INFOKARA RESEARCH ISSN NO: 1021-9056

Travancore Government and Public Health

1. Sindhu Thomas, Ph.D. Scholar, Dept. of History, Bharathidasan University, Tiruchirappalli, . 2. Dr. Y. Srinivasa Rao, Assistant Professor, Department of History, Bharathidasan University, Tiruchirappalli, Tamil Nadu.

Abstract

In independent , health services have definitely made remarkable progress. As a result,

the average expectation of life span has increased more them three times. can be

said to have made the transition from a society with high growth rate, high death rate and

high infant mortality rate. From 19th century onwards the changes took place with moderate

population growth rate, low crude death rate and relatively low infant mortality. There are

many socio-economic conditions unique to Travancore, which have been postulated to this

health model possible. This especially is the high female literacy, socio-cultural re-

awakening in the nineteenth century, introduction of western system of medicine, the advent

of missionaries and the patronization of the kings of erstwhile Travancore . So

the Travancore state contributed for the partial success of public health efforts in India as a

whole and made a unique model. This paper is mainly focussing on the initiatives and

efforts of Travancore State Government that has taken for its progress in the public health

care.

Key Words: Public Health, Trivandrum, Kerala Women, Vaccination.

Introduction

The public health activities of the Travancore state dates back to the first decade of the

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19th century. The introduction of vaccination so early as 1813 within a few years after its

discovery by Edward Jenner, laid the foundation of preventive medicine in the state. The

starting of the European system of medical aid in the country during the reign of Her

Highness Gowri Lekshmi Bai, in the year 1811 preceded the starting of vaccination only by a

couple of years. She opened a Charity dispensary in 1816 in Thycaud to give free supply of

medicine to the poor and the needy. It was under the aegis of the curative system, and as a

part and parcel thereof that the branch of preventive medicine in the state had its inception.

Among the Indian states, it is the role of a pioneer that Travancore has played in the realm of

modern medicine, public health and sanitation. It was with the introduction of vaccination the

regular efforts of public health care started in Travancore.

Travancore society in the earlier periods was confronted with a lot of communicable diseases

which shook the Travancore society and led to the increase of death rate. The year 1895 has

recorded the highest figure in the death rate being 19.52 per mile. In 1896 and the following

year the ratio fell to 15.01 and 15.72 respectively and 13.63 in 1898. After 1898 the figures

began to improve on account of the unusually severe prevalence of cholera and small-pox.

The prevalent-diseases in Travancore were fever, Cholera, and small pox among the

epidemics and ulcers anaemia, dropsy, diarrhoea, leprosy, elephantiasis, scabies, yaws or

farang worms and dysentery among the sporadic find which led to innumerable deaths in

Travancore. 1 In order to prevent the spreading of this type of diseases the Travancore

Government adopted several measures.

Vaccination Department

In 1865 a separate Vaccination Department was established and the government adopted

several measures for ensuring health and the public health institution in the state crystallized

itself.2This department was put in charge of a medical officer with required qualifications

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followed in Europe who was designated as Superintendent of Vaccination and placed under

the orders of the Durbar physician. Durbar physician was an ordinary official in the Indian

medical service. His period of service was five years. The main duty entrusted on him was to

treat the kings and the palace members and he was in charge of the Civil Medical

Department. His staff consisted of a Head vaccinator and twenty seven vaccinators in five

grades. The long established policy of the government had been to see the proper

medical aid is placed within the reach of all classes of people. Accordingly free

medical aid and a free supply of medicines were available to the public in all medical

institutions maintained by the Government. The government had come for passing a

Regulation to make vaccination compulsory in the rural areas according to the needs of the

localities. In the Madras province, it had been made compulsory in several rural areas and had

slowly been extended, and in a regulation was shaped in the Legislative Council. In

Travancore, compulsory registration of births and deaths has been introduced for it is easy to

keep the un protected register in all registering offices. As a first step it should be made

compulsory in all police conservancy towns and one or two taluks backward in vaccination

should be taken up first.3

The administration of the medical department continued to be vested in the Administrative

Board Medical Services till the close of August 1932.From which date the post of Darbar

4 Physician was restored. The Darbar Physician was made the sole head of the Medical

Department responsible for the entire administration and he was designated as ‘Durbar

5 Physician and superintendent General Hospital. The Superintendent of vaccination had to

supervise the work of the vaccinators, inspect the out-station hospitals and suggest measures

for the improvement of sanitation. This step marked the first stage in the progress of public

health work in the state. The superintendent of vaccination functioned as the sole Inspecting

officer up to the end of 1889 and two Inspectors were appointed in addition to assist him. A

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Vaccine Depot was established in 1886 for the preparation and distribution of vaccine

lymph.6

Primary Health Centre

The Primary Health Centre forms the base of the integrated structure of medical services in

the rural areas. The primary health centres and sub centres provide basic medical care to the

community through multi-purpose health workers. It lays stress on the preventive, promotive

public health and rehabilitative aspects of health care and points to the need of establishing

comprehensive primary health care service to reach the population in the remotest areas of

the country, the need to view health and human development as a vital component of overall

integrated socio-economic development, decentralized system of health care delivery with the

maximum community and individual self reliance and participation.7 During the first five

year plan a policy was sought to be implemented to control and eradicate communicable

diseases and to provide curative and preventive health service in the rural areas through the

establishment of a Primary Health Centre in each community development block. The health

staff of each centre consisted of one Health Inspector, one peon and one midwife working

under the medical officer of the centre. One important general trend in modern medicine was

to switch on emphasis from curative to preventive medicine. The realization was that more

individual curative care would not improve general health standards.8 A more community

minded and preventive approach was required needs of their affiliated teaching hospitals

increased.

The Health Survey and Development committee of 1946, Bhore committee recommended

that a three tier system of primary, secondary and tertiary levels should be developed with a

well-built referral system and that the poor should be given free medical care. 9 Primary

Health centre is a multi-purpose unit established at the peripheral level to render medical

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services to the community. There was one primary Health centre for every 100 villages.10The

main services provided were medical relief, maternity and child health care, family planning,

school health, health education and control of communicable diseases. In Travancore to

achieve the target envisaged in the first year plan twenty dispensaries in rural areas of

medical department were transferred to the Public Department towards the end of 1955. The

actual transfer was effected on 1 April 1956 but these centres continued to function mainly as

dispensaries since it took several months to sanction the MCH staff and other health staff

required to these Health units. For the same reason these Health units could not function as

effective agencies for providing curative and preventive health services to the people of the

localities concerned. In addition to the new twenty dispensaries transferred from the Medical

Department three more Health units were created during the period. Of the eight old Health

units Karunagappally was upgraded into a Secondary Health Centre. With the wide net work

of primary health centres, community health centres, health sub centres, mini health centres

and mobile health services the aim of the government was to reach the goal of health for all

even in the remotest areas and in the de-linked areas.

Towards this commitment, the government provided better medical aid and health care

facilities qualitatively and quantitatively. Primary health centre was the pivotal centre, where

from all activities relating to preventive, promotive and curative health care of the rural

population radiate.11 The Travancore Government implemented several innovative measures

for the improvement of maternal and child welfare programmes in the state.

Women and Public Health

In the absence of purdah (seclusion) and because of high status, women in Travancore were

educated and allowed to circulate in an environment under western influence. Education, in

turn, allowed them to contribute to the success of Public Health and medicine. Female

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contributions were made in two realms-in their homes and in institutions such as hospitals

and dispensaries. Schooling was very important since educational institutions, along with

hospitals, were the centres of health education and medical inspection. Among the

requirements of the 1909 Travancore Health Code, for example, the following were included:

All students had to be vaccinated before entering schools and revaccinated every five years,

all schools were subject to medical and sanitary inspection by the Medical, Sanitary and

Public Work Departments, women could replace domestic economy and hygiene for such

compulsory subjects as geography and history, and teachers training for English Schools and

Higher Grade Vernacular Schools were required to have taken a course in hygiene.12 By 1945

all government school texts, both in and Tamil, included lessons in hygiene. The

Travancore Education Reorganization Committee (1945) found this insufficient and

recommended that hygiene be taught on practical lines as a separate required course in all

primary and secondary schools. 13 A similar picture developed in Cochin. Due to the

inadequate number of schools prior to 1900, girls and boys were sent to study at the same

schools. The absence of purdhah made this possible. After 1900, however, a vigorous effort

was applied toward increasing the number of girls’ schools.

In these schools special courses in domestic economy and cooking were taught.

Housekeeping and nursing were required in the final examination of all girls’ high schools. A

half dozen specially trained women led the classes. Following the lectures on nursing given

by female physicians, the female students, under supervision, engaged in practical nursing at

the local hospitals. By 1930 it was generally recognized that a purely literary courses is not

what should be aimed at, but that facilities should be provided for the imparting of such

instruction as would fit the girls for the duties that await them in life as house wives and

mothers and to infuse some light and refinement into their homes. 14The Code Revision

Committee of 1932 made medical inspection compulsory at least three times during high

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school, and suggested extending medical inspection to lower schools. In 1936,30,382

students were examined 2,817 of which were women. Education was used in Travancore to

inculcate ideas related to health and hygiene. In many ways, attending schools meant more

than learning how to read and write; it also meant being exposed at an early age to the

required smallpox vaccination and to western ideas of hygiene and to western medicine,

While in Madras in the 1920’s basically illiterate female population was educated about

health through sporadically distributed health books and pamphlets, in Travancore and

Cochin, where female education was important, women were continually exposed in schools

to health related ideas. Later in the 1930’s, when the Rockefeller Foundation began

distributing health pamphlets in Travancore, it could expect 16.8 percent of the women to

read them. In Madras, only 3 percent could.

If education altered women’s perspectives on how to maintain health, high status allowed

them to realize in their homes what their education had shown them. Among the Pulayas, for

example, “women were not always found to be obedient to their husbands and were not

always particular about deferring to their husband. There is evidence that the spread of

education has been an important factor in making cleanliness a value for Pulayars, who are

among the poorest in the population.15 Higher castes have undoubtedly, therefore, benefited

as well.

Women have not only contributed to the development and success of Public Health and

medicine as mothers and home-makers, they were also employees in the health departments.

Before the end of the nineteenth century, having recognized the dangerous and unsanitary

habits of the dai, a traditional midwife, the governments and the missionaries began to train

midwives. By 1914, in Cochin, there were sixteen trained midwives affiliated with the

medical department. In a single year, these women attended 1,475 labor cases.16 This picture

improved continually. Three years later, twenty four more indigenous midwives were

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trained.17 In 1934/35, 50 midwives were affiliated with the department and attended 3,499

labor cases. Moreover, by 1933/34, female medical subordinates treated 75,196 women and

58,418 children. Similarly, in Travancore by 1901 there were thirty two licenses mid-wives,

six nurses affiliated with the Medical Department and eight female vaccinators attached to

the Sanitary Department. In the same year, the state of Baroda had only four trained midwives

and nurses.18

The Travancore government was so much concerned about the welfare of the women society.

His Highness the of Travancore passed an Act classed as the ‘The Travancore

Maternity Benefit Act’ in 1943. This was an Act to prevent the employment of women in

factories for sometime before and sometime after confinement and to provide for payment of

19 maternity benefit to them. Maternity benefit means the amount of money payable under the

provisions of this Act to a woman worker in a factory. The amount of maternity benefit for

the period up to and including the day of confinement shall be paid by the employer to the

woman within forty eight hours of the production of such proof as the government may by

rule prescribe that the woman has been confined. The amount due for the subsequent

period shall be paid punctually each work in arrear. In order to encourage private

participation in the field of health the Travancore government formed a Medical Advisory

Committee in 1946.20

By 1943-44, there were 106 trained midwives affiliated with the Travancore Medical

Department. They attended 11,222 deliveries. Finally, in 1951, two years after Travancore

and Cochin had combined to form the state of Travancore-Cochin, there were 106 midwives

attached to Public Health Establishments and 231 employed in the medical institutions. The

significance of the work done by these trained midwives cannot be overestimated. A 1936

Indian survey showed that the traditional midwife was responsible for a high proportion of

infant deaths because of her unsanitary habits.21 Travancore and Cochin’s midwives went out

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into communities which had no access to health facilities and treated women there. They thus

probably contributed to a drop in the infant mortality rate. In most major hospitals,

furthermore, women were trained for the position of nurses and female medical subordinates.

Women also held very prestigious positions; in the late 1920’s in Travancore, a woman was

appointed State Darbar (Court) Physician and member of the Darbar for Health. Cochin’s

Medical Department in 1932 included two Assistant Surgeons and eight Lady Sub-Assistant

Surgeons. After India’s independence, Keralite women also began to contribute to the welfare

of India. Sushila Nayar, Gandhi’s disciple and physician, soon became Minister of Health for

Independent India. Aside from these achievements, the high status of women is reflected in a

number of statistics. First it is apparent that only in Travancore, is female life expectancy

consistently higher that male life expectancy. Second, the number of females has always been

higher than the number of males. This occurs only in populations where women are treated,

fed and cared for as well, or almost as well, as males for example, the western European and

North American countries. Third, the age of first marriage was consistently higher for

Travancore women as compares to other princely states. It has risen with increased female

education and work opportunity but it seems that it was higher than in the rest of India even

before these factors became important. Evidence exists that the percentage of prenatal

mortality, shortened pregnancies and low birth weights is higher in mothers younger than

seventeen. This high age of marriage in Travancore has therefore probably contributed to the

declining infant mortality rate, though it is not the sole determining force. Literature also

demonstrates the high status of women. In 1889, O. Chandu Menon, a Nayar of Travancore,

wrote and published , a book which had a direct impact on the future of the Nayar

women community.22 One can grasp the uniqueness of the situation in Travancore only if one

compares it to the rest of India. There, though extensive overt female infanticide has

disappeared, female infants are not cared for, nursed or fed as well as male infants. To

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aggravate the situation, men consume the higher protein and healthier foods. Finally, the

nursing woman is the least fed in the family.

From where does this high status of women arise. The answer partially lies in the tradition of

which pervades Travancore and distinguishes it from the rest of India. A few

other matrilineal castes exist in the rest of India such as the Garos and Khasis of Assam, but

their proportion in comparison to the rest of the population is much smaller than in

Travancore. Although matrilineality does not always raise the status of women, it left women

with an influence and an independence of outlook which one will not find anywhere else in

India in particular, by maintaining a position for the women within her family, it has

prevented widowhood from becoming a tragedy which it was and to a great extent still is in

other Hindu Societies.23 It is difficult to attribute this high status only to matrilineality for two

reasons. First, the status of women in the Muslim matrilineal communities is low compared to

similar Hindu castes; the women practice at least partial purdah and their educational

attainment is considerably lower than among Hindu women. Therefore, religion also

influences female status. Most of these Muslims, however, reside in Malabar and not in

Travancore and Cochin. Second, even among the patrilineal castes, women enjoy higher

status than elsewhere; the never observed (widow burning) and

although they observed purdah, by 1930 the Nambudiri reform organization sought to

abandon it. Furthermore, the age of first marriage was higher among them than among the

Brahmins in the rest of India.24 It appears that the matrilineal castes influenced the matrilineal

castes in the way women were regarded.

The high status of women was very important to the success of public health and medicine in

Travancore and Cochin. This high status is partially due to the matrilineal system which

pervades the two states. The absence of purdah allowed women to circulate freely in an

environment where western influence was being increasingly felt. Women were encouraged

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to attend the numerous schools built for them where they were exposed to hygiene and health

education, vaccination and medical inspection. Status allowed them to implement in their

homes what their education had shown them. In schools, they were also educated in nursing

and allied fields so that they later could, in turn, strengthen the medical and public health

departments and contribute to the health and welfare of their communities. Today, the impact

of this emphasis on nursing education is being felt all over the world-Keralite nurses are

found practicing in many major cities. In order to create health awareness among the people

the Public Health Department of Travancore introduced Health education to maintain a

healthy and congenial environment for the people. The introduction of such a system of

education was whole heartedly welcomed by the public.

1 V. Nagam Aiyah, The Travancore State Manual, Trivandrum, p. 504. 2 M. K. Devassy, Trivandrum District Hand Book-9, Trivandrum, 1961, p. 29. 3 Government of Travancore, Administration Report of the Medical Department, Letter No.7862, dated 2 August1912, Kerala State Archives, Trivandrum. 4 Government of Travancore, Administration Report of the Medical Department, R.O.C.No. 1881/ 321/L. G. B., dated 28 September 1932, Kerala State Archives, Trivandrum. 5 Government of Travancore, Administration Report of the Medical Department, E. Dis No.147 of 36/L.G.B., dated 10 April 1935, Kerala State Archives, Trivandrum. 6 Ibid. 7 Vivek Ranjan Bhattacharya, A New Strategy of Development in Village India, Delhi, 1983, pp.216. 8 Madras Information, November 1956, pp. 9-11. 9 C.C. Kartha (ed.), Kerala-Fifty Years and Beyond, Trivandrum, 2007, p.191. 10 Madras Information, February 1959, pp. 30-31. 11 Government of Travancore, Administration Report of the Medical Department, No.1172/55/D. D., dated 13 May 1953, Kerala State Archives, Trivandrum. 12 Travancore Education Department, Travancore Education Code 1909, Trivandrum, 1909. 13 Report of the Travancore Education Reorganization Committee, May 1945, Trivandrum, pp.88-92. 14 T. K. Krishnan Menon, (ed.), Progress of Cochin, Ernakulum, 1932, p.192. 15 K. C. Alexander, Social Mobility in Kerala, Pune, 1968, p. 191. 16 Government of Cochin, Report on the Administration of the Medical Vaccination and Sanitation Department in Cochin State, Ernakulum, 1914-15.

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17 Ibid., 1917-18. 18 V. Nagam Aiyah, The Travancore...... , p. 541. 19 The Travancore Maternity Benefit Act, Section 23 of Act II of 1943,Vol XIII,Part-I,dated 8 June 1943, Kerala State Archives, Trivandrum 20 Ibid. 21 B. Muktha Bai, Infant Mortality in India, The Indian Medical Gazette, dated June, 1939, pp. 354- 360. 22 K. M. George, Western Influence on Malayalam Language, New Delhi, 1972, pp. 92-94. 23 George Woodcock, Kerala A Portrait of the , London, 1967, p.225. 24 R.S. Kurup, K.A. George (ed.), Population Growth in Kerala –Its Implications, Trivandrum, 1966, p. 190.

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