NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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from the works, for nothing is so unsettling a8 sickness, and, as malaria
in the labour camps increases, many members of families decimated
by the disease endeavour to reach their homes often under conditions
of great hardship. These points are very well illustrated in a case
referred to in another connection by Major Leonard Rogers, I.M.S.,
in his report upon Kala-Azar, 1897. ( P. xii, Appendix I).
" A coolie woman, aged 19, from the Assam-Bengal Railway (then
Under construction) was admitted to the Nowgong dispensary during
the rainy season of 1896 suffering from marked anæmia and dropsy
of the feet and face. The history of her illness was that she got on all
right until her father died, after which she lived with another coolie
girl, and according to her story she only received about one rupee a
month from the contractor (probably minimum living allowances,
tide Chapter VI) and was consequently unable to feed herself properly.
She Soon became ill and as she did not improve she left the works and
begged her way into Nowgong, living on what she could pick up on the
way."
The clauses in brackets are ours.
Thus it happens that new centres of infection are set up in places
even many miles removed from the original source of the mischief,
and once these have been established the gangs of fresh labourers
travelling to the scene of work contract infection as soon as they have
entered the dangerous zone, while they are still perhaps some distance
from their destination. And thus by one unending train of vicious
cycles once set in motion there may result a wide-spread epidemic,
far reaching and disastrous in proportion as its initial cause is
extensive and important.
And again those who return to their homes or seek new seats of
industry carry the infection of malaria wherever they go, and, if their
numbers be at all considerable, and they must often be so, serve to assist
in the dissemination of malaria throughout remote districts. Involved
secondarily in the general troubles are Europeans employed upon
the enterprise ; while should the conditions last for sufficiently long
a period, as they have done in the Duars and other places, we may.
9
hear of the occurrence among such people of cases of Black water
Fever. It often happens that the effects upon the actual labour,
forces and the neighbouring native populations may pass unnoticed
and unrecorded, only the outbreak of disease among Europeans'
attracting attention ; but there can be little doubt that were such
cases investigated it would be found that the infection of Europeans,
troops, and well-to-do natives was only a concomitant and a result
of a vastly greater amount of malaria among the poorer population,
and especially among the labour force itself.
In the case of railway construction we have, then, to deal not
alone with the formation of borrow-pits and the interference with
surface drainage, but with a peculiar 1 set of conditions mainly associated
with the human host which are probably more or less identical through-
out the tropics. In canal construction, too, we have other considerations
involved beside the mere formation of water channels, which, though
they may undoubtedly assist in increasing malaria, are probably not
the sole cause of canal epidemics. We have labour communities engaged
in the primary excavation of the main channels and subsequently
drafted off throughout the district for the purpose of cutting the dis-
tributing branches, and in addition the influx of immigrants seeking
to find employment and to secure land in the newly irrigated area.
All these things point to a complex of factors, which it is impossible to
dismiss without serious thought if we wish to understand the natural
history of great outbreaks of malaria. It is obvious that in the clear-
ing of jungle, the making of roads, and all such operations as are requir-
ed in the opening up of new countries, labour is necessary ; and one has
only to visit a large road under construction in forest country, or
a tea garden being laid out, to realise that the malaria associated with
such undertakings is merely the result of the conditions we have
termed tropical aggregation of labour.
Quite recently we have had the opportunity of seeing at Bombay
a typical example of the malaria of tropical aggregation of labour.
With the inauguration of large harbour works there has recently
appeared a serious outbreak of malaria. The epidemic, we are inform-
ed, came with the works and has got progressively worse year by year
1 SC
B
10
during the Seven years or so in which the harbour works have been in
progress. Captain Glen Liston, I.M.S., who has written on the subject,
has referred to this association of the harbour works and malaria. He
says :—" Moreover, it assumes an additional interest in view of the
fact that the present epidemic seems to be associated in some way
'with the construction of the new docks."
In the few days that we had at our disposal we were able to see,
owing to the kindness of Captain McKendrick", I.M.S., who is engaged
in anti-malaria work in Bombay, the conditions associated with this
epidemic.
The works in question covered an extensive site ; immediately
outside this along the Frere Road was the part of Bombay most severely
affected, though the condition of epidemic malaria extended for
nearlly half a mile into the city as ascertained by Captain McKendrick
-in his preliminary enquiries.
We satisfied Ourselves that here we had, 'in addition to many in-
teresting points we have not the space to touch upon,—
(1) The formation of a focus of intense .malaria by a large labour
aggregation.
(2) The implication secondarily of the inhabitants of Bombay.
That there existed indeed an aggregation of labour which was
involving not only a few European and others connected with it, as
in the Duars, but a large portion of the very heart of a populous city,
a portion that should otherwise have been almost free from the
disease.
As Captain McKendrick pointed out many of the houses most
affected were of good class and the residents well-to-do people. En-
quiry, however, elicited the fact that many coolies with no residence
and but few belongings are accustomed to spend the night on the pave-
ments ; and to judge from their accounts many have spent years in this
homeless state. In the very streets most affected we saw many coolies
living in this way. This state of affairs, which one could scarcely have
predicted without direct observation, would in itself be sufficient to
11
account for the secondary infection of the inhabitants of these better-
class houses.
It is immaterial from our present point of view what exactly are
the conditions in Bombay as regards anopheles ; what we wish to em-
phasize is the real nature of the present epidemic. It may not be with-
out interest, however, to point out that with the new insight we have
indicated such an epidemic could have been foretold and measures
could have been taken to prevent the formation of the malarial focus
with much less difficulty than will now be found in controlling the
conflagration to which it has given rise.
We are informed that at first labour was housed- on the dock site,
but that latterly it had almost all been accommodated in distant
portions of Bombay. If so, we should expect the epidemic to invade
new areas during the next few years, and quite possibly to extend
to large portions of the environs.
Hong Kong, Wilhelmshaven and many, instances of virulent
outbreaks of malaria, associated with-works could easily be given.
It is reasonable to believe after what we have said that the real
determining factor in all is that of tropical aggregation of labour.
But it must not be imagined that the conditions we have been
describing and the effects that we have indicated as resulting from
them are to be seen only on a small scale and confined within narrow
area, or that they occur only occasionally in the course of years and
constitute a mere unimportant item in the epidemiology of mala-
ria. We have seen that in the case of the Duars the inauguration
and extension of an industry has produced throughout a whole district,
many hundred square miles in area, an extraordinary condition of
exalted malarial endemicity, characterised by the occurrence of Black-
water Fever among Europeans and widespread anæmia among the
natives, a condition we shall describe in relation to the malaria of a
population as one of HYPER-ENDEMICITY.
Under similar circumstances the Darjeeling terai attained soma
years ago an unenviable reputation of a like nature ; and Assam, espe-
cially in past years before legislative interference enforced the adop-
B2
12
tion of certain sanitary precautions, was considered little less deadly
both for natives and Europeans. In Mauritius, although there may
have been a time when no suitable anopheles were present to transmit
malaria, there appears to exist a typical example of tropical aggrega-
tion of labour, and Dr. Bolton's description (in Ross' Report upon
Malaria in Mauritius) of the agglomerations of Indian huts scattered
over the island and the " camps " on the plantations, illustrates very
well the points we have alluded to. Nearly 30 years ago Hirsch ap-
pears to have connected the occurrence of the great malarial epidemic
which decimated Mauritius and Réunion in some way with the laying
out of sugar plantations, and although his explanation suggests a
different cause to the one which in the light of our present knowledge
appears most likely, his observation is significant when we remember
that at that time immigration of coolies from Bengal was in full swing.
A possible example of the working of this factor of tropical aggre-
gation of labour on a colossal scale is the series of vast epidemics of ma-
laria which have ravaged Bengal during the last forty years, which
are for the first time adequately explained by our hypothesis.
In a warm country like India there is perhaps every a priori reason
to expect malaria to be both prevalent and intense ; but if by such
intensity we mean the condition so characteristic of the African coast
we shall have to modify our conception. There is indeed a consider-
able amount of evidence to show that large tracts of India are not
particularly malarious in the sense that many tropical countries are.
Much of Bengal is deltaic in formation and we might expect that here
especially malaria would be particularly intense; but observations
upon the endemic index do not support this, and, except in certain,
parts liable to great epidemics of malaria, this disease does not pre-
yent the prosperity and. natural increase of the population.
Yet for many years, and more especially since the fifties, a tract
in Bengal, lying mainly to the north of Calcutta and comprising the
districts of Jessore, Nadia, Burdwan, Hooghly and portions of the
Birbhum and the 24-Parganas, has been the site of recurring epide-
mics of fever which every few years have broken out first in one place
and then in another. (Vide Map of Bengal. Frontispiece,)
13
The first recorded outbreak took place near Muhammadpur
amongst a body of six hundred prisoners working on the road from
Jessore to Dacca. Other outbreaks occurred in Jessore in 1846 and
1857, and in 1860-63 fever recurred to a much more alarming extent
involving Jessore, Nadia, Baraset and the northern portion of the 24-
Parganas. In 1867 the great Burdwan epidemic began, sweeping
through the district of that name and affecting parts of Bankura,
Birbhum and Midnapore. This outbreak, which is calculated to
have destroyed two million people, has been attributed to Kala-Azar,
but in our opinion there is not sufficient evidence that this disease
was concerned, and to us it appears probable that malaria was in the
main responsible.
The census of 1881 records that in 1872 the ravages of malaria at
Dinajpur were greater than in any other district in the division, that
by 1877 things had become still worse until at least 75 per cent, of
the inhabitants were in a .bad state of health, and 53 per cent.
suffered from enlarged spleen, while the recorded death-rate had
reached 43 per mille. In 1878-79 there was some slight remission ;
but in 1880 the condition returned with increased violence. In Rung-
pur, during the decade preceding 1880, the district increased progres-
sively in unhealthiness until 80 per cent. of the inhabitants were re-
ported to be anæmic, suffering from enlarged spleen, or laid up with
fever, and of the 20 per cent. supposed healthy only half could be
considered so in the European sense. In Rajshahi and the neighbour-
Ing portions of Pabna immediately north of the Ganges, is another
area ravaged by frequent epidemics of fever, which have occurred
about the years 1881, 1893 and at .other times. More recently Mur-
shidabad has. been the site of disastrous outbreaks and as late as 1907
Birbhum has suffered in a similar way, while from time to time many
other areas have been affected.
Over and over again, as the result of numberless enquiries, it has
been stated that the factor producing these epidemics has been a
change in the natural drainage of the country, But the theory that
ascribes to waterlogging of the soil the occurrence of such out-
freaks is probably based upon the old notions regarding malaria
modified a little to fit in with our present knowledge of. the mosquito
14
eyele of the parasite. We have never heard of. any investigation
having been undertaken with the object of ascertaining in what way.
malaria has been influenced, and whether or not there has been any
increase in anopheles mosquitoes in the specially unhealthy tracts or
during the unhealthy years-,
There is, it is true, a- way, But an indirect one, in which changes
in the great rivers may seriously influence malarial incidence and this
has already been well described by Chatterjee, who points out that
by the shifting of the river channels- to the east, towns and districts,
once prosperous and flourishing, suffer from loss of trade, industries
decay, and populations become subject to economic conditions favour-
able to malaria. But though this has no doubt played its part,
it appears insufficient to- explain why epidemics- have specially
prevailed during particular years in. certain parts of the country.
Commission after Commission reporting upon the question have
invariably dismissed the suggestion that the making of roads and rails
ways was-concerned in causing" obstruction to the drainage-
A glance at the- map of Bengal will show that the districts that
have been from time to time involved in epidemic malarial outbreaks
bear a certain relationship to Calcutta ; that they are practically
identical with the great industrial areas to the north and west of the
city and the expanding fan of railways that link the metropolis to
the great districts on the north-east and north-west. Above all
the recurring epidemics have often picked out in a curious
manner, parts like the great coal districts of Burdwan, the mill dis-
tricts of Hooghly, and other centres of industrial activity.
Before hazarding an opinion as to how far this is mere coincidence
or real association, let us consider the local history of this part of
Bengal. Prior to 1860 there is.little evidence of the existence of any-
thing like the movement towards the immense industrial expansion
of recent times ; but from about this time there commences a period
of phenomenal activity in commercial enterprise and an era which saw
the inauguration and completion of enormous public works. With-
irt a decade three great canal systems, the great railways, a vast net-
15
work of road's together with industries like those of coal, jute, cotton
and tea sprang into existence and underwent extraordinary develop-
ment. From 1868 onwards we find the Sone, Orissa and the Midna--
pore canals undergoing construction, the three schemes being nearly
'completed in 1881. The year 1871 saw the completion of 2,800 miles
of the first general scheme of railways in India linking up most of the
important towns and cities, Calcutta among them. Between 1872
and 1881, 525 miles of railway were constructed in Bengal and from
1872 and 1881-91 a 'further 1,051 miles had been added to this total,
which was still further increased by another 1,614 miles of line opened
in 1901.
The coal industry, which in 1860 had an output four times as
great as that of ten years previously, exported in 1905 from the
Bengal coal-fields alone seven and quarter million tons. The jute and
cotton industries, which in 1860 were in their infancy, now possess
mills scattered throughout the whole of Hooghly and the neighbour-
ing districts, jute mills alone in 1904 possessing nearly 20,000 spindles
and employing an average daily labour force of close upon 140,000
persons.
Calcutta, the centre of this new movement, rapidly expanded
under the stimulation of increasing commercial activity, which
necessitated also the establishment of docks and the extension of
harbours, together with the erection of vast blocks of buildings
throughout the city and its widening suburbs.
All this expansion has meant LABOUR—labour on the aggregate
in vast amount—labour brought together and. employed under con-
ditions little different and certainly no better than those that may be
met with at the present time whenever and wherever projects of a
similar nature to those we have alluded 'to, require to be carried out.
Year after year, now in this district, now in that, innumerable labour
camps must have been formed. Along every new railway, every canal,
every important road under construction, and around every engineer-
ing or building project, or associated with every rapidly develop-
ing industry there must have sprung into existence these more or less
temporary aggregations of labour with the almost certain consequence
16
of epidemic malaria similar to that which has occurred at Hong Kong,
Panama, and many other places in the tropics. And if we follow, as
closely as possible, the course of fever epidemics in those years
when they have been widespread and intense we find that they cor-
respond in an extraordinary manner with the times and places in
which industrial projects or large public works were being most ac-
tively pushed forward.
A special period characterised by the prevalence of epidemic
malaria coincident with an expansion in the coal trade and the con-
struction of great public works may be recognised in 1860-74, and
another in 1880-81 when, after times of lessened activity, numbers
of important and long postponed projects were put in hand,
and it is recorded that the expenditure on railways, irrigation works
and roads amounted to the sum of 20 crores of rupees within a few
years.
As the Presidency became opened up, its railways extended,- its
canals completed, and its up-country industries developed, the series
of malarial epidemics assumed a new phase and Dinajpur and Rung-
pur, which a glance at the map will show stand at the portals of the
tea districts, and Rajshahi, which lies immediately to the south, begin
to be conspicuous as the seat of epidemic malaria. Reference to the
Census reports will show that there has, been no more extensive emi-
gration in India than that which has taken place from the south-west-
ern portions of Bengal and part of the adjoining provinces to the'
tea gardens in the north-east. All the main lines of communication
pass through the areas we have mentioned, which are covered with a
network of roads and railways pushed forward, especially in Dinaj-
pur and Rungpur, to meet the growing exigencies of the tea and jute
industries ; for until comparatively recent times vast numbers' of emi-
grants travelled to their destination on foot or at least traversed con-
siderable tracts of country in this way. We have had an opportunity
of seeing some portions of this tract, including Dinajpur, and, though
we have not been able for want of time to study the conditions
closely, we find everywhere growing in the bazars and outskirts of the
smaller towns the characteristic little aggregations of immigrant
17
labour, all concerned indirectly or directly with, what we may term
expansion.
Quite recently epidemic malaria has attracted considerable at-
tention in Murshidabad town ,' and in connection with this we quote-
a newspaper cutting, dated August 1908—
" The mortality from fevers of which statistics- are given in the-
report of the Sanitary Commissioner for Bengal is something almost
past belief. Murshidabad among towns was the worst sufferer,
the mortality amounting to 46.08 per mille. It is added that this is
the third year in succession that this town has been the most fever-
stricken. We read :—' The civil surgeon is strongly of opinion that
the newly constructed branch of the Eastern Bengal State Railway
has affected the public health'. He says that the Railway Engineer-
ing authorities have been guilty as elsewhere of taking absoluttely no
means of draining the pits and hollows by the side of the embank-
meiitSj that he is convinced that in such a malarious neighbourhood
specially as that of Murshidabad town, this has led to increased and-
healthiness and should be remedied."
It is needless to say that more than borrow-pits and hollows are
concerned.
. Time and further research must decide whether we have exag-
gerated the importance of this matter, but if not, it seems to us that
this factor in malaria must be recognised and dealt with ; for there
appears to be every probability that, when allowed to act year after
year without attempt at control upon populations whose general
health is already in a state of precarious stability, it may so far up-
set this equilibriumm as to produce widespread outbreaks of diseasa
amongst them.
Industrial expansion in the tropics is but beginning; every year
its requirements become more urgent; every year it is taking fresh
strides ; and on the threshold of every advance in India, as well as in
every other tropical country, we are met with the necessity for this
industrial aggregation of labour.
ISC
C
18
There is nothing to make us believe that deltaic or other physical
conditions are necessary for the occurrence of epidemic malaria, for
anopheles mosquitoes exist throughout the country and can every-
where find facilities for continuous breeding ; and such being the case
we have reason to anticipate that, with each fresh impetus and new
direction given to industrial expansion, we shall find, in the absence
of proper measures of control, an extension in the geographical dis-
tribution of intense malaria and hear of new areas subject to the ravages
of the disease in epidemic form.
It may be said that these unfortunate influences, the action and
result of which we have indicated in broad outline, are in themselves
so vast that they lie beyond the power and scope of human
interference and that their recognition will not help us in the
war against disease. But although we may not be able to deal with
the malaria of a whole province, with a population numbering many
millions, many of whom are probably but little affected by the disease,
we can deal with malaria among the labourers on a railway, a canal,
a coal mine, or a tea garden, in a way that we cannot do with malaria
among the more widely scattered populations of great rural areas ;
and by this means we can prevent the occurrence of, or reduce the lia-
bility to, the otherwise inevitable scourge of intensified epidemic
malaria, and attain a result that will prove out of all proportion greater
than the mere direct effect upon those immediately concerned for
beyond the loss of life and suffering of the actual labourers is the all-
important question of the health of large communities which they are
liable to infect.
With the methods to be adopted in malarial prophylaxis we
do not here concern ourselves ; but if we are dealing with an exalta-
tion of malaria due to the action of factors affecting the human host,
where every influence that tends to increase susceptibility is at its
height, there are other measures required besides those of specific
prophylaxis, measures which, while they incidentally aim at relieving
hardship and misery, are directed at a vulnerable point in the de-
velopment of the most important of all topical diseases.
We cannot ignore such assistance, as we have not yet any
reason to believe that anti-larval operations are capable in the least