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Feature: Disease, Immigration and Ethnicity in Post-Colonial England

9 Aug, 2011

Medical facilities available at a modern health centre contrasted with ill health in old-fashioned housing, 1942. Credit: Wellcome Library, London.

Dr Roberta Bivins has some colourful early memories of her childhood in West Africa. She recalls hundreds of barely trained, caparisoned horses, their riders in traditional costume and armed with swords, charging across a dusty town square in Katsina, to celebrate the end of Ramadan. The thundering horses pull up at the last moment at the far end of the square, where the Emir is seated under a huge embroidered umbrella, and the riders make their bows to him.

“I never think about it, but when I’m telling someone, I do think, wow, that was really amazing,” she says. Having lived from her earliest memories in a village of about 1000 people, with no running water or electricity, she remembers the shock she felt, when she returned to the USA aged seven, on seeing her first escalator and eating her first apple instead of a papaya.

In the African village called Mahuta at the edge of the Sahara Desert, which was their first home, she and her sister caught every disease under blistering sun. Since they were 200 miles from the nearest western style hospital, their mother resorted to traditional, tribal medicine.

Dr Bivins feels those experiences shaped her lifelong interest in ethnic health and medicine and the conjunction of disease and culture. Now an Associate Professor of History at the University of Warwick (funded by a Wellcome Trust Strategic Award in the History of Medicine to the university), she is exploring how medicine has been part of the wider political and public response to the increasing social and ethnic diversification within the UK after World War II.

“I wanted to get a sense of what the effects of Empire were, as it fell apart, and how medicine became part of Britain’s attempts to define an exclusive citizenship and protect its borders,” she says. She is currently writing up her findings (some of which are discussed below) for a monograph, ‘Contagious Communities, Model Minorities: Immigration, Ethnicity and Medicine, 1948-1981’, to be published in 2012-13.

The Windrush Generation

When the British Empire transitioned into the New Commonwealth of Nations after the war, its former colonial subjects – keen to take advantage of their traditional right of abode in England (and initially invited to Britain) – came flooding to the country from all corners of the globe. The first of these arrived from Jamaica by boat on ‘The Empire Windrush’ in June 1948, earning this wave of immigrants the soubriquet ‘the Windrush generation’.

Britain’s workforce had been decimated by the war so, at first, the flood of immigrants was a much-needed solution to terrible labour shortages. A decade later, however, the economy slowed and the labour market tightened.

By the late 1950s and early 1960s, concerns about job and housing shortages and access to benefits and services from the new welfare state (supported by taxpayers’ money) began to generate resentment among the indigenous population against these ‘outsiders’.

It was fuelled both by the visible impact they were having on the cultural make-up of many British towns and cities and by their perceived unwillingness to assimilate and adopt British cultural practices. Discontent spilled over into outbreaks of violence against immigrant communities, notably the Notting Hill race riots in 1958 (the Notting Hill Carnival began the following year, as a response to the riots, to improve race relations in Britain).

Notting Hill Carnival. Credit: Anthea Sievekin.

Into this over heated melting pot came some new – or rather ‘old’ – enemies. Diseases like smallpox, tuberculosis, typhoid and rickets, once endemic in Britain but now considered to be well and truly banished from British shores, were ‘introduced’ by immigrants from the tropics.

Smallpox and the Commonwealth Bill

The British government contemplated the possible long-term social consequences of immigration from the colonies with growing unease. Social unity seemed under threat from immigrants’ ‘resistance’ to assimilation, and the British body politic was visibly changing its composition.

Late in 1961 Harold Macmillan’s Conservative government introduced the Commonwealth Immigrants Bill – proposing to abolish the automatic right of people of the British Commonwealth and Colonies to come and live in the UK – for Parliamentary discussion.

Politicians were, however, extremely reluctant to talk about race or social unrest. “This was the Cold War, when the West and the rest were fighting for authority and sway, and to persuade the non-aligned nations to become either capitalist or communist,” says Dr Bivins. The Commonwealth was bound to Britain in part by the right of its citizens to freely enter the ‘Home’ nation, and controls would be seen as evidence of racial or colour prejudice with a potentially dangerous impact ‘at home’ in Pakistan.

Ironically, while it was being handled with kid gloves in Whitehall, outside Westminster the new Bill triggered a massive increase in the influx of immigrants from Pakistan, all anxious to move to the UK before they lost their right of abode.

Crucially, this wave of immigrants were coming by air, unlike their predecessors who travelled by boat. Moreover, they were flying out from Karachi, which was in the throes of a smallpox epidemic. This, says Dr Bivins, proved to be a fatal combination – and ultimately a surprising ally for the Bill.

Several people flying out from Karachi had been infected there, but since smallpox has an incubation period of 14 days they arrived in Britain at the start of 1962 with no visible signs of the disease (which would have been visible on arrival if they had taken the much longer journey by boat). They travelled on public transport, busses and trains, to their destinations in the ethnic communities in London, Bradford, Birmingham, Glasgow and elsewhere, coming into contact with hundreds of people along the way.

Once the disease was identified in the immigrants – five in all had imported it from Karachi – Britain’s excellent public health system sprang into action. Thanks to a massive contact-tracing operation, the epidemic was nipped in the bud. It was over by March, with only 26 fatalities – a small number in view of its potential scale.

It was controllable partly because the British public health system had plenty of experience in ring-fencing imported infections: people had been bringing smallpox back from the Empire to Britain for 200 years. In the past this had attracted little comment. Following an outbreak ten years previously in 1951, again imported from Pakistan, this time by a white-skinned returning RAF officer, rather than an immigrant, the Ministry of Health was congratulated for secretly vaccinating around 200 people who had been exposed to infection, thereby preventing panic.

But this time, something had changed.

Britain, a third world nation?

Coinciding as it did with a turning point in attitudes towards post-colonial immigration and the Commonwealth – as well as the emergence of a highly reactive, sensationalist global media – the 1962 smallpox outbreak sparked great animosity in the press and public.

“People felt they were making this huge investment in a National Health Service and welfare state, and time and money was being wasted by police, local official, doctors and hospitals trying to trace and vaccinate every possible contact,” says Dr Bivins.

As well as indignation at this ‘waste’ of resources, they felt threatened by an ‘alien’ disease brought in by outsiders. After World War II, smallpox was no long a mundane domestic killer. It had become a tropical disease – an imported threat brought by immigrants.

Along with the fear of being infected, people were indignant that they had to be vaccinated if they wanted to travel to other ‘white’ areas like Europe, the USA and Canada. They needed additional paperwork and were subjected to humiliating border checks.

There was also anger at the impact on the global standing of the British nation – as well as their own status as its citizens. “What was really shocking to people was that it had happened at all,” says Dr Bivins. “This was an industrialized western modern nation. There were all these letters, to the press and the government, complaining, why are we suddenly becoming a third-world nation.”

Red and yellow circles (smallpox pustules) in the form of face, with text offering a reward for notification of the disease. Credit: Wellcome Library, London

Keep out the germs

As a result there were calls – from within the Ministry of Health and BMA as well as the public and the press – for wanted stricter border controls and health checks on immigrants. “Keep out the germs”, clamoured the ‘Daily Mail’.

The preference was for health checks in Pakistan before migrants left its shores for Britain. However, these were perceived as unreliable: all five smallpox importers carried international certificates of vaccination (required by Pakistan before the issuance of exit visas).

Failing that, the UK borders needed strengthening; X-rays for tuberculosis and checks for scabs indicating recent smallpox vaccination should be carried out in airports. Public and press railed against about government ineptitude and the looseness of British border controls compared to other western nations.

But border checks are not necessarily easy, reliable or efficient. “People go at speed through airports, it would really clog things up. Imagine going through Gatwick if everyone had to be X-rayed, it’s bad enough as it is, it would be logistical nightmare,” says Dr Bivins. “And tests aren’t always reliable. Tuberculosis, for instance, is quite hard to catch by X-ray alone. And other tests can’t necessarily discriminate between a latent, active or healed case.”

Airport checks were also a political nightmare: pulling Asians from airport queues and asking them to remove their clothes in public places to search for vaccine scab checks looked distinctly racist – and it was viewed as such back in Pakistan. The Pakistani press raged against the abuse and humiliation suffered by their people at English borders – and were quick to link this ‘discrimination’ to a wider political agenda concealed in the Commonwealth Immigrants Bill.

Medicine: a tool to talk about race

And indeed, British politicians were quick to seize upon the smallpox crisis to support restrictions on ‘coloured’ immigration – without talking about colour.

Although the smallpox outbreak itself had been controlled in Britain, preventing further outbreaks was extremely delicate politically. The government had to chart a precarious course between anxieties about disease and pressure for border health checks to prevent its importation on the one hand – and the need to manage Pakistani sensitivities on the other. They needed Pakistan’s cooperation to halt the spread of disease to Britain, as well as to maintain trading relations with the country (where there were now calls to boycott British goods) and prevent any possible alignment with communism. There were international treaty commitments to facilitate travel and trade to comply with – and the great UK spirit of liberal traditions to maintain.

At all costs, then, they had to avoid the appearance of racial discrimination. The timely arrival of smallpox gave them a way to talk about – and justify – legislation to exclude populations from Britain, without talking about race, or non-assimilation, or British national identity. The Bill was voted through, in July 1962. Dr Bivins stresses that this would have happened anyway. “Smallpox didn’t cause or even inspire the Commonwealth Immigrants Act of 1962. That Act was specifically intended to control the composition of Britain’s future body politic, not the health of its citizens, or even its economy. The smallpox outbreak certainly promoted vociferous public support for the Act, but wasn’t necessary for its passage. Macmillan’s government held a sufficient majority to ensure it.”

What the 1961-62 smallpox outbreak does offer however, is a useful window on public fears and feelings in both the UK and Pakistan – feelings that were exacerbated by an emerging global sensationalist media looking for high-impact stories and worst case scenarios in both countries.

Rickets and non-assimilation

Shortly afterwards another ‘old’ disease entered the medical and political arena.

Rickets, like smallpox, had all but disappeared from Britain, thanks to fortification of flour, margarine and other staple foods with vitamin D during the war, and better living conditions and diets subsequently. Like smallpox, it reappeared in Britain in the 1960s in the newly arrived Asian populations.

Unlike smallpox, however, rickets presented no obvious threat to the indigenous population. It wasn’t infectious and it didn’t require huge amounts of resources to track down contacts and contain it. The cases were few in number, and the disease was cheaply and easily treated with supplements.

Yet it became the focus of considerable clinical and media attention, igniting emotion and anger. The reason, says Dr Bivins, is that like smallpox, the re-emergence of an old, ‘Victorian’ disease was an affront to public expectations and eroded political and medical achievements. “It was seen as a sign of social regression. People felt that a more diverse population – with different health behaviours – was dragging Britain backwards. There was a lot of language about that.”

In addition, although by then it was construed definitively as a biochemical disease, rickets in Asians was nonetheless assigned a cultural origin. Once known as ‘English rickets’ because it was so prevalent in Victorian England, the disease was now called ‘Asian Rickets’.

Bottle of Super-D oil capsules, London, England, 1940-1945. Credit: Science Museum, London

“Often the complaint was that so many Asians are vegetarians. They had vitamin D deficiency, because they weren’t eating a proper British diet. Or Asian women didn’t get enough sunshine because they covered up and stayed indoors. There were arguments that because of their ‘dusky’ skin pigmentation they couldn’t absorb vitamin D from the British sunshine. They needed more sunshine, and more vitamin D in their diets to compensate.”

The public health/government response was very different to the wartime one: despite the researchers’ advocacy of that typical Asian foods such as chapatti flour should be fortified with vitamin D, the DHSS decided against fortification. This was partly due to fears that fortifying foods might lead to new cases of hypercalcaemia (a disorder caused by vitamin D toxicity linked to fortification in Britain after the war), and partly rooted in objections to ‘mass medication’ and the ethical issues surrounding the fluoridation of Britain’s water in the 1960s.

Perhaps more nebulously, since the re-emergence of rickets was blamed on cultural differences, responsibility for the disease was laid at the door of the Asians. It was due to their failure to assimilate and adopt British customs, and to adapt to its climate behaviourally. Many experts also believed that Asians would actively resist fortification, again on “cultural” grounds. The government therefore believed that acculturation was the solution to the ‘Asian rickets’ problem, and governmental efforts focussed on educating Asian women to speak English and to care for children in a British climate – rather than on fortification.

Right up until the 1980s members of the government, medical profession and public continued to make the link: between assimilation and health, and distinctiveness (and resistance to assimilation) and disease.

In the case of smallpox, rickets, and other diseases, medicine became part of the political discourse of the time, describing the malign effects of alien culture on bodies and the British body politic. “It became part of the process of defining and protecting a new post-imperial British identity,” says Dr Bivins. Tensions arose because that identity was rooted in a thriving public health network and welfare state; in the ability of British people to travel freely; in the British nation’s first-world status and its technological and medical parity with other such nations; in social unity and conformity; and in race.

The Centre for the History of Medicine, University of Warwick is supported by a Wellcome Trust Strategic Award in the History of Medicine.


Bivins R. “The people have no more love for the Commonwealth”: Media, migration and identity in the 1961-62 British smallpox outbreak. Immigr Minor 2007;25(3):263-289.

Bivins R. “The English Disease” or “Asian Rickets”: Medical responses to post-colonial immigration. Bull Hist Med 2007;81(3):533-68.

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