This is an investigation into how serious the kala-azar (visceral leishmaniasis) situation was in colonial Bihar, what the government's policy was to control it and how the people responded to it. Until 1903, medical men had little idea about the true nature of this disease, which spread rapidly in the wake of the opening up of communication by rail and road. British medical intervention against kala-azar succeeded only in 1919 with the introduction of the antimony treatment. Till then, and after, the powers that be failed to prevent and eradicate the disease, with a lack of qualified personnel, funds, treatment centres, sanitary measures and, above all, political will hampering whatever modest efforts were made.
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200847Black Fever in Bihar: Experiences and ResponsesAchintya Kumar DuttaAchintya Kumar Dutta (achintya6@rediffmail.com) is at the department of history in the University of Burdwan, West Bengal.This is an investigation into how serious the kala-azar (visceral leishmaniasis) situation was in colonial Bihar, what the government’s policy was to control it and how the people responded to it. Until 1903, medical men had little idea about the true nature of this disease, which spread rapidly in the wake of the opening up of communication by rail and road. British medical intervention against kala-azar succeeded only in 1919 with the introduction of the antimony treatment. Till then, and after, the powers that be failed to prevent and eradicate the disease, with a lack of qualified personnel, funds, treatment centres, sanitary measures and, above all, political will hampering whatever modest efforts were made. Black fever (visceral leishmaniasis) or kala-azar, as it is commonly called in India, is an infective disease caused by a protozoan parasite known as Leishman Donavan body, which is transmitted to man by a species of sand fly. Its characteristic symptoms are an extended fever, sometimes acute or sub-acute, enlargement of the spleen and frequently of the liver, a darkening of the skin, anaemia and progressive emacia-tion. Kala-azar was a fatal disease that occurred both epidemi-cally and endemically in India during the colonial period. With a mortality rate of more than 95 per cent, its effect on the popula-tion was devastating. It was a major health problem in British India, affecting a large part of the Indian subcontinent, with Assam, Bengal and Bihar suffering the most. It was also preva-lent in China, the Mediterranean basin, in European countries such as Italy, Spain and Greece, and in South America, making it a global phenomenon. Kala-azar appeared to be a sui generis disease to medical practitioners. Since its symptoms resembled those of malarial fever, they often misdiagnosed it as a “bad form of malaria”. Until 1903, medical men in England and India had no definite idea about the true nature of kala-azar and the same disease was known by different names – dum dum fever, malarial cachexia, chronic malaria, catchetic fever and so on.1 The people of Bihar called it ‘kala-dukh’ and the Garos called it ‘sarkari bemari’.2 Though kala-azar spread rapidly after the 1870s and became a menace to the people, British medical intervention was not suc-cessful in preventing it. So the ineffectiveness of the policy to tackle kala-azar was widely felt. This paper aims to show how serious the kala-azar situation was in Bihar, what the govern-ment’s policy to control it was and how the people responded toit. Incidence of Kala-azarIt seems to be difficult to date kala-azar’s first appearance in India. It has been pointed out that few accurate records of it can be found before the 1820s because there were so many types of fevers in the tropics, malaria had not been identified and “died of a fever” was a widely used phrase.3 It is often claimed that the outbreak of a fever known as ‘jwar vikar’ in Jessore (1824-25) and the dreaded Burdwan fever (1863-1874) were kala-azar. Leonard Rogers held that kala-azar had spread to Assam from Rangpur in Bengal and that Burdwan fever, which caused havoc in Bengal’s Burdwan dis-trict in the 1860s and 1870s, was a kala-azar epidemic.4 But, in both cases, he was unable to show a direct connection between the two. U N Brahmachari concluded, from clinical and statistical evidence, that Burdwan fever was mostly of malarial origin.5 Interestingly, most of the health officials who served in Burd-wan in the 1870s (James Elliot, J G French, David Wilkies and so
EPIDEMICS IN SOUTH ASIAN HISTORYmarch 22, 2008 EPW Economic & Political Weekly48on) observed both remittent and intermittent fever during the fever epidemic.6 Some of them found that it was amenable to quinine in some places, whereas others observed that quinine had only a temporary effect. Most of them used the term “epidemic fever” or “malarial fever” instead of malaria. There is no denying that kala-azar occurred in Bengal in the 19th century. But it is very difficult to establish that the kala-azar epidemic in Assam was an extension of the epidemic in North Bengal or that Burd-wan fever was kala-azar’s debut in India until a direct connection between the two is established. However, it appears that in some of the epidemics, malaria and kala-azar ran together and that in some of them, one disease was more prevalent than the other. Perhaps kala-azar was more common in Assam while epidemic malaria dominated in Burdwan.7 However, in Bihar, kala-azar was first reported in 1882 in Patna district, when a malarious type of fever with enlargement of the spleen and a peculiar cachexia, formerly unknown in this part, was prevalent and mistaken for malarial cachexia. This form of fever with Leishman-Donovan bodies was very common in the district and other parts of Bihar in the early 20th century as well as later, after the identity of kala-azar as a separate disease had been clearly established.8D F Michael, medical officer, Imperial Agricultural Research Institute and College (IARIC) in Pusa Estate, stated in the 1920s that kala-azar had been prevalent for long in North Bihar. The people confirmed that it had been known to them for many years as an incurable disease and they dreaded it as much as the plague or cholera.9 The outbreak of kala-azar was repeatedly reported in official records until the end of British rule. The notable epidemics came in 1891, 1917, 1933 and 1939 and it continued to act upon endemi-cally until the 1950s.10 The incidence of kala-azar rapidly increased in the 1900s, affecting a large number of districts – Patna, Gaya, Sahabad, Monghyr, Saran and Darbhanga among them. The situation in North Bihar was appalling in the 1930s and 1940s. Of the 92,000 cases treated in the hospitals and dispensa-ries of Bihar in 1939, 83,961 were in the districts of north Bihar.11 Further testimony to the alarming situation comes in 1944 when 170 villages in or near the Kosi belt in Darbhanga district were affected by the disease. In many villages in this area no children of three to four years could be found, and pregnant women did not survive for long.12 Working out the rate of incidence of this disease and the exact number of deaths it caused during colonial rule is a difficult task because there were many problems with the investigation to diagnose it. There was no suitable hospital where a study of the prevailing forms of the spleenic enlargement could be made.13 The rural system of maintaining vital statistics and collecting mortality figures was not reliable. Kala-azar and malaria were intermixed in many cases. As Leonard Rogers and W H C Forster acknowledged, the fact that it was very difficult to distinguish kala-azar from chronic malaria by purely clinical means in a live patient made it even more difficult to distinguish the two diseases from a history of the case after death. Many of the cases, which were recorded as “chronic malaria” or “malarial cachexia” or “en-larged spleen”, were nothing other than kala-azar. Only qualified medical experts could distinguish them; but they were hardly available in the villages. Sanitary and public health reports reveal that the data collected regarding deaths due to epidemic diseases, especially in the rural areas, were not very accurate. For, except in the towns and thana headquarters, there was a dearth of med-ical men and a diagnosis of the cause of death was made by the village ‘chowkidar’ or patients’ relations.14 Hospital and dispensary returns show only a small number of kala-azar cases and deaths due to it. At first sight one may get the impression that the disease was not prevalent to any appreciable extent. But before accepting this idea one should consider that most of these cases came from nearby villages and people in dis-tant villages tried to avoid long journeys. This cannot therefore reflect the real state of affairs, and closer investigations undoubt-edly point to the disease being endemic in the whole of Bihar.15 Moreover, many deaths, even in hospital statistics, were probably put down to malaria though they had really been due to kala-azar.16 The incidence of kala-azar was actually much higher than it was supposed to be. The mortality figures due to it seen in the hospital and dispensary returns are only a rough estimate. Official reports show that fever (intermittent and others) was exceedingly common among the people, that it was the most severe of the prevailing diseases and that mortality due to “fever” had been increasing.Kala-azar is said to have been the principal cause for the increase in mortality supposedly caused by “fever”. This can be reinforced by the observations of some medical men who dealt with it. Sanitary commissioners like W C Ross and P F Plomer observed that malaria was only responsible for a small proportion of deaths due to “fever”.17 L Cook, IGCH, Bihar and Orissa, pointed out in 1930-31 that kala-azar was one of the dis-eases that swelled the death roll from fever and the actual inci-dence of the disease must have been very high.18 Deaths due to kala-azar were registered under “fever” on many occasions. It was also admitted in the editorial of a renowned medical journal that the number of kala-azar cases coming to the Calcutta School of Tropical Medicine from Bihar, Assam and Bengal was higher than malaria cases.19 Kala-azar Established as an EpidemicLet us come to the more important question of why kala-azar was established as an epidemic in Bihar. This question may be addressed in the light of the ongoing controversy on the relation-ship between the tropical climate and epidemic diseases.In the neocolonial literature, the littoral countries of the Indian Ocean are described as a disease zone. India, in particular, is seen as a quagmire of lethal diseases and epidemics. The plague, malaria, cholera and smallpox are classified as Indian epidemics thriving on an enervating climate, untidiness, obscurantism and the lack of social services among the people. It is argued that the ruling class was not likely to enjoy a healthy life here and they migrated to India only to face death.20 The binary contrast bet-ween the “dark” east and the “civilised” west is also highlighted in the writings of colonial medical officers and imperial politicians. But many of these constructs are empirically untenable. Most of the diseases stated above were of global occurrence and some like the plague and syphilis were of European origin. The plague had been the most dreaded epidemic since the days of ancient
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200849Rome. Britain was pulverised by the plague from the 13th to the 17th centuries.21Cholera, smallpox and malaria were also ram-pant in Europe and on the American continent. We know that Plini, a Roman historian of the first century, said in a celebrated epigram that “Malaria has ruined and is ruining Italy”.22 Presumably the tropical climate did not abruptly change its character in colonial India. It was the same tropical climate that existed in pre-colonial India. But the outbreak of epidemics occurred repeatedly only during colonial rule, affecting the sub-continent as a whole. Cholera was known in India much before the British arrived but its appearance in an extremely virulent and fatal form was recorded only in the first quarter of the 19th century.23 Some of these lethal diseases also continued to act as endemic for quite a long time in the areas affected by the epi-demic. Though we see references to severe outbreaks of pesti-lence in a few parts of pre-colonial India, these were localised, occasional phenomena. For instance, in 1575, Gouda, once a magnificent city and the seat of wealth and luxury, was humbled by the outbreak of a pestilence – the cause of which was unknown – that killed thousands of people.24 In 1574, many people died in a virulent epidemic of smallpox in Assam.25 Recent writers have been critical about colonialism, regarding it as a major health hazard for indigenous people and something responsible for the outbreak of epidemics in India. The plague became an epidemic because of official negligence. Malaria was very much connected with British railway expansion in India, the migration of labourers and their concentration in unhygienic colonies near mines and factories and on British plantations. Not to mention an inadequate network of hospitals and dispensaries. Some epidemic diseases were unwittingly introduced by the Europeans to their colonies. The plague was brought to India by the Europeans, just as smallpox and measles accompanied the Spanish conquerors of Mexico and Peru in the early 16th century.26 British citizens who travelled to India carried incipient germs and these flared up in the inter-communicating zone when they met the “native” population. The Europeans also brought venereal diseases, such as syphilis, which was called ‘firangi roga’ (disease of the Europeans). The white soldiers were potent disseminators of this disease, about which K Ballhatchet has so vividly written in his Race, Sex and Class under the Raj.European commercial and political penetration in the 19th century and the creation of the colonial infrastructure facilitated the spread of disease vectors – the mosquitoes, fleas and lice by which epidemics are communicated – and the dissemination of diseases.27 The unhygienic coolie lines where labourers were forced to stay by the British capitalists facilitated diffusion of epi-demic diseases. Blaming the common people for their ignorance of sanitary considerations is pointless when it is the apathy and neg-ligence of the government that has to be underlined. There seems no doubt that colonial economic exploitation and the ecological changes it brought about have had far-reaching and enduring effects on public health. For instance, the expansion of irrigation canals and the construction of railway embankments created favourable habitats for malaria-carrying mosquitoes in India.28 The occurrence of kala-azar epidemics in India has also been attributed to climate, which is not convincing. For, this disease was not confined to India, it occurred even in the temperate zone. There was no racial or class immunity to it. Europe’s “civilised” people with clean habits also suffered from it. The global occur-rence of kala-azar would seem to indicate that the vector, the sand fly, had a worldwide existence. Sand flies were common in Assam and were there long before the outbreak of kala-azar in the Garo Hills in an epidemic form.29 So the possibility that sand flies aided the spread of the disease cannot be ignored. They must have found conditions suitable for further breeding after planta-tions grew up in the 19th century. The spread of kala-azar rapidly followed the opening up of communication by rail and road for British commercial and mili-tary penetration. During the course of his investigation in 1910 in Assam, Leonard Rogers had apprehensions the railway would spread kala-azar over the Assam valley. It came true a few years later. The opening up of tea plantations in large areas of Assam and the movement of tea-garden workers caused the diffusion of the disease not only throughout Assam but also to other parts of India.30 The unhygienic coolie lines where the labourers were forced to stay on the tea plantations facilitated the spread of this epidemic disease.Entry of Kala-azar into BiharKala-azar had never been heard of in Bihar in pre-colonial times. It was British economic policy that made Bihar a kala-azar-affected area. There was agricultural distress in Bihar in the second half of the 19th century. Famines and scarcities followed each other in quick succession. Indebtedness was very widespread and the material condition of the cultivating classes was bad, even worse than in Bengal.31 The population of Bihar increased during the second half of the 19th century but there was only a limited in-crease in the area of land under cultivation. The result was im-poverishment. The low price of cereals kept cultivators in poverty and landless labourers were in a wretched state. Landless agri-cultural workers and even members of many poor landowning agricultural families had to work as coolies in different sectors to make a living, resulting an exodus of labourers from Bihar to the jute mills and tea plantation areas of Bengal and Assam.32 Eco-nomic exploitation led to the destruction of village industries and artisans and craftsmen deprived of their occupation fell back on cultivation. Ultimately all had to depend upon land. Thus labour became cheap and this was exploited in different ways by the planters, the miners or the contractors.33 The civil surgeon of Saran district once estimated that about half a million people left the district a year to take up work elsewhere.34 A large number of labourers for Assam’s tea gardens were drawn from Bengal and Bihar. Most of them came from the tribal tracts and were absorbed as labour, and sometimes as tenants, in the tea plantations. In 1884-85, 21.6 per cent of the plantation labour force in Assam was recruited from United Province and Bihar. In 1889, half of it was from Chhota Nagpur, about a quarter from Bengal and only 5 per cent from Assam itself.35 Thus Assam got Bihar’s cheap labourers and Bihar got kala-azar in return. In Bihar, kala-azar was regarded as a disease imported by the labourers returning from the kala-azar areas of North Bengal and Assam.36 There was constant interaction between some parts of
EPIDEMICS IN SOUTH ASIAN HISTORYmarch 22, 2008 EPW Economic & Political Weekly50Bihar and the plantation sectors of Assam and Bengal. A large number of coolies who were employed in rail and road construction were also drawn from Bihar. Needless to say, the condition of the tea plantation workers in Assam was deplorable. Rising prices and relatively low wages worsened their economic condition. So when they fell sick, they returned to their homes, bringing the disease which they had acquired with them. Thus kala-azar was brought to some districts of Bihar and close association between the infected people and healthy people helped diffuse it. In 1913, the civil surgeon of Saran district rightly expressed the worry that this disease would become firmly established in the district.37 Medical Intervention There was no specific treatment for kala-azar before 1919 and no remarkable improvement occurred in the preventive measures either. British efforts at medical intervention succeeded in 1919 with the introduction of an antimony treatment in the form of tarter emetic. Kala-azar attracted much attention of the govern-ment in Bihar after 1920 when it took a huge toll of labourers and people in and around the Pusa Estate. Kala-azar might also possi-bly have seriously affected the supply of labourers to plantations and mines, and for rail and road work. A special kala-azar enquiry at Calcutta School of Tropical Medicine (CSTM) stimulated interest in the disease and not as many cases as before were being overlooked.38 By 1921, more effi-cacious drugs such as urea stibamine and neostibosan had been found and were being used by doctors. The government set up kala-azar treatment centres and provided them a special grant to purchase new drugs. The hospitals and dispensaries in different districts also received an additional grant for kala-azar medi-cines. The budget for the treatment of the disease and the number of dispensaries gradually increased. The government extended its anti-kala-azar policy in North Bihar in the 1930s. By 1939, 20 special kala-azar treatment centres had been set up in north Bihar districts, run entirely at government cost. Some doctors were deputed to Patna Medical College Hospital to receive train-ing in conducting kala-azar serum tests.39 Thousands of cases were treated in these centres and mortality due to kala-azar declined phenomenally. The government of Bihar reinforced its anti-kala-azar policy with the help of regulations, the objective obviously being the prevention of its further spread. Treatment of the disease was made compulsory with special kala-azar regulations in 1942, framed under the Epidemic Diseases Act, 1897, on the lines of a notification issued by the Assam government.40 Before that, when treatment was voluntary, a considerable number of patients stopped treatment before completing the course, which still made them sources of new infection. The reasons for it varied.Many patients, probably tired of the lengthy course of antimony treat-ment, discontinued it after a few injections of antimony, when the fever ceased and they began to feel well. This made it difficult to effect a complete cure. Under the new regulations, kala-azar patients were ordered to undergo the full course of treatment. But keeping in mind the fallout of ruthless anti-plague measures in Bombay, the government abstained from taking any drastic action to force patients to undergo treatment, as was done in Assam. The new regulations were enforced as a pilot project in the Kanti area of Muzaffarpur district to study its effect because health officials thought it might cause panic among the people if enforced in Bihar as a whole. Non-compliance with the regula-tions was punishable under Section 188 of the Indian Penal Code; but penal power under the regulations was used very sparingly. The regulations were mainly used as a lever to induce sufferers to take treatment without resort to prosecution. All persons refus-ing or discontinuing treatment before a complete cure were re-ported to the sub-divisional officer, Muzaffarpur, who took steps to induce them to resume the treatment. It is evident that very few prosecutions were carried out by him.41 Arrangements were also made under this project to disinfect houses where kala-azar cases were found. The project was found to have encouraging results with a large number of cases being treated and cured. The assistant director of public health, north Bihar circle, recommended the enforcement of the Epidemic Diseases Act in other areas. A public health campaign using pamphlets and leaflets was on for awakening health consciousness among the people and mak-ing them aware of epidemic diseases. Lectures on sanitation and hygiene were also given in rural areas with the help of magic lanterns by the health officials. Preventive measures against infectious diseases had been facilitated by the enforcement of the Bihar and Orissa Municipal Amendment Act, 1935, which pro-vided for compulsory notification and reporting of cases suffer-ing from infectious diseases in the municipalities of the prov-ince.42 The government also initiated a kala-azar survey in some parts of Bihar and appointed doctors to assess the prevalence of the disease.Ineffectiveness of PolicyThe other side of the story is not so pleasing. Despite the discovery of effective drugs and their successful use in kala-azar cases, the disease could not be prevented or eradicated. It raises the ques-tion of how effective the government’s anti-kala-azar policy was. Kala-azar treatment either with tarter emetic or urea stibamine was difficult, requiring a careful technique and an experienced doctor. This was lacking in rural areas and the treatment was mostly carried out in large hospitals in urban areas. The number of kala-azarcentres in rural areas was very small. The special grant for purchasing drugs for kala-azar treatment was insuffi-cient and health officials had to appeal to the government repeat-edly to enhance it. Even the enhanced grant was not adequate to provide proper relief to the affected people. Governmental funding for kala-azar treatment in the 1920s and 1930s, when the disease was rampant, was utterly inade-quate. For example, the government sanctioned Rs 10,150 in 1926 and Rs 5,000 in 1927 for kala-azar cases.43 In 1929-30, a sum of Rs 10,000 was provided. In 1929-30, 1930-31, 1931-32 and 1932-33, Rs 7,500 was provided each year for purchasing urea stibamine and other drugs and distributing them to ‘sadar’ and sub-divisional hospitals. The IGCH noted that the Rs 10,000 for treating kala-azar in the medical budget of 1936-37 proved absolutely insuffi-cient and there was an ultimate expenditure of Rs 20,000.44 North Bihar was believed to be only a slightly infected area and adequate attention was not paid to the disease there. No
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200851treatment campaign was initiated in Bihar before 1939. The Rs55,000 provided as a non-recurring budget in 1938-39 for the anti-kala-azar scheme was too little, noted the IGCH.45Moreover, the government wanted to close 20 kala-azar treatment centres in 1941 at a time when the treatment was really necessary and the centres were doing useful work. This was, however, stopped when S L Mitra,DPH, Bihar requested the government to continue them for another year.46 The government also spent only a meagre amount on kala-azar research to further investigate the epidemio-logy and the means of the disease’s spread and its prevention. The government seems to have been reluctant to do things on a generous scale for health. A sum of Rs 2,00,000 had been pro-vided in the budget for 1923-24 for recurring grants to the district boards in Bihar and Orissa for the extension of medical relief in rural areas. The grant to some boards was at the rate of Rs 10 per thousand of population, to some others at the rate of Rs 5 per thousand of population and to some at the rate of Rs 3 per thou-sand of population.47 Medical aid was, however, so inadequate in Bihar’s tribal areas that most of the people had to depend on local resources, which were mainly village quacks or ‘ojhas’.48 The ig-norant people of Chhota Nagpur did not know what kala-azar was. Many of them had not got used to hospitals. The doctors did not bother to go to the forest areas of Chhota Nagpur, where al-most every person suffered from this disease without receiving any medical aid. No special kala-azar treatment centre appeared in Hazaribag before 1939. The government sanctioned only Rs 80 (Rs 20 for Hazaribag Sadar Hospital and Rs 60 for Chatra Hospi-tal) during 1938-39 for the purchase of drugs to treat kala-azar patients in the district.49 In the early 1930s, L Cook, IGCH, Bihar and Orissa, pointed out that it was necessary to stimulate local bodies to spend larger sums on drugs for kala-azar cases in dispensaries. But govern-ment grants to each district were totally inadequate, making it difficult for them to consider treatment with any drug.50The dis-trict board health organisations were still in their infancy and could not provide adequate means to tackle epidemics. They also faced a lack of funds. But the government, instead of extending help, accused them of failing to tackle epidemics. In fact, it was the government that had failed to provide kala-azar treatment facilities in the affected villagers. Most of the people in north Bihar suffered because of shoddy medical management. It was the government’s lack of interest in such affairs, not ignorance, which was responsible for the shameful picture. Timely, adequate measures for combating epidemics, which were urgent, were lacking in the districts, and there was no effective organisation of the health sector in Bihar.51 The number of hospitals, dispensa-ries and health personnel were not adequate to even meet the province’s general healthcare needs. During 1936-37, 586 hospi-tals and dispensaries with 1,872 medical personnel served more than 30 million people in Bihar, the ratio being 1: 17,000.52 There were some serious defects in the working of the newly set up kala-azar treatment centres. A definite survey had not been carried out in the villages and in the adjoining areas of the centres and it was not known whether all the existing cases in a village received treatment. The medical officers in charge of these centres were reluctant to carry out a survey of kala-azar cases in the villages, preferring to treat only the cases that came to them. Complaints were also made about some of the doctors attached to the centres carrying out private practices on the side.53 Non-availability of medicines in the centres was also reported by the people of various areas in North Bihar. Conducting a large-scale survey and providing curative treat-ment as a prophylactic measure against kala-azar could have pro-duced results. Rogers noted that with sufficient funds and medical staff a great deal could be done to eradicate this terrible disease. But that does not seem to have found room on the health agenda of the government, which failed to bring the rural masses under the purview of treatment facilities. It was reported in a leading newspaper that thousands died in the villages for want of medical relief and a definite policy for the control of epidemic diseases was lacking. The woeful preventive measures were most ineffective, it said.54 In 1944, the secretary of the Kosi Sufferers’ Association noted that hundreds of kala-azar and malaria-affected patients went without medical aid and met their end uncared for.55 No effective means of prevention, based on a true epidemio-logy of the disease, had been devised.The ongoing research had added to the existing knowledge and provided important clues to incriminate sand flies as the vector of this disease. But the state did little to utilise this knowledge for vector control, even after 1942 when the mystery of how the kala-azar infection was trans-mitted was finally solved.There were no short-term or long-term plans for vector control, either by spraying insecticides (pyre-thrum orDDT) or by providing better sanitation. Sanitary improvement was suggested as a remedy by Ross and Rogers. An improvement of sanitation in rural areas and a liberal use of lime wash might possibly have been effective in making conditions unsuitable for sand flies. But the issue of village sani-tation was hardly acknowledged and there was no real organisa-tion to oversee sanitation in the rural areas. Sanitary conditions in almost all the towns of Bihar, as in other parts of India, remained thoroughly unsatisfactory till the close of British rule. The district boards and other local bodies were not in a position to do much in this respect. It is true that the villagers lived in complete indifference to their unhealthy surroundings and a sense of public cleanliness was wanting. But it is equally true that the diseases were to a great extent responsible for unhealthy con-ditions in the villages. A proper campaign to create and increase sanitary consciousness in village folk as well as an improvement in the level of general sanitation were required to combat them effectively.People’s ResponseIt is argued that the people were apathetic to allopathic treat-ment and reluctant to visit the dispensaries for medical aid. But their reluctance to go to dispensaries for the treatment of kala-azar might be explained in a different way. There was no curative treatment in the hospitals and dispensaries as no specific drug for kala-azar existed in India before 1919. The people rightly believed that the disease was incurable. That the affected did not go to dispensaries was dubbed a prejudice but this prejudice seems to have been justified in the context of medicine’s failure to cure the sufferers. The doctors were helpless as modern medicine
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200853kala-azar victims in north Bihar, with the help of Congress workers and others.66 ConclusionsBritish medical intervention could do little to arrest the disease and save the victims until 1919. Success against kala-azar came only when the antimony treatment arrived. It could also not be effectively prevented because the necessary measures were not in place. Considering the number of people infected with kala-azar, the funds spent on campaigns against it were low, qualified staff was scarce and sanitation in the towns and villages re-mained deplorable, providing habitats for the disease vector. The kala-azar situation became so serious that the matter was raised and discussed in the legislative assembly. The members attracted the attention of the government to the need to eradicate the dis-ease. But the government failed to give any satisfactory answer to this point or take any effective steps for it. In fact, the govern-ment did not seem to have thought of stamping out the disease. Notes 1 Upendranath Brahmachari,A Treatise on Kala-azar, London, 1928, p 1. 2 The word ‘kala’ means black and ‘dukh’ means sorrow or pain. Thus the disease which caused a blackening of the skin and severe pain was called ‘kala-dukh’. Scholars point out that the name kala-dukh was derived probably from the characteris-tic dark pigmentation of the skin produced by it. It was a slow and wasting disease with great and progressive debility. The word kala may, however, signify ‘kal’, i e, death, or a fatal illness. As was pointed out by Ross, the popular use of the adjec-tive kala did not necessarily imply blackening of skin but meant “deadly”. Similarly, he pointed out, black death signifying the plague indicated the terrifying effect of the disease on the imagi-nation of the people, rather than describing the nature of the disorder. This explanation cannot be excluded because some cases of kala-azar did not show great pigmentation of skin. For details, see P C Roy Chaudhury,Bihar District Gazetters: Purnea, Patna, 1963, p 644; Upendranath Brah-machari, op cit, p 2. The phrase ‘sarkari bemari’ used by the Garos meant it was a British govern-ment disease or ‘saheb’s disease’ (British disease), not because the Europeans suffered from it, but because they said the disease had been unknown among them until after the sahebs took over the country. For details, see, Leonard Rogers, Report of an Investigation of the Epidemic of Malarial Fever in Assam or Kala-azar, Shillong, 1897, p 166. 3 For details, see Mary E Gibson, ‘The Identifica-tion of Kala-azar and the Discovery of Leishmania Donovani’,Medical History, Vol 27, 1983, London, pp 203-213. 4 Leonard Rogers, Fevers in the Tropics, London, 1908, pp 203-213.5 Upendranath Brahmachari, op cit, pp 3-7.6 For details, see Upendranath Brahmachari, op cit, p 2; Mary E Gibson, op cit, pp 203-13; Arabinda Samanta,Malarial Fever in Colonial Bengal 1820-1939 Social History of an Epidemic, Kolkata, 2002, Chapters 3 and 4; Report on Epidemic Remittent and Intermittent Fever Occurring in Parts of Burd-wan and Nuddea Divisions by Dr J Elliot, Calcutta, 1863, pp 21-29.7 Upendranath Brahmachari, op cit, p 8; Acharya Prafulla Chandra Roy and Prabodh Chandra Ban-dopadhyay, ‘Kala-azar O Tar Pratikarer Itihas’ (in Bengali) [‘Kala-azar and a History of its Rem-edy’],Bharatvarsa, Bhadra 1348 BY, pp 305-07.8L S S O’ Malley, Bengal District Gazetteers: Patna, Calcutta, 1907, pp 80-81.9 Reports of the Kala-azar Commission, India, Report No 1 (1924-1925), Calcutta, 1926, p 277 (hereafterKala-azar Commission Report).10 Sushma Gupta and O P Sood (ed), Kala-azar: Pro-ceedings of the Fifth Round Table Conferenceheld at New Delhi on May 22, 1999, Ranbaxy Science Foundation, Haryana, 1999, pp 15-26.11 Annual Public Health Report of the Province of Bihar for the Year 1938, p 18 (hereafterAPHR, Bihar).12 TheSearchlight, September 2, 1944, pp 1-3.13 Report on an Enquiry into the Prevalence of Ma-laria in Bengal Season 1908-09 by W H C Forster, in Government of Bengal, Municipal Department (Sanitary), Prog Nos 14-15, September 1909, West Bengal State Archives, Kolkata (WBSA).14 APHR, Bihar and Orissa, 1929, p 9.15 Kala-azar Commission Report, p 279.16 Triennial Report on the Working of Hospitals etc, in Bihar and Orissa for the years 1926, 1927 and 1928, p 13 (hereafterTriennial Report of Hospitals).17 Annual Sanitary Report of the Province of Bihar and Orissa for the Year 1923, p 10 (hereafterASR, Bihar and Orissa).18 Triennial Report of Hospitals, Bihar and Orissa, 1929, 1930 and 1931,p 13, Government of Bihar and Orissa (GOBO), Local Self-Government (LSG) Department (Medical), B Prog Nos. 428-34, September 1933, Bihar State Archives, Patna (hereafter BSA).19‘Kala-azar in India, the Present Position’ in Editorial, Indian Medical Gazette, July 1923, pp 317-20.20 Philip Curtin, Death by Migration: Europe’s Encounter with the Tropical World in the Nine-teenth Century, Cambridge, 1989 pp xiii-xviii, Chapters 1 and 3.21 Chittabrata Palit, ‘Epidemics and Empire: A Cri-tique of Public Health Policy in Colonial India’, History, Vol II, No 1, 1999, The University of Burd-wan, pp 59-67.22 Anil Kumar, Medicine and the Raj British Medical Policy in India 1835-1911, New Delhi, 1998, p 178. 23 Ibid, p 170.24 Excerpt from Charles J S Montagu,A Concise His-tory of Bengal from the Earliest Period; edition 1840, p 31 inRecords of Past Epidemics in India, date and place of publication are not available (National Archives of India, New Delhi), p 2; Ach-arya Prafulla Chandra Roy and Prabodh Chandra Bandopadhyay, op cit.25Excerpt from E A Gait, History of Assam, edition 1906, p 100 inRecords of Past Epidemics in India, p 2.26 David Arnold (ed), Imperial Medicine and Indi-genous Societies, New York, 1988, Introduction, pp 3-5.27 Ibid, p 5.28 Ira Klein, ‘Malaria and Mortality in Bengal 1840-1921’,Indian Economic and Social History Review, Vol IX, No 2, June 1972, pp 132-60.29 JohnM’Cosh,Topography of Assam, Calcutta 1837, p 52.30 ‘Kala-azar in Assam’,The Lancet, July 5, 1913, p 33.31 B K Sinha, ‘Economic Condition of Bihar (1859-1939)’ in K K Datta (ed), The Comprehensive Histo-ry of Bihar, Vol III, Part I, Patna, 1976, pp 488-541; Final Report of the Survey and Settlement Opera-tion in the District of Saran 1915-21 by Phanindra Nath Gupta, Patna, 1923, pp 48-50;Memorandum on the Material Condition of the People of Bengal and Bihar and Orissa in the Years 1902-03 to 1911-12 by L S S O’Malley, Darjeeling 1912, p 4.32R R Diwakar (ed), Bihar through the Ages, Varanasi, 2001 (Reprint), p 777.33 Radhakrishna Chaudhury, History of Bihar, Madhipura, Bihar, 1958, p 271.34 ASR, Bihar and Orissa, 1913, p 17.35 Amalendu Guha, Planter Raj to Swaraj Freedom Struggle and Electoral Politics in Assam 1826-1947, Tulika Books, New Delhi (revised edition), 2006, p 37.36 NKumar,Bihar District Gazetteer: Patna, Patna, 1970, p 102.37 ASR, Bihar and Orissa, 1913, p 17.38 Triennial Report of Hospitals, Bihar and Orissa Triennial Report 1923, 1924, 1925, p 9.39 APHR, Bihar, 1938 and 1940, pp 18 and 13 respec-tively.40 Government of Bihar (GoB), LSG Department (Medical), B Prog Nos 276-278, November 1942 (BSA).41 Ibid.42 S M Wasi, Bihar in 1936-37, Patna, 1938, p 60.43 Annual Returns of Hospitals and Dispensaries in Bihar and Orissa for 1926 and for 1927, pp 3, and 3 respectively.44 GOB, LSG Department (Medical), B Prog Nos 168-185, August 1940 (BSA). 45 Ibid. 46GOB, LSG Department (Medical), B Prog Nos 440-41, Aug 1941 (BSA). 47 GOBO, LSG Department (Medical), Prog No 38, September 1923, File No Medl 263 of 1923 (BSA).48 Dr Sachchidanand, ‘Culture of the Adivasi of Bihar’ in K K Datta (ed), op cit, Vol III, Part II, pp 293-336.49Bihar Legislative Assembly Debates: Official Report, Vol IV, No 35, 1939, pp 2324-25.50GOBO, LSG Department (Medical), B Prog Nos 428-34, September 1933 (BSA).51 APHR, Bihar, 1937, p 15.52 S M Wasi , op cit, p 62.53 GOB, LSG Department (Medical), B Prog Nos 276-278, November 1942 (BSA).54 The Indian Nation, April 18, 1937 and May 29, 1938, p 11 and 12 respectively.55 TheSearchlight, April 10, 1944, p 2.56 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA).57Bihar Legislative Assembly Debates, Official Report, Vol III, No 8, 1938, p 730.58 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA).59 Kala-azar Commission Report, p 283.60 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA). 61 TheSearchlight, April 10, 1944, p 2.62 Ibid, September 26, 1944, p 3, October 10, 1944, p 2.63Bihar Legislative Assembly Debates, Official Report, Vol II, Nos 1-23, December 1937, p 904; Vol No 22, 1938, p 1293, Vol IV, No 7, 1939, p 479. 64 Quacks mean those who had no knowledge of any particular system of medicine. ‘Vaidyas’ and ‘hakims’ were not quacks, though British medical practitioners and the government called them so.65Memorandum on the development of public health by the Indian Medical Association, Bihar Branch’ inPatna Journal of Medicine, Vol XIX, 1944, No 3, pp 126-36.66 TheSearchlight, September 3, 9 and October 6, 1944, pp 2, 2 and 2 respectively.
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200847Black Fever in Bihar: Experiences and ResponsesAchintya Kumar DuttaAchintya Kumar Dutta (achintya6@rediffmail.com) is at the department of history in the University of Burdwan, West Bengal.This is an investigation into how serious the kala-azar (visceral leishmaniasis) situation was in colonial Bihar, what the government’s policy was to control it and how the people responded to it. Until 1903, medical men had little idea about the true nature of this disease, which spread rapidly in the wake of the opening up of communication by rail and road. British medical intervention against kala-azar succeeded only in 1919 with the introduction of the antimony treatment. Till then, and after, the powers that be failed to prevent and eradicate the disease, with a lack of qualified personnel, funds, treatment centres, sanitary measures and, above all, political will hampering whatever modest efforts were made. Black fever (visceral leishmaniasis) or kala-azar, as it is commonly called in India, is an infective disease caused by a protozoan parasite known as Leishman Donavan body, which is transmitted to man by a species of sand fly. Its characteristic symptoms are an extended fever, sometimes acute or sub-acute, enlargement of the spleen and frequently of the liver, a darkening of the skin, anaemia and progressive emacia-tion. Kala-azar was a fatal disease that occurred both epidemi-cally and endemically in India during the colonial period. With a mortality rate of more than 95 per cent, its effect on the popula-tion was devastating. It was a major health problem in British India, affecting a large part of the Indian subcontinent, with Assam, Bengal and Bihar suffering the most. It was also preva-lent in China, the Mediterranean basin, in European countries such as Italy, Spain and Greece, and in South America, making it a global phenomenon. Kala-azar appeared to be a sui generis disease to medical practitioners. Since its symptoms resembled those of malarial fever, they often misdiagnosed it as a “bad form of malaria”. Until 1903, medical men in England and India had no definite idea about the true nature of kala-azar and the same disease was known by different names – dum dum fever, malarial cachexia, chronic malaria, catchetic fever and so on.1 The people of Bihar called it ‘kala-dukh’ and the Garos called it ‘sarkari bemari’.2 Though kala-azar spread rapidly after the 1870s and became a menace to the people, British medical intervention was not suc-cessful in preventing it. So the ineffectiveness of the policy to tackle kala-azar was widely felt. This paper aims to show how serious the kala-azar situation was in Bihar, what the govern-ment’s policy to control it was and how the people responded toit. Incidence of Kala-azarIt seems to be difficult to date kala-azar’s first appearance in India. It has been pointed out that few accurate records of it can be found before the 1820s because there were so many types of fevers in the tropics, malaria had not been identified and “died of a fever” was a widely used phrase.3 It is often claimed that the outbreak of a fever known as ‘jwar vikar’ in Jessore (1824-25) and the dreaded Burdwan fever (1863-1874) were kala-azar. Leonard Rogers held that kala-azar had spread to Assam from Rangpur in Bengal and that Burdwan fever, which caused havoc in Bengal’s Burdwan dis-trict in the 1860s and 1870s, was a kala-azar epidemic.4 But, in both cases, he was unable to show a direct connection between the two. U N Brahmachari concluded, from clinical and statistical evidence, that Burdwan fever was mostly of malarial origin.5 Interestingly, most of the health officials who served in Burd-wan in the 1870s (James Elliot, J G French, David Wilkies and so 
EPIDEMICS IN SOUTH ASIAN HISTORYmarch 22, 2008 EPW Economic & Political Weekly48on) observed both remittent and intermittent fever during the fever epidemic.6 Some of them found that it was amenable to quinine in some places, whereas others observed that quinine had only a temporary effect. Most of them used the term “epidemic fever” or “malarial fever” instead of malaria. There is no denying that kala-azar occurred in Bengal in the 19th century. But it is very difficult to establish that the kala-azar epidemic in Assam was an extension of the epidemic in North Bengal or that Burd-wan fever was kala-azar’s debut in India until a direct connection between the two is established. However, it appears that in some of the epidemics, malaria and kala-azar ran together and that in some of them, one disease was more prevalent than the other. Perhaps kala-azar was more common in Assam while epidemic malaria dominated in Burdwan.7 However, in Bihar, kala-azar was first reported in 1882 in Patna district, when a malarious type of fever with enlargement of the spleen and a peculiar cachexia, formerly unknown in this part, was prevalent and mistaken for malarial cachexia. This form of fever with Leishman-Donovan bodies was very common in the district and other parts of Bihar in the early 20th century as well as later, after the identity of kala-azar as a separate disease had been clearly established.8D F Michael, medical officer, Imperial Agricultural Research Institute and College (IARIC) in Pusa Estate, stated in the 1920s that kala-azar had been prevalent for long in North Bihar. The people confirmed that it had been known to them for many years as an incurable disease and they dreaded it as much as the plague or cholera.9 The outbreak of kala-azar was repeatedly reported in official records until the end of British rule. The notable epidemics came in 1891, 1917, 1933 and 1939 and it continued to act upon endemi-cally until the 1950s.10 The incidence of kala-azar rapidly increased in the 1900s, affecting a large number of districts – Patna, Gaya, Sahabad, Monghyr, Saran and Darbhanga among them. The situation in North Bihar was appalling in the 1930s and 1940s. Of the 92,000 cases treated in the hospitals and dispensa-ries of Bihar in 1939, 83,961 were in the districts of north Bihar.11 Further testimony to the alarming situation comes in 1944 when 170 villages in or near the Kosi belt in Darbhanga district were affected by the disease. In many villages in this area no children of three to four years could be found, and pregnant women did not survive for long.12 Working out the rate of incidence of this disease and the exact number of deaths it caused during colonial rule is a difficult task because there were many problems with the investigation to diagnose it. There was no suitable hospital where a study of the prevailing forms of the spleenic enlargement could be made.13 The rural system of maintaining vital statistics and collecting mortality figures was not reliable. Kala-azar and malaria were intermixed in many cases. As Leonard Rogers and W H C Forster acknowledged, the fact that it was very difficult to distinguish kala-azar from chronic malaria by purely clinical means in a live patient made it even more difficult to distinguish the two diseases from a history of the case after death. Many of the cases, which were recorded as “chronic malaria” or “malarial cachexia” or “en-larged spleen”, were nothing other than kala-azar. Only qualified medical experts could distinguish them; but they were hardly available in the villages. Sanitary and public health reports reveal that the data collected regarding deaths due to epidemic diseases, especially in the rural areas, were not very accurate. For, except in the towns and thana headquarters, there was a dearth of med-ical men and a diagnosis of the cause of death was made by the village ‘chowkidar’ or patients’ relations.14 Hospital and dispensary returns show only a small number of kala-azar cases and deaths due to it. At first sight one may get the impression that the disease was not prevalent to any appreciable extent. But before accepting this idea one should consider that most of these cases came from nearby villages and people in dis-tant villages tried to avoid long journeys. This cannot therefore reflect the real state of affairs, and closer investigations undoubt-edly point to the disease being endemic in the whole of Bihar.15 Moreover, many deaths, even in hospital statistics, were probably put down to malaria though they had really been due to kala-azar.16 The incidence of kala-azar was actually much higher than it was supposed to be. The mortality figures due to it seen in the hospital and dispensary returns are only a rough estimate. Official reports show that fever (intermittent and others) was exceedingly common among the people, that it was the most severe of the prevailing diseases and that mortality due to “fever” had been increasing.Kala-azar is said to have been the principal cause for the increase in mortality supposedly caused by “fever”. This can be reinforced by the observations of some medical men who dealt with it. Sanitary commissioners like W C Ross and P F Plomer observed that malaria was only responsible for a small proportion of deaths due to “fever”.17 L Cook, IGCH, Bihar and Orissa, pointed out in 1930-31 that kala-azar was one of the dis-eases that swelled the death roll from fever and the actual inci-dence of the disease must have been very high.18 Deaths due to kala-azar were registered under “fever” on many occasions. It was also admitted in the editorial of a renowned medical journal that the number of kala-azar cases coming to the Calcutta School of Tropical Medicine from Bihar, Assam and Bengal was higher than malaria cases.19 Kala-azar Established as an EpidemicLet us come to the more important question of why kala-azar was established as an epidemic in Bihar. This question may be addressed in the light of the ongoing controversy on the relation-ship between the tropical climate and epidemic diseases.In the neocolonial literature, the littoral countries of the Indian Ocean are described as a disease zone. India, in particular, is seen as a quagmire of lethal diseases and epidemics. The plague, malaria, cholera and smallpox are classified as Indian epidemics thriving on an enervating climate, untidiness, obscurantism and the lack of social services among the people. It is argued that the ruling class was not likely to enjoy a healthy life here and they migrated to India only to face death.20 The binary contrast bet-ween the “dark” east and the “civilised” west is also highlighted in the writings of colonial medical officers and imperial politicians. But many of these constructs are empirically untenable. Most of the diseases stated above were of global occurrence and some like the plague and syphilis were of European origin. The plague had been the most dreaded epidemic since the days of ancient 
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200849Rome. Britain was pulverised by the plague from the 13th to the 17th centuries.21Cholera, smallpox and malaria were also ram-pant in Europe and on the American continent. We know that Plini, a Roman historian of the first century, said in a celebrated epigram that “Malaria has ruined and is ruining Italy”.22 Presumably the tropical climate did not abruptly change its character in colonial India. It was the same tropical climate that existed in pre-colonial India. But the outbreak of epidemics occurred repeatedly only during colonial rule, affecting the sub-continent as a whole. Cholera was known in India much before the British arrived but its appearance in an extremely virulent and fatal form was recorded only in the first quarter of the 19th century.23 Some of these lethal diseases also continued to act as endemic for quite a long time in the areas affected by the epi-demic. Though we see references to severe outbreaks of pesti-lence in a few parts of pre-colonial India, these were localised, occasional phenomena. For instance, in 1575, Gouda, once a magnificent city and the seat of wealth and luxury, was humbled by the outbreak of a pestilence – the cause of which was unknown – that killed thousands of people.24 In 1574, many people died in a virulent epidemic of smallpox in Assam.25 Recent writers have been critical about colonialism, regarding it as a major health hazard for indigenous people and something responsible for the outbreak of epidemics in India. The plague became an epidemic because of official negligence. Malaria was very much connected with British railway expansion in India, the migration of labourers and their concentration in unhygienic colonies near mines and factories and on British plantations. Not to mention an inadequate network of hospitals and dispensaries. Some epidemic diseases were unwittingly introduced by the Europeans to their colonies. The plague was brought to India by the Europeans, just as smallpox and measles accompanied the Spanish conquerors of Mexico and Peru in the early 16th century.26 British citizens who travelled to India carried incipient germs and these flared up in the inter-communicating zone when they met the “native” population. The Europeans also brought venereal diseases, such as syphilis, which was called ‘firangi roga’ (disease of the Europeans). The white soldiers were potent disseminators of this disease, about which K Ballhatchet has so vividly written in his Race, Sex and Class under the Raj.European commercial and political penetration in the 19th century and the creation of the colonial infrastructure facilitated the spread of disease vectors – the mosquitoes, fleas and lice by which epidemics are communicated – and the dissemination of diseases.27 The unhygienic coolie lines where labourers were forced to stay by the British capitalists facilitated diffusion of epi-demic diseases. Blaming the common people for their ignorance of sanitary considerations is pointless when it is the apathy and neg-ligence of the government that has to be underlined. There seems no doubt that colonial economic exploitation and the ecological changes it brought about have had far-reaching and enduring effects on public health. For instance, the expansion of irrigation canals and the construction of railway embankments created favourable habitats for malaria-carrying mosquitoes in India.28 The occurrence of kala-azar epidemics in India has also been attributed to climate, which is not convincing. For, this disease was not confined to India, it occurred even in the temperate zone. There was no racial or class immunity to it. Europe’s “civilised” people with clean habits also suffered from it. The global occur-rence of kala-azar would seem to indicate that the vector, the sand fly, had a worldwide existence. Sand flies were common in Assam and were there long before the outbreak of kala-azar in the Garo Hills in an epidemic form.29 So the possibility that sand flies aided the spread of the disease cannot be ignored. They must have found conditions suitable for further breeding after planta-tions grew up in the 19th century. The spread of kala-azar rapidly followed the opening up of communication by rail and road for British commercial and mili-tary penetration. During the course of his investigation in 1910 in Assam, Leonard Rogers had apprehensions the railway would spread kala-azar over the Assam valley. It came true a few years later. The opening up of tea plantations in large areas of Assam and the movement of tea-garden workers caused the diffusion of the disease not only throughout Assam but also to other parts of India.30 The unhygienic coolie lines where the labourers were forced to stay on the tea plantations facilitated the spread of this epidemic disease.Entry of Kala-azar into BiharKala-azar had never been heard of in Bihar in pre-colonial times. It was British economic policy that made Bihar a kala-azar-affected area. There was agricultural distress in Bihar in the second half of the 19th century. Famines and scarcities followed each other in quick succession. Indebtedness was very widespread and the material condition of the cultivating classes was bad, even worse than in Bengal.31 The population of Bihar increased during the second half of the 19th century but there was only a limited in-crease in the area of land under cultivation. The result was im-poverishment. The low price of cereals kept cultivators in poverty and landless labourers were in a wretched state. Landless agri-cultural workers and even members of many poor landowning agricultural families had to work as coolies in different sectors to make a living, resulting an exodus of labourers from Bihar to the jute mills and tea plantation areas of Bengal and Assam.32 Eco-nomic exploitation led to the destruction of village industries and artisans and craftsmen deprived of their occupation fell back on cultivation. Ultimately all had to depend upon land. Thus labour became cheap and this was exploited in different ways by the planters, the miners or the contractors.33 The civil surgeon of Saran district once estimated that about half a million people left the district a year to take up work elsewhere.34 A large number of labourers for Assam’s tea gardens were drawn from Bengal and Bihar. Most of them came from the tribal tracts and were absorbed as labour, and sometimes as tenants, in the tea plantations. In 1884-85, 21.6 per cent of the plantation labour force in Assam was recruited from United Province and Bihar. In 1889, half of it was from Chhota Nagpur, about a quarter from Bengal and only 5 per cent from Assam itself.35 Thus Assam got Bihar’s cheap labourers and Bihar got kala-azar in return. In Bihar, kala-azar was regarded as a disease imported by the labourers returning from the kala-azar areas of North Bengal and Assam.36 There was constant interaction between some parts of 
EPIDEMICS IN SOUTH ASIAN HISTORYmarch 22, 2008 EPW Economic & Political Weekly50Bihar and the plantation sectors of Assam and Bengal. A large number of coolies who were employed in rail and road construction were also drawn from Bihar. Needless to say, the condition of the tea plantation workers in Assam was deplorable. Rising prices and relatively low wages worsened their economic condition. So when they fell sick, they returned to their homes, bringing the disease which they had acquired with them. Thus kala-azar was brought to some districts of Bihar and close association between the infected people and healthy people helped diffuse it. In 1913, the civil surgeon of Saran district rightly expressed the worry that this disease would become firmly established in the district.37 Medical Intervention There was no specific treatment for kala-azar before 1919 and no remarkable improvement occurred in the preventive measures either. British efforts at medical intervention succeeded in 1919 with the introduction of an antimony treatment in the form of tarter emetic. Kala-azar attracted much attention of the govern-ment in Bihar after 1920 when it took a huge toll of labourers and people in and around the Pusa Estate. Kala-azar might also possi-bly have seriously affected the supply of labourers to plantations and mines, and for rail and road work. A special kala-azar enquiry at Calcutta School of Tropical Medicine (CSTM) stimulated interest in the disease and not as many cases as before were being overlooked.38 By 1921, more effi-cacious drugs such as urea stibamine and neostibosan had been found and were being used by doctors. The government set up kala-azar treatment centres and provided them a special grant to purchase new drugs. The hospitals and dispensaries in different districts also received an additional grant for kala-azar medi-cines. The budget for the treatment of the disease and the number of dispensaries gradually increased. The government extended its anti-kala-azar policy in North Bihar in the 1930s. By 1939, 20 special kala-azar treatment centres had been set up in north Bihar districts, run entirely at government cost. Some doctors were deputed to Patna Medical College Hospital to receive train-ing in conducting kala-azar serum tests.39 Thousands of cases were treated in these centres and mortality due to kala-azar declined phenomenally. The government of Bihar reinforced its anti-kala-azar policy with the help of regulations, the objective obviously being the prevention of its further spread. Treatment of the disease was made compulsory with special kala-azar regulations in 1942, framed under the Epidemic Diseases Act, 1897, on the lines of a notification issued by the Assam government.40 Before that, when treatment was voluntary, a considerable number of patients stopped treatment before completing the course, which still made them sources of new infection. The reasons for it varied.Many patients, probably tired of the lengthy course of antimony treat-ment, discontinued it after a few injections of antimony, when the fever ceased and they began to feel well. This made it difficult to effect a complete cure. Under the new regulations, kala-azar patients were ordered to undergo the full course of treatment. But keeping in mind the fallout of ruthless anti-plague measures in Bombay, the government abstained from taking any drastic action to force patients to undergo treatment, as was done in Assam. The new regulations were enforced as a pilot project in the Kanti area of Muzaffarpur district to study its effect because health officials thought it might cause panic among the people if enforced in Bihar as a whole. Non-compliance with the regula-tions was punishable under Section 188 of the Indian Penal Code; but penal power under the regulations was used very sparingly. The regulations were mainly used as a lever to induce sufferers to take treatment without resort to prosecution. All persons refus-ing or discontinuing treatment before a complete cure were re-ported to the sub-divisional officer, Muzaffarpur, who took steps to induce them to resume the treatment. It is evident that very few prosecutions were carried out by him.41 Arrangements were also made under this project to disinfect houses where kala-azar cases were found. The project was found to have encouraging results with a large number of cases being treated and cured. The assistant director of public health, north Bihar circle, recommended the enforcement of the Epidemic Diseases Act in other areas. A public health campaign using pamphlets and leaflets was on for awakening health consciousness among the people and mak-ing them aware of epidemic diseases. Lectures on sanitation and hygiene were also given in rural areas with the help of magic lanterns by the health officials. Preventive measures against infectious diseases had been facilitated by the enforcement of the Bihar and Orissa Municipal Amendment Act, 1935, which pro-vided for compulsory notification and reporting of cases suffer-ing from infectious diseases in the municipalities of the prov-ince.42 The government also initiated a kala-azar survey in some parts of Bihar and appointed doctors to assess the prevalence of the disease.Ineffectiveness of PolicyThe other side of the story is not so pleasing. Despite the discovery of effective drugs and their successful use in kala-azar cases, the disease could not be prevented or eradicated. It raises the ques-tion of how effective the government’s anti-kala-azar policy was. Kala-azar treatment either with tarter emetic or urea stibamine was difficult, requiring a careful technique and an experienced doctor. This was lacking in rural areas and the treatment was mostly carried out in large hospitals in urban areas. The number of kala-azarcentres in rural areas was very small. The special grant for purchasing drugs for kala-azar treatment was insuffi-cient and health officials had to appeal to the government repeat-edly to enhance it. Even the enhanced grant was not adequate to provide proper relief to the affected people. Governmental funding for kala-azar treatment in the 1920s and 1930s, when the disease was rampant, was utterly inade-quate. For example, the government sanctioned Rs 10,150 in 1926 and Rs 5,000 in 1927 for kala-azar cases.43 In 1929-30, a sum of Rs 10,000 was provided. In 1929-30, 1930-31, 1931-32 and 1932-33, Rs 7,500 was provided each year for purchasing urea stibamine and other drugs and distributing them to ‘sadar’ and sub-divisional hospitals. The IGCH noted that the Rs 10,000 for treating kala-azar in the medical budget of 1936-37 proved absolutely insuffi-cient and there was an ultimate expenditure of Rs 20,000.44 North Bihar was believed to be only a slightly infected area and adequate attention was not paid to the disease there. No 
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200851treatment campaign was initiated in Bihar before 1939. The Rs55,000 provided as a non-recurring budget in 1938-39 for the anti-kala-azar scheme was too little, noted the IGCH.45Moreover, the government wanted to close 20 kala-azar treatment centres in 1941 at a time when the treatment was really necessary and the centres were doing useful work. This was, however, stopped when S L Mitra,DPH, Bihar requested the government to continue them for another year.46 The government also spent only a meagre amount on kala-azar research to further investigate the epidemio-logy and the means of the disease’s spread and its prevention. The government seems to have been reluctant to do things on a generous scale for health. A sum of Rs 2,00,000 had been pro-vided in the budget for 1923-24 for recurring grants to the district boards in Bihar and Orissa for the extension of medical relief in rural areas. The grant to some boards was at the rate of Rs 10 per thousand of population, to some others at the rate of Rs 5 per thousand of population and to some at the rate of Rs 3 per thou-sand of population.47 Medical aid was, however, so inadequate in Bihar’s tribal areas that most of the people had to depend on local resources, which were mainly village quacks or ‘ojhas’.48 The ig-norant people of Chhota Nagpur did not know what kala-azar was. Many of them had not got used to hospitals. The doctors did not bother to go to the forest areas of Chhota Nagpur, where al-most every person suffered from this disease without receiving any medical aid. No special kala-azar treatment centre appeared in Hazaribag before 1939. The government sanctioned only Rs 80 (Rs 20 for Hazaribag Sadar Hospital and Rs 60 for Chatra Hospi-tal) during 1938-39 for the purchase of drugs to treat kala-azar patients in the district.49 In the early 1930s, L Cook, IGCH, Bihar and Orissa, pointed out that it was necessary to stimulate local bodies to spend larger sums on drugs for kala-azar cases in dispensaries. But govern-ment grants to each district were totally inadequate, making it difficult for them to consider treatment with any drug.50The dis-trict board health organisations were still in their infancy and could not provide adequate means to tackle epidemics. They also faced a lack of funds. But the government, instead of extending help, accused them of failing to tackle epidemics. In fact, it was the government that had failed to provide kala-azar treatment facilities in the affected villagers. Most of the people in north Bihar suffered because of shoddy medical management. It was the government’s lack of interest in such affairs, not ignorance, which was responsible for the shameful picture. Timely, adequate measures for combating epidemics, which were urgent, were lacking in the districts, and there was no effective organisation of the health sector in Bihar.51 The number of hospitals, dispensa-ries and health personnel were not adequate to even meet the province’s general healthcare needs. During 1936-37, 586 hospi-tals and dispensaries with 1,872 medical personnel served more than 30 million people in Bihar, the ratio being 1: 17,000.52 There were some serious defects in the working of the newly set up kala-azar treatment centres. A definite survey had not been carried out in the villages and in the adjoining areas of the centres and it was not known whether all the existing cases in a village received treatment. The medical officers in charge of these centres were reluctant to carry out a survey of kala-azar cases in the villages, preferring to treat only the cases that came to them. Complaints were also made about some of the doctors attached to the centres carrying out private practices on the side.53 Non-availability of medicines in the centres was also reported by the people of various areas in North Bihar. Conducting a large-scale survey and providing curative treat-ment as a prophylactic measure against kala-azar could have pro-duced results. Rogers noted that with sufficient funds and medical staff a great deal could be done to eradicate this terrible disease. But that does not seem to have found room on the health agenda of the government, which failed to bring the rural masses under the purview of treatment facilities. It was reported in a leading newspaper that thousands died in the villages for want of medical relief and a definite policy for the control of epidemic diseases was lacking. The woeful preventive measures were most ineffective, it said.54 In 1944, the secretary of the Kosi Sufferers’ Association noted that hundreds of kala-azar and malaria-affected patients went without medical aid and met their end uncared for.55 No effective means of prevention, based on a true epidemio-logy of the disease, had been devised.The ongoing research had added to the existing knowledge and provided important clues to incriminate sand flies as the vector of this disease. But the state did little to utilise this knowledge for vector control, even after 1942 when the mystery of how the kala-azar infection was trans-mitted was finally solved.There were no short-term or long-term plans for vector control, either by spraying insecticides (pyre-thrum orDDT) or by providing better sanitation. Sanitary improvement was suggested as a remedy by Ross and Rogers. An improvement of sanitation in rural areas and a liberal use of lime wash might possibly have been effective in making conditions unsuitable for sand flies. But the issue of village sani-tation was hardly acknowledged and there was no real organisa-tion to oversee sanitation in the rural areas. Sanitary conditions in almost all the towns of Bihar, as in other parts of India, remained thoroughly unsatisfactory till the close of British rule. The district boards and other local bodies were not in a position to do much in this respect. It is true that the villagers lived in complete indifference to their unhealthy surroundings and a sense of public cleanliness was wanting. But it is equally true that the diseases were to a great extent responsible for unhealthy con-ditions in the villages. A proper campaign to create and increase sanitary consciousness in village folk as well as an improvement in the level of general sanitation were required to combat them effectively.People’s ResponseIt is argued that the people were apathetic to allopathic treat-ment and reluctant to visit the dispensaries for medical aid. But their reluctance to go to dispensaries for the treatment of kala-azar might be explained in a different way. There was no curative treatment in the hospitals and dispensaries as no specific drug for kala-azar existed in India before 1919. The people rightly believed that the disease was incurable. That the affected did not go to dispensaries was dubbed a prejudice but this prejudice seems to have been justified in the context of medicine’s failure to cure the sufferers. The doctors were helpless as modern medicine 
EPIDEMICS IN SOUTH ASIAN HISTORYEconomic & Political Weekly EPW march 22, 200853kala-azar victims in north Bihar, with the help of Congress workers and others.66 ConclusionsBritish medical intervention could do little to arrest the disease and save the victims until 1919. Success against kala-azar came only when the antimony treatment arrived. It could also not be effectively prevented because the necessary measures were not in place. Considering the number of people infected with kala-azar, the funds spent on campaigns against it were low, qualified staff was scarce and sanitation in the towns and villages re-mained deplorable, providing habitats for the disease vector. The kala-azar situation became so serious that the matter was raised and discussed in the legislative assembly. The members attracted the attention of the government to the need to eradicate the dis-ease. But the government failed to give any satisfactory answer to this point or take any effective steps for it. In fact, the govern-ment did not seem to have thought of stamping out the disease. Notes 1 Upendranath Brahmachari,A Treatise on Kala-azar, London, 1928, p 1. 2 The word ‘kala’ means black and ‘dukh’ means sorrow or pain. Thus the disease which caused a blackening of the skin and severe pain was called ‘kala-dukh’. Scholars point out that the name kala-dukh was derived probably from the characteris-tic dark pigmentation of the skin produced by it. It was a slow and wasting disease with great and progressive debility. The word kala may, however, signify ‘kal’, i e, death, or a fatal illness. As was pointed out by Ross, the popular use of the adjec-tive kala did not necessarily imply blackening of skin but meant “deadly”. Similarly, he pointed out, black death signifying the plague indicated the terrifying effect of the disease on the imagi-nation of the people, rather than describing the nature of the disorder. This explanation cannot be excluded because some cases of kala-azar did not show great pigmentation of skin. For details, see P C Roy Chaudhury,Bihar District Gazetters: Purnea, Patna, 1963, p 644; Upendranath Brah-machari, op cit, p 2. The phrase ‘sarkari bemari’ used by the Garos meant it was a British govern-ment disease or ‘saheb’s disease’ (British disease), not because the Europeans suffered from it, but because they said the disease had been unknown among them until after the sahebs took over the country. For details, see, Leonard Rogers, Report of an Investigation of the Epidemic of Malarial Fever in Assam or Kala-azar, Shillong, 1897, p 166. 3 For details, see Mary E Gibson, ‘The Identifica-tion of Kala-azar and the Discovery of Leishmania Donovani’,Medical History, Vol 27, 1983, London, pp 203-213. 4 Leonard Rogers, Fevers in the Tropics, London, 1908, pp 203-213.5 Upendranath Brahmachari, op cit, pp 3-7.6 For details, see Upendranath Brahmachari, op cit, p 2; Mary E Gibson, op cit, pp 203-13; Arabinda Samanta,Malarial Fever in Colonial Bengal 1820-1939 Social History of an Epidemic, Kolkata, 2002, Chapters 3 and 4; Report on Epidemic Remittent and Intermittent Fever Occurring in Parts of Burd-wan and Nuddea Divisions by Dr J Elliot, Calcutta, 1863, pp 21-29.7 Upendranath Brahmachari, op cit, p 8; Acharya Prafulla Chandra Roy and Prabodh Chandra Ban-dopadhyay, ‘Kala-azar O Tar Pratikarer Itihas’ (in Bengali) [‘Kala-azar and a History of its Rem-edy’],Bharatvarsa, Bhadra 1348 BY, pp 305-07.8L S S O’ Malley, Bengal District Gazetteers: Patna, Calcutta, 1907, pp 80-81.9 Reports of the Kala-azar Commission, India, Report No 1 (1924-1925), Calcutta, 1926, p 277 (hereafterKala-azar Commission Report).10 Sushma Gupta and O P Sood (ed), Kala-azar: Pro-ceedings of the Fifth Round Table Conferenceheld at New Delhi on May 22, 1999, Ranbaxy Science Foundation, Haryana, 1999, pp 15-26.11 Annual Public Health Report of the Province of Bihar for the Year 1938, p 18 (hereafterAPHR, Bihar).12 TheSearchlight, September 2, 1944, pp 1-3.13 Report on an Enquiry into the Prevalence of Ma-laria in Bengal Season 1908-09 by W H C Forster, in Government of Bengal, Municipal Department (Sanitary), Prog Nos 14-15, September 1909, West Bengal State Archives, Kolkata (WBSA).14 APHR, Bihar and Orissa, 1929, p 9.15 Kala-azar Commission Report, p 279.16 Triennial Report on the Working of Hospitals etc, in Bihar and Orissa for the years 1926, 1927 and 1928, p 13 (hereafterTriennial Report of Hospitals).17 Annual Sanitary Report of the Province of Bihar and Orissa for the Year 1923, p 10 (hereafterASR, Bihar and Orissa).18 Triennial Report of Hospitals, Bihar and Orissa, 1929, 1930 and 1931,p 13, Government of Bihar and Orissa (GOBO), Local Self-Government (LSG) Department (Medical), B Prog Nos. 428-34, September 1933, Bihar State Archives, Patna (hereafter BSA).19‘Kala-azar in India, the Present Position’ in Editorial, Indian Medical Gazette, July 1923, pp 317-20.20 Philip Curtin, Death by Migration: Europe’s Encounter with the Tropical World in the Nine-teenth Century, Cambridge, 1989 pp xiii-xviii, Chapters 1 and 3.21 Chittabrata Palit, ‘Epidemics and Empire: A Cri-tique of Public Health Policy in Colonial India’, History, Vol II, No 1, 1999, The University of Burd-wan, pp 59-67.22 Anil Kumar, Medicine and the Raj British Medical Policy in India 1835-1911, New Delhi, 1998, p 178. 23 Ibid, p 170.24 Excerpt from Charles J S Montagu,A Concise His-tory of Bengal from the Earliest Period; edition 1840, p 31 inRecords of Past Epidemics in India, date and place of publication are not available (National Archives of India, New Delhi), p 2; Ach-arya Prafulla Chandra Roy and Prabodh Chandra Bandopadhyay, op cit.25Excerpt from E A Gait, History of Assam, edition 1906, p 100 inRecords of Past Epidemics in India, p 2.26 David Arnold (ed), Imperial Medicine and Indi-genous Societies, New York, 1988, Introduction, pp 3-5.27 Ibid, p 5.28 Ira Klein, ‘Malaria and Mortality in Bengal 1840-1921’,Indian Economic and Social History Review, Vol IX, No 2, June 1972, pp 132-60.29 JohnM’Cosh,Topography of Assam, Calcutta 1837, p 52.30 ‘Kala-azar in Assam’,The Lancet, July 5, 1913, p 33.31 B K Sinha, ‘Economic Condition of Bihar (1859-1939)’ in K K Datta (ed), The Comprehensive Histo-ry of Bihar, Vol III, Part I, Patna, 1976, pp 488-541; Final Report of the Survey and Settlement Opera-tion in the District of Saran 1915-21 by Phanindra Nath Gupta, Patna, 1923, pp 48-50;Memorandum on the Material Condition of the People of Bengal and Bihar and Orissa in the Years 1902-03 to 1911-12 by L S S O’Malley, Darjeeling 1912, p 4.32R R Diwakar (ed), Bihar through the Ages, Varanasi, 2001 (Reprint), p 777.33 Radhakrishna Chaudhury, History of Bihar, Madhipura, Bihar, 1958, p 271.34 ASR, Bihar and Orissa, 1913, p 17.35 Amalendu Guha, Planter Raj to Swaraj Freedom Struggle and Electoral Politics in Assam 1826-1947, Tulika Books, New Delhi (revised edition), 2006, p 37.36 NKumar,Bihar District Gazetteer: Patna, Patna, 1970, p 102.37 ASR, Bihar and Orissa, 1913, p 17.38 Triennial Report of Hospitals, Bihar and Orissa Triennial Report 1923, 1924, 1925, p 9.39 APHR, Bihar, 1938 and 1940, pp 18 and 13 respec-tively.40 Government of Bihar (GoB), LSG Department (Medical), B Prog Nos 276-278, November 1942 (BSA).41 Ibid.42 S M Wasi, Bihar in 1936-37, Patna, 1938, p 60.43 Annual Returns of Hospitals and Dispensaries in Bihar and Orissa for 1926 and for 1927, pp 3, and 3 respectively.44 GOB, LSG Department (Medical), B Prog Nos 168-185, August 1940 (BSA). 45 Ibid. 46GOB, LSG Department (Medical), B Prog Nos 440-41, Aug 1941 (BSA). 47 GOBO, LSG Department (Medical), Prog No 38, September 1923, File No Medl 263 of 1923 (BSA).48 Dr Sachchidanand, ‘Culture of the Adivasi of Bihar’ in K K Datta (ed), op cit, Vol III, Part II, pp 293-336.49Bihar Legislative Assembly Debates: Official Report, Vol IV, No 35, 1939, pp 2324-25.50GOBO, LSG Department (Medical), B Prog Nos 428-34, September 1933 (BSA).51 APHR, Bihar, 1937, p 15.52 S M Wasi , op cit, p 62.53 GOB, LSG Department (Medical), B Prog Nos 276-278, November 1942 (BSA).54 The Indian Nation, April 18, 1937 and May 29, 1938, p 11 and 12 respectively.55 TheSearchlight, April 10, 1944, p 2.56 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA).57Bihar Legislative Assembly Debates, Official Report, Vol III, No 8, 1938, p 730.58 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA).59 Kala-azar Commission Report, p 283.60 GOBO, LSG Department (Medical), Prog No 7, October 1921 (BSA). 61 TheSearchlight, April 10, 1944, p 2.62 Ibid, September 26, 1944, p 3, October 10, 1944, p 2.63Bihar Legislative Assembly Debates, Official Report, Vol II, Nos 1-23, December 1937, p 904; Vol No 22, 1938, p 1293, Vol IV, No 7, 1939, p 479. 64 Quacks mean those who had no knowledge of any particular system of medicine. ‘Vaidyas’ and ‘hakims’ were not quacks, though British medical practitioners and the government called them so.65Memorandum on the development of public health by the Indian Medical Association, Bihar Branch’ inPatna Journal of Medicine, Vol XIX, 1944, No 3, pp 126-36.66 TheSearchlight, September 3, 9 and October 6, 1944, pp 2, 2 and 2 respectively.
