Those Pock Marking Viruses

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Battling diseases has been one of the few constants in life. One scourge was yet to be tackled that another appeared. In this long passage, scholar Anita D Rana details the scourge of smallpox that devoured millions across Jammu and Kashmir. Its obituary was written quite recently in the 1980s when it was declared officially over

This transmission electron micrograph depicts a number of smallpox virions. The dumbbell-shaped structure inside the virion is the viral core which contains the viral DNA.

Smallpox was characterised by pustules and eruptions on the skin throughout the body and often involving the mucous membranes. Pustules were more intense on face and limbs. Two different viewpoints were prevalent among the people about the causation of this disease. Indigenous view, as in the case of cholera, attributed to the divine intervention of the disease and another was pathological or germ theory view held by the practitioners of western medicine.

The supporters of the indigenous view looked at it as the visitation of divine females. Hindus ascribed smallpox to goddess Sitala while Muslims considered shutel-beid responsible for this disease. Shutel beid is an imaginary old lady having divine powers (Mufti Gulzar, Kashmir in Sickness and in Health, p 34).

Accordingly, the treatment of the disease was also done in different ways. Sitala or sheetal in Hindi means cold. As the name signifies treatment for smallpox was to pacify or cool down the smallpox goddess and cold humorous diet like curd and rice were preferred. The folk treatment included the appeasement of mother goddess Sitala who is said to be responsible for the causation of the disease (CE Tyndale Biscoe, Kashmir and its Inhabitants p160). Throughout India, similar traditions of curing the disease were used. The whole body of villagers turned to the deity for protection when the calamity overtakes the village. Goddess was propitiated to avert the wrath.

The Hindus of Jammu and Kashmir felt happy at the outbreak of the disease that their goddess Sitala, to whom the disease was attributed, had decided to visit their dwellings (ML Kapur, Social and Economic History of J &K State (1885-1925) AD, p97). When the disease occurred in horrible form, the mother of the infected took a vow to present a she-goat or she-ass to propitiate the goddess (Biscoe, p160).

In my childhood days in the nineties of the twentieth century when western medicine and education had reached every household, I too saw the similar practices to be observed during the outbreak of smallpox in my neighbourhood. It was very difficult for the people to discard old ways in spite of the adoption of new. The remarks of the Tyndale Biscoe that the poor goddess responsible for causing smallpox is thus defeated and cast off with the advent of western medicine, proved false as she still haunted the minds of the people in the hilly regions and villages of the State. Though vaccination was accepted by the people they never forgot the goddess. Nowadays people in far off villages still use a combination of treatment for curing this disease.

William Jackson Elmslie, the missionary who was is the founder of vaccination in Kashmir

It is now a well-established fact that smallpox is a communicable viral disease caused by orthopoxvirus. Two strains of this virus Variola minor and Variola major cause the disease in humans. The incubation period is usually 10-14 days. The disease begins with fever and after that eruption and pustules on the skin are observed. The symptoms of the disease are itching, pain in the body, redness of the skin and eyes, swelling of the skin and restlessness of the mind. The ulceration even occurs on the cornea and this was the cause behind three- fourths of all blindness in India. Numerous people died due to smallpox and those who anyhow survived from mortality became invalid for lifetime. Survivors of smallpox developed immunity against the disease and were less to suffer if they caught it next time. That’s why this disease was more common in those who never suffered from this disease earlier. Usually, children born after the previous epidemic were more prone to this disease and the first attack of the disease is much dreadful. The disease had become so dreadful in north India that children were never counted as permanent members of the family because of the uncertainty of surviving in this disease (David Arnold, Colonising the Body: State, Medicine and Epidemic Disease in Nineteenth-Century India, p117).

The year 1891-92 was reported as lamentable year as various epidemics erupted in the State this year. This year smallpox appeared in both Jammu and Kashmir provinces and incurred great casualties. (Annual Administration Report for the year 1892-93, p 45). This made the Government establish a vaccination department in the State so that the epidemics could be dealt at the opportune moment. Before the introduction of vaccination in the State, smallpox was not unknown to anyone as everyone had to suffer from it and some became victims of it while those who survived became familiar to it. But due to vaccination, it claimed a negligible number of deaths in the twentieth century. The disease appeared at various occasions in epidemic form in 1892, 1902, 1910, 1912, 1913, 1915, 1916, 1919, 1920, 1923, 1932, 1936-37, 1939-40 (Amar Singh Chouhan, Health Services in Jammu and Kashmir 1858-1947, p 42).

Surviving Epidemics

In addition to these epidemic outbreaks, sometimes smallpox appeared in the sporadic form. In 1889 twenty-one cases of smallpox had been reported but the actual number of cases could be much more. Dr Jagan Nath reported that many cases were not reported by people (J&K State Annual Administration Report, 1889-90, p112).

In 1934 scattered cases of smallpox were reported from Bijbehara and Pulwama (File No PR-M-93/J, Publicity Department, 1934, State Archives, Jammu, p 22). In 1936, smallpox was reported from Leh and the villages affected were Panamick, Taksha, Lagjong, Desket, Khalsar Dog and Tegar. 839 vaccinations were performed so as to check the spread of disease in the neighbourhood (Ibid, p27). The disease was also reported from Skardu proper and its suburbs. It appeared in Anantnag in 1936 (Ibid., p72).

Vaccination

The vaccine for smallpox was discovered by Edward Jenner in 1798. It was introduced in India in 1802 (Anil Kumar, Medicine and the Raj: British Medical Policy in India 1835-1911, p163). Before the introduction of vaccination, variolation had been used as a prophylactic measure against smallpox virus variola. That is why the preventive measure was named as variolation, a process involving a healthy person was infected from the material taken from pustules of a sick person in order to develop a mild disease in him. This helped in immunisation of person against variola virus.

In the State of Jammu and Kashmir, Dr Elmslie was the first to introduce vaccination. On May 31, 1865, he vaccinated two children of a Brahmin who was head of financial affairs (William Jackson Elmslie, Seedtime in Kashmir, p102). This was the great day in the history of vaccination in Kashmir because a Brahmin who is held as the spearhead of religion agreed to vaccinate his children. In 1879, Sir Syed Ahmed Khan introduced a bill in the viceroys Legislative Council in British India for compulsory vaccination against smallpox in India. (Ibid., p117). But the vaccination was hotly opposed and debated in India at that time. The opposition in India was due to religious and caste prejudices. Caste prejudices were observed in the arm to arm vaccination. Though harmful in use it was objected by higher castes. Caste structure of the society did not allow a high caste Hindu to get vaccinated by coming in contact from a lower caste resource. This ruled out the possibility of the arm to arm vaccination in the State as caste restrictions were highly practised here. Muslims were not affected by caste restrictions and so they were not opposed to vaccination because of casteism.

The epidemics of 1892 had alarmed the people, as well as authorities in the State. So, in the year 1892-93, a vaccination department was sanctioned by the Maharaja in Council and after that, the lymph preparation began in the State itself which otherwise was earlier procured from the sanitary commissioner of Punjab (J&K State Annual Administration Report for 1892-93, State Archives, Jammu, p46).

Vaccination was introduced by the State Government in 1894 in the State (Pandit Anand Koul, Geography of Jammu and Kashmir State, p130) though the beginning was made much earlier by missionary doctors. But unlike the State of Travancore vaccination was not made compulsory by the rulers of the princely State of Jammu and Kashmir (J&K State Annual Administration Report for the year 1889-90, p112). So much people were not attracted towards vaccination and only negligible vaccinations were done in the State. About vaccination, it was a belief among the people that vaccination would tend to produce the disease itself. Dr Falconer who was medical expertise and GT Vigne who on their visit to little Tibet tried very hard to persuade and get people vaccinated but they failed (GT Vigne, Travels In Kashmir Ladakh Iskardo, p 257) as the belief of people was stronger than their efforts.

Small pox vaccination using a bifurcated needle

Initially, people were opposed to lymph vaccination. This opposition was because of religious prejudices. People in the State and especially Hindus considered calf as sacred and were not ready to vaccinate with calf lymph. The people of Jammu were more opposed to vaccination than the people of Kashmir who took more kindly to vaccination (ibid). This was because the majority of the population was Hindus and Muslims in provinces of Jammu and Kashmir respectively. Dr Jagan Nath also reported that the Hindu prejudice never allowed children suffering from smallpox being placed under any medical treatment.

In spite of all these odds, Dr Mitra who was CMO of Kashmir vaccinated 350 children and 150 adults in the valley for smallpox in 1889-90 (ibid). Because of religious prejudices, people did not opt western medicine and treatment for smallpox and often cases of the disease were concealed from the authorities from fear of vaccination (ibid). Due to opposition to vaccination exact number of cases of the disease was never revealed to authorities. In 1889-90, only 21 cases of the disease were reported and concealment was because of fear of offending deity (J&K State Annual Administration Report for 1889-90, p112).

Although Government records revealed that vaccination was not forceful yet the concealing of cases from authorities from fear, both things seemed contradictory. It was possible that the infected areas were vaccinated forcibly. Epidemics and huge mortalities incurred by these also played an important role in changing of people’s attitude towards vaccination. The escape of the vaccinated population from disease as compared to unvaccinated made the people shun their prejudices. Also, western education played an important role in changing perceptions.

For vaccinating people lanoline paste was used initially. This was procured from surgeon Major King of Madras. This lymph was suitable for cold climatic conditions as unlike tube lymph it did not solidify in winters (J&K State Annual Administration Report for 1890-91, p105). Thus it was suitable for cold climatic conditions in the State during winters. But the procurement of lymph from outside was not advisable. The durbar had sanctioned permission for a vaccination department to be worked with buffalo lymph (J&K State Annual Administration Report, Part–III, p107). So, Dr Mitra procured instruments for inoculation from Katch of Munich so that the inoculation of buffalo calves could be done and lymph could be produced within the State. This would lessen the cost of vaccine import and thus more vaccine could be produced for a large number of people (ibid) from the same budget.

A Hundred Years Later

It was observed by Dr Mitra that arm to arm vaccination was slowly becoming somewhat popular in the State. But due to its dangerous nature, it was objectionable to health practitioners (J&K State Annual Administration Report 1892-93, p46). Official records stated that up to the year 1896-97, the opposition for vaccination had faded away in Srinagar as it was not so widespread and was rarely met by vaccinating authorities. By realising the benefits of vaccination people were more attracted to it. In 1896-97, a Zamindar in Kashmir valley personally approached Dr Mitra and requested him to vaccinate the children of his village. As he (Zamindar) had noted that the disease had not appeared in vaccinated villages and was only found in unvaccinated villages (J&K State Annual Administration Report 1896-96, p95) so he was in favour of vaccination and approached authorities for vaccinating people of his village.

But it was not true for all regions and in some areas people were strongly opposed to vaccination and even attacked on vaccinators in order to show their resentment against it. In a village Rowasa in Handwara Tehsil, Thakur Swarup Singh was attacked during the night (File No PR-M-93/J, Publicity Department, State Archives Jammu, 1932). Regarding this incident, the inspector of vaccination reported that such incidents would discourage vaccination staff in discharging their duties (ibid).

Due to opposition vaccination was not cosmopolitan in the State. In addition to opposition by the people various other constraints like lack of staff, funds and unavailability of lymph in the State played an important role in making vaccination restricted to certain parts. At the beginning of 20th century 177 calves were inoculated so as to fulfil the requirement of lymph (J&K State Annual Administration Report for 1901-03, p491). Cost of vaccination remained two annas four pies for each successful case (ibid). Thus smallpox remained a menace even after vaccination due to these lacunas. Official reports for the years 1901-03 reported the number of vaccinations done in Kashmir, Jammu and Gilgit as 18,425; 21,231 and 2,680 respectively and the success rate of vaccination was 94.09% (ibid).

For removing the constraints of vaccination, a vaccination team having permanent staff consisting of seventeen vaccinators with one inspector to supervise the work of other team members was established in 1904-05 in the State. It worked in Jammu during winters and in Kashmir during summers (J&K State Annual Administration Report for 1904-05, p196). During this year the number of vaccinations increased to 33,784. As the vaccinations were not 100% successful so revaccinations were also introduced for complete immunity of people. People of Ghizar, Yasin, Chilas and Ishkoman in Gilgit Wizarat also showed great interest in vaccination (ibid).

Anita D Rana

In 1911 the number of members of vaccination staff was increased to twenty comprising of eighteen vaccinators, one Inspector and one Assistant Inspector to supervise the work of this committee. On the recommendation of Agency Surgeon, the vaccinators working in Gilgit Agency were brought on the Medical Establishment list. Up to this time, the popular prejudice against vaccination had completely ended and due to this, there was an increase in the number of vaccinations. Beginning from a few hundred the number now rose to 73,286 in 1911 (J&K State Annual Administration Report for 1911-12, p64).

In Jammu where there was the highest opposition to vaccination, there was an increase of 68%. This was due to two reasons- one was the outbreak of mild epidemic during 1911and another was the introduction of glycerinated calf lymph vaccine which was easy to use than lanoline. The total expenditure on vaccination during this year was 7,010-11-5(rupees-annas-pies) (ibid).

During 1912, the vaccination staff was organised and both Jammu and Kashmir provinces were provided with a separate staff which worked throughout the year, unlike earlier arrangement. Each group worked under an Assistant Inspector. Vaccination work in Gilgit was carried by local medical staff (J&K State Annual Administration Report for 1912-13, p78-79). In subsequent years there was a constant rise in a number of vaccination operations performed and total expenditure on vaccination. In the year 1924, the expenditure on maintenance of vaccination department rose as high as 18, 245-1-18 (Rupees-annas-pies) (J&K State Annual Administration Report for 1924-25, p55).

(After securing a gold medal for her masters in history, the author did her PhD from the Jammu University in 2017. The passages were excerpted from her doctoral thesis State Policy and Development of Health Services in Jammu and Kashmir, 1856-1947. She is a teacher.)

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