Over the past several weeks, I have narrated how epidemics were dealt with in South Asia during the British period, with a focus on the Punjab. This choice was primarily because we have the best records available from that time, and also since there are several correlations between that period and today.

With the recent coronavirus pandemic, issues which we dealt with in the past have become current problems, and questions we asked of historical events are being asked today. The government and public response to the coronavirus pandemic, in my opinion, will fundamentally change and challenge the way in which we have viewed such epidemics in the past and bring more depth and nuance to the study of health and medicine in South Asia.

While there are many lessons to be learnt from previous epidemics in South Asia, let me discuss a few, especially in relation to their importance today.

First, there is no real way in which a government can control the spread of an epidemic. As has been seen in the recent crisis, diseases are easily spread, regardless of education levels, better sanitary conditions, and government measures. Of course, personal and government measures can ‘contain’ the spread of a disease, but it cannot ‘control’ its spread beyond a certain limit. Just like the British Indian government tried and failed to prevent the spread of the plague from Bombay to other areas in India, similarly, the current coronavirus could not have been controlled in just one small area. Thus, a disease’s reasonable spread must be expected.

Secondly, the government must devise clear and concrete plans to contain the disease. The plague measures of the British government of India in 1898, where an infected area was sealed, its population removed to another location and tested, the area thoroughly disinfected and white-washed, were clear measures which enabled a limited control of the disease. It also signified a ‘process’ through which an infected area could pass through certain defined benchmarks and be eventually free from the disease. Such clear and planned measures are sorely lacking in Pakistan today.

Thirdly, past experience has exhibited the centrality of modern medicine to the eventual containment and cure of several diseases. While Ayurveda and Unani medicine did have some remedies for epidemics, they were very limited in their efficacy. It wasn’t until the advent of the British Raj that modern medicine made inroads into South Asian society and these diseases began to be contained and cured. The process of acceptance of modern medicine was long, as David Arnold shows, and in some cases still continues throughout South Asia.

Fourthly, an important lesson of the study of past epidemics is that any amount of government coercion, no matter how well founded and well-meaning, is bound to backfire. The British took extreme measures to contain the plague, with quarantines, regular checking, disinfection drives etc. But rather than being appreciative for government proactive-ness, the people simply turned against the government and resorted to rioting, arson, and assassinations.

Thus, by the end of it the real purpose of ridding the country from the epidemic was lost, and the gulf between the rulers and the ruled widened. Therefore, after experience, the Punjab Plague Manual by 1909 noted: “The cardinal principle of all plague administration must be that no pressure or compulsion, in any shape or form, is to be brought to bear on the people. Encouragement, persuasion and the provision of facilities for carrying out the measures advocated are the only legitimate means of influencing and guiding public opinion in the direction desired.”

Fifthly, government measures must include adequate ration provisions for the affected. For both evacuated areas and in areas where people are suffering, the government must intervene to provide basic necessities. This was all the more apparent during the influenza pandemic where due to war food and fodder were both expensive and, in some places, unavailable, rendering a large percentage of the people malnourished, and hence more susceptible to the disease. Even today the failure of the government is most stark in the lack of ration support to the people, which forces them to go out in search of work, further exacerbating the situation.

Sixthly, no government measures can be successful unless the people are educated of their benefits, and are co-opted by the government to aid the process. As the foreign ruling class, for the British therefore it was essential to involve ‘natural leaders’ among the Indians in the tasks of prevention and cure, if their measures were to have any effect. The Punjab Plague Manual noted: “… every effort must be made to enlist their sympathies and bring home to them through their natural leaders and in any other way that may be practicable, that it rests mainly with themselves to bring about, by their own action, the cessation of plague.” As more and more local people became involved, the provision of health facilities for the people improved, as did their understanding of the measures to be taken in times of an epidemic.

An important lesson of the study of past epidemics is that any amount of government coercion, no matter how well founded and well-meaning, is bound to backfire.

Much before political power, it was in the health sector that, at least in the cities, Indians had begun to take away the initiative from the British and numerous charity organisations ran hundreds of hospitals across the country providing high quality, and often free, healthcare to the people. For the thousands getting treatment from these hospitals, the government was no longer the only mai baap—(mother-father), in terms of healthcare. The sanitary commissioner of the Government of India noted this change in 1919: “Never before, perhaps, in the history of India, have the educated and more fortunately placed members of the community, come forward in such large numbers to help their poor brethren in times of distress.”

Seventhly, a concerted effort must be undertaken—both by the government and private organisations and citizens, to dispel rumours and panic during an epidemic. Past experience has shown that panic has always exacerbated the disease, while rumours have barred people from seeking help.

The fascinating sets of rumours during especially the plague epidemic, severely limited not only the ability of the government to help the people but also encouraged people to hide the sick, secretly bury the dead, and distrust all government measures. In the current pandemic too, several rumours have led people not to get tested and hide the infected, further spreading the disease. Thus, epidemic control is as much a medical emergency, as it is a public relations battle.

Eighthly, epidemics in the past and present show that public health reform and financing is critical for a safe and healthy population. The government of India was aware of this gap and in its own report of 1918, while commending the initiative of private philanthropists, indicted its own substandard provision of health care.

The 1918 Sanitary Report noted that: “History has shown that unnecessary loss of life through epidemics has been an important factor in awakening a public health conscience, and the appalling mortality in India during 1918 will not have been altogether in vain if it inculcates in the minds of the general public the dire necessity of public health reform…” A conference was called on public health in May 1919 where important resolutions were passed for the future of public health in India. The recommendations included the setting aside of at least half a million rupees for a separate medical department, the setting up of a separate health ministry, the creation of a Central Public Health Board led by professionals, setting up of provincial and local health boards, training of extra staff, addition of an epidemiologist to the medical service staff, and the setting up of a Central Research Institute to coordinate and lead disease research.

Without such a drastic overhaul of the public health provisions it was deemed impossible to properly deal with epidemics, and other related diseases. Thus, radical public health reform is key during and after an epidemic to strengthen and refocus medical institutions, staff, and research.

As in the past, public health emergencies caused by epidemics or pandemics lay bare the meagre financing of healthcare, be it under colonial or independent rule. They also exhibit the complicated process through which they are contained, cured, and, in some cases, finally eradicated. The study of epidemics clearly shows that it is often very hard to decipher the ‘right’ method during an epidemic and usually several, often competing, strategies are used.

However, historical experience can deliver some very important lessons. Primary among them is that harsh government measures never succeed. Thus, if you only put a place in ‘lockdown’ people will not follow government guidelines and there is bound to be an adverse public reaction. There also needs to be a clear and coordinated government policy with a focus on prevention and cure. The quarantines during the plague worked because places were evacuated, people tested, areas disinfected. Without clear measures to prevent and cure a disease by the government, the epidemic will only cause widespread misery and death.

Finally, it is in working with the people and through the people that the solution can finally be found. Unless the people accept and internalise preventive measures, they will never work. Investment in public health and a radical rethink of how to include people in prevention and relief measures are as much the need today as they were a hundred years ago.

(Concluded)