Health hath no fury: Part I
Public health and the value of human life in 19th-century India
The Indian past has never been more political. This newsletter questions the traditional (male, Hindu, dominant-caste, ‘secular’) orthodoxies presented in Indian schools’ history curricula. We investigate historical narratives by consulting sources and perspectives outside established media, and we review some of the most interesting academic books and articles currently languishing behind university paywalls.
There are no definitive answers here because we want to invite as many people as possible to an alternative conversation — on what it means ‘to do history’. If nothing else, we hope to convey that history matters, and to spark our readers’ interest in undertaking historical enquiries of their own.
Write to us with your thoughts and feelings at indianparallelcampaign@gmail.com!
Content-warning: the following piece discusses themes (covid-19, illness, death) that some readers may find distressing.
Hello again, friends —
We’re sorry to have disappeared on you for a while, but after what happened in India these past few months, we found ourselves trapped in a place beyond language. How could any words, shouted or sung, passionately spoken or clinically pronounced, remain meaningful in the face of so much relentless, cruel, preventable death?
No matter how you imagine this community, there was no immunity, no waking up from our shared nightmare. Unlike some others, the republic of death is truly democratic and secular — and sovereign over us all. And history? History has no oxygen cylinders to offer.
How can our national psyche even begin to come to terms with this kind of catastrophic stress? When it comes to individuals, mental health professionals sometimes recommend a three-step coping strategy — and given the visceral way in which the political has proved personal for many of us, perhaps this strategy can be extended from the individual to the collective.
The first step: trying to manage and process negative emotions — anxiety, anger, helplessness, despair. This, we believe, is the monumental task of art. Music, film, literature, painting: whatever its medium, art will prove critical in helping us process our collective distress and grief.
Detail from the Funeral and Cremation of Rama's Father, Dasaratha. Folio from the Bharany Ramayana series from 1775/1780 India, Pahari-Region, Guler or Kangra. Source: Kavita Singh in Scroll (it’s a lovely article, do read it!)
The second step: addressing the direct problem, the immediate cause of the stress. This was, and will have to continue to be, the tireless work of our healthcare providers, relief organisations, frontline workers, epidemiologists, civil society, journalists, activists, and many, many others — all of whom have been unceasing in their efforts to help us deal with disease, gross governmental negligence, and policy failure. It will also, eventually, require the discerning votes of Indian citizens. (In the meantime, you might continue to support mutual aid efforts here.)
The final step is appraisal. This means understanding (and challenging!) the structures and systems — along with the values and thought processes that underpin them — that have shaped both the contours of the problem as well as our response to it.
This appraisal, a true reckoning, is the work of history.
Yet, it feels like we’re at a point where history, like language, utterly fails to encompass human suffering. This is not the first time that our rivers have washed up corpses — and being confronted with this lack of change in our public health system, the haunting familiarity of the past, feels shattering.
But former Union Health Secretary K. Sujatha Rao, confronting this very lack of change in her (scathingly-titled) book on India’s health system, Do We Care?, makes the case for history nonetheless. The system, in her telling, is not the mere result of its policies, but also the product of its historical traditions — and how they have shaped our cultural, political, and social contexts, as well as our values.
Following her cue, we want to try and understand whether anything in our history can help make sense of India’s colossal public health failures — to seek some sort of explanation. Is this system really malfunctioning or is it just working the way it was designed to?
But history, at its most powerful, at its most humbling, makes us aware not just of the institutions that shape us — and fail us — but also of ourselves, and our susceptibility to forget. Beyond statistics, dates, numbers, and dry accounts of events, history makes us do the critical work of remembering — work that many people, past and present, have been too tired, too jaded, too cynical, too sad, too persecuted, too culpable, to do.
As the tweets and texts vanish into archival ether, as each ragged breath recedes, we are already beginning to forget. It’s July and we’re back to acting like nothing ever happened. Now that the heartwrenching crises of April and May seem more remote, it is tempting — maybe even kinder to ourselves — to forget. But we have forgotten before, and condemned ourselves to repetition. We’re hoping against hope that maybe this time around, in reckoning with our past, we may be able to learn from it.
This is going to be a split issue. Here, in Part I, we’ll start in the 19th century, to try and understand the basic assumptions on which the public health system in India came to be founded. How did the colonial idea of India and its people — as a ‘tropical observatory’ for medical and administrative experimentation — interact with existing indigenous systems of medicine?
We’re feeling so exotic
From the very beginning, India, in the British imagination, was a dangerous, even deadly, place. Disease appeared as a most insidious and intimate form of resistance against the colonisers — who envisioned themselves as fighting a constant battle against everything in their environment from heat to mosquitoes (and elephants). Nevertheless, the alien space of India had its own unique value — it was a place where diseases like malaria and leprosy could be studied more effectively, where hypotheses could be tested upon subject populations, and where path-breaking medical and sanitary discoveries could be made.
Alarming situation! An elephant running wild with Lord Aukland in its trunk. Coloured lithograph by H.B. (John Doyle), 1843. Source: Wellcome Collection
Starting with the surgeon Francis Buchanan-Hamilton’s 1807 study of Bengal, the East India Company commissioned several ‘medico-topographical’ surveys that combined descriptions of climate, environment, and wildlife with the diets, diseases, and physical condition of Indian people. This reflected not only the influence of climate-based theories of medicine, but also the position of medical practitioners as state servants first, scientists second.
By the 1830s, as the British presence began to feel more secure and officials grew ever more critical of Indian culture, the presence of endemic diseases in India began to be seen not just as an environmental problem, the result of a climate viewed as fundamentally inhospitable to white bodies — but also as a moral problem. It was the people’s morals that were in question, of course, not the state’s. As the historian David Arnold put it, “India’s pathogenic environment had been stretched to include social and cultural idiosyncrasies.” The comparative slightness of their bodies; vegetarian diets; crowded homes, child marriages, religious fatalism, and caste customs: all were cited as evidence that Indians had only themselves to blame.
The British struggle to maintain authority and control over India was not just a question of defending themselves against the environment, or political conspiracy and rebellion, but also against sickness — and, since most diseases were understood to be caused by filth, the assumed dirtiness of Indians themselves.
The Sanitary Commissioner for the Government of India reported in 1894 that the British in India would “never be safe so long as the native population and its towns and villages are left uncleansed to act as a reservoir of dirt and disease”.
The historian Rajnarayan Chandavarkar has pointed out that on this view, there were two possible options available to the British.
The first might have been undertaking a massive programme of sanitary measures. But that was considered too big, and expensive, a problem to take on. Town planning and public health were simply not imperial priorities. Rao notes in her book that, from 1889 to 1894 — basically the same time as the Sanitary Commissioner was reporting on India as a reservoir of dirt and disease — the British spent barely 0.15 per cent of state revenues on public health. Urban local bodies neglected sanitation and sewage disposal, choosing to instead allocate funds towards ‘cosmetics’ like street lighting.
Besides, in the aftermath of the 1857 Mutiny, the British considered it too politically risky to undertake any reforms that might be seen as meddling in the habits and customs of the natives. In Chandavarkar’s words, “they knew only too well [that] the key to enjoyment of their political kingdom lay not in social engineering but in salutary neglect”.
This worked well, too, with the prevailing medical racism: the eugenic notion that some types of people — because they are biologically and morally inferior — are more prone to disease, and both desire and deserve less care.
Initial interest in local forms of medicine had long given way to a conviction that non-white peoples were too superstitious and ignorant to be worth spending that kind of money on anyway.
A keen awareness of danger faded into an apathy and fatalism — disease was innate and natural to the subcontinent.
And as the Sanitary Commissioner for the North-West Provinces said in 1885, colonial officials could not hold themselves to blame: “if natives chose to live amidst such insanitary surroundings, it was their own concern”. (This view, and the tremendous mortality of Europeans in India, is arguably one of the major reasons why we never became a white settler colony like South Africa or Australia.)
A man climbing a coconut palm (Cocos nucifera L.) which stands by a banana plant (Musa sp.), in a waterside setting in Bombay, India. Engraving by J. Shury after J. Forbes, 1768. Source: Wellcome Collection.
The second, cheaper, option would have been segregation — rigorously maintaining social distance from native towns and their inhabitants. But India was too turbulent to be managed from afar. Besides, crucially, the army — which employed the overwhelming majority of British residents in India — could not possibly have functioned effectively without native troops.
This is why, barring its early environmental explorations, the European medical profession in India developed largely to preserve the strength of the occupying British military.
Approximately a hundred thousand British soldiers died in India in the first half of the 19th century from disease. The mortality rate between 1800-1856 was estimated to be about 69 per 1000; and of the 10,000 British who died during the 1857 Mutiny, only about 500 actually died in the fighting.
Given that it cost £100 at the time to recruit, train, and transport a single soldier, losing troops to malaria, cholera, typhoid, diarrhoea, dysentery, or syphilis in such numbers was considered unacceptable. Reports abound with almost-obsessive references to the death-rates of soldiers, and discussions of how to attain ‘20 per 1000’, or in peacetime, even ‘10 per 1000 per annum’.
And so by the 1860s, military cantonments were at the vanguard of health and sanitation practices. Hospitals were established in these cantonments, as well as in large civil stations, that were manned by qualified doctors and nurses — operating as privileged enclaves to exclusively serve the troops’ needs.
The state acknowledged no obligations to the health of the population at large. It was apathetic except upon matters that affected Europeans or interfered with the value of investment in troops — at which point that apathy quickly turned into the coercion and intimidation of natives who didn’t know what was good for them.
The 1894 Sanitary Commissioner’s report contains a graphic example of this logic. It points out that of the 70,642 British soldiers present in India, 63 per cent had contracted syphilis during their period of service. Admitting the impossibility of preventing troops from consorting with Indian women, it argues that the authorities in India should have the power of compelling such women to submit to treatment in hospital — recommending a compulsory lock hospital system if necessary, in which sex workers would essentially be permanently imprisoned for the use of soldiers, because a “woman under such circumstances is surely an acknowledged source of danger”. Her own health and wellbeing, of course, were entirely beside the point.
A sepoy in the service of the East India Company, with a woman (courtesan?) on the right. 19th century. Source: Wellcome Collection
The only other time the state concerned itself with the health of the native population was when it needed a ready supply of bodies to conduct medical experiments upon.
Prisons, in particular, offered the chance to conduct trials of new treatments upon heavily controlled populations of Indians. A jail sentence could quite effectively be a death sentence: in the mid-1800s, up to 25% of prisoners in Indian jails died each year. They were often the only reliable source of unclaimed cadavers for surgeons to study.
By 1855, Bengal had made the vaccination of prisoners compulsory, in part to enable doctors to test vaccine efficacy. In 1907, doctors in the Punjab experimented with using quinine as a prophylactic, administering it to prisoners in advance of one of the worst malaria outbreaks on record. (They proclaimed the success of their experiment when only 10% of prisoners fell ill, as opposed to roughly 90% of the general public outside.)
And so, by the end of the 19th century, health in India had been fundamentally yoked to metrics like economic productivity, state revenue, and profit.
The very foundation of the Indian public health system was bound up in preserving and extending state power because — as Arnold has powerfully argued in his monumental work on the history of medicine in colonial India — the Raj was interested in its subjects’ health only insofar as their bodies could be used as a site for the construction of its own authority and control.
But if all of this followed a coldly colonial logic of the value of human life, it also found some fertile ground within South Asian society itself.
A pox upon you
“On some lucky day of the month of Phalgoon and Chaitra (February to April), the Tikadars inoculate the healthy boys and girls, by thrusting or punching their arms with a pointed iron instrument, and infusing the pus previously collected in a cotton, from the good sort of ripened natural smallpox; and cause them to bathe and eat chilly and juicy food, repeatedly, until they excite a fever, which comes on violently in 6 or 7 days, accompanied by smallpox.
The fever goes off in 3 days, when all the pocks are visible, which are sprinkled over with a little water on the 5th day, to make them rise up, and then stained with bruised raw turmerick on the 7th, in order to make them ripen well the sooner. They are afterwards broken with the thorn of a shrub…this treatment terminates, and the patient perfectly recovers in three weeks; during which time, all the patients of a family are kept in a separate room, with great care, without allowing the approach of any unclean person; and also their parents and domestics live abstemiously, and worship the goddess "Situla", which presides over the smallpox…the Tikadars are remunerated according to the circumstances of the parents or patients; but they commonly charge the poor people one or two Rupees per each head...”
- Radhakanta Deb, a Bengali zamindar, describing an indigenous method of smallpox variolation (an early type of vaccination), in 1831
The body has often been an object of disdain in several South Asian traditions — many philosophical texts decry its impurity, its transience, its grossness. Manual labour, the work of the body, is degrading. The rites of death exist to free our spirits from these unworthy vessels. Bodies are meant to be expendable — and some always more so than others.
In the centuries before the invention of the microscope and the germ theory of disease, the ailments of the living could often only be addressed by interrogating the dead. But although some early Ayurvedic texts approved of dissecting corpses for the purpose of diagnosing and treating disease, this kind of empirical, observational work upon the body came to be regarded with such revulsion by South Asian elites that the introduction of European medicine to India was met with outright hostility and disgust.
Only members of the most oppressed castes — such as the Doms, whose customary role as funeral workers, executioners, and midwives made them intimately familiar with dead and diseased bodies — could be found to help European surgeons in hospitals. When a dominant-caste man, Pandit Madhusudan Gupta, condescended to perform a human dissection for the first time at Calcutta Medical College in 1836, the event was celebrated by the British with nothing less than a fifty-round gun salute as a triumph of rationality over superstition.
And yet, this well-trodden image of foolish and ignorant Indians not knowing what’s good for them is as much an image manufactured to excuse state failure as it has echoes in reality. In truth, Arnold argues, there were powerful and commonsensical motivations for Indians to suspect that the medical authorities of an occupying power did not act in their own best interests.
People responded to the projected ascendancy of European medicine in the colony not with some monolithic backlash of religious fervour, but with “onion layers of resistance, accommodation, participation, and appropriation”.
As the fascinating account of smallpox variolation from the start of this section illustrates, moreover, for all Indians’ squeamishness about dissection, the colonial state did not encounter a blank slate: indigenous systems of public health had developed intricate paradigms for treating disease.
One of the most fascinating aspects of these systems is that they were not ‘secular’: they regarded illness not as a phenomenon to be eradicated — something almost impossible in environments where a disease has become endemic — but rather as a divine force to be managed, appeased, and integrated into everyday life. This made sense at the time: in 1869 it was estimated that 95% of the population of the north Indian Doab was exposed to smallpox at some point in their lives. The social reformer Sir Sayyid Ahmad Khan remarked that smallpox was “the inevitable bridge which every child has to cross before entering into life...recovery from the disease is considered second birth.”
The folk goddess Sitala, deity of epidemic disease. Source: Wikimedia
However, while the vast majority of South Asians continued to privately patronize indigenous kavirajas, hakims, and vaidyas well into the twentieth century, one rupee per smallpox treatment was not cheap; these systems created and reinforced hierarchies of protection, access and bodily worth just as readily as medical racism did.
As enclaves of British power grew across India, and authorities moved to aggressively suppress indigenous practices even while they neglected to invest in any meaningful alternative public health system of their own, the gaps in both indigenous and European health systems were exposed.
Given each system’s notions of the relative value of human lives, it was those considered most expendable, those considered least worthy of medical attention, who fell through these gaps.
This was especially apparent in the British approach to the work of the variolators, or Tikadars, who were crucial to controlling smallpox in the countryside (this was at least partly driven by European doctors’ antipathy to oppressed-caste Tikadars, like Malis and Napits, whom they feared would damage the reputation of their own profession). Variolation was formally banned as early as 1804; by the 1890s, public health officials had effectively driven the practice underground — encouraging millions to avoid seeking formal treatment altogether, and further undermining low levels of public trust in state-sponsored medical programmes and vaccination.
Moreover, vaccination technology at the time was in some ways even more unpleasant than variolation; it involved using fresh pus from the arm of a deliberately infected child, leading the government to essentially requisition thousands of poor and oppressed-caste children by force and drag them from village to village with lacerating open wounds. Dominant-caste Hindus frequently refused to let this offensive form of bodily pollution occur, and when the arm-to-arm method was replaced by the lymph of young cows as a concession to their sensibilities, elite opposition instead reached a fever pitch.
Having decimated variolation, but now worried about the outcry and the possibility of inviting resistance, the state settled into its familiar but deadly apathy, even while smallpox killed a hundred thousand Indians each year and left millions more scarred and blind. The British were convinced that it was only by persuading the most privileged of Indians to get vaccines and embrace Western medicine that the message would percolate down to the ignorant masses — and so contented itself with a strategy of pursuing “leaders” and “natives of rank” exclusively and at the expense of more vulnerable groups.
Eventually, many middle-class households came to accept vaccination as “either desirable or unavoidable”. However, Arnold notes, they “treated it exactly as they had variolation, choosing an auspicious day for the operation, observing the old rituals and dietary taboos, employing a priest or paying the vaccinator to invoke the goddess of smallpox, and thanking Sitala Devi rather than Jenner Sahib for the child's safe passage”. It was an uneasy mixture, and its contradictions seem to have echoes for us in today’s India, where thali-banging and “go Corona go” exist in tandem with technocratic dreams about drone-delivered injections and digital vaccine portals.
Ultimately, the insincerity and contempt of the expanding state’s approach to physical well-being, and its shifts between apathy and coercion as dictated by the needs of political expediency, interacted uncomfortably with the underlying notion — both colonial and indigenous — that medical treatment was a form of largesse, a privilege, reserved for the ‘worthy’ rather than something that everyone deserved and was entitled to.
Together, we think they came to be institutionalised in a system where ‘public’ health and science existed to serve the state, not the people — a system that valued human life only in terms of instrumentalities, abandoning those it did not consider valuable or strategically worthwhile, often the most vulnerable in society, to the whims of fate.
It was a system that, rather unsurprisingly, led to catastrophe. In Part II, we’ll explore how this system coped with two of the most devastating pandemics of the early twentieth century —and why Independent India chose to accept this legacy in the ways that it did.
Until next time,
Excellent exposition and analysis