Mortality Levels

The reasons underlying this fall in mortality (and the earlier high levels of mortality) have been much debated. Kingsley Davis (1951) argued that India became "the home of great epidemics" only during the period of British rule (1757-1947), when it was "exposed to foreign contact for the first time on such a great scale." India's "medieval stagnation" was broken down later than that of Europe and so the region fell prey to pathogenic invasions, such as plague, at a later date. But, as in Europe earlier, India's population gradually developed an immunity to these diseases. Thus, Davis argued, even without medical and sanitary intervention, India's epidemic diseases began to lose much of their initial virulence. However, as Ira Klein (1973) has pointed out, some of the most destructive epidemics of the colonial period were not exotics but rather diseases long established in the region. Although India suffered very severely from invasions of plague and influenza between 1896 and

1918, diseases native to the region (notably smallpox, cholera, and malaria) also contributed substantially to the period's heavy mortality.

Davis probably exaggerates India's precolonial isolation. He also neglects its importance as a disseminator as well as a recipient of epidemic disease. The five pandemics of "Asiatic cholera" that raged between 1817 and 1923 all had their sources in India, as did the smallpox epidemics that caused such devastation at the Cape of Good Hope in the eighteenth century. Through extensive trading links developed long before the advent of British rule, as later through the exodus of its laborers and soldiers, South Asia acted as a source of several major diseases. Ancient ties of commerce and conquest with the rest of the Eurasian landmass saved the Indian subcontinent from many of the "virgin soil epidemics" that wrought such human havoc in the Americas and Oceania: Even plague had visited India several times before 1896. The critical factor was thus not so much the arrival of Europeans or the establishment of British rule as the greater degree of external contact that resulted from expanding trade and improved communications during the nineteenth and early twentieth centuries and the consequent social, economic, and environmental changes that facilitated the spread of epidemic diseases, whether exotic or indigenous in origin, throughout the region.

A second explanation for the twentieth-century decline in epidemic mortality focuses on the role of medical and sanitary intervention. Measures to protect South Asia from epidemic disease began early in the colonial period with the introduction of smallpox vaccination in 1802, and it has been claimed that this dramatically reduced the incidence of what had formerly been one of the region's greatest afflictions. Later measures against cholera, plague, and malaria - from mass immunization to chemical spraying - have likewise been identified as decisive factors in the eradication or control of these diseases. Davis (1956) claimed that by the mid-twentieth century, medical technology had the capacity to reduce mortality without waiting for supporting advances in socioeconomic conditions. But the limits of therapeutic intervention have since become apparent (especially with the resurgence of malaria since the 1960s), and recent writers are more skeptical about its effectiveness as an explanation for earlier falls in mortality. The low level of colonial (and postcolonial) expenditure on medicine and public health; the paucity of doctors, hospitals, and medical supplies relative to the size of the population; and the enormous technical, social, and cultural obstacles in the way of effective medical action — all have been cited as evidence of the limited human capacity to master epidemic disease in South Asia.

A third hypothesis draws close parallels with the European experience. It has been argued that the fall in mortality in eighteenth- and nineteenth-century England owed little to medical advances (apart, latterly, from vaccination) and derived instead from improved living conditions and diet. A comparable development has been suggested for South Asia, albeit at a somewhat later date. Despite massive famines that resulted in some 20 million deaths in British India during the second half of the nineteenth century, it is claimed that there was a significant improvement in economic conditions by 1900. The food supply became more dependable, helped by the construction of an extensive rail network and the expansion of irrigated agriculture; famine relief grew more effective in saving lives, and there was a rise in rural incomes through the stimulus of an expanding market economy. Those epidemic diseases most closely associated with famine - smallpox and cholera - declined with the disappearance of severe famines from India after 1908 (apart from the Bengal famine of 1943-4, which significantly saw a marked recurrence of epidemic mortality). The high death rate was sustained into the 1920s only by epidemics of plague and influenza, diseases that (it is claimed) had little connection with rural poverty and hunger (McAlpin 1983).

This argument has the virtue of singling out famine as a critical determinant of mortality trends in South Asia and hence provides a nonmedical explanation for the decline of two of the greatest killer diseases, smallpox and cholera. But although famine as such may have disappeared from most of the region after 1908, South Asia remained (and remains) afflicted by chronic poverty, with half the population below the poverty line. Malnutrition and overcrowded and unsanitary living conditions have remained fertile ground for disease and have kept mortality and morbidity at levels far above the norm in Western countries. Economic gains have failed to reach most of the people, and per capita foodgrain availability may even have fallen during the course of the twentieth century. There thus seems little basis for claiming that socioeconomic change has resulted in a healthier population. It would be more realistic to argue instead that although the cessation of major famines and the medical targeting of specific diseases like smallpox and cholera have been responsible for reducing or eliminating some of the earlier and most conspicuous causes of high mor tality, other "competing" causes of debility and death have taken over or have remained largely unaffected. Mortality has declined since 1900, but sickness and death remain all too common.

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