THE EVOLUTION?PAST AND PROSPEC-

TIVE ? OP MEDICAL AND SANITARY

WORK IN INDIA. By Brigade-Surgeon-Lieutenant-Colonel Kenneth

MACLEOD, M.D., LL.D.

Questions of medical reorganisation and sani- tary development in India are at the present time undergoing keen discussion. There seems to be a general consent that some change is necessary and impending ; but the grounds on which that change is needful and the manner in which re- form is to be accomplished do not appear to be always clearly realised. Service considerations loom too lai'ge in the argument, and it is not

sufficiently held in view that medical and sani- tary administration must constitute a part of general administration ; and that questions of reorganisation must turn upon the condition and

requirements of the country, and not upon the history or qualities or rights of present establish- ments, or the claims and qualifications of those who clamour to replace them. A review of the

evolution of general and medical administration in the past is necessary in order to understand

clearly the faults of the present and needs of the future in respect of medical and sanitary work.

For this purpose I have drawn up a table in which the more prominent features of the

history and administration of India, since the

granting of a Charter to the East India Company in the year 1600 up to the present time, are stated on one side, and the consequent changes which have taken place in the strength and con- stitution of the medical services are shown on the other.

Scheme of Administrative and Medical Evolu- tion in India.

Historical. Medical.

Seventeenth Centuiv. Fac- Surgeons to attend officials; tories; writers, native agents hospitals for soldiers and sub- and subordinates; ships ; a ordinates ; compounders and few soldiers. dressers to assist.

Eighteenth Century. Ac- Increased medical estab-

quistion of territory by ces- lisliment for attendance on sion and conquest; wars; civilians and troops and ser- armies, white and black; vice in navy. Superintend- navy. Civil administration, ing surgeons and Medical

by presidencies and districts, Boards appointed. Com- of acquired country ; collec- pany's medical officers posted torates, courts of justice, to districts for attendance gaols. Police established, on officials and charge of and subordinate revenue, Government gaols, hospitals, judicial and clerical services etc. Apothecaries and native organised. doctors trained in hospitals.

First Half of Nineteenth Medical staff enlarged ; all

Century. Extension of terri- medical supervision con-

tory ; increase of army and ducted by Company's officers; navy; annexation of new civil charges multiplied; provinces; centres of civil hospitals and dispensaries government multiplied ; established for medical relief

provincial adminstration of general population ; vac-

created ; considerable atten- cination started ; medical tion paid to education and schools founded ; subordi- meilical relief; peace, protec- nates trained in these em- tion and commerce extending, ployed in subordinate post3;

some attention paid to sani- tation of military canton- ments and civil stations.

1857. The Indian Mutiny. Medical officers largely Extensive disorganisation of utilised on service ; serious

military establishment and check to medical and sani- civil government. tary progress.

Suppression of Mutiny; Gradual return to the

augmentation of European status quo ante.

army; resumption of civil administration.

>

1858. Honourable East Great jealousy and friction India Company abolished, between British and Indian and government of India as- medical services. sumed by the Queen.

Some administrative con- 1860-65. Indian Medical fusion in consequence of Service closed ; civil medical transfer of Government from duties largely entrusted to the Company to the Queen. trained Indians and ?'

casu-

als." Increase of uncovenant- ed and subordinate medical services.

INDIAN MEDICAL GAZETTE. [Jan. 1896.

Scheme of Administrative and Medical Evolu- tion in India.?(Continued.)

Historical. Medical.

Re-organisation, military 1865. Indian Medical ser-

and civil. Rapid progress in vice re-opened. Officers re-

peaceful government, and stricted to charge of native great increase of schools and army and civil employment, hospitals; local self-help en- 1866. Administration of

couraged in these. Some British Army hospitals and measure of self-government medical staff assigned to established in presidency British Medical Department towns. 1867. Civil Medical Depart-

ment organised. Provincial

governments appoint their own medical inspectors.

Realisation of great sick- 1866. Sanitary Commis- ness and mortality among sioner with the Government

Boldiers, prisoners and popu- of India appointed. lation ; deplorable sanitary 1868. Provincial Sanitary condition of country becomes Commissioners created. Con- evident. siderable friction between

medical and sanitary depart- ments and between imperial and provincial medical in-

spectors. 1872. Lord Mayo's policy Provincial governments

of decentralisation gives in- take medical and sanitary creased responsibility and matters more into their own

power to local governments, hands, and resent interposi- Considerable increase of ac- tion of military medical

tivity in medical and sani- department. tary matters follows. Expediency of separating 1880. Military medical

military and civil medical administration unified, sepa- administration fully realis- rated from civil, and placed ed. Progress in public inedi- under one head. Civil medical

cal relief, medical education, administration re-organised sanitation, vaccination and and placed under control of vital statistics continues. provincial governments. Li-

centiates and graduates of Indian medical schools set-

tling in practice in large towns and villages.

1882. Lord Ripon's scheme Local bodies support and of local self-government ela- found hospitals and dispen- borated. Municipalities and saries, and employ medical local bodies created and en- subordinates for medical and trusted by law with power sanitary purposes. Great iu- of collecting and spending crease of sanitary work, and

money for local purposes? closer attention to health medical relief and sanitation matters in general. among them.

From this bird's-eye view of Indian adminis- tration, it is evident that our government of the Empire has been pervaded by several well- defined principles, chiefly, (1) Military unifica- tion ; (2) separation of civil from military ad- ministration ; (3) decentralisation of civil govern- ment; and (4) development of local self-govern- ment. It is on these lines that progress will

proceed in the future, and any change which is considered necessary in the interests of the

country ought to take the shape of gradual development rather than abrupt revolution. The recent creation of four army corps under

one chief, is another step towards consolidation of the military forces of India. Probably a higher degree of assimilation of the native to

the European section of the army will result in the course of time ; and the question of amal-

gamating and unifying the Army Medical Exe- cutive, medical administration having already been amalgamated and unified, will eventually arise. Meantime, the differences of constitution

and location of the two sections of the Army, and the different conditions under which the medical executive of each are engaged, will pro- bably militate against consolidation of the latter.

Military and civil medical administration have been completely separated since the year 1880, and the system then commenced lias worked well. No complaint has arisen from the Governments under which they have served of inefficiency or neglect on the part of that section of the Indian Medical Service which is employed under civil administrations. On the contrary, it is allowed that the work has hitherto been done well, and that officers of the Indian Medical Department have rendered splendid services in war and peace?in medical relief, sanitation, vaccination, e Jucation, the management of prisons and asylums, and in many other capacities. It is true that they are primarily recruited for

military service, are trained in the Army Medical School at Netley, have to serve two years with the colours, and are liable to recall from civil

employ in case of military exigency. As a

matter of fact, this recall has seldom taken place since the mutiny, aud as a matter of experience, these officers are none the worse?rather the better as regards status and discipline?of their military training. It was once the fashion to

disparage military medical work. It consists after all in treating the sick and wounded, and improving the sanitation of barracks, lines, can- tonments and camps. In India it is frequently combined with civil work. The work is b}' no means paltry, nor the men incompetent, and the reduction of the death-rate of the European army from 69 to 12 per 1,000, is no mean achieve- ment.

Equally anachronistic is the phrase, " fossil seniors." Administrative officers in these days are the survival of the fittest, and are carefully selected both at home and abroad. That the

liability to recall to military duty has not

damaged the work of civil surgeons in India is

quite certain. Whether the policy of maintain- ing in this manner a reserve of medical officers for military contingencies is expedient and sound or otherwise must depend on administrative considerations ; especially on the question, how far the contingency of military exigency on a large scale can be banished from Indian thought. The recent cry for a purely civil service has arisen from an interested class which hopes to profit by the change, and not from those who rule the country and administer its military and civil affairs. Even if it were decided to be advisable, on

administrative grounds, to entertain a purely civil medical service, it would be necessaiy to

obtain the same class of men as at present and in a similar way. The primary duty of civil medical officers is to attend on Government officials and their families, and take charge of

Jan. 1896.] A1YAR ON POISON-LORE OF THE HINDUS.

Government institutions. Europeans, or Euro-

peanised persons, are obviously best fitted for

these purposes, and the universal rule in India, that all official departments must, for efficiency and progress, be offered in chief by Europeans cannot, with impunity, be set aside in the case

of the medical and sanitary services. Plenty of employment has arisen, and more will arise, as the country develops for Indiaus educated in India without destroying arrangements which have hitherto worked so well.

The real cause of dissatisfaction with medical and sanitary services in India as now constituted is, that disease and death are yearly ravaging the country ; that sanitation is in a very back- ward state, and that these services are feeble in the conditions making for deterioration of health and destruction of life throughout a vast area covered by an immense population. What are a few hundred doctors and a few score sani- tarians to the 280 millions of India ? All this is quite true; but does the remedy lie in multi- plying and debasing the medical and sanitary executive, and is it the duty of Government to carry medical relief to every door and compass the cleansing of every home ? The remedy consists rather in following out

the lines of policy?decentralisation, and self-

government?already initiated, and developing the spirit and practice of self-help and self-sup- port among the people. This has been already done largely as regards medical relief, but it is even more necessary in matters of sanitation. Medical relief requires a skilled agency, but the

work of cleansing, which ought to commence with the home, can and must be wrought by the people themselves.

It is absurd to contemplate an army of sani- tarians and scavengers sweeping the Indian

Empire. The head of the house must be held

responsible for the cleanliness of the homestead, the urban authority of the town and the dis- trict and provincial authorities for the execution of important works necessary for the health of the community at large. The duty of Govern- ment consists in showing why and how sanitai'37 measures are to be undertaken. By means of advisers and inspectors, the sanitary needs of the country and community are ascertained, and this done, the ruling power ought to insist on the proper steps being taken by the local au- thority to secure cleanliness and prevent prac- tices dangerous to health. The present advising and inspecting agency requires strengthening and organising, and arrangements have to be made for the scientific study of disease causes.

But sanitary progress must depend on sani- tation becoming part and parcel of the rule of the couutry and life of the people as in England. As development proceeds in this direction, there will be abundance of employment for Indian medical meu.

I have in these remarks designedly limited myself to principles, and avoided comment on particular proposals and plans of medical re-or- ganisation. The points which I have endeavoured to es-

tablish may be summarised in these three pro-

positions :? 1. The sanitary defects and defaults of India

do not result from any ignorance or incapacity on the part of the Indian Medical Service, but depend upon the circumstances and habits of a teeming and ignorant population, spread over

a vast extent of unhealthy country. 2. The arrangements for medical aid to

Government servants and medical charge of

Government institutions and for medical ad- ministration are satisfactory; but the arrange- ments for supplying the sanitary requirements of India are rudimentary and ineffective.

3. Sanitary reform and progress can only be accomplished by educating, persuading and em- powering the people to adopt measures con- ducive to health as a detail of domestic and communal life. To that end the State requires an organised establishment, acting under the orders of imperial, provincial and district au-

thorities, to investigate, report and advise.