TB has existed in India for several thousand years. This page covers the history of TB in India from ancient times until the end of colonial rule and the coming of independence.
History of TB in India - TB in ancient times
TB in India around 1500 BCE
TB in India is an ancient disease. In Indian literature there are passages from around 1500 BCE in which consumption is mentioned, and the disease is attributed to excessive fatigue, worries, hunger, pregnancy and chest wounds.1Herzog, B. H. “History of Tuberculosis”, Respiration, 1998, 65:5-15
TB in India around 500 BCE
Then from around 500 BCE there are a number of Sanskrit manuscripts which are the texts from which the Ayurveda system of general Indian medical practice is derived.2Wujastyk, Dominic “The Roots of Ayurveda”, London, Penguin Books, 2003 In at least one of these there is a group of diseases referred to as Sosha.
These are diseases with a prominent feature of wasting, and there are other symptoms such as “cough and blood-spitting”. It is also said that the Moon-god, the king of the Brahmanas was the first to become a victim of this disease, which is as a result also known as Rajayakshma, or king’s disease.3Bhishagratna, K. K. L. “An English Translation of the Sushruta Samhita”, Calcutta, S. L. Bhaduri, 1916
TB in India around 900 CE
A subsequent important compendium on Indian medicine is the Rogaviniscaya, usually referred to as the Madhavanidana, and one of a number of commentaries on it is the Madhukosa. Neither the date of the Madhavanidana or the Madhukosa is absolutely clear but both are likely to have been written around 800 - 1000 CE.
The Madhukosa describes the disease referred to in a number of different texts as yaksman, consumption or rajayaksman (kingly consumption) and it also refers to how it has been identified by many as being what is in the twenty first century called Tuberculosis. However, the Madhukosa also says that the texts are clear that the ancient disease had a much wider range than TB, and covers a number of conditions between physical exhaustion through to cachexia or physical wasting.4Meulenbeld, G. J. “The Madhavanidana and its chief commentary”, Leiden, E. J. Brill, 1974
History of TB in India - TB in the nineteenth century
At the beginning of the nineteenth century it was generally thought that there was hardly any TB occurring in India. Then it was said that:
"It is a generally received error that pulmonary disease in India is rare and readily cured."
W. E. E. Conwell, 1829 5Conwell, W. E. “Observations chiefly on Pulmonary Disease in India and an essay on the use of the stethoscope”, Mission Press, 1829
Conwell, a respected surgeon, also said that he had “participated in the misunderstanding” before changing his mind on his return to India with an improved means of physical examination through the use of a stethoscope. He had also been able to observe the occurrence of TB more widely.
By the middle of the nineteenth century TB was thought to be common in some districts particularly among the English troops, and in some areas it was thought to be common “among natives as well”, such as in the district of Madras. It was also believed that TB in India was of “an extremely pernicious type”.6Hirsch, A “Handbook of Geographical and Historical Pathology”, Vol III Diseases of Organs and Parts, Translated from the second German edition by C. Creighton, London, The New Sydenham Society, 1886
In 1881 it continued to be believed that TB or “Phthisis” as it was often called, was more prevalent in India among European soldiers and their families, than among the native troops. This led some people to consider whether Europeans suffering from confirmed Phthisis would be better off going to India for a prolonged period. However, when this was considered in greater detail, it was believed that any advantage from the improved climate would be offset by other disadvantages.7Ewart, J “Scrofula, Tuberculosis, and Phthisis in India”, The British Medical Journal, May 21, 1881, 809 www.bmj.com/content/1/1064/808
Christian Missions in India
Towards the end of the nineteenth century there were an increasing number of Christian Missions in India. Although the primary aim of the missions was religious, they also worked towards the achievement of their aims through the provision of schools, food and increasingly western style healthcare.8McLean, A “The history of the Foreign Christian Missionary Society”, New York, Fleming H. Revell, 1919
archive.org/details/historyofforeign00mcle 9Stock, E “Beginnings in India”, London, Central Board of Missions and SPCK, 1917 http://anglicanhistory.org/india/stock_beginnings/12.html
History of TB in India - TB in the early twentieth century
Hospitals, Sanatoriums and Dispensaries
A sanatorium for “consumptive girls” was opened at Tilaunia between Ajmere and Phalera by the American Methodist Episcopal Church in 1907.10Stock, E “Beginnings in India”, London, Central Board of Missions and SPCK, 1917 anglicanhistory.org/india/ It was particularly meant for girls from the boarding schools and orphanages in Northern India that were connected with the mission. Cases of advanced consumption were said to be welcomed, and then segregated, rather than being turned away as they were from some other sanatoria.
A second smaller sanatorium, also established under mission auspices was started at Almora in 1908.11Lankester, A “Tuberculosis in India”, London, Butterworth, 1920
The first sanatorium to be established under Indian management was opened in 1909 at Dharmpur near Kasauli, and the first government run sanatorium was the King Edward VII sanatorium started at Bhowali near Nainital which opened in 1912.12Lankester, A “Tuberculosis in India”, London, Butterworth, 1920
A variety of other institutions were set up around this time for the open air treatment of TB, but in general only those people who could pay for their stay were admitted, and by around 1920 there were less than 500 beds available in all these institutions. A number of special wards were also set up in civil hospitals, but they could do little more than provide segregation and open air “treatment”. The numbers that could be accommodated though was tiny compared with the need.13Lankester, A “Tuberculosis in India”, London, Butterworth, 1920
Dispensaries were also established in some places for outpatient treatment, and from some of these nursing aid was provided. In some instances tuberculin injections were provided, but overall the major benefit of the dispensaries was their educational value.14Lankester, A “Tuberculosis in India”, London, Butterworth, 1920
TB and other causes of death
At the beginning of the twentieth century it was unclear how many deaths were occurring from TB, and how many were due to other diseases.15Lankester, Wilkinson, E “Notes on the Prevalence of Tuberculosis in India”, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002951/ At a conference on Malaria in 1909, it had been said that:
"The registered causes of death are always very misleading, with the heading ‘fever’ representing tubercle of the lungs, … and indeed, all the so-called medical diseases, except diseases like cholera and smallpox."
Lieutenant-Colonel J. T. W. Leslie, M. B., C.I.E., I.M.S, 1909 16“Imperial Malaria Conference October 1909”, London, His Majesty’s Stationery Office, 1912
Indian Research Fund Association
The Indian Research Fund Association was created by the Government of India in 1911. A sum of 5 lakhs rupees was provided by the Government as an endowment for research in connection with the Central Research Institute in Kasauli.
“The objects of the Association were:
(a) the cause and mode of spread of epidemic diseases;
(b) the prevention of epidemic diseases by direct attack upon the casual micro-organisms.” 17East India (Sanitary) “Progress of Sanitary Measures in India”, London, His Majesty’s Stationery Office, 1912
The work of the Association included the holding of an annual conference and the publishing of its official journal, the Indian Journal of Medical Research, which was first published in 1913. The early work of the Association did not include significant work on Tuberculosis, because of the perceived urgent need for work on other diseases such as Malaria, Cholera, Plague, Yellow Fever and Leprosy.18Bradfield, E “An Indian Medical Review”, New Delhi, Government of India Press, 1938
History of TB in India - The All-India Sanitary Conferences
The first All-India Sanitary Conference, Bombay 1911
At the first conference discussion of health issues was dominated by the “so called tropical diseases of plague, malaria, cholera and dysentery”. However, it was noted that according to a recent report published by Dr Turner, Health Officer of Bombay, the mortality from TB in large Indian cities like Calcutta and Bombay was already considerably higher than in Glasgow, Birmingham or Manchester in the UK.
One of the two chief sources of danger for the disease was noted as being milk and butter contaminated with tubercle bacilli, and the subject of the milk supply was a topic of discussion for the conference. It was again noted that the statistics for causes of mortality in different areas were lacking in accuracy, and it was suggested that this was chiefly due to the lack of accurate diagnosis.19East India (Sanitary) “Progress of Sanitary Measures in India”, London, His Majesty’s Stationery Office, 1912
There was particular mention of the situation in Calcutta, and the fact that:
"Tuberculosis is vigorously pushing its way through the crowded streets and lanes of the populous city of Calcutta and no step has yet been taken to resist its course. … we have hopelessly failed to stamp out Tuberculosis. … roughly speaking nearly one-eigth of the total number of deaths in Calcutta is due to this cause.20East India (Sanitary) “Progress of Sanitary Measures in India”, London, His Majesty’s Stationery Office, 1912"
The second All-India Sanitary Conference, Madras, 1912
At the second conference there was increasing discussion of TB and differing views were expressed as to the measures that should be taken. The measures discussed included the formation of anti tuberculosis societies, the establishment of more sanatoria, the establishment of dispensaries, the improved ventilation of homes and schools, improved sanitation in towns as well as villages, as well as the use of tuberculin.
There were also differing views on the prevalence of the disease in the country, with some people believing that:
Tuberculosis is a disease widely prevalent in this country. It is a disease that is very much neglected in the early stages by the patients as well as by the medical men in this country.”21East India (Sanitary) “Proceedings of the Second All-India Sanitary Conference held in Madras in November 1912”, London, His Majesty’s Stationery Office, 1913
In the conference resolutions a number of the measures discussed, such as the formation of anti tuberculosis societies, were recommended. However, doubts about the prevalence of TB led to a resolution that:
“Statistics appear to show that this disease is rapidly increasing in India, especially in urban areas, but that it is doubtful whether the increase is real or apparent only and due to such causes as more accurate diagnosis and registration.”22East India (Sanitary) “Proceedings of the Second All-India Sanitary Conference held in Madras in November 1912”, London, His Majesty’s Stationery Office, 1913
and it was also said that a full and thorough enquiry was desirable because of this uncertainty about the levels of the disease.
The third All-India Sanitary Conference, Lucknow, 1914
At the third conference there was again discussion as to whether the increase in TB in India was real or not, and again discussion about the preventative measures that could be taken. One of those who spoke about preventative measures was Dr Lankester, who was the Honorary Secretary of the Medical Missionary Association of India, and who was from the Church Missionary Society at Peshaware.
Dr Lankester strongly expressed the opinion that TB was greatly on the increase throughout India. He also strongly believed in the value of tuberculin treatment, although he warned against its “indiscriminate use by private practitioners”. There appears to have again been disagreement about most aspects of TB prevention and treatment.23East India (Sanitary) “Proceedings of the Second All-India Sanitary Conference held in Madras in November 1912”, London, His Majesty’s Stationery Office, 1913
In the conference resolutions it was said that:
"officers should .. study in detail the different problems affecting tuberculosis in India, to investigate the causes underlying it, and to organise efforts towards the diffusion of information on the subject, and measures for the prevention of infection."24East India (Sanitary) “Proceedings of the Third All-India Sanitary Conference held in Lucknow in January 1914”, London, His Majesty’s Stationery Office, 1914
The resolutions were further discussed at a meeting a few months later, when it was reported that despite his already strongly held views on a number of aspects of TB, Dr Lankester had been asked by the Indian Research Fund Association to carry out the investigation.25East India (Sanitary) “Meeting at Simla, the 23rd May 1914”, London, His Majesty’s Stationery Office, 1914
The work of Dr Arthur Lankester
In 1892 Dr Arthur Lankester went to India as a medical missionary to take charge of the Church Missionary Society hospital at Amritsar, and about two years later he went to Peshawar.
His enquiry into the situation regarding TB in India was carried out between July 1914 and June 1916. He travelled throughout India speaking to many people and obtaining information and advice. He visited many different institutions including hospitals, dispensaries and sanatoria. With regard to the prevalence of TB he came to the conclusion that in certain areas the prevalence of TB had certainly increased, whereas in other areas the supposed increase was largely a myth. He also investigated the social aspects of the disease, including those habits such as spitting, which he believed helped to spread the disease.
Dr Lankester made a large number of detailed recommendations in his report. However, probably the most important was that he looked at the question of whether, with all the other problems competing for public notice, the problem of TB was a problem on which significant time and money should be spent. His answer was that it most definitely was.26Lankester, A “Tuberculosis in India”, London, Butterworth, 1920
The King George Thanksgiving (Anti Tuberculosis) Fund
In 1927 Lord Irwin, the Viceroy and Governor General of India, wished to form a central organisation on the model of the National Tuberculosis Association of Great Britian. The opportunity arose in 1929 when to mark the recovery from serious illness of King George V, a Thanksgiving Fund was created for the alleviation and prevention of disease. The fund amounted to over 9 lakhs rupees, and after some consideration it was decided that of the various possible schemes considered, using the money for an anti tuberculosis scheme was the scheme likely to be of most benefit to India.27Bradfield, E “An Indian Medical Review”, New Delhi, Government of India Press, 1938
The administration of the Fund was handed over to the Indian Red Cross Society for anti tuberculosis work in India. The main activities of the fund were organising an education campaign, the training of TB workers and the organisation of TB dispensaries.
History of TB in India - TB in the 1930s
From reports collected from medical officers and others throughout India, it was estimated by Major General Sir John Megaw in 1933 (at the time he was the Director General of the Indian Medical Service) that there were probably two million cases of TB in India. He said that:
"Tuberculosis is evidently very widespread throughout the villages of India, but is specially serious in Bengla, Madras, the Punjab and Bihar and Orissa. Pulmonary tuberculosis seems to be much more common than extra pulmonary except in the United Provinces and Bombay."28Bradfield, E “An Indian Medical Review”, New Delhi, Government of India Press, 1938
The Tuberculosis Association of India
In 1937 the wife of the Governor General, the Marchioness of Linlithgow issued a public appeal, “in the name of the King Emperor” for an anti tuberculosis fund, and nearly a crore of rupees was collected.29“Report of the Health Survey and Development Committee”, Vol 1, Calcutta, Government of India Press, 1946, http://www.nihfw.org/Doc/Reports/Mudalier%20%20Vol.pdf Five per cent of this money was retained and the balance distributed to the Provinces and States. The Tuberculosis Association of India was formed in February 1939 using mainly the retained money.30“Tuberculosis Association of India”, http://tbassnindia.org/ The King George V Thanksgiving Anti Tuberculosis Fund was merged into the funds of the Tuberculosis Association of India.31“Report of the Health Survey and Development Committee”, Vol 1, Calcutta, Government of India Press, 1946, http://www.nihfw.org/Doc/Reports/Mudalier%20%20Vol.pdf
In May 1939 Dr Frimodt Moller became the Association’s first Medical Commissioner. During the time that he held office three major measures were carried out by the Association. These were the establishment of the TB clinic in New Delhi, the creation of the Lady Linlithgow Sanatorium at Kasauli, and the formation of a scheme for organizing home treatment as an essential part of India’s anti TB campaign.32“Report of the Health Survey and Development Committee”, Vol 1, Calcutta, Government of India Press, 1946, http://www.nihfw.org/Doc/Reports/Mudalier%20%20Vol.pdf