Disease Control and Immunisation: A Sociological Enquiry Author(s): Veena Das, R. K.

Das, Lester Coutinho Source: Economic and Political Weekly, Vol. 35, No. 8/9 (Feb. 26, 2000), pp. 625-632 Published by: Economic and Political Weekly Stable URL: http://www.jstor.org/stable/4408959 Accessed: 22/10/2008 17:57
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Speciallarles__

Disease

Control
A

and

Immunisation

Sociological Enquiry

Understandingthe processes through which immunisationcomes to be institutionalisedas a routinepractice in public health managementprovides an interestingfield of sociological enquiry.A wide range of issues may be examined in this field: processes of state formation in relation to public health, the practices of science in developing countries, the role of global institutionsand policy formation, the constructionof the inotionsof consent as well as of citizenship,the relationship between the politics of the day and research institutions,and so on. These dimensions of public health need to be seriously addressed at the policy level.
VEENA COUTINHO DAS,R K DAS,LESTER his collectionof essays1addresses from a questionson immunisation socialscienceperspective. Untilreas cently,immunisation an object of investigationwas limited to historiansof scienceandmedicine,orto policy-makers with publichealthissues. Yet, concerned understandingthe processes through which immunisationcomes to be institutionalised a routine as in practice public an excephealthmanagement provides field It tionally interesting of enquiry. opens a windowto a wide rangeof issues pertainingto popularconceptionsof immin unity,the processesof state formation relation publichealth,the practicesof to sciencein developingcountries,the role as of globalinstitutions well as notionsof and citizenship consent.We hope thatthe following essays will contributeto the in literature thisfield.The essays growing arebasedon the analysisof policy docuhealth surveillance historiments, reports, cal archives, fieldworkovera number and of sites includingvillages, urbanslums, health ministries health, of centres, primary andcourtsof law. The methods hospitals, of analysisare also diverserangingfrom statistical projections, participant observations,and ethnographic interviews, to discourse analysis. All the authors workedas a closely-knitteam in this project- hence we prefer to draw attention some of the salient findings to of the project,as a whole, ratherthan each individualessay. These summarise T for findings,we hope,will haverelevance both social science researchand public in healthmanagement India. Immunisation againstsmallpoxas part of the public health programmes under boththe colonialregimeandsome of the princelystateshas a long historyin India. Even before the discovery of Jenner, variolisationwas known and practised selectively in India and Chinasince the of seventeenth century.Historians medicine and anthropologists working on colonialmedicine have suggested links betweenthe imperialist projectandintroductionof biomedicinein the colonies both are seen to be cut from the same cloth. There is an impressive array of coloniallegislation- e g the Compulsory VaccinationAct, Cantonment Act, Epidemic Diseases Act - throughwhich the body was soughtto be colonised,to use the felicitous phrase of David Arnold. who pioneered the study of colonial medicine from a subalternperspective [Arnold 1993]. The three essays in this collection dealing with historicaltrajectories [by Dasgupta; Misra and take Naraindas]* a close look at theintersection of legislativepower and administrative practices of the colonial state. Theyshow thatwhile in timesof epidemics the statedid use draconian powersto restrict the liberties of subjects - this exercise of power was sporadic, unsystematic, and often accompaniedby strong difference of opinion and hesitancy on the part of differentwings of the colonial government.The story of colonialmedicine as something, which was implemented a confidentexercise as of bio-powerin the face of resistanceby the subjects,appears,on closer analysis, to be much more complicated.For instance, the scientific status of different theories of disease causation was not settled- hence the state moved between a hygienisttheoryand practiceto one in whichdiseaseproneareasweresubjected to surveillance and compulsory immunisation.Further,the native populationsalsoshowedadifferentiated response thatranged fromresistance vaccination to to proactivedemandsfor it. Finally,it is clear that though many bureaucratic recordsspeak about 'panic' on the part of native populations in the midst of epidemics,and hence construethe problem in termsof maintaining publicorder, the responseof the communitieswas, in There were fact, much more variegated. local ideas of prevention, therapeutics andcare, which were given no attention in bureaucratic renderingsof so-called native responsesto epidemics. A second,important of the storyis part the alliancebetweenstate and science in this period.The firstlaboratory produced vaccineto be testedin field trials,viz, the vaccineagainstVibriocholoraewas produced in the laboratoriesof Pasteurin Parisby Haffkinebut was testedin India in 1893. These field tests were made

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possible because detailed administrative aboutcholeraproneareaswas knowledge available. The response of the already colonialstateto the prospectof testinga new vaccine in India was not that of unqualifiedsupport.While the British did government not wish to be seen as in opposingscientificresearch the eyes of otherEuropean nations,especiallyFrance it and Germany, didnotalsowishtoprovoke 'nativerebellions'.Hence,it tooka stance of beingperfectly passive- neither opposing the trials nor endorsingthem. It is interestingto see how notions of trust, reliability, and consent were worked out in the field situation in relation to and bothscientificexperimentation rights of subjects. Global Programming, National Sovereignty, and Childhood Immunisation Despite the heated debates that took place duringthe Britishperiod on compulsory vaccinationand the legislative powerthatthe statebestoweduponitself, it is clear that achieving high coverage was neverthe goal of the Britishadministration.The concern was much more limited- reducingthe morbidityof soldiers and assuringthat tradedid not get severely affected by epidemics. Thus it was that at the time of independence, whenthe BhoreCommittee was set up to considerthe ways andmeansof reaching of health thelargesegments underserved to that it wasestimated only 3.6 populations, per cent of the populationhad been coveredby smallpoxvaccination. This is not the place to review the health delivery which system set up afterindependence, combinespublicandprivatesectors,and has been the subjectof many interesting books. It is necessary,however,to point outthatthehealthdeliverysystemis based on territorial ratherthanon organisation the burden disease or on local ecology of of disease.As is well known,the achievementsin publichealthshow considerable variation across different the statesinIndia. A highdegree successhasbeenachieved of in the stateof Keralafollowed by other southernstates(exceptAndhraPradesh) whiletheperformance Bihar, in Rajasthan, MadhyaPradeshand Uttar Pradeshhas been dismal.The puzzle thatKeralaalso as reportshigherratesof morbidity comparedto Bihar,is likely to be a resultof easier access and better utilisation of medical services in Kerala.

In the context of immunisation, it is important to note is that there has been an important shift in policy since 1985 when the Universal Imnmunisation Programme(UIP) was adopted with the aim of targetingchildhood diseases thatwere vaccine preventable. Instead of thinking of immunisation as a strategy to protect populations at risk from epidemics, the childhood immunisation programmes ought to make inmmunisationa routine practice for prevention of vaccine preventable diseases, viz, childhood tuberculosis, diphtheria, whooping cough, tetanus and polio in the firstinstance, andthen measles, which was added in the immunisation schedule in 1985. What are the implications of this shift, which has broughtglobal institutions such as the WHO and the UNICEF for the first time as major partners in health planning and policy in India? How far has the emphasis on targeting specific diseases been successful in securing better health for children? From the perspective of understanding the shift that has taken place in the role of global institutions in public health management in developing countries, the most important event in recent years has been the eradication of smallpox from the world in 1976. A scholarly history of this event from the social science perspective still awaits to be written - the most authoritative histories have been produced in by participants thisprogrammeandhence focus much more on its success ratherthan the difficult questions of sovereignty, informed consent and citizen rights. Some recentwork does suggest thatin theirefforts to concentrateon aggressive immunisation rather than public health education, there was a manufacture of global consent in which issues of national priorities were sidestepped. It is not our intention here to go into these points in any detail [but see Greenough 1995; Naraindasforthcoming]. We are interested in seeing how the success of the smallpox eradication programme paved the way for bringing global institutions as important players in the public health management in India. Although there is a clear realisation among epidemiologists and microbiologists that very few infectious diseases can be targeted for eradicationon the model of smallpox (polio is the immediate candidate followed by measles and perhapshepatitis B) - the success story of smallpox eradication has fired the imagination of health planners. They feel that more tangible results can be obtained by technocratic solutions

whichparticular diseasesaretarthrough rather thanprogramgetedfor eradication mes for health educationwhich seek to alterbehaviour. an aside,we maynote As that the dismal failure of anotherproeradication viz, gramme, the malaria prois gramme hardlyeverpartof the storyof the understanding roleof globalprogramin healthmanagement. ming Althoughchildimmunisation programmes werepartof thepublichealthscenario in independent India, onlylimited progress was madein thisendeavour untilthe mideighties becauseof formidable problems in delivery,and especially in cold chain In management. any case, comprehensive coverage was not considereda serious policy optionin India.It was only in 1985 thatthe UIP was adoptedin India,both becauseof thepushgiven in thisdirection and by UNICEF laterby theestablishment of the Immunisation Mission underthe The adoption Rajiv Gandhigovernment. of the UIP can be interpreted a partof as the processof globalisation communiin It cationandcommerce. signalledagreater concernwith child healthon the partof internationalbodies like UNICEF and WHO.It also constituted strategicshift a in methodsof resourcemobilisationfor since international organisations, highcoverage achieved under immunisation could be presented a tanas programmes gible success story and could convince international donorsthatmoneywasbeing effectivelyutilised.It hasbeenclaimedby UNICEF and WHO that the target of 80 of immunising per centof the children the world has been achieved.The major task now, they contend, is to cover the 20 remaining percentof children. Despite some reservations aboutthe qualityof the data, most public health officials now assumethat there has been a significant reduction child mortality is attribin that uted to the success of immunisation We programmes. brieflyreviewourmajor in this respect. findings The macro picture on childhood immunisation India in suggeststhatthough overall coverage has improveddramatically, the resultshave not been uniform acrossthedifferent statesin Indiaandalso across years. all with States betterresources, in and higher growth income, better governance have generally performedbetter. Femaleliteracyseemsto be a contributory factorin statesreporting highercoverage between female though the relationship is literacyand demandfor immunisation complex,as suggested themicrostudies by

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in presented this collection.Thusthe aggregatepicturemasksthe realityof wide of gaps in performance differentstatesin the immunisation programme. DasandDasgupta havecollatedthedata on immunisation coveragefor the major Indian in statesfromexistingreports their havealso estimated proand paper.They from injected the net infantpopulation sourcesin orderto review the dependent success of the strategyof achieving the targetsset by international organisations andministries health. wouldbeobvious of It thattargets immunisation only be for can fixed realistically the basis of dataon on the number childrenin the populations of that are being served. At presentthese targetsare set by takingthe birthrateof a state over a period of time and then it translating into estimatesof net infants to be covered.Thesetargets obviously are to subjected some errordue to intra-year births.Further, coveragefigurestend the to be upwardlybiased by the natureof record keepingandtheincentivestructure whichrewards localofficialsforachieving high coveragebut punishesthem for reon of porting thedifficulties achievingthe set targets. Therefore,the quantitative estimatesare subjectto inestimable error margins.Nevertheless,reductionin the diseaseburden fromvaccinepreventable diseases overtimesuggeststhatthepicture of high coverage is correctbut only in broad terms.Usingdescriptive qualitative statistical models to comparethe performanceof immunisation differentstates in of India,Das andDasgupta theirpaper in in this collection,concludethatalthough coveraggregate figuresof immunisation ageshowedmorethan85 percentachievement of targets, there were significant in variations the performance different of states.By carrying demographic out projections for estimatingtargetpopulation for immunisation the year 2006, they in predictthatthe total numberof children will steadilygo up in all the states.This meansthatin the underachieving states, viz, Uttar Pradesh,Rajasthan,Madhya BiharandOrissa,the number of Pradesh, childrenwithoutaccess to immunisation is likely to increaseif the presenttrends continue.This is because in additionto new cohorts children of therewouldbe an of childrenin the increasingpopulation oldercohorts,who would not have been vaccinated, seriously jeopardising any herdimmunityin the population.Given this scenario,it is likely that local level epidemics against vaccine preventable

diseases will continue in these underachieving states.

Records as Political Documents

As mentioned earlier, the emphasis on disease eradicationanduniversal coverage of children was part of a new strategy of resource mobilisation within the international organisations. We suggest that this has influenced the nature of record keeping, though initially the connection seems remote. Our studies, both at the macro and micro level show thatthe recording system in relation to vaccine coverage is geared towards counting the number of doses of various antigens distributed and not the number of children immunised. That is to say, coverage is calculated on the basis of doses that local level health workersreport they have administered to the estimated number of children in the population they were supposed to cover. Now it has been assumed in most internationaland national reports that these figures are interchangeable - i e, if x number of doses of antigens have been administered then x number of children have been immunised. . Hence claims have been made that 80 per cent of the world's children have been immunised and that our task now is to reach the remaining 20 per cent. This is seriously misleading in the case of India andperhaps other countries. On the basis of our analysis of the primarydata collected by NFHS, as well as the micro studies reportedin this collection, we find that the number of partially immunised children (i e, matching age of the child with the number of doses he or she had received) was significant in the population. The aggregate figures in National and InternationalReporting Systems are at present not geared towards capturing this fact. The conclusion arrived at the macro level was supported by our findings at the micro level since we found thateven districtsreporting high level of coverage in Gujarat and Kerala, contained significant number of partially immunised children. Thus, a pool of non-immunised or partially immunised children continue to exist, who are easy prey to local epidemics of vaccine preventable diseases. Hence, we have to conclude that though the overall incidence of these diseases has come down, there are likely to be local incidences of epidemics for years to come. It is interesting to see that though local level health workers are often blamed for fudging records, the protocols devised by internationalorganisations and

their national counterpartshave not come under serious scrutiny. It is part of the politics of numbers that only certain kinds of information is foregrounded in discussions of the success or failure of immunisation programmes. Yet, it is clear that the protocols of reporting immunisation coverage need to be changed in the direction of child centred records and the story of success of immunisation programmes would have to be modified when such records begin to be available. It is not our intention to suggest that there are no serious problems in the management of records at local levels. First, the system of disease surveillance at present is seriously deficient. In the course of the micro studies we found that local level health workers are not adequately trained to recognise vaccine preventable diseases. Further, records of the occurrence of vaccine preventable diseases are not maintained.With the exception of polio on which surveillance has been stepped up since it is targeted for eradication by the year 2000, there is no awareness among health workers even in the states with better primary health facilities such as Kerala and Gujarat,that it is importantto record incidence of vaccine preventable diseases. Given this scenario it is difficult to monitor and measure the exact impact of immunisation programmes on the reduction of disease load. Thus, while it is probable that childhood immunisation programmeshave led to a significant reduction in child mortality, it is difficult to measure this in the absence of statistics on prevalence of vaccine preventablediseases. Another significant aspect of the record keeping is that till recently, local level health workers were not encouraged to reportadverse reactions to vaccines. It was felt by many functionaries in the international and health bureaucracies that an emphasis on adverse reactions could cause panic and lead to resistance on the part of users to vaccines. This has meant that important inequalitieshave been introduced in the system of health administration. Parents whose children suffer from adverse reactions to vaccines in the developed world have various legal rights to compensation. Such rights are not only denied to parents in the developing countries but even the figures on adverse reactions are not available. Add to this the fact that in our experience, ANMs could not identify and recognise vaccine preventable diseases. The occurrence of a local level epidemic of any vaccine pre-

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ventabledisease led to blame being attachedto eitherthe healthworkersor the communitieswithin which this had ocBisht curred the papersby Coutinho, [see in andRaje,andCoutinhoandBannerjea thiscollection]. Hence,it is not a surprise to see that local health workerstried to information thisandit wasthe on suppress media, which played a proactiverole in bringinglocal epidemicsto light. On the cost side of the immunisation we programme, have looked at data on materials production. and Unfortunately, the it is not possible to breakdown mancosts itemwise. powerandadministrative financial are grants givenby the Although the international part organisations, major in of the expenditureon immunisation India is financedby the centralgovernfor ment.Theproduction capacity existing vaccines is likely to meet the projected in demandfor vaccination coming years althougheffortswill have to be made to ensurecontinuedqualitycontrol.Therefore, both from the point of view of resource cost and productionwe do not envisage any problemsof sustainability to comparable thatbeing faced by many in Africancountries whichtherehas been a withdrawal international through of aid were whichtheimmunisation programmes funded. Finally, it is best to primarily that programmes, recognise immunisation by themselves,cannot reduce neo-natal due mortality to such causes as low birth of weight,orpoormanagement childbirth. In India40 per cent of infant mortality occursin the first 28 days of the birthof to thechild.Clearly programmes integrate child and maternal healthare imperative to levels. toreduce incidence acceptable this The Logic of the Local: Micro Level Community Studies that How do policies and programmes at have been formulated the global and national level impactupon the local patHow terns health of delivery? doweaccount of for the way in whichpatterns relationand atthelevelof community family ships influencethe outcomesof these policies In to andprogrammes? order answersome we of thesequestions designeda seriesof communitystudiesto capturethe Variations in immunisation coverage and the quality of care. Initially the study was betweenthetwo designedas a comparison in districts ofPauri Garhwal Uttar Pradesh, andSurat Gujarat, in districts representing with low andhigh coveragerespectively.

However, following the first phase of fieldwork, it was felt necessary to include two more districts in order to further problematise and verify some of the initial findings. It was also felt thatPauriGarhwal being a hill district posed certain topographic specificities. In this context we decided to take up another district within the same state, viz, Kanpur Dehat, which also had a low reported coverage. Similarly, in order to better understand the phenomenon of high coverage in a different socio-cultural setting we chose Trivandrumdistrict of Kerala. The selection of all field sites was also influenced by the availability of competent researchers who were fluent speak the local languages, as this was not intended to be a survey-based study, but essentially an intensive anthropological study. The emphasis in the micro level studies was to understand the manner in which immunisation programmes are implemented at the local level by the health workers and the supervisory staff. These studies also addressed the issues of the family and community level factors that promote or inhibit acceptance of immunisation programmes. The ANM obviously plays a crucial role in the implementation of immunisation programmes but is also responsible for implementation of other programmes such as the family planning programme. How do these responsibilities translate at the local level? First of all, as global and national priorities in health alter, changes are communicated as commands from above. Through an accumulation of such programmes over the years the ANM is currently expected to motivate mothers to accept contraception, to encourage them to come for prenatalcheck ups in the primaryhealthcentre, to conduct safe deliveries and to motivate mothers to bring their infants for immunisation. Now all this requires prolonged contact with the community and the responsibility towards one programme can interfere with the responsibility toward another. For instance, in some cases women who had become pregnant soon after the birth of one child were hesitant to take the child for immunisation because they felt that they would be 'scolded' by the ANM for failing to adopt contraception. Similarly, full immunisation of children requires contact with the PHC on the partof the mother at least five times during the first year of the child's life. Thus, ANMs have to ensure that afterevery dose the mother had the incentive to bring back

the child. Some ANMs told us that they sometimesfelt compelled to reduce the dosage of the antigensbecause in local which they often shared, understandings, a more 'potent'dose was likely to cause fever and make the child irritable. Thus, in order ensurethatthemother bring to did the child back for the next dose they felt it waspreferable give a reduced to dosage. Yet, they understood perfectlywell that this reduceddosagewas contrary what to they had learnt in trainingsessions for correctimmunisation. our understandIn between ing,then,theANMhastomediate the normsof biomedicineand the norms of the community. Becausethe systemof one, she has reportingis a hierarchical every incentive to suppressinformation aboutthecommunity dose schedinspired as ule thatshe actuallyimplements, also on the occurrences VPDs in the comof munitiesunderher supervision. Let us now consider community the and familylevel factors,whichhaveanimpact on socialdemand immunisation. the for In literature adoption new technology, on of it suchas thatof immunisation, is common to conceive of the communityas either agents who demandthis technology or who are hesitantto adopt it because of social resistancegeneratedby incorrect beliefs about the technology. This dichotomyof social demandandresistance does not provideus with adequatetools to understand relationbetweensocial the attitudesand technology adoption.Our studiesshow thatit wouldbe incorrect to are assumethatregionswithhighcoverage characterised a demand vaccinesfor by conversely, we did not find any active resistanceto vaccinationin regionswith low coverage. Rather,we prefer to describehigh or low coverageas a resultof a complex configuration factors that of includecharacteristics thehealthdelivof ery system as well as certainfeaturesof the communities which vaccination in is delivered. major The factors,which being influence the high or low coverage in are immunisation, describedbelow. First,since the publichealthsystem is model that asorganisedon a territorial sumeshomogeneity space,it is unable of to take care of factors related to local Our ecology andterrain. studiesshowthat both physical and social featuresof the environment determine to accessibility the health system. Physical featuresof the whichaffectaccessibility are environment, a that to primarilyterrain is difficult traverse for mothersbecause of forests, flooded

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rivers,or sheerphysical distanceof the the housefrom placewhereimmunisation sessionsareheld. Social features,which are affectaccessibility, social isolationof or within village the sections hamlets certain in of because the operationof hierarchy communities. casteaswellas withintribal the Further, tabooson women to appear inpublic coupled placesduring pregnancy demands femalelabour on bothwithin with makeit difficult outside household the and for the mother to take the child for This immunisation. was most evident in scarceeconomies such as that of labour or Garhwal withinnuclearhouseholdsin which young mothersdid not have the of support older women for household workor child care. Isolation of certain segmentsof the populationbecause of socialstigmaincludingstigmaof disease, of or the perception the public places as becauseof high incidence of dangerous crime, made it difficult for mothersto accessthehealthservicesandalso created for impediments the free movementof of ANMsin these areas.The withdrawal several kindsof servicesfromregionsthat are markedby political insurgenciesor of affectsperformance civilwarinevitably We the immunisation programme. found caused thateven short-term disturbances by frequent publicralliesor strikesled to of services.It is disruption immunisation to be notedthatphysicaland social inaccessibility of a region or a cluster of householdsdefines both the access that ANMshaveto thesegroupsas well as the access thatmothershave to these health facilities. and Therelation between femaleliteracy reduction infantmortality received of has muchattention the social science and in public health literature.But the exact mechanisms whichliteracyfuncthrough tionsto promote betterhealthfor children arestill obscure.Ourstudiesshow thatit is not literacyat the householdlevel that affects demandfor vaccination.Indeed ourdatado not show a criticaldifference withliterateor non-literate in households mothers in terms of impact on immunisation. However,thereis a sharp difference demandfor and acceptance in ofvaccination between which communities haveathinlayerof educated womenversus thosewhichmayhaveliterate women,but not educated ones in the community[see Final Reportof the Social Science and Immunisation 1998]. Country Study-India: Ourunderstandingthata criticalnumber is of womeninthecommunity makesa sharp
Economic and Political Weekly

difference in the capacity of the community, especially women, to take advantage of services offered to them by the state and make the local level health workers more responsive to the demands put on them. This tfight also be restated as the importance of building social capital in the community for effective utilisation the social services offered by the state. However, since these observations are made on the basis of case studies, they need to be tested on a larger sample of the population of takingcharacteristics communitiesrather than households as significant variables in delineating the relation between female literacy,female educationandperformance of immunisation and other public health programmes. The importance of building the community's capabilities to access the health system is also highlighted by our finding that the presence of a cadre of village workers such as the anganwadi workers who could stand between the women in rural areas and the health system, greatly facilitated the community's access to health services, including immunisation. Anganwadi workers were found to play an active role in announcing immunisation schedules, gathering mothers with infants and offering help in taking the children to the immunisation sessions in both Gujarat and Kerala. Thus, where the anganwadi scheme had been successfully implemented it had become a major resource for mothers to access the health system for both the needs of their children and for their own needs. On the basis of the micro studies on childhood immunisation, we can see that though conceived as a technocratic solution towards reducing morbidityburdenof children, especially in developing countries, this scheme has been successful only in conjunction with other changes that have taken place in the transformationof ruralcommunities. These changes include increase in female education, building up the capabilities of local level health workers as well as removal of supply side constraints in the public health system. The very fact that immunisation schedules require an ongoing contact between mothers and local level health workers means thattheprogrammecannotbe implemented as a purely technocratic solution to the problem of child health. On the basis of the macro and micro studies conducted by us we have seen that although the overall burden of vaccine preventable diseases in India has gone

down, there are significantregionaland local variations the immunisation in coverage of children.Thus, threatsof local epidemicscontinue.Is the public health to systemin Indiaprepared dealwithsuch a health scenario?As it happened,the fieldwork, periodin whichwe, conducting saw a numberof public health crises. Significantamong these were the emergence of a new strainof cholera(Vibrio cholorae0139) in variouspartsof India in 1993, an outbreak dengueepidemic of in Delhiin 1996andreports deathsfrom of adversereactionsto oral polio vaccinein partsof WestBengalwhichseemedto put theimmunisation there programme in some jeopardy.These were obviously not the only public health crises - the re-emergence of resistantstrainsof tuberculosis, in as well as significant increase incidence to of HIV transmission. threaten become majorhealthissuesin the yearsto come.2 Ourcase studies,thoughlimited,help us to understand relationbetween state the and citizenship in the managementof perceivedpublic health crises. Crisis, Epidemics and Health Management As we have seen, thereare significant of lapsesintheimplementation thegovernment programmes geared towardschild and maternalhealth in several states in India- these rarelyreceive sustainedattentionin the media.They arenot seen to havethe potential putthe legitimacyof to the government question.In the public in cultureof India, it is epidemicsthat become occasionsfor theexerciseof citizen rightsin the field of health.The situation is somewhat similar thefactthatfamines to and starvationdeaths receive far more attentionin the media thandoes chronic that hunger.It appears a crisisin the form of an epidemicis seen to be mostdangerous for the legitimacyof the state.In the cases of choleraoutbreaksin 1993 and of 1994, as well as the outbreak dengue in 1996, the governmentfirst tried to managethiscrisisby denial.Forinstance, in thecase of theepidemicin WestBengal causedby a new strainof cholera(0139) which emergedin 1993 andreplaced the classic cholera causing strain (01), the health bureaucrats refused to name the disease as choleratill almostthe end of the epidemic. In explainingthis denial the duringthe courseof interviews, state level bureaucratsmade the claim that the naming diseasemighthaveled topanic

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amongilliterate populations. Theyargued thatepidemics,even if local in character, receive a lot of publicityin the internationalmedia.At least in one case, thatof the plagueepidemicin partsof northern andwesternIndiathe publichealthcrisis led to a decline in tourism,fall in stock prices, and a number of court cases. However, the bureaucratsconsistently failed recognise panicmaybeequally to that caused by rumourswhich flourish in a political culture of secrecy and denial, leading to such reactionson the partof families as hoardingof medicines, self and prescription, in some cases to costly litigation.In the cases describedin this the volume,it was only through persistent role of the media and sometimes the mediationof courtsof law thatthe crisis was acknowledged.This led to serious delays in effective managementof the epidemics. Thereare some interestingfeaturesof urbanIndia, which come to light in our study.Thoughone cannotsay thatthere is a greater awareness therightto health of acrossthe specamongurban populations trum disease,citizenshavebegunto use of mechanisms such as existinginstitutional the mediaand the courtsof law to press for their demandsfor effective managementof thecrisis.Forexample, dengue the in epidemicin Delhi resulted a high court case againstthe state government its for allegednegligenceand led to highly dramaticandvisible actionon the partof the it that However, appears while government. focuses on seriouslapses publicattention in sanitationand organisationof health careduringa periodof crisis, thereis no sustained for demand thesecollectivegoods duringperiodsof normalcy. As far as the reactionof the state is concerned,we found that public health officials and political parties in power tendedto respondto a health crisis by out of mapping a geography blame.Thus was attention focusedon the healthpracthanon the tices of thecommunity rather deficienciesof the public healthsystem. Forexample,slumdwellerswere blamed for theirhabitsto accountfor the emercholera gence of epidemic despitethe fact thatclean drinking wateris not supplied to them(see paper IshitaGhosh).Simiby of larly,when a number deathsoccurred in a Muslim-dominated followingthe area administration measlesvaccinein one of case andpolio dropsin another, comthe was munity blamedforbeingsuperstitious in [Coutinhoand Bannerjea this collec-

tion]. Emphasis is placed on their religion or ethnicity rather than their poverty or lack of education. In one case the official explanation for the death of a child that occurred within 24 hours of having been administered the polio drops, was that the child was suffering from acute diarrhoea and hence her death had no connection to the pulse polio campaign. Our point is not that assumptions about contamination of vaccines in these cases were correct, but that to blame the community in the face of this tragedy showed that in the zeal of administering vaccines to achieve the targets assigned to them, health workers had shown themselves to be blind to the immediate threatof disease and death that the child was facing. Instead of referring the child immediately to a hospital they had simply administered the polio drops and allowed the family to take her home. Before we move on to issues pertaining to vaccine research, we would like to point out some aspects of health care which have important implications for the infectious disease scenario in the coming years. In an important study of the health practices in developing countries Van der Geest (1988) pointed out the co-existence of a formal and informal medicine distribution and health care. What this means is that not only are there a wide range of medical practitioners owing allegiance to the different medical systems, but also that biomedical products, such as injections and drugs, are freely prescribed by various kinds of practitioners. In the absence of effective regulation to control the use of drugs, we found widespread use of injections and antibiotics prescribedby not only untrainedmedical practitionersbut also by those who had training in cosmopolitan medicine. In most cases the use of prescription drugs was haphazard. In a systematic study of the mannerin which drugs are prescribed in a village in Garhwal,Das and Das (1999)3 conclude that this pattern of misuse has important consequences: The free availabilityof drugsandthe lack of legally enforceablerestrictions who on can buy themorprescribethemcompound the misuse of drugs in two specific ways. First, treatmentis often limited by how manypills thepatientcan afford;hence the full course of treatmentneeded to eliminate the pathogen responsible for a particulardisease is seldom completed. Second, cheaper,less effective drugsareoften used to treat infections... this patternof misuse has two main consequences:in the shortterm,the disease is not cured,effectively leading to increasedmorbidity,and

sometimesmortality.In the long term,and on a population level, antibiotic misuse leads to emergence of resistantstrainsof bacteriathatwill be increasinglyharderto treat in the future [Das and Das 1999]. In almost all illness episodes that we have collected we have found that patients and their families follow a patternof resort in which patients are likely to take medications prescribed by practitioners in the informal sector. This can lead to worsening of the illness but even if the pills prescribed are harmless such as tonics, patients and their families have to spend large amounts of money relative to their incomes on such placebos.4 This suggests how inaccessible competent medical care is even in urban India. Infectious diseases are not produced by biological pathogens alone but also by political, social, cultural, and economic pathogens. For all of these reasons it appears to us that public health priorities will have to shift from eradication of particular diseases to issues of health education for both patients and doctors: otherwise it is likely that as some diseases are eradicated, new diseases as well as resistant strains will appearto wipe out the health benefits to the population.

Experimental Dimension
An importantcharacteristic of biomedicine is the combination of the therapeutic and the experimental: the vision of continuous progress in the eradication or elimination of disease could not be sustained without consistent endeavours to develop new products such as drugs and vaccines. Although vaccine researchin the 19th century was geared towards both therapeuticand prophylactic vaccines, the discovery of antibiotics shifted the emphasis away from therapeutic vaccines. In common understandingtoday vaccines are associated with preventionratherthancure. It is important to mark the fact that the existing paradigms on vaccine research may alterradically in the near future. First, some attempts towards the development of therapeuticvaccines, especially against diseases relating to the immune system are underway. Second, a shift of emphasis has taken place in the western societies from populations to individuals as the configured users. In that context immunisation appears as a life long practice in which individuals need to consider carefully the risks to which they may be exposed and take vaccines accordingly. It is unlikely that such a shift of emphasis will take place

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in poor countries because there is an organisoppositepushfrominternational ationsas well as pharmaceutical compain nies whoarguethatinvestment vaccine can research be sustained only if thereis a commitment thepartof governments on to includenew vaccinesin immunisation for schedules wholepopulations. Finally, adare manynew innovations primarily dressedto delivery level problems.For example,the shift towardsoral vaccines, or needleswhich bend aftera single use are cannotbe recirculated, and therefore especiallygearedto deal with misuse of injectionsin poor countriesof Asia and the For Africa. allthesereasons, processes in research offer ofexperimentationvaccine window for understanding an important flows shape(or hinder) howtransnational scientificresearchin India. in on Ourresearch vaccinedevelopment the Indiafocused on understanding networks moveavaccinefromthe'bench' that to to the 'bush' and from the laboratory the market.We examinedthe processes the underlying developmentof an antivacvaccine(theMw anti-leprosy leprosy vaccine(the cine)anda fertility regulating hCG vaccine), both of which were researched the NationalInstituteof Imat Delhi. In addition,the history munology, of the developmentof vaccines against the of cholera, development a new recomoralbivalentvaccineagainstcholbinant of era, and a trial for the introduction B hepatitis vaccineas partof theimmunisationschedulein Delhi were studied.We offer the following observationson the basis of these studies. to It is interesting observethatin all the cases of vaccine developmentwe found that scientificcontroversiesplay a very role.These and important evenproductive we controversies, suggest,shouldbe seen not as aberrations events that stand but between normal science and paradigm shifts.Theyrangefromissues pertaining of to interpretation results,scientificjurisdiction, ethics, as well as efficientuse of resources. foundthatin almostall We did cases, controversies not get resolved only by settingup further experiments resumed weretemporarily abandoned, they and sometimes resolved as a result of mediation the stateand global instituby criticisms women's tions.Forinstance, by healthgroupsanddoubtsthatwereraised of aboutthereturn fertilityamongexperimentalsubjectsof trialson fertilityreguhalt latingvaccines,led to a temporary on to thesevaccinesanda return the drawing

board. However, we also found that the politics of global institutions, competition over candidatevaccines, andrumoursgenerated about a particularvaccine could lead to a scuttling of promising lines of research, especially in developing countries. Unlike the processes of research in the physical sciences in which the invention of objects in the laboratorycan be ideally separatedfromconsiderationsof how these may be used in the outside world, biomedical research has to necessarily include experimentation on human subjects as part of the research process itself. This is why the politics and ethics of research are built into the research design in complex ways. Thus a crucial aspect of vaccine technology development is the relation between the therapeutic and the experimental. For researchto move at the experimental level it has to negotiate the therapeutic level, and conversely good therapy is seen as that which incorporates new findings. Thus the concern for the patients' well being can lead to modifications of the experimental design. A good example of this is the introduction of Mw anti leprosy vaccine as an adjunct to the multi-drug therapy. In this case the research design would have been more robust if the efficacy of the vaccine were to be tested on populations which were not taking any other medications. But clearly after the success of multi drug therapy had been demonstrated as a result of a series of fortuitous circumstances, it would have been unethical to deny the patient population this therapyin the interest of a more robust research design. Similar examples may be found in the administering of trail drugs when strictly experimental considerations have to modified for therapeutic reasons even when the trial is on. The experimental design of a trial is important because in the case of most vaccines which are prophylactic in nature, populations which are currently healthy are administered the vaccine to counter future risks. Double blind trials currently provide the gold standard in vaccine research. The emphasis rightly is on the need for objective assessment. Trust created through numbers plays an important role here for the movement of a vaccine from a laboratory to the market. Many of the considerations around the ethics of vaccine research subjects arose because of the justifiable fear that human subjects may be used as guinea pigs in scientific experiments. The experience of Nazi medicine in which human subjects were exposed to

cruel experiments hauntsthe discussions on ethics in biomedicalresearch.However, as the recentAIDS activismin the United States has shown, a community Thus mayalso treatthe trialas a resource. it is not only scientistsbut also the communitywhich may have a stake in trials. The problemis that membersof a community maynothavethesameunderstanding of the risksinvolved,as the scientific communitydoes. In the case of trialsof the anti leprosy vaccine we found that becauseof theprolonged periodof contact between the biomedicalpersonnelwho were conducting follow up studies in Dehat, the villagersbeganto treat Kanpur the trial as a resource for all kinds of of medicalneeds.Text book formulation ethics do not deal with the groundlevel issues that arise when doctors are faced withthedemands madeon themin theface of illness and dismally poor quality of healthdeliveryin thevillages.The general issue of scientificknowledgeand demoraises overbiomedicine craticaspirations vexedissues notonly abouttheregulation of expert knowledge but also how bioethics functionson the ground. Ourstudieson trialsof the anti-fertility and anti-leprosy vaccines emphasisethe to need for userperspectives be builtinto the process of technologydevelopment. Successof massimmunisation programmes in developingcountries,have led policyinto makers imagining vaccineson this all model. There are, however, important differencesin the way in which the user needsto be configured thesecases. For in vaccinemaybe example,the anti-cholera useful only in populations wherecholera is endemic and where there is a lack of adequatesanitation,includingprovision of clean watersupply.In contrast,a fervaccine is a productthat tility regulating in could be used by any woman.Further, this case vaccines provide one kind of methodamongothers.This contraceptive is why it is important figureoutwhether to the vaccineis being imaginedas offering a greaterrange of choices to individual women or as a method of population control, especially geared towardspoor womenwhose overallfamilialconditions may not allow the privacynecessaryfor Simiusingotherkindsof contraceptives. vaccines larly,in the case of anti-leprosy thatarerecommended adjuncts multi as to the drugtherapy, use by patientsraisesa differentset of issues than their use as for prophylactics relativesor close contacts.Debatesaboutthe successorfailure

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in Amsterdam), whose critical comments and of a newdevelopment vaccineresearch leprosy vaccine) has moved from the labosuggestions on earlier versions of these into ratory to the market. Even when Indian have to take this user configuration papers have been helpful. All the papers in account. Yet we found that scientific scientists have shown remarkable ability this volume have earlierappearedas working discussionsrarelypaid attentionto this - they were the first (along with scientists papers of Social Science and Immunisation innovation. Series of the Centre for Development working in ICCDR in Bangladesh) to aspectof technological Economics. The series comprised of 20 Whilethereis a generalconsensusthat identify the new strain of cholera - the working papers as well as a two volume final in subjects vaccinetrailsmustbe recruited research is mired in bureaucratic delays report of the Project. A limited number of only on the basisof informedconsent,at and lack of co-ordination. We fear that in copies of the other papers and reports are the heartof this issue is the problemof an era when new norms of bio-sociality available on request. bio- are emerging and global institutions are 2 Since AIDS and tuberculosisare both chronic findingeffectiveways of translating infectious diseases, these need to be studied medical views of riskto the communities taking a lead in defining priorities in rethrough different methodologies. Lester of users.Methodsthathave been used to search and institutionalreforms,the weakCoutinhois currently engagedin thegovernment the communicate notions of risk to the ness of institutional structuresof research andnon-government responsesto the increased have non-literate populations experimented in India may seriously distort health rates of HIV transmission. with variouscommunication techniques, planning. Our own efforts in addres- 3 See Das, JishnuandDas Saumya, 'HealthCare in a Developing Country: Learning and for examplethe use of videos. In some sing these questions have been motivated Complexity', 1999, Mimeo. countries potentialsubjectsare given an by a concern to show the complex char- 4 The exception is the case of cholerain the slum examination assesstheirunderstanding acter of public health issues in the area to areas in Calcuttawhere prolongedexperience of risk. We agree that informedconsent of immunisation. i3 with the disease leads to the knowledge in is a veryimportant which people immediatelygo to the infectious goal,butit stillremains diseases hospital although they also try to get an illusive end. In India, interactions * These threeessays, 'Care,WelfareandTreason: The Adventof Vaccinationin the 19thCentury' out of it as soon as possible. and between doctors patientsarebasedon by Harish Naraindas; 'The Productivity of trust. Thisdoes not meanthatdoctorsare Crises: Disease and Scientific Knowledge and References In alwaystrustworthy. fact,in manycases the State in India' by Kavita Misra; and of malpractice have no legal reVaccine Controlling patients aCunningDisease:Cholera in Bengal' by AbhijitDasguptaare partof this Arnold, D (1993): Colonising the Body: State sort.But it does mean that in a medical Medicine and Epidemic Disease in the collection of papers and will be published culturein which bureaucratic practiceis NineteenthCenturyIndia, Oxford University subsequently. is notembedded everydaylife, consent in Press. Delhi. moralinteractions seen in the day-to-day Coercion Greenough,Paul (1995): 'Intimidation, Notes and Resistance in the Final Stages of the rather thanas a legal category. South AsianSmallpoxEradication Campaign', Thus,even whennecessarydocuments 1973-75,Social ScienceandMedicine,Vol 41, papersin this collection have been signed by a subject giving I All theof the Social Science andwere produced as part No 5: 633-645. Immunisation it informed consent, is noteasytoconclude Project, carried out under the aegis of the Social Science and Immunisation Project(1998): thatnotionsof riskhave been adequately Centre for Development Economics, Delhi Final Report of the Social Science and School of Economics. Veena Das andR K Das ImmunisationProject - CountryStudyIndia, Informed communicated. consentin such Centre for Development Economics, Delhi cases becomes a kind of documentary were the principalinvestigatorsof this project. This project was partof a largertransnational School of Economics, Delhi (mimeo). practicefor claiming legitimacyfor the study carried out in six other countries. We Van der Geest S (1988): 'The Articulation of We scientists. shouldaddthoughthatthis are grateful to the governments of Denmark Formal and Informal Medicine Distribution is not only a problemin India but now andtheNetherlandsfor supportingthis project. in South Cameroon' in S Van der Geest and Thanks to Pieter Streefland (Royal Tropical S R Whyte (eds) The Context of Medicines engages the attentionof many medical in Developing Countries: Studies in Institute, Amsterdam) who supervised this in the west who arestruganthropologists Pharmaceutical Anthropology, Kluwer, project,and to Paul Greenough(University of the to understand consequencesof gling Dordrecht. Iowa), and Anita Hardon (University of medicine underthe constantly conducting shadowof law. In some cases advocacy actual groupshave emergedto represent ISSUES IN MODERN INDIAN HISTORY users.We found,though,thatin the femiForSumitSarkar nist critiqueof fertility regulatingvac,^ Edited by Biswamoy Pati ... cines, for instance,little attemptswere This book focuses on a variety of issues and themes that attractthe historiansof made to find what the actualusers conthe 'Modern' together 0 that Indianhistorytoday.Severalscholarscomeand to investigate diversities an assumpsideredimportant. Therewas i constitute'Modern' theirinterlinking histories.The India,the commonpeople tion thata single categoryof womencan cover a wide canvas essays in this felicitationvolumededicatedto Prof.SumitSarkar, be configured represent to diverseexpethat stretchesacross the 18thcenturyto the present.The social historyof Health,the riences in this field. idea of slavery,the Bhil rebellion,colonialdiscourseand the 19thcenturybhadralok Our research thisfieldof immunisation in in with'left' society, landlordism theTelengana region,thepoliticaldiscourseassociated showsthatserious collaborative studieson writingson contemporary Indian politicsaresome of the issues addressed here. L vaccinedevelopment necessary order in are SubhoBasu,SanjoyBhattacharya, Indrani DavidArnold, Contributors: P.K. Chatterjee, to understand organisational other the and SumitGuha,I. Thirumali, Datta,AmarFarooqui, Pati,AmiyaP. Sen,HariSen, Biswamoy 1L Srimanjari, DeveshVijay. constraintson innovationin this field. scientiststook Despitethe factthatIndian HB ISBN: 81-7154-658-7 Rs, 400.00 a lead in the seventiesin many areasof Popular Prakashan Pvt. Ltd., 35-C, Pt. M.M. Malaviya Marg, Tardeo, Mumbai 400 034 thisresearch, only one vaccine(Mw anti-

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