Of Cholera and Post-Modern World
Item
- Title
- Of Cholera and Post-Modern World
- Creator
- Mohan Rao
- Date
- 1998
- extracted text
-
>52?
PERSPECTIVES
Of Cholera and Post-Modern World
Mohan Rao
An examination of the political and economic forces underlying
the recent epidemic of cholera in Latin America
reveals striking resemblances to the situation in which the
pandemics of cholera occurred in the 19th century. It draws
attention to the fact that not only does politics inform the
occurrence of disease, but the shape and content of health policy
and intervention as well.
The Cholera’s Coming
The cholera's coming - oh dear, oh dear,
The cholera’s coming - oh dear!
To prevent hunger’s call
A kind pest from Bengal
Has come to feed all
With the cholera, dear.
The people are starving - oh dear, oh dear.
The people are starving - oh dear!
If they don’t quickly hop
To the parish soup shop
They’ll go off with a pop
From the cholera, dear
The cholera’s a humbug - oh dear, oh dear,
The cholera’s a humbug - oh dear!
If you can but get fed
Have a blanket and bed
You may lay down your head
without any fear.
—A popular song of the 1830s in England.
THIS article, by way of a preliminary en
quiry, is divided into three pans. The first
briefly describes the conjuncture within
which arose the cholera pandemic currently
sweeping Latin America. The second harks
back to the 19th century to examine cholera
pandemics emanating from India and
threatening existing order in Europe. I end
with observations and speculation on the im
pact of what has been described as the post
modern world order on the health of the
poor in third world countries.
I
Cholera, a disease known from antiquity
(the word is derived from the Greek, ‘kolera’,
meaning diarrhoea) now shows its minatory
face over the US, at the apotheosis of her
power and glory. Cholera, that king of
dismay has always been a disease that stalked
the poor and haunted the rich. Now, where
did this awesome threat emanate from?
Peru, the land of the glorious Inca
civilisation.
To historians of disease Peru is of singular
interest. What baffled historians was how
this mightycivilisation succumbed so rapid
ly, so easily, so very meekly to the small band
of Spanish conquistadores lead by Pizarro.
i
i
I
i
I
t
Was it the superior technology of gun
powder? McNeill offers the explanation that
it was in fact disease, in this case small pox,
which scaled the fate of the Amerindian
civilisations. Unexposed to small pox, the
Indians were ravaged by the disease; the
Spaniards, in contrast, supremely immune,
seemed supematurally protected. While
small pox savaged rhe Incas, the conquistadores marched unharmed, unopposed, to
raid the capital, its. temples and treasures.
Thus was Peru ‘integrated’ into the world
market. The events in Peru recalled the
similar amazing conquest of the Aztec em
pire of Mexico and her millions by the
Spaniard Hernando Cortez with an army
numbering less than 600. Infectious disease
then has had a profound, if not decisive,
effect on the tide of history.
Al the heart of the Spanish Empire, Peru
was plundered by colonial rule. Her ‘tryst
with destiny’, when it arrived, was but a sad
one. Peru is today one of the poorest nations
of South America with a population of 20
million and an external debt of 25 million
dollars. A poor country with a primarily
peasant economy Peru could ‘naturally’ only
rely on export of primary products to build
her economy. The economy, equally natural
ly, was guided by the US since the Peruvian
ruling class was preoccupied with a lavish
life style and holidays in Florida. Other
events were natural consequences. A coun
try whose ruling class lives beyond its means
gets into debt. The iron laws of international
economics are unbending: they will not per• mil the prices of the primary commodities,
that Peru exports, to rise. The irresponsible
ruling class cannot tighten its bek; indeed
they cannot even control their own peasant
rebels. Security assistance from the US is
necessary and is forthcoming to quell those
.rebels. The niceties of parliamentary demo
cracy may have to be given short shrift for
some time.
______
This, too, is ‘natural’‘for does the eco
nomy not have to be put on rails? Produc
tivity must increase, exports must go up;
there should fre a cutting down on ‘wasteful’
social expenditures, particularly those
’ 1792
1
'
directed towards vulnerable populations; in
efficient public enterprises must be made ef
ficient, that is to say, almost axiomatically,
privatised. Thus runs the wisdom of the
package on structural adjustment enunciated
by the IMF-World Bank towards which Peru,
‘naturally’, turns for loans. As the country
was being further ‘integrated into the-world
market’, in August 1990 was implemented
the IMF-World Bank sponsored programme
described as ‘Fujishock’ or "the most severe
zform of ‘economic engineering’ ever
applied’’.
And Peru did adjust structurally, if pain
fully. The pain was not, of course, equally
apportioned—the IMF-World Bank prescrip
tions did not envision that for it would
involve unthinkable changes in patterns of
investment and consumption. The pain was
‘naturally’ distributed to the poor in their
over-crowded shanty towns, slums or barrios.
Structural adjustment has meant devasta
tion to the lives of the poor and indeed even
the salariat. Consequent to wage freeze and
an unprecedented price rise has occurred a
drastic squeeze on the purchasing power of
the people.’Unemployment and casualisation of wage labour has reached dismaying
heights. It is estimated that the real purchas
ing power declined by 85 per cent even as
the cost of bread increased by an incredible
1150 per cent. State support to health and
education has been phased out leading to
a collapse of health and educational institu
tions. Essential humanpowrr, of trained doc
tors and nurses, look flight to greener
pastures contributing io a further drain of
capital from Peru. Public hospitals, despite
inadequate staff and widespread lack of
drugs and equipment, have attempted to
‘recover costs’ through fee for services^ The
impoverished population cannot therefore
avail of medical care leading to a decline in
hospital attendance and admissions even as
morbidity levels increased; the rich, of
course, never dependent on public institu
tions have their private havens. Public health
activities such as water supply, nutrition and
sanitation, seldom an area of high priority,
have come to a grinding halt.
It is in this context of poverty, squalor,
hunger and misery that the disease of under
development flares up. It is not fortuitous,
therefore, that cholera should break out in
the barrios. Cholera was first reported in
several coastal cities of Peru almost
simultaneously.in January 1991..It spread
rapidly across the country.. crossing the
Andes, to affect other cities in less than a
month. Within six months the disease had
marched to neighbouring countries. Since
January 1991 cholera has taken a fearful toll
of 2,681 lives in Peru alone; the reported
number of cases is 2,81,513. By the begin_ ning of this year close to four lakh cases and
more rhan"3,00Qdeaths'hive been reported
from 15 countries. The accompanying table
-. Economic and Political Weekly ’ Auguit 22,' 1992
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shows the number of cases and deaths in
Latin America since cholera made its debut.
There have been 28 cases, with no mor
tality, so far in the US but alarm bells have
begun to rjng. A recent issue of The Jour
nal of the American Medical Association
(JA.MA) carried an article entitled ‘Cholera
Threatens US Population from Elsewhere in
This Hemisphere* while a weekly watch is
being kept on the depredations of the
disease.
The causes for the current pandemic, the
consequences and the reactions evoked in the
US bring to mind the uncanny if not sinister
resemblance to the 19th century in England
when cholera erupted from her backyard,
India. To this we shall now turn our
attention.
n
India was ‘integrated’ into the world of
capitalism by the British East India Com
pany with the Battle of Plassey. The colonial
loot of the jewel in Britain’s crown was both
instantaneous and staggering. It has been
estimated that the treasure taken from India
alone between Plassey and Waterloo was an
astounding 500 million pounds to a 1,000
million. Thus, while India provided the
capital for Britain's industrialisation began
the process of her own underdevelopment.
The consolidation of the British empire
in India was not as easy as the Spanish con
quest of South America. Several wars were
waged and populations displaced. During
one of these movements of troops broke out
a fearful disease, regarded then as entirely
new but later recognised as cholera. Snow
notes: “In June 1814 the cholera appeared
with great severity in the 1st battalion 9th
regiment NI, on its march from Jaulnah.”
Little however, is heard of this outbreak.
What was of great import, and with grim
consequences, w-as the epidemic breaking
out in August 1817 in Jessore. The Marquis
of Hastings made the following entries in
his diary.
‘73 November, 1817: The dreadful
epidemic, which has been causing such
ravages in Calcutta and the southern pro
vinces, has broken out in camp... I march
tomorrow, so as to make the Pohooj river,
though I must provide carriage for 1,000
sick.
75 November. 1817: We crossed the Pohooj
this morning. The march was terrible, for
the number of poor creatures falling under
the sudden attack of this dreadful infliction
and from the quantities of bodies of those
who died in the wagons, and were necessarily
put out to make room for such as might be
saved by the conveyance. It is ascertained
that 500 have died .since yesterday!’
While the toll on the British army was no
doubt fearful, that on the population of the
country was devastating although of course
no reliable estimates are available. One
estimate placed cholera mortality in the four
years between 1817 and 1821 in British India
at 18 million deaths. Over the next few years
Economic and Political Weekly
the disease fanned out across neighbouring
countries advancing along three discrete
routes. To the west through Persia and up
the river Tigris to Baghdad, spreading thence
via camel caravans to Syria and southern
Russia. To the east the disease marched
through Burma, Malaya, Java and the
Philippines where a number of Europeans
were massacred with the not-all-toomistaken belief that they had spread the
disease. For as the empire opened up to trade
new pans of the globe, there were forged new
epidemiological links in disease transmis
sion. To the nonh the disease conquered the
vast land mass of China.
_ Was the disease in fact new? Or was it
merely unfamiliar to British doctors? Had
a new, and more virulent, strain of the
disease come into existence? The ease with
which the El Tor cholera vibrio originating
in the Celebes in 1964 replaced the classical
cholera vibrio in Asia in a few years admits
the plausibility of this speculation. It is more
likely, however, that colonial intervention
had altered the ecology of the disease.
McNeill, for instance, suggests that “old and
established pattern of cholera endemicity in
tersected new British-imposed patterns of
w trade and military movements. The result
was that cholera overleaped its familiar
bounds and burst into new and unfamiliar
territories where human resistance and
customary reactions to its presence were
totally lacking?
The next wave of this worldwide epidemic
or pandemic reached Moscow in 1830 and
soon spread over Russia, eastern and central
Europe. Hungary was particularly badly af
fected; in less than three months over a
quarter of a million were affected and nearly
1,00,000 died. The disease established itself
soon at the Baltic sea pons, to the horror
of the British; for, a major pan of Britain’s
trade passed through these pons. Repons
meanwhile poured into London of a ternble
outbreak in the Middle East taking, it was
claimed, 30,000 lives in Cairo and Alexan-
dria in one day. The British government wai
ched with macabre fascination and terror
The king’s speech at the opening of parlia
ment on June 21, 1831 observed:
“It is with deep concern that I have to an
nounce to you the continued progress of a
formidable disease... in the eastern part:
of Europe... I have directed that precau
tions should be taken against the introduc
tion of so dangerous a malady into th
country’ As Snow notes “cholera began
spread to an extent not before known... I
approach towards our own country, after
entered Europe, was watched with more
tense anxiety than its progress in other dire
tions.”
Everywhere the disease was observed •
have terrible social, political and dem
graphic consequences. The disease occurr
despite whatever measures governments
the people—in some cases'driven in
religious, penitential frenzy—took. In Russ
troops were deployed around affected vilk
ges with orders to shoot starving peasan:
• struggling to escape. But the disease spree,
to neighbouring communities. Prussic
equally true to her heritage, stationed he
army at the borders; to no avail The dolef
influence of Malthus’ An Essay on the Pri.
ciple of Population, published in th
historic year of the French Revolution, w.
now being felt on the continent with fea.
ful consequences. Convinced that the disea.
was a conspiracy of the ruling class ar.
physicians to bring down the population c
the poor—for it was strange, if not sinister
that both members of the ruling class ar..
physicians seemed relatively unaffectedpeasants attacked several manors i
Hungary, butchering the nobility. The arm
was, of course, called in but in several cas.
the men had deserted and shot their officer
In St Petersburg occurred the first ‘choier
riot’, to become familiar later in England
The riot came to an end when the Czar ap
peared, falling on his knees on the street t.
offer a public prayer that-his country b
Table: Latin American Epidemic
Country
Month of
1st Report
Cases
Deaths
Dcath-to-Case
Ratio (Per Cent
Bolivia
Brazil
Chile
Colombia
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Peru
United States
Total
August
May
April
March
February
August
July
October
June
November
September
January
April
109
2611
411
9774
39154
709 +
2247
5+
2028 +
l+
696 +
281513
16 +
336554
6
3
2
132
600
25
36
0
25
0
20
2631
0
3538
7
1
5
....... 1.3 .. .
1-5
3-5
1.6
0
12
0
2.9
0.9
0.0
1.05
• By countryift the Americas, as of November 19, 1991 (data are from the Pan American Health
Organisation).
+ Laboratory-confirmed cascsjonly.
Source: JAMA, vol 267, no 10. March 11. 1992.
August 22, 1992
1793
spared the disease. The disease revived forgot cholera was kept out of the island. The
Qeneral's office was the remarkable utili
board’s recommendation that quarantine
tarian Edwin Chadwick whose work saved
ten horrors of the Black Death in public
measures be strengthened was vigorously op
more lives than all the doctors in the 19th
memory. The psychological impact of the
posed by the city and business interests and,
century. Assisting him was William Farr who
approach of cholera has been noted to be
indeed, the .Admiralty, which claimed they
raised medical staiistics to a science. Behind
unique. Says Vigarclld, “It seemed capable
would not be able to adequately help imple
of penetrating any quarantine, of by-passing
them both in their endeavours were the
ment
these
measures.
The
compromise
any man-made obstacle. It chose its victims
enlightened public, amongst them Carlyle
evolved placed the responsibility squarely on
and Dickens. Chadwick’s conversion from
erratically, mainly but not exclusively, from
a poor law reformer to a public health cam
the lower classes. It was, in short, both uni non-existent or ineffective local governments.
When cholera at last made its long feared
paigner was due mainly to his consideration
quely dreadful in itself and unparalleled in
appearance from Hamburg in the port town
for financial economy. For in his view, it was
recent European experience Reaction was
of Sunderland, the first reaction was to deny
wasteful that every year thousands of
correspondingly frantic and far-reaching.”
its existence. Commercial interests in the
Indeed it would be no exaggeration to say
widows and their children were thrown on
town, aided by doctors, were vehement that
to the poor rates by the death of the bread
that cholera was one of the twin spectres that
the port was disease-free. The same situa
haunted Europe in early 19th century; the
winner .of the family.
tion prevailed later when London was struck;
other was, of course Revolution.
Chadwick’s investigations and zeal lead
The London Medical and Surgical Journal,
io the presentation to parliament of The
As England anxiously watched the ravages
supported by a solid body of doctors main
Report on the Sanitary Condition of the
of the disease on the continent, fearful of
tained that it was a false alarm. The Lancet
■Labouring Population of Great Britain in
ns arrival, the unresolved conflict between
editorially beseeched “the members of the
1942. The Report was loaded with hard hitmiasmatic and contagionist schools of
medical profession not to be misled by the
disease causation came to a head. The
ling statistics and made pragmatic economic
commercial cry that malignant cholera is not
sense. Striking for instance was the data on
former, going back to Hippocratic days, held
in the metropolis”.
life expectancy: in Derby it was 49 years for
that disease was caused by miasma (mean
Cholera swept through England, Scotland
the gentry, 38 for a tradesman but only 20
ing stain); miasma emanated from spoilt air
for a member of the working class. In Leeds
or atmosphere. Putrefaction, decay and din . and Ireland reserving its horrors especially
for those towns and cities that had grown
were therefore, at the heart of the miasmatic
the figures were 44, 27 and 19 respectively.
rapidly during the industrial Revolution. For
The Report stressed the enormous waste of
theory of disease causation. These pro-cesses
here huddled in over-crowded slums, sans
potential labour and hence of money, caus
were of course, central to the florid lives of
water, sanitation, air and sunlight were the. ed by preventable disease, pointing out that
the tropics, wherein emanated cholera, with
impoverished workers; the only certainty in
their excesses of heat, humidity and indeed
it would be far cheaper to put the cities in
their lives was the insecurity of employment.
order. In this the report echoed the practi
of passions as opposed to the cool, the dry
They were cholera’s natural victims.
tioners of the new science of political
and the temperate. Diseases thus had
As the disease spread, so did panic Towns
geographic, meteorological and ecological
economy, who like the Physiocrats before
were deserted by those who could afford to
causes.
them, saw the wealth of the nation, in terms
flee, carrying the disease into the hinter
of efficient labour. The sanitary maps in the
The contagionist aetiology of disease or
lands. What cholera did. above all, was to
Report showed how cholera cases clustered
the germ theory of disease, all loo often at
expose the unbelievable poverty hidden
tributed to Robert Koch in the late 19th cen
together in the poorest and worst drained
behind the facade of metropolitan prosperi
areas. Chadwick’s labours led to the setting
tury, goes back in fact to as early as 1546
ty.
Cholera
unveiled
the
rotten
underbelly
of
and Giraiamo Fracastoro. Fractastorius
up of a Royal Commission on The Health
capitalism; of the poverty, squalor and
maintained that disease was caused by
of Towns. The Royal Commission’s two
misery of the people on which it was built.
discrete animalcules transmitted through
reports, based on a detailed study of 50 large
To the Bread Riots, the Luddite riots and
human interaction. The contagionist theory
towns with the highest death rates was dam
the Chartist riots in early 19th century
provided the basis for the elaborate medieval
ning. All these reports however came to
England were added the cholera riots. Given
Mediterranean quarantine regulations,
naught, parliament was loath to pass the
the very high mortality in hospitals—experi
enacted to guard against plague. The conta
Public Health Bill recommended.
ence had, not incorrectly, convinced the poor
gionist theory, however, fell victim to
But the bill had a powerful ally—cholera,
that chances of survival in hospitals were
Napoleonic ambitions. His. adventure to
readying itself for another onslaught in 1948.
Santa Domingo had been laid low by yellow distinctly less than if they suffered-in their
It was finally the threat of cholera, accom
homes, and the general distrust of upper
fever; when yellow fever broke out in
panying the age of revolutions of 1848,
class doctors and the fears of the sacrilege
Barcelona in 1822 French physicians were
which led to the passage of the Public
of post-mortem riots occurred at several
asked to make a ‘definitive’ study of disease
Health Bill and the establishment of a new
towns. Mobs raided hospitals, smashing
causation. They concluded that there was no
Board of Health. Public health was finally
everything in sight and delivered patients to
possibility of contact among the victims of
acknowledged as the responsibility of the
their homes. Seldom before had the medical
yellow fever—not having known of the role
state.
profession been exposed to be so impotent
of the insect vector, mosquito. The con
Six pandemics of cholera reached England
even
as
they
bickered
over
what
caused
tagionist theory of disease aetiology was
in the 19th century, five of them emanating
cholera,
how
it
spread
and
how
to
cure
it.
thence given a premature demise. Medical
from Ihdia. But the importance of cholera,
When cholera receded it had left 60,000
reformers were henceforth at the forefront
as indeed of all infectious diseases, declin
dead. It also left behind in the minds of a
of efforts to dismantle the quarantine
ed as England completed her sanitary revolu
section of the middle class, the sanitary idea.
regime. They were vociferously supported by
tion and improvements occurred in nutrition
Most crucial to this concept was the under
British free traders. Regulations on free
and the general standard of living. It is
standing that the poor did not choose to live
trade, it was argued, was a superstitious relic
significant that this decline occurred prior
of contagionist fears not based on scientific
in squalor. The sanitary idea embraced the
to the discovery of the cause of the disease.
empirical facts.
need for hygienic housing, clean piped water
The sway of the miasmatic theory of. disease
The government in Britain was now in the
in adequate quantities, efficient sewers and
was, however, so strong that when Snow
throes of a crisis over the agitation for the
paved roads.
published his remarkable findings, a classic
Reform Bill. But when cholera broke out in
The reformed parliament in 1933 passed
in epidemiologial research, On the Mode of
Hamburg in 1831—a port with which
the Registration Act for the compulsory
Communication of Cholera in 1849, it was
England had vast maritime contact, a board
registration of births and deaths; it also
largely ignored. The tide of sanitary reform,”
...oLhealth was set up. The primary respon- -• passed the notorious Poor Law’s. The author
however, could not be ignored; it swept
sibility of the board was to ensure that
of the Poor Laws, manning the Registrar - • through the continent also. The urban land-
1794
...
and Political Weekly ' August 22, 1992
scape of Paris was transformed; the Second
Empire rebuilt the city with wide boulevards
as much to let in air to ward off noxious
miasmata as to control revolutionary mobs.
And Germany, having completed her sani
tary reform, was rewarded with seeing
cholera now respect boundaries, this time
sanitary.
Cholera, then, became a disease of the
Other: a tropical disease. But with each new
pandemic from India, the British govern
ment came in for international censure. A
series of international sanitary conferences
took place in 1866, 1874, 1875 and 1885
devoted specifically to cholera and the ques
tion of quarantine. The first conference at
Constantinople in 1886 had embarrassed the
British government" by pronouncing India
the natural home of cholera. Threats of a
trade boycott were in the air; the French
spoke of the possibility of riots breaking out
in Marseilles if the British did not control
communicable diseases in the. Indian ports.
The cholera pandemic of 1861 had, further,
decimated the British army killing one in
every 10. It was not only expensive but
physically not possible to keep shipping in
fresh recruits. Military men in India, par
ticularly after the 1857 uprising, were acutely
aware of the proportion of Europeans and
Indians in the British army and the constant
and large number of the former invalid in
hospitals. All these factors together propell
ed the government to initiate public health
measures in India directed towards protec
tion of the army.
What evolved was a policy of cordon
sanuaire. The British army and important
civilians were to be segregated in sanitary,
self-contained areas, secluded from the
natives. Fears of miasma emanating from
the latter even lead to the construction of
walls between Indian and European troop
locations to keep miasma out. A broad
based sanitary reform on the lines of the
west encompassing the entire population was
never on the colonial agenda—as indeed it
is not in the nationalist agenda of the day;
the government was unwilling to make the
necessary financial expenditures. Sanitary
reforms for the general population compris
ed ad hoc arrangements at pilgrimages.
Arnold observes trenchantly "Cholera in
India was more than a dreaded disease. It
was associated with much that European
medical officers and administrators found
outlandish and repugnant in Hindu pil
grimage and ritual—so much so that the at
tack on cholera concealed a barely disguis
ed assault on Hinduism itself!’ No such
assault on cholera was in fact in the offing;
for, sanitary reforms for the general popula
tion was also blocked on the specious
grounds that they would offend the religious
sensibilities of the people. Cholera thus was
the leading cause of death in India in the
19th century frequently accompanying the
terrible famines which swept ,yario.us.j)arts_
oTthe country.
The reasons for the decline of cholera, as
indeed the decline of death rates in India
commencing in the 1920s, is a matter of con-
t
1
1
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e
1.
c
y
le
d
<g
a.
>n
is
or
se
<w
ic
of
as
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pt
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>92
’
Economic and Political Weekly
be controlled ‘on a war footing’. In other
words while hospitals and medical colleges
came up., primary health centres did not.
In the third plan the Mudaliar Commit
tee’s recommendations came to force. This
HI
committee had noted that the primary health
care system that had evolved bore no resem
The history of cholera throws light on
blance to that visualised by the Bhore Com
some salient issues. First, the occurrence of
mittee. Very curiously, however, the con
disease is not necessarily ‘natural’ but con
tingent on a large number of interlinked
solidation of existing services to be on par
with
the west rather than building up the
socio-economic factors. In other words, a
web of factors resting on a socio-economic
PHC network was recommended. The fami
ly planning programme now took wing. The
milieu not only sets the ground for occur
extension education approach not having
rence of a disease but also contours the
limits of health intervention. Second, it
been successful, the IUCD was relied upon;
focuses attention on the limits to medical
that having proven a failure a targettechnology. Technical solutions offered to
oriented, time-bound programme was laun
problems social in nature, while having great
ched.- During the Third and Fourth Plans
health budgets continued to decline even as
short-term appeal, offer no long-term cure
expenditure on family planning increased
to community health problems. Third, mor
sharply. Health obtained 2.63 and 2.12 per
bidity and mortality are seen to be not mere
ly biological phenomena shared by the
cent; family planning was allocated 029 and
human population. Diseases are not the
1.76 per cent respectively. Over this period
great levellers they arc frequently thought to
the colossal malaria eradication programmes
be; the disease and death load in a popula
suffered a series of set backs. Among other
tion are distributed as unevenly as are
reasons, technical and logistical, one of the
resources. Lastly it shows us above all that
major reasons for the failure of the pro
politics informs not only the occurrence of
gramme was that a health structure, one
disease but the shape and content of health
capable of carrying out surveillance, had not
policy and intervention. That is to say that
been developed adequately. During the Fifth
given a set of health problems imagpnmuniPlan health and family planning received
ty, it is politics which decides w’tHch of these
1.92 and 124 per cent respectively. Even as
problems are important;, and jhese are not
recognition is said to have dawned that
necessarily epidemiological imperatives.
“development is the best contraceptive” this
Politics also determines whichb'f a possible
plan period witnessed the use of brutal
range of interventions is selected.
methods to obtain family planning targets.
Now, how does all this have any remote
And in view of the continuing set backs to
bearing en India in the late'20th century?
the malaria eradication programme, a nr*
Is it relevant now at the dawn of a brave new
strategy for the control of malaria was drawn
up: eradication became a long-term objec
world? To consider these questions we shall
tive. Efforts were belatedly made now to in
briefly survey the evolution of health services
tegrate the vertical programme; a task not
in India.
At the glimmerings of the dawn of indcyet adequately achieved.
pendence in India was established the Bhore
During
the
‘ Sixth Plan
.................................
health and family
Committee to draw up the blue-print for the
planning received 1.86 and 1.03 per cent of
the budget respectively.- In a departure from
health system of India. In view of the quan
previous plans the Sixth provided for an in
tum and nature of the health problems in
crease in the allocation for rural health. This
the country the Bhore Committee drew up
was, however, at the expense of preventive
a plan that laid emphasis on preventive ser
vices focusing on rural areas linking health
programmes: reduction of medical expen
to overall development. These recommenda
diture was only 4 per cent whereas that for
tions were considered eminently feasible
the control of communicable diseases was
within available resources; they were ac
II per cenu The family planning programme
cepted as the.mimmum irreducible if a dent
now came to be directed at poor women
was to be made on the health profile of the
whose reproductive profligacy was con
country.' The recommendations were ac
sidered the cause of the country’s poverty.
This period also witnessed official policy to
cepted by the government of India; they were
encourage the corporate sector to enter the
not however to sully the conscience of our
planners. During the first two plan periods
health market.
The Seventh Plan made some efforts
health obtained 3.3 and 3 per cent of the
towards strengthening health infrastructure.
total plan outlays, much below the irreduci
Health and family planning were allocated
ble minimum of 10 per cent recommended
l.SS and 1.80 per cent of the budget respec
by the Bhore Committee. Further within this
tively. Yet towards the end of this period,
budget, 55 to 60 per cent was allocated to
curative health services and to medical
given the lack of correlation between pro
gramme performance and birth rates, it was
education. Public health obtained a mere
grudgingly acknowledged that the massive
third of the budget. Of the funds available
.fpr. public heahh,--the major .share-was— -family planning programme had not been
successful. With financial incentives from. .
garnered by the vertical programmes like
the state there occurred a mushrooming of
malaria, small pox and soon even family
super speciality institutions for high
planning, for, by the early 1960s, it was
technology curative care during this period.
decided that the number of poor ought to
troversy. One fact however, is generally ac
cepted and that is that public health policy'
and intervention had little to do with the
decline. .
August 22. 1992
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What is striking however, is that in our
country now, not only is the morbidity and
mortality load still high but there has been
no change in their overall character; infec
tious diseases continue to be the major
causes of morbidity and mortality; malnutri
tion continues to be widely prevalent. Data
from the National Nutrition Monitoring
Bureau reveals that while the prevalence of
severe malnutrition has somewhat declined
that of moderate malnutrition has in fact
increased, while the prevalence of mild
malnutrition remains unchanged.
What we have achieved has been to evolve
plural and divorced worlds of health sys
tems. One endowed with advanced and ex
pensive technology, concerned with cancer,
diseases of ageing and so forth and another
at the periphery which fails to confront
preventable morbidity and mortality. The
former attends to the needs of a small
minority whose living standards includes ac
cess to public health services. The latter fails
to recognise that the prevailing morbidity
and mortality arc rooted in poverty and are
therefore, not amenable to technical
solutions.
India is now poised at a new conjuncture.
The World Bank-IMF policies of structural
adjustment is pregnant with dire conse
quences for the health of the majority. They
will further wrench apart the distance bet
ween these dual health systems. The cut in
health budgets would mean that health in
stitutions, on the verge of collapse, may
simply go under. Al the recent World Health
Assembly in Geneva the minister for health
and family welfare declared that we do not
have sufficient resources for primary health
care. Reports, meanwhile, have come in of
cholera deaths in Tripura and in Bihar; while
Delhi, the most endowed of Indian cities, has
started reporting cases of cholera. The threat
of cholera flaring up again therefore,
persists.
These are not merely Cassandra’s fears.
Data not just from Peru but a number of
other countries that have implemented the
World Bank-IMF dictated policies of struc
tural adjustment reveal the grim conse
quences of these policies. UNICEF’s The
Stale of the World’s Children 1992 notes that
given the problems of external debt, of
declining terms of trade and of protec
tionism in the markets of the First world the
1980s were disastrous economically for the
majority of the countries of the developing
world. It states “UNICEF has watched the
deterioration of that economic environment
being translated, in many countries, into ris
ing malnutrition, preventable disease and
falling school enrolments”. The. report fur
ther goes on to warn that “the developing
world will find it difficult to find a place in
the new world order”.
To illustrate, a 10-country study on the ef
fects of recession and structural adjustment
on_heakh, published by UNICEF, showed
a deterioration in the nutritional.status of
children in eight of these countries. Infant
and child mortalit/ rates which had been
declining for two decades since the 1960s
showed either a reversal of the trend or a
slowing down of the rate of decline. Data
from Zambia show that between 1980 and
1984 hospital deaths due to malnutrition in
creased from 2.4 to 5.7 per cent in the 0-11
months age group and from 38 to 62 per cent
in the age group 1-4 years. Between 1980 and
1985 infant mortality rates went up from 146
to 168 in Ethiopia, from 97 to 108 in
Uganda, from 103 to 110 in Tanzania and
from 87 to 91 in Kenya. Similarly childhood
mortality rates went up from 32 to 38 in
Ethiopia from 18 to 21 in Uganda, 19 to 22
in Tanzania and 15 to 16 in Kenya over the
same period.
The devastation to people’s health and liv
ing conditions in the developing world has
lead to calls by UNICEF for “adjustment
with a human face”. As India prepares to
tread the same path some sobering reflec
tion is called for. Are we prepared to con
demn the country, in perpetuity, to be a ‘fac
tory of disease’?
Notes
Stockholm, 1982.
Snow, John, On the Mode of Communication
of Cholera, John Churchill, London, 1855,
reprinted USAID, New Delhi, 1965.
UNICEF, The State of the World’s Children,
1992, OUP, Delhi, 1992.
Vigarello, G, Concepts of Cleanliness: Chang
ing Attitudes in France Since the Middle
Ages, CUP, Cambridge, 1988.
*
‘Cholera: Fall Out of New Economic Order’,
EPW, Vol XXVI, no 34, p 1941, August 24,
1991.
‘Epidemic Cholera in Latin America’, The Jour
nal of the American Medical Association,
vol 267, no 10, March II, 1982.
‘Cholera Threatens US Population • from
Elsewhere in this Hemisphere’, ibid.
‘Cholera in the Americas’, JAMA, vol 267, no
11,‘March 18, 1992.
‘Epidemic Kills 32 in Darbhanga’, The Times
of India, New Delhi, May 30, 1992.
‘Over 3-Fbld Rise in Cholera Cases’, The Times
of India, New Delhi, May 22, 1992.
■Diarrhoea Claims 86 Lives in Bihar’, The
Times of India, New Delhi, June 2, 1992.
Tripura Epidemic Claims 150 Lives’, The Times
of India, April 23, 1992.
[I am grateful to Padma Prakash for not only
mooting the idea of this paper but also sup
plying me with data from JAMA. 1 am alone
responsible for errors and infelicities.]
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Bibliography
Arnold, David (cd). Imperial Medicine and In
digenous Societies, OUP, New Delhi, 1989.
—, ‘Cholera Mortality in British India
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Chossudovsky, Michel, ‘Under the Tutelage of
IMF. The Case of Peru’, Economic and
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Cornia, G, Jolly. R and Stewart, F, Adjustment
with a Human Face, Clarendon, Oxford,
1987.
Guha, Sumit, Environmental Sanitation in the
Health Transition: India and the West in the
19th and 20th Centuries, paper presented
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Kanjt et al, ‘From Development to Sustained
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Klien, Ira, ‘Cholera, Dysentery and Develop
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Longmate, N, King Cholera: The Biography of
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McNeill, W, Plagues and People, Penguin, Harmondsworth. 1979.
Naraindas, Harish, Poisons, Putrescence and
the Weather: A Genealogy of the Advent
of Tropica! Medicine, unpublished paper
presented at CSDS workshop, Delhi. 1990.
Park. J E. A Textbook of Preventive and Social
Medicine, Bhanot. Jaipur. 1991.
Qadecr, 1, ‘Beyond Medicine: A Analysis of the
Health Status of Indian People’, Think/
India, vol 2, no 1, January 1990. . •
Ramasubban, R, Public Health and Medical'
Research in India: Their Origins under the/
Impact of British Colonial Policy, SA REC, •
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