Abstract
This is a book that testifies to an immense amount of labour. The author must be congratulated for the wide variety of sources consulted, and of course all the hours spent in the archives. Successive chapters are dedicated to the institutionalisation of allopathic medicine and the interaction of biomedicine with indigenous systems of medicine, colonial public health policy, cholera and plague epidemics and policies, malaria and small pox epidemics and policies, followed by a conclusion. In post-modern times, the attention to data here is wonderful and necessary. But there is also a fundamental weakness here: gathering data is not enough. This weakness is not that of this author alone but of a school of history-writing on health. I shall elaborate upon this during the course of this review.
One of the most remarkable things about the last century was the extraordinary improvement made in human health around the globe. India commenced the twentieth century with an average life expectation of 22 years in 1901—the life expectation of early agricultural societies. This was a terrible indictment of colonial rule and a reflection of the levels of hunger and infectious diseases—two of the horses of the apocalypse—that haunted us.
Today, of course, we live a lot longer. Conventional wisdom is that this is a result of dazzling advances in medicine. Wonderful new drugs, investigations and their increasing availability to the population are said to be the ‘magic bullets’ that brought about this miraculous transformation, vanquishing germs and microbes. Such a germ-centric history lies at the heart of the history of public health both in India and the West. 1 This is partly due the historiographic conflation of the history of health with that of medicine and disease. This seriously distorts the understanding of health and its determinants, with profound policy implications.
The history of health is, of course, the history of the remarkable decline of infectious diseases. It involves tracing secular trends in the exposure to diseases (the agent factors), and human resistance to infectious disease (the host factors), in a changing complex environment, social and biological (the environmental factors). Together, these changing, interacting, evolving systems constitute the epidemiological triad.
Turning the spotlight on germs and diseases has, however, left us in the dark about the other determinants of diseases. What also occurred at the same time is a shift in the concept of health itself, from one encompassing broadly social factors—availability of food, regularity and security of employment, wages, hours and conditions of work, the structure of the family and of work for women, leisure time and care of infants and children, a more nebulous sense of solidarity and community—to the absence of diseases. 2
In this broader view of health, a range of social and economic factors, interacting with the environment, acted to determine the prevalence of diseases in a population. In contrast, the Chadwickian revolution narrowed public health to water supply and sanitation, while the germ theory narrowed perspectives further. By restricting disease causation to a single cause, germs, the social determination of health was eclipsed. Together with the behavioural approach to health, these factors profoundly shaped how public health workers and historians approached health.
There have been exceptions of course. Zinsser’s classic Rats, Lice and History comes to mind. 3 Rich with epidemiological and historical insights, this work excavates the history of typhus, its impact on society and indeed on the tides of history, tracing the decline to a broad range of socio-economic factors. In other words, in the West, there has been some work that has looked at the broader determinants of health.
When we turn to India, the situation is very different. It is largely due to the overwhelming influence of that guru of modern demographers, Kingsley Davis. In his classic, The Population of India and Pakistan, he argued that the gift of death control technologies from the West was responsible for the decline of the death rate in India, commencing in the 1920s. 4 He was referring, of course, to the role of quinine, and later of DDT, in the control of malaria. Davis’s argument was fuelled by Cold War concerns—he was convinced India would become a communist country should her population continue to grow, and he felt population control was a solution to that.
Davis’s arguments went somewhat like this. In the West, the death rate had come down, and, following that, the birth rate had declined due to socio-economic change. In India, on the other hand, the death rate had declined due to public health intervention. Indeed socio-economic change was notoriously difficult in India. A population bomb therefore loomed. This could only be defused by birth control technologies.
So confident was he with his assertions that he felt no need to prove them. Picking up from Davis, the Cambridge Economic History of India also assumes that the post-1921 decline in the death rate was due to public health measures. 5 While the plague somewhat mysteriously declined, cholera and small pox were vanquished by public health intervention. This is how academic orthodoxies are created.
One significant problem, however, is that there is very little empirical data to substantiate these claims. Commencing in the 1920s, this decline of the death rate, a major proportion of which was due to a decline in malarial deaths, preceded by at least three decades of the launch of the malaria eradication programme in the 1950s. Further, over the same period, mortality due to other diseases, for which there were no preventive measures or specific therapies, also declined. These included diseases such as cholera and small pox. 6
Sumit Guha dismisses Davis’s explanation as ‘certainly not applicable to India between the Wars’. 7 Sheila Zurbrigg’s work on malarial mortality in Punjab between 1868 and 1940 reveals a most remarkable decline, commencing around 1908. 8 In the forty-one year period between 1868 and 1908, malaria deaths were predicated upon not just rainfall, essential for malaria transmission, but also food grain prices, soaring in years of soaring food grain prices. What hunger did was to make diseases lethal. Malaria deaths dropped in the period between 1909 and 1941 to less than a third of that earlier. This drop was accompanied neither by a decline in epidemiological indices of malaria transmission, in rainfall and flooding, nor in entomological indices. More significantly, there were no significant preventive or therapeutic measures widely applied. Indeed, per capita availability of quinine was so low as to rule this out as an explanation. What did change was the incidence and severity of famines and acute epidemic hunger.
In other words, Zurbrigg showed us, with data, the broader determinants of malaria, completely disproving the Kingsley Davis hypothesis. Yet Gagandip Cheema repeatedly invokes Davis. On page 78 she refers to the success of selling quinine through post offices, leaving us to infer this may have been responsible for the decline of malaria. On page 278, she states this explicitly: The decline in malaria mortality rates was ‘due partly to abundant availability of quinine and partly to various administrative measures’. The astonishing fact is that the author has also read Sheila Zurbrigg.
In the case of cholera, she notes, ‘A sharp decline of cholera mortality among the hospitalised patients was the vindication of the efficacy of the improved medical technology’ (p. 76). Again, a Davisesque pronouncement with not a shred of data to support it. Indeed, the data indicate that hospitalisation and treatment actually increased cholera mortality leading to ‘cholera riots’ all across Europe. 9
What becomes clear is that through all the mountains of work Cheema has put in, she does not question the assumptions on which many of these are based. She is a serious scholar of history, but it becomes a bit difficult to take her seriously when she invokes David Fraw(d)ley to make the case for indigenous systems of medicine. But then, we live in times when the difference between history and myths is being blurred, not least by David Frawley. The book would also have been helped by better copy-editing.
But the sheer amount of data collected and documents accessed make this book useful to read for other students of history and public health. It will show us that while facts are important, indeed necessary, we also need a framework to analyse them.