NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Distribution of Leprosy.
87
first time, the real value of their produce. In the old days little
was grown beyond grain crops for the year's food. The
slightest failure meant local distress, while a bumper harvest so
depreciated the value of grain that part of the crops was often
left unreaped to rot in the fields. In 1880 and 1881 a suspen-
sion of revenue had to be granted to the district of Sylhet be-
cause the harvest was so bountiful that it would not pay the
cost of carriage to market, and consequently the farmers had
no means of obtaining money. Even so late as 1873 the
Collector of Rungpore reported that ' the yield of rice was
considered too good by the ráyats, as prices were there by kept
down.' The extended cultivation of staples for export, such
as cotton, jute, and oil-seeds, together with the substitution of
more valuable crops for the inferior grains, is now modifying
the entire system of Indian agriculture. Land is not being-
withdrawn from food crops to any appreciable extent, but the
ráyat is everywhere learning to cultivate high-priced subsidiary
crops which will help to pay his rent."
These changes in the well-being of the people are becom-
ing more visible from year to year, and the general condition of
the population has improved considerably during the last de-
cade. Applying the results of the present census to this en-
quiry into the possible effect on the leper density of a famine,
it will be seen that there is an almost general decrease of
leprosy all over the country. It is thus not necessary to
encumber this chapter with further statistics and tables.
What conclusions may be drawn from this change with re-
gard to the question under discussion ? Two courses plainly
are open. Firstly, it may be claimed that from a comparison
of census figures no legitimate deductions can be drawn, as it
is impossible to gauge the correctness of diagnosis and enu-
meration. Any argument based on a comparison with the re-
cent census especially may be questioned, as this year errors
were excluded as rigorously as possible. Again the decrease
in the leper population in the majority of famine districts,
88
REPORT OF THE LEPROSY COMMISSION:
according to this last enumeration, may be said to destroy the
whole value of the above suggestions. Secondly, those who,
after making due allowance for errors, attach more value to
census figures may assert that with the improvement of the
condition of the people a diminution of leprosy has taken
place. The latter, however, as explained above, must not be
considered to be so large as the figures seem to indicate, the
census on the present occasion having been taken much more
critically.
Poverty and Leprosy.
Undoubtedly leprosy attacks the poor and destitute much
more frequently than the rich and prosperous, not that the
latter are spared altogether, but they certainly suffer to a far
less degree. Again good nourishment and care are most im-
portant agents in the treatment of the disease, ameliorating
the general, as well as the local, conditions of the patient, and
keeping the destructive pro cesses in abeyance. It may thus
reasonably be asked, whether or no the leper ratios vary with
the material prosperity of the masses. It is not sufficient to
compare two provinces or presidencies with each other, as
the areas are too vast, and thus the conclusions and state-
ment too general. The best mode of procedure which sug-
gests itself is to examine the various districts of several pro-
vinces, and subsequently select those regions where leprosy is
highly prevalent, and enquire into their economic conditions,
and conversely investigate, in like manner, those tracts which
present the smallest leper population according to all cen-
suses.
It is extremely difficult to obtain accurate data regarding
the relative prosperity of Indian districts. The whole empire
being, generally speaking, overcrowded, and the areas of cul-
tivable land insufficient for the large masses of an agricultural
population, shows everywhere the most unmistakable signs of
poverty, as the term would be understood by western nations.
India cannot be called a rich and prosperous country, but
Distribution of Leprosy.
89
there are great differences in this respect as regards the vari-
ous districts. The wealth of a country, besides other stand-
ards, must be estimated by -the area and revenue returns, the
density of the population, the trade and wages, food-supply,
and the support that it can offer to the increasing population.
This implies a special knowledge and a long experience, such
as cannot be gained by a temporary stay in India. But even
all these data cannot supply absolutely correct information
regarding the wealth or poverty of the masses.
Since more than two-thirds of the population of India are
supported by cultivation, the best mode of judging the condi-
tion of the people is an enquiry into the agriculture and pro-
ducts of the various provinces. " The cultivation of the soil
forms the occupation of the Indian people in a sense which it
is difficult to realise in England. As the land-tax forms the
mainstay of the imperial revenue, so the ' ráyat: or cultivator
constitutes the unit of the social system. The village con-
tains many members besides the cultivator, but they all exist
for his benefit, and all are maintained from the produce of the
village fields. Even in considerable towns, the traders and
handicraftsmen frequently possess plots of land of their own,
on which they raise sufficient grain to supply their families
with food. The census of 1881 returned a total of 51, 274, 586
males as engaged in agriculture throughout British and Feu-
datory India. Adding to these seven and a quarter million of
adult day labourers, there is a total of upwards of fifty eight
and a half million persons directly supported by cultivation,
or 72 per cent, of the whole male population engaged in some
specified occupation. The number of persons indirectly
connected with agriculture is also very great. The Famine
Commissioners estimate that 90 per cent, of the rural popula-
tion live more or less by the tillage of the soil. India is,
therefore, almost exclusively a country of peasant farmers." 20
( 20 ) Imperial Gazetteer of India, Vol. VI, page 482.
9°
REPORT OF THE LEPROSY COMMISSION:
On such a population, imbued with fixed prejudices, the
increase of population must have a great influence, and this
is noticed in the development of a large landless class. " The
cultivated area no longer suffices to allow a plot of land for
each peasant ; and multitudes now find themselves ousted from
the soil. They earn a poor livelihood as day labourers, and,
according to the census of 1881 , comprise 7, 248,491, or one-
eighth of the entire adult male population. There is still
enough land in India for the whole people, but the Indian
peasant clings to his native district, however over-crowded.
Migration or emigration has hitherto worked on too small a
scale to afford a solution of the difficulty." 21
No connexion can be traced between the density 22 of the
population taken by itself and the amount of leprosy in a dis-
trict, and in like manner, a dense rural population does in no
way predispose an area to the disease. This is fully borne
out by the census reports, and it will not be necessary to add
further statistical proof.
In estimating the material prosperity of the various pro-
vinces, general impressions and the experience of Government
officials most familiar with the country must be the guides of
argument. Information as accurate as possible was obtained
from the area and revenue returns, and from facts supplied by
Mr. J. A. Baines, Imperial Census Commissioner, Mr. J. E.
O'Conor, Assistant Secretary of the Government of India in
the Department of Finance and Commerce, and others. Yet
the following remarks can only be general, and are intended
chiefly to suggest a line of enquiry into the aetiology of the
disease worthy of the consideration of those who, through long
continuous residence, are in a position to make themselves
more familiar with the economic conditions of the empire.
Bengal is, as regards natural resources, the richest and most
productive as well as the most populous province of India.
( 21 ) Imperial Gazetteer of India, Vol. VJ, page 483.
( 22) V. infra.
Distribution of Leprosy.
91
With but few exceptions the whole of the Bengal plain is
richly cultivated. Chota Nagpore and a part of Southern
Behar are elevated and hilly, and up to the middle of this
century the whole of this country was a very wild tract of hill
and forest, and Chota Nagpore is still so in a great measure.
Assam, though in possession of fertile soil, must be considered
poor, with large areas of unreclaimed land, being backward
and inaccessible, and with very deficient means of inter-com-
munication. " Upper Assam is still mainly either forest or
marsh with gigantic grass ; the latter to a width of from six to
twenty miles on the borders of the river, the former on the
higher ground and the adjacent hills. The marsh land when
cleared is converted into rice fields, and tea-gardens are estab-,
lished in clearings in the forest, but these are of insignificant
extent in proportion to the unreclaimed land. " 23 The North-
Western Provinces and Oudh are next to Bengal Proper the
richest and most populous tracts of British India. " There
are but few portions of country that are not capable of yielding
two crops annually to the tillage of its industrious peasants." 24
Judging from the absence of severe famines in most parts of
the territory the Central Provinces must be considered pro-
sperous. " The Wardha valley produces some of the finest
cotton in India ; the Nerbadda Valley in the cold season is a
vast spread of wheat and pulse crops, and the Chhattisgarh
plain, the granary of Central India, is equally prolific of rice
and wheat. The forests yield valuable teak and sâl timbers,
bamboo, stick-lac for the manufacture of lac, gum, and dye,
tusser silk, and tanning materials." 25 Burma again is very
fertile and never subjected to such distressful conditions as
scarcity or famines. It is difficult to speak in general terms
about Bombay and Madras. In any case these few remarks
show that through a consideration of this nature, on such
( 23 ) H. E. Blandford. Op. cit., pages 94 and 95.
( 24 ) H. E. Blandford. Op. cit., page 71.
( 25 ) H. E. Blandford. Op. cit., page 121.
92
REPORT OF THE LEPROSY COMMISSION:
general lines, nothing is gained. Between the natural richness
and fertility of a province and the leper population no connexion
can be traced. From them also the material prosperity of the
masses cannot be deduced. With regard to the former point
it will be seen that in the richest province, Bengal Proper, the
leper ratios are very high ; in the Punjab and the North-Western
Provinces below the average. But when such factors as
famines, scarcity, density of population, decrease of labour and
wages are taken cognisance of, it will at once be seen that the
natural capability of an area to support its inhabitants cannot
be a test of the well-being of the people.
Leprosy is undoubtedly a disease which affects the masses
more than the wealthy. It may be impossible to give statistics
proving this statement beyond all doubt, but nevertheless, for
India at least the fact exists, and the most exclusive con-
tagionist would hardly venture to deny this. It may be asked
whether those districts where the disease is commonest are also
the poorest. Leprosy is undoubtedly most prevalent in Bengal
Proper, and especially so in the Burdwan, Bankoora, and Beer-
bhoom districts of the Burdwan Division. Now, as regards
agricultural conditions, Bengal is the richest province in India,
and Burdwan in this respect not inferior to other divisions in
the presidency. But the material prosperity of an area cannot
be gauged in this manner. It must be remembered that Ben-
gal has the greatest specific population, about four hundred
and seventy per square mile, that the three districts are like-
wise overcrowded, four hundred and fifty—five hundred per
square mile. Though the soil is most fertile and the crops
most abundant, the proletariat is great and the land cannot
supply food for all. Besides, these districts are most unhealthy,
cholera and malarial fevers being endemic here. This may
explain to a certain extent the great prevalence of leprosy.
" The natural drainage is extremely deficient, and it is
difficult to establish any artificial system. The result of the
climate is a population and vegetation rank and luxuriant, and
Distribution of Leprosy.
93
earth and air charged with decaying animal and vegetable
matters. Life under such conditions must be unstable, and the
quickly matured man must in every stage of his growth and
decadence, even under the most happy circumstances, maintain
a state of health perilously liable to become one of disease. " 26
Cholera and fever are the chief causes of mortality amongst
the inhabitants of Bengal. " Insanitary conditions abound
throughout rural Bengal, and have been only partially dealt
with in the better class of towns. The dwellings of the poor,
sessile on damp ground, are crowded, and if perchance clean
within are surrounded by dirt-heaps and dirt-pools. Clothing
is deficient, often dirty ; the food is largely composed of un-
wholesome material, and. too generally is insufficient for the
needs of the body, and the water is impure. Want, ignorance,
and carelessness, or fatalism result in neglect of precautions
against disease " 27 Dr. Coates describes the population as
"poor, ill, and insufficiently clad, badly fed, debilitated, and
broken down in constitution." 28 In the Chittagong Division
the people are, for Bengal, an healthy and able-bodied race,
thrifty and industrious, and in a condition of considerable pro-
sperity, and here the smallest leper ratio of any Bengal division
is found. Again in Rungpore the tracts where leprosy is
extremely prevalent are characterised by marshy and uncul-
tivable land, the people being of lazy habits and living in
wretchedly built mat or grass huts, and miserably clothed.
On the other hand, the areas of comparative immunity are
extensive local plains covered with paddy, the inhabitants
given to other pursuits besides agriculture. Trade here is
pretty active, rice crops being abundant and exported to a
great extent, while the people themselves are more civilised,
feed and clothe themselves better. 29
( 26 ) F. N. Macnamara. " Himalayan India, its Climate and Diseases," page
127.
( 27 ) F. N. Macnamara. Op. cit., page 129.
( 28 ) F. N. Macnamara. Op. cit., page 130.
( 29 ) F. N. Macnamara. Op. cit., page 209.
94
REPORT OF THE LEPROSY COMMISSION:
Assam is a poor district, and the population, besides being
exposed to unhealthy climatic and telluric conditions, live in
poverty. Labour has to be imported, and the prices of food are
high. The most prosperous districts of Assam are Darrang
and Nowgong, and here the leper population is comparatively
scanty. Burma also, though extremely fertile and never visit-
ed by famines, cannot claim prosperity for her inhabitants.
The Burman lives from hand to mouth, in poor sanitary
conditions, and surrounded by filth. Peace and enterprise
have worked considerable changes ; a great improvement is
visible all over British Burma, and with the opening up of
railroads a further progress undoubtedly will take place. The
leper ratios for Burma are high for the first two censuses, but
amarked decrease has taken place since the first enumera-
tion.
The hill tracts are the home of an exceedingly poor people,
living as a rule in filthy and unhygienic conditions, working
as day labourers or coolies. It has been shown above that
leprosy is common in these districts. In some of these immi-
gration of lepers may account for an excessive ratio, but this
is excluded in others, and no doubt the disease is particularly
common in the Himalayan tracts.
The Punjab and North-Western Provinces, considered as a
whole, are prosperous tracts. Here leprosy is not very preva-
lent, as compared with the rest of India. In the Bombay
Presidency the smallest ratios are found in Sind. Here the
climate is dry with extremes of temperature, the population
omnivorous, and this division contains a considerable area of
cultivable land, producing more than is required for the
support of the existing population. Kaira, Broach, Dharwar,
Kanara, Khandesh, Ahmedabad, and Belgaum, considering all
things, are about the most prosperous areas, while Ratnagiri,
Kaladgi, Ahmednagar, Sholapur, Satara, and Thana are per-
haps the poorest. Comparing the leper ratios of these two
groups it will be seen that the more prosperous areas, on
95
Distribution of Leprosy.
an average, have the smaller ratios. This will be shown in
tabular form.
TABLE XVI.
Prosperity and Leprosy.
DISTRICT.
BOMBAY PRESIDENCY.
A.—Poorest District
Ratnagiri .
Kaladgi .
Ahmednagar
Sholapur ,
Satara
Thana
B.—Prosperous
Districts.
Kaira
Broach
.
Dharwar
Kanara
Khandesh*
Ahmedabad
Belgaum
Ratio of lepers
per 10,000 of
population
(.872).
I2..1
7.4
14.0
11.9
11.8
8.3
5.2
5.3
11.6
3.9
14.8
2.9
10.0(5.1)
Ratio of lepers
per 10,000 of
population
(1881).
9.3
2.9
10.1
6.8
11.0
8.2
2.4
2.5
1.8
1.2
14.1
•8
3.3
Ratio of lepers
per 10,000 of
population
(1891).
9.7
4.1
7.8
8.0
I2.I
6.1
1.3
2.2
2.0
.4
11.6
1.0
3.3
REMARKS.
* Cf. previous re-
marks on Khan-
desh for 1881.
Cf. previous re-
marks on the leper
census for Bom-
bay (1872).
It will be seen that, broadly speaking, the ratios under (A)
are higher than those under (B). An absolute harmony can-
not be expected, even if the present theory be correct, as all
figures depend on the uncertainty of a general enumeration,
however slight the errors for a particular district may be ;
again famine may, as was above suggested, reduce the ratios ;
and, thirdly, it is only possible to estimate the well being more
or less approximately.
In Kaladgi a great difference is
noticed between the ratios of 1871 and 1881, but perhaps this
is explained by the ravages of the great famine. Khandesh
96
REPORT OF THE LEPROSY COMMISSION :
has good soil and rainfall, but is not yet opened out and grows
bad cotton ; and the conditions of Ahmedabad are variable,
having part of the richest and also part of the least prosperous
land of the presidency.
With these remarks this sketchy review regarding the pos-
sible relation between the density of the leper population and
poverty must be concluded. A table is added wherein the
districts of Bengal are arranged according to their prosperity.
The required information has been gathered from Sir William
Hunter's Statistical Account of Bengal. It must be ac-
knowledged that this table contains at least some evidence in
favour of the views expressed.
TABLE XVII.
Poverty and Leprosy.
PROSPEROUS
DISTRICTS.
Backergunge.
Chittagong .
Dacca .
Darjeeling .
Dinagepore .
Jalpaiguri
Jessore
.
M aida .
Noakholly
Singhbhoom.
Tipperah
Ratio of lepers per
10,000 of popula-
tion (1872.)
I.1
2.0
4.S
10 0
3.8
4..5
3.4
5.3
.7
.3
4.1
Ratio of lepers per
10,000 of popula-
tion (1881).
2.5
4.3
5.6
11.8
7.4
12.9
4.0
7.2
2.6
4.7
4.9
Ratio of lepers per
10,000 of popula-
tion (1891).
1.4
2.3
3..5
7.5
4.6
9.9
3.9
6.0
1.4
3.5
3.8
DISTRICTS
IMPROVING IN
PROSPERITY.
Balasore
Bhagalpur .
Cuttack
Furreedpore
Hazaribagh
Hooghly and
Howrah.
Mymeusigh.
Nuddea
Sarun
Sonthal Per-
gunnah,
24-Pergun-
nahs.
Ratio of lepers per
10,000 of popula-
tion (1872).
2.5
3.1
2.9
4.1
.1
6.0
7.4
9.7
3.3
4.0
4.0
Ratio of lepers per
10,000 of popula-
tion (1881).
I3.7
5.0
11.2
4.0
2.0
9.0
8.4
9.4
5.4
501
5.1
Ratio of lepers per
10,000 of popula-
tion (1891).
12.0
4.5
8.6
2.7
1.6
5.4
8.3
7.0
4.4
3.9
3.4
POOR
DISTRICTS.
Bankoora
Beerbhoom .
Burdwan
Champarun .
Chittagong
Hill Tracts.
Gya
Manbhoon .
Midnapore .
Monghyr
Moorshedabad
Patna .
Poorce .
Pubna .
. Rungpore
Shahabad
Tirhoot
Ratio of lepers per
10,000 of popula-
tion (1872.)
29.9
41.2
22.6
2.1
5.4
8.3
3.0
I3.1
7.1
3.3
4.2
IO.7
6.0
2.5
Ratio of lepers per
10,000 of popula-
tion (1881).
37.2
32.7
29.5
3.6
9 -.1
12.3
9.2
5.4
12.7
7.6
13.6
6.4
I4.9
8.2
3 -.0
Ratio of le
10,000 of p
tion (1891)
36.3
35.2
21.5
3. I
5.9
7.5
1.3
7.9
6.4
8.2
3.9
15.9
4.1
6.8
4.4
2.7
Distribution of Leprosy.
97
Before proceeding to the remainder of this chapter it may
be well to summarise the results arrived at. Attention must
again be drawn to the many difficulties encountered. These
depend in the first instance on the vastness of India, and an
imperfect knowledge of all such matters as the habits and
customs of the people and their material condition. Secondly,
the census figures are only of relative value where numerical
questions, such as the specific leper population, are under con-
sideration. For the general distribution and prevalence of the
disease they convey sufficiently accurate information, but for
the study of more special points in the aetiology of leprosy
their value is perhaps not so great. At present only three
sets of figures exist for India, and this is not sufficient to act
as a safe check, especially as in a decennium many changes
occur, capable of seriously affecting the ratios. To gauge the
calculations and deductions based on them more efficiently
returns should be made at frequent intervals—a matter of im-
possibility.
All that has been said on climate, cholera, and famine de-
monstrates clearly that great caution must be exercised in all
arguments regarding the numerical diffusion of leprosy.
Though all these statements cannot be taken as absolute, and
are not free from doubt and above criticism, they at least show
that, in any comparison of two areas, all the concomitant
conditions which may influence the population at large must
be carefully considered ; and this has been only too often
neglected by those who raised the outcry about the rapid in-
crease of leprosy in India. It has not been the intention of
the Commissioners to convey the idea that a severe famine
invariably does act on the leper population in a particular
manner, but that it may do so, and if the census figures be
correct, in many instances seems to do so. Again a particular
climate has not been considered the cause of a scanty leper
population, but it has been claimed that a climate, combined
with the telluric, geological, ethnological, and other conditions
H
98
REPORT OF THE LEPROSY COMMISSION:
of a district, may have a definite influence. Cholera has been
used as a test of unhealthiness and bad hygiene, and it has
been suggested that in a district, the permanent home of cho-
lera, the surroundings may be such as to favour the diffusion
of leprosy.
Still greater difficulties make themselves felt while discus-
sing the relation between the material prosperity of the people
and leprosy. The Commissioners incline greatly to the belief
that the greater the poverty of a district, the more prone the
latter is towards leprosy. Considering India as an unit the
masses are poor and live in defective hygienic conditions, far
below the level of the western European nations, and appa-
rently have lived in such surroundings for centuries. An
absolute comparison between the individual provinces and dis-
tricts is impossible, but the Commissioners express their
strong belief that it can be shown that the numerical diffusion
of leprosy depends, among other factors, greatly on the well-
being of the population, and that with the furtherance of pro-
sperity, education, and hygiene, and in fact with a substitution
of a standard of maintenance for that of subsistence, leprosy
will materially decrease in India as it has done in Europe.
Such progress has been going on actively in India for the last
twenty years, and it is hoped that under the British Govern-
ment the native standard of health and wealth will more and
more approach that of the masses in the mother country.
Leprosy an Endemic Disease.
In a subsequent chapter it will be more fully explained that
in leprosy, as in tuberculosis, a special individual disposition is
necessary for the acquisition of the disease. Here an attempt
has been made to show that it is by no means improbable that
the general susceptibility to leprosy of a district and its inhabi-
tants depends on certain conditions : in other words, there
seem to be certain factors, partly connected with the climatic,
economic, social, or hygienic conditions which establish the