The coronavirus pandemic has elicited all sorts of responses around the world. As it is the first world-wide epidemic since influenza in 1918-19, there was little historical or institutional memory of dealing with such a large-scale medical emergency in large parts of the world. In the history of South Asia, epidemics and pandemics are not a new phenomenon. In fact, in the past, there was almost an expectation of an epidemic every couple of decades, and certain diseases, like the Indian-origin cholera, came back with regular frequency and destruction. The 1817-21 cholera epidemic is said to have led to the death of nearly 18 million people in India, while the bubonic plague from 1896-1901, had caused the death of over ten million Indians by its end.

The lockdowns imposed by the Pakistani and Indian governments, and to a lesser extent the Bangladeshi and Sri Lankan governments, have prompted numerous comparisons with the past. While some have compared the lockdowns with the drastic measures of 1896, others have lamented the continued under funding of medical institutions across South Asia, calling it ‘colonial.’ Given an uncertain future, the past has become the main avenue of inquiry, comment and judgment.

But before we revisit how India dealt with several epidemics in the past, let me flag some very common fallacies in such an endeavour. First, we must not engage with the issue (or any issue historically), from the present. Every issue needs to be understood in and from its context. For example, in 1918-19, no one in the world had a clue about influenza, how it was caused, spread and cured. A hundred years later we know quite a lot. Thus, blaming governments (either in India or elsewhere) for not doing the ‘right’ thing, or for not taking the ‘right’ decisions, is wrong. Just as in the current pandemic when we know very little about the coronavirus, most governments actually do not know for sure what the ‘right’ strategy to deal with it is. Some governments have therefore imposed a curfew-like lockdown, while in other jurisdictions it is a lot more relaxed, while some have only restricted certain types of movement. Since every government is trying to understand and devise a strategy, there is no single ‘right’ or ‘wrong’ strategy here (until clearly proven). The ‘fog of the pandemic’ if one can appropriate a metaphor, is only cleared much later and only then can one actually understand the phenomenon.

Secondly, one must not approach such issues (or any issue) with a perfect solution in mind and then assess performances against it. Coupled with the benefit of hindsight, such an approach will never lead to a deeper understanding of the historical event, and will always lead to a very skewed critical approach. Most governments, and people, are reacting against a pandemic as it is happening. Hence, except for clear lapses, deliberate omissions, and the like, one needs to assess responses ‘as they develop,’ not from an ideal later position. This enables a fuller understanding of how an event actually unfolded, rather than giving a post-hoc ahistorical view.

Thirdly, all events need to be understood in their historical global context. This is critical since if something was not happening anywhere in the world, it is bizarre to expect one country or government to pioneer it. Of course, this can happen, but to expect it is to not understand the context. What might seem ‘obvious’ later, might not be the case at the time (for several reasons), and so understanding what is happening in a particular country, as well as around the world, is essential.

With the above noted, let us revisit how several epidemics were dealt with in India in the past. In this series, I will investigate small pox, cholera, bubonic plague, and influenza, looking at two main issues: a) How did the British government of India respond, and b) how did the people of India react to both the disease and government measures relating to it. These two will enable us to understand not only the history of epidemics/pandemics in India, but also how to understand and assess current government policy and people’s responses across the different governments of South Asia in the coronavirus pandemic. A lot of the comment below will be from primary sources, but the general framework will follow the pioneering work on disease and medicine in India of Professor David Arnold.

Smallpox

In the nineteenth century, smallpox was perhaps the deadliest of diseases in India. Called the ‘scourge of India’ it claimed over a hundred thousand lives every year for decades. Deadly, especially for children, it affected a very large percentage of the population of India. In fact, Pringle claimed in 1869 that nearly 95 per cent of the population between the Ganges and the Yamuna had been exposed to the disease. The mortality rate of the disease was a high 30 per cent and combined with a vast geographical and demographic spread, its containment was one of the most important public health issues in India.

Whereas there was no cure for smallpox, and only palliative care could be given to its patients, the development of a vaccine sparked an interest in the control, and the final eradication, of the disease. However, vaccination was very slow to pick up in India and by the end of British rule in 1947, it was nowhere near universal, whereas it had long been virtually eradicated in Europe and North America. It took the concerted efforts of the World Health Organisation from 1959 onwards to finally lead to the world-wide eradication of smallpox.

So why did smallpox take so long to be eradicated in South Asia?

First, vaccination against smallpox was seen as a religious affront in several parts of India. There was a Hindu deity, Sitala, who was called the ‘goddess of smallpox’ where the disease was a manifestation of her personality. Popular in large parts of India, she was prayed to when anyone got the disease and especially when one recovered from it. It was said that the disease was her ‘play,’ and therefore the ‘cure’ was not medicinal but ritual.

Thus, as David Arnold notes, “To some Hindus, recourse to any form of prophylaxis or treatment was impious, likely to provoke the goddess and further imperil the child in whose body she currently resided.” Thus, medicine, especially ‘Western’ medicine, could not be used, as it could further increase the wrath of the deity. As Arnold further notes, “The body was Sitala’s temple, the shrine at which devotees worshipped and praised an all-powerful but difficult deity. The physical heat experienced was understood as ritual heat, an expression of the ambivalent strength of sakti, Hinduism’s female principle, a potentially fierce and destructive force which, if ritually appeased and accommodated, could be transformed into protection, good fortune, and fertility.”

The only ‘medical’ intervention used in India was the method of ‘variolation’ where older scabs were rubbed into the body of a healthy person through artificial scratches. This would lead to the onset of a mild form of the disease, from which the person would recover in a couple of weeks, thus attaining immunity against any further attacks. This method was widely used in north and central India, and it is noted that several caste groups, from Brahmins to lower and even outcastes were variolators, and went from village to village in the early part of the year, inoculating people. The fairly large spread of variolation in India is explained by David Arnold by noting that inoculating, “…was seen more as a religious ceremony and a ritual invocation of Sitala than as a medical procedure as such.”

Even though the small pox vaccine was introduced in Bombay in 1802, within a few years after its introduction in the United Kingdom, it remained largely confined to the British in India initially. Local people were very slow to accept it, so much so that between 1803 and 1806, less than 18,000 vaccinations took place in the whole of eastern and northern India. Even later, between 1818 and 29, they averaged about 30,000 a year in the populous Bengal presidency. The reasons for its slow uptake were various.

First, there was the clear religious dimension. If smallpox could indeed be prevented by a vaccine, what was the point of worshipping Sitala devi? Her annual fairs in early spring in a number of locations, her pujaris, her devotees, would be left without a goddess to worship, and it would have social and economic consequences. As David Arnold has explained, opposition to vaccination was primarily because it was seen as a ‘secular’ endeavour. The conduction of the vaccination process by unknown outsiders, who had no connection to the religion, locality, etc, further exasperated this tension, and made people unwilling to submit to it. Furthermore, the fact that the vaccine derived itself from cow pox further enraged the feelings of high-caste individuals.

Secondly, vaccination directly related to the process of variolation. As long as variolation continued, the British argued, not many people would get themselves vaccinated. Thus, in several areas the law was invoked to ban variolation, so that people could adopt vaccination. The government, especially in Bengal, also moved to convert these variolators into vaccinators, in order to co-opt them. Thus, by 1873 there were nearly five hundred former variolators who had become vaccinators in Bengal, which within five years rose to nearly a thousand.

Thirdly, there were various rumours against vaccination which received widespread traction. One rumour stated that vaccination was going to violate caste and lead to a conversion to Christianity. Another claimed that by vaccinations the British were trying to find Kalki, the last avatar of the Hindu god Vishnu, who was going to come and expel the British and become the emperor of India. Some Muslims thought that the promised Mahdi had arrived and that the British were trying to find and kill him through the process. These rumours had a lasting effect in some communities and solidified their opposition to the process.

Fourthly, the supply of the vaccine itself was initially an issue in India. Cow pox was rarely available in India and had to be imported from England. Several times the lymph was months old and almost unusable by the time it reached India. Furthermore, the ‘arm to arm’ method used was slow and some people, especially high caste Hindus, refused to let their child be either vaccinated through the arm of a lower caste or pass it on to them. Thus, it was only after technical advances in the latter part of the nineteenth century that vaccinations became easily available and readily given. Various provincial governments also then carried out an active programme to go to villages for vaccination, rather than waiting for people to approach them. As a result, vaccinations increased from 350,000 in India in 1850, to 5 million in 1883, and 8 million by the end of the century. By the turn of the century therefore, nearly 80 percent of children had been vaccinated by the Bombay presidency while in the United Provinces the percentage was 50. Thereafter, the number and percentage of vaccinations kept on increasing.

Vaccination eventually took hold in India, especially after the passing of the 1880 Vaccination Act which was then gradually applied to India. However, this only happened after considerable local opposition. However, as late as 1878, the sanitary commissioner for the North Western provinces (as the United Provinces were then called) lamented that the low levels of vaccination were the result of the “natural apathy [of the people], … their disinclination to accept a new thing, and their unreasonable religious beliefs or caste prejudices.” For the British, trying to push vaccinations was not just a public health issue, it also gave credibility to their ‘civilising mission’ stance in India. The members of the Smallpox Commission in 1850 therefore noted that it was the government’s duty to “save from willful self-destruction the ignorant and thoughtless millions, whom Providence has committed to its charge and protection.” Thus, even if initially the Government of India was not keen in expending many resources on the control of smallpox, they continued to support the effort as an example of their commitment to ‘humanity’ and ‘charity.’

The acceptance of vaccination could never spread throughout India without the support of local, especially influential, Indians. Hence, efforts were made to enlist their public support for the case. The mantle was picked up by the likes of Sir Sayyed Ahmed Khan who in September 1879 introduced the Vaccination Bill, which argued for compulsory vaccination. In introducing the bill, Sir Sayyed called upon the government to put to action its oft-repeated commitments. He noted that in the past people “had prejudices, to which superstition and ignorance had given birth, against the practice of vaccination. But the time has now arrived when such notions no longer find place in the minds of the gentry of India.”

The bill, which finally became the Vaccination Act 1880, was, however, only permissible in nature, and only allowed those places to make vaccinations compulsory which wanted to do so. As David Anrold has noted, “Quite apart from the ever-present financial considerations, the colonial regime remained nervous of a backlash against compulsory vaccination and coercive state medicine.” Hence the law was only slowly extended, and it was still a few more decades before opposition to vaccination died down and the practice became routine.

To be continued…