Nutrition, sanitation, hygiene, and the likelihood of death: the British Army in India c. 1870-1920.

Abstract

We shall never return to the demonic and miasmatic theories of the past, and the practical application of the principles developed by a series of clear thinkers and brilliant investigators from Fracastorius to Chapin - has forever banished from the earth the major plagues and pestilences of the past. This type of explanation was vigorously challenged by McKeown2 and others, some 30 years ago. McKeown argued that modern medicine had little effect on mortality before the later half of the twentieth century, and that progress before that time must be explained broadly in terms of 'profound changes in conditions of life'. More specifically, he assigned an important role to improved nutrition, rising incomes, and the beginnings of environmental sanitation. The thesis that mortality had declined because of rising living standards was initially offered as a residual explanation, after all other likely causes had been ruled out. But, responding to criticisms in his last published work, he also sought to support it 'on extensive experience of infectious diseases in relation to nutrition in the Third World'.3 The evident assumption is that conditions in present-day Third World countries are reasonably similar to those in the no longer observable preindustrial west. On the other hand, the power of modern medicine and sanitation, banished from the vital revolution in the West by McKeown, was reinstated by S. H. Preston, to explain the rapid population growth in many backward countries between 1940 and 1970. He, too, proceeded by using McKeown's process of successively excluding various causes, with the residual effect being attributed to a residual cause.4 It must be evident that if Preston is correct, then modern studies of the Third World cannot be depended upon to understand early European experience, as modern medicine must have altered the epidemiological profile of the population substantially. An explanation similar to Preston's was developed for the State of Kerala by Panikar and Soman in a book trenchantly criticized by Imrana Qadeer for weaknesses in its evidence and its 'bias in