/Mal/Conf.3, part 2.
26 On the (sometimes) countervailing demands of sovereignty and biopolitics,
see Michel Foucault, Society Must Be Defended: Lectures at the College de
214 Notes
France, 1975–76 (David Macey, trans., London: Penguin, 2003), esp.

pp. 242–50.
27 UN, Technical Assistance Programme, ‘Social Services in Burma’, File
No. TAA 173/85/04, Report No. TAA/BUR/9, 1955 [British Library of
Political and Economic Science, UN Collection].
28 UN, ‘Burma’, TAA/BUR/9 (1955).
29 See Vaughan, Curing Their Ills. The consultants from Burma wrote that ‘the
extra-marital habits of the Kachins, while of great ethnographic interest, is
by no means the core of the problem’ of venereal disease. UN, ‘Burma’,
TAA/BUR/9 (1955).
30 UN, ‘Burma’, TAA/BUR/9 (1955).
31 Cf. Chatterjee, Politics of the Governed, p. 37.
32 The phrase ‘ethnographic state’ is from Nicholas Dirks, Castes of Mind:
Colonialism and the Making of Modern India (Princeton: Princeton University
Press, 2001), part 3.
33 L. Mara, ‘Malaria Control in South Malabar, Madras State’, Bulletin of the
World Health Organization, 11 (1954), 679–723.
34 L. Mara (1954) ‘Malaria Control’.
35 Cf. Stoler, Education of Desire, p. 39.
36 M. Foucault, The Archaeology of Knowledge (trans. A. Sheridan Smith [1972];
London: Routledge, 2003 ed.), p. 56.
37 UN, ‘Burma’, TAA/BUR/9 (1955), p. 153.
38 The words, here, of Robert Young: R.J.C. Young, ‘Foucault in Tunisia’, in
Postcolonialism, An Historical Introduction (Oxford: Blackwell, 2001), p. 433.
39 B. Anderson, Imagined Communities: Reflections on the Origin and Spread of
Nationalism (London: Verso, 2nd ed. 1991).
40 D.K. Viswanathan (WHO Regional Adviser on Malaria) ‘Report on a Visit to
Burma in Connection with the Malaria Eradication Project in Burma’, 2–
19 February 1957. SEA/Mal/7 [Restricted], Annex.
41 D.K. Viswanathan, ‘Report on National Malaria Control Programme in
Afghanistan’, 23 June–7 July, 1956, WHO. SEA/Mal/4, 23 July 1956
[Restricted]; Viswanathan, ‘Report on Malaria in Indonesia’, 18 August–
7 September, 1956; WHO. SEA/Mal/5, 17 October 1956 [Restricted];
Viswanathan, ‘Report on Anti-Malaria Work in Ceylon’, 26 October–
4 November, 1956, WHO. SEA/Mal/6, 19 November 1956 [Restricted];
Viswanathan, ‘A Visit to the Malaria Control Project in Rapti Valley,
Nepal’, 20–26 April, 1957, WHO. SEA/Mal/8, 27 May 1957 [Restricted].
Viswanathan’s journeys might be seen as a culmination of a process
which Warwick Anderson dates to the early twentieth century: a gradual
decline in the power of the ‘tropics’ to captivate the medical imagination.
Writes Anderson: ‘Scientific tropical narratives in this period seem to
mute the late nineteenth-century rhetoric of sublime nature, and to sub-
stitute for it a rhetoric of the techno-scientific sublime … It is the irre-
sistible technical force of modern colonialism … that stuns the new
generation of scientists, exciting wonder and trepidation’. Anderson,
‘The Natures of Culture: Environment and Race in the Colonial Tropics’,
in P. Greenough and A. Lowenhaupt-Tsing (eds), Nature in the Global
South: Environmental Projects in South and Southeast Asia (Durham, N.C.:
Duke University Press, 2003), p. 42.
Notes 215
42 V. Thompson and R. Adloff, Minority Problems in Southeast Asia (Stanford:

Stanford University Press, 1955), p. 77.
43 Thompson and Adloff, Minority Problems, p. 77.
44 J. Manevy, ‘Le Dr Malaria’, UNESCO Le Courrier, May 1958, Vol. 11, No. 5,
pp. 15–17.
45 United Nations Career Records Project (UNCRP), Modern Political Papers
collection, Bodleian Library, Oxford. Papers of A.E. Brown, MS Eng c 4664,
File 2, fol. 104, February 21, 1954.
46 Brown Papers, MS Eng c 4664, File 2, fol. 139, February 21, 1954.
47 Brown Papers, MS Eng c 4664, File 2, fol. 105–7.
48 See Vaughan, Curing Their Ills, chapter seven, on the ‘jungle doctor’
memoirs. International variants on that theme can be seen in R. Calder,
West Meets East (London: News Chronicle, 1952); J. Manevy, La Guerre
Contre La Maladie a Travers le Monde (Paris: Hachette, 1964).
49 Cf. Pierre Bourdieu, Logic of Practice (R. Nice, trans., Cambridge: Polity,
1990).
50 UN, ‘Burma’, TAA/BUR/9 (1955), p. 152.
51 UN, ‘Burma’, TAA/BUR/9 (1955), p. 152.
52 See Chapter 1, above, on the origins of the mantris and the very different
roles defined for them in the 1930s.
53 K. Osterkov Jensen, ‘Assignment Report on Tuberculosis Control in
Indonesia’, WHO. SEA/TB/5 (April, 1958), [Restricted], p. 29.
54 On early post-war efforts in nursing education in India and Southeast Asia,
supported by the Rockefeller Foundation: RAC, RF, RG 12.1, Box 10: Janet
D. Corwin Diaries, 1944–1948. The most comprehensive history of India’s
health services concurs that no great efforts were made in the field of
nursing in the 1950s: R. Jeffery, Politics of Health.
55 J. Ferguson, Expectations of Modernity: Myths and Meanings of Urban Life on
the Zambian Copperbelt (Berkeley and Los Angeles: University of California
Press, 1999), p. 36.
56 L. Mara, ‘Malaria Control’, (1955), p. 694.
57 WHO. SEA/Mal/5 (1956), p. 9.
58 WHO. SEA/Mal/5 (1956), p. 3.
59 WHO. SEA/Mal/7, (1957), p. 6.
60 G. Sambasivan, Guide for Training Spraymen (Rangoon: Government Press,
1957).
61 Government of India, Jawaharlal Nehru on Community Development (New
Delhi, 1957), pp. 17–18. On the changed context for mass action after inde-
pendence, see D. Chakrabarty, ‘In the Name of Politics: Sovereignty,
Democracy and the Multitude in India’, Economic and Political Weekly,
23 July 2005.
62 Nehru on Community Development, p. 17, from a speech delivered in August
1952 to the first group of Community Development Project Officers. On the
language of mission, cf. P. Van der Veer (ed.), Conversion to Modernities: The
Globalization of Christianity (London/New York: Routledge, 1996).
63 National Planning Committee, Report of the National Health Sub-Committee,
Chair: S.S. Sokhey, K. Shad (ed.) (Bombay: Vohra & Co., 1947), pp. 43–4.
Although published after the Second World War, the report was the result
of discussions in 1938–39.
216 Notes
64 Nehru on Community Development, p. 50.

65 Nehru on Community Development, p. 13.
66 Frankz Kafka, The Great Wall of China (London: Penguin, 2005 [trans.
M. Pasley, 1973]). Not all international health officials were convinced that
such enthusiasm could be sustained indefinitely. A WHO sanitary officer,
V. Venkat Rao wrote that in Burma, ‘Spraying will hereafter be carried out
by voluntary spraymen, recruited mainly through the newly formed
National Solidarity Councils. This is a bold experiment, but, in the very
nature of things, it is not practicable to expect people from rural areas
to go about from village to village and carry out spraying for prolonged
periods without any remuneration’. V. Venkat Rao, ‘Assignment Report on
Malaria Eradication Project’, 1955–59, 11 January 1960 [Restricted], WHO.
SEA/Mal/17, p. 13.
67 Paul F. Russell, Man’s Mastery of Malaria (London: Oxford University Press,
1955), p. 1.
68 The case was summarized in WHO, Malaria Eradication: A Plea for Health
(Geneva, 1958).
69 On the longer history of mosquito resistance to insecticides, see
A. Spielman and M. D’Antonio, Mosquito: A Natural History of Our Most
Persistent and Deadly Foe (New York: Faber & Faber, 2002).
71 G.A. Livadas and G. Georgopoulos, ‘Development of Resistance to DDT By
Anopheles Sacharovi in Greece’ Bulletin of the World Health Organization, 8
(1953), pp. 497–511.
72 F.J. Dy, ‘Present Status of Malaria Control in Asia’, Bulletin of the World
Health Organization, 11 (1954), 725–63, p. 741.
73 E.J. Pampana, ‘Changing Strategy in Malaria Control’, Bulletin of the World
Health Organization, 11 (1954), 513–520, at p. 518.
74 Pampana, ‘Changing Strategy’, p. 518.
75 WHO Archives, Geneva, Second Generation Files (WHO.2) From Director,
Division of Communicable Disease Services to Director-General, Re: Briefing
for Visit to Southeast Asia Region, 27 October 1954. [On microfiche; no file
number given]
76 Official Records of the World Health Organization, No. 63, Eighth World
Health Assembly, Mexico, 10–27 May 1955. Committee on Programme and
Budget: Sixth Meeting, p. 200.
77 WHO, Committee on Programme and Budget, Sixth Session, 1955, OR, 63,
pp. 200–1.
p. 205.
p. 198.
80 See Randall Packard, ‘No Other Logical Choice’: Global Malaria Eradication
and the Politics of International Health’, Parassitologia, 40 (June 1998),
pp. 217–30.
81 On this, see H. Cleaver, ‘Malaria and the Political Economy of Public
Health’, International Journal of Health Services, 7, 4 (1977), pp. 557–79,
p. 571. Harry Cleaver shows the process by which a number of American
public health officials, committed to WHO, were able to persuade the US
Notes 217
government that supporting the malaria eradication campaign ‘could be a

tool of American foreign policy’, and ‘would do much to counteract the
anti-United States sentiments which have been aroused by subversive
methods’. Thus, Cleaver shows that the malaria eradication campaign did
not come about as a result of US manipulation of the WHO, but rather that,
by offering public health as an instrument of foreign policy, the WHO’s
American supporters were able to restore public health to a position of
importance in international government; a position which they feared it
was losing.
82 ‘Information on the Status of Malaria Eradication in South-East Asia:
Burma’, Third Asian Malaria Conference New Delhi, 16–21 March 1959,
WHO. SEA/Mal/Conf.3, part 2.
83 ‘Information on the Status of Malaria Eradication in South-East Asia: India’.
WHO. SEA/Mal/Conf.3, part 2.
Chapter 5 The Techno-politics of Public Health

1 Mitchell, ‘Can the Mosquito Speak?’ pp. 41–2. My use of the term
‘techno-politics’ in this chapter has been influenced by the illuminating
work of James Vernon: ‘The Ethics of Hunger’.
2 James Ferguson, The Anti-Politics Machine: ‘Development’, Depoliticization
and Bureaucratic Power in Lesotho (Cambridge: Cambridge University
Press, 1990).
3 Extract from a letter from the Doctor, protagonist of Phanishvarnath
Renu’s 1954 novel, Maila Anchal (Delhi, Rajakamal Prakashan, 1954);
here and elsewhere in this chapter, I have used Indira Junghare’s
idiomatic translation: The Soiled Border (Delhi: Chanakya Publications,
1991), p. 162.
4 Jaswant Singh, ‘Malaria in Indonesia: Report on a Four Weeks’ Visit’,
July–Aug 1955. WHO. SEA/Mal/3, 31 December 1955 [Restricted].
6 Jaswant Singh, ‘Malaria in Indonesia: Report on a Four Weeks’ Visit’,
July–Aug 1955. WHO. SEA/Mal/3, 31 December 1955 [Restricted]
Appendix 8. My emphases.
7 P. Bertagna, ‘Sorption of Insecticides on Mud Walls’, May 1956
[Restricted], WHO. MH/AS/111.56.
8 WHO, Division of Malaria Eradication, Monthly letters, 1957–1959,
WHO Library, Geneva, D64.1931.
9 Report on the Third Asian Malaria Conference, Delhi, 19–21 March 1959,
WHO. SEA/Mal/16, Annex 3, Opening Address by Jawaharlal Nehru.
10 UN, ‘Burma’, TAA/BUR/9 (1955), p. 167.
11 V. Venkat Rao, ‘Assignment Report on Malaria Eradication Project:
Burma, 1955–59’, WHO. SEA/Mal/17, 11 January 1960 [Restricted].
12 WHO. SEA/Mal/17 (1960).
13 WHO. SEA/Mal/17 (1960).
14 D.K. Viswanathan, ‘Report on Malaria in Indonesia’, WHO. SEA/Mal/5,
17 October 1956 [Restricted].
15 WHO. SEA/Mal/5 (1956).
218 Notes
16 For an overview of the campaign, see WHO, International Work in

Tuberculosis Control (Geneva, 1965).
17 WHO. SEA/TB/3 (1956).
18 WHO. SEA/TB/3 (1956).
19 WHO. SEA/TB/3 (1956).
20 WHO. SEA/TB/3 (1956).
21 Dr C.F. Borchgrevink (Senior WHO Officer) and Dr Nio Kok Hien
(National director, Indonesian BCG Campaign) ‘Report on BCG
Campaign in Indonesia’, February 1957, [Restricted], WHO. SEA/TB/4,
Annex 1.
22 WHO. SEA/TB/4 (1957), Annex 1.
23 L. Grasmo (WHO BCG Nurse), ‘Report on BCG Campaign in Indonesia’,
WHO. SEA/TB/4, February 1957 [Restricted] Annex 2.
24 Government of India, Central Council of Health, ‘Minutes of the Central
Council of Health: Third Meeting, Trivandrum, 1955’ [mimeographed,
National Medical Library, New Delhi]; RAC. RG 12. Richmond K.
Anderson Diaries, 1955. 23–25 January, 1955.
25 J. McLary, WHO Public Health Nurse, ‘Assignment report on National
Tuberculosis Programme, India’ (Restricted), February 1961, WHO.
SEA/TB/30.
26 Dr E. Kjolbye, ‘Assignment Report on BCG Vaccination in India’,
(Restricted), August 1962, WHO. SEA/TB/40 Rev.1.
27 See, for example, WHO. SEA/Mal/3 (1955), which begins with a consider-
ation of the ‘context’: population, terrain, distribution of malaria and
questions of government.
28 WHO. SEA/Mal/5 (1956); WHO. SEA/Mal.7 (1957); WHO. SEA/Mal/6
(1956).
29 See the essays in P. Kratoska, R. Raben and H. Schulte Nordholt (eds),
Locating Southeast Asia: Geographies of Knowledge and Politics of Space
(Singapore: Singapore University Press, 2005).
30 A report on the implications of the Haj for malaria eradication exposed
another challenge posed by population movement, this time of an inter-
regional kind: M.A. Farid, ‘The Pilgrimage and its Implications in a
Regional Malaria Eradication Programme’, 9 April 1956, WHO/Mal/168.
31 Agnese Lockwood, The Burma Road to Pyidawtha, Carnegie Endowment
for International Peace, International Conciliation, No. 518, May 1958,
p. 433.
32 Lockwood, Pyidawtha, p. 433.
33 Edmund Leach, ‘The Frontiers of “Burma”’, Comparative Studies in Society
and History, 3, 1 (1960), 49–86, p. 61.
34 Ludu U Hla, The Caged Ones ([1958] trans. Sein Tu, Bangkok: Tamarind
Press, 1986).
35 Dr F. Loven (Senior WHO Officer), ‘Final Report on Tuberculosis Control
and Training Centre, Mandalay’, WHO. SEA/TB/13, (Restricted), February
1958, p. 11; on tuberculosis and migration see J.B. MacDougall, Tuberculosis:
A Global Study in Social Pathology (Edinburgh, 1949, pp. 4–5).
36 WHO. SEA/TB/13 (1958).
37 A WHO sampling and registration manual states that: ‘Every member of
the households comprising the sample group must be included in the reg-
Notes 219
istration, and all intruders must be excluded. In many instances the correct
status of an individual may be difficult to establish…should doubt remain,
the doubt is recorded on the card.’ WHO/TUB/Techn.Guide/1, p. 6.
38 WHO. SEA/TB/13 (1958).
39 WHO. SEA/TB/13 (1958).
40 See, for example, WHO. SEA/Mal 7 (1957); WHO. SEA/Mal/18 (1960),
and WHO. SEA/TB/5 (1957).
41 M. Foucault, The Archaeology of Knowledge, p. 37.
43 Renu, Soiled Border, p. 132.
45 Renu, Soiled Border, pp. 188–9.
46 Indeed, numerous studies from the time suggest that the majority of
India’s rural cultivators did, indeed, face an acute shortage of land. The
Indian national sample survey of rural holdings, conducted in 1954–55,
showed that more than one-fifth (22 per cent) of households surveyed
owned no land at all. Altogether, approximately 61 per cent of house-
holds owned either no land, or fragmented and uneconomical plots of
less than one hectare. By contrast, the upper 13 per cent of households
owned 64 per cent of all land. National Sample Survey, Eighth Round,
Number 10, First Report on Land Holdings, Rural Sector; analysed in detail
in F. Frankel, India’s Political Economy, 1947–1977: The Gradual Revolution
(Princeton: Princeton University Press, 1977), pp. 98–100.
47 WHO, Seventh World Health Assembly, May 1954, Third Plenary
Meeting, Dr A. Stampar, OR 55, p. 80.
48 Socrates Litsios, ‘Selskar Gunn and China: The Rockefeller Foundation’s
“Other” Approach to Public Health’, Bulletin of the History of Medicine, 79,
2 (2005), pp. 295–318.
49 Government of India, Community Projects: A Draft Outline (Delhi, 1952);
Government of India, Community Projects: A Draft Handbook (Delhi,
1952); Government of India, Jawaharlal Nehru on Community Development
(Delhi, 1957).
50 UN, Report of the Mission on Community Organization and Development in
South and Southeast Asia, Horace Belshaw and J.B. Grant, ST/SOA/Ser.0/10,
p. 24. Emphases mine.
51 UN, Community Organization, pp. 124–5. Ultimately, even the Firka
scheme could only translate into the language of technical assistance in
terms of numbers:
‘During the first five years of operation 1,076 wells were constructed or
were under construction and 732 were repaired or improved, as well as
hundreds of miles of road, 228 schools, 73 reading rooms, 3,061 latrines,
1,154 cesspits, 22 miles of village drains, 11 ponds, and 14 dams. Nearly
200 minor irrigation tanks, lakes and ponds were repaired. Over a
million trees were planted and 6.230 acres of waste land were brought
under cultivation’. See also Administration Report of the Director of Rural
Development for the Year 1951 (Government of Madras, 1952).
52 UN, Community Organization, p. 3, p. 25.
53 Frankel, India’s Political Economy, p. 198. See also Partha Chatterjee,
‘Development Planning and the Indian State’.
220 Notes
54 Health Cooperatives (Visvabharati Bulletin, No. 25, 1953), p. 17, p. 19.

55 On Indonesia, see Wolf Ladejinsky, ‘Land Reform in Indonesia’ (1963),
in L.J. Walinsky (ed.). Agrarian Reform as Unfinished Business: The
Selected Papers of Wolf Ladejinsky (Washington DC, World Bank, 1977).
On Burma, J. Silverstein, ‘Burma’, in G. Kahin (ed.), Governments and
Politics of Southeast Asia (Ithaca: Cornell Southeast Asia Program, 1959),
pp. 75–154. For a more recent perspective on the failures of land reform,
particularly comparing India and Indonesia, see D.A. Low, The Egalitarian
Moment: Asia and Africa, 1950–1980 (Cambridge: Cambridge University
Press, 1995).
56 For arguments about Kerala’s ‘exceptionalism’, see R. Jeffrey, Politics,
Women and Well-Being: How Kerala Became a Model (Cambridge:
Cambridge University Press, 1992).
57 I am grateful for Dr J. Devika (pers. comm.) for her comments on Kerala’s
challenge to my broader arguments about technical assistance and
depoliticization.
58 For a recent view of Kerala’s modernity, see J. Devika, ‘Domesticating
Malayalees: Family Planning, the Nation and Home-Centred Anxieties in
Mid-20th Century Keralam’, Centre for Development Studies, Working
Paper 340, (Thiruvananthapuram, 2002).
59 J.C. Caldwell, ‘Routes to Low Mortality in Poor Countries’, Population and
Development Review, 12, 2 (June 1986), pp. 171–220, p. 198.
60 J. Mencher, ‘The Lessons and Non-Lessons of Kerala: Agricultural
Labourers and Poverty’, Economic and Political Weekly, 15, special number
(October), pp. 1781–1802.
61 J. Devika, personal communication, 30 September 2005.
62 Caldwell, ‘Low Mortality’.
63 To take one example of the spread of ideas about modernization, an
early proposal for the syllabus for the BSc. Programme in nursing at the
Delhi School of Nursing included a significant component of sociology:
Books: Park and Burgess, Introduction to the Science of Sociology; McIver,
Society, Its Structure and Change; Hobhouse, Social Development;
C.H. Cooley, Human Nature and the Social Order; Ginsberg, The
Psychology of Society; North, Social Differentiation; Rivers, Social
Organization; Encyclopaedia of Social Science, article on culture …
Rockefeller Archive Centre, Rockefeller Foundation Files, Record Group 2
– 1945, Series 464, Box 307, folder 2083: ‘Syllabus for B.Sc. (Nursing). See
also, Margaret Mead, Culture and Technological Change, and the early
issues of the journal Economic Development and Cultural Change.
64 WHO. C.F. Borchgrevink (WHO Senior Officer) and Nio Kok Hien
(Indonesian National BCG Director), ‘Report on BCG Campaign in
Indonesia. WHO Project: Indonesia–8D’ [Restricted], 5 February, 1957.
SEA/TB/4.
65 Winslow, ‘Economic Values’, p. 193.
66 Vaughan, Curing Their Ills, p. 147.
67 F.W. Clements, ‘The WHO in Southeast Asia and the Western Pacific’,
Pacific Affairs, 25, 4 (1952), p. 344. On the view of H.V. Wyatt, the
unusual effectiveness of yaws treatment played a major role in making
injections a popular form of therapy across large parts of Asia and Africa.
Notes 221
H.V. Wyatt, ‘The popularity of injections in the Third World: Origins

and Consequences for Poliomyelitis’, Social Science and Medicine, 19
(1984), pp. 911–15.
68 Megan Vaughan has written of this problem in the context of late-
colonial Africa: ‘What evidence could be brought to bear to show that
African patients actually believed in the theories of biomedicine, rather
than merely utilizing its practices? I would argue that it would not be
possible to “prove” that the theory of biomedicine had been adopted and
internalized’. Vaughan, ‘Health and Hegemony’, p. 199.
69 Pramoedya Ananta Toer, ‘Science, Religion and Health Care’, in The
Mute’s Soliloquy: A Memoir, trans. W. Samuels (New York: Penguin, 1999),
pp. 237–48.
70 R. Dubos, Man Adapting (New Haven: Yale University Press, 1965), p. 364.
71 G. Canguilhem, The Normal and the Pathological (trans. C.R. Fawcett, New
York: Zone Books, 1989 [1943]). A rare contemporary study of attitudes
to pain and disease in 1950s India is K.A. Hasan, Cultural Frontier of
Health in Village India: Case Study of a North Indian Village (Bombay:
Manaktalas, 1967).
72 Only after a contaminated batch of vaccine caused hundreds of injuries, for
example, did the WHO begin to record ‘adverse reactions’ to vaccination in
the international BCG campaign. WHO. SEA/TB/4 (1957).
73 WHO. SEA/TB/4 (1957), my emphases.
74 Hari Vishnu Kamath, Lok Sabha Debates [LSD], 4 April 1956, p. 4289.
75 This point will be developed in the book’s conclusion, below.
76 WHO. SEA/TB/3 (1956).
77 C. Rajagopalachari, BCG Vaccination: Why I Oppose It (Madras: Indian
Express Press, 1956). The pagination in my copy of the document is illeg-
ible: all quotations from the document are from the first five pages.
78 I am not, here, making any claims as to whether or not these injuries
and maladies were in fact caused by BCG vaccination; the point is, rather,
to highlight that the association was made by a number of people, and
came to light in Rajagopalachari’s criticisms.
79 All of the letters cited are published in Rajagopalachari, BCG: Why I
Oppose It (Madras, Indian Express Press, 1956), after the main body of
Rajagopalachari’s text.
80 W. Anderson, ‘The Third World Body’, in R. Cooter and J. Pickstone (eds),
Medicine in the Twentieth Century (Amsterdam: Rodopi, 2000), pp. 235–45.
81 As Michel Foucault noted, ‘We must make allowance for the complex
and unstable process whereby discourse can be both an instrument and
an effect of power, but also a hindrance, a stumbling block and a point
of resistance and a starting point for an opposing strategy …’. A History of
Sexuality, Vol. 1: The Will to Knowledge, trans. W. Hurley (London:
Penguin, 1990), p. 101.
82 See Monica Felton, I Meet Rajaji (London, 1962); Ramachandra Guha,
‘The wisest man in India: aspects of C. Rajagopalachari’, in The Last
Liberal and Other Essays (Delhi: Permanent Black, 2004).
83 Rajagopalachari, BCG.
84 From across the political spectrum from Rajagopalachari, Hari Vishnu
Kamath, a radical socialist, put the issue much more forcefully in a
222 Notes
parliamentary debate in 1956: ‘The Government’s, rather the Minister’s

attitude to BCG is itself BCG; it is brazen, it is cussed, and it is
grotesque … the mass scale BCG, in the manner in which it is done,
is simply mass bacteriological warfare, and nothing else’. H.V. Kamath,
LSD, 4 April 1956, pp. 4289–90.
85 On vaccination and anti-vaccination, see Alison Bashford, ‘Foreign
Bodies: Vaccination, Contagion and Colonialism in the 19th Century’, in
A. Bashford and C. Hooker (eds), Contagion: Historical and Cultural Studies
(London/New York: Routledge, 2001), pp. 39–60; also, N. Durbach, Bodily
Matters: The Anti-Vaccination Movement in England, 1853–1907 (Durham,
N.C.: Duke University Press, 2005). For a critical review, see Susan
Pedersen, ‘Anti-Condescensionism’, London Review of Books, 27, 17, 1 Sept
2005, pp. 7–8. For an Indian study, see Arnold, Colonizing the Body,
chapter five.
87 Rajagopalachari’s pamphlet is full of citations from the British Medical
Journal, the American Journal of Public Health, from memoranda by the
British Ministry of Health and medical textbooks like Topley and Wilson’s
Principles of Bacteriology and Immunity, Volume II (third edition by
G.S. Wilson and A.A. Miles).
88 Report on the Health Conditions in Madras State 1955 [Tamil Nadu State
Archives Library, Chennai].
89 Reconstructed from Report on the Health Conditions in Madras State 1955
[Tamil Nadu State Archives Library, Chennai]. Unfortunately, I could not
locate statistics at this level of detail for subsequent years, making it
difficult to quantify the ‘recovery’ of the vaccination campaign.
90 Report on the Health Conditions in Madras State, 1956 [Tamil Nadu State
Archives Library].
Archives Library].
92 WHO. SEA/TB/3 (1956).
93 Government of Ceylon, Administration Report of the Director of Health
Services for 1955 (Dr D.L.J. Kahawita), (Colombo, 1956), para. 54.
94 WHO. SEA/TB/3 (1956).
95 WHO. SEA/TB/3 (1956).
96 ‘BCG Team Obstructed’, Ceylon Observer, July 30, 1955.
97 It was another Madras study, carried out by the Indian Council of
Medical Research, that showed the relative ineffectiveness of the BCG
vaccine: Anonymous, ‘Trial of BCG vaccines in South India for tuber-
culosis prevention: first report: Tuberculosis Prevention Trial’ Bulletin of
the World Health Organization, 57, 1979, 819–27.
98 Rajagopalachari, BCG.
99 The Final Report of the International Tuberculosis Campaign (Copenhagen,
1951) wrote that: ‘By and large there was no substantial opposition to
BCG vaccination, except in Madras where an active counter-propaganda
was waged by certain groups’. The causes of this earlier resistance remain
obscure, but my informal interviews with a number of older people in
Madras suggested that it was a result of some cases of ‘adverse reaction’
to vaccination.
Notes 223
100 Rajagopalachari’s critiques simply ‘would not have made sense’ in the politi-
cal culture of neighbouring Kerala: J. Devika, pers. comm. (30 September,
2005).
103 M.C. Balfour, ‘Problems in Health Promotion in the Far East’, in
Modernization Programs in Relation to Human Resources and Population
Problems (New York: Millbank Memorial Fund, 1950); H. Cullumbine,
‘An Analysis of the Vital Statistics of Malaria in Ceylon’, Ceylon Journal
of Medical Science (D), 6 (1950), parts 3 & 4; S. Rajendran and
S.H. Jayewickreme, ‘Malaria in Ceylon’, Indian Journal of Malariology, 5
(1951), 1–124; R.H. Gray, ‘The Decline of Mortality in Ceylon and the
Demographic Effects of Malaria Control’, Population Studies, 28, 2
(1974), 205–29.
104 WHO Expert Committee on Venereal Infections, Report on the Third
Session, WHO Technical Reports Series, 13 (1950); S.L. Walker and R.J. Hay,
‘Yaws – A Review of the Last 50 Years’, International Journal of
Dermatology, 39, 4 (2000), 258.
105 WHO. SEA/TB/3 (1956).
106 Soper, ‘Problems to be Solved’, p. 736.
107 Cf. Peter Baldwin, Contagion and the State in Europe, 1830–1930 (Camb-
ridge: Cambridge University Press, 1999). Baldwin argued, for nineteenth
century Europe, that mass vaccination (like quarantine) was a technique
employed by relatively weak states, which lacked the capacity to imple-
ment less intrusive (but more demanding) systems of surveillance. It
seems to me that a similar argument could be applied to the WHO in the
1950s.
108 J.C. Scott, Seeing Like a State: Why Certain Schemes to Improve the Human
Condition Have Failed (New Haven: Yale University Press, 1998), p. 4.
109 Cf. Packard, ‘Malaria Dreams’.
Chapter 6 The Limits of Disease Control

1 See Chapter 5, above. Tuberculosis Chemotherapy Centre, ‘A Concurrent
Comparison of Home and Sanatorium Treatment of Pulmonary
Tuberculosis in South India’, Bulletin of the WHO, 21 (1959), 51–144.
2 WHO. SEA/TB/28, Dr J.H. Angel (WHO Medical officer), ‘Assignment
Report on Tuberculosis Chemotherapy Centre, Madras’ (Restricted,
November 1960).
3 TNA. PRO, FD 7/1020, W. Fox (TCC, Madras) to P. D’Arcy Hart (MRC,
London), 27 December 1958.
4 Interview with Sir John Crofton, Edinburgh, October 2002.
5 Government of India, Census of India, 1961, Volume 9, Part 11 C, ‘Slums
of Madras City’ (1965), p. 26.
6 C.V. Ramakrishnan et al., ‘The Role of Diet in the Treatment of
Pulmonary Tuberculosis: An Evaluation in a Controlled Chemotherapy
Study in Home and Sanatorium Patients in South India’, Bulletin of the
WHO, 25 (1961), 339–59, p. 339; emphases in the original.
224 Notes
7 Chemotherapy Centre, ‘Concurrent Comparison’, p. 109. On the sanato-

ria of Victorian Britain, see Linda Bryder, Below the Magic Mountain:
A Social History of Tuberculosis in Twentieth Century Britain (Oxford:
Oxford University Press, 1988). For another perspective on changing
treatments of tuberculosis over time, see Alison Bashford, ‘Tuberculosis
and Immigration in Australia, 1901–2001: The Great White Plague Turns
Alien’, in M. Worboys and F. Condrau (eds), The History of Tuberculosis in
International Perspective (London/New York: Routledge, 2006, forth-
coming). I thank Dr Bashford for showing me the typescript.
8 Ramakrishnan et al., ‘Role of Diet’, p. 340.
9 Ramakrishnan et al., ‘Role of Diet’, pp. 351–54.
10 Chemotherapy Centre, ‘Concurrent Comparison’, p. 107.
11 Ramakrishnan et al., ‘Role of Diet’, pp. 357–8.
12 Stig Andersen (WHO sociologist), ‘Assignment Report on National
Tuberculosis Institute, Bangalore, India’. WHO. SEA/TB/49 (November
1963) [Restricted], p. 20.
13 National Tuberculosis Institute, Bangalore, Annals of the NTI: 40 Years of
Accomplishment (Bangalore: NTI, 2000), p. 24.
14 Interview with Dr D. Banerji, Delhi, 5 September 2003.
15 D. Banerji, ‘Society, Health Problems, Modern Medicine and Social
Medicine: An Analysis of Their Inter-relationship in a Cross-Cultural
Context’, Cornell University dissertation, 1963. [Cornell University,
Kocher Library, rare books and manuscripts, Thesis 1963 B.215].
16 D. Banerji and S. Andersen, ‘A Sociological Study of Awareness of
Symptoms among Persons with Pulmonary Tuberculosis’, Bulletin of the
WHO, 29 (1963), 665–83, p. 665.
17 Banerji and Andersen, ‘Study of Awareness’, p. 666.
18 Banerji and Andersen, ‘Study of Awareness’, pp. 677–81.
19 Andersen, ‘Assignment Report’. WHO. SEA/TB/49 (1963).
22 Andersen, ‘Assignment Report’. WHO. SEA/TB/ 49 (1963).
24 S. Andersen and D. Banerji, ‘A Sociological Enquiry into an Urban
Tuberculosis Control Programme in India’, Bulletin of WHO, 29 (1963),
685–700, p. 691.
25 Andersen and Banerji, ‘Sociological Enquiry’, p. 691. My emphases.
26 Dr D. Savic, WHO Medical Officer, ‘Assignment Report on the National
Tuberculosis Programme, India’. WHO. SEA/TB/91 (October 1968)
[Restricted], pp. 21–2.
27 Government of India, Ministry of Health ‘Recommendations for a
District Tuberculosis Programme in India’, Annex to ‘Mass Campaigns
and General Health Services’ (Preliminary notes), Working Paper for the
WHO Secretariat Committee on Mass Campaigns and Public Health,
April 1964. WHO, PHA/Mass Camp/1 (1964).
28 WHO/UNICEF Joint Committee on Health Policy, Thirteenth Session,
Minutes of the First Meeting, WHO, JC13/UNICEF-WHO/Min/1 (January
1962) [Restricted].
29 Interview with Dr C.V. Ramakrishnan, Chennai, 1 February 2003.
Notes 225
30 Monica Felton, ‘Letter from India: Tackling Tuberculosis in India’,

New Society, 52 (26 September 1963).
33 Interview with Dr C.V. Ramakrishnan, Chennai, 1 February 2003.
34 TNA. PRO, FD7/1022, Dr Johs. Holm (head of TB, WHO) to Wallace Fox,
25 April 1957.
35 TNA. PRO, FD7/1022, Holm to Fox, 25 April 1957.
36 TNA. PRO, FD7/1022, Holm to Fox, 25 April 1957.
37 Felton, ‘Letter from India’.
38 PRO, FD7/1022, Holm to Fox, 25 April 1957.
39 WHO, JC13/UNICEF-WHO/Min/1, p. 15.
40 Cf. S. Kunitz, ‘Explanations and Ideologies’, p. 379.
41 WHO, JC13/UNICEF-WHO/2 (1962), p. 2.
42 WHO, International Work in Tuberculosis, 1949–1964 (Geneva, 1965), p. 15.
43 WHO, JC13/UNICEF-WHO/2 (1962), p. 19.
44 WHO, Expert Committee on Tuberculosis, Eighth Report, Technical Reports
Series, 290 (Geneva, 1964), pp. 3–4.
45 WHO, Expert Committee on Tuberculosis, Eighth Report, Technical Reports
Series, No. 290 (Geneva, 1964).
46 See my ‘Plague of Poverty?’ p. 64.
47 M.C. Raviglione, A. Pio, ‘Evolution of WHO policies for tuberculosis
control, 1948–2001’, The Lancet, 359 (2002), pp. 775–80.
48 Miss K. Das, ‘Problems of Relief for Poor Tuberculosis Patients’,
Proceedings of the 14th Tuberculosis Workers’ Conference, Madras, January
1958 (TB Association of India) [National Tuberculosis Institute Library,
Bangalore], pp. 150–5. My emphases.
49 The Employees’ State Insurance Corporation, launched in 1956, was a
scheme of contributory insurance for state employees, and included a
network of dispensaries.
50 Das, ‘Problems of Relief’, p. 154.
51 G.R. Banerjee (Head, Department of Medical and Psychiatric Social Work,
Tata Institute for Social Sciences, Bombay), The Tuberculosis Patient (Tata
Institute of Social Sciences, c. 1965) [NTI Library, Bangalore], p. 50.
52 Banerjee, The Tuberculosis Patient, p. 50.
53 Yet as Pierre Bourdieu has shown, the ‘rational’ disposition itself had
particular preconditions for is existence. ‘Rational economic choice’
presupposes a certain level of economic security, provided by stable
employment and a regular income, failing which ‘agents cannot perform
actions which presuppose an effort to “take a grip on the future”:
management of resources over time, whether financial or fertility’.
Pascalian Meditations (Richard Nice, trans. Cambridge: Polity, 2000),
p. 70. The original research is presented in Bourdieu, Algerie 60: Structures
Economiques et Structures Temporelles (Paris: Les Editions de Minuit, 1977).
54 S. Andersen and D. Banerji, ‘Urban Tuberculosis Control, p. 690.
55 S. Andersen and D. Banerji, ‘Urban Tuberculosis Control’, p. 690.
56 C.M. Lomasney, WHO Nurse, ‘Assignment Report on the Nursing
Aspects of the Tuberculosis Chemotherapy Centre, Madras’. WHO.
SEA/TB/44 (July 1963) [Restircted], p. 16.
226 Notes
57 Andersen and Banerji, ‘Urban Tuberculosis Control’, p. 689.

58 Andersen and Banerji, ‘Urban Tuberculosis Control’, p. 689. The 1961
census of Madras, too, talks of ‘a number of dwellings … [which] offer no
surface on which a number could be painted, not even a substantial door
post or indeed a door at all’: Government of India, Census of India, 1961,
Volume 9, Part 11 C, ‘Slums of Madras City’ (1965), p. 96.
59 This is James C. Scott’s term. J.C. Scott, Seeing Like A State: How Certain
Schemes to Improve the Human Condition Have Failed (New Haven and
London, 1998).
60 A social survey of Bangalore noted that: ‘The rapid growth of industries
and trade attracted many outsiders to settle and work in some factory or
other in the city … Government service, domestic services, general labour,
factory labour, cart driving, brick laying and mason work, trade and
money lending businesses have attracted outsiders’. K. Venkatarayappa,
Bangalore: A Socio-Ecological Study (Bombay: University of Bombay, 1957),
p. 32.
61 M.N. Srinivas, Indian Society Through Personal Writings (New Delhi, 1998),
pp. 53–5. On the broader struggles over urban space in Bangalore in this
period, see J. Nair, ‘Battles for Bangalore: Reterritorializing the City’,
available at www.sephis.org/pdf/nairpap.pdf. See also, S. Kaviraj, ‘Filth
and the Public Sphere: Concepts and Practices about Space in Calcutta’,
Public Culture 10, 1 (1997), pp. 83–113.
62 Venkatarayappa, Bangalore, p. 41.
63 See, for example, WHO Tuberculosis Chemotherapy Centre, Nairobi,
‘Drug Acceptability in Domiciliary Tuberculosis Control Programmes’,
Bulletin of the WHO, 1963, 29, 627–39.
64 Foucault, ‘The Politics of Health’, p. 285.
65 I.B. Throup, ‘Assignment Report on Tuberculosis Control Programme in
Burma’, Appendix 23, WHO. SEA/TB/67 (1967) [Restricted].
66 Throup, ‘Assignment Report’, SEA/TB/67 (1967).
67 Throup, ‘Assignment Report’, SEA/TB/67 (1967).
68 Government of India, Census of India, 1961, Vol. XI: Madras. Part I–A (i):
General Report, P.K. Nambiar, Superintendent of Census Operations
(Madras, 1966), pp. 225–6.
69 The report, for example, quotes from the 1908 Imperial Gazeteer of
Madras: Census of India 1961, Vol. XI: Madras, p. 44.
70 This argument is also made by Warwick Anderson in his ‘Third World
Body’.
71 Spielman and D’Antonio, Mosquito, p. 159.
72 J. Siddiqi, World Health and World Politics: The World Health Organization
and the UN System (London: Hurst, 1995), p. 154.
73 M.J. Colbourne, ‘Prospects for Malaria Eradication with Special Reference
to the Western Pacific’, Transactions of the Royal Society of Tropical
Medicine and Hygiene, 56 (1962), pp. 179–201, p. 179.
74 Colbourne, ‘Prospects for Malaria Eradication’, p. 183.
75 Colbourne, ‘Prospects for Malaria Eradication’, pp. 186–7.
76 G. Covell, Discussion of Colbourne, ‘Prospects’, Transactions, p. 195.
77 J. McArthur, Discussion of Colbourne, ‘Prospects’, Transactions, pp. 196–7.
78 J.F.B. Edeson, Discussion of Colbourne, ‘Prospects’, Transactions, p. 198.
Notes 227
79 Government of Ceylon, Administration Report of the Director of Health

Services for 1956, Dr D.L.J. Kahawita (Colombo, 1957), pp. 15–16.
80 G. Harrison, Mosquitoes, Malaria and Man: A History of the Hostilities Since
1880 (London: John Murray, 1978), p. 254.
81 F.R.S. Kellett, ‘Field visit report on malaria eradication programme,
Ceylon’, WHO. SEA/Mal/51, 14 May 1965 [Restricted]. See also
A. Gabaldon, ‘Assignment report on malaria eradication, Ceylon’, WHO.
SEA/Mal/59, 12 July 1966 [Restricted].
82 Yet by 1961, reports were coming back of widespread resistance to the
chemotherapeutic agents, too, and not just DDT.
83 Colbourne, ‘Prospects’, p. 181.
84 G. Harrison, Mosquitoes, Malaria and Man, pp. 250–51.
85 G. Harrison, Mosquitoes, Malaria and Man, p. 252.
86 Cited in V.P. Sharma and K.N. Mehrotra, ‘Malaria Resurgence in India:
A Critical Study’, Social Science and Medicine, 22, 8 (1986), 835–45, p. 839.
87 Sharma and Mehrotra, ‘Malaria Resurgence’, pp. 840–1.
88 Karl Evang, Sixteenth World Health Assembly, 7–23 May, 1963, OR 123,
pp. 176–7.
89 Evang, OR 123, pp. 176–7.
90 Evang, OR 123, pp. 176–7.
91 See the debates at the 1963 World Health Assembly, OR 123; E.J. Pampana,
‘Problem Areas’, WHO Print Archives, WHO Library, Geneva [WHO];
Mal/Exp.Comm.14/67.10, 27 June 1967. Only in 1969 did the WHO
formally recognize the ‘failure’ of malaria eradication: ‘Reexamination of
the Global Strategy of Malaria Eradication’, WHO, Official Records 176
(1969) Annex 13, 106–26.
92 R. Dubos, Man Adapting (New Haven: Yale University Press, 1965),
pp. 374–5.
93 Dubos, Man Adapting, p. 377.
94 Dubos, Man Adapting, p. 382.
95 N.S. Scrimshaw, C.E. Taylor, J.E. Gordon, Interactions of Nutrition and
Infection (Geneva: Who Monograph Series 57, 1968); W. McDermott,
‘Modern Medicine and the Demographic-Disease Pattern of Overly
Traditional Societies: A Technological Misfit’. Journal of Medical Education,
41, 9 September 1966, pp. 137–62; Kunitz, ‘Explanations and Ideologies’;
W.H. Mosely and L.C. Chen, ‘An Analytical Framework for the Study of
Child Survival in Developing Countries’, in Mosely and Chen (eds), Child
Survival: Strategies for Research, Population and Development Review, 10
(1984), supplement.
96 Connelly, ‘Population Control is History’.
97 Szreter, ‘Demographic Transition’, p. 680.
98 P. Demeny, ‘Social Science and Population Policy’, Population and
Development Review, 14, 3 (1988), 451–79, p. 458.
99 See Cleaver, ‘Malaria’.
100 See Chapter 3, above, for a discussion of early experiments in population
control funded by the WHO in India.
101 Mohan Rao, ‘The Structural Adjustment Programme and the World
Development Report 1993: Implications for Family Planning in India’.
Rao’s is a historical perspective on contemporary policies in the 1990s,
228 Notes
and he argued that family planning in India ‘has not only failed … but
has also damaged the growth of health services in the country’.
102 Matthew Connelly, ‘The Cutting Edge of Population Control: The
Origins of Coercive Family Planning in India’, (forthcoming, 2006).
I thank the author for sharing a draft with me.
103 Harrison, Malaria, p. 259.
104 Harrison, Malaria, p. 260.
105 Cf. S. Bose, ‘Instruments and Idioms’.
106 Cf. Connelly, ‘Cutting Edge’.
107 D. Fenner, D.A. Henderson et al., Smallpox and its Eradication (Geneva:
WHO, 1978), full text of over 1,000 pages available at http://www.who.int/
emc/diseases/smallpox/Smallpoxeradication.html.
108 Fenner, et al., Smallpox.
109 Harish Naraindas, ‘Crisis, Charisma and Triage: Extirpating the Pox’,
Indian Economic and Social History Review, XL, 4 (2003), 425–58, p. 456.
See also P. Greenough, ‘Intimidation, Coercion and Resistance in the
Final Stages of the Smallpox Eradication Campaign, 1973–75’, Social
Science and Medicine, 41, 5 (1995), 633–45.
110 Dr H. Mahler, ‘Priority Considerations for the Formulation of an
Effective National Tuberculosis Programme in Africa’, Seminar on
Integrated Tuberculosis Control, Brazzaville, 1969, p. 5. WHO, AFR
192/03-04.
111 S.R. Whyte, S. van der Geest and A. Hardon, Social Lives of Medicines
(Cambridge: Cambridge University Press, 2002), p. 24, pp. 88–9.
112 H.V. Wyatt, ‘The popularity of injections in the Third World: Origins
and Consequences for Poliomyelitis’, Social Science and Medicine, 19
(1984), 911–15.
113 Whyte, et al., Medicines, pp. 112–13.
114 Whyte et al., Medicines, p. 113.
115 See Jean Drèze and Amartya Sen, India: Development and Participation
(Oxford: Oxford University Press, 2002), esp. chapter six.
116 Anant Phadke, Drug Supply and Use: Towards a Rational Policy in India
(New Delhi: Sage, 1998).
117 Whyte et al. suggest that ayurvedic practitioners in India began dispens-
ing allopathic drugs in large quantities from the 1960s. This was part of a
broader tendency. On ‘plural medicine’ more generally, see W. Ernst
(ed.), Plural Medicine: Tradition and Modernity, 1800–2000 (London:
Routledge, 2002).
118 On the consolidation of the global pharmaceutical industry, see
J. Goodman, ‘Pharmaceutical Industry’ in Cooter and Pickstone (eds),
Medicine in the Twentieth Century (Amsterdam: Harwood, 2000).
119 Phadke, Drug Supply and Use.
120 Cited in Whyte, Medicines, et al., p. 148. The WHO’s short-lived embrace
of ‘primary health care’ in the 1970s has yet to find its historian, though
it appears that the moment was a short one: For a preliminary considera-
tion, see Kunitz, ‘Explanations’, and Packard, ‘Postcolonial Health’.
121 Whyte, et al., Medicines; see also D. Melrose, Bitter Pills: Medicines and the
Third World Poor (Oxford: Oxfam, 1982).
122 Whyte, et al., Medicines.
Notes 229
123 Whyte et al., Medicines, p. 90.

124 See the moving ethnographic study by Sheila Zurbrigg, Rakku’s Story:
Structures of Ill Health and the Source of Change (Bangalore: Centre for
Social Action, 1984).
125 M. Nichter, Anthropology and International Health: South Asian Case Studies
(Amsterdam: Kluwer, 1989), p. 235. This is a view echoed by health
activist Anant Phadke (in Drug Supply and Use), and in many interviews
I conducted with health workers in India, too numerous to name: I
thank them for sharing their insights and experiences, and hope to
incorporate these more fully in future work.
Conclusion
1 K. Davis, ‘The Amazing Decline of Mortality in Underdeveloped Areas’,
American Economic Review, 46, 2 (1956), 305–18.
2 R. Jeffery, The Politics of Health in India (Berkeley: University of California
Press, 1988), p. 121.
3 J.C. Caldwell, ‘The Social Repercussions of Colonial Rule: Demographic
Aspects’, in UNESCO, General History of Africa: VII: Africa Under Colonial
Domination, 1880–1935, A. Adu Boahen (ed.) (Paris: UNESCO, 1993),
pp. 458–86; J. Iliffe, Africans: The History of a Continent (Cambridge:
Cambridge University Press, 1995), pp. 243–5.
4 UN, Preliminary Report on the World Social Situation (New York: UN, 1952),
p. 3.
5 G. Stolnitz, ‘A Century of International Mortality Trends, I’, Population
Studies, 9 (1955), 24–55.
6 United Nations, ‘Preliminary Report on the World Social Situation’,
E/CN.5/267/Rev.1, p. 32.
7 On Davis’ influence, see Hodges, ‘Governmentality, Population and the
Reproductive Family’.
8 Davis, ‘The Amazing Decline of Mortality’, p. 305.
9 Davis, ‘The Amazing Decline of Mortality’, p. 314.
10 Pramoedya Ananta Toer, ‘My Kampung’ [1952], in Tales From Djakarta:
Caricatures of Circumstances and Their Human Beings (translated from the
Indonesian language by Sumit Mandal), pp. 75–86 (Jakarta and Singapore:
Equinox Publishing, [1963], 2000).
11 Frantz Fanon, ‘Medicine and Colonialism’, in Studies in a Dying Colonialism,
trans. H. Chevalier (New York: Monthly Review Press, 1965), pp. 121–46,
p. 128. Georges Canguilhem’s view of ‘life expectancy’ is apposite here:
‘The techniques of collective hygiene which tend to prolong human life, or
the habits of negligence which result in shortening it, depending on the
value attached to life in a given society, are in the end a value judgement
expressed in the abstract number which is the average human life span’,
Normal and the Pathological, p. 161.
12 S. Preston, ‘The Changing Relation Between Mortality and Level of
Economic Development’, Population Studies, 29, 2 (1975), pp. 231–48;
S. Preston, ‘Mortality and Development Revisited’, Population Bulletin of the
United Nations, 18 (1985), 34–40.
230 Notes
13 Preston, ‘Changing Relation’, p. 237; S. Preston and V. Nelson, ‘Structure

and Change in Causes of Death: an International Summary’, Population
Studies, 28 (1), (1974), pp. 19–51.
14 W. McDermott, ‘Modern Medicine and the Demographic-Disease Pattern of
Overly Traditional Societies: A Technological Misfit’. Journal of Medical
Education, 41, 9 September 1966, pp. 137–62.
15 S. Amrith, ‘In Search of a “Magic Bullet” for Tuberculosis: South India and
Beyond, c. 1955–1965’, Social History of Medicine, 17, 1 (2004), pp. 113–30.
16 Preston, ‘Mortality and Development’, p. 34.
17 On drug-resistant tuberculosis: J. Crofton, ‘Propter Koch, Post Koch: A
Global Review’, [typescript courtesy of Sir John Crofton].
18 Preston, ‘Changing Relation’, p. 243.
Archives Library], p. 24.
20 Rockefeller Archive Centre, Tarrytown, New York (hereafter, RAC), Rockefeller
University Archives, Rene J. Dubos Papers, Record Group 450, D 851, Box 26,
folder 2: ‘Longevity, Health and Infection’ [typescript, 1955].
21 R. Carson, Silent Spring (London: Hamilton, 1963). For a recent discussion of
Carson’s impact, see: R. Guha, Environmentalism: A Global History (New
York: Harlow, Longman, 2000).
22 R. Dubos, Man Adapting (New Haven: Yale University Press, 1965), pp. 280–81.
23 Dubos, Man Adapting, pp. 316–7.
24 Dubos, Man Adapting, pp. 362–3. H.G. Wells, Mind at the End of its Tether
(London: Heinemann, 1945); if such an ‘anti-utopian’ strain of writing can
indeed be identified, it would be associated with the work of Ivan Illich,
whose Limits to Medicine (London: Marion Boyars, 1976) was very
influential in the ‘radical’ critique of medicine.
25 G. Stedman Jones, An End to Poverty? A Historical Debate (London: Profile
Books, 2004), pp. 1–5.
26 Stedman Jones, An End to Poverty?, p. 5.
27 Karl Evang, Chronicle of the WHO, 3, 6 (June 1949), p. 217.
28 WHO Print Archives, WHO Library, Geneva; Regional Committee for
Southeast Asia; SEA/RC7/Min.1, Annex 1, Inaugural Address by Prime
Minister Nehru to the Seventh Session of the WHO Regional Committee,
New Delhi, September 21, 1954.
29 P. Chatterjee, ‘Populations and Political Society’, in The Politics of the
Governed: Reflections on Population Politics in Most of the World (New York:
Columbia University Press, 2004), pp. 27–52.
30 Charles Rosenberg, ‘Anticipated Consequences: Historians, History and
Health Policy’, in R. Stevens, C. Rosenberg and L. Burns (eds), Putting the
Past Back In: History and Health Policy in the United States (Rutgers University
Press, forthcoming).
31 Pierre Bourdieu, Pascalian Meditations, Richard Nice, trans. (Cambridge:
Polity, 2000), p. 127.
32 Chatterjee, ‘Populations and Political Society’; Veena Das and colleagues have
shown that political rights to health have been exercised in India in a sporadic
fashion, and often around the question of epidemics: V. Das, R.K. Das and
L. Coutinho, ‘Disease Control and Immunization: A Sociological Inquiry’,
Economic and Political Weekly (19–26 February, 2000), pp. 625–32.
33 Bourdieu, Pascalian Meditations, p. 127.
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Index
Afghanistan, 75, 101–2, 109, behavioural change: health and, 17,

aid, foreign, 14, 84–5, 87, 102–5, 118, 30, 175, 187
174, 213n. Bengal Famine (1943–4), 69–71
Amrit Kaur, Rajkumari, 96 Beveridge Report (1942), 56, 188
Andersen, Stig, 153–4, 162 Bhore Committee (1944–6), 57–63,
Anderson, Benedict, 14, 109 79, 80, 92
Anderson, Carol, 87–8 Bhore, Sir Joseph, 57–8
Anderson, Warwick, 9, 138 biopolitics, 14, 29, 69, 82, 110
antibiotics, 2, 16, 17, 101, 105, 150–2, body, the, 9, 16, 17, 23, 28, 33, 43,
162, 172, 180, 185 70, 137–8, 189
Arnold, David, 8, 41, 101, 197 n. Bourdieu, Pierre, 17, 190–1
Asia: health conditions in, 1–4, 76–8, British government, 48, 49, 56, 61,
146, 165, 176–8, 179–81 67–9, 74, 75
networks connecting, 2–3, 11–15, see also India: Government of
21–2, 25–6, 28–9, 36–42, 43–4, British Empire, 14, 41, 46, 65, 110
75, 76–8, 80, 81–2, 100–3, British Medical Research Council,
108–10, 143, 149, 165, 186–7 151
compared with Africa, Latin Broadley, Sir Herbert, 95–6
America, 14–15 see also under FAO
Asian Relations Conference (1947), Brown, Arthur E., 111–12
77–81, 84 Burma, 14, 15, 22, 28, 36, 42, 80,
auxiliaries, medical, see under health 106–7, 109–10, 127–9, 164–5
workers civil war, 124, 127–8, 129
Aykroyd, W.R., 28, 33, 34–6, 38, 39, health conditions in, 42, 103,
45, 65 106–7, 109, 112–13, 118, 124,
and Gandhi, 33, 45 164–5
see also nutrition malaria in, 109, 118, 120, 127–8
Ayurveda, see under medicine: migration within, 127, 128–9
indigenous Pyidawtha policy, 87
technical assistance missions to,
Bandung (Indonesia), 38 106–7, 109, 112–13, 115, 124
Inter-Governmental Conference on tuberculosis in, 128–9, 164–5
Rural Hygiene (1937), 36–42
Asian-African conference (1955), 106 Cambodia, 111–12
Banerji, D., 153–4, 162 technical assistance mission to,
see also National Tuberculosis Institute see under Brown, Arthur
Bangalore, 153, 163 Canguilhem, Georges, 229n.
BCG vaccination, 3, 17, 82–3, 98, Carson, Rachel, 168, 170, 188
100, 102, 122, 125–6, 129, 136, see also DDT
137, 146, 149, 174 Ceylon, 41, 133
opposition to, 137–46 and BCG vaccination: resistance to,
see also Rajagopalachari, C.; 138, 140, 143–4
tuberculosis DDT trials in, 50–2
255
256 Index
Ceylon – continued Davis, Kingsley, 180–2

health conditions in, 77, 146 DDT, 2–3, 16, 47–56, 98, 100–3, 104,
see also entries for individual 107, 110–11, 113–14, 131, 146,
diseases 166–9, 170, 180, 185, 188
malaria in, 50–2, 118, 119, 147, trials of, 50–6
167, 176, 180–1 and malaria eradication, see under
mortality decline in, 146, 180–1 malaria
Tamil population of, 143–4 resistance to, 117–20, 122–4, 166–9
WHO campaigns in, 102, 109, 125, decolonization, 12, 15, 46, 72
138, 143–4 Delhi, 77–8, 81, 97, 120, 124, 161,
Chand, Gyan, 95 development, 2, 4, 6, 21, 34–6, 39,
Chatterjee, G.C., 41 40–3, 46, 73, 85–98, 103, 111,
Chatterjee, Partha, 86, 190 115, 132–3, 170, 172–4, 180–90
Chellapah, Wilfred, 50–2 development economics, 18, 92–4
China: health conditions in, 12, 25, health and, 17, 18, 34–6, 39, 60, 72,
26–7, 56, 60, 93, 128 77, 89–90, 91–8, 103, 117,
health policies after 1949, 13, 173–4, 183–4, 186–7
15 ideologies of, 16, 17, 38, 45–6,
and League of Nations, 12, 26–7, 172–4, 183, 189–90
65–6 disease eradication, 1, 3–4, 17, 25, 48,
relationship with WHO, 75 53, 83, 92, 98, 100, 108, 117–20,
see also Stampar, Andrija 125, 127–8, 136, 147, 165–71,
Chisholm, Brock, 75, 89, 96, 98 173–5, 176
Chopra, Ram Nath, 24 criticism of, 117–20, 169–71,
civil society, 10, 16, 87 187–9
Colbourne, M.J., 166 see also Dubos, Rene; malaria;
Cold War, 14, 72, 83–5, 88, 100 Soper, Fred
v. non-alignment, 14, 106 Djakarta (Jakarta), 182–3
see also malaria; United States see also Toer, Pramoedya Ananta,
colonialism, 6, 7–11, 13–14, 15–16, doctors, 14, 22, 24, 29, 58, 62, 67,
28–9, 34, 36, 43, 45–6, 57, 67–8, 110, 111, 134, 168
70, 110–11 v. auxiliary workers, 18, 108,
colonial discourse, 15–6, 76–7, 95, 125–6
106–8, 111–12, 136, 165, Dubos, René, 136, 170–1, 187–9
182 Man Adapting, 170–1
colonial medicine, 2, 7–11, 21,
22–6, 28, 34–5, 38–42, 61–2, education, 27, 40–1, 42, 77, 80, 92,
106–8, 136, 140 135
legacies of, 15–16 health education, 26, 40–1, 59, 60,
Communism, 10, 29 154, 186
community development, 87, 115, medical education, 25, 61, 102
130–5 environment, 23, 39–40, 41, 51, 55,
Congress party (Indian National 72, 77, 82, 89, 106–7, 127, 150,
Congress), 44, 57, 63, 95, 115, 160, 162–5, 176, 182–3, 187–8
134 epidemics, 4–5, 6, 22, 38, 48, 49, 54,
and National Planning Committee 71, 79, 81, 83, 129, 167
(1938–45), 44, 63, 92 control of, see under public health
consumption, 46, 175–8 see also under individual diseases
see also pharmaceuticals evolution, 159–60, 170–1
Index 257
Food and Agriculture Organization 79–80, 94, 118, 120, 146,

(FAO), 65, 95–6 151–2, 165–6, 179, 181, 187
and nutrition, 65 see also under specific diseases
relations with WHO, 75, 95–6 health policy, 10–11, 22–5, 29, 36,
Foucault, Michel, 9, 30, 108, 129, 41, 45–6, 57–63, 101, 102–4,
164, 194 n., 221 n. 115, 118, 120, 126, 132–5, 156,
see also biopolitics, governmentality 165–6, 167–9, 173, 190
Frankel, Francine, 86, 133 see also Bhore Committee
nationalism, Indian, 32–4, 43–4,
Gandhi, Mohandas Karamchand, 21, 103–4, 115–16
28, 32–4, 39, 43, 44, 87, 132 Partition of (1947), 79–80, 127
gender: international health and, relations with Southeast Asia, 14,
113 15, 81–2, 110
see also health: of mothers and relations with United Nations, 82
children relations with United States, 102–3
globalization, 7–8 relations with WHO, 81–2
governmentality, 9–11, 46, 187 Indonesia (including Dutch East
Grant, John B., 59–60 Indies), 9, 14, 15, 28–32, 38, 41,
see also Bhore committee; 43–4, 80, 100–5, 124–5, 127, 129,
Rockefeller Foundation 135, 136, 182–3
Great Depression, 21, 26, 27, 28–9, health conditions in, 100, 118, 122–3,
36 136, 146, 181, 182–3, 198 n.
see also under specific diseases
Hansen, Kirsten, 125, 137, 144 technical assistance missions to,
health, see under medicine and public 100, 101–2, 104–5, 114, 122–5,
health 126, 135, 136
health centres, 21, 29–30, 37, 60, 62, internationalism, 4–7, 46, 47, 70
134, 160, International Labour Organization
health workers, 18, 60–1, 114–15, (ILO), 66, 67–8
121, 126, 137, 147, 149, 167, Asian regional conference of (1947),
175–6, 177, 181 77–8
hospitals, 62–3, 79–80, 150, 160, 164, interest in public health, 27–8,
168 64–5, 77–8
human rights, 2, 74–5, 87–90 see also League of Nations: Health
health and, 2, 74–5, 88–9 Organization
see also World Health Organization International Tuberculosis Campaign,
Hydrick, J.L., 29–32, 38, 39, 41 82–3
see also Red Cross; tuberculosis
India, 1, 12–14, 15, 75, 110, 127,
130–5, 138, 162–4, 186, 196n Kamath, Hari Vishnu, 137, 221–2 n.
colonial rule in, 8, 43, 139–40 Kerala, 134, 168
Five-Year Plans, 86, 87
Government of: colonial and Lashio, see under Burma: technical
post-colonial, 13–14, 15, 38, assistance missions to,
43, 69–71, 80–2, 96, 102–4, Leach, Edmund, 128
105, 115, 126, 132–5, 139–40, League of Nations, 1, 5–6, 11–12, 186
151, 153, 173 collapse of, 64, 65, 68
health conditions in, 13, 22–5, as compared with WHO, 68, 73, 74,
34–6, 52–3, 57–63, 69–71, 75, 131
258 Index
League of Nations – continued medicine, 15, 18, 22–5, 29, 38–9,

Health Organization, 6, 11–12, 61–3, 65–9, 72, 75, 77–80, 89–90,
25–8, 33, 34, 44–6, 53, 60, 62, 96, 97–8, 106–10, 112–13, 130–1,
65–6, 68, 131, 186 134, 136, 137, 139–40, 149–65,
see also under nutrition 167–8, 175–8, 184–7, 188–9
Inter-Governmental Conference on colonial, see under colonialism:
Rural Hygiene in the Far East, colonial medicine
36–42 indigenous, 23–4, 63, 132–3, 177,
relations with Rockefeller 228 n.
Foundation, 6–7 globalization of, 4–7, 156–7, 175–8,
Loven, Frank, 128–9 184–5
Ludu U Hla, 128 medical education, 14, 23–4, 60–1,
63
MacKenzie, Melville, 68–9 medical research, 21, 25, 149–65
Madras city: health conditions in, military medicine, 48–56
150–6, 157–8, 164–5 tropical medicine, 72, 76–8, 100,
slums of, 151–2, 164–5 137, 166–7
see also Tuberculosis see also social medicine; public
Chemotherapy Centre, health
Madras state, (Madras Presidency migration, 8, 104–5, 127–9, 131, 213 n.
until 1947), 22, 24, 29, 35–6, 132, see also refugees,
138, 140–3, 151 missionaries, 10, 16, 24–5, 41, 59,
‘magic bullet’, 18, 53, 135, 140, 156, 60–1, 107, 111, 112, 115–16
184, 186 Mitchell, Timothy, 54–5, 101, 121,
Mahler, Halfdan, 175, 177 213 n.
malaria, 3, 39–41, 62, 94, 103, 130–1, mortality, 10, 71, 76, 77, 87–8, 106,
146, 174, 180 171, 172, 182–3
control, methods of, 39–41, 48–55, mortality decline, 3, 24, 95, 146,
83, 100–6, 113–15 179–82, 184–5, 188
see also DDT see also under specific diseases
eradication of, 15, 83, 104–6, mosquitoes, 49, 51–2, 53, 117–18, 122,
110–11, 146, 174, 188 123, 124, 128, 131, 149, 167, 185
Malaria Eradication Programme see also under malaria
(1955–1968), 3, 19–20, Mudaliar, A. Lakshmanaswami, 58
113–15, 116–20, 124–7, municipal sanitation, see under
127–8, 165–9, 188 sanitation; urban areas
and health services, 150, 167–70 Myrdal, Gunnar, 94
resurgence of, 127–8, 165–9,
184–5 Nair, T.M., 24, 197 n.
resistant strains of, 120, 122–4, nationalism, 1, 32–4, 43–6, 70
166–7, 170–1 and public health, 103–6
treatment of, 42, 177 see also entries for individual countries
Malaya, 1, 36, 166–7, National Tuberculosis Institute
Malthus, influence of, 44, 73, 90, 94, (Bangalore), 151–64
182, 188, 189, see also Andersen, Stig; Banerji, D.;
mantri, 30–2, 114, 124–5, 126–7 sociology
Mara, Luigi, 110–11, 113–14 Nehru, Jawaharlal, 70, 81–2, 115, 189–90
McCarrison, Sir Robert, 28, 33 views on public health, 77, 105,
see also under nutrition 189–90
Index 259
on malaria, 124 Rajagopalachari, C., 122, 137–46

and WHO, 81–2, 189–90 see also BCG vaccination
Notestein, Frank, 94–5 Rajchman, Ludwik, 6, 27, 65–8
nursing, 31, 67, 79, 104, 161, 215 n. Ramakrishnan, C.V., 157–8
WHO and, 102, 112, 113, 125, 126, see also Tuberculosis Chemotherapy
144, 162 Centre (Madras)
see also under mantri Red Cross, 5, 82–3, 145
nutrition, 2, 9, 21, 24, 28, 29, 33–6, see also International Tuberculosis
39, 41, 42–4, 55–6, 60, 65, 88, 92, Campaign
96, 128–9, 132, 150, 152, 159–60, refugees, health of, 79
171, 175, 184 Renu, Phanishvarnath, 122, 130,
nutritional research, 25–6 145–6
see also League of Nations; Gandhi, rice, 28, 34–6, 39, 76, 152
M.K.; Aykroyd, W.R. Gandhi’s views on, 32–3
Rockefeller Foundation, 6–7, 12, 18,
Pakistan, vis-à-vis India, 13–4, 79–80, 25, 48–9, 54, 59–60, 79, 119
166 and India, 58–60
Pampana, Emilio, 37, 118 and League of Nations, 6–7, 25
Pharmaceuticals (also drugs), 42, 47, and rural public health, 21, 26–7,
55, 149–64, 167, 175–8, 185, 187, 29–30,
228 n. see also Grant, John B; Hydrick, J.L.
pharmaceutical industry, 105, rural reconstruction (also rural
177–8 hygiene), 1, 21, 26, 27, 29–42, 43,
see also consumption 47, 60, 93, 132–3, 186
Poerwokerto Health Centre (Java), see also, community development;
29–32 Gandhi, M.K.; Hydrick, J.L.;
see also Hydrick, J.L. League of Nations
population, 9–10, 13, 48, 104–5, 106, Russell, Paul F., 116–19
107, 127, 128 Ryle, John, 58, 78, 88, 100, 188
growth, 45, 124
control, 63, 171–5 sanitation, 34, 55, 160
v. public health, 4, 72, 73, 90–8 in urban areas, 163–5
overpopulation, 3, 4, 90, 94–8 Scott, James C., 147
see also FAO; WHO: debates within Second World War, 2, 16, 47–71,
public health: as responsibility of 82–3
government, 2, 10–11, 12–14, and technological innovation, 2,
27–9, 36, 44–6, 61–3, 72–3, 76–81, 16, 48–55, 72
87–9, 99, 102, 115–16, 168–70 see also under DDT
v. clinical medicine, 18, 106–8, humanitarian relief, see under
139–40, 157–9 UNRRA
debates about, 18, 41–2, 169–75 importance to international health,
see also under social medicine 2, 47–8, 63–71
economic justification for, 61–3, military medicine in, 48, 55
72–3, 86–7, 90–4, 171–4 Sigerist, Henry E., 58–60, 61
post-colonial, 7–16, 42–5, 46, Singh, Jaswant, 104–5, 122–3
75–82, 103–8, 115, 186, 196 n. Sircar, Sir Nil Rattan, 23–4
poverty and, 13, 17, 27, 28, 39–40, smallpox, 79, 169, 174–5
44, 60, 72, 77–8, 95, 96, 122, eradication of, 174–5
130–5, 151–2, 182–3, 189, 219 n. socialism, 26, 30, 44, 57, 87, 145–6
260 Index
social medicine, 18, 26–7, 29, 30, 40, Tuberculosis Chemotherapy Centre
46, 48, 58–60, 74–5, 93, 189–90 (Madras), 150–64
see also, public health; Ryle, John; see also Ramakrishnan, C.V.;
Stampar, Andrija, National Tuberculosis Institute
sociology, medical, 153–6, 220 n.
Soper, Fred L., 18, 48–9, 54, 147 UNICEF, 73, 82–3, 102–3, 105, 125,
sovereignty, 67, 69, 76, 79–83, 106, 159, 208 n.
110, 127–8, 139–40, 213–4 n. United Nations (UN), 2, 82, 83, 84,
Soviet Union, 26, 60, 61–2, 63, 68, 83, 86–90, 92–6, 106–8, 132–2, 173,
85, 174 179–80
Stampar, Andrija, 7, 26–7, 74, 85, 88, origins of, 66–8, 73
131, 188 see also under individual UN agencies
Sze, Szeming, 74 (FAO;UNICEF; UNRRA; WHO)
United States, 6–7, 14, 26, 65
Tagore, Rabindranath, 133 Cold War policies of, 83–4, 87–8,
Taiwan, 46 101–2
malaria eradication in, 166 colonial rule in Philippines, 9
technical assistance: attractions of, foreign aid, 14, 56, 83–4, 85, 106,
84–7, 91–2, 104 132, 172
characteristics of, 3, 72, 85–7, health conditions in, 25, 26, 87–8
88–90, 93–8, 101, 115–16, 121, support for malaria eradication,
147–8, 158–60, 179–80 87, 104, 120, 168, 169, 170,
discourse of, 72, 85–7, 103–9, 115, 216–17 n.
120, 121, 123–4, 127–9, 135–7 relations with India, 14, 102–3, 104,
importance of improvisation in, 132
124–5 relations with WHO, 14–15, 68–9,
origins of, 84–7 73–4, 85, 89, 104
as practiced in Asia, 99–100, 101–3, UNRRA, 55–6, 64, 68–9, 70, 82
104–5, 108–14, 146–7 urban areas, 93, 162–5, 226 n.
and staff, 125–7 health conditions in, 151, 162–3,
weaknesses of, 120, 122, 123–5, 164–5
133 see also sanitation
techno-politics, 59, 100, 119–20, 121, urbanization, 129, 135, 163
217 n.
Tinker, Hugh, 22–3 Vaughan, Janet, 58, 62, 92
Toer, Pramoedya Ananta, 136, 182–3 Vaughan, Megan, 8–9, 112, 221 n.
tropics, the, 8, 214 n. venereal disease, 107, 182, 214 n.
tropical medicine, see under medicine see also under yaws
tuberculosis: causation of, 128–9 Viswanathan, D.K., 52–3, 101,
chemotherapy, 4, 150–64, 175–8, 108–10, 114, 124–5
185, 187 see also under malaria: control
see also International Tuberculosis
Campaign; Tuberculosis welfare, 1, 9–11, 13, 73, 76–80, 106,
Chemotherapy Centre 107–8, 173, 189
incidence of, 17, 82, 87, 128–9, welfare state, 56–7
136, 146, 183 Winslow, Charles-Edward Amery,
as social disease, 41, 87, 128–9, 93–4, 98, 135
169–70 The Cost of Sickness, the Price of
vaccination against, see under BCG Health, 93–4
Index 261
World Health Organization (WHO), Southeast Asian office, 81–2

2–4, 10, 12, 14–15, 19, 98, 99, see also entries for individual
103–14, 135–7, 176–9, 180–1, countries
188–91 World Health Assembly, 75, 88, 90,
Budget of, 90–1 93–8, 117–19, 131, 169
Constitution of, 2, 73–5, 190–1
debates within, 18, 87–90, 95–8, X-ray, 55, 83, 112, 126, 154, 160
116–20, 158–9, 169–70, 188–90
foundation of, 7, 12, 73–5, 174, yaws, 3, 17, 39, 92, 98, 100, 101,
188–91 103, 113, 136, 146, 169, 176,
and human rights, 2, 87–90 220–1 n.
policies of, 83, 96–7, 100–14, Yugoslavia, 27, 56, 83, 85,
122–9, 137–45, 146–8, 150–64, Zagreb School of Public Health,
174–5, 180–1 26
see also under specific diseases see also Stampar, Andrija

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Decolonizing International

Cambridge Imperial and Post-Colonial Studies Series

List of Tables and Figures ix

List of Abbreviations xiii

Chapter 1 Depression and the Internationalization of

Chapter 2 War and the Rise of Disease Control 47

Chapter 3 The Political Culture of International Health 72

Chapter 4 Building A New Utopia 99

Chapter 5 The Techno-politics of Public Health 121

Chapter 6 The Limits of Disease Control 149

3.1 WHO Income, 1949–57 91

1.1 A Mantri’s House Visit 31

I acknowledge, gratefully, ﬁnancial support from: The Ellen MacArthur

Mkandawire, V.R. Muraleedharan, Lion Murard, Thelma Narayan,

I have continued to beneﬁt from her wisdom in the process of writing

AIIMS All-India Institute of Medical Sciences, Delhi

of the possibility of improved conditions of life is the growing desire to

eradication slipped out of the WHO’s grasp: insecticide resistance

International health and international organizations

As Charles Rosenberg has argued, however, the collective recognition

established its International Health Division in 1913. The health divi-

Colonial and post-colonial health

The starting point of this alternative narrative is that to speak of

rians who see colonial medical discourse in monolithic terms,

Native bodies were increasingly recognized not simply as the body

Across Asia, nationalist thinkers and activists responded to the govern-

touched a tiny proportion of indigenous populations. Historians of India

Locating international health: ‘Southeast Asia’

health moved through Asia in the 1930s. International public health

state, consolidating territorial boundaries, and negotiating the place of

only reluctantly joined the WHO; and in Africa by a newly energetic,

The colonial inheritance

The very limitations of the earlier colonial attempts at transforma-

Technology and its discontents

The boundaries of medicine

ability of certain kinds of archival material, even 40 or 50 years after

parallel narrative to chapter four, suggesting that the techno-politics of

This chapter is concerned with the constitution of an international dis-

and communitarians. Modernists across Asia and beyond wondered if

The limits of colonial medicine

As suggested earlier, recent historical work has emphasized the import-

In 1930 the Satara District Board would only sanction measures to

disease. Schemes for village water supplies in Bombay dragged on

Statistics, he pointed out, ‘only … demonstrate the feeble resources

An alien trusteeship of a people’s life and fortune is almost a contra-

The relatively large number of Indians trained in western medicine –

debate, which scrutinized colonial public health efforts, while staking a

within colonized societies: Maneesha Lal’s work on the hygienic

sanitation across Asia were themselves constitutive of a newly

The internationalization of public health

The Depression played a catalytic role in launching rural public health

of social medicine conﬁrmed by his own observations in China: the

pointed out the problems associated with aggregate poverty statistics,

Two visions of rural hygiene

The Indies and the world

a manifesto for the new gospel of rural hygiene, published in 1936 in

He must possess an inexhaustible patience, because he will be

together; his method of leading the conversation; where he sits; his

Figure 1.1 A Mantri’s House Visit

To be a mantri was a craft, a cultivated set of dispositions and practices.

unrealizable – intention that all the Indies would, in time, come to

If we would be national instead of provincial we would have to have

Translated into speciﬁcally Indian terms (as, for example, in

In an article entitled ‘Green Leaves’, Gandhi declared that ‘since the