The Cholera Pandemic in India [1800s]

India prior to the mid-1800s was an ununited land, where it was made up of independently ruled states. Although India was considered just as developed at the time as Britain was, the division within the country made it susceptible to the income of British colonizers.

While India did not become an official colony of Britain until 1858, the British had influence prior in India through the East India trading company, where the British would be making alliances and sighing treaties with the separate states to gain influence and later complete control. The British during the colonial rule established disparities within the Indian population, potentially to keep them divided and ununited, where they expanded the gap between classes through teaching higher classes such as local leaders and their elites English and allowing them to partake in the army or civil services.

India was an important colony to the British, who consumed around 20% of British exports in the 1880s. India was also their greatest military resource, with Britain using the Indian army around the world, notably in WWI and WWII.

The image shown on this slide is of British troops and Indian conscripts into their army.

The Bengal region of India is often referred to as the origin of cholera in India. There were reports of cholera outbreaks in India prior to the Cholera Epidemic of the 1800s. In fact, nearly 70 outbreaks of cholera were reported between 1503 and 1817, however, these were mostly contained by lack of transportation. It is no surprise, then, that cholera cases rose as more colonizers moved in, and the Industrial Revolution began.

On this map of India, the darkly highlighted region towards the right of the map is the Bengal region.

As colonizers moved in, British troops marched from place to place, and they brought cholera with them. Beginning in August 1817, and over the course of several months, over 25,000 soldiers stationed near Calcutta were treated for cholera and almost 20,000 died. The colonial military establishment of the time suspected that their sickness was due to contact with locals of lower caste systems (of which had little to no access to clean water).

The Industrial Revolution also meant that there was a higher demand for products to trade. It is possible that migrant workers from Bengal traveled to Jessore in order to work in indigo manufacturing. These workers would have been traveling from the countryside, which is where the bodies of water containing cholera originated. Locals needed work, and traders needed materials, leading to higher case volumes within manufacturing districts.

For some local Indians, the cholera outbreaks were perceived as acts of god. Those who lived in and around Bengal, most notably Culcutta, had a long history of cholera (or diseases similar to cholera) outbreaks in their area. These outbreaks were thought to be a result of Ola Bibi: The Lady of the Flux. At her temples, people would donate and worship to be spared. Those who became ill viewed this as a result of divine anger from Ola Bibi.

In 1800s India, cholera was spread through contaminated water sources, as seen throughout developing countries in the world. Many of the water sources were considered still sources, where water did not move freely which allowed for water contaminated with decaying garbage, poor sanitation, seasonal changes, and high population density to be a perfect breeding ground for cholera.

High population density in developing worlds coupled with poor sanitation provides cholera the perfect areas to thrive in and negativity affects developing countries within slums.

The bar and line graphs show the average number of cases based on location, and throughout the months, it shows that the locations closer to ports seemed to have larger issues with the disease. It was noticed many of the outbreaks occurred between April and October, which include months where temperatures reached over 30°C and during the monsoon seasons in port cities.

These cities in tandem with below average sanitation, created a high risk factor which caused the outbreaks to occur.

The risk table on the right shows how the different environmental factors, as well as the infrastructure issues would lead to a high risk for a cholera outbreak, where higher temperatures, rainfall, and poor or damaged water and sanitation access caused a high risk scenario.

In the 1800s there were two groups who were affected differently from cholera in the Village of Vadakkankulam, the layout of the village pictured. It was found that the High caste society split by the street on the West side, had a cholera outbreak, oddly enough the low castes in the same village were not affected. The initial reaction to the outbreak was that the High castes provoked the deity into anger and that was why they were being punished with this outbreak.

The reason the lower castes were not affected was due to the lower caste people not being able to use the same well water as the higher castes. This difference led to the observation that the wells were poorly built and allowed seepage into them, polluting the water with contaminated water used for cleaning and was the cause of this cholera outbreak.

The belief that people have angered a deity has now started to dwindle due to the research and knowledge that drinking contaminated water is the root cause of these outbreaks.

The population density of people living within a confined area travelled between villages and to other countries, which allowed cholera to spread to the surrounding populations.

The government's slow actions in stopping the spread, poor sanitation issues, general lack of upkeep of infrastructure, and societal persecution had all contributed to the cholera outbreaks throughout the 1800s.

In general, peri-urban slums (impoverished areas located immediately adjacent to a city or urban area) seen pictured were particular hot spots for the spread of cholera outbreaks in the 1800s because of their high density of people and poor sanitation infrastructure. However, due to the caste system implemented throughout India, these slums of people were deemed outcasts and were persecuted. They were looked down on as people to not care for, which resulted in people having little to no support from the government. This would lead to the perfect storm for a cholera outbreak.

The government in recent years has attempted to quell the spread and outbreaks by investing more into the required services to help the most prone areas, however, there is still room to grow, as socio-economic divides still riddle the country.

Healthcare in India as a result of British influence dates back to the 1600s with the British East India Company. The establishment of medical facilities is predominately due to the British colonizers needing to establish healthcare establishments to support their entourage of military personnel and civil servants.

Throughout the 19th and 20th century following the established British colonial rule in 1858, there became an influx of medical facilities throughout the entire country for Indian subjects. The image on this slide features the British spreading medical care to Indians, where the total number of hospitals and dispensaries constructed under colonial rule reached around 1902 by the end of the 19th century.

The intervention with medical care to the Indian population arose as a necessity to face the challenges of diseases and epidemics that were predominant throughout the country. In particular the British focused on tackling cholera, which was a new illness to the British at the time. It severely impacted colonial troops and officers who first arrived in India. The need to tackle this disease throughout the country was focused on preventing the British population from contracting it, otherwise, they considered it a disease of the poor population.

Following the 1868 cholera epidemic in India, a Cholera Committee was established to investigate the causes of the disease. In their research, the committee devised that the best method to tackle cholera was improving sanitary conditions of India, and improving hygienic conditions of public spaces such as hospitals and where cultural festivals were being held. This led to colonial influence in improving infrastructure and water sanitation systems. These developments were biased towards the upper-class and the British rule who were stationed in India, resulting in the rural population lacking access to sanitary developments sanctioned by the British.

This lack of equal treatment of diseases throughout India's population is in part why cholera is still prevalent in 21st century India, especially in its lower castes, who don't reek the full benefits of the medical care implemented in the country.

Cholera treatment from the 1800s to the present day has not changed dramatically. Emergency rehydration with fresh clean water is still a requirement, where the predominant way to counter the effects of the disease require as much hydration as quickly as possible. Seen on the left, a young girl receiving an intravenous drip (IV), and on the right nurses tending to a man, feeding as much of the newer water solution as a way of adding electrolytes to replenish nutrients in their system. By consuming more water and replenishing nutrients that have been excreted from the body, the body can rid itself of the cholera virus, enabling swift recovery in 8-10 days.

Adding antibiotics to the treatment for cholera lessens the duration of the disease and reduces the severity of symptoms.

However, antibiotics are not a requirement as long as the people afflicted with the disease drink enough fluids over the course of the infection, they are able to recover fairly quickly.

Pictured here, a young girl drinking from clean water. India has made strides to fix its sanitation and water issues, however, cholera is still an issue for the country as massive poverty and other social issues have not been accounted for nor resolved.

According to the World Health Organization (WHO), each year there are 1.3 to 4.0 million cases of cholera reported each year, with 21000-1430000 deaths due to the disease.

While there has been significant development in treatments and prevention against cholera, India continues to rank high among endemic countries. Issues still remaining to this day are the lack of access to immediate treatment for the disease and the overall need for the development of water sanitation and hygiene, especially in poorer regions of the country. The only long-term solution to preventing cholera is establishing a strong basis of communal hygiene and sanitation systems, where their risk of contamination is completely removed.

In India, there is a problem of open deification across the country due to a lack of lavatories. While there has been significant improvement in past years, where from 2015 to 2019 the number of people without access to sanitation went from 568 million to 118 million, there still remains a relatively large amount of the population (particularly the poor) who live without access to clean water.

Present resolutions to tackling cholera and other sanitary-related diseases are already in action, branching under the term of WASH programming/initiatives (Water, Sanitation and Hygiene). Global aid establishments such WHO and the Indian Government are working towards water and sanitation implementations, where their mission goal states:

"The long-term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. Actions targeting environmental conditions include the implementation of adapted long-term sustainable WASH solutions to ensure use of safe water, basic sanitation and good hygiene practices in cholera hotspots."

The image here shows the lack of sanitation available in India, especially within lower class areas, where open deification and urination was common on the streets.