Policy Papers

World trade and world disease

Sheldon Watts |

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Executive Summary

  • The modern history of the international application of government policies founded on medical science, does not present quite the ideal picture of progress informed by principles of science and humanitarianism that might be supposed
  • the nature of the powerful commercial interests which can influence government medical policy- and with it the fates of millions- has been of a truly global nature for much longer than is commonly appreciated
  • British imperial history shows that individual whistle-blowers are inadequate to prevent abuses in this specialist area without an alert and independent medical and scientific press, something increasingly difficult to guarantee in a thoroughly commercialised environment
  • The chequered history of medical interventions by the west in the east and the south counsels greater sensitivity to the concerns of less-developed countries over the intentions and consequences of scientific policies imposed from outside

The strange reversal of official British medical policy on cholera in India in 1868

At a time when the Non-West, and particularly the Muslim world, has become distrustful of policy initiatives put forward by the UK and the US, it is important to join historians in examining earlier policies which - in Non-Western eyes - went badly wrong, and perhaps to learn from past mistakes.

A less well-known example of a revolutionary new policy, introduced in mid-1868, which proved to be extremely costly in lives (in 1900 leaving nearly a million dead in India, with a similar mortality rate in Egypt in 1902) was the result of a radical change in official British Government thinking on the control of cholera on the Indian subcontinent and elsewhere in the colonial world.

Before its policy volte-face in mid-1868, the British authorities allowed medical and sanitary officials in India to carry out active, interventionist measures against cholera, for example by establishing cordons sanitaires and quarantines. Such a strategy, pursued in the North India epidemic of 1867 for instance, followed from what were then new scientific findings, indicating that cholera was a preventable disease within the competence of enlightened human kind to control. The Lancet, one of the leading British medical journals of the time, fully endorsed these ideas.

However, in mid-1868, for reasons which could have had nothing at all to do with developments in scientific medical thinking and certainly found no parallel in the United Kingdom itself, official cholera policy in India was reversed. Henceforth, there was a refusal to allow any interventionist measures to be used. Strangely, this cannot be explained by the arrival on the scene of a new individual with different medical ideas or by the over-ruling of the relevant medical officials in charge. The very same official- James McNabb Cuningham (1829-1905), who had overseen the successful implementation of the policy of cholera control through intervention in the North of India epidemic of 1867, was promoted in 1868.

In his new capacity as fully empowered Sanitary Officer with the Government of India (GOI) from mid-1868 to 1884 (when he retired), and subsequently as Surgeon General and Director General of the Indian Medical Service from 1880 to 1884, Cuningham enjoyed a powerful position. Indeed, he could have wrecked the careers of run-of-the-mill medical officers who did not perform as he saw fit. The new, anti-interventionist policy from 1868 could not have been prosecuted without Cuningham's sanction and approval. Yet this went against his own previous- and successful practice in India and also against the new European orthodoxy on cholera. For instance, in England, John Simon, the nation's chief Medical Officer to the Privy Council during the 1860s, correctly held that cholera was a preventable disease, caused by a germ in infected faecal matter, which could contaminate drinking water supplies, and that this causal chain could best be broken by controlling human movement.

Even more intriguingly, Cuningham himself provided full documentation of the centrality of his personal role, both in first putting into effect in 1867 the medically-sound European, standard interventionist policy and, secondly, in rigorously enforcing the opposite, anti-interventionist policy introduced in mid-1868. In 1867, in his capacity as acting sanitary commissioner for the GOI, Cuningham had made full use of cordon sanitaire and quarantine to successfully safeguard urban populations in the large cities of northern India during the cholera epidemic of that year. He sent notice of his 1867 achievements to the UK government in a 145 page document (with a 35 page appendix) now found in the India Office, in London.

Two years later, in his new capacity as full sanitary commissioner for the GOI, Cuningham, sent in another annual report in which he boasted of the ways in which he was disciplining medical men and under-officers who dared to claim that cholera was spread by a germ carried by human movement and which could therefore be blocked by cordon sanitaire and quarantine.

Given the closed system of government then found in England and the public's general disinterest in anything that happened overseas, only a small number of specialists at the government medical school and hospital at Netley were aware of these developments in distant India. At least three Netley professors (including tropical medicine expert Edmund Parkes) were outraged by J. M. Cuningham's betrayal of medical good-practice. It was said to be "nihilistic" by professor De Chaumount. For his part, Netley professor W. C. Maclean in his farewell lecture (published in 1886) cited chapter and verse, first from Cuningham's report of his highly successful interventionist campaign against north of India cholera in 1867, and then from his later "reports", in which he fiercely attacked any medical officer who dared to think in terms of breaking the cholera causal chain through forceful interventionist measures.

Maclean concluded in 1886 that: "It is impossible to resist the conclusion that...political considerations weighed with this able officer when he changed his opinions in this remarkable manner." Several years later (in 1894) J. M. Cuningham was still in the good graces of the UK government and was chosen to serve as "India's representative" at the Paris International Sanitary Conference. The official who had long served as Cuningham's principal supporter at "home" in London, Sir Joseph Fayrer, remained at his post as president of the Medical Board in the India Office and as a member of the Army Sanitation Commission until 1895.

The influence of business and politics on government and medicine

Close reading of contemporary documents makes it abundantly clear what was the nature of those 'political considerations', to which Professor Maclean somewhat obliquely referred. The sudden volte-face in British cholera policy in India (in mid-1868) was intimately linked to the imminent opening of the Suez Canal, cutting through Egypt. Slightly delayed, the actual opening was in November 1869. In an era when India was one of the UK's principal trading partners, big money was involved. It was understood that if no human-created blockages (such as quarantines) stood in the way, passage through the Canal would reduce by nearly half both the mileage and the time a steam-freighter required to sail between England and the west-coast port of Bombay (shipping center for India's export trade). In that era there were close links between members of the government, and investors and financiers who were concerned with trade and investment overseas. For instance, when Prime Minister Gladstone ordered the British invasion of Egypt in 1882, 37% of his personal investment portfolio was in Egyptian bonds.

The new official British doctrine on cholera in India was announced in the middle of 1868, and put into effect by the end of the year, just prior to the opening of the Suez Canal. As stated by officials in England and by J. M. Cuningham in India, it was now hotly denied that cholera was caused by a living germ, that it was carried from place to place by human beings (in the human gut), or that it was carried from place to place by people travelling on railways or by ship. In inter-departmental reports, Cuningham and officials in the India Office, the War Department, and the Foreign Office (after 1882, responsible for Egypt) repeatedly claimed that quarantine routines, at Suez, could not possibly be relevant to preventing the passage of cholera from Asia to Europe. They failed to mention that in 1832, 1849, and 1866 cholera had been carried from Europe across the Atlantic to the USA in precisely this manner. Other than by ship, and human movement, there would have been no possible way the disease could have come to the New World. These explorations into non-medical logic bring us directly to Egypt.

In 1878, the Egyptian government (not yet managed by Britain) ordered a complete freeze on the movement of Egyptian pilgrims who sought to return home from the Holy Cities in Arabia where cholera was raging. That year, there was no cholera in Egypt: the curtailment of human intercourse had worked. Three years later, in 1881, the British ruling authority in Aden (on the Red Sea) conveniently forgot to advise the Egyptian government of a local outbreak of cholera. As soon as the Egyptians learned of this, they clamped a tight quarantine on British shipping coming from cholera-infected Bombay, working through the international agency at Alexandria which enforced quarantines. Gentlemanly Britain was furious. A few months later, using other pretexts, it shelled Alexandria and conquered Egypt: this was the origins of the occupation which lasted until 1952.

In 1883, only a few months after the British conquest, cholera broke out in Egypt, with a mortality rate of 8.95 per 1000 (60,000 dead out of a population of 6.7 million). Britain at the time was at odds with the other European powers and felt obliged to prove that cholera had not come to Egypt by ship from the chronically cholera-infested port of Bombay (the main port used by ships en route to Suez and Europe). In London, a well-organized inter-departmental campaign was mounted to prove that cholera was endemic in Egypt and that it could not possibly have been brought in by a British ship from Bombay.

To "prove" this point, a high-powered inspection Commission was sent to Egypt. The Commissioners arrived after the epidemic had died down. They made no attempt to use modern laboratory techniques to test for cholera, despite the fact thatonly a few months before (in December 1883), such laboratory techniques had been used by Robert Koch- in Alexandria itself- to make his historic discovery and identification of the actual cholera causal agent (the cholera vibrio). Instead, the English Commissioners, following instructions from London and trusting only to hearsay (rather than to empirical testing), claimed that they had convinced themselves that cholera had been endemic in Egypt since 1865, if not before. They sent back preliminary reports to this effect to the Foreign Office, which were published in the world press.

While the Commissioners were in Egypt, an Egyptian medical doctor who had studied in Berlin, and knew Robert Koch personally, wrote an article in an English-language Cairo newspaper, advising the world that the British Commissioners were medical incompetents. Evelyn Baring (the later Lord Cromer) forced the doctor to write an apology in the Cairo press and then sent him into retirement.

But in fact, much the same thing was happening in England to competent medical doctors who dared to criticise gentlemanly Britain's new cholera policies in India and the Middle East, and who saw them as motivated solely by commercial considerations (to prevent the use of quarantine at Suez). To this end, the India Office and the UK Government saw to it that the principal voice of authentic medicine in India, Michael Cudmore Furnell, was removed from his post as sanitary commissioner of Madras in 1884. Apparently, seeing which way the political wind was blowing,during these same months, John Netten Radcliffe, a principal cholera advisor to the Local Governent Board and a strong proponent since 1866 of interventionist policies to prevent the entry of infectious diseases into England, also began to claim that quarantine controls at Suez were "unnecessary."

The silence of the medical free press

It is equally salutary to reflect on a more general collapse of reportage on cholera in Egypt or India in the medical press itself, including both The Lancet and the British Medical Journal, in or soon after 1884. In subtle ways, both journals had earlier made clear that they regarded the Commissioners sent to report on cholera in Egypt as medically incompetent. This was not acceptable to Government. Though the timing was not identical, within months of writing their acid comments on the Commissioners' final report to Parliament and to London-based medical societies, the British Medical Journal and The Lancet in effect fell silent on cholera.

Six years later it was still seen as politic to comply with the official line. Speaking at an international conference held in London in 1891 in the presence of a key official from the India Office (Fayrer), the Inspector-General of Hospitals in England (a personage of some importance) held that cholera was not necessarily brought into a new area by human kind, but that "it seemed probable that the exciting factors were conveyed by the air...and consequently it was not in our power to exclude them". This was a convenient position to take for anybody who wanted to excuse or overlook the absence of any quarantine measures at Suez.

In 1902 a medical officer who had long served in India after training at the Royal Army Medical College at Netley, Dr Andrew Duncan, wrote in the recently-founded, Journal of Tropical Medicine, exposing the fraud of British cholera policy in India after its volte face in 1868. The article was ignored.

In the same year, 1902, when cholera again broke out in Egypt (resulting in more than 34,000 dead), the British policies undertaken by the de facto ruler there, Lord Cromer, were more than usually culturally insensitive. Soldiers invaded Al Azhar University and Mosque and fired live bullets at students who refused to allow one of their sick friends to be carted off to a British-run cholera camp, where it was assumed he would die, his corpse to then be hacked up by anatomy students. British duplicity in the face of cholera in Egypt (this time brought in by airplane from India) was again in evidence as late as 1947.


Neither in 1883 nor in succeeding years was any leading Egyptian man of medicine taken in by British thinking on cholera. The details of the sorry history related here is news even to a well-informed British audience. People in general are, understandably, reluctant to confront and accept unsavoury accounts of the past behaviour of those who were entrusted to represent their nation and its interests, and the acts are all the more forgettable if they occurred in far-off 'foreign' lands and were hardly acknowledged at the time. But all that has been recounted here has never been entirely forgotten in Egypt.

It should be remembered at all times by western foreign policy advisers and ministers that the modern history of imperial and colonial rule over so much of today's less developed world has left many difficult legacies, such as the events detailed here. Much of this is not fully recognised in the standard historical accounts, which have been written mainly from the perspective of the west. Thus, the innovations of modern scientific medicine and its deployment in poor countries is generally considered to be one of the great success stories of the rise of the west and an example of its beneficence. However, the actual experience of that relationship and the conditions on which western medical science has been made available to the world's poorer peoples also has a much murkier side to its history, as has been shown here. The lessons of that history should be taken into account today when, for example, criticising the South African President's unwillingness to accept "expert" western advice on the cause of AIDS. Western advisers and policy-implementers should be much more willing to listen to and to seek to understand the historical sources of such apparently 'irrational' objections as these.

Editors of British medical journals can be cautioned to re-double their vigilance to ensure that their contributing authors are not following in the footsteps of J. M. Cuningham in allowing themselves to be swayed by non-medical considerations. Behind the government policies documented here, there lay extremely powerful commercial and financial interests. The independent authority of medical science and the status of medical doctors is probably much stronger than it was a century ago. But it would be rash to assume that this area is now entirely immune to this type of influence. That it certainly continues today to impact on medical policy is illustrated by the recent episode on the costing of drugs for HIV/AIDs in Africa, which saw protracted negotiation even on this emotive issue, only eventually resulting in the climbdown (a partial climbdown, however, it should be noted) by the commercial suppliers.

Another significant recent example has been the stance of the W.T.O. in threatening trade sanctions against several Asian countries who have wanted to restrict import of cigarettes, particularly the 'glamorous' U.S. brands. All the medical epidemiological evidence available predicts that, without the strong public health campaigns which western governments have endorsed for their own populations during the last quarter century, the citizens of these less developed countries will now be consumed by the same tobacco epidemic which swept western populations in the twentieth-century, with devastating and expensive consequences in terms of premature mortality. The W.T.O. is insisting on enforcement of the principles of free trade without also insisting that the same standards of health information for consumers be in place for poor countries as in affluent countries. Future historians will want to examine how it was that the interests of the tobacco industry have so far prevailed over medical science in influencing the policies of the W.T.O. in this vital health arena. As with the British rule in India and Egypt, once again we appear to be in a situation in which quite different standards of acceptable preventive health practices are condoned by the world's most powerful governmental institutions as being legitimate for the inhabitiants of less developed as against those of more developed countries.

Further Reading

Sheldon Watts, 'Cholera and Civilization: Great Britain and India, 1817-1920', and 'Afterword: To the Epidemiologic Transition?', in S. Watts, Epidemics and History: Disease, Power and Imperialism (London, Yale University Press, 1997), 167-212; 269-79.

Sheldon Watts, 'From Rapid Change to Stasis: Official Responses to Cholera in British-Ruled India and Egypt: 1860-1921,' Journal of World History, Vol. 12, No. 2 (2001), pp. 321-74.

Sheldon Watts: 'Review' of David Arnold, The New Cambridge History of India vol. 3 pt. 5, Science, Technology and Medicine in Colonial India. Cambridge University Press, 2000, Bulletin of the History of Medicine, 2001, 78, 337-40.

Giovanni Berlinguer, Everyday Bioethics. Reflections on Bioethical choices in daily life (New York, Baywood 2002), ch.5, 'Global Health'.


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