Edited by David Arnold (Oxford University Press, 1989).
In a National Convention on Mother and Child Care held a few years ago in New Delhi, a young doctor startled the audience, (which included some distinguished Obstetricians and Gynecologists), when he stated that the maternal mortality rate was nearly nil in a tribal area of Karnataka where he had been working for the past several years. Surprise turned to skeptical disbelief, when he went on to add that far from being the result of any “intervention” by himself or his voluntary agency, what he described was infact the situation that prevailed naturally in that area. In the discussion that followed the doctor stated that he had gone into the tribal area inspired by the work of Albert Schwitzer - he felt that he would be performing a very noble task by rescuing the tribals from disease, insanitation and ignorance. "I was soon to learn that they were quite capable of taking care of their health needs very well provided they were not totally deprived of the resources to sustain their way of life".
What the young doctor said conveyed a point that is increasingly obvious now. While initially it was only the Government that was the major dispenser of “aggressive development", increasingly the various voluntary agencies and movements for social change have also joined in the dissemination of this kind of development. The volume under review gives us some glimpses into the origin of this type of thinking and its roots in our colonial past.
Medicine as a Civilising Agent
For many nineteenth and early twentieth century European administrators, reformers and physicians the hazards and depredations of disease were an established part of a hostile and as yet “untamed” tropical environment. Africa, Asia, the America, were all seen to have their fatal and incapacitating diseases and only through the superior knowledge and skill of European medicine was it thought possible to bring them under effective control. In this view, European medical intervention represented progress towards a more ‘civilized’ social and environmental order (P.3)*. Florence Nightingale who was an important personality in the history of Britain's colonial medical policies, felt that the creation of a public health department for India was part of a mission to - "bring a higher civilization into India". She believed that introducing health care to the subcontinent, was not only “a noble task”: but was nothing less than “creating India anew". Similarly the missionary explorer David Livingstone felt that - "medicine offered a way to rescue Africa from its suffering state, ‘civilize’ it, and prepare it for the "blessings" of Christianity” (P.3).
Medicine and Imperialism
The volume under review contains a set of nine papers compiled by David Arnold. This is a part of the series - "Studies in Imperialism" which are meant to explore the ideology of Imperialism and its varied expressions. Three of these papers pertain to India - namely papers on the treatment of the European insane in British India in the early nineteenth Century, Small Pox and colonial medicine and the Plague Epidemics between 1896 and 1918. The other essays pertain to various other colonies such as New Zealand, Congo, Philippines, Rhodesia, etc. The colonial encounter (especially with reference to India) can be broadly divided into two phases - before and after the end of the 18th century. The Europeans who were there in India earlier came with an attitude of a people that had set out to observe and learn from a different civilisation which was famed for its riches and achievement and could possibly have much to teach in various areas including medicine. During this phase they had observed, studied and incorporated whatever they could of Indian Science and Technology (including medicine) into European practice and had also freely made use of individual medical practitioners to take care of medical requirements of the Europeans in India. Thus it is said that - "The Spanish in the Americas, despite their general disregard for the indigenous cultures, adopted a number of local medicines, including the use of cinchona ('Peruvian bark’) as a febrifuge; and, until the Inquisition intervened, the Portuguese in Western India used Brahmin 'pandits’, practitioners of Hindu Ayurvedic medicine, as their physicians. The English East India company encouraged its servants to rely on local rather than expensively imported medicines, arguing in 1622 that "the Indies hath drugs in far greater plenty and perfection than here" (i.e. England) (P.11).
This view was to change radically at a later date particularly after the beginning of the nineteenth century, A part of the reason for this seems to be that with the progression of the nineteenth century, ill health among the indigenous people fostered a growing European sense of innate racial and physical superiority in the Darwinian age. This led to the belief that what was biologically fittest was superior. In fact, while the disastrous health consequences of European presence are now well recognised it was often argued that medicine was a prime example of the constructive and beneficial effect of European rule. This was especially so by the close of the nineteenth century, when Europeans began to pride themselves on their scientific understanding of disease causation and mocked what they saw as the fatalism, superstition and barbarity of indigenous responses to disease (P.7).
What seemed to have been conveniently overlooked was the role that colonization had itself played in the declining health of the colonized. Even where some contact had existed before 1800 in Africa and Asia, nineteenth-century European commercial and political penetration and the creation of colonial infrastructures - roads, railways, systems of labour migration, military recruitment and civilian administration - broke through the coastal barriers and destroyed the quarantining effects that distance and slow land transportation had formerly had on the dissemination of imported diseases. The way in which the 1918-19 influenza pandemic spread along these interior lines of contact and communication in Africa - through soldiers and mine workers, through markets and railways stations - was a striking demonstration of the degree of European commercial and administrative penetration by the end of the First World War. Some diseases were transmitted directly by Europeans themselves. The spread of syphilis - known to sixteenth and seventeenth-century India as firangi roga, (i.e. the "European disease”) - was closely associated with European sexual contact (P.5-6).
There are several pointers in this volume to understand and lay bare the motivations for the organisation of colonial medical systems. This is particularly striking in the case of what has been discussed and outlined with respect to the treatment of the insane Europeans in British India. What was important was not so much the treatment of the disease or paying attention to the patient, but ensuring that the Europeans who fell physically or mentally sick were quickly institutionalised or sent back to Europe before the image of white superiority could become tarnished. Ill health among the colonized fostered the growing Happens sense of innate racial and physical superiority.
The Europeans in India were not a homogeneous community but were rather divided along lines of social class and national or regional origin, presided over by what has been labelled a “middle class aristocracy". This European elite, though mainly middle-class in origin, assumed in India an air of aristocratic exclusiveness, maintaining an ostentatious life-style and upper-class manners. The majority of Europeans, however, belonged to the lower classes. Their manners were often regarded as obnoxious by the European elite. It was argued that not only would their "low and licentious" behaviour tend to "vex, harass and perplex the weak natives", but that it would also be detrimental to the maintenance of British rule in India. A ‘spectacle’ such as "needy and reckless Europeans wandering about" the country was seen to be “humiliating to the British character" and it was consequently urged that the government make arrangements by which "fellow country men however degenerate, may cease by this public and humiliatory exhibition of these vices to dishonour here the country from which they spring”. The oft-asserted “superiority of the European character" and the proclaimed enlightened spirit of British civilization were considered vital to the legitimacy of colonial rule. The colonial ideology of European superiority undoubtedly contributed not only to the consolidation of British rule over Indians but also to the policing of Europeans within India (P-30).
Vaccination against Smallpox
However, it is the chapter on Smallpox and efforts to control it by the colonial authorities which gives an interesting insight into the encounter between the long held traditional beliefs and practices and the alien order that was imposed upon India. What is of great interest is that this encounter shows various characteristic features which makes it the fore-runner of a series of such later date encounters. In fact, it appears as if, it is this same encounter which is being repeated right down to this day in the area of Public Health and some of the official reports and documents regarding the reaction of the general public, its "inertia", “resistance to (Government sponsored) change” etc. read very much like current day reports!
To many nineteenth-century British medical officers, smallpox was "the scourge of India”. Reputedly “one of the most violent and severe diseases to which the human race is liable”, smallpox was held responsible for "more victims than all other diseases combined", outstripping even cholera and plague in its "tenacity and malignity". Several million deaths in the late the nineteenth century alone were attributed to its destructive powers. Fatal in a third of all cases, smallpox also resulted in the permanent scarring and disfigurement of many of its survivors : one estimate blamed the disease for three-quarters of the blindness in India (P.45). A major cause of Indian mortality, smallpox was greatly feared among the Europeans in India. Before 1800 British residents had observed the Indian practice of inoculation against smallpox using the technique of variolation. This has been described in great detail by British observers such as J.Z. Holwell in Bengal in 1767.* It was under these conditions that the British started introducing the vaccine developed by Jenner into India around 1807. In a situation where smallpox was almost universal, variolation was practised on a scale the British were unable to match until late in the nineteenth century. In 1871, there may have been twenty times as many variolators as vaccinators in northern Bengal. In 1873, it was reckoned that in one district of Orissa alone a hundred tikadaras (i.e. traditional inoculators) were at work, carrying out 25,000 inoculations in a single season. A "vaccine census” conducted by the Government of Bengal in 1872-3 revealed that out of 113,015 people examined, 57 percent had been inoculated, 15.23 percent had survived an attack of smallpox and so had acquired natural immunity and 10.42 percent remained unprotected while but only 17.23 percent had been vaccinated. Other estimates place the proportion inoculated even higher at 70 percent or more of the population of mid-century Bengal. Variolation was certainly not so widespread elsewhere in India, but the figures give some indication of the size of the task that colonial medicine faced in trying to oust an indigenous rival (P.50-51).
The description of the detailed and careful procedures followed by tikadars suggested that they were fully aware of the contagious nature of the disease. He, (i.e. Holwell) said that they used various matter collected the previous year - "they never inoculated with fresh matter, nor with matter from the disease caught in the natural way, however distinct and mild the species" (P.51). This implied that they deliberately propagated an attenuated form of the virus in order to induce a moderate reaction. After 1802 however, with the introduction of vaccinating into India, European physicians started taking a far more critical view of the Indian practice.
Most Europeans in nineteenth - century India held a "secular" view of smallpox and in the later decades, took readily to the germ theory of disease causation. For the majority of Indians however, smallpox bore a strong religious significance. But to nineteenth century British doctors, missionaries and administrators such beliefs were rank superstition, evidence only of Indian apathy and ignorance. From a position of such hostility and contempt, the British were ill-placed to understand the tenacity with which Indians clung to their faith in sitala. The European community confidently anticipated that Indians would take up with gratitude, the discovery which Europe had already found to confer "such inestimable benefits”.
Vaccination was soon to offer a welcome opportunity to win good will from the people and give “fresh proof of Britain’s humane and benevolent intentions". Such expectations soon evaporated as Indians from the outset proved reluctant to submit to vaccination or to take up the practice themselves. In some places, as in the villages of Madras people gathered to drive away vaccinators sent to “diffuse the benefits of vaccination among them". Such a negative response confirmed in many Europeans an unfavourable view of Indian. Shoolbred in Bengal in 1804 called Hindus "naturally averse to all innovation" and denounced the labouring classes as “stupid and insensible" for failing to recognise vaccination’s "inestimable value’. Duncan Stewart, Superintendent-General of Vaccination for the province in the early 1840s, likewise blamed Hindu gratitude and ignorance, especially “the trammels of a degrading religion, by which their thoughts are chained, their reasoning faculties hoodwinked and their mutual affections thwarted". Even “the most simple, obvious and unquestionable temporal advantage" was, he claimed, unacceptable to Hindus if it entailed "the slightest deviation from ancient usage”. Such sentiments persisted well into the second half of the century. In 1878, for instance, the North-Western Provinces" Sanitary Commissioner attributed the limited impact of vaccination to the “natural apathy of the people, their disinclination to accept a new thing, and their unreasonable religious beliefs or caste prejudices" (P. 53).
To this reviewer what is remarkable about the above narration is not any insight that it may provide into the working of British India but rather that all this has a very "familiar" ring about it! These statements bear a remarkable resemblance to analyses about various current day efforts in Health Care. Well over a century later we find the same old - "Apathy, disinclination to accept a new thing, unreasonable religious belief" etc. being listed as reasons for our lack of progress and failure to "catch up with the West".*
Many of the "problems" of today seem to have been encountered in the last century - even the responses have been worked out earlier or so it seems. Today, it is quite common place to observe that much of what is imposed on our people is a totally alien product that has no roots or connection whatsoever to what goes on in the community. This was also said of vaccination. One of the greatest objections to vaccination was its secularity. There was no dietary or ritual preparation as in variolation; no invocation of Sitala; no priestly ministrations to provide reassurance during and after the operation. Such an “irreligious" act was thought to be offensive to the Goddess and was certainly out of keeping with the religious conceptualisation of disease and medicine among Hindus and Muslims alike. There was, however, some room for com-promise. Despite the disapproval of their superintendents, some Indian vaccinators (especially those who had formerly been tikadars) diluted the raw secularity of their work with a few Sitala prayers and rituals (P.56)! Such desperate efforts to cloth the modern medical system in the idioms of the Indian are still to be seen in several ways. For example, a young doctor known to this author from a prestigious medical institution said that he and his colleagues have taken to feeling the Nadi (the pulse of the patient in the method of a traditional Vaidya) particularly with patients from rural backgrounds in order to inspire trust and confidence.
Also very similar is the tendency to blindly increase the intensity of efforts (setting up of “targets") with no conception or understanding of reasons for the failure. The “intensive The vaccination programme” of the Bombay Presidency was one such example. A much more ambitious programme was devised in Bombay, which was meant to carry vaccination to the doors of the people who were said to be "too lazy, too poor, or too ignorant to see it" (P.57). But the Bombay system had its limitations. There were frequent reports of vaccinators submitting false returns, exaggerating the number of vaccinations actually performed, or being too illiterate to fill in the forms correctly (P.57-58).
The other familiar ploy is to use whatever is left in the traditional sector which still commands respect and credibility to carry the “modern" message. Thus in Bengal, where the challenge from variolation was strongest, the government adopted a series of expedients to try to supplant the rival practice. Soon after vaccination was first introduced into the province, attempts were made to recruit some of the leading tikadars as government vaccinators and persuade Brahmin pandits to issue public declarations that there was nothing in the Hindu sastras or sacred texts that prohibited vaccination or made variation a religious duty. This has a very familiar tone - it seems to be exactly on the same lines as the use of the dai (traditional birth attendant) to impart various "messages'' such as family planning etc*. This ploy had little effect however, and in Calcutta, the principal seat of British power in India, the number of variolators appears actually to have increased during the early nineteenth century! (P.57-58).
The Nature of Colonial Medicine
The book does offer some valuable pointers to understand the nature of colonial medicine. To begin with sometimes what happened in medicine itself was just incidental. Medical institutions and knowledge were just tools of an imperial policy one of the proclaimed purposes of which was to “educate the natives in European ways”. In this process, medicine was just a means. As one of his first acts the Governor of New Zealand Sir George Grey in 1846 set up hospitals in New Zealand that were opened to both European and Maori patients. In the admission book it is recorded with evident pride that an early patient refused "to go out in the blankets in which he was admitted and has bought a new suit". The Governor said that hospitals would encourage “civilisation” (P.77-78). Similarly, the missionaries hoped that their hospitals would inculcate Christianity. As Bishop Smythies of the Universities Mission to Central Africa testified in 1893: "there are some mission fields in which only doctors seem to be able to gain any great influence. There is a fantastic hatred to (sic) Christianity, which can only be broken down by sympathy shown for the sufferings of the body.... together with the power to alleviate them. It seems as if it is only through medical work... that an opening to the hearts of these people can be found" (P.17).
Over and above any specific technical or scientific input, modern medicine seems to have had a deep impact at the very approach that the colonized societies have adopted to understand and treat disease. In the closing years of the nineteenth century, medicine became a demonstration of the superior political, technical and military power of the West, and hence a celebration of imperialism itself. It gave expression to Europe’s faith in its own innate superiority, its mastery over man as well as nature. Medicine registered the imperial determination to reorder the environment and to refashion indigenous societies and economies in the light of its own precepts and priorities. Medical intervention impinged directly upon the lives of the people, assuming an unprecedented right (in the name of medical science) over the health and over the bodies of its subjects. Whereas In the pre-colonial past, health and medical care were matters for individual initiative or at most communal effort, under imperial rule they become part of a wider process of state regulation and centralized control.
The Indianisation of medical personnel probably facilitated the eventual acceptance and as- simulation of what had once been exclusively the white man’s medicine (P.20). The position of western medicine during the Afro-Asian struggles for independence was often ambiguous. On the one hand, some nationalists looked to a revival of indigenous medicine as part of a rediscovery of their own cultural roots and rejected the West's alien therapeutics. On the other hand, indigenous practitioners of Western medicine were often influential members of the nationalist middle class and colonialism was condemned for its stringiness in bestowing the benefits of Western medicine (P.21). This ambivalence has been "resolved" in a peculiar way today with indigenous medical systems enjoying ostensible political support which amounts to very little substantial support, while the modern medical system corners most of the state support and patronage. This perhaps had a large effect in terms of alienting entire communities from government approaches that seem to have very little to do with indigenous ways of seeing and doing things.
The author has made it clear that his effort is part of a rigorous academic exercise of performing -"Studies in Imperialism". After outlining in graphic detail the disastrous health consequences of the European presence in the colonies, the author hastens to add. "It may be that the spate of epidemics which afflicted many societies following the white man’s arrival have assumed significance simply because Europeans were on hand to record them. Many earlier epidemiological and ecological catastrophes may have preceded them without finding their way into any surviving historical account’’(P.5). He thus reassures his readers (and perhaps himself), of his “academic objectivity".
Whatever may be the goals of the author, for us the value of book lies mainly in that, it traces the roots of much of the current day attitudes to public health and policy making to the colonial period with which it seems to be in essential continuity. It lays bare the basic designs and intentions that motivate the modern medical systems relatively free from the bright "glare" of its comparative more recent and much publicised technical achievements and therein lies its great value.
A.V. Balasubramanian
PPST Foundation
Madras
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