Empire of the Doctors

On the outskirts of most Indian cities you still encounter the war graves of imperialism: the melancholy, unvisited Christian cemeteries which contain the serried ranks of monuments commemorating British subjects and their children buried there during the days of the Raj. Perhaps it is not surprising, or particularly shocking, that it was fear for European rather than Indian lives which drove the growth of tropical medicine in India. Mortality among British troops and civil servants remained appallingly high well into the later 19th century. Nor is it surprising that for the European mind, India was the seat of global infection. After 1818, cholera, the terrible ‘westering’ disease, moved out of its endemic haunts in Bengal and north India in the wake of British armies of conquest. Striking overland and along the sea lanes, it became the chief public health problem for 19th-century European governments and a potent source of popular fear and potential disorder. It seemed as if the horrid filth and turbulence of the Orient had infected the seamy underworld of the European city. In the 1890s, bubonic plague appeared in Bombay and threatened to slip into the commercial arteries of the world’s greatest trading nation, arousing archaic panics about Black Death wherever it appeared. This theme of fetid disease and corruption stealing in from the East often surfaced in 19th-century literature – Dr Watson, an Indian Army doctor, first met Sherlock Holmes while he was convalescing from Indian enteric fever, which had caused his ‘life to be despaired of’. In our century, only anxiety about Aids and social disintegration in Africa has brought a comparable merging of physical and political terror with fear of the Other.

The history of science and the history of medicine have been late developers in colonial historiography, and India has even lagged behind Africa. But now there is a considerable spurt of interest, partly as a spin-off from developments in European history. Scholarly attention has been focused by the enlightened patronage of the Wellcome Trust and historians whose fear of the sciences dates back to schoolboy cuffings by the biology master have realised they can do medical history without knowing much medicine. Even better, Michel Foucault has seemed to suggest that colonial medicine was not so much a bounty conferred on the least advanced parts of humanity by the more advanced, but a discourse deployed by governing powers to aid them in ruling.

These themes strike a particular chord in colonial history. Along with canals and railways, the introduction of Western medicine was one of the proudest boasts of the Raj. In 1901, the Director General of the Army Medical Service credited British doctors with stopping the ravages of cholera in India and ‘improving the whole condition there’. Naturally, Indian nationalists have taken the opposite view. For them, British medicine was deployed only in small enclaves of colonial power; no money was spent to improve the health of the mass of the population. Where sanitary measures were introduced it was with such spectacular clumsiness and insensitivity that they sparked public disturbances, as in the riots which followed the imposition of plague regulations in Bombay and Cawnpore in the late 1890s. In such accounts medical history merges into the history of popular resistance to alien rule.

These two books represent a more reflective and nuanced stage of the debate. Neither accepts the contemporary British estimate of the effects of medical intervention; both deal with indigenous resistance to its more brutal forms. Yet neither provides evidence for the bleakest view of colonial medicine. They demonstrate that public health benefits did very slowly and unevenly spread to the Indian population, though often through the efforts of Indian doctors and philanthropists.

David Arnold’s book covers the early 19th century in greater detail and includes a chapter on the anguished responses to the first cholera pandemic of 1818-25. He provides fascinating material on the period when Europeans were trying to come to grips with Indian medical knowledge and dealing with Indian practitioners with much less contempt than became common later. Mindful of the discovery of quinine bark by the Jesuits in the New World, Europeans of the Enlightenment could not afford to ignore the possibility that the tropics hid other such ‘magic bullets’, or that indigenous physicians were hoarding medical lore more advanced than the West’s. In the 1780s, Sir William Jones, the great Sanskrit scholar, had included medical remedies among some of the very earliest translations he made from the ancient Indian classics. Over the following decades, large numbers of Indian pharmacopoeia were collected and published. In the 1820s, Whitelaw Ainslie of the Madras Medical Staff asserted that the ancient Indians had made great strides in medical sciences and that the modern practitioners were ‘correct, obliging and communicative’. Transfixed by that classic ‘flesh-eating bug’, cholera, Europeans knew they themselves had little to crow about. The most modern remedies then included massive bleeding, the application of mercury and the denial of fluids to the patient: all likely to hasten an agonising death. A few perceptive expatriate Britons noticed, however, that they stood a better chance of survival if they were treated according to the more thoughtful Indian authorities, who recommended copious draughts of herb and kid’s meat broth instead of bleeding and purging.

Why, then, did the mood change, so that by mid-century, Indian practitioners were reduced to a lowly status and Indian medical knowledge was disparaged as primitive, even laughable? One answer is the professionalisation of medicine and the emergence of the Indian Medical Service as a rule-bound cadre. The IMS was in many ways the intelligentsia of British India. Its practitioners were drawn from the brightest and best of the grammar schools and ‘new’ universities, and especially from Scotland and Ireland. They had unique access to Indian society and made major intellectual advances in Oriental scholarship and early anthropology. But all professions are jealous. As the IMS became more self-confident and hidebound, it fretted over the way in which the Company’s Indian soldiers and even deathly-ill Europeans continued to put themselves in the hands of Indian practitioners when in direst need. This, said one doctor, ‘can only throw undeserved discredit on our profession and serve to foster native prejudice against us’. As the British became more enamoured of their status as a ruling race, physical and intellectual contact with Indians had to be reduced. Indian medical practitioners might still be allowed to have some ‘dexterity’ in removing a guinea worm or ‘couching’ a cataract; but they were denounced as theoretical idiots, for theory is the fetish of all emerging professions.

A second reason for the disrepute of Indian medicine was the growing ideological investment in British medicine as a justification of Empire. This became more necessary as the first generation of English-educated Indian critics began to emerge in the great port cities of Madras, Bombay and Calcutta. As early as 1802, Lord Wellesley, the Governor-General, hailed the introduction of vaccination against smallpox as a means of displaying the superior benevolence of alien rule to a marvelling Indian population. In an early campaign of colonial propaganda, Edward Jenner, discoverer of vaccination, was portrayed as a saviour of mankind and dialogues written in Indian languages for vaccinators urged natives to ‘pray for the stability of the English Empire’. For all that, the hostility of indigenous inoculators slowed the spread of the technique, as did resistance by high-caste people to what they took to be pollution by impure substances. But vaccination and, later, large public health and sanitation projects, remained closely tied to British perceptions of their own power in the subcontinent. It offered, as Arnold argues in Foucauldian vein, a mode of controlling and ‘knowing’ the body of the Indian subject.

Mark Harrison’s book concentrates on the later 19th and early 20th centuries. He carefully charts the origins and organisation of the IMS and its relationship with colonial government. Despite the achievements of Sir Ronald Ross and his team, who discovered the malaria vector, the IMS was often slow to respond to new ideas and its development was closely bound up with perceived threats to the stability of British rule. The painfully slow diffusion of modern remedies among the population was justified on the grounds that Western medicine might provoke resistance from already embittered Indians. It was only because of the threats constituted by plague and malaria to government revenues, trade and agricultural development that a more comprehensive system of public health provision came into being in the first two decades of the 20th century.

This paid off. The main reason Western medicine established dominance in India was that, when backed up with resources, it worked better than indigenous medicine. Harrison’s figures show a slow decline in British, and a slower decline in Indian deaths from major diseases after the 1880s. Local government bodies also allocated a modestly increasing proportion of their funds to sanitation and public health projects over the same period. Government kept a close eye on the implications for health of pilgrimages to Mecca and Medina, though this often brought them into conflict with Muslim authorities. In some areas, the interests of the colonial government in keeping trade and agriculture functioning coincided with that of the new generation of Indian public figures.

These improvements were often pushed through against heavy odds, however. Harrison’s book includes a valuable discussion of the politics of public health in late 19th-century Calcutta, where financial interest rather than any religious or cultural aversion to Western methods held back medical improvements. European residents paid scant attention to the needs of the ‘native city’, and Indian landlords and millowners, who were dominant in the Calcutta Corporation, saw little purpose in raising taxes to improve the medical and sanitary conditions of their poorer countrymen.

Both books are strong on the analysis of the ideologies and structures of British colonial medicine. They also include convincing accounts of Indian resistance to the ‘colonisation’ of their bodies by medical methods which often smacked of violence and condescension. Future historians, however, will wish to enter further into the issue of what exactly constituted ‘medicine’ in India and how the values it embodied were changed by Western impact. For health in the modern Western sense was for Indians part of a wider feeling of ‘well-being’. Both the Muslim Greek-derived tradition and the ancient Hindu tradition of medicine were deeply environmentalist in their assumptions. We are what we eat. We take on the coloration of where we live. It was these beliefs perhaps which made it easier for the Europeans of the early 19th century, to whom they would not have seemed strange, to accept some Indian remedies. Indigenous medicine treated the whole person, and the whole of nature was capable of physical and moral transformation. It merged with cooking, erotics and the preparation of the philosopher’s stone by the many alchemists still practising in India. Disease was not an invasive external enemy, so much as an imbalance between inner humours and outer conditions, conditions that might include the effects of the heavenly bodies, previous evil acts or the local vegetation. Medicine was designed not simply to kill disease but to adjust the balance between the body, the mind and the external world.

An interesting question is how, against this background, Western medicine began to get its purchase. In the early days the British deliberately recruited men of the old medical families and castes into the new service. Even fear and loathing of the pollution of dissection was overcome by the obvious rewards of medical practice, which combined intellectual status with the possibility of wealth to which few Indians could aspire in those professions that were dominated by Europeans. Questions of purity and pollution had in any case always been negotiable and contingent. The mass of society, of course, saw little of these new Western doctors. They saw hardly more of revived traditional practitioners, who used the old remedies but reinforced them with the panoply of pills, certificates and apparatus beloved of Western medicine. Change came about by slow diffusion and mimicry. The common pan-shop selling betel nut, tobacco and medical remedies, began to sport a few Western drugs and the ever-present medicinal brandy. The native cataract doctor acquired a range of European instruments. Army medical orderlies went back to their ancestral villages and set bones with more precision than the traditional potter-caste which had once performed this service. It was in this way, rather than through the noisy debates between allopathic and classical herbalist physicians in Calcutta, that the hegemony of Western medical knowledge was established.

Yet to put these two books into perspective it is important to remember how few Indians, even at the end of the Raj, could afford the services of even the lowliest medical specialist, indigenous or Western. For many people, fasting, special diets, prayers or the ministrations of the local holy man were the last and only resort in time of illness. The anthropologist McKim Marriot asserted in the Fifties that Western medical facilities had ‘hardly touched’ the villages of north India. Even today the culture of pills and potions often remains a ruinous last throw for peasant families who have tried everything that nature and prayer could offer. In 1947, average Indian life expectancy was barely half that of citizens of the modern West. The new medical history of India helps remind us of that brute fact.