Selective tuberculosis vaccination in Britain, 1960s-2000s: A case of epistemic injustice in vaccine policy?

 Case study lead: Michael Bresalier (Swansea University)

Led by Dr. Michael Bresalier (Swansea), this case study develops and tests epistemic injustice frameworks for examining the history and ethics of ‘selective’ vaccination policies designed to control tuberculosis in Britain. Unlike universal or mass vaccination, which target entire age groups (i.e., infants or children) or entire populations (as with Covid-19 vaccines), selective vaccination targets specific groups based on identified clinical, epidemiological or social risks. By definition and necessity, selective vaccination discriminates between those who should and should not be targeted for vaccination. A crucial issue is determining the potential benefits and harms for those being targeted and for the wider community. Selective policies can reinforce or give rise to forms of stigmatization, discrimination, or injustice that unintentionally and negatively impact the people they intend to protect. In the case of tuberculosis, selective vaccination of specific immigrant and ethnic minorities has been widely adopted in high-income countries, where the incidence of the disease is low incidence in the general population but high in particular communies.. Britain was an early adopter, with policies starting in the mid-1960s, specifically aimed at South Asian newborns and infants. The history of these policies is valuable for gaining a long-term perspective on the changing rationales, challenges and consequences of selective policies and the potential epistemic harms that have arisen from their conceptualisation and implementation.

Methodological framework

In considering epistemic injustice as a framework for examining these issues, the case study engages with work on epistemic injustice in global health. Much of this work is grounded in historicising epistemic injustices in relation to colonial histories that have shaped health knowledge. Researchers have used the concept of the ‘coloniality of knowledge’ to highlight the colonial roots of global health and the persistence of colonial ways of knowing in policy and practices. This approach is effective for analysing selective vaccination as it puts a spotlight on the processes by which certain ways of knowing – and knowers – are included and excluded in health policy making and programmes. It asks how, why and with what consequences some ways of knowing health, illness and disease have been granted credibility and authority while others have not. These processes have been identified as being key to how power works in healthcare systems. In turn, analysts have traced how health policies have systematically excluded the voices, realities, ideas and experiences of marginalized groups they are designed to serve. That is, how  they are girded by forms of testimonial injustice in which some knowers and ways of knowing are not deemed credible on the basis of their educational background, social or economic status, or identity. At the same time, health problems and solutions, such as vaccination, have been typically framed in language and terminology that is inaccessible to most, and especially to marginalized groups. The result is the perpetuation of forms of hermeneutical or interpretative injustice in which people most in need are unable to contribute to, access or take-up knowledge that could prove vital to understanding, ameliorating or protecting their ill health.

It is evident from the research so far that selective TB vaccine policies can and do produce both forms of injustice. In certain instances, they can also produce what is called ‘contributory injustice’, where conceptual resources created by marginalized communities on vaccination are dismissed or discredited by policy-makers, because these communities are not seen as credible contributors to the epistemic task at hand.

Research programme

Based on ongoing archival and document analyses of British BCG vaccination programmes and policies in England and Wales between 1965 and 2005, three key issues have emerged and are being explored as part of the research for this case study:

1. The multiple challenges in developing and implementing selective TB programmes in Britain, including uncertainties about the efficacy of BCG vaccine in infants born into ethnic minority families, ill-defined ethnicity-based selection criteria, and poor uptake in target groups.

2. How immigrant and ethnic minorities’ knowledge and experiences of tuberculosis, BCG vaccination, and their relative risks, have been included or excluded from British tuberculosis vaccination policies and programmes.

3. How stigmatization or marginalization can be an unintended consequence of vaccine policy and resulting in forms of epistemic injustice. In turn, the study examines or proposes approaches based on inclusive, effective cross-cultural communication and understanding to address epistemic determinants of vaccine hesitancy.

Appointments

Between September and December 2025, Michael Bresalier is Visiting Professor at the Department of Social Studies of Medicine (SSoM) at McGill University, Canada. He will be giving talks on this EPIC case study at the McGill University International TB Centre/WHO Collaborating Centre and at SSoM, along with giving guest lectures on courses in the Department of Global Health and in SSoM.

Talks and lectures

“Selective tuberculosis vaccination: Connecting the coloniality of knowledge and epistemic injustice in vaccine policy”, Department of Social Studies of Medicine, McGill University, 19 November 2025

“Selective BCG vaccination in Britain: What can its history teach us about epistemic injustice in vaccine policy?” McGill University International TB Centre/WHO Collaborating Centre. 7 November 2025

“Colonial history of global health”, Invited lecture, Fundamentals of Global Health, Department of Global and Public Health, McGill University, 19 September 2025.

“The post-colonial history of selective BCG vaccination in Britain: A case of epistemic injustice in healthcare?” Health & Society Program – Annual Lecture, York University Canada 16 April 2025. https://events.yorku.ca/events/health-society-program-annual-lecture