NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( viii )
STATEMENT No. V.
Showing the particulars of Vaccination by Inspecting Officers in the North-West Frontier Province during the year 1921-22.
Serial No.
1
1
2
3
4
5
6
7
8
9
10
11
12
DISTRICTS.
2
Hazara
...
...
Peshawar ... ...
Mardan Sub-Division
...
Kohat ... ...
Bannu
...
...
Dera Ismail Khan ...
Political Agencies.
Sherani Country
...
...
Kurram Agency ...
Tochi
„
...
Wana
„
...
Chitral
„
...
Malakand „
...
TOTAL ...
TOTAL NUMBER
OF PERSONS
VACCINATED.
Primary.
3
15,775
20,038
18,149
8,909
8,429
10,591
...
1,452
652
...
4,066
420
88,511
Re-vaccinations.
4
2,005
2,294
517
1,440
941
3,961
...
335
117
...
98
...
11,708
TOTAL NUMBER
INSPECTED.
By-Civil Surgeons.
Primary.
5
1,664
1,150
143
462
241
222
...
1,122
12
...
166
...
5,181
Re-vaccinations.
6
326
...
...
91
...
1,035
...
268
5
...
8
...
1,733
By Superinten-
dents.
Primary.
7
12,227
15,353
13,887
7,815
6,417
6,637
...
...
...
...
3,600
...
65,936
Re-vaccinations.
8
1,440
1,961
316
1,232
587
1,550
...
...
...
...
90
...
7,176
By Divisional
Inspectors.
Primary.
9
1,884
2,368
5,749
2,241
4,118
2,704
...
...
...
...
...
...
19,064
Re-Vaccinations.
10
239
744
27
237
164
401
...
...
...
...
...
...
1,812
PERCENTAGE OF INSPECTIONS TOTAL
NUMBER VACCINATED.
By Civil
Surgeons.
Primary.
11
10.54
5.73
.78
5.17
2.85
2.09
...
77.27
1.84
...
4.08
...
5.85
Re-vaccinations
12
16.25
...
...
6.31
...
26.13
...
80.00
4.27
...
8.16
...
14.80
By Superin-
tendents.
Primary.
13
77.50
76.61
76.51
87.42
76.13
62.66
...
...
...
...
88.53
...
74.49
Re-vaccinations.
14
71.82
95.48
61.12
85.52
82.38
39.13
...
...
...
...
91.83
...
61.20
By Divisional
Inspectors.
Primary.
15
11.94
11.76
31.67
25.06
48.85
25.53
...
...
...
...
...
...
21.53
Re-vaccinations
16
11.92
32.43
5.22
16.4
17.42
10.12
...
...
...
...
...
...
15.47
PERCENTAGE OF CASES FOUND SUCCESS-
FUL OF TOTAL NUMBER INSPECTED.
By Civil
Surgeons.
Primary.
17
88.10
100.0
97.90
95.67
100
64.86
...
97.05
100
...
90.30
...
93.30
Re-vaccinations
18
84.66
...
...
88.9
...
45.60
...
06.64
...
...
100
...
03.24
By Superin-
tendents.
Primary.
19
98.40
97.02
99.33
91.04
99.03
97.18
...
...
...
...
83.33
...
96.69
Re-vaccinations.
20
84.65
75.62
96.83
96.6
60.81
77.16
...
...
...
...
65.55
...
80.97
By Divisonal
Inspectors.
Primary.
21
80.63
93.45
98.88
50.6
98.34
96.19
...
...
...
...
...
...
90.23
Re-vaccinations.
22
58.99
59.94
74.07
74.2
81.09
61.84
...
...
...
...
...
...
64.23
PERCENTAGE
OF SUCCESS
REPORTED BY
VACCINATION.
Primary
23
97.45
98.10
99.46
98.72
99.16
97.20
...
96.62
90.80
...
91.50
98.30
97.93
Re-vaccinations.
24
89.30
77.88
97.94
87.65
65.63
76.90
...
93.73
52.67
...
74.44
...
81.21
Serial No.
25
1
2
3
4
5
6
7
8
9
10
11
12
( ix )
APPENDIX A.
Statement showing the number of vaccinations performed in Municipal towns
on children under one year of age.
Serial No.
1
1
2
3
4
5
6
7
8
9
10
11
12
13
TOWNS.
2
Hazara District.
Abbottabad ...
Nawanshahr (Notified Area)...
Buffa ... ...
Haripur ... ...
Peshawar District.
Peshawar ... ...
Nowshera Kalan (Notified
Area).
Becketganj-Khawajaganj
(Notified Area).
Kohat District.
Kohat ... ...
Bannu District.
Bannu ... ...
Lakki (Notified Area) ...
Dera Ismail Khan District.
Dera Ismail Khan ...
Kulachi ... ...
Tank (Notified Area) ...
Number of births during the year
3
112
281
306
218
2,437
311
256
646
529
172
1,216
201
116
Number of deaths among children
under one year during the year
1921-22.
4
33
84
110
56
580
39
70
120
80
36
177
58
33
Number of successful vaccinations
on children under one year of
age ending March 1922.
5
93
116
101
143
1,222
417
109
965
651
170
802
150
20
Date of extension
of the Vaccination
Act to towns.
6
21st May 1906.
Act not in force.
1st October 1904.
November 1904.
Act not in force.
December 1897.
20th January
1906.
( x )
APPENDIX B.
Statement showing the annual number of successful vaccinations and the annual
ratio of deaths from small-pox per 1,000 of population for the
five years ending 1921-22.
Serial No.
1
1
2
3
4
5
6
DISTRICTS.
2
Hazara ...
Peshawar ...
Mardan Sub-Division
Kohat ...
Bannu ...
Dera Ismail Khan ...
Total ...
Total in
Political
Agencies' Staff.
Total in Cantonment
Staff.
Total in Dispensary
Staff.
GRAND TOTAL ...
1917-18.
Number of successful cases.
3
50,021
22,236
15,357
10,364
6,338
8,952
113,268
8,485
1,872
...
123,625
Annual ratio of deaths from
small-pox per 1,000 of popu-
lation.
4
0,009
0.04
0.20
0.05
...
...
0.03
...
...
...
0.03
1918-19.
Number of successful cases.
5
42,842
19,358
13,442
9,319
6,346
8,137
99,444
12,142
3,008
105
114,699
Annual ratio of deaths from
small-pox per 1,000 of popu-
lation.
6
0.07
0.02
0.001
0.01
...
...
0.08
...
...
...
0.08
1919-20.
Number of successful cases.
7
43,318
22,206
14,625
9,507
9,464
19,815
118,935
8,671
3,839
...
131,445
Annual ratio of deaths from
small-pox per 1,000 of popu-
lation
8
0.60
1.08
0.87
0.54
0.40
0.12
0.81
...
...
...
0.81
1920-21.
Number of successful cases.
9
34,421
16,629
15,047
8,890
8,887
14,874
98,748
7,236
3,060
80
109,124
Annual ratio of deaths from
small-pox per 1,000 of popu-
lation.
10
0.24
0.16
0.15
0.36
1.73
4.00
0.86
...
...
...
0.86
1921-22.
Number of successful cases.
11
16,663
18,717
18,306
9,587
8,573
11,737
83.583
6,371
1,711
657
92,322
Annual
ratio of deaths from
small-pox per 1,000 of popu-
lation.
12
.07
.03
.10
.27
.50
.31
.16
...
...
...
0.16
Serial No.
13
1
2
3
4
5
6
N.-W. F. P. Govt. Press, Peshawar—14 C. M. O.—145—M. Y.—20-6-22.
MALARIA IN THE DUARS
BY
CAPTAIN S. R. CHRISTOPHERS, M.B., I.M.S.,
AND
Dr. C. A. BENTLY, D. PH.,
(Officers on special duty).
BEING THE SECOND REPORT TO THE ADVISORY COMMITTEE
APPOINTED BY THE GOVERNMENT OF INDIA
TO CONDUCT AN ENQUIRY REGARDING BLACK-
WATER AND OTHER FEVERS PREVALENT
IN THE DUARS.
SIMLA:
PRINTED AT THE GOVERNMENT MONOTYPE PRESS.
1911.
ISC
Plate I.
BENGAL
Shewing hyper endemic and epidemic areas.
MALARIA IN THE DUARS
BY
CAPTAIN S. R. CHRISTOPHERS, M.B., I.M.S.,
AND
Dr. C. A, BENTLY, D. PH.,
(Officers on special duty).
BEING THE SECOND REPORT TO [THE ADVISORY COM-
MITTEE APPOINTED BY THE GOVERNMENT OF INDIA
TO CONDUCT AN ENQUIRY REGARDING BLACK-
WATER AND OTHER FEVERS PREVALENT
IN THE DUARS.
SIMLA:
PRINTED AT THE GOVERNMENT MONOTYPE PRESS.
1911.
ISO
MALARIA IN THE DUARS.
CONTENTS.
CHAPTER I. —
Introduction
CHAPTER II. — The Duars and Malaria
CHAPTER III. — Anopheles in the
Duars
CHAPTER IV. — Immigration
CHAPTER V. — The Duars Labour System
CHAPTER VI. — Economic
Influences
CHAPTER VII.— Sickness and arrangements for the medical treatment
of the sick.
CHAPTER VIII. — Vital Statistics
CHAPTER IX. — Sanitation
CHAPTER X. — Malaria and black-water fever among Europeans in
the Duars.
CHAPTER XI. — Summary of the chief causes at work in bringing
about a condition of intense malaria in the Duars and the pos-
sible remote effects of this condition.
APPENDIX I. — List of endemic indices on a number of gardens in
the Duars.
APPENDIX II. — Tabular statement of results of observations on vital
occurrences in a test line.
PAGE
1
21
27
36
42
51
64
73
79
87
89
93
95
MALARIA IN THE DUARS.
I.—INTRODUCTION.
It is a very common assumption that, just as an epidemic outbreak
of malaria must, it is thought, be due to some unusual prevalence of
anopheles or to the introduction of some species especially favouring
the transmission of the disease, so an intensely malarious area must
be so by reason of the existence of special facilities for the breeding
of anopheles, or the presence of particularly dangerous species.
Under such an assumption the prevalence of malaria in the Duars
might be put down to the particular physical features of this country
especially favouring the breeding of anopheles, or to the existence of
a particular species, M. listoni, a species which it was suggested by the
Royal Society's Commission might be a factor in bringing about a
condìtìon of intense malaria.
But the facts given in the body of this report suggest that the
extraordìnary prevalence of malaria in the Duars—for we may state
without going into details that we found malaria extraordinarily pre-
valent and peculiarly intense throughout the whole area—is not solely,
or even maìnly, the result of special facilitios for the breeding of ano-
pheles, or of the existence of a partìcular species, but on the contrary
is bound up in what we shall call the " human factor,'' an increased or
diminished supply of anopheles, so long as there are any at all present,
appearing to exert little or no influence upon the prevalence of the
disease.
The Duars, with its 150,000 immigrant coolies aggregated in its
numerous làbour camps, is an example on a great scale of conditions
that in our experience are practically always associated with an extra-
ordinary prevalence of malaria. These conditions, though hitherto
they have not been recognised in their bearing upon malaria, are
nevertheless very distinct and important. They may, speaking
1 SC
A
2
briefly, be said to be those associated with the " labour camp " in
the tropics.
Labour camps, such as we refer to, must be familiar to almost every-
one. They are seen in a very typical form on railways under con-
struction, on almost all engineering projects—notably great excava-
tion works, on operations involved in the opening up of tropical country
such as clearing, road-making, laying-out and working plantations ;
and they are very characteristic of many tropical industries, notably,
in India, coal and tea in Mauritius, sugar, and so on. The Duars—
almost exclusively dependent on the tea industry—contains some
thousands of labour camps, the tea coolie lines, and the conditions on
a single one of these camps is representative of the whole Duars.
Without at the present going into details, we may say that in our
researches on malaria we have for some time recognised the almost
constant association of labour camps with severe malaria ; and, what-
ever be the cause of this association, we believe that in it lies the expla-
nation of the association of outbreaks of malaria with soil disturbance,
opening up of new country and so on. It is not the soil disturbance,
we believe, but the occurrence of labour camp conditions, or what
we shall call for convenience of description THE TROPICAL AGGREGA-
TION OF LABOUR, in association with these enterprises which has
given them their evil reputation.
Anopheles under such conditíons are often plentiful, especially as
squalor and aggregation of human beings undoubtedly tends to
foster anopheles. Not only so but the work in hand often increases
facilities for breeding, and may even lead to " importation " of ano-
pheles, a factor we believe which comes into play much more than
has been supposed. But a condition of increased anopheles preva-
lence is not necessary for intense malaria under such conditions, and
very frequently anopheles are so few in a malaria-stricken camp that
it is difficult to detect their presence. The existence of extensive breed-
ing places is even less necessary; and the common idea that these
camps are malarious, because of the formation of borrow-pits and
hollows is, when one has seen and studied many of them, found to
be quite erroneous. The peculiar prevalence of malaria in labour
3
camps is, we believe, not dependent upon the number of anopheles
(a certain number of which are always present), but on the human
factor.
It is desirable before going further to see what is known in regard
to this much neglected human factor in malaria ; for it is obvious that,
if in such diseases as cholera and typhoid we were to be ignorant of,
or neglect, the part played by human disseminators, we should have
a very imperfect notion of the mechanism at work in the spread of
these diseases, though we might know well enough that they are con-
tracted by the swallowing of particular germs.
Koch investigating malaria at Stephensort described three types
of villages :—
(1) Villages with little or no malaria.
(2) Villages with malaria in considerable amount, but confined
almost entirely to the young children.
(3) Villages where malaria was prevalent, not only among
young children, but among] the general adult population
as well.
Examination showed that the population of the third type of
village, instead of being fixed or permanent, as in the case of villages
of types 1 and 2, was subject to fluctuation owing to causes which led
to the introduction of non-immune immigrants. At each introduction
of such people a sudden burst of increased malarial infection occurred,
lessening as this new population became partially immune by longer
residence, but showing recrudescences whenever a fresh immigration
took place.
A condition of continual immigration similar to that described by
Koch is conspicuously present in the Duars, Assam and elsewhere:
in India, where the constant introduction of non-immune immigrants
may be likened to the continual heaping of fresh fuel upon an already
glowing fire.
This factor, which when it acts temporarily, is capable of produc-
ing epidemic malaria and when long, continued must give rise to an
A 2.
4
increased endemicity, we shall term for descriptive purposes the
FACTOR OF NON-IMMUNE IMMIGRATION.
But non-immune immigration does not alone constitute the whole
of the human factor in malaria.
Celli in a recent reference to malaria in Italy has corrected the
popular notions that the Roman Campagna is an undrained marshy
tract, and that malaria there is due to want of drainage. He believes,
on the contrary, that the causes at work in producing the intense
malaria of the Roman Campagna are in the main bound up with the
social and economic condition of the people, and especially with the
hardships that the labourers have to undergo while working in the
Campagna under a system which leaves them largely in the
hands of the headmen and labour contractors, a statement singularly
in accordance with what we shall hereafter find it necessary to make
in regard to the Duars.
As regards India, Stephens and Christophers have called atten-
tion to a feature of malaria as observed by them in this country, namely
that among different classes living in the same locality under very
similar conditions as regards exposure to malaríal infection there exist-
ed a greater prevalence of malaria among those of low social status
than among those of a higher level. It is unnecessary to go further
into this question beyond stating that among aboriginal tribes and
certain poverty-stricken communities in India a very high endemic
index of malaria may frequently be found, depending apparently upon
the general squalor, the hand-to-mouth existence, and other conditions
associated with low social status.
The way in which such economic conditions influence malaria
seems to be in bringing about relapses and a state of continued infection.
Boss, in computing the probable time during which infection may
remain in the body capable at any time of being stimulated into ac-
tivity by the action of depressing influences, fixes the period in British
troops at about six months. In this case he was dealing with Eu-
ropeans, originally healthy, picked men, well-fed, well-housed, and,
under constant medical supervision. But, when we consider natives,
5
often originally possessed of poor physique and little stamina,
living under conditions of depression, privation, and hardship
pushed to their extreme, it is obvious that these form a soil far more
suitable for the continued existence of malaria, and the problem
therefore becomes an entirely different one, for the solution of which
we at present have no data. But experience seems to show that,
in a community composed of malaria-stricken subjects in a state of
physiological poverty and exposed to hardship and privation,
infection diminishes very slowly, even in the absence of anopheles, and,
in these circumstances, the presence of a very few anopheles seems
to be quite sufficient to keep up the maximum degree of parasitic
infestation. In such circumstances evidence seems to point to the
possibility of a few mosquitoes doing as much damage as a large number;
and this, we believe, is the explanation of conditions very frequently
encountered, where it is impossible to find a direct relation between
the amount of malaria present and the number of anopheles. This fac-
tor, which we shall term the FACTOR OF RESIDUAL INFECTION, is scarcely
less important in the epidemiology of malaria than the factor of non-
immune immigration. Under its influence whole communities are
converted into reservoirs of infection ever ready to involve their neigh-
bourhood in epidemic disease, and capable on the migration of their
members of diffusing infection far and wide.
We have thus, in addition to the anopheles factor, two great
factors concerned with the human host, namely, the factor of non-
immune immigration and the factor of residual infection due to phy-
siological misery. These may occur singly or together. A famine or
scarcity, it is evident, may bring about the second without the first
as seems to have happened lately in the Punjab. On the other hand,
we may have non-immune immigration under conditions not parti-
cularly associated with hardship. But in labour camps both factors we
have described act together in their fullest intensity, and we can
recognise a new state of affairs in the appearance of a system of vicious
cycles always producing the same result, namely, the extraordinary ex-
altation of malaria. And whilst the human factor must play a part in
many ways and in many circumstances, in tropical aggregation of
labour it seems to bo paramount and to dominate the situation.
6
Before going further it is necessary for us to indicate the various
influences at work in such a combination and the way in which they
act in relation to malaria.
Labour, whether in India, Africa, or elsewhere in the tropics, is
usually of the kind known as " coolie labour." Coolies are brought
together from far and wide and settled down in labour camps some-
where in the immediate neighbourhood of the scene of the operations.
These more or less temporary camps may contain hundreds or even
thousands of inhabitants. But they resemble neither village nor
town ; for the hastily erected huts which form the vast majority of the
dwellings are almost invariably the rudest of temporary shelters, while
the density of the populations on the camp site becomes as great or
even greater than is met with in towns. Such aggregations also lack
the sanitary arrangements, the permanent houses, and the material
comforts of abundant food supply and a. sufficiency of comparatively
good water usually enjoyed by urban communities. Such camps,
moreover, are just the size and offer just the amount of aggregation
favourable for anopheles, which can breed over a wide area around and
about them. Their coolie inhabitants are drawn from various locali-
ties, often from different provinces or perhaps even from distant coun-
tries ; some come from malarious places, others from regions compara-
tively healthy; some are already infected with malaria, others when
they first arrive are free from infection and very susceptible. Thus
from the very commencement of operations month by month, even
year by year, if the work extends over a long period there is an as-
sociation of infected and susceptible persons eminently suitable for
the great exaltation of malarial infection. Again the more unhealthy
a centre becomes the greater is the loss by death, desertion and migra-
tion, and this necessitates the introduction of new recruits in increas-
ing numbers and at more frequent intervals adding still more to the
extension of the mischief.
Nor is it the immigration factor alone which becomes of increasing
importance; for by the very nature of things large numbers of the des-
titute and needy and those feeling the pinch of necessity are in the first
place gathered together along with the miscellaneous crowd of workers
and not only so, but the very conditions associated with aggregation
7
of labour tend to cause hardship and p\ill\ivation. The man with no
wife to cook his food, the mother without means to nourish her children
the stranger without friends, those poor physique and perhaps low
intelligence, all suffer under such circumstances to a far greater extent
than they would under ordinary rural or urban conditions. Prices
of food are usually high and there is nothing to maintain a proper re-
lation between the amount of pay actually received and the cost of an
adequate diet: while the sum that in ordinary conditions would ensure
plenty, is under such conditions often insufficient to prevent hardship
and privation. Native contractors and sardars too in their endeavour
to avoid loss or to increase their gains, and even to retain their coolies
by indebtedness, adopt systems of minimum living allowances and give
advances at usurious rates of interest.
Hardship conduces to sickness and this again to further hardship
while every case that occurs, by becoming a source of infection, tends
to increase its amount and to involve those originally the more healthy
and strong, for under these conditions partial immunity to malaria,
which would enable many to resist a less degree of infection, is broken
down and the partly immune person suffers along with the rest. And
so by a whole series of factors and combinations of vicious cycles
affecting mainly the human host is brought about in the labour camps
a state of exalted malaria and the formation of an epidemic focus.
The mischief does not end there. It will be gathered from what
we have already indicated that along our railway lines throughout
our canal zone, or scattered over an area devoted to an important
industry requiring labour of this kind, there will exist various foci of
malaria in the form of labour camps. In the ordinary course of things
small shops and markets spring up near the larger labour camps, and
villagers come in with supplies of food, also numerous petty traders
and others engaged in carting and carrying operations of all kinds move
constantly backwards and forwards between the new scenes of industry
and the older local trade centres. As a result many small villages
and, if the undertaking is a large one, even towns on the line of ap-
proach form recognised halting places, and become swollen and over-
crowded by the influx of strangers. To these places come sick coolies