The first two waves of the Covid-19 pandemic possibly claimed four million lives in India. Still, the question of healthcare remains absent from national politics.

A man walks past a mural showing a health worker and a shadow of a Hindu deity, painted to create awareness about the spread of Covid-19 in Mumbai. November 2021. Photo: ZUMA Wire / IMAGO
The first two waves of the Covid-19 pandemic possibly claimed four million lives in India. Still, the question of healthcare remains absent from national politics. A man walks past a mural showing a health worker and a shadow of a Hindu deity, painted to create awareness about the spread of Covid-19 in Mumbai. November 2021. Photo: ZUMA Wire / IMAGO

Pandemics have always revealed the weakness of the Indian state

In 'Pandemic India', David Arnold offers a reflective study of Covid, cholera, plague, the Spanish flu and other historical mass contagions, from the time of the British Raj to the Modi government
Ideologically insular, culturally singular, economically inconsequential, modern India has been of little world-historical moment. Indeed, its historic set pieces have a bathetic quality. Potentially spelling the end of empire, the Revolt of 1857 ended in failure. Compared with the events in, say, Haiti or Ireland, India's protracted decolonisation was a rather dull affair, the product of half a century of constitutional wrangling. Partition? With some 12 to 15 million displaced, the Subcontinental tally was on a par with the number of Germans expelled from Czechoslovakia and Poland at the end of the Second World War. Across Europe, the figure stood at 60 million, and in China alone 90 million. Ideologically speaking, postcolonial Indian currents were sui generis, steering clear of exportable archetypes. Tempered by altruism, Nehru's socialism was too idiosyncratic to be properly socialist. Absent state capacity, his daughter's Emergency regime was too sickly and sensitive to the popular will to be properly authoritarian. Straitjacketed by precedent and pluralism, Modi's India is still very much a work in progress for it to be deemed properly theocratic.
Medical history, however, is another matter. There, India's pre-eminence as the sick man of the world is difficult to dispute. The staggering death tolls in David Arnold's Pandemic India speak for themselves. Of the 72 million pandemic deaths worldwide in the century to 1920, India accounted for 40 million. Spanning two hundred years, Arnold's reflective study expertly reconstructs the dilemmas and decisions of India's ruling classes in trying conclusions with those four horsemen of the epidemiological apocalypse: cholera, plague, flu, coronavirus. His strengths evidently lie in social history, which forms the core of the book, so it's a pity that he first treats us to a ponderous excursus on decoloniality, complete with obligatory nods to empire's "pedagogic pedestal" and "heterotemporalities". Pandemics, we learn, "served, in Western minds, to delineate the temporality of the modern, 'civilized' world from the imagined medievalism of Indian minds and bodies." More prosaically, Raj apparatchiks were a self-absorbed lot – but we must presumably be too stupid to discern this without Arnold's vehement editorialising. Writing in 1872, a colonial administrator observed how a "squalid pilgrim army of Jagannath" could, "impregnated by infection, … slay thousands of the most talented and beautiful of our age in Vienna, London, or Washington," to which Arnold adds: "Was there no one 'talented' or 'beautiful' among India's own cholera dead?"
'Pandemic India: From Cholera to Covid-19' by David Arnold. C Hurst & Co Publishers (May 2022)
'Pandemic India: From Cholera to Covid-19' by David Arnold. C Hurst & Co Publishers (May 2022)
All the same, Arnold is a thoughtful writer capable of clever turns of phrase, adroitly drawing connections and detecting ironies centuries apart. Moreover, in a field plagued by deterministic and sweeping claims, the sobriety of his prose is commendable. There is a marked contrast with, say, the lurid sensationalism of the journalist Laura Spinney's account in Pale Rider: The Spanish Flu of 1918 and How It Changed the World: "it influenced the course of the First World War and, arguably, contributed to the Second. It pushed India closer to independence, South Africa closer to apartheid, and Switzerland to the brink of civil war. It ushered in universal healthcare and alternative medicine, our love of fresh air and our passion for sport."
A sorry state
The picture Arnold paints is of devastating, if periodic, social breakdown. We meet, for example, a bureaucrat shooting snipe on the Narmada during the Spanish flu, wading in a sea of rotten corpses mutilated by crocodiles and turtles. In another chapter, we are treated to a graphic description of the effects of cholera: severe cramps, watery diarrhoea, wrinkled skin, sunken eyes, bluish hues; the cumulative impression easily mistaken for arsenic poisoning. Imagine the unenviable position of lawmakers, charting a course between two monstrous options: either lockdowns, which meant starving the working classes in the short run before rewarding them for their forbearance with stagflationary supply shocks, or inaction, letting the virus rip through the population while herd immunity worked its ruinous magic. The former option is unjust, the latter uncaring. Both are just as unpalatable – and so it was in an age of incipient nationalism as it is in an age of mass democracy. Administrators in the late-nineteenth century walked a fine line between interventionism, provoking Muslim outrage when male doctors uncovered women in purdah, and indifference, touching off cries of colonial neglect. It was in laissez-faire, plague-ridden Calcutta that the Irish instructress Sister Nivedita turned to Indian nationalism, becoming Vivekananda's greatest disciple. Damned if you do, damned if you don't.

Spanning two hundred years, Arnold's reflective study expertly reconstructs the dilemmas and decisions of India's ruling classes in trying conclusions with those four horsemen of the epidemiological apocalypse: cholera, plague, flu, coronavirus.

Then as now, religion was a sore point. Raucous pilgrims had their way at the Haridwar Kumbh Mela of 1867, drinking and bathing in the cholera-infested but ostensibly holy waters of the Ganga, the festivities proving a faster path to heaven than they imagined. The corresponding superspreader event of our age, of course, was the Haridwar Kumbh Mela of 2021, brought ahead by a year on an astrological whim, giving us ample reason to doubt His ways. Like the Raj before him, Modi had to walk a tightrope. On the one hand, there was palpable disquiet in his forlorn calls to devotees to make a "symbolic" mental peregrination rather than a dangerous one on foot. Yet on the other, there were full-page newspaper ads featuring his grinning visage emphatically assuring us of the opposite: the festival was "clean" and "safe". There's a transhistorical and transcultural truth here. Truculent subalterns aren't easily ignored. For instance, in Faith, Reason, and the Plague in Seventeenth-Century Tuscany the historian Carlo M Cipolla chronicles a similar story of a botched attempt to ban a religious procession in 1630s Florence, which, in the event, went ahead under popular pressure. More recently in Italy, I saw disaffection graffitied alongside the street shrines of Napoli laying into the mayor, a particularly impassioned zealot of the country's Covid lockdown: stop dittatura sanitaria ('Stop sanitary dictatorship').
In India, the 'sanitary dictatorship' arrived with the Epidemic Diseases Act of 1897, a piece of legislation to combat plague that was reintroduced in 2020. Its tyranny – enforced quarantine, mandatory hospitalisation, preventive detention – prompted nearly 400,000 residents of Bombay at the turn of the twentieth century, almost half the city's population, to leave for the countryside, also detonating weavers' and millworkers' revolts that spilled into riots. Likewise, the brutal 68-day lockdown that Modi abruptly announced on 24 March 2020 saw a mass exodus of workers from India's cities, who were assaulted and sprayed with disinfectant by the police as they fled. The harsher side of statism was, of course, equally on display in other countries – China and Israel using the pandemic as an excuse to beef up their surveillance apparatuses, South Korea tracking its citizens through their mobile phones to uncover illicit movements and extramarital affairs.

Subcontinental rulers have historically maintained a light touch. Heir to a trading empire, the British Raj distrusted quarantines and cordons sanitaire at the outset.

In particular, India's pandemics reveal a telling peculiarity of statism, so much more punitive than redistributive. Arnold mentions in passing the country's etiolated state capacity, but surely this is of greater import. This received some air-time during the Covid-19 pandemic, when India's appallingly low health spending of 1.5 percent of GDP was unfavourably compared to not just the global average of 10 percent but also the relatively open-handed allocations of many other developing countries. Famously, the upshot was first hubris, then nemesis. Early on in 2021, sporting a lockdown beard, Modi voiced an ill-advised triumphalism: India had miraculously emerged from the first blows of the pandemic relatively unscathed, registering a mere 80 deaths per million where the advanced capitalist world surpassed the 600 mark. Explanations for the Indian exception ran the gamut from its youthful population and airier lifestyle to the population's supposedly superior immunity, the result of greater exposure to unsanitary conditions. Much of the press at the time was too squeamish to point the finger at poor state capacity. The United Kingdom and the United States had a per capita toll over six times higher because both were testing six times as many people.
By April 2021, with just under a tenth of the population inoculated and millions of doses of the Covid vaccine rashly exported as diplomatic largesse, the effects of Modi's conceit were plain to see: thousands dying every day, crematoria burning the midnight oil, old and young furiously gasping for air, price gouging on oxygen cylinders in a land that had belatedly swallowed market nostrums with the zeal of a new convert. Until June, India's states were embroiled in a domestic bidding war for vaccines, as richer states in the south and west clinched supplies at the expense of the east and north. The importance of state capacity, or lack thereof, was further underscored by concatenating crises: Covid was accompanied by a cyclone in Bengal, a locust plague in Rajasthan, Zika virus in Uttar Pradesh, forest fires in Uttarakhand and floods in Kerala, the worst in a century.

India's pandemics revealed a telling peculiarity of statism, so much more punitive than redistributive.

Equally, the pandemic revealed India's place in the world. In desperation, Modi had to turn to his Chinese nemeses for imports of emergency equipment, and capitulate to his ally Trump's blackmail to export the anti-malarial hydroxychloroquine to the United States, later discredited as a coronavirus treatment. Time was when India was at the forefront of pandemic research. Europeans and Indians working in Bombay, Madras and Calcutta were behind the biggest epidemiological breakthroughs of the early twentieth century. No more. Decades of disinvestment in research and development have pushed India to the lowest rungs of the global supply chain. India's competitiveness in vaccine manufacturing owes to low wages and modest infrastructure rather than scientific prowess. The Serum Institute of India, the flagship of the country's contribution to the global anti-Covid effort, had its competitive advantage in the manufacturing and distribution of Covishield, not its development. The vaccine itself was the child of a singularly Western connubium between private capital and public research, joining together AstraZeneca and Oxford.
All in all, the first two waves of Covid possibly claimed four million lives in India. Still, the question of healthcare remains absent from national politics. Early in the spring of 2020, Modi was touting his "navratri pledge", imploring people of means to adopt nine needy families. Meanwhile Sonia Gandhi, the Congress party president at the time, declared that austerity was "the need of the hour." This at a time when Indians were dropping like flies. Not for nothing does the Republic have the dubious distinction of accounting for one in three rabies and tuberculosis deaths worldwide, not to mention one in five infant deaths. Malaria – the fifth horseman of the epidemiological apocalypse, as it were – continues to kill thousands of Indians every year. AIDS, the sixth, also thrives, killing some 150,000 annually at its peak in the mid-noughties. India is home to the third largest HIV-infected population, behind South Africa and Mozambique.
Plagued by passivity
The reasons for the state's dereliction of duty are evident. Four stand out.
First, Subcontinental rulers have historically maintained a light touch. Heir to a trading empire, the British Raj distrusted quarantines and cordons sanitaire at the outset. Disease control and medical discovery only came on sufferance, as it dawned on British mandarins that what happened in India didn't stay in India – the interlocking world of port cities could potentially turn every epidemic into a pandemic. Then again, diseases that stayed stubbornly tropical, such as yellow fever, could be disregarded. In any case, pandemics could be fought on the cheap. Provincial sanitary commissioners were appointed in 1868 to proffer health advice. Potable water reached two in three Calcuttans two years later, banishing cholera to the mofussil. Apathy prevailed until 1894, when the bacteriologist Waldemar Haffkine's vaccine, developed in Bombay and tested on tea planters in Assam before compulsory inoculation was instituted at religious events, finally conquered the disease.
By the end of Calcutta's cholera century, Bombay had picked up the plague baton. Originating in 1850s Yunnan, plague probably arrived from Egypt along with imported cotton, ensconcing itself on some stowaway rats that were later discovered dead in the Bombay docks in 1896. As it turned out, no sooner had Haffkine's plague vaccination programme commenced than it was suspended. A Russian Jew who obviously had it in for the Raj, so it was argued, he was made to take the blame for the 19 tetanus deaths in Mulkowal in 1902, though they were less likely caused by his vaccine than by contaminated forceps. The vaccine was discredited amid rumours of it causing impotence and sterility.
Apathy prevailed until 1894, when the bacteriologist Waldemar Haffkine's vaccine, developed in Bombay and tested on tea planters in Assam before compulsory inoculation was instituted at religious events, finally conquered the disease. Photo: Wellcome Trust / Wikimedia Commons
Apathy prevailed until 1894, when the bacteriologist Waldemar Haffkine's vaccine, developed in Bombay and tested on tea planters in Assam before compulsory inoculation was instituted at religious events, finally conquered the disease. Photo: Wellcome Trust / Wikimedia Commons
In the event, India got lucky. Plague's spread was contained on account of the relative absence of the Oriental rat flea, the vector of transmission, in the south and east. Inoculation played a part, it is true, but so did herd immunity, the decline of famines, better nutrition and healthcare. The final blow was dealt by DDT spraying in the 1940s and 1950s, then innocently à la mode. The so-called Spanish flu – the tag was earned since neutral Spain was the only country to report on the malaise at a time of war and censorship, though the flu had originated elsewhere – was different, taking away nearly one in twenty Indians. In Bombay, where infected troopships coming from Port Said and Basra in 1918-19 brought the disease to the Subcontinent, that number was one in ten. Erroneously designed to battle a bacillus, vaccines proved useless: flu is a virus. The grim reaper had his way until the flu ran its course, no real vaccine forthcoming. Thereafter, pandemics disappeared – until Covid, that is. Bubonic plague struck Surat in 1994, as one in four residents left the city, but the epidemic scarcely lasted two weeks, killing only fifty-six. Swine flu was a more genuine harbinger of Covid, killing 2500 in India in 2015. But then again, an antiviral drug, oseltamivir, and rapid testing quickly brought the situation under control. As for cholera, today it accounts for hardly a dozen annual deaths in India, finding more hospitable terrain in such trouble spots as Haiti and Yemen.
Second, not all lives mattered. Epidemics are supposed to turn us into socialists. As the adage goes, "we're all in it together". Truth be told, we never were. It was with relief, for instance, that an 1820 survey concluded that "the higher class of native, and Europeans generally," had escaped the worst of the cholera outbreak. But it was unsurprising. The government's advice to the upper crust – avoid ice rinks – was easier to heed than the recommendation to the hoi polloi: "do not travel in overcrowded tramcars." What's more, the high-born could be notoriously obstreperous. Vested interests saw that cinemas were kept open in Bombay during the Spanish flu, to the consternation of health officials, one of whom, an especially egregious killjoy, described a cinema hall as a "dark, inadequately ventilated … almost perfect medium for the interchange of microbic infections." More disturbingly, the Raj learned the hard way the cost of alienating the upper castes when, inspired by the nationalist icon Bal Gangadhar Tilak, three Brahmin brothers assassinated the plague commissioner of Poona in 1897 for having the temerity to 'violate' upper-caste bodies and homes. The upshot was that public authorities gave the middle and upper classes a free hand, focusing instead on slums, whose meeker ranks more easily submitted to the invasive indignities visited by health authorities. As it is, civil society was divided on caste and religious lines. There were separate plague hospitals for Brahmins, Muslims, Parsis and so on. As a result, wealthier communities recovered faster than did poorer ones.
Subcontinental rulers have historically maintained a light touch. Heir to a trading empire, the British Raj distrusted quarantines and cordons sanitaire at the outset. Interior of a plague hospital in Bombay, 1896. Photo: Wellcome Trust / Wikimedia Commons
Subcontinental rulers have historically maintained a light touch. Heir to a trading empire, the British Raj distrusted quarantines and cordons sanitaire at the outset. Interior of a plague hospital in Bombay, 1896. Photo: Wellcome Trust / Wikimedia Commons
Third, there was little pressure from below for the ruling class to mend its ways. Subalterns could be quite fatalistic, attributing pandemics to divine agency. Corona Mata was only the latest in a long line of pandemic deities. Eighteenth-century Bengal had a Hindu cholera goddess, Ola Chandi, and a Muslim counterpart, Olabibi. Then there were cholera demons, often Dalit women, who were either ostracised or beaten to death to ward off the disease. For its part, the Spanish flu was a fantastic time to be a missionary, as nuns and priests discovered during the attendant widow and orphan boom. Philanthropists and nationalists alike rushed to save women and children from beggary, prostitution and a life of crime. Equally dispiriting was the popular embrace of quackery. There's a long history here. Extolling the virtues of cow dung and urine as cut-price hand sanitisers while his pseudo-pharmaceutical Coronil, ostensibly a cure, was flying off shelves, the yoga guru and entrepreneur Baba Ramdev was only following in the footsteps of the Nobel laureate Rabindranath Tagore, who brewed his own marvellous medicine to heal his students reeling from the Spanish flu. "I am inclined to believe [in] the miracle of the Panchatikta Panchan", he wrote to a scientist friend of his, whose disapproval can only be imagined. It hardly needs saying that the Ayurvedic medicine was only a febrifuge of neem leaves and some herbs – snake oil, in other words.
Fourth, pandemics were insufficiently politicised. If remedies resided in decoctions and deities, the causes were likewise beyond human control. Indeed, the long shadow of climatic determinism was hard to shake off. For one thing, it suited the British. The Raj "could hardly be expected to outlaw the monsoon," writes Arnold. Indian nationalists, too, saw pandemics in similar terms. Much was made of Amritsar's 379 deaths in the Jallianwala Bagh massacre in 1919. Not so the 12 million Indians killed the same year by the Spanish flu, for which, on account of state neglect, government culpability was equally undeniable. All pandemics, after a fashion, are man-made. They belong to our epoch, the Anthropocene. It was the establishment of Calcutta, that famous "city in the swamp", in 1690 as a British bridgehead that turned it into the global capital of cholera. Arnold relates how the waterborne disease was seen in contemporary European discourse as "Asia's revenge", a weapon of the weak pressed into service by an angry precapitalist race against a more advanced people. But really, it was nature's revenge. Deforestation in deltaic Bengal made zoonotic transmission possible.

State intervention in pandemics has all too often meant draconian measures to curb free movement and free speech rather than higher spending on welfare and healthcare.

Over the course of the nineteenth century, cholera made at least five merciless sorties across Eurasia, each time originating in India. On every occasion, the desultory state response exacerbated the impact. Cholera coincided with a cyclone in 1876 and with famine in 1877, both forcing peasants to drink contaminated water. Forty years later, flu and famine formed a feedback loop. The Punjab had it worst – there, between 10 to 30 percent of all men of military age in every district enlisted in the First World War, depriving the fields of able-bodied farmhands. An enervated population was left to battle a debilitating disease. Compounding the Malthusian problem, grass and straw were exported wholesale to feed army animals on the Mesopotamian front, reducing milk supply in India. Pullulating pyres created a shortage of the firewood more ordinarily used as a domestic fuel, the dead damning the living. Commodity prices soared, as labour shortages put coalfields in Bihar, gold mines in Mysore, and cotton and rice plantations in Sind out of business.
In the absence of mass disaffection, is it any surprise that there's been so little change from on high? State intervention in pandemics has all too often meant draconian measures to curb free movement and free speech rather than higher spending on welfare and healthcare. Comparing the 1837 and 1897 plagues in the immediate aftermath of the latter, the Bombay journalist and historian R P Karkaria concluded that "there is nothing new under the sun, and history repeats itself with strange persistency." Ironically for him, history would repeat itself yet again: it was another pandemic, the Spanish flu, that possibly did him in. Here, then, is a cautionary tale against whiggish temptation. But this isn't the note on which Arnold closes his book. What we get, instead, is an incongruously upbeat conclusion: "history has heft … It yields timely warnings and persistent lessons; it posits a way forward. History communicates reassurance in the sense of knowing that the present need be no worse than the past and, forearmed by past experience, might conceivably turn out better." I, for one, am not reassured. Sadly, history is one thing, politics quite another.
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