Under my byline

Ship to sure death

Posted in Books, Health, Living by Rrishi on 4 April 2009

Scanning electron micrograph of a flea, Xenopsylla cheopisA history of mass disease tells us we should beware of sea-borne weapons of mass destruction

Trust the ancients to know the oldest things best. Sushruta, the famous Indian surgeon of the 1st millennium BCE, wrote a treatise on surgery called the Sushruta Samhita. In it he prescribes a mantra to recite after surgery, a sort of prayer against post-operative infection — also the bane of modern surgery. Part of it reads as follows: “May such abnormal physical phenomena as drought, floods, excessive rain, the overpopulation or extinction of vermin like rats, mosquitoes and flies which invariably portend evil and mortality in a community abate and cease.”

Elsewhere, he writes: “A season exhibiting unnatural or contrary features affects and reverses the natural properties of water and vegetables: when consumed, these cause dreadful epidemics.”

And again: “Sometimes the pollens of poisonous flowers and grasses wafted by the winds, invade a town or village and produce epidemic cough, asthma, catarrh or fever, irrespective of all constitutional peculiarities or deranged bodily humors. Towns and villages have been depopulated through malign astral influences, or through houses, wives, beds, carriages, animals, precious stones assuming inauspicious features.”

In other words, Sushruta knew there was a link between mass disease and animals, natural (or supernatural) disasters, climate change and, to an extent, human activity. Also, his notion of disease “wafting” through the air was quite modern, at least up until the late 19th century. But ancient Indian medicine probably did not know of plague or cholera, the major killers of the colonial era.

These quotes come from an excellent new book on plagues and history, called Uncertain Life and Sure Death, by the noted doctor-writers Kalpana Swaminathan and Ishrat Syed. They write under the joint pseudonym “Kalpish Ratna”. They present a hard-won worm’s-eye view, on the parallel history of human disease and the medical science and practice evolved to combat it. So far it has been a tale largely told by Western physicians and historians, about Europeans on the home continent or in colonial lands.

No longer: with the help of extensive archival work in Mumbai and Goa, access to archives in Portugal and elsewhere, and a re-reading of well-known Western sources like Thucydides, Swaminathan and Syed have unearthed more than enough material to question this dominant narrative. Non-Western historians may not be surprised, but such a sweeping tale has never been told in a non-scholarly book like this.

Among other things, the authors pick out the role Indians played in the history of epidemic — whether they were hakims and vaids with prescriptions that couldn’t be bettered by European physicians, or simply those who died, by the hundred or million. Yet, as Mumbaikars, the authors can localise the source of their inspiration: about the repeat cholera outbreaks of the 19th century in India, they say over the phone with something approaching pride, “Bombay was a vast laboratory of human suffering.” And, “We found it exciting that all the changes that modern medicine has given us, [started] in Bombay and in our [alma mater,] Grant Medical College.”

It is critical to the tale that Mumbai is a port city, whose modern history is as old as colonialism in India. Because epidemics travel in two ways: along with armies, and along trade routes. In Portuguese and then British Bombay the two came closely related. The authors take as example Shashti Island, or “Sixty-six Villages”. In the Portuguese records this land goes from lush, healthy and prosperous when they arrived to (reading between the lines) a part-wasteland created by fanatic Catholic officers and the diseases that the conquistadors brought from over the sea.

The authors create a memorable image of sick, filthy, lice-ridden and starving Europeans stumbling off their equally unsanitary ships onto this green and pleasant land. Chief among their complaints, as the rather brutish Vasco da Gama discovered on his way here and back, was scurvy — not quite a “plague” in the way we know the term, but one which in the 17th century was no less fatal.

Scurvy results from a lack of vitamin C, which has to be taken in in the diet. In a severe case, the gums weaken and turn spongy, teeth fall out, the body bruises easily and the skin tears and refuses to heal. Given a voyage of such unprecedented length, much of the time without fresh fruits and vegetables, scurvy killed half of da Gama’s sailors. The ones who lived did so because eventually, too late for many, some connection was made between fresh greens or oranges and the disease. Observation had suggested a cure — not yet a preventative. But arrogance almost prevented it, because of da Gama’s refusal to accept the traditional port arrival-gift of fresh food from local African potentates on his outward journey.

Yersinia pestis, the plague bacillusThe fact that the authors include scurvy in this book along with various kinds of plague and cholera illustrates what they mean by “plague” in the general: a disease new to a population, which strikes without discrimination anyone exposed to the right conditions, and which physicians and scientists are unprepared to deal with.

As such, a plague is an excellent way to test the state of medical knowledge and range of therapeutic tools. When the authors argue that, without plagues, medical “science” would not have received the jolts it needed to break out of outworn patterns of thinking (religious ideas included), they make a persuasive argument. As they imply, without useful received wisdom the desperate physician is thrown back on the oldest and perhaps most reliable medical tool of all: observation, or what the authors, as working doctors themselves, call the “medical eye”.

But the European medical eye in 17th-19th-century India was most effective when it looked not only at the patient but also at local healing practices. This meant learning from whatever was most effective in “native” medicine — like the hakims and vaids. Although what European physicians in India usually learnt and applied was “remedies” rather than the Indian systems of medical understanding, this still had the salutary effect of showing them the holes in their own ideas: such as not to cover a dysenteric patient with blankets and cut his fluid intake in hot weather, but rather to give him kanji, an Indian version of the modern oral rehydration therapy (ORT).

In ayurveda, for instance, unlike European medicine, there was a clear sense of the relationship between the weather and environment, and health. This seems wise in retrospect, if not in quite the same way, because of what we now know about how SARS and avian flu — let alone the traditional plagues — became human diseases: because of newer, more crowded ways of living where different species of animals or birds were in close company with humans. There is also the question of human damage of the environment and its blowback effects in terms of disease, to which Swaminathan and Syed repeatedly return.

For instance, historian Seema Alavi of Delhi’s Jamia Millia Islamia says, “British sanitation officers were very worried about pilgrimage of all kinds. In the case of Hindu pilgrimage within India, all the cholera deaths were completely linked to pilgrimage. Similarly, about the Hajj pilgrimage, there was this real anxiety about pilgrims carrying diseases back and forth” — particularly as Arabia was closer to Europe. “Late 19th-century pilgrimage figures show a marked increase with better [steamship] transport, and cholera also increases.”

Cholera ravaged Europe, and London, in the 1830s. So, Alavi says, “British doctors from India were in great demand, they were called back. They wrote a huge amount of tracts in the 1830s and 1840s based on their experience.”

The Portuguese in early Bombay lived off the land revenue — but the British were smarter, and built on trade. To build their commercial city, they imported labour, drawn from the rural hinterland and further afield. Colonial wars trailed famine; famine undercut immunity and boosted indebtedness; the poor and dispossessed fell sick more easily, and pathogens got the chance to adapt better to humans. The poor drifted to Bombay, among other cities. Inevitably, what diseases, such as cholera and plague right into the early 20th century, befell them in large numbers also befell their British employers; yet the European victims figure largest in the records.

At every turn in this history of mass disease, the observer meets with these engines of modernity at some stage of development: commerce, globalisation, urbanisation and science. Now shipborne diseases are minimal; as Captain K S Nair, a director of the Shipping Corporation of India, says, the chief health problems aboard are “boredom, obesity, diabetes” and so on. Ship journeys are much shorter, there are refrigerators for fresh food, and rats are slowly on their way out because there is more container and less loose cargo (like cotton bales).

But there’s a dire warning from Swaminathan and Syed: with the benefit of their long view, they know that, while now (like the best colonial administrators in their time) we can “manage” outbreaks of mystery illnesses like SARS, our expertise and resources have yet to be seriously tested. At any place where natural disaster and large human populations come together, there is the potential for novel disease. And our interference with the natural environment may change the conditions against us: a hotter climate may mean a stronger monsoon (witness Mumbai 2005), which may stir up the seas around and bring more nutrient matter to surface waters, on which can feed the microscopic life which harbours, for instance, the cholera germ. And this is not even to mention the daily clash of man and nature (think sanitation and drainage) right in the middle of our own cities.

The history of mass disease may still be a work in progress.

Black Death, Toggenburg Bible, 1411

Uncertain Life and Sure Death: Medicine and Mahamaari in Maritime Mumbai
Kalpish Ratna
Maritime History Society
xvi + 368

(This story was written at speed and I don’t think it quite does justice to the book, which contains a most stimulating and revisionist view of the intertwined history of mass disease, commerce, exploration, colonialism, medical science, etc. — so I urge you to go buy the book. You can also read the article in Hindi, translated by Pawan Sinha.)

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