An outlier in public health history in India: A.T.W. Simeons's scheme for rural medical relief, Kolhapur, 1943-47

Albert Theodore William Simeons, Md (1900–70)

Simeons [Figure - 1] was born in London in 1900 of German parents. He returned to the country of his ancestors as a teenager spending the later years of the First World War in the German army—albeit as a non-combatant. The autobiographical details as provided by Simeons to the British authorities in India are to be found in the ‘Simeons Papers’ archived at the British Library, London.^[1] He obtained his medical degree with highest honours from the University of Heidelberg. His hospital experience in Switzerland seeded his life-long interest in endocrinology and nutrition. He specialized in Tropical Medicine at the renowned Bernard Nocht Institute at Hamburg in the course of which he spent two years studying malaria in Africa.

Figure 1: A.T.W. Simeons, MD (1900–70). Source: Dust jacket of the American edition of Simeons novel The Mask of a Lion, published by Alfred K. Knopf, USA in 1952.

Armed with these impressive credentials, Simeons arrived in Bombay (presently Mumbai) in September 1931 and set himself up in practice. His presence in the city was hardly unique, for he was but one of numerous highly-qualified medical expatriates of German and Austrian extraction (some were Jews) to seek employment in 1930s India.^[2] Other favoured locations according to Kronenberger were princely states such as Jaipur, Bikaner and Mysore. Bombay was an attractive destination, there being an estimated 40 such specialists in the city just before the Second World War.^[3] Like his confreres, Simeons had a successful practice (Bombay elites showed a partiality for the foreign specialists, to the chagrin of local medical men).^[4] His clientele provided him opportunities to formulate and put into practice his highly individualistic theories about nutritional, endocrine and psychosomatic disorders. As a malariologist, Simeons travelled to Colombo in 1935 and collaborated with Ceylonese (Sri Lankan) medical authorities evaluating a chemotherapy (‘atebrin’) as a mass treatment in tackling the raging deadly epidemic of the disease.^[5]

Simeons and The Government of ‘British India’

Britain's declaration of war against Germany in September 1939 pulled the rug from Simeons's comfortable life. Within hours, dozens of German residents of Bombay were rounded up under the ‘Enemy Foreigners Order 1939’ and despatched to internment camps at various locations in the Province. The four camps in Bombay Province were at Purandhar (near Pune), Ahmednagar and Satara. The camp at Balachadi, Nawanagar (Jamnagar in today's Gujarat state) was hosted by the ruler, Jam Saheb. ‘Confidential’ documents at the British Library (London) highlight the suspicions of the Central government about the loyalty of Simeons and his wife. Simeons's failure to report for service (non- combatant) in the German army in the First World War, and to adopt British nationality on arrival in India (some German émigrés had prudently done this) were duly noted. His protestations at various times that he was indeed a British national, thoroughly British in upbringing and loyalty, cut no ice. Restrictions were placed on his movements. Where and how he practised his profession after 1939 became subject to sanction by the Government of India.

The Parole Camp, Satara (1941–43)

In 1941 Simeons was appointed in medical charge of the hospital at the Parole Camp for German families at Satara in southwest Bombay Province. There were advantages in the arrangement-he could be watched; he could practice his profession and the Government of India's duty to provide high quality medical service to the internees fulfilled at little expense. By 1943, however, policy changes resulted in relocation of many inmates. Simeons expressed frustration at the enforced idleness and loss of income.

How best to utilize his medical skills while restricting his movements was a problem for the colonial authorities. A suggestion to employ him as malariologist at the Camp for Polish inmates at Balachadi (Jamnagar, Gujarat) was swiftly shot down by the inmates themselves, who ‘declared that they will under no circumstances have Mrs Simeons owing to her pro-Nazi views’. Appointing ‘a German-born doctor to work at a Polish inmates camp [is] fraught with … possibilities of friction and mutual dislike’, opined a bureaucrat.^[6]

The Princely State of Kolhapur (1943–47)

Nevertheless, the year 1943 proved fateful. Simeons, on the recommendation of an influential courtier, was consulted for an ailment by Maharani Tarabai, Regent of the premier Maratha Princely State of Kolhapur. So impressed was she by Simeons's skill, that—after obtaining his consent—the governing Regency Council petitioned the authorities at Bombay and Delhi for permission to employ him as ‘Director of Public Health and Physician in Chief for the Kolhapur State’. The justification was that ‘[T]he Public Health Organization of the State is in a primitive condition, and it is believed that Dr Simeons in view of his qualifications will be able to effect a vast amount of good in the State. The Regency considers that it is very fortunate to obtain the services of Dr Simeons and has unanimously decided to offer him this post.’^[7]

The proposal of the Regency Council, the Executive head of which was a sympathetic British Indian Civil Service (ICS) officer as ‘Prime Minister of Kolhapur’, did not meet with unqualified approval from the Political Department in Delhi, notwithstanding that Simeons had never violated his parole conditions at Satara. A new fear haunted the authorities—that the ‘German national’ would exploit visits to Bombay to ‘play up’ to ‘intriguers’ in the Congress Party in order to obtain permanent residence in India.^[8] The Congress government elected to office in Bombay Province in 1937, had resigned in October 1939 in protest against the Government of India's decision to enter the Second World War without consulting Indian opinion. The conduct of Provincial affairs was therefore the responsibility of the Governor, his Council and the British Representative in the Deccan States. After much deliberation the employment was sanctioned, but with conditions. Simeons and his wife, were permitted to travel anywhere in India only after 24 hours prior intimation to Kolhapur Police. Additionally, Simeons was ‘excluded from Bombay city unless expressly permitted by the Bombay authorities’. He was ‘to take no part in politics and [was to] avoid political contacts of any sort.’^[9] As Director of Public Health, Simeons was to report directly to the ‘Prime Minister’. He was permitted private practice.

Despite the tensions, Simeons's four and a half years in Kolhapur proved productive. His professional horizon hitherto preoccupied with the ailments of Bombay elites and European internees, now encompassed healthcare planning and services for rural communities.

Almost immediately he was confronted with a tropical medicine emergency—an epidemic of bubonic plague broke out with a mortality rate of over 20%. In an interesting paper, he described the measures adopted by his department, without causing public panic. He concluded that sanitary measures supplemented with sulpha drug treatment were superior to preventive inoculation.^[10]

Kolhapur Development Committee

In the mid-1940s, provincial governments in ‘British India’ were under orders to plan for ‘post-War reconstruction’. Princely Kolhapur, though not obliged to comply, independently set up a ‘Development Committee’—there being no pre-existing ‘construction’ to ‘reconstruct’—comprising knowledgeable persons for all-round attention to infrastructure and public services, including health.^[11] The committee's chairperson and secretary were visionaries—Dhananjay R. Gadgil and Jayant Pandurang Naik (‘J.P. Naik’), respectively. Gadgil (1901–71) later founded the Gokhale Institute of Politics and Economics and J.P. Naik (1907–81) lauded today as an educationist and social thinker, was particularly concerned about bettering the quality of life in the state's capital city. Improving air and water quality, efficient garbage and night soil disposal, enforcement of domestic and public sanitary arrangements and free medical care to the poor were taken in hand. Naik encouraged Public Health Department's campaigns against malaria and intestinal parasite infestations in Kolhapur city which were widespread on account of insanitary habits and practices—points earlier emphasized by Simeons.^[12]

Rural Medical Relief Scheme

What of Kolhapur's rural areas? The Public Health Department's ‘Rural Medical Scheme’, which came into being in 1944 after months of deliberation, had a hierarchical structure. At the base was a special cadre of Gram panchayat-selected, ‘respectable’, literate, village residents with an assured income (e.g. school teachers), who were trained and supervised by the Department. ‘Sub-dispensers’—as they were designated—rendered basic medical services such as dressing wounds, taking temperatures, dispensing government-supplied medicines and disseminating sanitary, hygienic and nutritional knowledge. A handbook written in simple Marathi, using colloquial names for the drugs, guided the sub-dispenser in recognizing and treating common ailments such as anaemia, scabies, etc. Unfortunately, no copy of the Marathi manual survives either in the Kolhapur district or the Maharashtra State Archives.

To the ailing villager, the sub-dispenser was the face of the princely state's health system. The rule was that sub-dispensaries— each served a population of about 10 000--were to remain open for at least half an hour every day; none could remain closed for longer than 48 hours without permission from the Public Health Department. A small charge of one anna (an old unit of currency, one-sixteenth of a rupee) for 1–3 days' medicines was levied on patients attending the sub-dispensary. A sub-dispenser was permitted free home visits when necessary. He (the scheme did not envisage women sub-dispensers) was paid an honorarium of ₹5 per month. His duties were strictly circumscribed—illnesses beyond his brief were to be referred to a qualified doctor.

The latter requirement not only averted opposition to the scheme by local medical practitioners, but, Simeons claimed, actually promoted their interests.

‘… Rural sub-dispensaries are preparing the ground upon which a qualified medical practitioner will later be able to thrive in rural areas.’^[13]

An initial experiment with 10 sub-dispensaries was successful, and 60 more became operational. When the scheme was officially adopted in 1945, it envisaged bringing every village with more than 1000 inhabitants under its aegis.^[14]

A group of sub-dispensaries served as feeder to a designated ‘Peta’ dispensary (a ‘Peta’ was an administrative unit) manned by ‘district medical officers’; in turn the dispensary fed the well- equipped and well-manned new apex ‘Central Hospital’ in Kolhapur city.

Documentation of The Rural Medical Scheme

The rural scheme aroused interest in other states, for whom Simeons authored an elaborated English version of the Marathi manual (pharmacopial drug names replaced the colloquial).^[15] The village sub-dispenser's manual [Figure - 2] dated 1945 emphasized the circumscribed sphere of activity of this category of worker who was expressly discouraged from harbouring personal ambitions above and beyond his station. Some excerpts:

Figure 2: Manuals by Simeons for the ‘Rural Medical Relief’ scheme, Kolhapur. Photocopies courtesy the Librarian, Ministry of Health, Rome, Italy

‘…You must clearly understand that you are in no way a qualified doctor, but merely a person who has passed an examination qualifying him to be a village sub-dispenser…’

‘… You are required to give simple medical help to the villagers, using only those medicines which you have been taught to use in your training.’

An annual bonus was an incentive, but ‘…irregularity in attending the sub-dispensary, uncleanliness, not keeping the records or accounts properly, etc. will disqualify you from getting the bonus.’

Simeons also brought out an Index for district medical officers [Figure - 2] (undated, but probably 1945) manning the ‘Peta’ dispensaries. He was convinced that the greatest good of the greatest number of patients could only be achieved by ‘applying the most modern therapeutic measures and methods’ even in dispensaries where there was ‘no X-ray apparatus, no pathological laboratory and only primitive facilities for observing hospitalized cases.’^[16]

Importance of The Rural Scheme

The scheme was weighted towards medical relief, rather than sanitary progress. It was novel in giving primacy to trained literate village residents as first-line medical caregivers. Its other claim was that it was started from scratch--there had never been a formal public health set-up in the princely state before 1943. Neither was there a working precedent elsewhere in India. The sub-committee on ‘National Health’ headed by Sahib Singh Sokhey, was appointed by the Indian National Congress as early as 1938-39. It recognized the importance of community health, and pointedly recommended utilizing trained ‘non-medical workers.’ However, its ‘Report’ was published only in 1948, by which time the Kolhapur scheme was well-established.^[17] Rather than merely enunciating desirable policies, Kolhapur's Public Health department demonstrated successful working at the ground level in real life. It accommodated decision-making by grassroots power structures (Gram panchayats) in the selection of persons to be trained as sub-dispensers while the department kept a watchful eye on the quality of service rendered.

It is curious that the Bhore Committee itself had nothing to say on first-line healthcare services in rural areas. Its focus rather was on getting around the difficulty in attracting medical practitioners to the countryside: ‘… the most satisfactory method of meeting the situation would be to provide a whole-time salaried service, thus enabling governments to ensure that doctors are made available where their service are most needed.’^[18]

A Role For J.P. Naik?

A claim made in connection with the rural scheme and the extent of Naik's involvement in it warrants comment.

‘On this vast canvas of activities [at Kolhapur], what stood out most strikingly, was his [Naik's] extremely imaginative work in … the organization of a novel but simple scheme of village medical aid which anticipates the barefoot doctor concept…’^[19]

The China analogy though evocative was off the mark. First, the therapeutic armamentarium of Mao Tse Tung's (Mao Zedong) ‘barefoot doctor’ scheme (started in 1949), was firmly grounded in Chinese medical tradition, e.g. herbal remedies and procedures such as moxibustion, acupuncture, etc. Contrarily, Simeons, as is clear from the passages from his manuals quoted above, was a firm advocate of modern allopathic (i.e. western) chemo- therapeutics. Sub-dispensaries were stocked with enterovioform, aspirin, mepacrine and sulpha tablets. Medical officers at Peta dispensaries were exhorted to notice ‘how much of modern therapeutics can be utilized to the great advantage of rural medicine.’^[19] Second, Chinese ‘barefoot doctors’ were encouraged to use their initiative and some serious diseases were not outside their purview.^[20] The ambit of competence of the Kolhapur subdispenser—the alleged Indian progenitor of the ‘barefoot doctor’ – was far more limited.

The Development Committee undoubtedly provided opportunity for fertile interaction between the agile minds of Naik and Simeons, but to maintain that the former ‘organized’ the simple rural scheme is problematic. Naik himself did not claim as such either at the time or in the Lakshmanaswami Mudaliar Oration delivered by him in 1977.^[21] The field manuals and medical publications strongly point to the scheme being Simeons's handiwork.^[13] So much so, that in 1954-5 years after the incorporation of Kolhapur into Bombay state, when Simeons was no longer on the scene--senior medical men referred to ‘… the scheme … originally started by Dr A.T.W. Simeons while he was

Director of Health Services of Kolhapur State’ as a model one.^[22],[23] There is further evidence that the scheme in all its details endured successfully for several years after Independence in 1947.

‘[The] Rural Medical Relief Scheme is … rendering wonderful service to the village population, so far as relief of common ailments is concerned. There at present 117 centres working throughout the district. They are providing allopathic medical aid to the public. The scheme is providing simple remedies at a price within the reach of village patients. The scheme is run by sub-dispensers who are either school teachers, secretaries of panchayats or social worker from a village…. The ex-Kolhapur State Administration was the first in the whole of Bombay State to start this Scheme.’^[24]

The scheme was brought to the attention of Dr Munchershah Gilder, Health Minister in the first post-Independence Bombay Cabinet, who promised to extend it to other regions of the state ‘if found beneficial’.^[25] However, the bedrock of rural medical relief in the eyes of medical politicians such as Gilder, was a cadre of qualified doctors who would be enticed to move to rural areas through subsidies. Trained lay personnel of the sub-dispenser category had no place in such a scenario.

Simeons, Kolhapur and The Mask of a Lion

This work[Figure - 3], Simeons's first foray into fiction, published simultaneously in Britain and the USA in 1952, was another notable consequence of his tenure at Kolhapur. It was also the first India-based fictional work in English, centred on a person with leprosy.^[26] It is unlikely that a modern leprologist would have heard of either the author or the work, because Simeons made no contribution to scientific leprology, and the novel was not reviewed in the main leprosy journals of the day. (In contrast Miracle at Carville, a semi-autobiographical American novel pseudonymously authored by leprosy sufferer ‘Betty Martin’, and also based on the sulphone-wrought revolution, was noticed in Int JLepr 1952; 20: 314.) It was reviewed, however, in Kushta Patrika edited by Manohar Diwan of Datttapur, the veteran Gandhian leprosy worker and was also serialized in a widely circulated periodical of 1950s Bombay, The Illustrated Weekly of India (Vol. 74, March-May 1953).

Figure 3: Dust jacket of the American edition of Simeons's novel The Mask of a Lion, published by Alfred K. Knopf, USA in 1952

The setting is the period of transition of leprosy treatment from chaulmoogra oil to sulphone. The novel is a sympathetic yet detached depiction of the fortunes and misadventures of the protagonist Govind, formerly proprietor of ‘The Handsome Gent's Tailoring Mart’, now leprosy-afflicted and outcasted. Through Govind the reader experiences the responses of Indian and foreign medical personnel when confronted with leprosy. Govind inserts himself into an itinerant ‘leper brotherhood’ which has perfected the art of survival in an indifferent world. Guided by leper gossip, Govind searches for a mysterious institution known only as ‘The Park’ where ‘lepers live like ordinary villagers, till their own fields, earn money and become rich’.

Govind finds redemption when his wanderings take him to the gate of ‘The Park’ and is accepted by the community. His leprosy heals following a successful trial of a ‘new treatment’. The survivor of many vicissitudes is finally re-united with his faithful wife and his children.

A reader familiar with Kolhapur will have no difficulty in identifying ‘The Park’ with Shenda Park, the leprosy isolation colony established by a former ruler. As Director of Public Health, Simeons supervised improvements and upgradation of the institution.

The Last Years and Other Preoccupations

By 1947, with the Regency Council disbanded, War ended and India independent, Simeons returned to Bombay where he resumed some private practice. Around 1950 he left India permanently for Europe, choosing to settle (understandably) neither in Germany nor in Britain, but in Rome, Italy. He joined the Salvador Mundi International Hospital where he gained renown (some would say notoriety) designing and promoting a hormonal-cum-dietetic treatment for obesity.^[27] These decades of Simeons's life, as also his several books written in an easy style airing his unorthodox views on psyche-soma interaction,^[28] nutrition,^[29] etc. are outside the scope of the present article. He died in 1970. He and his wife (died 1985) are buried together in the Protestant cemetery in Rome, not far from the graves of the poets John Keats and Percy Shelley.