public health threats, for example an elaborate system of drainage in and around the city of Calcutta reduced the risk of malaria.

The Sanitary Commissioners sometimes expressed shame that health conditions in India and Britain had come to diverge so widely since widespread sanitary measures began to be undertaken in Britain in the 1880s. They often sought to lobby the higher administrative authorities to expand the scope of public health services in India. The ongoing struggle within the administration is evident in the annual sanitary reports, for example in statements such as “if the District Collector does not sanction the construction of an improved washing ghat, even his table linen will be washed in filthy water”.

The spare but systematic colonial approach to public health service provision is reflected in its successes and failures. During the first half of the twentieth century, the mortality spikes from epidemics were sharply reduced. By the end of the colonial era mortality from diseases such as cholera and the plague had fallen sharply,<sup>9</sup> but diseases such as malaria and gastro-enteric infections continued to take heavy tolls. Independent India’s First Five-Year Plan notes that only 3 percent of households in India had toilets, and that much of the population lacked basic water, drainage and waste disposal services.

# **4. Public health in Independent India**<sup>**10**</sup>

Little remains of the colonial public health arrangements, beside an impressive capacity to control outbreaks once they have occurred. The capacity to _prevent_ outbreaks from occurring has atrophied. By 1950, much had changed both globally and in India, which led to this atrophy. Some of these factors include:

- Techniques for mass-production of antibiotics were refined during the 1940s. This made it possible for local elites to protect themselves from dying of communicable diseases, without having to maintain rigorous environmental hygiene to prevent exposure to disease for rich and poor alike. The developed world also became better able to protect themselves from the prospect of epidemics spreading from the developing world, and the focus of medical research shifted away from finding new technologies for communicable disease control — except when threatened by newlyemergent diseases against which they have no protection, such as the avian flu.

- The public health successes achieved in the developed world meant that by the 1940s their main causes of death shifted from communicable to non-communicable diseases such as cardiovascular diseases and cancer. At the same time, advances in medical technology offered the promise of managing these diseases through clinical and surgical interventions. The glamour and status earlier accorded to public health authorities was now accorded to medical doctors. The intellectual cutting edge shifted from improving public health systems, to improving curative technologies and methods of health care financing.

- Multilateral and other donor agencies have encouraged creating separate institutional structures and programs for controlling specific communicable diseases, thereby

> 9 See for example Arnold 1989, and the other papers in Dyson 1989.

> 10 This section draws on Nath (2003), Jeffrey (1988), Government of India (1996, 2002), Government of Karnataka (2001), and the Government of India Five-Year Plans.

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