2. The Problem of Tuberculosis

As compulsory notification of TB was not adopted in most Caribbean colonies until the early 1910s, information about the incidence of the disease prior to this date is scarce. Based on a few existing statistics and some general literature, Dr Santon Gilmour, who carried out a TB survey in several Caribbean colonies in 1943–4 funded by the National Association for the Prevention of Tuberculosis (NAPT) and the Colonial Development and Welfare Fund set up under the CDWA, surmised that there was little TB in the British Caribbean in the early nineteenth century and that it affected mainly the European minority. Because slaves did not interact much with Europeans as they were confined to the plantations, Gilmour argued that they must have been relatively free of the disease. After emancipation in 1838, ex-slaves moved away from the plantations and the incidence of TB in the region rapidly increased. Gilmour estimated a death rate of 700 per 100 000 of the population by the middle of the nineteenth century. By the end of the century, the death rate was down by a third, largely because people developed acquired immunity to TB. And it declined further thereafter due to improved sanitation. Yet on the eve of the BCG campaigns, as table 1 illustrates, TB was still a major problem.Footnote ¹⁶

Table 1: TB 1950. Source: Pan-American Sanitation Bureau, Summary of Reports on the Health Conditions in the Americas 1950–3 (Washington, D.C.: PASB, 1954), 74–5.

Because of the small quantity of milk consumed, TB in the Caribbean in the decades leading up to the mass campaigns was mostly pulmonary TB. It was largely an urban phenomenon, affecting mostly young adults, and usually taking a rapid and fatal course. The white minority,Footnote ¹⁷ which was the most affluent group in society, had the lowest incidence and death rates, followed by the Indo-Caribbean population, which in Trinidad and Guyana constituted about a third of the population, while the black majority suffered the highest rates as they tended to be located more in overcrowded urban areas.Footnote ¹⁸

While in most Caribbean colonies the TB death rate declined after the Second World War, the disease was still a ‘serious problem’ on the eve of the campaigns. For example, in St Kitts in 1950 the TB death rate was nearly five times that of England and Wales and the disease was the main cause of death.Footnote ¹⁹ But what led the Colonial Office in particular to define TB as a ‘serious problem’ in the Caribbean was the region’s rapidly growing population, whose poor wages and living conditions did much to increase susceptibility to the disease. Between 1940 and 1950, the population increased from 2 692 400 to 3 243 300.Footnote ²⁰ Slum clearance, the building of new houses and the creation of new jobs failed to keep step with this population growth. Hence many people not only lived in heavily overcrowded ‘yards’ with poor sanitation but also suffered from unemployment, underemployment and low wages, which does much to explain the pockets of undernutrition or malnutrition that contributed to the high incidence of the disease.Footnote ²¹

That TB incidence and death rates varied across the region, as illustrated in table 1, was because of differences in the degree of urbanisation, the development of transportation and facilities to control the disease. Urbanisation and with it the development of slums occurred first in the larger and more prosperous colonies. For example, by 1943 some 85% of Jamaicans already lived in the capital Kingston, which had a population of 201900.Footnote ²² In the smaller and less prosperous colonies, such as St Kitts, it was not until the Second World War that transportation improved and young people from the country moved in large numbers to urban areas in search of work. Because of their low wages, they tended to live in the most infectious areas and when they contracted TB, they usually moved back home and thereby helped to spread the disease into rural areas.Footnote ²³

The larger and more prosperous colonies were also the first to adopt measures to control TB, ranging from isolation wards in poorhouses and TB clinics to sanatoria. It was first voluntary organisations and later the (central and local) government, and in the case of Jamaica also the Rockefeller Foundation, that undertook these initiatives. For instance, the first TB clinic in the region, which predated many others in the British Empire, was set up in Guyana in 1908 by the Society for the Prevention of Tuberculosis.Footnote ²⁴ A similar organisation had been established in Trinidad two years earlier but it only opened a clinic in 1917. It was the Rockefeller Foundation that established the first TB clinic in Jamaica in 1928, the same year that the island’s Anti-Tuberculosis League was formed. On the eve of the BCG campaigns, there were permanent TB clinics in Guyana, Trinidad, Jamaica and Honduras, where people could get tested, and receive food and medication, and which also employed nurses that undertook case-finding and follow-up work, while most health centres in the smaller colonies held weekly TB clinics.Footnote ²⁵

In the early 1930s, Guyana, Trinidad, and Jamaica started to isolate TB sufferers in poorhouses and government hospitals and set up special TB hospitals for advanced cases. It was not until the 1940s that smaller colonies erected TB isolation wards in their poorhouses and hospitals. Just after the Second World War broke out, large sanatoria, made possible by the CDA, were opened in Jamaica and Guyana.Footnote ²⁶ Trinidad had also requested CDA funds for a sanatorium but its application had been turned down because the colony was seen as capable of paying for the institution itself.Footnote ²⁷ The island was more successful under the CDWA. This act had been largely facilitated by the West India Royal Commission (WIRC), which had investigated the reasons behind labour riots that had taken place in the Caribbean between 1934 and 1938.Footnote ²⁸ In its preliminary report released in 1940, the WIRC recommended not only constitutional changes, such as an extension of the franchise and increase in the power of elected members of the Legislative Councils,Footnote ²⁹ but also various social welfare measures and a financial scheme to fund them.Footnote ³⁰ With CDWA funding, a large sanatorium was built in Trinidad, which opened its doors in 1950, followed by smaller sanatoria in Grenada and Honduras. The treatment offered in these institutions included ‘rest cure’, surgery for ‘hopeful cases’, and on the eve of the mass campaigns also the use of the drugs streptomycin, PAS, and INAH on a small scale.Footnote ³¹

In the immediate post-war period, the governments in Jamaica, Trinidad and Guyana took full responsibility for TB work by establishing a separate TB division within their medical department led by a TB officer. They also sent medical staff abroad for training in TB work.Footnote ³² In the smaller colonies, TB control work was less co-ordinated and carried out mostly by non-specialists, including District Medical Officers (DMOs – general doctors in a particular district), Medical Officers of Health (MOHs – public health doctors in a particular district) and public health nurses, and in non-specialist institutions, such as general hospitals and rural health centres.Footnote ³³

There was thus an increase in efforts to control TB in the Caribbean in the years leading up to and following the Second World War, which exceeded that of many other British colonies and was largely made possible by the CDA and CDWA.Footnote ³⁴ Yet there was variation between the colonies, with on the one hand the big three – Jamaica, Trinidad and Guyana – which offered almost as many beds as the annual number of TB deaths and had specialist staff, institutions and equipment, and the smaller colonies on the other, where TB work was integrated into the general health services. St Kitts, for example, only had twenty-three beds in a general hospital, a weekly TB clinic held at a health centre and several public health nurses that did case-finding and follow-up work.Footnote ³⁵ It was largely because of their financial capabilities that the smaller colonies had less advanced TB schemes. All colonies could apply under the CDWA for grants or loans to set up specialist TB institutions but smaller colonies were reluctant to do so because they would have to pay part of the costs and also the wages of the institution’s staff, which were not covered by CDWA funds.Footnote ³⁶ They did, however, receive CDWA funding, like the larger colonies, for water supply, nutrition and sanitation projects; rural health centres, hospitals, school medical services, bureaus of health education and public health nursing schemes; and house construction and land settlement schemes. Although these schemes were limited by material resources and in some places also popular resistance, they did help to control TB by tackling overcrowding in urban areas, raising awareness of TB, and making it easier for tubercular people to seek medical treatment.Footnote ³⁷

It was not only the fact that BCG was available for application on a mass basis thanks to the ITC that led in the late 1940s to calls by doctors from within the region for the wide-scale use of BCG but also the rate of population growth and increase in the number of young people migrating to urban areas. In May 1948, Dr Richard Cory, the doctor in charge of the Jamaican sanatorium, proposed that all schoolchildren be vaccinated. Not long thereafter, BCG was procured from the Henry Phipps Institute in Philadelphia and administered to some 400 tuberculin negative reactors, including several student teachers and probation nurses. The results of these vaccinations led the TB officer to recommend the construction of a BCG factory as well as the vaccination of all school leavers in rural parishes. The plans for a BCG factory were abandoned, however, when WHO announced it would set up such a factory in Mexico City but vaccinations continued to be administered on a small scale until the start of the mass vaccination campaign in October 1951.Footnote ³⁸ In Honduras and Trinidad too, the senior medical officers favoured the wide-scale use of BCG and in the latter colony the vaccine was administered to probation nurses and some others before the start of the campaign, while St Kitts had already started to vaccinate schoolchildren by the time it sought UNICEF/WHO support.Footnote ³⁹ These small-scale BCG programmes were not the first attempt in the region to control TB by means of vaccination. In 1939, the Rockefeller Foundation had started a controlled trial with heat-killed tubercle bacilli vaccine in Jamaica. It began with the vaccination of schoolchildren in Kingston and was gradually rolled out to others. By 1940, some 11 000 people had taken part but the trial came to an end in 1942 when it appeared that there was little difference between the vaccinated and non-vaccinated groups.Footnote ⁴⁰

Thus like many of the other non-European countries where UNICEF/WHO carried out BCG campaigns, the British Caribbean was an ideal location. First of all, TB here was a serious problem because of the rapidly growing and highly mobile population. Second, most of the Caribbean colonies were small, both in terms of land mass and population, and had a decent transportation infrastructure. Third, the TB services as well as the general medical services were relatively developed largely because of the CDA and CDWA so that by the early 1950s even the smaller and less densely populated colonies had several general hospitals, rural health centres, a district nursing system, child welfare centres and a school medical service.Footnote ⁴¹ Fourth, as a result of several decades of TB work, the Caribbean population was well aware of the dangers of TB. And finally, the senior medical officers in the region, key to any mass campaign, regarded BCG as an important means to control TB. But because the British Caribbean was not independent, the colonial governments in the region had to seek approval from the Colonial Office for a UNICEF/WHO-sponsored campaign. The following section explores the Colonial Office’s gradual acceptance of BCG as a means of addressing the problem of TB in the colonies and mentions some other factors that facilitated the Caribbean BCG campaigns.

3. Negotiating a Campaign

From 1949 onwards the Colonial Office began to address TB seriously. In addition to ordering more TB surveys, it appointed Professor Heaf from the University of Cardiff as TB consultant. Heaf scrutinised all TB-related requests for CDWA funding and more generally helped the Colonial Office to develop a ‘co-ordinated attack on the disease’.Footnote ⁴² That BCG soon became an integral element of this ‘attack’ was first of all because large-scale evidence from trials had become available showing its efficacy. In the years leading up to the Second World War, France and the Scandinavian countries had begun to administer BCG on select groups. Results of these trials and of smaller ones carried out in North America led several leading TB experts at the 1947 Commonwealth and Empire Tuberculosis conference, sponsored by NAPT and supported by the Secretary of State for Commonwealth Relations, to conclude that the ‘safety’ and ‘efficacy’ of BCG was ‘beyond dispute’ and that it was of particular value in the colonies, where ‘ordinary control is difficult’. Professor William Tytler from the Welsh National School of Medicine, for instance, said that ‘child vaccination may not only be of value’ in the colonies but ‘may prove to be the most effective, as it is one of the least expensive means of prevention’.Footnote ⁴³ And there was even more endorsement for BCG at the 1949 Commonwealth and Empire Tuberculosis conference, which included, amongst others, a paper on BCG vaccination in India that concluded that ‘it could reduce considerably the morbidity and mortality rate’.Footnote ⁴⁴ By that time, there was also less opposition to the use of BCG within the UK. In 1949, the vaccine was offered to nurses and a year later the Medical Research Council began a trial with schoolchildren.Footnote ⁴⁵

Professor Heaf was not as convinced as some of the TB experts at the two Commonwealth and Empire Tuberculosis conferences about the efficacy of BCG. For example, he stressed in meetings of the Colonial Advisory Medical Committee that BCG did not afford ‘permanent protection’ and that its usefulness was doubtful in ‘advanced age groups’. Yet he was also of the opinion that UK methods to tackle TB, such as the sanatorium regime of good food, exercise and fresh air, would not work in the colonies, where emphasis should be placed on prevention rather than treatment, and that as such BCG had a role to play. Like Dr Wilson Rae, the chief medical officer in the Colonial Office, he particularly envisioned a role for freeze-dried BCG as the live vaccine lost its potency after fourteen days and was thus not suitable for use in many colonies.Footnote ⁴⁶

That BCG became part of the ‘co-ordinated attack’ on TB in the colonies should furthermore be seen in light of the demand for it from within the colonies in the immediate post-war period. Not just Caribbean but also some African and Asian colonies were keen to vaccinate if not whole populations than at least select groups. They asked the Colonial Office to help them secure supplies of BCG and fund vaccination campaigns.Footnote ⁴⁷ And finally, WHO’s endorsement of BCG for developing nations made the Colonial Office more receptive to the use of BCG in the colonies. In September 1948, WHO asked the Colonial Office if the colonies wanted to use its TB services, which ranged from medical literature, fellowships and visiting experts to demonstration teams and BCG vaccination (through the ITC). The Colonial Office responded that it would have to consult each colony individually because of its policy to guide colonies towards responsible self-government and also the fact that a mass BCG campaign would involve considerable costs for a colonial government as any government that entered into an agreement with the ITC had to pay a share of the costs.Footnote ⁴⁸ Two years later, WHO asked the Colonial Office to consider its TB scheme for ‘countries with undeveloped or underdeveloped programmes’. BCG vaccination, which was seen as the ‘only practical way so far known for producing specific resistance against tuberculosis (even if this resistance is not absolute)’, played a central role in this programme.Footnote ⁴⁹

As a result of these various factors at home and abroad, in May 1950 the Colonial Office decided to ‘aim at B.C.G. vaccination on the widest possible scale’. It not only made arrangements with the Pasteur Institute to supply freeze-dried BCG to colonies who wanted it, such as Trinidad, but also supported colonies who applied to the ITC, including Singapore and Malaya, where BCG campaigns started in the autumn of 1950. Although never overtly articulated, support for colonies applying to the ITC was largely influenced by financial considerations as a significant part of the vaccination campaign would be carried by neither the colonial nor the imperial governments, and such a campaign was of course also infinitely cheaper than slum clearance, sanitation works and other non-medical methods of prevention. Yet the Colonial Office stressed, like WHO, that BCG did not offer absolute immunity and would only be effective if part of a comprehensive TB-control scheme.Footnote ⁵⁰

But it was not only the Colonial Office’s endorsement of the widespread use of BCG that facilitated the mass BCG campaigns the Caribbean. The establishment of a BCG laboratory in Mexico City in 1949 that allowed for the use of the liquid, and thus more effective vaccine, and the work already undertaken by UNICEF and WHO in the region – eg. a school feeding programme in Honduras, an insect control scheme in Guyana and a VD campaign in Trinidad – also played a part, as did the recruitment for mass BCG campaigns by WHO’s newly founded regional office for the Americas, which may have been largely informed by the fact that the British Caribbean was increasingly becoming part of the theatre of the Cold War.Footnote ⁵¹ In August 1950, Dr Lourie, the recently appointed TB adviser of the Pan American Sanitation Bureau (PASB), which doubled as WHO’s regional office, visited Jamaica. He met with medical staff to ascertain the scale of TB in the island and determine whether there was a medical infrastructure for a mass vaccination campaign. Shortly thereafter, Lourie drew up a scheme based – like the ITC campaigns – on joint contributions from UNICEF and the Jamaican government that would provide for four mobile units for a period of two years starting in April 1951. The teams would test and vaccinate the population and also X-ray positive reactors.Footnote ⁵²

A brief comparison of how the Rockefeller Foundation came to undertake TB work in Jamaica in 1927 with how Lourie’s scheme was accepted in 1950 illustrates first of all that it was not until decolonisation that colonised people in the Caribbean themselves were able to significantly shape public health policy, and second that they fully realised the opportunities offered by the newly established UN agencies to raise health levels. In 1927, Crown Colony government was in place in Jamaica. The island had a unicameral legislature consisting of fourteen elected members and an equal number of ex-officio and nominated members presided over by a governor. The elected members did not have the right to propose monetary matters and could only overturn a monetary proposal made by the government if nine of their number voted against. Yet the governor could always overrule their veto if he deemed it a matter of ‘paramount importance’. In 1927, the Rockefeller Foundation proposed to undertake and pay for a TB survey in Jamaica. This survey used the ‘intensive method’, which was similar to that employed in the mass BCG campaigns as outlined in the next section and consisted of small teams who administered tuberculin tests to different age groups but mainly schoolchildren, starting in various neighbourhoods in Kingston and then moving on to areas outside of it.Footnote ⁵³ The Rockefeller Foundation liaised directly with the Director of Medical Services (DMS), Dr Wilson, who deemed such a survey of ‘considerable interest and value’ and in light of the government’s lack of funds for such an exercise, immediately tendered an official invitation to Dr Opie, a well-known American TB expert to start the survey.Footnote ⁵⁴ In 1933 Dr Opie submitted a set of proposals to combat TB based on the findings of the survey, the majority of which were implemented in following years. The elected members of the Legislative Council, however, had no real input in the implementation of Dr Opie’s proposals; they were merely asked to approve the necessary funds. For example, the government put £2 500 on the island’s budget for 1934–5 to take over the Kingston TB dispensary from the Rockefeller Foundation, which had been the headquarters of the survey. Some elected members complained about this, stating for instance that the government did not fund other parishes to tackle TB to the same degree as Kingston. But their complaints were quickly brushed aside by the governor and the sum was easily approved.Footnote ⁵⁵

Lourie had come to Jamaica as a result of enquiries made by the DMS to produce BCG locally. Yet it was not this appointed ex-pat DMS, who proposed the motion to apply to UNICEF for a BCG campaign but a locally born elected official. In 1944, Jamaica was given a new constitution that provided for a small Privy Council, dealing mainly with matters of defence; a nominated Legislative Council; an elected House of Representatives; and an Executive Council responsible for determining policy and introducing legislation. The Executive Council included five elected members, each of whom was assigned a specific area of administration for which they were spokesmen in both the House of Representatives and Executive Council. It was the elected member and quasi-Minister for Social Welfare, Donald Sangster, who moved the following resolution first in the Executive Council and later in the House of Representatives:

The Executive Council fully supported the motion and was in fact ‘most anxious that this opportunity for tackling one of the island’s gravest health problems is not lost’. And on 10 October 1950, the House of Representatives equally voted in favour of Sangster’s motion.Footnote ⁵⁷

That the Jamaican BCG campaign was delayed until October 1951 was largely because decolonisation intersected with internationalism. UNICEF had been set up in 1946 as an emergency measure to provide children in war-torn Europe with food and clothing. The gradual expansion of its geographical reach and activities, including the ITC, led to questions about its future status, in particular whether it should provide long-term assistance to developing nations. The uncertainty over the organisation’s status also affected its budget. Shortly after the Jamaican House of Representatives had voted in favour of Sangster’s motion, it was told that UNICEF could only contribute $110 000 instead of the original $143 000 and that the scheme had to be revised.Footnote ⁵⁸ Because the island was a colony and not an individual member state of the United Nations, this revised application to UNICEF to pay for transport, tuberculin, BCG, medical equipment, observation visits and technical assistance had to be reviewed by both the Colonial Office and the Foreign Office. Its dependent status also meant that Jamaica could not directly negotiate the terms of the agreement with UNICEF but had to do this via the UK delegation at the United Nations in New York, which reported to the Foreign Office and this also held up the onset of the campaign.

The Secretary of State for the Colonies quickly gave his approval in principle for Jamaica’s application to UNICEF not only because of his Office’s commitment to raise colonial standards of living but also because the fund set up under the CDWA to achieve this aim was limited and there was little chance it would substantially increase in the near future.Footnote ⁵⁹ The application was subsequently sent to the UK delegation and was discussed on 1 November 1950. UNICEF, however, was only able to grant $2500 to send one doctor and two nurses from Jamaica to Ecuador to observe a BCG campaign because at the time ‘general arrangements’ for BCG campaigns after the take-over of the ITC by WHO and UNICEF had ‘not yet been submitted to the board’ and also simply because UNICEF lacked funds.Footnote ⁶⁰ The UK delegation in New York strongly advised the Jamaican government to accept this offer as it ‘left open the possibilities of further allocation later’. A month later, UNICEF’s executive approved $85 000 for all its BCG activities for 1951 and a new area allocation for Latin America of $840 000, most likely in response to the changing global political landscape – not only had North Korea invaded South Korea in June but South America had become an increasing area of concern, especially for the United States which had strategic and economic interests in the region. This was used by the UK delegation to demand that Jamaica’s BCG scheme be discussed at the next meeting.Footnote ⁶¹ This pressure paid off as the executive board recommended at its meeting in January 1951 that $110 000 from the area allocation for Latin America be used to fund the rest of Jamaica’s BCG scheme subject to technical approval by WHO.Footnote ⁶² The improvement in UNICEF’s financial position furthermore led Dr Lourie to suggest that Jamaica submit a second application to UNICEF for two mass radiography units and follow-up treatment at rural health centres of confirmed TB cases so that the scheme as a whole would offer much better diagnostic and ambulatory treatment.Footnote ⁶³

At the same time that the acting governor was forwarding the first Jamaican application for UNICEF assistance to the UK delegation, he also submitted an application for £55 941 under the CDWA to help Jamaica pay its share of the BCG campaign.Footnote ⁶⁴ This application was supported on the grounds that: TB was a serious problem; BCG offered the ‘best immediate prospect of tangible results’; experience elsewhere suggested that the scheme would be successful; it offered a unique opportunity for getting financial and technical support from UNICEF and WHO; and BCG would become an integral part of the island’s TB scheme because after the campaign one of the teams would be retained to vaccinate newborns and other susceptible groups.Footnote ⁶⁵

As was common for all CDWA applications from the region, Jamaica’s application was reviewed by the West Indies Development and Welfare Organisation, set up under the CDWA, which assisted local governments in drawing up submissions for the CDWA and devising development plans and by the Colonial Office. But as this application involved recurrent spending, such as the BCG team that would stay on after the campaign, it was also reviewed by the Treasury. The Comptroller in charge of the West Indies Development and Welfare Organisation and the chief medical officer and TB consultant in the Colonial Office approved the scheme because it would allow Jamaica to significantly enhance its existing TB control programme, and the Treasury was sufficiently confident that Jamaica was in a position to pay the recurrent costs.Footnote ⁶⁶

Each of the three offices had questions about the application that were passed on to relevant Jamaican officials and which delayed things considerably so that it was not until 19 June 1951 before the CDWA grant was finally approved. Further delay to the start of the campaign was caused by the Foreign Office’s decision to use the Jamaican application to draft a standard agreement between colonial governments and UNICEF setting out the obligations and rights of each that could be used for all projects involving the Fund not just the BCG campaigns, listing such general things as the immunity of UNICEF’s assets, property, income, operations and transactions from taxation. This not only illustrates that the Foreign Office expected UNICEF soon to become a permanent member of the UN (it did so in 1953) but also that it was of the opinion that the Fund had an important role to play in raising the colonial standard of living. Because Jamaica had semi-responsible government, the Foreign Office could not just discuss the formulation of an agreement for Jamaica that would become the standard for all future agreements with UNICEF, but also had to consult the Jamaican government and the Colonial Office. As a result, numerous drafts were sent between London and Kingston. On 25 July, the Foreign Office, Colonial Office, and Jamaican government had completed a final draft but then UNICEF proposed several amendments and another round of drafts started so that it was not until 2 October 1951 before the agreement was signed by the UK delegation in New York.Footnote ⁶⁷

The negotiations surrounding the first campaign in the Caribbean have been discussed here at length in order to demonstrate that in non-European, colonised territories it was not always easy for UNICEF/WHO to start a mass BCG campaign, especially when they first took over from the ITC. Even if the colonising power did not object to specialised agencies of the UN operating in its colonies – whether for financial reasons or as a useful means to stem anti-colonial propaganda –Footnote ⁶⁸ and elected local officials fully supported a campaign, it could take a long time to get it off the ground because UNICEF/WHO had to deal with various offices in both the mother country and the colony, each with their different lines of commands and priorities. And it has been suggested above that their still evolving role also made it initially difficult for UNICEF/WHO to start a campaign. Yet once a contract was signed, UNICEF/WHO were able to conduct a campaign quickly because they used the standard methods and materials pioneered by the ITC. For instance, in March 1953, the Honduras scheme was approved. Two months later staff was sent abroad for training and a mass campaign started on 13 September that lasted until 15 April 1954, covering a rugged area of some 8800 square miles and a population of 75 782.Footnote ⁶⁹ The following section will show, however, that a lack of financial and other resources made it difficult for colonies to live up to their promise to UNICEF/WHO to integrate BCG vaccination into their existing health structures.

4. The Campaigns and their Aftermath

While the Jamaican government, Foreign Office, Colonial Office and UNICEF were drafting a standard agreement to be used for all types of UNICEF assistance to British colonies, Trinidad submitted a request to UNICEF for a BCG campaign.Footnote ⁷⁰ Soon other colonies followed of their own accord or because, like Jamaica, they too had been approached by a WHO consultant. After a colony applied to UNICEF, a survey of local conditions was carried out by a WHO consultant and if he or she recommended a campaign, an agreement was drawn up. Because of their health infrastructure and size, the agreements varied somewhat between colonies but as in the case of the ITC campaigns they all specified that UNICEF would provide the equipment, WHO the technical expertise and local government the rest.Footnote ⁷¹

In their Caribbean campaigns, UNICEF/WHO did not just build on but also to some extent improved the ITC campaigns by paying even more attention to local conditions. When the ITC moved outside Europe in 1949, it adapted some of its standards and procedures to make them more efficient and provide a better fit with demographic, social and cultural contexts. For instance, it began to employ lay vaccinators alongside local and international medical staff, adopted a single tuberculin test – in Europe negative reactors were tested again with a stronger dose of tuberculin –, simplified the method of record keeping, and also no longer required parental consent for schoolchildren.Footnote ⁷² There was no need for UNICEF/WHO to employ lay vaccinators or international staff in the Caribbean because there were enough doctors and nurses available locally.Footnote ⁷³ The Jamaican medical service, for example, employed some 160 doctors and 1000 nurses in 1951.Footnote ⁷⁴ With the exception of more senior posts, such as senior medical officer of a hospital, the government medical services in the Caribbean consisted largely of locally born men and women by the early 1950s. Most of the local doctors were trained in the UK but a large number, especially those of African descent, had studied in North America. It was not until 1948 that doctors were trained within the region when a medical school was opened at the University College of the West Indies in Jamaica. Nursing schools, however, had been set up in most colonies from the turn of the century onwards and in 1943 a Public Health Training Centre was established in Jamaica that served the whole region.

As in the ITC campaigns, the doctors and nurses in the Caribbean campaigns were put into field teams. The number and make-up of the teams varied between colonies depending upon demography, geography, and financial and other resources.Footnote ⁷⁵ Jamaica, for instance, had four teams of one doctor, two nurses and a driver each but Barbados had two teams made up of only nurses as it was smaller and also had a less developed medical service. One field team from each colony was sent elsewhere to observe BCG work and upon their return trained further teams.Footnote ⁷⁶ The doctor who had taken part in observation work became the campaign organiser, while the colony’s TB officer or DMS acted as the chief of the campaign, ie. he was responsible to the three partners involved. WHO provided each colony with a TB expert for the first month of the campaign. In Jamaica and Trinidad, this was Dr Knut Osvik, WHO’s regional TB adviser, but as the campaigns progressed WHO decided that this role could be undertaken by a local doctor and appointed Dr Ronald Lampart, the Jamaican campaign organiser, as BCG consultant for the region.Footnote ⁷⁷

Lampart’s appointment and the observation work undertaken by the teams went some way towards realising the WIRC’s recommendation to unify the region’s medical services, as did the establishment of the medical school and the Public Health Training Centre, the formation of the Caribbean Council of the British Medical Association in 1951, and the conferences of heads of the medical services that were started after the War. Until the late 1930s, apart from the occasional medical conference and movement of senior staff from one colony to another, there was little interaction between the region’s medical services.Footnote ⁷⁸ The WIRC recommended unification of the medical services because it would provide local staff with ‘greater possibilities for advancement’ and ‘more opportunity for gaining wider experience’.Footnote ⁷⁹ By facilitating regional co-operation, the BCG campaigns did much to widen the experience of local staff. Only few of the campaign doctors and nurses had prior experience with TB work. Gaining this new experience allowed some to advance their career, most notably Dr Lampart, who had been a junior hospital doctor before the campaign. WHO not only made him BCG consultant but also gave him a fellowship to study for an MA in Public Health. And the two Jamaican public health nurses who had done observation work with Lampart in Ecuador managed to secure teaching positions on the basis of their BCG work.Footnote ⁸⁰

With regards to materials and techniques used, the method of record keeping and the process of field work, too, the Caribbean campaigns largely mirrored other non-European BCG campaigns.Footnote ⁸¹ Thus also here a single tuberculin test was used; schoolchildren did not require parental consent and were re-tested to obtain information on the allergy caused by the vaccination; and the individual cards used for schoolchildren and groups cards for the general population with information about vaccine lot etc. formed the basis of monthly statistical reports that were forwarded to WHO’s Tuberculosis Research Office in Copenhagen.Footnote ⁸² And like the ITC teams, the Caribbean field teams also first covered urban areas and then moved to rural districts, testing and vaccinating schoolchildren – a convenient controllable population – before the general population. Upon arrival in a new district, the teams held meetings with local health departments, teachers and local authorities to explain the campaign; selected sites for vaccination centres; and used public lectures, film shows and loud-speaker propaganda to ask people in the area to come forward for testing.Footnote ⁸³ Government and medical authorities supported the work of the field teams by organising publicity drives. In Honduras, for example, publicity committees were formed in all districts several months before the start of the campaign, consisting of government officials, members of the Legislative Council, and representatives of the schools, churches and voluntary organisations. All medical practitioners in the colony officially approved the BCG campaign and school managers promised that teachers would actively co-operate with the campaign, while the DMS formally opened the campaign with a broadcast on BCG that was reprinted in all papers.Footnote ⁸⁴

That UNICEF/WHO paid considerable attention to local conditions can be seen especially in the age limits adopted in the Caribbean campaigns. In Jamaica, UNICEF/WHO set out to test people aged 0–20 in urban and 0–30 in rural areas but it set other age limits for other colonies depending on the survey carried out before the start of the campaign and a colony’s resources. In St Kitts, for instance, UNICEF/WHO selected the age groups 0–25 in urban and 0–45 in rural areas.Footnote ⁸⁵ The Jamaica campaign, however, soon proved that vaccinating children under the age of one was impracticable in the field and none of the Caribbean campaigns therefore vaccinated newborns.Footnote ⁸⁶ In most colonies the upper age limit was also quickly adjusted. In both Jamaica and St Kitts, for instance, it was raised to 50 because many parents, who accompanied their children to testing centres, asked to be tested.Footnote ⁸⁷

The raising of the age limit may explain why the Caribbean colonies achieved a higher coverage rate than many other non-European countries, ranging from 40% to nearly 70% of the total population.Footnote ⁸⁸ Even with regards to the main target group – children aged 0–14 – the region compared favourably. For example, in Jamaica 52% of children were tested compared to 21% in El Salvador and 22% in Malaya.Footnote ⁸⁹ And the Caribbean colonies also stood out from other non-European countries in terms of the number of people who had their test read, which averaged 95% whereas for instance in Egypt it was only 65% .Footnote ⁹⁰ Besides the factors already mentioned in the first section, the relative success of the Caribbean BCG campaigns should also be seen in light of the use of local doctors and nurses and the high rate of school attendance – some 75% of all children in the British Caribbean aged 5 to 14 were enrolled in schools in 1949–50.Footnote ⁹¹ This is not to say that there was absolutely no objection by the local population to the campaigns. For example, just before the campaign was to start in the Jamaican parish of Portland, The Gleaner, the island’s biggest-selling newspaper, published an extract from the South African Medical Journal that raised doubts about BCG. Although the medical department quickly issued a statement, published on the front page of the paper, that ‘there have been no reports of any ill effects suffered by anyone who has had the vaccine’, the damage was done; most Jamaican parishes had a coverage rate of 45% but in Portland it was only 29%. Yet resistance such as in Portland was the exception rather than the rule.Footnote ⁹²

Table 2: Results of tuberculin tests. Source: WHO reports.

The Caribbean colonies not only differed from other non-European countries in terms of the high coverage rate and percentage of tests read but also in the number of positive reactors (see table 2), which were higher than in Europe but lower than in the Middle East and Asia, where TB services were less developed. In Greece, for instance, positive reactors made up 28.9% but in India 59%.Footnote ⁹³ The percentage of positive reactors varied across the region depending on such factors as the extent of urbanisation and development of TB services. Also varying between the colonies were programmes for positive reactors. Jamaica had the most comprehensive scheme. Positive reactors aged 15 to 30 were given a coupon for a free X-ray, carried out by mass radiography units that had only arrived in the island four months after the start of the campaign. Many positive reactors also had bacteriological tests done and if found tubercular, were referred to one of the specialist institutions or given ambulatory treatment.Footnote ⁹⁴ Guyana also used mobile mass radiography units, offering not just positive reactors but everyone a free X-ray. The first few months of its mass radiography campaign, however, were marked by severe mechanical problems.Footnote ⁹⁵ Honduras, on the other hand, did not obtain a mass radiography unit until the end of the campaign.Footnote ⁹⁶ And although no such units were included in the agreements between UNICEF/WHO and governments of St Kitts, Grenada and Barbados these colonies did try to offer all positive reactors an X-ray.Footnote ⁹⁷

That not all agreements between UNICEF/WHO and the colonial governments included mobile mass radiography units to test positive rectors and that in many colonies they were not in place by the start of the campaign suggest that the focus of UNICEF/WHO at the time was on the prevention rather than the cure of TB and in the case of WHO also with data for its research into tuberculin sensitivity. WHO’s reports of the Caribbean BCG campaigns, for instance, zoom in on the percentage of positive reactors, tuberculin sensitivity and the re-testing of schoolchildren but omit to state what further tests were offered to positive reactors, what proportion was eventually diagnosed as tubercular, and what treatment these patients were given.Footnote ⁹⁸

WHO’s conviction that BCG was the most practical and cost-effective method of prevention against TB can also be seen in its decision that countries could only retain the testing kits, vehicles, labs and other equipment if they submitted a plan for the continuation of BCG vaccination. While some Caribbean colonies aimed to make BCG vaccination a routine procedure in child welfare centres, the majority proposed to test and vaccinate schoolchildren. It was not just the distribution of positive reactors amongst the age groups that determined their decision but also such factors as existing medical infrastructure and degree of economic development. In Honduras, for instance, there were some eighteen, well-attended child welfare centres. The colony therefore decided that a nurse would visit each centre once a year and test and vaccinate all children aged one and a half.Footnote ⁹⁹

To what extent did the colonies live up to their promise to continue BCG vaccination? The few annual medical reports available for the late 1950s and early 1960s and other sources indicate that some colonies first undertook a follow-up BCG campaign before taking steps to test and vaccinate schoolchildren or babies. In Barbados, for instance, a follow-up campaign started in April 1957, when all schools were visited and entrants tested as well as children that had not shown a satisfactory take in the mass campaign. Thereafter, one nurse was employed full-time for BCG work, working both in the St Michael’s TB clinic and in schools.Footnote ¹⁰⁰ Trinidad and Guyana also appointed full-time BCG nurses. The latter colony, for instance, had a permanent BCG team made up of a health visitor and two nurses, who tested and vaccinated schools entrants and from 1961 onwards also school leavers.Footnote ¹⁰¹ Jamaica, on the other hand, did not set up a permanent BCG team to vaccinate babies, as it had promised in its CDWA application, but instead opted for the testing and vaccination of schoolchildren and added this to the duties of parochial health nurses.Footnote ¹⁰²

Thus in most Caribbean colonies BCG vaccination was placed under the direct control of the central health department and was part of a larger specialist programme to control TB that also included clinics, sanatoria and so on, but in some colonies it was integrated in the general health services and was, like most other preventive work, made the responsibility of local health departments. That the Jamaican health nurses had visited only half of all schools by 1960 because they were ‘so smothered by other duties’ seems to suggest that the general approach was less successful than the specialist.Footnote ¹⁰³ However, as the permanent BCG teams were very small, they too struggled to meet their targets. The Trinidad team, for instance, had tested a total of 108 308 schoolchildren and vaccinated some 61 270 by 1960 but it never succeeded in visiting all 400 schools in the island on an annual basis.Footnote ¹⁰⁴

That the Caribbean colonies did not make more staff available for BCG work was largely because of their financial and human resources. For example, by the late 1950s Guyana and several other colonies began to experience a shortage of nurses as many migrated to America and Britain because of higher wages. And while CDWA money was used in some places like Jamaica to fund the BCG campaign, this source of funding not only came to an end in 1958 with the creation of the West Indies Federation but was also only intended for the development of social welfare services and not their upkeep. The BCG continuation work, then, had to be paid for from normal revenue but nearly all colonies at the time experienced a trade deficit because of an increase in the price of imports, especially colonies that lacked a principal export crop and did not have extractive industries.Footnote ¹⁰⁵

That the relative success of the BCG campaigns in the Caribbean was not sustained in the late 1950s and early 1960s should also be seen in light of the colonies’ long-standing bias against preventive medicine. While preventive medicine has always played second fiddle to curative medicine,Footnote ¹⁰⁶ this was especially the case in colonial settings. Before the Second World War, for instance, only 8% of all medical expenditure in Barbados was on preventive medicine.Footnote ¹⁰⁷ While this pre-war bias was largely because government medical services were set up before the development of preventive medicine and most doctors were trained in curative medicine, racial and colour biases of both the medical and political establishment also played a role. Preventive medicine in the Caribbean targeted the predominantly dark-skinned lower classes. Local politicians, whether white or black, tried as much as doctors and other members of their class to distance themselves from this group and advance the interests of their own. Hence, they were usually more in favour of the building of new hospitals than the establishment of child welfare clinics, a public health nursing system etc.Footnote ¹⁰⁸ The medical establishment’s bias against preventive medicine and the black middle class’s prejudices against their lower-class and invariably darker-skinned brothers and sisters was so engrained that even with the CDWA-funded expansion of preventive medicine and the gradual ‘blackening’ of local legislatures in the years surrounding the BCG campaigns, the Caribbean colonies failed to achieve an optimal balance between preventive and curative services.Footnote ¹⁰⁹ And this combined with the afore-mentioned economic conditions meant that TB did not feature much in budget discussions and when it did, politicians were more inclined to vote sums in favour of TB clinics, hospitals, sanatoria and ambulatory drug regimes than vaccination, case-finding and follow-up work.