No other Indian province suffered as severely as Assam did from visceral leishmaniasis, often known as kala-azar. During the colonial era, it wreaked havoc in Assam, destroying nearly every aspect of society and leaving the victims in destitution of an unseen level. The colonial administration took action to control it as soon as it started spreading as an epidemic, and these controls persisted until the end of colonial authority. However, it was unable to provide the anticipated results, and the illness persisted, continuing to pose a major threat to the Assamese population. This chapter attempts to explain the causes, mechanisms, and outcomes of the disease's Brahmaputra-wide spread. The effectiveness of British medical policy and contemporary medicine in halting its advancement is examined in that setting. The chapter also examines how the populace viewed the illness and how they reacted to government anti-kala-azar initiatives. In this context, a short account of the condition of Assam's people and the health scenario of the province as a whole would help understand the context of the outbreak of kala-azar and its perilous effects.

A Brief History of Assam: The Condition of the People and the Outbreak of Disease

Situated on the northeastern part of the British Empire in India and bordering the powerful neighbouring states of China, Burma, and Bhutan, Assam was the most important British possession in this region. The extraordinary fertility of the region, with its vast lowlands and agricultural productivity, made it very attractive to its people and even outsiders. Before the Burmese occupation in the early nineteenth century, Assam was under the Ahom rule (1228–1818) and was, on the whole, prosperous.

Appendix: Number of Kala-azar Patients Admitted for Treatment in Bengal

Apart from the scarcities and famines that afflicted its people, Bihar witnessed the repeated strikes of severe epidemics of cholera, smallpox, and fever during colonial rule. It also experienced a time of tribulation and affliction caused by kala-azar. Despite kala-azar being known as Dumdum fever, malarial cachexia, chronic malaria, catchetic fever, and so on, the people of Bihar called it kala-dukh (black sorrow), perhaps because of the severe sufferings it brought about, as the Garos called the disease kala-hazar and the Bengalis kala-jwar. The disease spread rapidly from the early twentieth century, which is said to have been facilitated by the continuous movement of people from Bihar to the plantation areas of Assam and Bengal. Bihar increasingly went on acquainting itself with medical intervention from the colonial health administration. Unfortunately, sources of the medical history of Bihar testify that kala-azar kept on attacking people till the end of colonial rule, and question is thus raised about the effectiveness of anti-kala-azar measures. This chapter is devoted to studying the occurrence of kala-azar in Bihar and the extent of its proliferation and containment. It aims to examine the causes of the occurrence of this disease combined with its perilous effects on people. I have tried to unearth, in the chapter, how and why kala-azar broke out there and caused ‘black sorrow’, the usefulness of anti-kala-azar measures, and the extent of the success of these measures in the containment of the disease.

Bengal was one of the most productive regions in the Ganges delta that came under British control in the eighteenth century. The British East India Company consolidated its hold on the region following the Battle of Plassey in 1757 and the Battle of Buxar in 1764 and, by 1793, took complete control of the region. Thus, colonial rule started its journey from Bengal (that is, Bengal, Bihar, and Orissa) in the eastern part of the Indian subcontinent, and its resources were exploited by the British to extend and consolidate their empire. Apart from colonial exploitative pressure, the region experienced several natural calamities, including the inroads of famines and epidemic diseases, that caused unprecedented ravages and torment for the people. This chapter aims to look into the epidemiology of kala-azar in Bengal, the colonial medical intervention to combat it, and the effectiveness of the methods implemented to contain the disease. It also brings into focus how the indigenous people, including medical professionals in particular, responded to the illness and the state's medical measures to manage it. It may not be out of place here to provide a brief note on the area, its people, and the disease environment to have a better understanding of the occurrence of black fever and its containment.

A Peep into the History of Bengal: People and Public Health

Bengal was one of the prosperous and healthiest regions in eastern India, and its prosperity, whether agricultural, commercial, or industrial, even in the early nineteenth century, was widely acclaimed. However, it lost its affluence because of colonial exploitation. The colonial rule brought about certain significant changes in Bengal's economy that severely affected agriculture and manufacturing works, leading to subordination and economic decline.

Black fever, also known as visceral leishmaniasis, or kala-azar in India, had been a serious health issue in British India for a century, threatening a large part of the Indian subcontinent in the nineteenth and twentieth centuries. There were several names for it, including Dumdum fever, kala-hazar, Assam fever, black sickness, and others. The Garos described it as sarkari bemari, or ‘saheb's disease’, referring to it as a British government illness not because any Europeans had it but rather because the Garos claimed to have been unaware of it until after the sahebs (referring to the British) took over their domain. This would seem to show that following the establishment of British control, outsiders brought the disease vector to the area. In Bengal, it was referred to as kala-jwar, which means ‘black fever’ or ‘fatal fever’, while it was known in Bihar as kala-dukh, which means ‘black suffering’ or ‘fatal misery’. With a high fatality rate of more than 95 per cent, kala-azar seemed to be an uncommon but deadly disease. It began spreading so quickly in the 1870s that the British government felt compelled to attempt to control it through medical intervention, but the results of such intervention were not seen until the 1920s. From 1921 onward, kala-azar mortality significantly decreased, and modern clinical medicine significantly contributed to this reduction.

Given that the disease was one of the leading causes of death in eastern India under British control, there is no dispute about its terrible impact. Despite being a neglected illness, it has recently been mentioned extensively in the press due to its comeback to epidemic proportions in north Bihar in 1976–1977.

The story of urea stibamine is itself worthy of recording as a dramatic medical break-through which may be related…. A Bengali worker Dr U. N. Brahmachari, himself a chemist, was producing various products which he was testing on kala-azar cases. The Government Director of research programmes under the aegis of the Indian Research Fund Association, Colonel G. D. W. Greig IMS, asked him to send these to me to test at my special kala-azar hospital in Shillong, the capital of Assam. Among others, he sent me a product he called ‘urea stibamine’ which he had tried and merely passed over with a formal favourable comment. When I tested it I found it was so effective that cases could be treated and cured by about eight doses instead of taking many weeks or even months and then with unpredictable results.

To begin with, the question as to who Upendra Nath Brahmachari was can be addressed by referring to the remarks of Nilratan Sircar, an outstanding medico of Bengal. While presiding over a meeting of the Calcutta Medical Club, held on 20 September 1923, he said,

Brahmachari (see Figure 7.1) was one of the medical superstars, and an unsung hero, in the fight against one of the dangerous enemies of public health in the British Empire in India. The process of defeating this disease may be said to have been started with the introduction of tartar emetic by Leonard Rogers, and it reached a height of success with the availability of Brahmachari's brainchild, urea stibamine.

There have been competing and conflicting ideas about diseases in different phases of human civilization, and none of them is said to be exclusively deterministic and universally acceptable. Disease has been defined in a way society wanted it to be defined, and consequently, the concept and ideas of illness are found to be changing with the changes of time and culture. More importantly, an interpretative rather than positivist approach to determining the definition of disease or illness has also been given by historians, sociologists, and anthropologists. This book is not intended to revisit this area and re-examine it. Broadly speaking, disease may be, in the light of modern medical research, due to several groups of causes, and specific aetiology for a specific disease has been established after the discovery of germ theory. It may be due to congenital defects or faulty working of the organs or may be the result of improper nutrition. There are certain diseases caused by some microbes (viruses, bacteria, or parasites), which are communicable from one person to another. This is the most important category of diseases from the point of view of public health services because these diseases can be prevented, and many can be successfully treated. Many such diseases, which caused havoc in colonial India, still pose a serious threat to the state and the people.

The most panic-inducing disease in British India was fever, which, in one form or another, had taken millions of lives. Besides mortality, fever also caused thousands of cases of illness, leaving the affected people weak, listless, and wrecked. British India experienced various types of fever, such as Burdwan fever, Dumdum fever, malarial fever, and so on—black fever, known as kala-azar (visceral leishmaniasis), being one of the most dangerous among them. Kala-azar was widely prevalent in colonial eastern India but was not only an Indian disease. It was rather a widespread disease and occurred in many parts of the world during the period under study, exhibiting its presence in China, Arabia, Sudan, Central Africa, Tunis, Sicily, Italy, Algeria, Crete, Spain, Portugal, Greece, Malta, Turkestan, Central and South America, South Africa, and so on.