Selective tuberculosis vaccination in Britain, 1960s-2000s: A cas e of epistemic injustice in vaccine policy?
Selective tuberculosis vaccination in Britain, 1960s-2000s: 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 as a framework for analysing the development, implementation and uptake of selective tuberculosis (BCG) vaccination policies and programmes for Asian infants born in Britain between 1965 and 2005. It uses this framework as a method of historical analysis to examine the epistemic determinants and ethics of selective vaccination. The case study consists of document analyses of archival, governmental and published papers of advisory bodies, health departments, local authorities, researchers and health professionals involved in selective vaccination policy-making and programming in Britain, along with published surveys of the knowledge, attitudes and experiences of families and communities for whom selective programmes have been developed. Research for the case study has identified two problematic areas in selective vaccination policies, which are the focus of research papers being developed. The first is related to uncertainties about the efficacy of BCG vaccine in protecting Asian newborns against tuberculosis, an issue that remained unresolved until the early 1990s. The second is related to uncertainties in criteria used to identify at-risk newborn for purposes of BCG vaccination, a problem that persists to this day in selective programmes. Analysis of both problems helps to understand historical and often unexplored assumptions and biases that have impacted the implementation, uptake, perceptions and experiences of selective BCG vaccination among those delievering programmes and in immigrant and ethnic minority communities that are targeted by them.
More generally, the case study is also used to explore epistemic and ethical issues that are, in important ways, inherent to selective vaccination and not necessarily encountered in mass vaccination policies that target entire populations (as with Covid-19) or universal vaccination that targets entire age-groups (as with childhood immunization). As the case study shows, selective vaccination is underpinned by decisions about the inclusion and exclusion criteria used to determine who will and will not be vaccinated. Determining which groups should and should not be targeted is an epistemic problem with potential ethical and political consequences. A crucial issue for policy making is determining the potential benefits and harms for those being targeted and for the wider community. This is especially the case when risk criteria used in selective vaccination policies are primarily based on social or cultural markers such as sexuality, gender, ethnicity or race. Such markers do not readily correlate with embodied individuals or groups and run the risk of producing or reproducing prejudices, stigmatization, or discrimination that unintentionally and negatively impact the people they intend to protect. The case study provides valuable lessons on the changing rationales, challenges and consequences of selective policies and the potential epistemic harms that have arisen with their conceptualisation and implementation. In turn, findings from the case study may also contribute to understanding the broader issue of vaccine hesitancy in immigrant and ethnic minority communities in Britain.
Research materials:
The case study is predominantly based on the analysis of archival, governmental and published documents. Interviews with researchers, policy-makers and health-care professionals involved in selective BCG vaccination are planned to supplement document analysis in the next phase of research (2026-2029). Below is an indicative list of some of the documents collected and analysed. The method of analysis is detailed in the section below.
Archives
The National Archives (TNA):
· Joint Committee on Vaccination and Immunisation and BCG (Tuberculosis) Subcommittee (TNA JA 628). Collection includes correspondence, meeting reports, drafts of recommendations and guidance on BCG vaccination, that have been crucial to reconstructing and analysing the development of selective BCG vaccination policies and programmes, along with identifying key figures and studies involved in decision-making processes.
· Ministry of Health (TNA MH154), Department of Health and Social Security, and Department of Health (England and Wales), and Chief Medical Officer. This varied collection of documents includes correspondence with the JCVI and BTA and BTTA (see below), key policy discussions and decisions on tuberculosis in immigrants, including memoranda, letters and reports on BCG vaccination, along drafts and reviews of the ‘Green Book’ on ‘Immunisation against infectious disease’. These materials have been used to examine the translation of JCVI recommendations into selective BCG policies and programmes.
· Medical Research Council (TNA FD10). Collection includes unpublished materials on the epidemiology of tuberculosis in Asian populations and research on BCG vaccination in Asian infants carried out in conjunction with the Public Health Service Laboratory (PHLS) and its successor, the Communicable Disease Surveillance Centre (CDSC). The collection includes a previously closed and confidential file that details an influential study on the efficacy of BCG in Asian newborns in Britain (TNA FD10/1114 A Case Control Study to Assess the Protective Effect Against Tuberculosis of Given at Birth Among Children of Asian Ethnic Origin). The file provides valuable insight into the absence of research on the efficacy of BCG in Asian newborns in Britain until the mid-1980s.
Wellcome Archives:
· National Association for the Prevention of Consumption and other forms of Tuberculosis (SA/NPT), British Tuberculosis Association (BTA) and British Tuberculosis and Thoracic Association (BTTA) collections (SA/BRT/B). Major holdings of NAPT, BTA and BTTA reports on “Asian” and immigrant tuberculosis, as well as a large collection of BCG vaccination pamphlets and promotional materials, that have been valuable for charting changing public health representations and communication of TB risk and BCG efficacy to ethnic minority populations.
· Health Education Council/Health Education Authority (SA/HEC). An important collection that contains pamphlets, leaflets, and other forms of information on TB and BCG vaccination produced and disseminated for parents and practitioners.
Government publications
· Collection and analysis of changing guidance on tuberculosis vaccination in the ‘Green Book’ on Immunisation Against Infectious Disease published since 1984.
· Collection and review of official memoranda on BCG vaccination and tuberculosis, Chief Medical Officer letters, and committee reports on tuberculosis epidemiology and prevention, including BCG vaccination.
· Hansard Parliamentary debates contain a small but useful collection of discussions in the House of Commons on tuberculosis in immigrant (Asian) populations and BCG vaccination.
Medical and public health journals
· Articles, reports and letters in major medical and public health are being analysed to detail the changing epidemiology of tuberculosis in Britain, the roles of different experts in shaping BCG vaccination of Asian newborns, debates on selective vaccination policy, and assessments and audits of selective programmes. The sample of journals includes: British Medical Journal, Lancet, Tubercle, Thorax, International Journal of Epidemiology, Public Health, Communicable Diseases Review, Archives of Disease in Childhood, Bulletin of the World Health Organization, Postgraduate Medical Journal, Public Health, Respiratory Medicine.
Methodology:
The case study tests and uses epistemic injustice as a methodological framework for examining the history and ethics of selective vaccination. It draws on work on epistemic injustice in global health, which is grounded in historicising epistemic injustice in relation to colonial histories and structures that have shaped health knowledge, systems and policies. This works has been especially valuable for analysing selective vaccination because it puts a spotlight on the historical pathways and processes by which certain ways of knowing and knowers have been included or excluded in health policy making and programmes. The framework used in the case study 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. It has been used to examine archival, governmental, and published sources related to selective vaccination policies with a view to analysing processes of epistemic inclusion and exclusion in policy-making and implementation. Examining these processes through an historical lens provides an approach to understanding and contextualising epistemic determinants of vaccine policies and the unintended forms of power to which they may give rise or reproduce. They make it possible to consider in what ways vaccine policies are girded by forms of testimonial injustice in which some knowers and ways of knowing are not deemed credible based on their educational background, social or economic status, or identity. They also offer ways to examine forms of interpretative injustice in which vaccine policies have been framed in language or terminology that have been made inaccessible to groups for whom they have been developed. The approach thus opens for analysis the historical roots of obstacles and challenges vulnerable or marginalised people have encountered in contributing to, accessing, or taking-up knowledge about vaccination and the diseases they are meant protect against.
Methodological advance
The case study has developed and tested epistemic injustice as a new methodological framework for researching problems in the history of medicine and healthcare. Approaches to epistemic injustice pose questions about the processes by which certain ways of knowing and knowers are included and excluded in healthcare relations and systems and in healthcare policy-making. Asking how, why and with what consequences some ways of knowing health, illness and disease have been granted credibility and authority while other ways of knowing have not are valuable questions for developing new lines of research in the history of medicine and healthcare. The case study demonstrates how this framework can facilitate new ways for historians of medicine and healthcare to examine how, why and with what consequences some knowers and forms of knowledge have been granted greater credibility & authority than others in healthcare policies and systems.
Key findings
The case study has made two major findings regarding the development and implementation of selective neonatal vaccination in Britain, which are the focus of research papers that have been presented in various fora and are being prepared for publication:
1. Selective vaccination of Asian neonates proceeded for over two decades (1965-1991) without underpinning research or evidence of the efficacy of BCG vaccine in this population.
2. Selective neonatal vaccination has historically rested on uncertain and poorly defined risk criteria for the identification of Asian babies for BCG vaccination, which has continually raised concerns among health care professionals and communities that the policy was discriminatory and, in some instances, racist.
These findings point to significant epistemic and ethical problems in selective BCG vaccination policies and programmes targeting Asian infants, which can be assessed as specific forms of testimonial and hermeneutical injustice. It may also be the case that, in certain instances, they also produce what ‘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.
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, 3 December 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
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.