Arnab Chakraborty argues we should examine histories of healthcare from health workers’ perspectives, and highlights both the collaboration and competition between colonial and Indian medical services in British India.
Colonial India presents a compelling case study for understanding medical services, or to be more precise the healthcare practitioners. This holds even truer for the Madras presidency, which remained one of the most peaceful provinces in British India and allowed the state to experiment and establish a healthcare practice unique to the region. In this post, I will explain how the colonial medical administrators collaborated as well as competed with the Indians, subordinates in most cases. While recasting the focus on the subordinates, the contribution and nature of collaboration between the colonial administration and medical services need to be understood in a more nuanced manner.
Healthcare in colonial India has primarily been analysed from the perspective of the elite medical bodies or diseases, while the subordinates largely remain in the periphery barring a few cursory mentions. The local people of Madras, despite being considerably educated, found it increasingly challenging, especially in the twentieth century, to find a career in the British Indian military and this compelled them to turn to the healthcare sector. With the outbreak of the Great War in 1914, there was a severe shortage of medical practitioners in the civilian department as they were called for military duties. While the Indian Medical Service (IMS hereafter) recruits were bound to serve the military if required, they left a huge vacancy in the civil hospitals and dispensaries in the region. While the Great War exhausted the IMS ranks across British India, Madras, with its already reliable healthcare set up, realised the importance of involving the subordinates and intermediaries trained in the Western medical practices. This endeavour also put a check on the influx of quacks, compounders and traditional medical practitioners who were trying to flood the medical marketplace in the absence of trained senior doctors.
The tension that was already brewing during the War took a more critical turn after its conclusion. The military doctors began to rejoin the civilian services pushing the Indian subordinates back to the fringes. Those who had the opportunity to work independently in the district or taluk hospitals and dispensaries, soon figured out that there was a steady flow of cash in private practice involving Western medicine. Private practice played a significant part in the collaboration and competition among British and Indian practitioners while the Government of India (GoI hereafter) was dependent heavily on both the groups and so it was impossible for them to pick a side. The government had to generally side with the British doctors, as only a few of them came to the colonies and were in high demand. However, the presidency had to abide by the requirements and demands of the Indian subordinates and the wealthy locals as they were either supporting the system with workforce or with money. After facing this contradiction, it dawned upon the Madras government that expansion of the medical marketplace was of utmost importance. This would not only let the competition thin out, but also work better for the subordinates, the officers as well as the government. The local civilians, in turn, received medical attention, which also helped expand the market for Western medicine, and benefitted the government financially.
The Rockefeller Foundation (hereafter RF) conducted a few surveys in British India. Their reports and letters identified the complicated nature of private and public medical practices and how the British doctors were keeping most of the profitable positions – those allowing the maximum private practice. There was a drastic upheaval of medical structure in Madras that imparted increased importance and responsibilities to Indians from the late 1920s. The new responsibilities included being in charge of hospitals and other medical institutions and running more prominent district and city hospitals in the absence of British higher ranked officers. The Rockefeller surveys contributed to significantly changing the structure of rural healthcare that in particular provided access to Western medical care for the local Indians. In a vast region like the Madras presidency, it was indeed difficult to reach the rural parts, and the local government and the RF failed to gauge the actual expanse of rural and urban areas. Thus, it can be argued that the rural areas that were far off from the cities were under the aegis of Indian doctors trained in Western medical tradition or they had to rely only on the ‘indigenous practitioners’, including the midwives (dhais) for every type of medical intervention. However, questions were also raised concerning the positions that accommodated Indians. Major General Sahib Singh Sokhey wrote to the RF explaining that the colonial state did not encourage Indians to be good teachers or researchers – they were mostly looking to obtain assistants.
The RF surveys also demonstrated the contradiction among colonial officers regarding the approach towards healthcare in the presidency. Even though the overall approach was shifted to a more preventive form of healthcare, a few instances exposed how difficult it was to implement that in practice. With the steep cost of medicine and diagnosis, it was impossible for the local Indians to consult Western medical institutions. Finance was not the only factor: societal stigma and the discomfort of the Indians – mostly the women – to consult male doctors, restricted the total number of the patients. However, with some measures like encouraging women to join the field medicine, providing subsidies for rural practitioners and also for women medical graduates, the state showed their intent to disseminate healthcare. The wealthy Indians came forward to cooperate and pledge large sums of money for the development of medical hospitals and dispensaries for men and women in Madras. This enabled the wealthy section in the region to wield their dominance in the larger scheme of things within the presidency. The Madras government remained persistent in keeping to the class, caste and religious segregations and in turn, contributed to the inhabitants developing an even more rigid mentality towards other religions or castes. Such local issues and collaborations among different powerful groups allowed the subordinates to control the medical and administrative structures in the presidency. Colonial healthcare should not only be understood from a top-down or a bottom-up perspective but is required to base its arguments around all distinct perspectives available in the region.
Thus, perusing the history of the Madras presidency in the late nineteenth and early twentieth centuries makes it apparent that this was not a monolithic province and the healthcare and administrative changes call for a detailed study to map the transformation of medical services. Healthcare, particularly colonial healthcare, as this article argues, should be examined from the perspective of the health workers as they were the ones directly responsible for its dissemination. It can also be argued, taking the case of the Madras presidency, that it is essential to discuss the contradictions as well as stories of collaboration among the Indians and the colonial state. In this province, in particular, hierarchical hegemony did not work in a uniform pattern as the subordinate and intermediary medics colluded within their local circles to establish their control in the lower levels, which in turn began to affect major government decisions. This research can be carried forward in the future, and other hitherto underexplored colonial contexts can be examined using the subordinates’ perspective.
Arnab Chakraborty is a doctoral student at the Centre for Global Health Histories, University of York. Twitter: @ArnabChakrborty
 For more details on this see, D. P. Ramachandran, Empire’s First Soldiers, (New Delhi: Lancer 2008).
 W. S. Carter report, 1926, Box 10, Series- 464/464A India, Record Group (RG) 1.1, Records of the Rockefeller Foundation (RF), Rockefeller Archive Center, Sleepy Hollow, New York (RAC hereafter)
 Arnab Chakraborty, Understanding Subordinate healthcare in colonial Madras: shift in women and rural healthcare (1918-1932), Rockefeller Archive Center, 26 April 2018, access at: http://rockarch.issuelab.org/resource/understanding-subordinate-healthcare-in-colonial-madras-shift-in-women-and-rural-healthcare-1918-1932.html
 For more details on how local politics worked in the region see, David Washbrook, The emergence of provincial politics: the Madras Presidency, 1870-1920, (Cambridge: Cambridge University Press 1976).