Review by Saman Kelegama
by S.A . Meegama, Sridevi Publication, Sri Lanka, 2012, pp.460, LKR 750
This book explores some aspects of the roots of modern Sri Lanka through the social history of health during the period when it was a British colony. The author charts out the impact of colonial policies on peasant agriculture, food availability, and the living conditions of the common people. Bringing together rarely documented facts, backed by data from surveys, government reports, and entries in diaries of officials, the author writes of the devastation wrought by famine, new diseases, and volatile epidemics and the consequent fear generated among the subject peoples.
The work details, with particular reference to the politics of health in a colonial context the gradual modification of Eurocentric and imperial attitudes among the governing elite under pressure from enlightened officials, medical men and popular leaders. The author traces the evolution of the health transition detailing the campaigns against many diseases, the efforts to develop preventive health care by providing sanitation and safe drinking water, the provision of primary health care to restore the appallingly high levels of maternal, infant and child mortality and the uphill battle to improve the abysmal living conditions of immigrant workers in the plantations.
This book also analyses the impact of the malaria epidemic and famine of the 1934 -35 period on the social policies of governments elected by the people’s vote after the grant of universal suffrage in 1931. The author comments on the gradual opening of a road to a more egalitarian society through multiple state interventions in health, education, and food security that also made the expectation of life and health care in this Third World country nearer to the levels attained by developed countries.
The author, S. Ananda Meegama, has worked on the subject of mortality and disease in developing countries for several decades. This book contains his knowledge and experience gathered during his versatile career and is essentially a continuation of the work on mortality trends in Sri Lanka that he submitted many decades ago for his doctoral thesis at the London School of Economics.
Spread of Communicable Diseases
In Chapter 1 the Introduction, the author emphasizes that Poverty, Famine, and Disease, the defining symbols of the Third World, find their roots in the colonial experience. However, Sri Lanka an integral part of the old world trading system and a meeting point for traders from the West and East, had long been exposed to many of the diseases that are conveyed through human carriers. Consequently, the population had gained some immunity whilst also benefiting from the introduction of medical practices and medicines of many countries, all of which added a new dimension to the nature and treatment of disease in the country.
While in the current set-up, the main diseases prevalent in modern Sri Lanka which a reader today is more familiar with are non-communicable diseases (NCDs) such as cancer, cardiovascular diseases, strokes, neurological diseases, etc., the diseases prevalent during the colonial times and which evoked fear and panic in the population were the communicable types of diseases. These ranged from parangi or yaws introduced by the Portuguese, to smallpox epidemics, cholera, plague, tuberculosis, malaria, etc., during the Dutch and British colonial periods. While initially these were confined to the Maritime Provinces, after 1815, these spread to the rural areas as well.
With the enactment of the Crown Lands Encroachment Ordinance and Waste Lands Ordinance in 1840 grew the plantation economy commencing with coffee which also led to the disruption of the villages and rural life. The wrecking of village institutions and irrigation systems and the take-over of village lands led to famine which assisted in the spread of epidemics such as dysentery, cholera, tuberculosis, malaria, and ankylostomiasis spreading fear and terror among the Sri Lankan peasants.
The Introduction also deals with the policies of health in the early decades of the 19th century when the medical services were under the control of the military until 1858 at which point the Medical Department was established under civilian control. While the villages and rural areas had their own unique features which led to the spread of contagious diseases, the problems facing the towns, especially with rapidly rising populations, were those mainly of sanitation such as the absence of drains, pipe-borne water, systems of disposal of human waste, etc., and which become a veritable nest of infection of regular epidemics of typhoid dysentery, cholera, etc.
Small Pox and Vaccination
Chapter 2 of the book deals with smallpox, one of the most dreaded and feared diseases that invoked fear until inoculation and vaccination brought it under control. Epidemics of smallpox figure in the history of the island from early times but it was never endemic. The infection was invariably carried from the neighbouring Indian sub-continent and with regular contacts with South India, there was no way in which it could have been prevented from emerging from time to time in Sri Lanka.
Although vaccination was started in Sri Lanka as early as 1802, lapses in the programme led to almost yearly outbreaks till even as late as 1908, the 1870s and 1880s being the grim period where it plagued the country. Though there was initial fear and distrust of vaccination, the Government took the vaccination campaign very seriously and the number vaccinated each year were published in the Government Gazette. The enactment of the Quarantine and Prevention of Diseases Ordinance No. 3 of 1897 led to restrictions being placed on the entry f immigrant abourers from India. The Medical Department however faced several problems in implementing the vaccination programme such as a shortage of vaccinators, the quality of the vaccinators, lack of supervisors, apathy and even hostility of the population as well as a shortage of lymph. Vaccination was made compulsory in 1863, and by the 1930s vaccination becomes a routine and smallpox no longer became a serious threat to public health in the country.
The fear and panic in the age of Cholera is described in Chapter 3. In 1821 cholera swept through the Northern and Western parts of the country with devastating consequences, while the 1866-67 cholera epidemics virtually destroyed entire villages with over 10,000 deaths in the Jaffna Peninsula alone. The Cholera Commission that was appointed found many factors that were relevant including lack of adequate sanitary facilities, food scarcity, poverty, polluted drinking water, unprotected wells, unauthorized burial grounds, limitations and evasion of quarantine.
The Medical Department followed several general rules in containing the epidemic. These included cordoning of infected areas, fresh water supplied to infected houses, supervised burials, disinfection of infected articles, and improvement in quarantine procedures, among others. In the absence of Sanitary Inspectors, police constables called “contagious disease constables” were entrusted with the task of controlling the spread of the disease. These methods of control become gradually successful in keeping outbreaks under control. The slow and steady development of public health services through improved sanitation and the provision of uncontaminated drinking water led to the decline of cholera in Sri Lanka with only 74 cases recorded in 1946.
Chapter 4 of the book deals with parangi or yaws a contagious disease that led to chronic debility and disfigurement but was rarely fatal. It is believed to have been introduced by the Portuguese and the Dutch who were accompanied by a number of natives of Africa and it is believed that they may have introduced parangi in addition to syphilis. The first steps in its eradication took place in the last decades of the 19th century with the discovery of the bacterial origins of many diseases and it was discovered that parangi was caused by bacteria and transmitted mainly through skin contact. Steps were taken by medical institutions to treat the disease through injections and after 1940, with the discovery of penicillin, it was eradicated in Sri Lanka.
Two other major factors that led to the various outbreaks of contagious diseases in Sri Lanka during this early period were the occurrence of pilgrimages and the influx of immigrant labourers consequent of the rise of the plantation economy.
Disease Spread —Pilgrimages
Chapter 5 deals with the spread of diseases with pilgrimages at that time. Pilgrimages were popular both among Buddhist, Hindu, Muslim and Christian people. However they become a focal point from which epidemics could spread with disastrous swiftness. Two issues which faced the Medical Department related one to the protection of the pilgrims from epidemic disease and the other the dangers posed by returning pilgrims to their villages and wayside communities. This, for example, led to the enactment of the Ordinance Relating to the Annual Pilgrimage to Kataragama No. 14 of 1873 among other measures.
Disease Spread – Immigrant Labour
Chapter 6 deals at length with the topic of immigrant labour consequent on the rise of plantations. They were largely from South India where poor peasants were fleeing from epidemics of cholera and smallpox and food shortages resulting from drought, landlessness, and high taxes.
The terrible journey to a traumatic life in the plantations is vividly described and is largely indebted to Ian Vandendriesen’s famous book “The Long Walk” given in the bibliography. While the planters were triumphant, the immigrant labourers lived in wretched conditions in line rooms poorly clothed, badly fed and subject to diarrheal diseases and other infections. The government was forced to intervene and enacted the Medical Aid Ordinance No.14 of 1872 followed by Acts in 1880, 1882 and 1912 to alleviate conditions and which led to effective government intervention in the plantations. The implementation of the Medical Wants Act of 1912 brought a great transformation in the life of the immigrant workers resulting in better water and sanitation conditions, minimum wages, lower maternal and child mortality and better health education.
Health of Cities
The problems of health in the cities (Chapter 7) were more of a different kind. These resulted from issues of over-population, the crisis in water and sanitation, disposal of waste leading to epidemic diseases such as tuberculosis, cholera, dysentery and typhoid etc. In 1906, the government produced the Chalmers Report under Dr. A. J. Chalmers (he was the first registrar of the Ceylon Medical College) which analyzed these problems and suggested remedial measures including their financial implications. The problems of high maternal and infant mortality were also investigated and steps taken in this connection were the training and provision of more midwives, free dispensaries for the poor, better health education, the establishment of a separate Division for Maternal and Child Welfare in the Municipality in 1925, maternity homes, among others. These are discussed in Chapter 8 of the book.
Apart from disease is the problem of famine dealt with in the book (Chapter 9). Several causes are identified for this issue among which were droughts, shortfall in food production, distributional problems, disintegration and collapse of agriculture and irrigation communal works, and political economy problems resulting from scorched earth military tactics of the British during times of rebellion as in 1818 and 1848. The abolition of “Rajakariya” on the recommendation of the Colebrook-Cameron Commission in 1832 led to the virtual collapse of the ancient irrigation system and tanks which were hitherto maintained by this system of communal labour. This was accentuated by the expropriation of village land under the Waste Land Ordinance of the 1840s, increasing inequality and a debt-ridden peasantry, a plethora of overhead taxes such as the Grain Tax Ordinance No 5 of 1866 and No. 6 of 1873 and defects in the relief system.
One of the principal issues dealt with and which has relatively recent origins was the malaria epidemic of 1934-35, though there were earlier epidemics in the dry zone (Chapter 10). It was a major cause of death until the late 1940s and depended on the extent to which conditions favoured the malaria carrying vector mosquito both in the dry zone and wet zone. Scientific work on the nature of the disease, its method of infection and remedies were made only after the discovery of the bacteriological modes of its transmission. Strategies of prevention and control of malaria included measures such as quinine treatment, prevention of mosquito bites, D.D.T spraying, prevention of the formation of stagnant pools of water, destruction of mosquitoes, abolition of breeding places, setting up malaria centres and health education. The Chapter deals with the main problems in respect of the malaria epidemic and its consequences.
The crisis also brought out the best in society and the public and various voluntary organizations and national figures played a key role in providing relief such as the All Ceylon Buddhist Congress under L. H. Mettananda and the Suriya Mal Movement led by Philip Gunawardena, Dr. N.M. Perera and Dr. S.A. Wickramasinghe consequent on political awareness and numerous parliamentary debates. The political consequences of the events of 1934 -35 were immense and it awakened the country to the underdevelopment of rural Sri Lanka, the penury of the masses under colonialism, inadequacies of the health system, and hastened reforms in many spheres.
New Deal to Combat Spread of Disease
The condition of the people during these various epidemics and endemic in the 19thcentury, the beginning of government intervention such as the establishment of the Medical School, dispensaries and hospitals, medical officers, fees charged, nursing and hospital care, international cooperation, development of maternity and infant care and the beginnings of a new deal are all dealt with in Chapter 11. Though the beginnings were slow it picked up in the late 1930s particularly with the new policy put into practice in 1939 by W. A. de Silva, Minister of Health. It included the expansion of health services for the rural peoples, maternal and child care services, rural and cottage hospitals, health education and sanitary reform.
As stated in the Conclusion to the book, the health transition in modern Sri Lanka was a continuous process beginning from the second half of the 19th century, a process that went through several phases beginning in the 1870s and reaching maturity in the period 1938-1950. It was characterized by many aspects as mentioned previously and included the assistance of administrators, philanthropists and elected politicians apart from various social organizations and international cooperation. Along with measures in health came the developments on nutrition levels, irrigation and settlement schemes in the dry zone, free education, free health services, and preventive healthcare. The trials, field work and experience were built up over a century all of which cumulatively led to the health transition in Sri Lanka by the middle years of the 20th century.
Overall the book contains a very exhaustive and detailed account of the health conditions in Sri Lanka during a crucial period of its history. Supported by historical maps, documents, statistics and a detailed bibliography, a feature that strikes the reader is the inclusion of some very rare and interesting illustrations and pictures that helps to emphasize the episodes related. To a modern reader living in today’s conditions of a relatively advanced health care system composed both of public institutions and private hospitals, it sometimes feels astounding to read the gruesome and horrific epidemics which Sri Lankan people had undergone in the previous two centuries, epidemics such as smallpox, cholera, malaria, parangi, typhoid, high maternal and infant mortality etc.
One may feel sometimes a little critical on the repetitions of various facts and incidents in different sections of the book. This is however inevitable when different diseases which have common origins and common causes for their spread are related. Further, most of the diseases became contagious and spread rapidly due to the widespread insanitary conditions, the physiological conditions of the people, the unsatisfactory nature of living conditions, the lack of adequate facilities for prevention and treatment, etc. which are common throughout.
Overall the book is of immense interest and historical value not only to economic historians, medical men and doctors and students but is of contemporary relevance to administrators and policy makers as well as to the general public alike.
(The reviewer is the Executive Director of the Institute of Policy Studies of Sri Lanka)