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Scientific and Political Representations: Cholera Vaccine in India

Author(s): Veena Das and Abhijit Dasgupta

Source: Economic and Political Weekly, Vol. 35, No. 8/9 (Feb. 26, 2000), pp. 633-644
Published by: Economic and Political Weekly
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Economic and Political Weekly.
Scientific and Political Representatio
Cholera Vaccine in India
Thispaper, in the context of various cholera vaccine trials during the present century,
examines critical issues of vaccine research, and demonstrateshow the movementfrom
laboratoryto field, and then to routine practice involves the complex interaction between
science, state and the public sphere. Through narratives of scientists and administrators, the
authorstry to show the social negotiationsthroughwhich knowledgeeither movesfrom laboratory
to the field or is inhibited in this movement.Several questions of scientific management,
organisationalstructuresand scientific diplomacy are addressed, in addition to questions about
notions of medical efficacy and of risk and its perception by the different social actors.


he inception of research on a codified the practice,involvingthe state of research.It is to this codificationthat

vaccine, its movementfrom the overtly (see Naraindas forthcoming). we now turn our attention.
laboratoryto the field and subse- Haffkine's system of inoculationmight It was only afterthe secondworldwar
quentlyto the sphereof routinepractice, appearto be includedwithinthis frame- thatmoral,ethicaland legal issues about
involvesthecomplexinteractionbetween work of administrative practicein thatit biomedicalresearchcameto publicatten-
science,state,andthepublicsphere.Kavita followed the same principle - that of tion in the west. The NurembergCode,
Misra'spaper(forthcoming)has analysed defendingthebodybeforethediseasecould institutedin 1947 embodiedthe firstfor-
thedevelopment of Haffkine'santi-cholera strikebygeneratingasympathetic response mal expressionof these issues. The code
inoculationin the last decadeof the 19th in the body. However,Misraarguesthat wastheresultof theNuremberg warcrimes
century.Takingthat as the point of de- inbeinginstituted thecholeravaccinebroke trials, which had demonstratedthe need
parture, we movetotwotrialsof thecholera outof thisframeworkto createa new one. for clearly defined standardsto judge
vaccineconductedinIndiaandBangladesh Unlike Jenner's vaccine, Haffkine's physiciansand.scientists who had con-
in the 1960s and 1970s, and follow this vaccinewas a laboratoryproductandwas ductedexperimentson prisonersin con-
with an analysis of the emergence of a seenas anexperimental one.Itbroughtthe centrationcamps.It laiddownthefollow-
new strainof the cholerapathogenin the notionof risk, as it was understoodboth ing mandatoryconditionsforanyresearch
1990s.The biomedicaland social impli- withinthescientificandmedicaldiscourse involving humansubjects:(i) voluntary
cationsof the emergenceof a new strain and within the political context, to the consent of the subject;(ii) adequateex-
of a disease, that was considered as centreof discussion.It is evidentthatthe perimentaldesigns protectiveof the sub-
'routine'inpublichealthmanagementare colonial governmentin Indiawas deeply jectsandbasedonprioranimalexperimen-
important factsin themselves.In addition, concernedwithissues of publicorderand tation;(iii) highest technicaland profes-
the developmentof new techniquesof the risk to the legitimacyof the statethat sional standardsregarding equipment,
vaccineproductionthroughrecombinant thiskindof operationof testinganexperi- facilities,andstaffskills;(iv) cessationof
technologyin this periodhas raised im- mentalvaccineposed.The colonial state theexperimentattherequestof thesubject
portantquestionsfortheinterfacebetween desired,on the one hand,to be regarded or the experimenter; and(v) a risk-benefit
social and healthsciences. as patronandpromoterof science.On the analysiswhich acceptsno riskthatis not
As all the papersin this volume show, otherhand,therewas an effortto ensure exceededby the humanitarian importance
infectiousdiseases,especiallythose with thatreligiouscodesshouldnotbe violated of the problem[Basch 1994].
epidemicpotential,havebeenof particular in conductingany experimentalexercise, Clearlythe evolutionof ethical stand-
concernto the scientific communityas andalso thatthereshouldbe transparency ardsin researchinvolvinghumansubjects
well as to governmentsbecause of the regardingnew scientificmethodsso that (and also animalsubjects)is not simply
threatthattheypose to the healthof body therewas no occasionfor the circulation a given, politicalexperienceof research
populations.MisraarguesthatHaffkine's of rumorsaboutthe experimentalvaccine is necessaryforsuchcodesto develop.The
anti-cholera inoculationmarkeda turning leading to public disturbances.In this HelsinkiDeclarations of 1964and1975of
point in the managementof epidemic regard,the conceptof whatis now articu- theWorldMedicalAssociationarefurther
diseases. The frameworkwithin which lated as 'informedconsent' was brought evidence of such a transition.Helsinki-I
inoculationwasperceivedbeforeHaffkine into the discussionof the vaccine.As this was a generalguide for physiciansdoing
camefromJenner'svaccine.Vaccination was the first time that a laboratorypro- clinical work, while in Helsinki-IIthe
hadbeen partof 'western'medicalprac- ducedvaccinewasbeingtestedinthefield, emphasishad shiftedfrom assessingthe
tice for over a century,and practisedin it initiatedquestionsaboutthe methods performance of investigatorsto protecting
traditionalsystemsof healingfor longer and the ethics of trials.1However,these therightsof subjects.Themovementfrom
than that. In 1880 the VaccinationAct concernswerenot codifiedintoprotocols an enunciationof codes andguidelineson

Economicand PoliticalWeekly February19-26, 2000 633

paper,to their practicemight entail am- patientwas asked to reportimmediately diseasewas endemic(in orderto carryout
biguitiesandhencedifferences.The next to the CentralField Hospitalat Matlab long-termcontinuousstudies).It was also
two events that we addressdemonstrate Bazaarfor medicalcare if he or she suf- requiredthat scientists have laboratory
the mannerin which two trials of the feredfromanysymptomsresemblingthose facilitiesfor etiologicaldiagnosisof chol-
cholera vaccine were conductedin the of cholera.One accountstates: era.Third,any analysisof the efficacy of
subcontinent.That they came to be per- Manyof the peoplelivingin the surveil- the choleravaccine shouldbe basedonly
ceived in completelydisparateways is lance areabecameso attachedto their on provencases of cholera- both severe
partlya functionof how these trialswere cardsthattheyframedthemandhungthem andmild- invaccinatedandcontrolgroups.
conducted,andpartlyof the way in which onthewallsof theirhouses[vanHeynigen Further,trialswererequiredto be properly
science and politics intersected in the and Seal 1967:159]. randomisedanddouble-blind,the control
differentspatialand temporalcontexts. Thecardswereprobablyassociatedwith groupreceivinga comparablenon-cholera
the advantagesderivedfromtheirpartici- vaccine such as typhoid,paratyphoidA
Second Pandemic and Vaccine pation in the trial. The rigorousdemo- andB. The vaccineswere to be adminis-
Research graphicand diseasesurveillancenecessi- teredatintervalsin orderto give maximum
tatedby the trialensuredthatnutritional response,for example, a series of three
Thesecondpandemicof cholera,which status was closely monitoredand diar- doses, spaced at intervalsof four to six
commencedin 1961 and was spreadover rhoealdiseaseswererapidlydetectedand weeks. Finally, scientists were also re-
the continentsof Asia, Africaandeastern treated.The trial might have been per- mindedthat mass trials were unlikelyto
Europe, intensified interest in cholera ceived by the volunteersas havingthera- provide as much value as concentrated
researchandthedevelopmentof a newand peutic benefits.Of course, it is reported studies carriedout on relativelylimited
more effective vaccine. Two different thatthe experimentalnatureof the entire groupsduringepidemicsandbetweenthem.
periodscan be demarcatedin the experi- exercise had been communicatedto the Two furthertrials were carriedout in
mentswithcholeravaccines.Thefirstphase volunteers,andinformedconsenthadbeen Matlabin 1966-67 and 1968-69. All the
beganwith Ferran'sexperimentin 1885 obtained.However,the questionof how trials held in Matlabwere subsequently
andlasteduntilthelate-1950s,duringwhich biomedicalnotionsof risk were commu- also carriedout in whatwas perceivedas
several cholera vaccines with varying nicated to the personsconcernedis un- the ideal atmospherewhere the subjects
degreesof efficacy were tested [Pollitzer clear. It is very difficultto communicate were as muchpartof the trialas were the
1969].However,trulysystematicattempts the notion of a placeboto subjectpopu- scientists.At leastin thepublichealthand
to evaluatethe effectiveness of cholera lationswhicharenot familiarwith proto- biomedicalcommunity,Matlabcameto be
vaccinesbymeansof controlledfieldtrials cols of is notclear regardedas the idealfield site for thefield
were made only from the early 1960s fromthe descriptionsof the Matlabtrial trials of vaccines.
onwards[Cventovic1965]. whether,in obtaininginformedconsent In contrast,the 1975 vaccine trials in
In November1963, the first of a series fromthesubjects,it wasexplainedto them Calcuttashowhoveanepisodein biomedi-
of field trialsfor a choleravaccine were thatsome of the peoplemaybe receiving cal researchbecame a scandal and got
conductedin MatlabThana,Bangladesh, not the vaccine against cholera but the labeledas 'ethicallywrong'[Bhattacharya
under the guidance of Benenson and placebo. Since the descriptionsof the 1981j.3In 1975,theCalcuttabasedCholera
Oseasohn.Itcameto be hailedas the 'ideal proceduresfor obtaininginformedcon- ResearchCentre(CRC)tookuptheproject
fieldtrial'andwas constructedas a model sentin thesetrialshavenotaddressedthese of conductinga controlledfield trial for
of reciprocitybetweenscientistsandsub- issues, the scientific and public health a choleravaccine which had been com-
jects in an experiment[vanHeynigenand communityhas acceptedthe construction bined with an aluminumadjuvant.The
Seal 1967]. While the scale of the field of theMatlabtrialas anidealone,wherein project was sponsored by the Indian
trials was large, it continued with the a perfectreciprocityexistedbetweensci- Council of Medical Research (ICMR).
traditionof field trialsin which vaccines entists and their subjects.2 After 540 days of the follow up of the
developedin laboratories in thewest have Forthe follow up studyof this vaccine, trial, a reportwas publishedby the CRC
to be tested on human subjects in the 23 villagesweredividedinto3 groupseach accordingto which:
developingor underdevelopedcountries of which was supervisedby an experi-
(E)arliercontrolledfield trials with a
because.ofthe necessityof findingareas encedfield workerwithgraduatetraining controlledcholeravaccinerevealedthe
in which large samples of population in social sciences,assistedby seven field limitationsof the currentlyused vaccine
exposed to the risk of choleracould be workersand a midwife (dai) residentin in affordingsignificantprotectionagainst
located. Whathappenedin the field? each village. Familieswere visited twice cholera,especiallyin childrenbelowfive
The immunisationsby single injection dailyforinquiriesaboutdiarrhoeal disease yearsof age. A highmousepotencyvac-
mainlyby jet gun were completedin six andwereencouragedto makepromptuse cine and oil adjuvantvaccine, though
months beginningNovember 11, 1963. of the field hospital in case of illness. producedhigherdegreeof protectionfor
Out of a totalpopulationof 27,639 in 23 Wheneverany new episode of diarrhoea a longperiodwerenotacceptable because
of theirhighreactogenicity.A controlled
villages, 14,059or51 percentvolunteered occurred,detailswereenteredin a simple field trial was initiatedin Calcuttain
for the trial. Of these 61.7 per cent be- reportform and stool sampleswere col- February1975, with a new aluminum
longedto the5 to 14yearsage group.Each lected andsent to Dhakawithin24 hours
volunteerwas givena cardon the backof for bacteriologicalexamination. total of over 2,00,000personswerein-
whichwas statedin Bengalithatthe study Among the strictguidelines,that were cludedin thetrial,halfof whomreceived
teambe notifiedpromptlyin case of the laid down for this trialwas thatit should thecholeravaccineandtheotherhalfthe
occurrenceof diarrhoeaof any sort. The takeplacein an accessibleareawherethe toxoidas placebo.The follow up of the

634 Economic and Political Weekly February 19-26, 2000

vaccinated individualsatthehospitallevel to one prominent NGO (Norman Bethune hadbeenobtained[Palet al 1980:741-451.
wasstartedsevendaysaftertheinitiation Janaswathya Andolon), this represented Theannualreportsof theCholeraResearch
ofthevaccination phase[Cholera Research misuse of authority against thousands of Instituteand the paperspublishedby the
Institute:Annual Report 1976:5]. residents of Calcutta, who had been sub- researchteam state that the protocolsof
Thepurposeof the studywas to deter- jected to what was perceived as unscru- vaccine trialswere previouslyapproved
minewhetheracombinedcholeravaccine, pulous experimentation. In all, the Com- by therelevantauthoritiesandwerestrictly
containingtoxin/toxoidwith whole cell mission received as many as 3,000 re- followed.Criticsof the trial,though,had
adsorbedto aluminumhydroxide,would presentations pertaining to excesses (The anotherversionof the events.Thoughthe
producea betterimmuneresponse than Statesman, Calcutta, September 13, 1978. ethicsandthemethodology of thetrialcame
thatproducedby eithercomponentalone, Also from interview with the chairman of undercriticism,therewasunanimityabout
andtodetermine thenatureof theantibody the commission and ex-judge, June 25, the enhancedefficacy of the vaccine.7
response soproduced.Attemptsweremade 1996). Regarding the appointment of The disputeover the trialfinally came
to searchfor a new simple and sensitive the Commission, the government of to an end when the scientistsat the CRI
testto measurethe functional activities West Bengal declared in a notification approachedthe CalcuttaHigh Courtwith
of antibodies. of August 12, 1977: a petitionthat,since the centrewas a reg-
Theresultsof the first 180 days of the ...whereas there is a widespreaddemand
istered body like the ICMR,the scientists
follow-upshowed that the vaccine was from differentsections of the publicfor an and other personnelworkingthere
capable of offering nearly 100 per cent not government servants and theiractivi-
inquiryinto allegationsof persistentmis-
protectionagainstcholeratochildrenbelow use of authorityof powersduringtheperiod ties didnotcome underthepurviewof the
five yearsof age, and 60.6 per cent pro- from March 20, 1970 to May 31, 1975 commission.The verdictof thehighcourt
tectionto personsof all otherage groups. whereby the citizens in the state were wentin favourof theCRI.Thedisputewas
As manyas73.3 percentof thevaccinated deprived of their democratic rights and, thus resolved, not with referenceto the
volunteers in allagegroupswereprotected whereasthe governmentis of the opinion rights of subjects of trials, but through
duringthe first three months.The high thatit is necessaryto appointa commission questionsof jurisdiction.
degreeof protectionin childrenwas con- of inquiryto enquireinto mattersof public At this point, it may be askedwhether
sideredto be significantsince the same importance, mattersrelatingto the persistent it was the violationof ethicalcodes which
degreeof protectionwas not observedin misuse of authorityof powers, the com- led to the disputebetweendifferentsocial
anyof theearlierfield trialswith conven- mission should intervene. Therefore the actors, or ambiguityregardingwhat the
terms of referenceof the commissionis to codes and
tionalcholeravaccines. proceduresoughtto have been
the scientists at the CRI enquire misuse of powerby publicservants in this situation. It was clear
Apparently, particular
whichtookplaceduringtheaforesaidperiod thatthe scientistsinvolvedin the trialdid
had achieveda breakthrough in vaccine
(SarkarCommission Report 1975).6 not considerthe trialof the 'new' vaccine
development.The field trial, however,
becamea subjectof controversyon several In his evidence, the drug controller of as trulyexperimentalin natureand,there-
counts.Itwaspointedoutby certainexperts the union government and the deputy drug fore, of any unanticipatedrisk to the
thatthe vaccine had not undergonead- controller of the government of West subjects.This had to do with the nature
equatetests in the laboratory,on animals Bengal informed the commission that no of the vaccinein question- it was a com-
oron humanvolunteers,beforeits experi- relevant information relating to the trial bination of two known and previously
mentationin the field.4Moreover,it was had been'submitted to them, and they had tested components and hence, did not
saidthattheresultsof the tests whichhad not been approached for permission to come underthe categoryof new drugs.8
beenconductedhadnotbeenpublishedin conduct the experiment. Several teachers Thiswas probablyalso thereasorn why the
anyscientificjournalor presentedin any from the local schools, and residents of the rigorousprocedureof conductingtestson
scientificconference.It was alleged that area testified that the vaccinators had not the animalmodelsandthentrialsof safety,
the standardprocedureof obtainingper- disclosed the experimental nature of the ratherthanefficacy,on humanvolunteers
missionfromtheDrugControllerhadalso exercise, or the fact that it was a new was notfollowedpriorto thefield trialfor
beenignored.Theissueof informedconsent vaccine that was being tested (Interview testing efficacy.
alsocameunderscrutiny,as it was alleged of June 25, 1996). The scandal createdin this particular
thatthe 150persons,who hadtemporarily In a rejoinderto all the allegations being field trial of the choleravaccine soured
beenemployedas vaccinators,had been levelled at the methods of the trial, S C Pal relations between CRI (now called the
toldto say thatthey were representatives et al pointed out in a paper published in NationalInstituteof Choleraand Enteric
of thegovernment,andnotto mentionthat the Bulletin of the World Health Diseases (NICED))andthe West Bengal
theyweretryingout a new vaccine.The Organisation, thatthe areafor the trialwas government.Thetensionpersistedintothe
entiretrialcame acrossin the eyes of its selected in consultation with the depart- 1980s, as a consequenceof which there
criticsas unsystematicand unethical.5 ment of health of the government of West was considerablereluctanceon thepartof
OnDecember5, 1977 the opponentsto Bengal, and that 60 teams, each consisting thescientistsof thisinstituteto doresearch
the trial petitioned the Sharma Sarkar of a recorder and a vaccinator, were on vaccines. Though the conflict was
Commission,which had been appointed employed to carry out the vaccinations. detrimentalon this front,it did bringinto
by theWestBengalgovernmentto inves- Duringthepreparatoryphase,they received focus the issue of ethics and informed
tigatemisuseof powerby publicservants. intensive training in the methods of consent.It also raisedthe questionof the
It is importantto note that this was one vaccinating. It was categorically stated definitionof a 'new drug' and what it
of the cases amongothersthatwere sub- in this paper that the volunteers were vac- constitutes.One can say thatconflictand
mittedto the commission,and according cinated only after their informed consent resistancearenot destructive,butin fact,

Economicand PoliticalWeekly February19-26, 2000 635

productiveof new forms in addressing cell vaccinewasused,becometheoccasion may collapse. The second is the fact that
issues,bringingaboutnoveltyin discourse for a new vaccineto be developedby the though public health measures necessary
andpractice.The 1975episoderevealsthe Indian scientists. One might note here to control cholera are well understood,
wayin whichnormsandrules,andexperi- thoughthatimportant scientificleadshave the actual processes involved in the patho-
mentsevolve simultaneously.Thedispute been lost in vaccineresearchbecauseof genesis of the disease are yet to be fully
regardingthe trialalso throwsinto relief thecontroversiesandthepoliticalcosts of understood. The first kind of uncertainty
the questionof the purityof science and thesecontroversies.Yet,aswenotedearlier, is exemplified in the tragic case of refugees
whetherscienceis insular.It becomesin- thesecontroversies havealsobeenproduc- from Rwanda, who succumbed to the
creasinglyclearthatthepracticeof science tive becausethey have compelledscien- epidemic with the case fatality ratios being
involves its nexus with other spheresof tists andbureaucrats to takethe rightsof as high as 22 per cent in the initial phase
societal knowledgeand organisation. subjectsof trials more seriously. of the outbreak. The second case is exem-
It is also interestingto observethatthe plified in Latin America, when the El Tor
very same trialhas come to be regarded Cholera and Vaccination strain acquired a virulent form after a
as far more ethicalin publicdiscussions in 1990s 100-year absence. More dramatically the
among some NGOs in Bangladesh.In a cholera epidemic in India and Bangladesh
critiqueof the field test of an oralcholera Contemporary researchon the cholera caused by a novel strain of V cholerae,
vaccine (developedby two Swedish re- vaccinemay be viewed in termsof three showed that the organism continues to
searchers),whichconsistedof thepurified events that have dominatedthe global change in unpredictable ways.9
B sub-unitcells and killed V cholerae cholerascene in the 1990s.The firstwas The years 1992 and 1993 can be seen
cells,UBINIG,a voluntaryorganisationin the unexpectedreappearance of epidemic as an importantturningpoint in the history
Bangladeshhas accused the researchers cholerain the Americasin January1991, of cholera, as a new epidemic strain of the
and the WHOof violatingthe principles causedby Vibriocholerae01 El Tortype Vibrio cholerae was identified by scien-
of theHelsinkideclaration. Apartfromthe after 100 years. The second was the tists at the NICED in Calcutta. While
questions of how informed consent was breakoutof choleraepidemicin the refu- V cholerae 01 strains are known to pro-
obtainedandwhethertherewas any pro- gee campsin Gomain Zairein 1994where duce a cholera toxin, and are responsible
vision for recordingof adversereactions, the populationfleeing fromthe devastat- for the epidemic form that the disease
this organisationhas raisedvery interest- ing Rwandancivil war was estimatedto takes, the V cholerae non-O 1 strains were
ingquestionsabouttheethicsof cost.They be between70,000 and one million.The generally incriminated only in cases of
pointout thatcheapestratecited for this thirdwasthegenesisin late-1992in south- acute gastroenteritis, but not in large
vaccineis US $ 60. Now obviouslythecost ern Indiaof a novel strainof V cholerae epidemics. A large explosive outbreak of
of a vaccinemaygo downif it canbe used with epidemic and pandemic potential a cholera like illness occurred in the port
in routine immunisations programmes [WHO1991,1993;CholeraWorkingGroup town of Madras in southern India dating
for children and adults. But vaccines 1993]. Each of these events occurredin from October 3, 1992. The strains causing
against cholera remain outside these the global context of the resurgenceof this disease were received in November
programmes becausethe threatof cholera infectiousdiseaseslayingto restthe com- 1992 at the NICED which is the National
is limitedto areaswherepublicmeasures, fortable theories of an epidemiological Reference Centre for cholera in India. The
suchas sanitationand provisionof clean transition.These events necessitatedthe main characteristic of the strains received
drinkingwater are not available.Under reviewof beliefs, strategiesandpractices was that the isolates of V cholerae did not
suchconditions,anexpensivevaccinecan on the managementof infectiousdiseases agglutinate with the 01 antiserum. While
only be treatedas a traveller'svaccinein in general and cholerain particular.As we need not go into the history of the
which case no benefit would accrue to settled notions aboutinfectiousdiseases classification of V cholerae, it may be
the poor.In contrast,the critiquereferred were destabilisedthere were fresh chal- noted that up to this point epidemic and
to whatit calledthe 'Calcuttavaccine' as lengesto thesocialsciencesto reviewtheir pandemic cholera was associated only with
not only moreefficaciousbut also much ideas about the political economy and the 01 serogroup of V cholerae while
less expensive. cultureof infectiousdiseases. strains that did not agglutinate with the 01
to the cost of the ICDDR,B's In termsof publichealthmanagement, antiserumwere known to be widely distri-
combinedB subunit-whole cell vaccine, the techniquesforprevention,controland buted in the aquatic environment, but were
thevaccineusedin theCalcuttatrialwas managementof cholera are well estab- not incriminated in epidemics. Similar
very inexpensive.Yet the resultsof the lished.Yet, withthe spreadof the seventh isolates were received from Vellore and
Calcuttatrialweresuperiorto those ob- pandemicof cholerainto LatinAmerica, Madurai. At about the same time, an un-
tainedby theoralcholeravaccineof the the numberof countriesreportingcholera usual increase in 1993 in the number of
ICDDR,B. TheCalcutta trialhadprovided cases increasedfrom 35 in 1984 to 54 in admissions of patients was noted in the
100percentprotection to childrenforsix 1991, and 94 in 1994. Apart from the Infectious Diseases Hospital in Calcuttaas
months,88.9 percentfor 12 monthsand requirements of an administrativeculture shown below:
91.7 percentfor 18 months.The overall andthe systemof healthintelligencethat
protection was58.5percentfor18months is in place, two kinds of uncertainties Year Cases Admitted AnnualPercentage
for all age groups[UBNIG1996:24]. Change
constitutemajorrisks in the emergence
In thenextsection,we shallsee thatthe of cholerain epidemicform.The first is 1990 18028
problem of inadequate protection for the risk of politicaluncertaintiesaccom- 1991 19858 10.15
1992 23333 17.5
childrenas well as the residualdiarrhoea panying war, civil disorder,or natural 1993 44522 90.8
reported bysubjectsevenwhenkilledwhole disasterswhennormalhealthcareregimes

636 Economicand PoliticalWeekly February19-26, 2000

In their report on this epidemic in orlackthereof,in controllingtheoutbreak of healthofficershadsubmittedtheirreport
Calcutta, Bhattacharya, Goswami et al came underscrutinyfromthe opposition (Amrit Bazar Patrika, May 20).
(1994) stated: parties,the media and the medicalcom- Finally,on the May 21, the government
The IDH, Calcuttabeing the referralhos- munity.Therewere complaintstime and admittedthat the disease that had so far
pital for patientswith diarrhoea,bore the again regarding the lack of adequate been called enteritis,was actuallya kind
mainbruntof the epidemicin Calcuttaand medical facilities, the paucity of safe of cholera.In a press release, the health
its neighbouringdistricts.In 1993, 44522 drinkingwater, absence of chlorination secretarysaidthattheteamof government
patientsof acutediarrhoeawere treatedas and so on. Often, therewere allegations healthofficialswhichhadbeen sentto the
in-patientsat IDH, a more than two-fold that the governmenthad eitherfailed to NICEDhadexaminedthebacteriathatwas
increaseas comparedto the previousthree tackle the situationor was indifferentto causing the so-called enteritis and had
years andduringthe peak of the epidemic it. Ina demonstration of protestagainstthe concurredwith the scientistsat the Insti-
180 to 300 patients were admitted daily indifferenceof thegovernment,theRevo- tute.Followingthe government'sofficial
at the IDH [Bhattacharyaet al 1994].
lutionaryYouthFrontstageda dharnain recognitionof the choleraepidemic,the
The epidemiological profile of the pa- front of the corporation(Amrit Bazar termenteritiswas replacedby cholerain
tients showed that the disease primarily Patrika,April30). Inanotherincident,the all official documents.
affected the adult population of certain member of the mayor council De was
endemic areas in Calcutta. Second, the gheraoed(surrounded) for an hourand a Medico-Political Ramifications
clinical profile was similar to the cholera half by the representativesof the corpo- of 0139
caused by the 01 strain- severe dehydra- rationwhodemandedhisresignation. They
tion being recorded in a high proportion alleged that the outbreakwas takingthe In this section,we examinethe manner
among the affected. There was also a shapeof anepidemicdueto thecallousness in which the communityof scientistsre-
significantshift,describedas 'unexplained' of thecorporation healthdepartment whose spondedto the threatof this new disease,
in the medical literature, in the isolation timely interventioncould have savedthe especiallyintheireffortsto getrecognition
rates of V cholerae from the previously situation.A casewasfiledagainstthemayor fromtheinternational communityof health
dominant 01 serogroup to the non-O1 andthe membersof the mayorcouncilby scientiststo recognisethe new strainas
serogroup.The epidemic in Calcutta was the vice presidentof the South Calcutta thatof cholerawithepidemicpotential,as
followed by a fresh outbreakin the southern YouthCongress,on the groundsthatthe alsointheirattemptstodevelopaneffective
coastal belt in Bangladesh between De- healthdepartmentwas not ableto control vaccineagainstthedisease.We shalldraw
cember 1992 and January 1993. Here too, the outbreak.This was the firstsuchcase upon publishedresearch,our interviews,
the strains of V cholerae did not aggluti- ever to be filed againstthe corporation. as well as semi-formaldocuments,such
nate with 01 antiserum. On the basis of Yet, the governmentdid not officially as annualreportsof institutionslike the
the clinical profile of the patients suffering name the disease till the very end of the NICED,to unravelsome of thesefactors.
from this disease, which showed similarity epidemic. The first official view of the One of the importantoutcomesof this
of clinical presentation with patients matter appearedin a news item dated crisiswas thatthedepartment of bio-tech-
suffering from cholera caused by the 01 March31. The reportquoted the health nology, governmentof India, provided
strain, Bhattacharya et al (1994) desig- ministeras havingsaid,"thesymptomsof financialand logistic supportfor a col-
natedthe disease as cholera. Similarly, the this disease are exactly like enteritisand laborativeprojecton the developmentof
reports from Bangladesh simultaneously yet it is not enteritis.In medicallanguage an oral, recombinantcholeravaccine, to
characterised the disease as cholera. it is the non-O1type."In this statement a teamof scientistslocatedin Calcuttaand
Chart 1 shows the spread of the disease the healthministerwas probablyreferring Chandigarh.By February1996, the team
afterit was initially reportedfrom Madras. to the fact thatthe diseasewas symptom- wassuccessfulindevelopingsuchavaccine
Chart 1 atically similar to cholera caused by andtestingitontheanimalmodelsforsafety
V cholerae0, andyetit wasanon-O1type. and efficacy. The clearancefor phase1
Month Place of Epidemic
However,in spite of namingthe cholera clinical trials of human subjects was
EarlyOct 1992 Madras
causingorganism,he choseto classifythe awaitingclearancefrom the office of the
LateOct 1992 Madurai
LateNov 1992 Calcutta diseaseloosely as enteritis.In theabsence drugscontrollerat thetimeof thisresearch.
LateNov 1992 Vellore of any official statementby the govern- By following the trajectory of the
LateDec 1992 Amravati ment,it was the medicalcommunityand developmentof this vaccine,we hope to
EarlyJan 1993 Nagpur, Wardha, Bhandra, thescientistsengagedinunderstanding the showthesocialnegotiationsthroughwhich
Chandrapur,Beed and other
cities in Maharashtra. natureof the pathogenswho took the re- knowledge,eithermoves fromlaboratory
EarlyFeb 1993 Visakhapatanam sponsibilityfor namingthe disease in a to the field, or is inhibitedin this move-
May1993 Alldistrictsof AndhraPradesh
May1993 Allepyand Mumbai
press release on May 19. The NICED's ment. Several questions of scientific
June 1993 official statementthat the disease was management, organisational structuresand
July 1993 CentralIndiaandNorthernIndia cholera had an immediateeffect on the scientificdiplomacyare involved in this
July 1993 Ahmedabadand other cities in - in additionto questionsrelatingto no-
government.The very same day, a team
of officers was sent to the NICEDlabo- tions of medicalefficacy. At the heartof
We are not going to review the various ratory.Thehealthsecretarystatedthatthe it seems to be the notion of risk and its
measurestakenby the West Bengal govern- healthdepartment hadtakenthisinitiative perceptionby the differentsocial actors.
ment to tackle this threat [for a detailed afterreadingthe pressstatementmadeby Theserological classification
of V cholerae
account see Das, Dasgupta, Ghosh and theNICED,butthatthegovernmentcould has undergone several changes over a
Misra 1996]. The goverment's efficacy, only decide on the matterafterthe team periodof time. The classificationon the

Economicand PoliticalWeekly February19-26, 2000 637

basis ofO antigen was initiated by Gardner patientsadmittedin the hospitalbetween stage.Forthemoment,it is onlynecessary
and Venkatramanin 1935 in a paper on December1992 andJanuary1993.When to notethatthisnewtoxin(ZOT),reported
the antigens of the cholera group of interviewedby us, S K Bhattacharya said in this workshopcontinuesto be studied
vibrios. Until 1972 only strains which that on the basis of the clinical features from differentangles.
agglutinated with the 01 antiserum were it was clear to him thatthe disease they At the NICED,G B Nairandhis group
termedV cholerae.These were considered weredealingwithwascholera,sincein all were engagedin the studyof the non-O1
as "truecholera vibrios capable of causing cases therewas waterydiarrhoea,vomit- strainsof Vibrio cholerae.As Nair ex-
cholera". The other vibrios were collec- ingandseveredehydration (Interviewcon- plainedin an interview,he was fascinated
tively labeled as non-agglutinable vibrios ducted in CalcuttaJuly 20, 1996). The by this organismbecause its processes
(NAGs) or non-cholera vibrios. The des- serumandstool electrolyteswere similar remainedso elusive.
ignation of V cholerae was extended in to those of cholerapatients.It was thus I thoughtsince everyoneis studyingthe
1972 by the International Committee on clear from the clinical presentationsand 01 strainsand that is naturalbecause
Systematic Bacteriology based on a mini- the epidemiologicalprofilesthatthe dis- that is the disease causingstrain,why
mal number of taxonomic traits required ease was cholera,but thatit was also not don'tI lookat theotherstrains.Themore
to classify a strain as V cholerae. This, causedby the Vibriocholerae01. It was we studiedtheotherstrains,themorecon-
however, did not take care of the problem firston the basis of the clinicalpresenta- vincedI wasthatoneof thesestrainscould
that not all the strains of V cholerae that tion of the diseasethatBhattacharya et al in the futurebecomepathogenic(Inter-
sharedtaxonomic traits caused cholera, as designatedthe disease as cholera.As an viewconducted inCalcutta, July21, 1996).
a clinical disease. The clinicians felt that interestingaside, we may note thatsome Thuswhenthe strainsfromdifferentparts
it was necessary to distinguish between of the publicationstalkedabouta cholera of the countrywere received and it was
cholera causing strains and the strains not likedisease.Meanwhile,thehealthadmin- discoveredthatallof themproduced cholera
associated with the disease. Hence, the istrationtalkedonly aboutan outbreakof toxin,butdid not agglutinatewiththe 01
phrases Type 1 or type 01 were appended gastro-enteritis or acute diarrhoearather polyvalent antiserum, the researchers
to V cholerae. As mentioned earlier, till thancholerawhilenewspapers werepress- thoughtthattherewas s strongpossibility
the genesis of V cholerae 0139, epidemic ing the governmentto recognisethe dis- thata non-O1strainof Vibriocholeraehad
and pandemic cholera was not associated ease as a choleraepidemic. acquiredvirulencefactorsdue to genetic
with the non-01 strains. Whenthe strainsof the Vibriocholerae exchange.Thestrainsweresentforcharac-
As we can see from this section, there were receivedin Calcuttafrom Madras, terisationto JapanwhereY Takedaandhis
is alreadya taxonomic tension between the Vellore,CalcuttaandthenBangladesh,it groupsat the departmentof microbiology
bench scientists and the clinicians. For the was foundthatthe strainsproducedchol- attheKyotoUniversityandT Shimadaand
clinicians what was dangerous about chol- era toxin, but that the isolates did not hisgroupattheNationalInstituteof Health,
era was its epidemic potential and the agglutinatewith 01 antiserum.The story Tokyo,collaborated withNairandhisgroup
threat it posed to the life of the affected takesaninterestingturnherebecauseNair at NICED. As Nair stated; 'The results
patients.The microbiologists were not only andhisgroupof microbiologists atNICED were startling'.Since none of the strains
fascinated by the pathogenesis of cholera, had been workingon the non-Ol strains agglutinatedwith antiseraagainstany of
but also by the unexplained facts which fornearly15years.Inthe 1980s,theCentre the existing 137 serogroupsof Vibrio
continued to emerge when the properties for Vaccine Development (CVD) in choleraenon-l1 recognisedat thattime
of the non-01 strains were studied. We Marylanddevelopeda series of oral re- butall strainsproducedcholeratoxin,the
shall see the significance of this at a later combinantvaccines. It was found that strainswere named0139.
stage. At the moment let us look at the volunteersfed with candidatelive oral The periodfrom 1992 to 1997 is now
question of how the outbreakin 1992 came vaccinestrains,or geneticallyengineered of specialinterestbecauseunprecedented
to be characterised as 'cholera'. mutantsincapable of producingwhole eventshaveoccurredin the historyof the
In interviews with clinicians and scien- biologicallyactivecholeratoxin,developed disease cholera.In 1992, as we saw, the
tists, who were closely associated with the mild to moderate diarrhoea. This led novel causative serogroupclassified as
identificationof the Vibrio cholerae 0139, several investigatorsto searchfor addi- Vibriocholore0139 wasidentified.Atthe
we could delineate the following sequence tional toxins that could be implicatedin heightof the 0139 epidemicin Calcutta
in thenamingof the disease. Since a regular the pathogenesisof cholera.In 1983, S C the El Tor biotype of 01 was displaced
system of surveillance of all cases of Sanyal and his colleaguesat the depart- for a brief period of 6 monthsbetween
diarrhoeaadmittedto IDH at Calcutta was mentof microbiologyattheBanarasHindu Januaryand June 1993. Surprisinglythe
in place, S K Bhattacharya and his col- UniversityhadinLancetreportedona new ElTorbiotypeof V cholorae01 reappeared
leagues from NICED and IDH could choleratoxinidentifiedby them.In ajoint in Calcuttaandin otherpartsof Indiaand
immediately detect a change in the pattern Indo-UK workshop held in 1989 in replacedthe 011139 serotypeagain be-
of the diseasein 1992-93 thatwas described Calcutta,S C SanyalandS Sahareported coming the dominantserogroupcausing
earlier. Further, the disease primarily on a new candidateoral vaccine which cholera.However,thestudieson01 strains
affected the adult population in Calcutta, theyhadtriedon differentanimalmodels. in the post 0139 periodshow that El Tor
who would normally have a degree of This vaccinewas basedon a new cholera 01 strains which displaced the 0139
immunity from the disease. Meanwhile, toxin which was geneticallyengineered strains in Calcutta belonged to a new
the surveillance system of diarrhoeal and which differedfromcholeratoxin in clone,andsuggestedthatthereis acontinu-
disease in the DiarrhoealDisease Hospital its antigenicnature.We havenotbeenable ous genetic reassortmentamong El Tor
in Bangladesh also showed a similar un- to determinewhy this candidatevaccine strainsof V choloraestrains[see Sharma,
precedented increase in the number of couldnot move intothe humanvolunteer Nair,Mukhopadhyay et al 1997].Thishas

638 Economicand PoliticalWeekly February19-26, 2000

profoundimplicationsfor development of work.Theorganism simplypassesthrough Here is another extract from a different
vaccines,fortreatmentofpatients afflicted the body, thatis if it can pass the acid scientist:
with different kinds of strains as well barrier - that's thetoughpartbuno=cethat
The bacteriacannotdo anythingby them-
as for ourunderstandingof the resurgence is doneit canattachitselfto a cell inside selvesexceptattachto thecolonicepithelium
of infectious diseases on the global scene the smallintestinesthroughfilaments.It with filaments.Now this virus is so clever
[Yamasaki,Nair,Bhattacharyaetal 1997].
thensecretesatoxinthatleadstothewatery that it infects the
bacteria,using the same
diarrhoeaanddehydration. filamentsto enterthebacteriaandthe same
Imagining the Microbe The visionof the 'enemy'hereis some- mechanismto express the virallyencoded
whatsimilartothatof a spy,disguisedwith toxin. It is like a series of deceptions -
Beforewe go on to consider the response a new coat, one who does not enterthe things never appearwhat they seem like.
of the scientists to this crisis especially in system but can release poisonous sub- ThesocialimaginarywithinwhichtXeenemy
the directionof vaccine development, we stancesthatleadthebodyto reactin a way is imagined is not one who invades by
wantto consider for a moment the appear- that it becomes dehydrated,with watery announcing his presence, but hides behind
anceof certainmetaphorsin the interviews diarrhoea.EmilyMartin(1994) has given others who the system is deceived into
given by the scientists, although these find a vivid account of the use of military thinking are the real enemies. In somewhat
no place in the publications for obvious metaphorsin the descriptionsof the im- similarbutmoredramaticimagery,thenews
reasons. Geertz (1973) has stated that in mune system in popular imagery in section of Science summarisessome recent
doing ethnography, one moves from the America.She does not explorethis argu- research on cholera research as follows:
immediacies of one form of life to the mentfurtherto see how the publichealth
But sometimesVibriocholeraeturnsviru-
metaphors of another. It is possible that administrationmay have, in fact, used
lent, and infection is transformedfrom a
in communicating with social scientists these very metaphorsto put systems of mild or even unnoticeable event into a
whose immediate life-world does not routine vaccinationin place, or in the deadly disease...Although the details of
consist of laboratories and microbes, the eradicationof a markeddisease such as this Jekyll-to-Hydemetamorphosishave
scientists needed to resort to metaphors small pox - thus realisingthe exchange remained a mystery...[Williams 1996].
as a form of communication. The more betweentheimaginary andthereal.1IEmily
Does this altered image of 'the enemy'
interesting possibility is that such meta- Martinnotesthatmanypeoplecouldpro-
phors form a subterraneanunderstanding, duce alternativeimageriesof the immune find any resonance in other discourses?
which escapes from the strictly bound We shall see that at least in one case the
system such as that of eating, dancing, scientist-bureaucrat
facts of the laboratory0l and diffuses presents the dangers
playingor simplypersuadingthe foreign of recombinant vaccines in terms which
into societal understanding of disease, to
organism go away. But whereas we
though not identical, are similar to this
prevention, and cure. knowthatthe militarymetaphorwas used
When talking aboutthe Vibrio cholerae, not only to representthe fight against vision. In this constantly changing world
it was commonfor scientists to characterise of microbes in which things never seem
disease, but to organise 'campaigns'to
the organismas having as agency of it own. what they are, some scientist expressed a
immunise,andwas backedby legal struc-
But the microbe is not presented here in belief in the constancy of 'mother nature',
tures, we do not know yet how these
a military mode - not as an armed enemy although such a statement was offered
other metaphorshave been realised at
that could penetratethe body after having with a touch of scepticism, irony, or the
the level of policy formulation.In the
sentence that, "what I am saying
brokendown its defences in a military-like images presentedby the scientistsin re- framing is of course not Science (with a capital S)".
campaign. Although military metaphors lationto Vibriocholerae0139, the imag-
often appearin medical literature in such ined vaccine was more like a trickster I am basically scepticalaboutanti-fertility
analogies as a campaign against the dis- which could matchthe clever organisms vaccines. Will mothernatureallow manto
ease, or the conquest over a disease, or thattricktheirway into the body.12Yet, invent something that would interfereso
even in the picture of the body at war many scientists expressed the difficulties drastically with life? Surely she will pro-
against foreign invaders - in the present for human societies to win against the tect her own creation.
context scientists often talked about the clevernessof the microbes.Considerthe Q: Do you think that would apply to
'cleverness' of the organism. For instance, extract from one of theinterviews microbes also? Does mothernature
one scientist described the Vibrio cholerae with a prominentscientist. protectall hercreationsequally,you
0139 as having 'disguised' itself by think?.
I know this soundsfantastic,but some- Ans: When you put it like that m- aybe
changing its coat. He said; timesI feel thatjustas thescientistssuc- - who knows?
If you can imagine it like this - think of ceeded in makinga oral recombinant
We suggest that the changing descrip-
thesamepersonchanginghis familiarcoat vaccineagainstcholerathatpromised some
tion of the microbe corresponds to a dif-
anddonninga new one so thatyou would success,theorganismchangedits formto
be trickedintolettinghim into yourhouse. deceivethe body.So now we havebeen ferent way of thinking about infectious
This intruder,then, is not someone who successful inmakinganother vaccinewhich diseases. As against the militant mode of
is effectiveagainstthe 0139. But for all talking, evident in the literature on the
comes announcing the beginning of war-
we knowthe organismis continuingto eradication of small pox, in the case of
fare, but someone who enters stealthily
and colonises the cell. changeandit mayagainchangeits form diseases such as cholera which cannot be
andthenwe againstarton a newvaccine eradicatedfrom the environment,scientist
It is not even as if the organismentersthe - and so on and so on - I shall be dead are imagining a world in which humans.
blood streamorthe system- so thatis why longbeforewe canpermanently
beatsuch co-exist with microbes. If one were to
vaccines based on this principle do not a cleverorganism. permit oneself a momentary flight of

Economicand PoliticalWeekly February19-26, 2000 639

fantasy,it would appearthatthe manner - indeed, in the case of vaccine develop- withit. As one of the scientistssaid,"The
in which the scientistsdescribethe acti- ment and vaccine trials, political issues fate of Dr Pal who nearlylost his job, is
vities of the microbes is similar to the have always been important.It is interest- almost like folklore in the Instituteand
mannerinwhichthethreatof globalisation ing, nevertheless, to see how politics casts amongscientists".The mannerin which
is presentedinthepoliticalcultureinIndia. its shadow on this activity and in turnhow the politics of the state government,its
Forinstance,the threatof globalforcesis scientists claim citizenship through their conflictswiththecentralgovernment,and
not presentedin terms of invasion and activities in science. the structureof unions in the scientific
conquest,but in terms of international In their report on Vibrio cholerae 0139 institutionsget folded into the everyday
institutions,such as multinationalsusing in Calcuttapublished in the Indian Journal life of the institutionswill have to be
the structureswithin India and releasing ofMedical Research in 1994, Bhattacharya understood,in orderto see how the po-
poisonoussubstancesin the formof elec- et al concluded the description of the epi- litical institutionscast a shadow on the
tronic images, consumeritems, films - demic in terms of the following statement: work of the scientists,and especially,of
thesewouldattachto the bodypoliticand Inorderto controltheepidemicin Calcutta, thosewhoareworkingin thisvolatilearea.
makeit lose its authenticidentityandthus the health authoritiestook measuressuch In severalinterviews,not only with the
its vitality.The globalcapitalthatsimply as (i) adequatechlorinationof the drinking scientists working on cholera but also
'passes through'this body politic need watersuppliedto the city; (ii) people were others,the mannerin whichbureaucratic
only to attachitself to some partsto do advised not to eat outside or drink from rulesimpingeuponthe workingof scien-
its dangerouswork, it has no need to ponds or other unsafe sources; (iii) if tists was often mentioned.For instance,
colonise the countryas in earliermodels possible to boil the waterbefore drinking; one scientiststatedthatthereasonwhythe
of domination.Thus, both, the imagina- (iv) proper disposal of human excreta; new strainof Vibriocholeraewasisolated
tion of what it is to live with others (in (v) educatingthe people aboutproperper- so easilywas becauseof theease of global
thiscasemicrobes)andwhatit is toimagine sonal hygiene including hand washing communication.Withinweeks the strains
thethreatof theotherareradicallyaltered. practicesanddomestichygiene.Withthese from Bangladeshwere received and the
measures the epidemic subsided in June sero-groupmatchingwas done in Japan
Responses to New Epidemic 1993, although there was a second peak because the scientistswere alreadyin a
in September-October 1993.Forpreventing collaborative relationwiththeUniversities
In his workon the relationbetweenthe such epidemics in future,long-termmea- of Kyoto and Tokyo.
sures such as safe water supply, environ-
subjectpole of modernityand the object mentalsanitation,andfood safetyarebeing Yet thereis so littletrustin the scientists
pole, Latour(1993) has arguedthat "re- undertakenby public health authorities. thatevery time we wantto enterinto a
presentationof things throughthe inter- colaborativerelationwithanyotherinsti-
mediaryof the laboratory"came to be Ishita Ghosh and Lester Coutinho in tutionabroad,we are requiredto seek
foreverdissociatedfrom "therepresenta- their paper in this collection closely ex- permissionfromnotonly the ministryof
tion of citizensthroughthe intermediary amine the understanding of the people in scienceandtechnologybutalsothe min-
of the social contract".Latourtracesthe the endemic areas in Calcutta where the istryof home.Wecannotinviteanyoneto
proliferationof hybridsandthecontradic- epidemic took a major toll, as to whether comeandgivea lecturewithoutgettingthe
torylabours of mediationandpurification such long-term measures were undertaken permissionof severalministries.
througha fascinatingseries of contradic- and whether these continue to guide the Anotherscientist explainedhow rules
tions throughwhich natureand society public health administration in Calcutta. which had been framedto monitorreli-
come to be conceptualisedwithin this From reports in the newspaper, Ananda gious donations from fundamentalist
framework.In the response to the new Bazaar Patrika, as well as the interviews groups abroad,became resourcesin the
epidemictherelationbetweenscienceand conducted by Ishita Ghosh it would appear handsof the bureaucratsto exercisecon-
politics,andmorespecifically,therelation that the measures that came were too late troloverthe scientificcommunity.Not all
betweenscientistswho managethe labo- and few. Neither do Bhattacharya and scientists,however,felt oppressedby the
ratory,and the bureaucratswho manage others explain in this paperas to why there bureaucracy. One felt thatin manyof the
the polity came into sharprelief. was a second peak in the incidence of the new developmentsin bio-technology,it
Consideringthat in 1993 the relations disease in September-October, if these was importantto proceedwithgreatcare.
betweenthehealthministryin WestBengal measures were already in place in June. Anotherstated that "autonomyis never
andthedirectorof NICED,appearto have As for the other parts in India, it was the given- it has to be taken"butthat"many
beenstrainedoverthequestionof naming importantwork of the scientists at NICED, scientists are too timid to take this au-
the new strainof the pathogenas cholera; especially of the team of medical inves- tonomy".Wepresentthesedifferencesnot
and thatin 1975 the directorof NICED tigators led by Bhattacharya, and of the as an amalgamof opinionsof nameless
was facedwitha majorcrisis over a field doctors at Vellore who were able to iden- scientistsbutto pointoutthatindeedthere
trial of a choleravaccine that had been tify the outbreak of the new disease from were very different perceptionsof the
undertakenwith the supportof the West various parts of India. Many of these relationbetweenpoliticsand science and
Bengal government,we can understand investigations were conducted due to the someof thedifferenceswererelatedto the
thatregardlessof the separationbetween initiative taken by the ICMR and in one complexityof issues involvedin research
the subject pole and the object pole of case by a memberof parliament.Yet, these pertainingto sensitivesubjectslike thatof
modernityin Latour's(1993) rendering, very doctors seemed extremely hesitant in infectiousdiseases and their resurgence.
science in India is conductedunderthe their public pronouncements to fault the A briefaccountof the considerationsthat
shadowof politics.I do notwish to imply government for either the delays in wentintoresearchon the developmentof
bythisstatementthatthisis uniqueto India recognising the epidemic or in dealing a newcholeravaccinemayshowthenature

640 Economicand PoliticalWeekly February19-26, 2000

of this complexity. In this partof the paper organism interested us a great deal. We - this combinationshouldsupplythe body
we shall departsometimes from a straight- could see thata partof the choleravaccine with all the immunogens and that way it
forwardnarrative,to weave a tapestry of initiates this kind of residual diarrhoea. will be protected.Main advantageor main
voices in conversation with each other Andthisis early1992.Andthenwe stumbled professed advantage of this is that it is
so that the social logic of the different upon this new organismwhich we called totally safe because nothing can revert.
0139 - it produceda toxin identicalto the Some protein goes in, either does some-
positions may become clear. old strain.What we did was - it gave us thing or doesn't at all. The disadvantage
In a meeting at the departmentof bio- a rareopportunity- we startedpicking up is, numberone, to producepure B is very
technologysoon afterthe 0139 strainhad the acute and convalescence serum of expensive.15This B has to be completely
beenidentified,DrTandonwho was chair- patientswith 0139 from the I D hospital. free from any other kind of protein. For
ing the meeting admonishedus. He said Remember this a cholera endemic area. the purificationof B subunit, one has to
thatwhathave you cholerascientists done There are cases of cholerathroughoutthe be able to get the gene out completely,
in thisimportantfield of vaccine develop- year. Most of the patientswho were down clone it andget it madeandget it free from
ment? And he was right because when with0139 hadveryhighantitoxinelements all contaminated proteins...this is very
therewere meetings of this kind we used againsttheO1strain.Thebloodtitresagainst expensive procedure.The disadvantageof
to be silent. There were all these small the 01 toxin were high. They were suffi- a killed vaccine is that it can never elicit
laboratoriesandthey weredoing theirown ciently protectedagainstthe toxin. So why as much immunogenicityas a live one. So
work but people said Indians can never did they succumbto cholerain November if one makeslive vaccine, which also does
worktogether- so we thoughtthat three 1992? This gave an answer - proved it. not have any other virulencefactors, then
of us - (i e, G B Nair, Ranjit Ghosh and It meantthatananti-toxinimmunitywhich this should act as a vaccine. Because this
Amit Ghosh) would collaborateon a re- many people were forgettingwas not the will go and colonise the intestine and
combinantoral vaccine.13 one and all in causing cholera was not producemore antitoxin.But thereis some
Here is how Nair (and also Ghosh) sufficient. Because if antitoxin immunity theoreticalpossibilitythatthis can become
describedthe strategy of the new vaccine. was protective,then these patientsshould againvirulentthroughsomegene exchange
not have come down with cholera. and...So that'sthereasontheWHOformed
If you really look at it critically cholera is a committee to look into this. Those who
moreof a bio-chemicaldisease. The exact In the interviews with the scientists it
was clear thatany effort at vaccine develop- developed the live vaccine were unhappy
immunemechanismof this organismhas becausetheirvaccinewasnotrecommended
ment has to address the problem not only
neverbeenclearlyunderstood.So theearlier for field trials. They were saying that the
vaccines were not successful - the clichi
of the safety and the efficacy of the vac- inherentriskof gene transferis so low, that
was that they are more painful than pro-
cine, but also how the new productis likely if you do not allow field trials, you will
tective. In the 1970s, people realised that
to compare with the other candidate vac- never know.
since the organism does not enter the cines, which have been developed or are
bloodstream-it passesthroughalmostlike The strategy of vaccine development
in the process of being developed. In the
a transientpassenger- so whatwas the use
case of fertility regulation most scientists pursued by the Indian scientists was quite
of puttingthevaccinein yourbloodstream? different. They startedwith a set of clinical
justify the efforts to work on several kinds
Then startedthe efforts to develop a vac- strainswhich did not producecholeratoxin,
of vaccines, because of the immense
cine that could follow the route of the thus taking a non-toxin producing strain
organism and to do what the organism variability of the immune system which and they then gave it additional attributes
makes it important that a variety of vac-
naturallydoes- i e, give thevaccinethrough which produced the toxin in a way that was
cines are available in addition to different
the oral route and let it dissimulate the innocuous. The basic strategy was to iso-
toxin and things like that. The strategy
choices of contraceptive methods. So it is
late the toxin producing genetic compo-
followed by the researchersat the Centre
interesting to see how the scientists placed
for Vaccine Development was to take a nent from the virulent strainusing specific
their own efforts within the field of the
fully potent Vibrio cholerae strain then
other cholera vaccines. Amit Ghosh ex- enzymes and then introducing this genetic
deleteits capacityto producethe toxin but isolate into the genome of the E coli bac-
plained the difference in this way:
not in such a way that it is completely terium, again using specific enzymes. The
atoxic. The cholera toxin has two parts,In one of the strategiestheyhave takenone E coli thus modified, functions as a bio-
one which allows the toxin to adhere to componentof thecholeratoxinwhichhelps logical factory producing genetically iden-
thecell, andthe second which triggerstheit to adhereto thecells andthey have added tical toxin. These E coli are then 'mixed'
epithelial cells and leads to the waterykilled cells to it, the idea being that the with the non-toxin producing strains of
diarrhoeatypicalof cholera.So the earlier
killed cell will continue breeding all the Vibrio cholerae. As the genomic structure
strategywas to delete the second partandimmunogensthatarenecessaryto produce is complementary some infiltration of
to leave that part which would allow thethe anti toxin. The main advantageof this
toxin to adhere to your intestine simply genetic material takes place. The resultant
killedsubunitvaccineis thatit is totallysafe. strains include some Vibrio cholerae or-
becauseitwouldevokeanimmuneresponse. The cholera toxin has two componentsA
andB. The structureis Al B5. So, the idea ganisms containing the toxin producing
Nair went on to explain that these were
is if one can knockoff the virulentsubunit genetic segment.
the initial efforts and then in the eighties The laboratory vaccine was then tried
but keep some of the virulence factors,
they came up with oral candidate vaccines out on different animal models and found
- CVK 70, and the CVD series. And it was then it can act as a vaccine. But it turned
out that it cannot because there are other to be non reactogenic. It was tested on
at this point thatthe problem of the residual the rabbit ileal loop model and found
diarrhoeamentioned earlier in this paper immunogenic components in the Vibrio
cholerae that are also important- includ- to have 100 per cent efficacy. It is inter-
was encountered.
ing zot, cep, and all that.14So the idea is esting to see what factors would permitthe
So thatwasthetimethatourgroupsentered thatif one gets pureB andthen also killed vaccine to move from the laboratoryto the
the scenario. The microbiology of the cells - this is total Vibrio cholerae killed phase-1 clinical trials which are likely to

Economicand PoliticalWeekly February19-26, 2000 641

be conductedin ChandigarhP G Hospital testsareconcerned,we arehopingto recruit as a statement of denial, as if one inhabited
andaretobeco-ordinated byBhattacharya, people only from NGOs or professional a hostile world in which the worth of
the clinician who first identifiedVibrio peopleso thatthereis no misunderstanding. scientists as Indians had to be proclaimed.
cholerae0139. But we also understandthatin cases where This reactive identityalso becomes evident
The dataon safetyand efficacy on the drugs are to be tested for people who are in the manner in which the use of the
animalmodelswassubmittedto theICMR terminallyill, the pressuresmay be very vaccines developed in India are imagined.
different.On the one hand,we don't want
which is the co-ordinatingbody for all In contrast to, say, private sector organi-
drugs to be testedjust because the person
trialsthroughthe department of bio-tech- is dying. On the other hand, sometimes sations in the US, that go into vaccine
nology,the fundinginstitution.Whenwe people who are terminallyill may want to research and development with the clear
interviewedsome of the scientists and try new experimentalmedicines. Should notion of the competition that they are
bureaucratsin February1996, the hope we decide for them whethera risk should facing in the global markets and try to
was thatthefirstphasetrialswouldbegin be taken or not? These are the problems devise strategies that would give them
in July, but it has increasinglybecome especially now with gene therapy and marketadvantages over their competitors,
clearthatmoretimewouldbe requiredto recombinantvaccines, ideas of risk have Indian scientists and bureaucrats seem to
to be carefullystudied.We arenow study-
get the clearancesfor the trials.What is work with the idea of freeing India for
theperceptionof differentsegmentsof the ing the redline guidelines (developed by their own products rather than capturing
theFDA in theUS), whichmakestandards
scientificandbureaucratic communityon of safety less stringentand try to combat
other markets.
this partof the story? Finally, there are the new threatsthat are
delays in the case of therapyfor terminally
The scientistsinvolved in developing ill people.These have been recentlyissued only hesitantly articulatedpertainingto the
thelaboratory vaccinedefinedthemselves by the NIH and we are going to revise our molecular genetics and recombinant tech-
as 'benchscientists'andrepeatedlystated guidelines accordingly. nologies that are set to dominate the field
thatthe clinical and the field trialswere When asked specifically about the rea-
of vaccine research in the future. One of
not their speciality. Nevertheless,there the scientists we interviewed said:
sons for the delays in moving into the first
wasaperceptionthatwhileall safetyregu- I would not blame anyone who wants to
lationsneededto be followed, the system phase of clinical trials for the cholera
vaccine, she said that there were no undue be extremely cautious in permitting re-
in Indiawas notlike thatin theUS, where combinant vaccines to enter the Indian
there are centres for vaccine testing delays but that in the case of recombinant
scene without stringentcontrols. You see
vaccines, the question of safety was much
whichhavewell workedout networksfor with recombinant vaccines there is an
more complex and it was better to have
recruitingvolunteers.Initially,the scien- unintendedrisk that gene exchange may
tistswhohaddevelopedthe vaccinemade clarity initially ratherthanface these prob- occur,especially if these vaccinesareused
lems mid-way. The story shall have to be for mass immunisationprogrammes.But
theofferthatsomeof theirowncolleagues left at this stage, but some observations on
and they themselves were ready to be more seriousis the dangerthatone cannot
the manner in which themes of nation and know what may be introduced in the
volunteersin the first phase trials. "We
science come to be woven together may populationthroughrecombinantvaccines.
hopedthatthis would persuadeeveryone be of interest. The advantagewith developing your own
thatwe thoughtthatthe vaccinewas safe vaccines is that you can ensure that it is
One of the motifs that came up repeat-
andthattheriskswereminimal".Thiswas, your own governmentthat is involved in
edly in interviews with scientists involved
however,not acceptableto the ICMRor in vaccine development (i e, not only in the entire process, and you can ensure
to the choleragroupin the departmentof complete transparencyby having the ap-
relation to cholera research but to other
bio-technology,becauseit wasfeltthatthe propriatemechanismsof overseeing each
vaccines as well) was thatIndian scientists
scientistscouldnotbefullyobjectiveabout stage from research to production.
were able to break the monopoly of west-
their own vaccine. An excerpt from an We offer the above statement to show
ern scientists in the field of research on
interviewwith a seniorbureaucratin the that the anxiety with reference to the new
vaccine development, as is evident from
department of bio-technologyrevealsthe technologies is not simply evidence of
the following examples.16
dilemma.She said: paranoia. The administration of vaccina-
People say that Indians can never work tion, as our historical studies show, were
In thecase of vaccinetrialsyou haveto together. We have shown through our
be very careful.We have a well tried collaborativework that Indianscan work integrated with military needs. Despite
procedure. Ourguidelinesforapprovalof stringent regulations, more research now
together and work together successfully. tends to show that standardsof safety have
a drugarebasedupontheNIHguidelines The laboratories,that collaboratedin the
whicharevery stringent.Everytrailre- been violated in whatMargaretLock (1996)
developmentof the choleravaccine, were
completely Indian in character. They calls the 'zeal for science' but to which
thevolunteersandtheexperimental nature were not like laboratoriesthataresituated we would add other kinds of zeal such as
of thedrugorthevaccineshouldbeclearly in developing country, but are run pri- the zeal for profit and for maintaining
explained.Incasethepersonis notliterate, marily throughinternationalfunding and
thena thumbimpressionhas to be taken. public order. To take only two examples,
internationalexpertise.17 A M Brandt has shown that despite reser-
We areveryconcernedthatan illiterate There may be many problems with the vations expressed by the Laboratory of
personmaynotunderstand the natureof scientists like Talwarwho are too visible
experimental vaccine.Especiallywomen Biological Control about the killed polio
but they are the ones who have put India virus vaccine produced by several manu-
who areilliterate- we have to see that on the world map.
theirrightsareprotected.So we arenow facturers,the public pressure for a vaccine
insisting on an awareness-building In such statements, the identity that is was so strong that national tests were
programme in areaswhereany drugor claimed is an Indian identity but it is also conducted in the mid-1950s in the US. It
vaccinehasto be tested.As faras clinical a reactiveidentity.Eachstatementis framed was found that some of the batches from

642 Economicand PoliticalWeekly February19-26, 2000

the Cutter Laboratories contained live of eradicationandcontrolof disease,it has in theview of many,thedangersof market
virus and260 cases of polio and 11 deaths alsoevokednewkindsof anxieties- some mechanismsreplacingthe presentsystem
could be traced to the Cutter's vaccine of whichrequirethecultivationof a degree of vaccine supply throughinternational
[Brandt 1979]. The other story of the of scepticismregardingthemagicof shots. donorsmakesit imperativethat skills in
identificationof SV40 by Hilleman at the Finally,we raisesomeof thequestionson vaccine researchand vaccine production
laboratoriesof Merck has been described technology developmentin relation to be constantlyencouraged.What is the
in detail in Galambos and Sewell (1995). vaccine trials for generalconsideration. relativeimportanceof protectedmarkets
The main point of this story is that after in this scenario versus pressures from
the purified Salk vaccine developed by Questions in Lieu of Conclusions global firms to open up markets for
Merckwasreleasedby the US Public Health pharmaceuticalincludingvaccines?
Service, evidence of a wild indigenous In the usualdivisionof labourbetween The 1990sis likely to be a decadewhen
virus in the monkey kidney cells which developinganddevelopedcountries,bench the recombinantDNA technology and
was used to grow the polio virus in the research is normally conducted in the knowledgeof gene activity in viral and
laboratorywas discovered. The authors developedcountrieswhilethe developing bacteriologicalpathogensmay introduce
describethe subsequent events as follows: countriesprovidesamplesfor field trials, a new cycle of innovation.While Indian
TherewasnoevidencethatSV40hadcaused especially for infectiousdiseases. In the scientistshavedemonstrated theircapabil-
case of cholera,for instance,field trials in
ity mastering the science of vaccines,
any problems in the millions of persons
who had been given eitherthe Salk or the can only be conductedin areas that are thepoliticalandbureaucratic organisation
Sabine vaccines to date. This included endemicin orderto assessefficacy.There is still thinkingin terms of incremental
thosebeing immunisedin the huge Soviet is thusa territorialisation
of international changesratherthanarchitectural changes.
campaignthenunderway.Moreover,it was space,whichinthecaseof Indiais reversed Would this have any significantimpact
not evident whether or not SV40 was in a limited numberof cases due to the uponthemovefromlaboratoryto society?
activatedin the processof makingPurivax emphasis on technology development. As one of the scientistsstated,it is clear
[Galambosand Sewell 1995:80-81]. Whatarethe implicationsof this?Should thattheycangetpaperspublishedin highly
Galambos and Sewell then go on to questionsrelatingto costs of vaccinesbe competitive journals,butwouldtheproduct
show how the notions of risk were con- an integralpartof thediscussionon ethics of theirresearchbe onlypapersandscienti-
stituted. They "had to weigh the factual at this stage of technologydevelopment fic recognitionor would it also be the
damageof removing the means to prevent itself ratherthanbe introducedonly at a developmentof vaccines for publicuse?
polio this coming season against the theo- later stage? As notionsof clinicaltrialscome to be
retical problem of continuing injection of Vaccine researchin Indiais primarily debatedin termsof whathavebeentermed
vaccinesuspectedof containinglive SV40". supportedby governmentfunding.Thus, as 'catastrophicrights' (e g, in the case
The company decided not to remove its the networkingbetween bio-technology of AIDS trials or in debates about the
vaccine from the market unilaterally, but companies,venturecapital,clinicians,and refugees in Goma), would there be two
to await the results of further tests. The the FDA, as well techniquesof scientific differentstandards- one takingthe gold
additionaltests, however, showed both at diplomacy typical to private sector standard,doubleblindrandomisedtrialas
Merck and at the NIH that SV40 induced organisationswhichdevelop,produceand the standardfor clinical trials, and the
tumoursof varying degrees of malignancy marketnew vaccines is not replicatedin second taking single arm trials as the
in hamsters. Galambos and Sewell con- India. What impact does this have on standard? Whatwouldbe theimpactof the
clude on the somber note that: scientific innovation?For instance, we political economy of infectiousdiseases
noticethatin the case of choleravaccine, on the developmentof field trials?
This raised the possibility that a cancer-
the differentstages from laboratoryre- We hope that our presentresearchcan
producingsubstance had been given to
millionsof personsand would be given to searchto field trialsconceptualisetime in stimulatefurtherresearchintotheseques-
more in the US, in the USSR, and else- strict sequentialterms - the notions of tions. We reiteratethe necessityof going
where in the months ahead. Although concurrentlyactivatingdifferentkindsof beyondrhetoricgesturingaboutthedomi-
Hillemanwas convinced thatthe problem networks has not been used as an nanceof science, so thatwe can be better
of SV4o could be solved, the company organisationalprinciple.Thusthe depart- informed about the relation between
could no longer tolerate the risk. After mentofbio-technologywhichitselffunded democratisationof knowledge and the
several agonising discussions the firm the researchdid not set up the committee environment necessary for scientific
removed purivax from the market and to considerthe new ethicalissues arising innovationin the country.gj
abandonedpolio vaccine entirely.18 out of recombinantvaccinesconcurrently
Clearly this episode raises very trou- withtheworkof thebenchscientists.Time Notes
bling questions about the notions of risk, as an organisationalresourceis thuslost.
[This paper is part of a larger paper that re-
risk competence and the power to use time Accordingto estimates,70 per cent of viewed critical moments in the experience of
as a strategicresource. The question to ask the world's supplies of vaccine by the cholera on the subcontinent for the last 100
is whethernationalgovernments are likely end of the 1980s was providedby four years [see Das, Dasgupta,GhoshandMisra1996].
to constitute risk differently from the majorfirmsin the US. Oneof the reasons We decided to separate the historical parts
manner in which it was handled in this given for the emphasison researchand [see Misra] and the community experiences
(see Ghosh andCouitinho,also in this collection).
case. We suspect that it would be naive development byIndiainthefieldof vaccine The earlierpaperalso includeda discussionof the
to imagine that the solution could be so researchby scientistsand bureaucratsis media reports on cholera which we have not
simply found, but it does reiteratethe idea thattheywouldbe ableto keeppriceslow been able to includefor reasonsof space.We want
that while vaccine research holds promise forthepoorby a systemof subsidies.Thus to thank the scientists in the various research

Economicand PoliticalWeekly February19-26, 2000 643

organisationsin Calcutta, Chandigarh,and Delhi CTX element is known to carry at least six Coleman, William (1989): 'Koch's Comma
who generously gave us theirtime to discuss the genes, including ctxAB (encoding the A and Bacillus: The First Year', The Bulletin of the
issues involved. Our grateful thanks to the B subunits of CT), zot (encoding zonula History of Medicine, 61(3).
members of the NGOs in Calcutta as well as occludent toxin), cep (encodingcore encoded Cvetanovic, B (1965): Paper presented at the
legislators and bureaucratsin various ministries pilin), ace (encoding accessory cholera proceedings of the Cholera Research
of health for their co-operation.] enterotoxin),and orfU (encodinga productof Symposium in Honolulu, US Government
unknown function). Printing Office, Washington, DC.
1 This has important bearings for our 15 As we saw earlierin the paper,this is precisely Das, Veena (1996): 'Rumouras Performative',
understandingof the nature of colonial rule, the point made by UNLIP in their criticism S C Bose Lecture, Philosophy Society,
especially for such issues as that of coercion of the oral recombinantvaccine developed by St Stephen's College.
and consent. We have pursuedsome of these the Swedish scientists and approvedby the - (1998): 'Official Narratives,Rumour and the
questions elsewhere, but only note here that WHOforcommercialproduction.Thequestion Circulation of Hate', Social Identities.
the authorityof science was not established of including eventual costs of the vaccine in Galambos, Louis and Sewell Jane E (1995):
as a simplecorrelateof the colonial state's will discussionof ethics is an extremelyimportant NetworksofInnovation,CambridgeUniversity
to domination. one and would shift the emphasis from the Press, Cambridge.
2 It is importantto note here that a similar trial presentindividualisticconstructionof theissue Geertz,Clifford(1973): 'Introduction',TheInter-
in 1985 for an oral cholera vaccine supported of consent. pretationof Culture,Basic Books, New York.
by WHO came in for criticism precisely for 16 It is notuninterestingtoobserve thatin a recent Greenough, Paul (1995): 'Global Immunisation
violation of ethical standards[UNILIP 1996]. paper in Science, the authors, Waldor and and Culture', Social Science and Medicine,
3 Informationon this trialwas collected through Mekalanos (1996) report their work in 41(5):605-07.
interviews of doctors, legal experts and horizontalgene transferthat may depend on Latour, Bruno (1993): We Have Never Been
government officials. They have not been in vivo gene expression and the implications Modern,HarvardUniversityPress,Cambridge.
named on their own stipulation. of their work for vaccine development.They Lock. Margaret (1998): 'Displacing Suffering:
4 It may be noted that the vaccine was prepared state that "These data further suggest that TheReconstructionof Deathin NorthAmerica
at the Central Research Institute at Kasauli classical strains of V cholerae may be less and Japan' in Kleinman Arthur,Das Veena,
wherepotencyandtoxicitytestswereperformed. suitable as live attenuatedcholera vaccines and Lock M (eds), University of California
5 The media was responsiblefor this perception thanElTorstrains,giventheirelevatedpotential Press, Social Suffering, 207-44.
to a large extent. See for example, The re-acquisitionof functionalCTgenes by means Martin, Emily (1994): Flexible Bodies, Beacon
Statesman,Calcutta,June8, 1978. As we shall of CTXo transduction.The authors do not Press, Boston.
see, the controversiesaroundthis issue were refer to the new 0139 strainsor the work on N, Harish (1996): 'Vaccinationand the State in
not so muchresolvedas abandoned.Therewas vaccine development in Calcutta and 19th Century India', Paper presented at the
some truthin the allegationthatsubjectswere Chandigarh which has taken only non-01 Social Science and ImmunisationWorkshop
not properlyinformedaboutthe experimental clinical strains. The implications of the August 1996.
natureof the vaccine since awareness about possibility of gene transfer have important Nair, G B, M J Albert, T Shimadaand Y Takeda
the ethical issues was not very sharp in the consequences for assessing risks of vaccine (1996): 'Vibrio cholerae 0139 Bengal: The
seventies. From the point of view of the development. New SerogroupCausingCholera',Reviewsin
scientists, the vaccine may not have been 17 Although the scientist did not name the Medical Microbiology, 7(1):49-51.
regardedas strictly experimental because it laboratoryit is obvious that he is referringto Nichter, Mark and Mimi Nichter (1996):
was a combinationof two known substances. the ICDDR in Bangladesh. AnthropologyandInternationalHealth:Asian
This issue will be discussed later. 18 Galambos and Sewell( 1995) attribute the CaseStudies,GordonandBreach,Amsterdam.
6 Itis to be notedthatSharmaSarkarCommission change from the post- WorldWarII scenario Pal, S C et al (1980): 'A ControlledField Trial
Report of 1975 was soon to be followed by in which a mixed system of private,publicand of an Aluminum Adsorbed Cholera Vaccine
another commission appointed by the state professionalnetworksdominatedthe vaccine in Calcutta',Bulletinof the WHO,38(9):741-45.
government- theEmergencyExcesses Inquiry industryto thatof theconcentrationof vaccine Pollitzer, R (1969): Cholera, WHO, Geneva.
Authority- in December 1978. Its objective researchand productionin the hands of four SharmaCharu, G B Nair, A K Mukhopadhyay,
was to investigate misuse of authorityunder majorfirms to threeprimaryfactors: intense S K Bhattacharya,R K GhoshandAmit Ghosh
theemergency.This commissioninquiredinto price competition, search for economies of (1997): 'MolecularCharacterisationof Vibrio
cases of forcible sterilisation,but most cases scale, and the necessity to remaininnovative cholorae 01 Biotype El Tor Strains Isolated
were dismissed for lack of evidence. as technology moved to molecular genetics between 1992 and 1995 in Calcutta, India:
7 This was pointedout duringan interviewwith and recombinantvaccines. Evidence for the Emergenceof a New Clone
one of the organisersof the movementagainst ofthe El TorBiotype', TheJournaloflnfectious
the trial. July 2, 1996.
8 See the DrugsandCosmetics Act of Indiawith
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644 Economicand PoliticalWeekly February19-26, 2000