Scandinavian Health Internationalists Navigating Postcolonial India

Mahler was stationed with the WHO in New Delhi for a time. Photo: Old Delhi in New Delhi today, Annie Spratt, Unsplash.

Summary: A look at Karl Evang and Halfdan Mahler’s time on WHO assignments in the 1950s creates a window into international health work at a time of decolonisation and early mass vaccination programmes. Health services in the Nordic countries and India were developing in very different ways and contexts. Evang and Mahler specialised in different areas of medicine and were at different stages of their careers, but India had an impact on both men’s thinking on social medicine. Social medicine greatly influenced both Mahler’s and Evang’s work on and contribution to international health governance.

1950s India was characterised by the political establishment of new norms after independence from Great Britain in 1947, and health care was no different. The World Health Organisation (WHO), too, was very young, having been founded in 1948, and its leaders were keen to embrace forms of knowledge exchange where all countries, including India and other recently decolonised countries, were on an equal footing.

The expansion of state-run health services in Norway and Denmark

In the 1950s, the Nordic countries’ comprehensive welfare systems were still being established, but the concept of the welfare state had been gaining ground in the region since the inter-war period.

Karl Evang (1901-1981) was the main architect of the Norwegian welfare state following the Second World War, and was very influential in terms of health and welfare policy particularly from 1938 onwards. Photo: Wikipedia (CC BY-SA 4.0).

Evang (1901-1981) was already a highly successful and strong-minded health bureaucrat by the time he went to India in 1953. As a medical student at the University of Oslo, he had adopted Alfred Grotjahn’s ideas of the interconnectedness of society, individuals, and health, and had been a radical leftist in the 1920s. Evang took a strong stance on the importance of access to contraception and safe abortions for women, and in the 1930s, he conducted social medical-inspired research on diet and living conditions in poorer households. Appointed Norwegian Director of Public Health in 1938, Evang soon became a key early architect of the Norwegian welfare state. Gradually, his radical views were toned down, and he began to see the state as a core enabler of the population’s health. During the Second World War, he forcefully brought his social medical ideas into early UN fora, most notably in the young WHO. Evang’s influence continued to grow when Norwegian society was rebuilt following the war.

In 1945 at the United Nations Conference on International Organization in San Francisco, Evang and two medical colleagues from China and from Brazil (Szeming Sze and Geraldo de Paula Souza) planned a joint initiative: the World Health Organization. All three subsequently became members of a special Technical Preparatory Committee appointed to draw up proposals for the International Health Conference and a constitution for the new organisation. The first WHO Constitution was signed by representatives of 51 states on 22nd July 1946.

Halfdan Mahler, 1923-2016. Photo: Erling Mandelmann, wikipedia.

In contrast, Mahler (1923-2016) - Evang’s junior by 22 years - had not yet fully developed firm views on particular approaches to medicine. He had a clinically-orientated medical education in Copenhagen and grew up in an emerging social democratic welfare state where health increasingly became a government responsibility. Access to health care in Denmark was, for the vast majority, secured through mandatory membership of insurance-based associations, which had existed locally since the nineteenth century. By 1945, these had begun to receive substantial public funding and, when Mahler was finishing medical school in the late 1940s, debates had begun about a tax-based, state-run health care system where family doctors would become state employees.

On arriving in New Delhi as a 28 year-old, Mahler had already been posted to Germany and Ecuador on vaccination programmes with the International Tuberculosis Campaign, a Scandinavian initiative whose work was subsumed by the WHO and UNICEF in 1951. Mahler came to India to take up the post as medical officer for the campaign. Despite his clinically orientated education, growing up in an emerging welfare state arguably disposed him favourably towards social medicine.

Developing ideas on social medicine

Evang and Mahler would go on to become two of the strongest advocates of social medicine in the 20^th century. Social medicine emphasised the broader social and economic context of health. Proponents of it were often critical of bio-medical and clinical understandings of disease, and were more sceptical about sophisticated technology as a solution to health challenges. Instead, they advocated wider sanitary interventions and improvements in housing and nutrition as measures that could preempt ill health.

Approaches to medicine differ over time and context, but social medicine is generally considered to have had its heyday during the 1930s and 1940s, before a more technology-focused, vertical approach became dominant from the 1950s, certainly in the WHO. Vertical interventions target specific areas and often have separate ways of administering or funding treatment, as opposed to horizontal approaches which take a longer-term, overarching approach. While thinking on social medicine thinking did grow in popularity again in the 1970s and influenced how public health developed, it is generally thought the WHO was more focused on curative and vertical approaches throughout the post-war years, particularly during the 1950s when Evang and Mahler were in India. A look at Evang’s and Mahler’s writings and work for the WHO tell a slightly different story: They appeared to have been inspired by social medicine and even rather hostile towards clinical medicine, exemplified by one of Evang’s letters and one of Mahler's reports:

“[clinical medicine] concerns [itself] with a few, preferably odd and rare cases, discussing the finer points of treatment…while epidemics are raging, right outside their doors.” (Evang, 1953).

“As long as it is considered infinitely more important to remove an inflamed appendix – occurring amongst the privileged 2 to 3 per cent of the total population – than to give 10,000 … vaccinations in the rural areas, one could hardly expect Public Health workers to develop that high working spirit which is indispensable …” (Mahler, 1955)

Nurse training at Ram Chand Lohia Center in New Delhi in 1950. Photo: WHO permission granted.

They came across social medicine ideas in India in various settigs including the reports of the Health Survey and Development Committee, commonly known as the Bhore Committee. It was established in 1943 and was tasked with conducting a survey of existing health services in British India and making recommendations for the future. Another example is how health is referred to in the first (1951-56) and second (1956-61) five-year plans in India. That is not to say that social medicine was uniformly supported in India; just like elsewhere, attitudes towards health and how medical care was administered varied, and there was a strong clinical strand among Indian doctors. Despite these competing strands, social medicine probably resonated politically in India not least because basic living standards for millions of people were not met; it was difficult to consider advanced technological approaches when basic sanitation and adequate housing were lacking. This, for sure, was the position taken by Evang and Mahler.

Exchange of medical ideas in a period of decolonisation

Evang spent time in the area around Bombay, now Mumbai. Photo: colourbox.

Evang worked in India for two months in 1953 and he was vice chair of a WHO ‘Visiting Team of Medical Scientists’ comprising of 15 high-profile medical experts. Teams such as these had previously been called ‘teaching missions’, the one-sided nature of which the WHO was keen to shed. Spending time in the Bombay and Madras areas, the aim was to exchange views with other specialists on an equal footing, but this seems to have been difficult to achieve. The WHO and the Indian government disagreed over the team’s composition and focus, causing considerable consternation on both sides. Despite personal frustrations, the experience certainly made a lasting impression on Evang, who underlined his strong admiration for the work of the Indian medical services in his letters, arguing that India was a “key country”. He also was impressed by the extensive family planning work that was being undertaken, but was puzzled by what he saw as the gap between the high standards of medical knowledge, and the general Indian population’s state of health. Thus, Evang’s exchanges with his Indian interlocutors show us that his belief in social medical ideas had, if anything, been strengthened by the trip.

By contrast, the first time Mahler came to India, in 1951, he was only a medical officer supervising efforts to control tuberculosis through a mass-vaccination conducted by the Government of India in close collaboration with WHO and UNICEF). He returned to India in the late 1950s for a WHO secondment in Bangalore, then becoming one of the architects of India’s national programme to combat tuberculosis. Not only was tuberculosis Mahler’s specialist field, it also exemplified a social disease intimately tied to the conditions under which people lived. The programme Mahler helped to design was integrated into the existing health service and based on people’s own perception of their medical needs, also known as the ‘felt need’ approach.

Experiences in India generating new ideas and strengthening existing preferences

The work of individuals such as Evang and Mahler in India opens a window on intellectual exchanges between Scandinavian doctors and their counterparts both in India and in the WHO, as well as how the WHO navigated complex postcolonial settings in the 1950s. Against this backdrop, ideas about social medicine still appeared to be very relevant during this time period. As well as learning from the expertise of the WHO and professionals from other countries, India can be seen as a site where new thought and political practice in health was in fact generated and/or developed.

Evang and Mahler’s experiences in India had an impact on their future careers as medical doctors and as health administrators, and influenced their work within international health. Evang was Norway’s Director of Health from 1938 to 1972. He chaired all Norwegian delegations from the first WHO Assembly in 1948 to 1972 and was also President and Vice-President at the second and fourth World Health Assemblies. Mahler had a significant career in the WHO and was its Director General between 1973 and 1988, his tenure being greatly associated with the ‘Health for all by the year 2000’ campaign and Primary Health Care strategies developed in the 1970s.

This article is based on two academic articles published with a short common introduction by the authors in the journal Medical History entitled ‘Negotiating social medicine in a postcolonial context: Halfdan Mahler in India 1951-61’ and ‘The complexities of postcolonial international health: Karl Evang in India 1953’. (Medical History. 2023; 67(1), p. 5-22 and p. 23–41).

Medical history can shed light on postcolonial settings

This article was published in response to readers' interest in the relationship between the Nordic countries and the Global South.

The New Nordic Lexicon