Sir Geoffrey Prior, political officer of the Persian Gulf, including Bahrain, who told me that Ibn Saud had asked us to remove that St John Philby because he was preaching sedition against England and in favour of a Saudi Arabia alliance with Germany. Our authorities waited till he was on a boat going to India to spread his doctrine there, and then arrested him. There was talk of detaining him in a mental hospital, but this fell through and after holding him for some time, he was released, as too mad to be dangerous.12
St John Philby, a famous intelligence agent who helped establish ARAMCO, an Arab-American company, was also the father of Kim Philby and whether the course of the cold war would have been altered if Philby Senior had
been admitted to the mental hospitals in Bombay must remain a matter of speculation!
Weldon Dalrymple-Champneys’ personal notes thus are a source of first-hand information about the health services. As he writes:
[T]he two important things in India are the public opinion and the medical profession. The condition of both is very unhealthy at present. Public spirit and concern for the welfare of others, especially, the poor, is rare in a country like India, as was shown in the recent famine (the Bengal famine) (perhaps) due to the harder struggle for existence (and) the diversity of races and languages, and tradition and ideology. The medical profession badly needs reform. However slow may be the Indian rise, this is the leaven which will one day leaven the lump. To the traveller, artist or student, the fascination of India lies largely in the infinite variety, but not till this variety can be wedded to unity will India be mistress to the great future, which surely lies in store for her.
And where better can this unity be forged than on the anvil of public health.
In a public lecture in Bombay in November 1944, he goes on to describe the plans for the reform of the health services in the UK with the message that it would be an appropriate model to follow for India. These included plans for universal healthcare along those for the National Health Services (NHS) as being developed under the Beveridge Plan.13 He is saddened by the “lack of [a] smile on Indian women’s faces” but then also concludes that (since it is) “not uncommon for a woman to be nailed down through her hands and feet to drive out evil spirits, so what does the peasant woman have to smile about”.14
Dalrymple-Champneys gives a talk on BBC India services where he argues that rationing can help avert famine in the UK. As he says, “from India we have had the best tea, coffee and beans,15 from the US, India, Canada and Australia the finest wheat”. At dinner with Claude Auchinleck (then the supreme commander of the allied forces in India) just before they return to the UK, they discuss the future of India. He recalls it as
one of the mistakes he (CA) thought we had made in India was not to give the people a chance to make mistakes. We have always stepped in promptly when anything has gone wrong, and taken over. In future, he (CA) thought, we must take the risk of letting them mess things up a bit, even if we had to clear up the mess in the end.16
Dalrymple-Champneys had a puckish sense of humour and wrote some contrived limericks about the people he met. The opaque nature of the official process disappointed him and the need to “protect one’s own turf” and “not appear too adventurous in ones opinions” was quite
evident. As he noted:
[I]t was the finest exhibition of cunning and lying to which we have been treated. Dr Punnar Lal is a fieldsher, i e, a barber-surgeon, quite unqualified, but an ICS officer of low standing. He adopted a frankly defeatist attitude in which he was followed by the second DB, and perforce by the DPH, who was obviously warned off the grass by the
chairman several times when he was about to make helpful contributions. The DPH struck me as helpful and sincere, but he naturally has no intention of spiking his future prospects.
He also meets Dr B C Roy, a highly influential private practitioner who was the personal physician to Mahatma Gandhi but charged 100 pounds for private consultations otherwise. In addition, he had many other investments and interests, and Dalrymple-Champneys wonders “how pure his motives are in urging cleaning up Government and health progress I cannot tell”.
Worthwhile suggestions included one by Dr Erulkar for compulsory two-year service in villages for every graduating doctor (a scheme that has several claimants since then, but no executors). He was also a witness to
attempts by some “health minister” in the provincial governments to get relatives off the hook for hoarding (the war was on) while others tried to get some other privileges sanctioned.
In summary, the experience of meeting the medical staff and politicians left him vaguely troubled and cynical about the affairs of India. His personal report to secretary of state for India Leo Amery was ordered to be destroyed and no copies kept, so we have to rely upon other reports to gauge the impact of his opinions. The report, however, was read by many others, including Adrian Hill, who wrote to him saying that the future of India depended on what its women could do, while various war office colleagues found it an excellent “masterpiece” of “tact and fact”.
John Ryle was a professor of medicine at Cambridge, and then the first Nuffield professor of social medicine (Epidemiology) at Oxford in 1943. A towering figure in public health planning, he was one of the first to enunciate the principles of social medicine and the need to plan for it. Uniform access to healthcare as a social need, and the growth of scientific humanism offered him an opportunity “to envisage and design a close equality of opportunity for health in the coming generations (that) is no longer an extravagant fancy. Whether at home, in India or the colonies, or in the broader international field, it may shortly become our most urgent common interest.”17 The prevalence of diseases in certain countries (India) was to him “linked rather with a
stage of historical development than with latitude or climate”.18
The summary by Ryle19 of his visit covered administration, public health, medical relief, education and research. As he admits, it made for depressing reading. A defeatist attitude was apparent in the administration, attributed to the vastness of the problem, the poverty of India, and the unstable political situation. He points out the fallacy in not identifying health as an economic asset and counting pennies. He also finds the practice of selecting only provincial men for health unwelcome and could hinder further developments as experience in one part could not be transferred to another. Subordinate staff was often appointed for sectarian reasons and often did not comply with instructions from
medical staff. Licentiate doctors were being encouraged to provide care to the rural poor and their standards were woeful (a scheme that is being resurrected now) and he hoped these would be replaced by adequately trained doctors at the earliest.
Medical education was dismal as most teachers were busy with the practice and students were chosen on a communal basis and not by merit. In the licentiate schools, it was much worse. Specialist education was available only in the UK but this was not on merit but offered only to those who could afford to pay. In any case, the situation in the UK was not good and doctors from India did not get the necessary respect and training. He hoped, however, the opportunities for training for students from India in the UK would be improved and that the proposed setting up of the “Johns Hopkins” kind of institution in Delhi
would be kept an integral part of the university as medical science should never be dissociated “intellectually or geographically from the biological and social sciences and the humanities”.20
The recommendations of the Bhore Committee, if not followed by “early legislative discussion and action”, would have a very adverse effect, while early attention could even improve the political atmosphere. The advice from the group, he points out, was that the “health of the people is something above nation and party and that it could and should be worked for even when great and difficult constitutional problems remain to be solved”.21 In summary, though he recognised the immense national, political, communal and religious
difficulties, the primary economic importance of health could not be underestimated. In any case, Cumpston from Australia and Sigerist and Mountin from the US had offered to help in many ways, including teaching and research, and since medicine and health were basically international issues, he hoped that the developments in the near future would be witness to this.
Janet Maria Vaughan was the principal of Somerville College, Oxford. More importantly, she had successfully initiated the first-ever blood transfusion service in the world in London during the second world war. She was also a member of the Committee Against Malnutrition with Fredric Le Gros Clark and was one of the influences on the Socialist Medical
Association.22 This association was to later include scientists like Richard Doll. Vaughan was one of the first to explore systematically the link between poverty and ill health and also the need for free healthcare as a necessary political decision. Their ideas were the foundation for the NHS that was to be introduced under the Labour government eventually. She had been taught by J B S Haldane who encouraged her interest in physiology and was invited by Amery to be part of the advisory group in September 1944 based upon her work with the Goodenough Committee that suggested reforms in medical education and training. It was suggested that these experts would make a “comprehensive review of the health problem as a whole, taking into account all the various factors affecting the health of the
community”.23 Her correspondence with Cumpston and Dalrymple-Champneys thus had a role in the final drafting of the Bhore Committee.
Henry Sigerist, the professor of history of medicine at Johns Hopkins and a well-respected though iconoclastic scientist, brought his vast knowledge of the history of medicine into his suggestions. He had been one of the first to propose “socialised medicine”, the need for physicians to have regular salaries and the need for preventive medicine, and had featured on the cover of Time magazine. He was particularly impressed by the Soviet system of planning and provision by the state of almost all requirements for healthcare, including preventive aspects. However, by his persistent advocacy of Soviet style thinking for socialised medicine, even after the beginning of the cold war, Sigerist fell prey to the McCarthy era. His liberal view on the social face of medicine did not go down well with the increasing specialisation and niche marketing of the medical profession and he was forced out. He ended his life as an intellectual exile in Switzerland.
However, when he visited India in 1944, he was at the peak of his official standing in the US. He wrote and read Sanskrit and was as much enamoured of the Indian traditions of healthcare unlike Sir Weldon, who was
sceptical; indeed, he shocked him by suggesting that colleges for indigenous systems of medicine should be established alongside the ones that were to emulate the standards of Harvard and Massachusetts General Hospital. Whether it was his endorsement that saw the rapid rise in colleges of Indian medicine in the post-Independence era is not clear. His suggestion24 was that all forms of indigenous medicine be researched, taught and practised because as far as he was concerned, Hippocrates and Galen (whom western medicine looked up to) found their equivalent in Charaka, Sushruta, Vagbhata and the texts of the Vedas, Upanishads, Quran, Bustan and Gulistan. One of his suggestions was to establish an institute for the history of medicine, or at least a department in the new medical college that was being discussed. In his view “health education was wasted unless it is somehow combined with education in
citizenship, which is impossible without history”.25
John Henry Cumpston was a prominent Australian doctor who had risen to a position of power and influence at the Australian School of Tropical Medicine and would go on to play an important role in public health in Australia. He had spearheaded the need for effective infant healthcare with schemes for home visiting nurses and maternal education. These ideas would be at the centre of health planning in independent India. As the first Commonwealth director-general of health in Australia,26 he advocated that unemployment, inadequate housing, and inadequate social security were the greatest impediment to health. Cumpston was instrumental in creating the National Health and Medical Research Council (NH&MRC), which finds a mirror in the Indian Council of Medical Research (ICMR) in India. As he stated:
[P]reventive health is the centre of the NH&MRC’s programme leading to a widespread national campaign which will ensure complete and adequate supervision of an intelligent kind over the bodily health of infants, pre-school children and school children, over the physical culture of the school child and over the diet of the community.
Even with this degree of support, a universal health service scheme (like the NHS) could not be implemented in Australia till the mid-1970s when a national health insurance scheme was finally created (India is toying with that now, and proponents of that are again seen as “path-breakers and innovators”!). This scheme included a fee for specialist services while general hospitals and community care were free
(again as being attempted in India).
At another level, his overarching zeal in advocating political change (in the particular case, the constitutional structure of Australia) so that healthcare could be better administered, gave a fight to the establishment.27 Cumpston was soon moved out, and the department of health was then administered by civil servants rather than doctors (a practice assiduously followed in independent India). Despite his leanings towards universal and socialised healthcare, he was a strong advocate of “White Australia” and to some extent his attention to infant health was related to a desire to “have a bulwark of able bodied men for self-defense…soldiers”.28
In his comments, made in letters to Vaughan,29 he views the problem as being caught between the needs of 7,00,000 villages and the “problem of providing inspired direction from authoritative sources”. He roots for the former and lists environmental sanitation and dietary reform as the major targets. On a visit to Singur, he meets a lady doctor, Dr Sengupta who lists poverty, illiteracy, lack of transport and communication and shortage of staff of all categories. Cumpston is sceptical of the large numbers of “dais, health inspectors, health visitors, primary and supervisory doctors”, and though he is aware of the deficiencies in training, is hopeful that things could be improved in a generation.
He based this concern on his observation that one of the primary reasons for the delay in recognising the gravity of the Bengal famine was the breakdown of the vital statistics, which, in turn, depended on poorly qualified public health staff and interference by local authority. The local dispensaries “could not be accepted as satisfactory from any aspect”.30 Administrative control was deficient, with the Public Health Board having only advisory powers and, in general, tended to “disregard established forms of democratic government in both central and local spheres”, being autocratic and prone to manipulation.31
He is struck by the “depression and discouragement (of) enthusiastic medical officers” in the face of “cold official reception” and inertia. As far as officials of the IMS were concerned, there was no hope for improvement of public health in India. Despite this, he makes suggestions for improving administrative morale, targeting interventions (epidemic disease, vector-borne endemic diseases, mother and child health, and environmental sanitation). The action to address these should be the responsibility of a well-defined chain of command from the centre to the periphery, which would overcome the “inertia”. This, he hopes, would “(dissipate) the shadow of tradition, precedent and political tactics in the bright light of a new deal based upon a high and human ideal”.32 Additionally, India should become
self-reliant in medicines and surgical goods, which would be profitable in itself, as also in “terms of a better profit, in pride and self-reliance”.33
In his detailed notes he focuses on medical education, and the need to ensure that it is “not dictated by sectional interests” and that “suitable students are not denied the opportunity for lack of means”. He strongly urges that the current medical schools that provide a three-year licentiate course be abolished as soon as possible and replaced by full five-year training in medicine (a reintroduction of the three-year training scheme for doctors is being considered again!). He suggests a one-year pre-medical, two-year para-clinical and two-and-a-half years of clinical training, followed by a year of
internship (the format that was followed for almost 50 years later). He views the proposal to establish a “Johns Hopkins” kind of hospital with some scepticism. Delhi was too far and too unrepresentative of the medical problems faced by the majority of India and that such a hospital would need to be an integral part of an advanced university (which did not exist). In any case, there were not enough medical teachers the world over. This centre should first focus on a “really complete service” for Delhi province and this could then be replicated across the country.
These detailed comments were shared with Janet Vaughan who, as described above, was influential in public health and medical education in the UK.
Joseph Mountin from the United States Public Health Service (USPHS) had a long and distinguished career in public health. He had served under successive Roosevelt administrations and was a strong believer in the New Deal and universal healthcare. Early in his career, he had strongly supported that the medical care for native Americans be subsumed under the USPHS instead of a separate section of the Bureau of Indian Affairs as he felt that universal healthcare was incompatible with sectarian provision of care. Later, he initiated a whole scheme of rural clinics and services that focused on the need to
…minimise the impact of these (medical) costs on individual families through distribution of the costs among groups of people and over periods of time. To what extent the result shall be attained through more extensive use of tax support and to what extent through social insurance, or through a combination of both, is not at issue.34
These views were shared in common with the other members and held quite consistently. In 1946, in a testimony to a senate committee, he was later to opine:
[A] highly inequitable cash barrier now keeps medical care from millions of our citizens…only a nationwide program of medical care, under official auspices, holds the promise of assuring adequate medical care for all the people.
The change of political opinion at the end of the second world war and the beginning of Truman era, and of McCarthyism, led to a decrease in his public support for a National Health Program,35 though he continued to espouse this till quite late. In addition, based upon his early experience with malaria control and public health issues, he established the Centre for Disease Control in Atlanta in 1949, which continues to advise on basic public health issues even today, and the
Government of India has now renamed the National Institute for Communicable Diseases (which also began as a malaria control initiative) as the National Centre for Disease Control.
The advisers to the Bhore Committee thus came from an eclectic and divergent background ranging from civil servants and doctors, to historians and social medicine specialists. They all shared the view that central planning for public health services and that universal and free access to medical care was imperative in the future. This universal access was an essential political right of the people, which was to be mediated by
Unlike these international specialists who, while being doctors, were also part of the larger political process, and continued to be so, the medical advisers from within India to the Bhore Committee did not have any explicit political orientation. With the possible exception of Dr B C Roy, most of the others were career civil service doctors. The secretaries were men from the civil service and there is hardly any evidence that the constituents of the committee brought as diverse a range of political opinions and experience as did the advisers.
The medical elite in India were mainly in the private sector, and the academic and political
ideologies that guide access to healthcare had hardly ever been discussed in the profession itself (it is hardly ever done even now) or by the populace. In India, the advisory committee was thus confronted by a decaying centre of the imperial administration and the imperial medical service, a civil servant at the heart of the process (Joseph Bhore), a number of doctors in practice and with “influence”, and hardly any from the academic or teaching faculty.
That many of the subsequent developments in medical care in India reflected some of the ideas and apprehensions of these international experts is thus hardly a surprise. To be fair, social medicine was surely an idea whose time had come in the middle of the 20th century. But despite all its intentions, the costs and administrative detail for the
implementation of the suggestions made by the Bhore Committee would prove too much for the British and the rulers of independent India.
Aftermath: A Vision Betrayed?
When confronted with the suggestions for a NHS like scheme in 1944 (at the end of the Medical Mission’s tour), Leo Amery pointed out that since the tax collected per person in India was less than the per capita expenses envisaged, it could not (and would not) be carried out. The viceroy, writing to Amery, reflected the establishment’s view that
[P]roductive items such as electrification, industrial development, irrigation projects and agricultural improvement should come before unproductive items such as health and education. I believe that some of the leading Indian businessmen are of the same view: they recognise that unproductive items can be financed only from surplus, and the first step is to increase the surplus”.36
These views were quite in concurrence with those of the Bretton Woods initiatives regarding post-war economic planning and developments in the social sector, including health, in the soon to be decolonised world.
The viceroy’s opinion and the Bombay Plan (that is referred to by the viceroy above as the leading Indian businessmens’ view) was criticised soon after37 and its impact on further planning for the entire social sector, including healthcare, has been reviewed in recent years.38,39 However, others pointed out that if India could spend millions of pounds every day for the military needs of the second world war, it should not be too difficult to mobilise the necessary finances for healthcare in peace time.40 Debating these recommendations in the British House of Commons, Hill pointed out:
[T]he Report, when it comes forward, will demand a drastic improvement and invigoration of the whole of the medical services of India. Such details are largely unknown to the public and scarcely appeal to public sentiment. The more experienced Indian is apt to assume, and not without excuse, that nothing will get done and that it will all be stopped by the Finance Department.41
On the eve of Independence, Dalrymple-Champneys predicted that the Bhore Committee’s recommendation would, most likely, soon recede into the background.42 This proved true and ultimately the recommendations of the committee were partially implemented for only a certain category of the government employees as a test-case before it was extended to the whole population.43
The devaluation of the rupee soon after Independence and the dire straits of the economy in the early 1950s made the Bhore recommendations even more of a mirage. With the shift in politics towards laissez-faire capitalism and healthcare transforming
itself into an ever more capital-intensive enterprise, all thought for a universal and socialised system of medicine were buried by a succession of committees.44 Not mentioning or publicly discussing this change of policy as part of a nuanced resistance to universal healthcare by private sector interests (as in 1944) thus became a strategy in the 1950s.
This retreat of the state and gradual control by the private sector of healthcare has become even more evident in the recent past.45 Medical education and treatments were to a considerable extent privatised (almost half of all medical colleges are now in the private sector) and all attempts to have a uniform access to qualified medical services whittled
down. Medical care now serves those who have a “surplus” income and often neglects those without incomes.
Despite the lofty rhetoric and the optimism of some of the international group, it was the weary cynicism of the economic costs of healthcare that finally seemed to have guided the provision of health services. The inability to shift perspective from the colonial mindset made most of basic reform implausible and the international finance-guided planning now seems to be the preferred mode,46 much like the ideas that guided the viceroy in the 1940s. Indeed, as early as 1951, the secretary to the Bhore Committee was already bemoaning the fact that somehow “primary health care had been transformed to a primary level of health care” and wondering
whether the recommendations were being whittled down as an expense of Rs 11 per head was thought impossible, though Ceylon was spending Rs 10 (without any apparent hardship). 47 Spending on health continued to decline in real terms and the 15% suggested by the Bhore Committee remained a distant dream as did universal healthcare as a fundamental right. To paraphrase Mapother, the transfer of the “white man’s burden”, at least as regards healthcare services, proved too heavy to survive the transfer of power.
2 A V Hill, “A Report to the Government of India on Scientific Research in India” (1944).
3 Mayo Katherine: Mother India; New York (1937).
4 Legislative Assembly Debates, 20 February 1936, pp 1290-91.
5 B Pati, M Harrison: Health, Medicine and Empire. New Perspectives in South Asian History, Orient Blackswan, 2005, Hyderabad.
7 Evening Standard, 22 January 1945 (in : Medical mission to the Health Survey and Development Committee, India, 1944) Arch. & MSS GC/139/H.2:Box 2; Wellcome Library) [henceforth: Dalrymple Papers].
8 Mills J H, Jain S Clio Med. 2009; 86:223-42. “A Disgrace to a Civilized Community”: Colonial Psychiatry and the Visit of Edward Mapother to South Asia, 1937-8.
9 A V Hill (op cit).
10 Medical mission to the Health Survey and Development Committee, India, 1944 GC/139/H.2 (Dalrymple Papers).
11 Dalrymple-Champneys (op cit).
12 Dalrymple-Champneys (op cit).
13 Haydn Davies, Guide to the Beveridge Plan for Social Security, News Chronicle and The Star, London, 1942.
14 Dalrymple-Champneys Indexed diary of tour, op cit.
15 Rice also was written in, but struck off [by the official censor with the note that adherence to the corrected script is COMPULSORY]. An indicator of the censorship applied to the Bengal famine.
16 P 162, op cit.
17 J A Ryle, “Social Medicine: Its Meaning and Its Scope”, British Medical Journal, 1943 November 20; 2(4324): 633-36.
18 J A Ryle, “Social Pathology and the New Era in Medicine Bull”, New York Academy Medicine, 1947 June, 23(6): 312-29.
19 Ryle/Wellcome/Dalrymple papers (in GC/139/ H.2 Dalrymple-Champneys papers (op cit).
20 P18/Ryle (in GC/139/H.2 Dalrymple-Champneys papers (op
21 P3/Ryle (in GC/139/H.2 Dalrymple-Champneys papers (op cit)).
22 “Pemberton J Origins and Early History of the Society for Social Medicine in the UK and Ireland”, Journal of Epidemiol Community Health, 2002; 56:342-46.
23 Letter/Henry Withing to JV/22/8/1944 (Dalrymple-Champneys papers (op cit)).
24 E Sigerist Henry, “The Need for an Institute of the History of Medicine in India”, Bulletin of History of Medicine,XVII/2 pp 113-126.
25 P 123/Sigerist (Dalrymple-Champneys papers (op cit)).
26 Fiona Stanley, “Doing More for Our Children in the 21st Century”, Cunningham Lecture 2002; Academy of Social Science, Canberra, 2002.
27 Beddie Francesca, “Putting Life into Years: The Commonwealth’s Role in Australia’s
Health since 1901”, Commonwealth Department of Health and Aged Care, Canberra, 2001.
29 Cumpston to Vaughan; Letter 1.XII.1944 (in GC/139/H.2
Dalrymple-Champneys papers (op cit)).