British India has half a million villages made of mud. Most of them took all their mud from one spot, making thereby a commensurate hole, and built themselves on the edge of the hole.
The hole, at the first rains, filled with water and became the village tank. Thenceforward forever, the village has bathed in its tank, washed its clothes in its tank, washed its pots and its pans in its tank, watered its cattle in its tank, drawn its cooking water from its tank, served the calls of nature by its tank and with the content of its tank has quenched its thirst. Being wholly stagnant, the water breeds mosquitoes and grows steadily thicker in substance as it evaporates between rain and rain. It is sometimes quite beautiful, overgrown with lily-things and shaded by feathered palms. It and its uses pretty generally insure the democratiza-tion of any new germs introduced to the village, and its mosquitoes spread malaria with an impartial beak--though not without some aid.
Witness, small Bengali babies put out to lie in the buzzing grass near the tank's edge.
"Why do you mothers plant your babies there to be eaten alive?"
"Because if we protect our babies the gods will be jealous and bring us all bad luck."
One of the most popular and most glorious gifts that a liberal rich man can make to his own village is the digging of an extra tank. One of the fondest dreams of the British Public Health official is to get all tanks filled up.
Nobody knows the exact incidence of malaria in India, for village vital statistics are, perforce, kept by primitive village watchmen who put down to "fever" all deaths not due to snake-bite, cholera, plague, a broken head or the few other things they recognize. But a million deaths a year from malaria may be regarded as a conservative estimate of India's loss by that malady.
Malaria originates in many places aside from tanks. There is, for example, the water-front of the city of Bombay, needless and deadly poison-trap for the sailors of the world. There are railway embankments built without sufficient drainage outlets, asking for remedy. There is the water-logged country in the Punjab; there is the new farm-land of the United Provinces, cut out of the tiger haunts of the Himalayan foot-hills--both by nature heavily malarial, but both being ditched and drained as a part of the huge agricultural irrigation schemes now under development by Government.
Malaria, altogether, is one of the great and costly curses of the land, not alone because of its huge death-rate but even more because of the lowered physical and social conditions that it produces, with their invitation to other forms of disease.
Under present conditions of Indianized control, govermental anti-malarial work, like all other preventive sanitation, is badly crippled. Yet it generally contrives to hold its own, though denied the sinews of progress.
And one recognizes with satisfaction, here and there, a few small volunteer seedlings springing up, strangers and aliens to the soil. Preeminent among these is the Anti-Malaria Cooperative Society of Bengal, an Indian organization now trying to bring control of malaria into the lives of the people, through educating the villagers in means of protecting their own health. Much praise is due to the enthusiasm of its chief exponent, Rai Bahadur Dr. G. C. Chatterjee, with his ardent coadjutors, Dr. A. N. Mitra and Babu K. N. Banerjee. Not only are these gentlemen, whom I visited at their center in Nimta, trying to do anti-malaria work, but also they are raising funds to make available to the Bengali villagers the services of Indian doctors properly trained in western medicine.
Aside from its precious tank a village may have a well. The depth of the wells averages from twenty to forty feet. Their content is mainly surface seepage. A little round platform of sun-dried brick usually encircles the well, a log lying across the orifice. Squatting on that platform and on that log at all hours of the day you may see villagers washing their clothes, taking their baths, cleaning their teeth and rinsing their mouths, while the water they use splashes back over their feet into the pit whence they drew it.
Also, each person brings his own vessel in which to draw the water he wants--an exceedingly dirty and dangerous vessel from a doctor's point of view--which he lowers into the well with his own old factotum rope. When he returns to his house, he carries his vessel with him, filled with well-water for the family to drink.
One of the great objectives of the British Sanitary Administration is to put good wells into the villages and to educate the people in their proper use. Now, not infrequently, one finds such pucca wells. But, exactly as in the Philippines, the people have a strong hankering for the ancestral type, and, where they can, will usually leave the new and protected water-source for their old accustomed squatting- and gossiping-ground where they all innocently poison each other.
As for pumps, the obvious means to seal the wells and facilitate haulage, some have been installed. But, as a rule, pumps are impractical--for the reason that any bit of machinery is, to the Indian, a thing to consume, not to use and to care for. When the machine drops a nut or a washer, no one puts it back, and thenceforth that machine is junk.
Now, this matter of Indian wells is of more than Indian importance. For cholera is mainly a water-borne disease, and "statistics show that certain provinces in British India are by far the largest and most persistent centers of cholera infection in the world."[1]
[1. The Prevalence of Epidemic Disease...in the Far East, Dr. F. Norman White, League of Nations, 1923, p. 24.]
The malady is contracted by drinking water infected with the fasces of cholera patients or cholera carriers, or from eating uncooked or insufficiently cooked infected food. It finds its best incubating grounds in à population of low vitality and generally weak and unresisting condition.[2] There is a vaccine for preventive, inoculation but, the disease once developed, no cure w known. Outbreaks bring a mortality of from 15 to 90 per cent., usually of about 40 per cent. The area of Lower Bengal and the valley of the Ganges is, in India, the chief cholera center, but "the disease is very gen-erally endemic in some degree throughout the greate/ part of the whole [Indian] peninsula."[3]
[2. Cf. Philippine Journal of Science, 1914, Dr. Victor G. Heiser.]
[3. A Memoranda on the Epidemiology of Cholera, Major A. J. Russell, Director of Public Health in Madras Presidency, League of Nations, 1925, which see, for the whole topic.]
Since the year 1817, ten pandemics of cholera have occurred. In 1893 the United States was attacked, and in this explosion the speed of travel from East to West was more rapid than ever before.[4]
[4. Recent Research on the Etiology of Cholera, E. D. W. Grieg, in The Edinburgh Medical Journal, July, 1919.]
In ordinary circumstances, in places where the public water supply is good and under scientific control, cholera is not to be feared. But the great and radical changes of modern times bring about rapid reverses of conditions; such, for example, as the sudden pouring in the year 1920 of hundreds of thousands of disease-sodden refugees out of Russia into Western Europe.
Without fear of the charge of alarmism, international Public Health officers today question whether they can be sure that local controls will always withstand unheralded attacks in force. With that question in mind, they regard India's cholera as a national problem of intense international import.
In estimating the safety of the United States from infection, the element of "carriers" must be considered. Each epidemic produces a crop of "carriers" whose power to spread the disease lasts from one hundred and one days to permanency.[5] Moreover, the existence of healthy carriers is conclusively proved. And India is scarcely a month removed from New York or San Francisco.
[5. E.D.W. Grieg in Indian Journal of Medical Research, 1913; Vol. I, pp. 59-64.]
"Whenever India's real condition becomes known," said an American Public Health expert now in international service, "all the civilized countries of the world will turn to the League of Nations and demand protection against her."
Bengal, one of the worst cholera areas, is about the size of Nebraska. It has a village population of over 43,500,000 persons, living in 84,981 villages. In the year 1921, a mild cholera year, the disease was reported from 11,592 of these villages, spread over 26 districts, the reported deaths totaling 80,547.[6] Imagine the task of trying to inoculate 43,500,000 persons, scattered over such an area, in advance of the hour of need; bearing always in mind the fact that the virtue of a cholera preventive inoculation lasts only ninety days. Imagine also the task of disinfecting all these village wells, when first you must persuade, not compel, the incredulous, always fatalistic and often resisting people to permit the process.
[6. Statistical Abstract for British India, 1914-15 to 1923-24, pp. 2 and 382; and 54th Annual Report of the Director of Public Health of Bengal, Appendix I, p. xxviii.]
In the winter of 1924-5 sporadic cases of cholera appeared in the Indian state of Kashmir. The British authorities did what they could to induce those of Kashmir to act, but the latter, Indian fashion, could see no point in disturbing themselves about ills yet only in bud. Consequently, in April, came an explosion, killing in a single month 2 per cent, of the entire population of the State. Across the border of British India, in the Punjab, the hasty Indianization of the Public Health Service had already so far proceeded that only one British officer remained in the department. Result: for the first time in thirty years the deadly scourge overflowed the Kashmir border and reaped a giant harvest among the Punjabi peasantry.
In the normal course of events, however, the main danger source for widespread cholera epidemics is the periodic concentration of great masses of people in fairs and festivals and in pilgrimages to holy cities. During the past twelve years or more, the British sanitary control of the crowds, in transit and also in concentration, where temporary latrines are built, pipe-lines for water laid, wells chlorinated and doctors and guards stationed, has been so efficient as greatly to lessen the risks. Of the possibilities of the future the Kashmiri incident speaks.
Hookworm, an intestinal parasite, saps its victim's vitality, eventually reducing him, body and mind, to a useless rag not worth his keep to himself or any ont else. Hookworm is contracted by walking with bare feet on ground contaminated with the fasces of persons infected. The procedure against hookworm is (a) to have the people use proper latrines, and (b) to have them wear shoes.
As Mr. Gandhi has shown, Hindus, anywhere, dispense with latrines, but are not, beyond that, always greatly concerned as to what they use. In one town I found from the municipal chairman that latrines had been built obediently to the Health Officer's specifications and desire; but the people, he said, were leaving them strictly alone, preferring to do as they had always done, using roads, alleys, gutters and their own floors.
This was in part because the town was short of out-castes and therefore had no one to remove night-soil--a thing which no caste man would do though he smothered in his own dirt; and in part because it was easier so to observe the Hindu religious ritual prescribed for the occasion concerned.[7] Villagers, in any case, always use the open fields immediately surrounding their village, fields over which they continually walk.
[7. See Hindu Manners, Customs and Ceremonies, pp. 237-40.
To sum up in the words of Doctor Adiseshan, Indian, Assistant Director of Public Health of Madras: "How are you to prevent hookworm when people will not use latrines, and when no orthodox Hindu, and certainly no woman, will consent to wear shoes?"
Under such circumstances it appears that, although the cure for hookworm is well established, absolute, simple and cheap, it would be an indefensible waste of public monies to administer that cure to patients sur« to be immediately re-infected.
It is estimated that over 80 per cent, of the people of Madras and 60 per cent, of those of Bengal, harbor hookworms. And in this connection Dr. Andrew Bal-four makes an interesting calculation. As to India, he says:[8]
[8. Health Problems of the Empire, pp. 193-4.]
A conservative estimate shows that 45,000,000 wage» earners in that country are infected with hookworm. In 1915 the Statistical Department calculated the average wage of an able-bodied agricultural labourer in Bengal at 10 rupees monthly...Assuming that the average yearly wage of the 45,000,000 infected labourers is 100 rupees each, these men are at present earning Rs. 4,500,000,000 annually. Now the managers of tea estates in the Darjeeling district estimate that the Rockefeller anti-hookworm campaign there...has increased the labour efficiency of the coolies from 25 to 50 pei cent.
Suppose that in India generally only 10 per cent, increased efficiency is achieved. Even so the Rs. 4,500,000,000 [$1,500,000,000] become Rs. 4,950,000,000 [$1,650,-000,000].
Bubonic plague was first introduced into India in 1896, coming from China. Today India is the world's chief reservoir of infection,[9] and has lost, since 1896, some 11,000,000 lives by that cause alone. The case mortality is about 70 per cent. Of pneumonic plague, which sometimes develops in conjunction with the other form, only an occasional case survives.
[9. Prevalence of Epidemic Disease in the Far East, Dr. F. Norman White, p. 21.]
Plague uncontrolled at its source may at any time become an international scourge, a danger to which international health officers are the more alive since latter-day observations continue to show the disease breaking out in regions where its occurrence has been unknown before.
Plague, unlike cholera, is not communicated by man to man, but to man by fleas from the bodies of sick rats. The flea bites the man and leaves a poisonous substance around the bite. Man, scratching the bite, scratches the poison into his skin and the deed is done. When plague breaks out in a village, the effective procedure is to evacuate the village at once and to inoculate the villagers with plague vaccine.
In most countries you simultaneously proceed to real control by killing the rats. But. this, in a Hindu land, you cannot effectively do, because of the religion.
The constant obstacle in the Public Health Officer's path is, characteristically, a negative one--the utter apathy of the Indian peoples, based on their fatalistic creed. The intermittent obstacle, acute of latter years, is the political agent who runs here and there among the villages, whispering that an evil Government is bent on working harm. To such a pitch have these persons from time to time wrought their victims, that the latter have murdered the native health agent entrusted with the task of getting them out of an infected site.
With repeated examples, however, of the results of following Government's behests, a degree of improvement has taken place. In some parts where plague has struck often, the people have begun to evacuate of themselves, when rats begin to die, and to flock into the nearest dispensary begging for inoculation. But in general the darkness of their minds is still so deep that the agitator can easily excite them to resistance, even to violence, by some tale of wickedness afoot.
When the first Indian lady of the district can say to the English lady doctor brought to her bedside: "Why should I show you my tongue when the pain is so much lower down? And besides, if I open my mouth like that a lot more devils will jump in"; or when the chief landlord of the district will tie a great ape just beyond claw-reach of his ten-day-old son and then torment the ape to fury to make it snatch and snarl at the child, to frighten away the demon that is giving him convulsions, what is to be expected of the-little folk squatting by the tank?
In the winter of 1926 I went through a plague-infested district in company with a British Public Health officer on tour. The first village that we visited was a prosperous settlement of grain-dealers--shopkeepers and money-lenders--the market town for the surrounding farmers. Each house was stored with grain in jars and bins, and rats swarmed. The rats had begun to die. Then two men had died. And on that the British District Commissioner had ordered the people out.
Now they were all gathered in a little temporary "straw village" a few hundred yards beyond their town gate, there to await spring and the end of the scourge. As the doctor, a Scotchman thirty years in the Indian Medical Service, approached the encampment, the whole lot, men, women and children, rushed forward to greet him and then to ask advice:
"Sahib, if we build fires here to cook our food, and the wind comes, it will blow sparks and burn these straw houses we have made. What, then, shall we do to cook our food? Please arrange."
"Build your fires over yonder, behind that mound."
"Ah, yes, Sahib, to be sure."
"Sahib, if while we sit here, outside our gates, bad folk creep into our houses and steal our grain, what then?"
"Even so, is it not better that bad men die of the plague than that the plague kills you? Also, you may set watchmen at a distance."
"The Sahib is wise. Further: there is, in a tent near by, a stranger of no merit who wishes to push medicine into our skins. Is it good medicine? Shall we listen to him? And what is the right price?"
"The man in the tent is sent by Government. The medicine is necessary to all who wish to live. It is free medicine. There is no price."
A pause, while the people exchange glances. Then the headman speaks:
"It is well, indeed, that the Sahib came."
"It looks," says the doctor, as we move on, "as if my little dispenser fellow had been squeezing those people for money before inoculating them. They will do that! And then, if the people won't satisfy them, they report that inoculation is refused. Except in the case of soldiers and police, we have no authority to compel inoculation. It is a risky business, this fighting wholesale death with broken reeds!"
Later we find the "stranger of no merit" squatting in his tent, a traveling dispenser of the Public Health Department trained and charged to do minor surgery, well disinfection and plague inoculation, to give simple medicines for simple ailments, to lecture, and to show lantern slides on health propaganda. By his own showing he had sat in this tent for a month.
"I call the people every day to be inoculated, but they refuse to come forward," he complained. "'Plague-doctor,' they say, 'now that you are here the plague must come!' and they laugh at me. They are a backward and an ignorant people."
The doctor inspects his equipment. On the inner lid of his plague box the dosage is written. Within are the serum tubes, the needles, the disinfectant equipment, undisturbed. Also his medicine chest--"Dyspepsia Powders," "Country Medicines," simple drugs in tablets.
"Let me see your instruments," says the doctor. All are rusty, several are broken and useless.
"You should have sent those in, each one as soon as you broke it. You know it would have been replaced at once," says the doctor, patiently. "Now you have nothing to work with."
"Ah, yes, I meant to send them. I forgot."