Fractured States: Smallpox, Public Health and Vaccination Policy in British India, 1800-1947 (review)

This book by Sanjoy Bhattacharya, as the principal author, attempts to explore and break new ground while examining the public health policies, principally vaccination against smallpox, in British India, heavily depending on primary sources from the archival materials of two independent but closely related colonial administrations: the East India Company, and the British Government. The authors claim to have extended this research over about one hundred fifty years, yet there is very little effort to examine the vaccination or public health policy for the period 1800–1857—and this is the first weakness in the title, and thereby in the contents, of the book. Thus little is made known about the efforts by the East India Company and its officials to introduce and extend vaccination, and the evolution of the medical department and public health policies, during the first fifty-seven years of the nineteenth century. The authors fail to record whether there were significant changes in the funding, formulation, and approach to vaccination policy when the historical transfer of power took place from the Company to the British Government. Second, the complete absence of evidence demonstrating the extent and changing level of smallpox mortality during 1800–1947 leaves the uninitiated reader in the dark as to how important smallpox was as a cause of death in unvaccinated and vaccinated populations. There is not even one table or graph explaining how either smallpox mortality or patterns of vaccination levels changed due to new policies across or within the states over such a long period. Perhaps a less ambitious but more apt title for this book would have been "Fractured States: Public Health and Smallpox Vaccination Policy in British India 1857–1947."

Having said this, the book definitely breaks new ground in referring to and judiciously using several new archival materials hitherto overlooked in the works of other medical historians of the subcontinent. For example, cogent and forceful arguments are built up using this new material to demonstrate how the formulation, implementation, and budgetary support of vaccination policies underwent a significant change in the twentieth century in different states, following the devolution of political power to the state and local governments. The authors are right in saying that previous studies on the subject have oversimplistically, and incorrectly, extrapolated from studies of specific places and limited periods to an all-India context and for the whole colonial period. Their efforts in the present work to dismantle this monolithic approach are laudable.

Chapters 2 and 3, covering the period 1900–1947 and constituting the bulk of the book, are well written and address the issue of why there was passive resistance to vaccination on the part of the local officials. The inadequacy of funding to support the extension of vaccination staff to rural areas, and even within certain municipal bodies across the states—particularly in nonepidemic years—is well illustrated. Similarly, effort has been made to show how the quality of vaccines, vaccine production and preservation methodology, vaccination techniques per se, and the growing realization of the limited efficacy of primary vaccination in granting lifelong immunity led to serious differences in opinion not only among the scientific community but also between the civil and public health administrators. This resulted in situations when, despite the known preventive efficacy of the vaccine, and despite consistent and continued support from the central government to the states, the implementation of the vaccination policy was neither uniform across the states of the subcontinent nor sustained with the same vigor.

The authors could have been more prudent in differentiating terms such as "Bombay" and "Bombay Presidency," "Madras" and "Madras Presidency." On the whole, however, this is a readable book with interesting insights into the nuances of the historical and political aspects of twentieth-century vaccination, and some aspects of public health policy.