EIPC - Developing Palliative Care in West Bengal

Watching my cousin deliver a presentation at the Nehru Centre in London on palliative care a few weeks ago, I was reminded of when we had first met.  With me growing up in the UK and he in India, we had not met as young children but when I was 19 in Calcutta, on my first trip to India for 15 years, and I think he was 12, at one of India’s public schools modelled on the UK.  As with most of the educated in India nowadays he could, even at the age of 12, discourse in perfect flawless English, Hindi, and his mother tongue, Bengali of course.  Not having much in common, I guess, at those ages we took to the roof of our grandfather’s Calcutta house to play cricket.  As in many hot countries the roofs of houses are often special places, in the city yet not in the city, your own private family space, away from the grime of street Calcutta.  Sometimes Calcuttans sleep on the roof to benefit from cooling breezes in the hottest parts of the year.  But even there one cannot escape the sounds and the smells that make up the unique experience of Kolkata, the city of joy.  Kites are flown from roofs and if there are celebrations, after an Indian cricket victory perhaps, firecrackers and fireworks are let off.

Fast forward a few years, 15 perhaps, and I am at my cousin’s home on the outskirts of Calcutta.  In the intervening years my cousin has become a doctor.  My aunt and uncle are unfailingly kind and I have brought a bottle of scotch for my uncle. A shot is called a “peg".  My uncle worked with what he called “Britishers” in the oil industry and was clearly influenced by them.  After a Bengali lunch I wander around the house and find in a glass cabinet a letter in my father’s handwriting.  Reading it I realise my cousin had asked advice about his future career, and my father had responded with strategies and plans.  I don’t know if it was my father’s influence but my cousin seemingly always wanted to be a doctor and then a surgeon.  Through hard work, and I hope some good advice from my father, my cousin achieved both his ambitions.

He passed surgeons’ exams in both India and the UK, worked as a surgeon but later switched to oncology.  Not long after my cousin came to the UK my father sadly passed away.  He had had a lung disease and was confined to bed in our house for a few weeks.  In that time my father received excellent palliative care  from the social services and care visits a couple of times a day.  His end was peaceful surrounded by members of his family.

I only mention my father’s passing as my cousin, Dr Sankha Mitra, is endeaveouring to bring high quality palliative care to West Bengal in particular and trying to change the mindset in India regarding this important facet of medicine.

Palliative care is best defined as treatment and strategies to reduce pain and other symptoms, and offer psychological, social, and emotional support holistically generally when a patient has a chronic life limiting illness or  is dying.  A couple of years ago Dr Mitra set up a charity - Eastern India Palliative Care in UK  Charity No. 1151116 (EIPC) to help fund the projects in India.

Along with the focus on EIPC the evening at the Nehru Centre included a performance by the Goan soprano, Viola da Cunha, accompanied by Yukiko Osedo, and a short performance of Tagore songs by Dr Mitra's wife, Susmita. My cousin, Sankha, was first generously introduced by Professor David Oliviere who among other things lectured on palliative care.  Sankha talked about what he and his project team  are trying to achieve in India.  I have amalgamated his presentation with my discussions with him later.

Sankha began his charity primarily because of the inequity of high  quality palliative care available to his cancer patients in Sussex and the almost negligible provision in West Bengal.  The poor in West Bengal often cannot get to a government hospital, and sadly die in great numbers in great pain through neglect.  The middle classes, although moneyed, do not really understand the concept of palliative care and therefore die in pain in ignorance.  The upper classes, as is their wont in India, throw money at the problem; patients are often kept alive on ventilators usually in great pain.  Often it is a status symbol to suggest a relative had been kept alive on a ventilator for several weeks. Private hospitals in towns and cities have no interest in offering true palliative care as they are paid at an expensive daily rate  for the use of expensive facilities like ITU and ICU.

It could, Sankha believes, be so different.  West Bengal had up to now no real palliative care facilities.  With support from UKDFID and partnerships in India and with funding from his charity EIPC , Sankha is bringing - still in a limited way - palliative care.  There are a number of major obstacles: while morphine is cheap it is almost unavailable because of the draconian opioid drug rules from 1985 and few pharmacies stock morphine.  Government hospital doctors are not trained in palliative care, nor are nurses and social workers.  And  the regional government and Health Ministry have not been as helpful as anticipated.

So, to try and inculcate and develop a palliative care mindset Sankha has set up a training centre to train doctors, nurses and social workers.  What he has found is that there are almost no local volunteers to be found in a region where poverty is endemic (in the UK for example one would find volunteers relatively easily).  With funds from a number of sources a training centre has been set up in a not for profit Cancer Centre in Thakurpukur near Calcutta. The Training Centre has facilities for nurses and social workers to stay, lecture halls and computer facilities. Volunteers have come from the UK and all over India to assist in the training.  But one issue has been that local doctors are not keen  to be dedicated to palliative care;  often doctors would prefer to spend time in their own lucrative private clinics and practices.  Eventually Sankha intends to have 14 training centres attached to government hospitals, 18 local palliative care clinics in each district of  West Bengal and train up 1000 doctors, nurse and social workers.

These EIPC clinics are often very basic by Western standards but providing minimum standards are met they are a huge improvement on any existing facilities and care.

Interestingly Sankha gave his presentation at the Nehru Centre almost at the same time as the House of Lords was debating assisted dying in the UK which is a related topic within the scope of palliative care.  It is widely felt that the law is perhaps lagging behind public sentiment and that assisted dying, within strict parameters, should be made legal.

But back to West Bengal.  There are still many obstacles to ensuring palliative care is widely available.  The charity needs to be able to scale effectively and ensure sustainable funding for sustaining the centres.  The project will be a mix of government funding, charitable funding, NGOs and with help from (Western) volunteers.  The private sector, including the Narayana Health  Foundation, has shown an interest in developing its own palliative care model, but a business model not a charitable one.  Sankha also wants to try and set up a social enterprise model, one that is profitable, so that profits can be used to set up and run further clinics.  There has also been a strategy of informing and educating, in schools, so that the next generation can raise  awareness  of the availability and benefits of palliative care.

Perhaps I am biased because Sankha is my cousin and the project is active in my parents’ home state of West Bengal, but it is heartening to know that his enthusiasm and drive has already resulted in many receiving high quality palliative care when none existed.  Yes, there are many obstacles to be overcome but making a start is often the hardest part: making alliances, partnerships, and getting the message out – the evening at the Nehru Centre was a part of this process.

Palliative care is a relatively basic and relatively cheap  healthcare provision but one clearly that the Indian state is currently unable to deliver.  So it is up to charities and perhaps businesses to step up; it requires simple facilities and by most healthcare standards basic nursing and medical care.  Social enterprises are one facet of the overall equation but perhaps also some kind of insurance model may need to be fully explored.  Sankha would also like his project to be the model for palliative care clinics all over India.  This might be the greatest legacy for such projects, in shaming governments at all levels in creating high quality medical services provision in a country that is growing strongly, and sadly exports many of its doctors and nurses who cannot find worthy jobs and careers at home.

http://www.eipc.org.uk

To donate to EIPC: 

https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=Z3WDL4BEMNMFJ 

Girl Summit 2014 - London

I had my first serious relationship at the age of 17. If anyone had suggested that we get married at that point, my reaction would have been one of complete horror and bewilderment.  Why on earth would I want to do that?  I had plans – to go to university, to travel, to pursue a career, to meet interesting people, to get out of the suburban mundanity I had been brought up in.  Marriage was nowhere on my agenda.  As with many teenage relationships, it didn't last and we split up after 18 months.  By the time I eventually had my son at the age of 35, I had lived a bit, pursued some of my ideals and dreams and was ready to take on the responsibilities of parenthood.  I could also be a better mother because of my education and life experience.

I realise now that I was lucky.  I took my freedom for granted - never questioning my ability or right to be able to choose my own partners or do what I wanted – resources permitting. All over the world, millions of children have no choice over whom or when they marry.

Child marriage is defined by Unicef as marriage before the age of 18 and considers this practice a violation of human rights.  India tops the league table of rates of child marriage. Mahatma Gandhi himself was married at the age of 13 to Kasturbai, aged only 14.

My own son is nearly 13.  He is still growing, changing and finding out about himself and the world.  Like many teens and pre-teens he spends his time at school or playing numerous video games or browsing You Tube.  The idea that he should be married at his age, or thereabouts, just seems unbelievable and very premature.

Today, Girl Summit 2014 was co-hosted in London by UNICEF and the UK Government.  Their stated aim is to end female genital mutilation, child, early and forced marriage within a generation. In 2010 13.5 million children were married before they were 18.  In the developing world 1 in 7 girls are married before they were 15, with some as young as 8 or 9.  This can have devastating consequences.  For example, in the Yemen, last September, an 8 year old girl was reported to having been married to a 40 year old groom.  During intercourse on the wedding night, the 8 year old’s uterus ruptured and she later died as a consequence.

According to Unicef figures, around 43% of women in India aged 20-24 are married before the age of 18[1].  This may be to partners they don’t know, or haven’t consented to marry.  For the boys / men it can be a burden to have to then provide for their wife and consequent children at such a young age.  For the girl / woman, however, the impact can be life altering and life constraining.  Forced into premature sexual intercourse with their husband, this can amount to rape.  Commonly the girl then stops any education and her life is taken up with childcare and domestic responsibilities, with little opportunity for herself outside the home.  Early childbirth can also be damaging for immature bodies not capable of bearing a child leading to complications and / or low birth weight babies.  The women too are also at risk from domestic violence, compounded by their vulnerable status as child brides.

This is a problem for the women in India, but also a problem for girls and women in the UK.  Every year thousands of girls in the UK face being taken out of school on ‘family holidays’ to Pakistan, India and other place, only to find out they are to be married.  This morning I was listening on the radio to the story of a woman from the UK who was married off at the age of 13 in Pakistan – against her knowledge, consent or will – only to give birth to a son at the age of 14 on returning to the UK.  At the time, no-one questioned it or raised it as an issue.  She managed to escape and, now in her 40s, campaigns against child and forced marriage – with the price of being disowned by her family.

Last year the UK government’s forced marriage unit dealt with 1032 cases.  Of these 82% of victims were female and 18% male while 15% were under the age of 15.  The cases involved 74 different countries with 43% relating to Pakistan, 11% to India and 10% to Bangladesh[2]. To a Western audience, it is inconceivable that a girl or woman should have no choice but to marry someone not of their own choosing or without their consent.  This is not a question of cultural relativity: it is a question of human rights.  It’s a gross violation of children’s rights to make them marry someone – with a sexual relationship to follow and childbirth – that usually means an end to the girl’s education and a lifetime of rape or non-consensual sex, childrearing and domestic duties.

Worldwide more than 700 million women were married as children, with 1 in 3 of them married before their 15^th birthday.  About a third of child brides live in India. Female genital mutilation (FGM) has been illegal in the UK since 1985, and since 2003 anyone taking someone out of the UK for FGM has been punishable by up to 14 years in prison[3]. Enforcement of these provisions, though, is woefully lacking to date.  A new law also came into effect in the UK on 16 June 2014 making it a criminal offence, punishable by up to 7 years in prison for parents who force their children into marriage – though it remains to be seen how rigorously this new power will be used or enforced.

In India, the Prohibition of Child Marriage Act states that girls can’t get married before the age of 18 and boys before the age of 21 – although this is widely ignored.  Many campaigners were disappointed last October at India’s refusal to sign the first-ever global resolution on early and forced marriage of children led by the UN Human Rights Council.

I am inclined to be cynical about David Cameron’s stated commitment to Girl Summit Day – given his blind spot to women colleagues in the recent past.  But let’s hope FGM and forced /early marriage will become as unacceptable as torture or imprisonment without a trial (or unfair trial) for this is what it is.

For development to be effective in India, women must be prioritised.  Women are the ones who look after, educate and care for the medical needs of our children in their early years.    By allowing women to pursue an education, freedom in whom they marry and rights within the marriage, it is a service to themselves, their children, community, husbands and humankind.  

http://tooyoungtowed.org/

https://www.gov.uk/government/topical-events/girl-summit-2014

http://www.girlsummitpledge.com/ 

http://www.karmanirvana.org.uk/

[1] http://www.unicef.org/india/Child_Marriage_Fact_Sheet_Nov2011_final.pdf.  Accessed 22/07/2014

[2] http://www.bbc.co.uk/news/uk-27830815

[3] Ibid.

Sukanya – Highlights of Ravi Shankar’s Opera at the Royal Opera House

Late last year I had attended a presentation by David Murphy, the composer, and Amit Chaudhuri, the author who is a librettist, at the Nehru Centre in London on Sukanya, the opera that Murphy and Ravi Shankar collaborated on till Shankar’s death. You can read my review of the presentation here: http://www.indiainlondon.com/inventor-of-genius-ravi-shankars-opera-sukanya-previewed-at-the-london-nehru-centre/

I had ended my initial review by suggesting that I was looking forward to the actual production but I had not anticipated being invited to a select gathering. Following my review Murphy had graciously invited us to a highlights programme at the Royal Opera House (ROH) this week. The audience was perhaps more opera focussed than Indophile. But there were a number of leading Indian-English families there too. We were also joined by Shankar’s wife, Sukanya, who was in part the inspiration for the opera, and his daughter, Anouskha, who is a sitarist and a collaborator on the project.

Murphy began by taking us through the background to the project and how he had first met Ravi Shankar. Most of this is relayed in my earlier blog. Just to recap Sukanya is based on an excerpt from the Mahabharata and had been a potential project for Shankar for many years. He had wanted to combine Western and Eastern music, opera, dance and animation. Indeed Shankar had told Murphy that he were not a musician he would have wanted to be a film maker. Shankar had worked with Satyajit Ray on a number of projects. Tellingly Shankar did not distinguish between Western and Eastern music nor even a joint project as fusion, but just music.

The programme included four scenes from Act 1 of the opera Sukanya, which I understood has been the only Act completed to date. It also appears that Chaudhuri’s libretto is still in the draft phase. The Linbury Theatre in the ROH has a small stage and at first I thought the sheer range of performers would overwhelm the production but I worried unnecessarily. The Indian musicians, with the shehnai, whose sounds I love, sitar, mridangam and table, took centre stage, with younger musicians from the London Philarmonic Orchestra on either side, the soprano and tenor towards the front, and a dance floor.

I found the entire production utterly spellbinding, and some of the comments I heard beside me included “fantastic” and “brilliant”. Each of the Western and Eastern traditions took priority at times but when they combined there was a driving beat, and it did not seem incongruous, but in fact blended superbly. Equally the combination of a soprano and tenor together with Eastern music worked amazingly well. When the classical Indian dancers came on it was almost sensory overload, one almost did not know where to look. There was also the animations, created by 59 Productions, which were projected onto a screen behind, and some of the transparent walls between the performers. But the overall effect was of a production that was seamless and near flawless both in execution and quality. I am not an opera buff but I could recognise the high quality of the soprano (Susanna Hurrell) and tenor (Amar Muchhala). At times Muchhala sounded like a Qawwali singer which greatly added to the atmosphere.

It seems that the completed production will be performed at some point in 2015. I am anticipating seeing this work, with its unique combination of music, opera, dance and animation. My only caveat would be that perhaps this intimacy could be never be replicated on the larger stage; nevertheless worth waiting for.

http://ravishankaroperaproject.org/

www.davidmurphyconducts.org

www.amitchaudhuri.com

www.anouskhashankar.com

Modi's victory: Thatcherism Indian style?

[caption id="attachment_1305" align="alignleft" width="300"] flickr.com / creative commons[/caption]

This week, in one of the most significant elections for a generation, the Hindu Nationalist leader of the Bharatiya Janata Party (BJP), Narendra Modi was elected Prime Minister of India.  The scale of his victory and number of seats gained in the Indian Parliament – well over the 272 needed for a majority – has decisively ended the Indian National Congress domination of Indian politics, at least for the moment.  The Congress campaign run by Rahul Gandhi, aided by his sister Priyanka looked half hearted and lack lustre, compared to Modi’s campaign.  It also probably cost less than Modi’s estimated campaign costs of £500m including holographic projections of him as well as today’s obligatory social media platforms of Twitter, Facebook and You Tube.  Modi’s victory tweet – ‘India has won!’ became the most retweeted tweet in India (though still falling some way behind Obama’s victory tweet for his second term in office).

Supported by many younger voters, the Modi brand has the promise and allure of a liberalised consumerist capitalist economy.  Modi has been credited with the economic transformation of Gujarat – whether deserved or not – and his campaign has led on this message and promise of such an economic transformation across India.  The appeal of this promise is easy to see.  India’s economy stagnated under the socialist-welfarist policies of the Indian National Congress and despite the liberalisation reforms in the 1990s under the government of PV Narasimha Rao and his finance minister at the time (later Prime Minister) Manmohan Singh leading to rapid economic growth in the early 2000s, India’s economic growth has once again faltered in the last few years.

From a UK perspective the success of Modi, the outsider, has a certain resonance.  In the UK, from the end of WW2 up until 1979 Britain had 8 Prime Ministers.  All were white and male.  5 out of 8 came from upper class / aristocratic families and attended public schools (the exceptions were Harold Wilson and Edward Heath were grammar school boys while James Callaghan a secondary school).   3 out of 8 went to Eton.  6 out of 8 studied humanities / social science at Oxford University – either PPE [politics, philosophy and economics], modern history, classics or languages  (the exceptions were Winston Churchill, who did not excel at his public school and joined the army and James Callaghan who passed the Oxford entrance exam but could not afford the fees so joined the civil service instead).

Then Margaret Thatcher was elected prime minister in 1979.  Female and the daughter of a Lincolnshire grocer she was grammar school educated and went to Oxford, but studied chemistry instead of the almost obligatory PPE  / modern history – although subsequently went on to train as a barrister.  Thatcher was in gender and class terms an outsider, who nevertheless managed to break up the establishment dominance and become elected on a populist mandate based on a radical right wing, neo-liberal, nationalist, free market ideology.

The parallels with Modi are clear.  Since independence, Indian politics has been dominated by the Nehru / Gandhi family.  Similar to the Bhuttos in Pakistan, the leadership of the Congress party has been handed down between the generations, effectively stifling any true political meritocracy or fresh leadership.  As with the British political establishment, the Gandhi / Nehru family have attended elite UK universities: Jawaharlal Nehru (Cambridge), Indira Gandhi  (Oxford), Rajiv Gandhi (Cambridge) and Rahul Gandhi (Cambridge) – leading to a suspicion of neo-colonialist rulers and continued domination of a UK educated elite.  Nehru himself is famously reported to have said to JK Galbraith at the time that he would be the ‘last English ruler of India’.  Despite India’s ideal of democracy, since independence its political, industrial, social and cultural elite have been overwhelmingly from the English speaking Hindu upper-castes, with little commitment to social and economic justice.

Modi, by contrast, also comes from a family of grocers – in this case the Ghanchi-Teli oil presser caste, categorised as an ‘Other Backward Caste’ by the Indian government.  As a boy, Modi helped his father run a tea stall at a railway station, later joining the Hindu nationalist Rashtriya Swayamsevak Sangh (RSS) and completing degrees in politics from Delhi and Gujarat Universities.   He, too, has campaigned on a right-wing, pro-market agenda with the promise of economic transformation in India.  He even claims the same physical energy as Thatcher, reportedly rising at 5am, finishing at 11pm and never taking a day off.  His vegetarianism and teetotalism, though, is in contrast to Thatcher’s known liking for a glass of whiskey.

It is not difficult to see Modi’s appeal, particularly to a frustrated younger generation in India – fed up of stagnant class and caste ridden politics in India.  But let’s not forget our own experience of going down this road.  Thatcherism brought privatisation, economic liberalisation and rising prosperity (for some) to an 80s Britain.  It also brought huge inequality, a protracted miner’s strike, unemployment as traditional industry was shut down and for many areas, destructive of local communities.  Money and wealth became the sought after goods, denigrating anything else that could not be commodified:  care, compassion, social justice and protecting the vulnerable.   Privatisation and ‘light touch’ banking and City regulation has been a central cause of our current economic crisis.  Sometimes the free market really does not know best, as those doing the dealing do not fully understand (or perhaps care about) the goods they are dealing (debt) and the impact this has on the poorest and weakest.

The 2002 riots in Gujarat, however, remain an issue for many, with Modi being accused of taking insufficient action in the Hindu-Muslim riots in which an estimated 2000 Muslims died, with many more being injured.  In 2005 he was denied a US visa because of his behaviour during the 2002 anti-Muslim riots.  Discrimination against Muslims remains rife throughout India – particularly in jobs and housing and Modi’s lifelong membership of the Hindu nationalist RSS (itself inspired by the fascist movements of Europe) brings a potentially divisive religious dynamic into Indian government in direct contrast to the avowedly secular Congress.  If Thatcher’s ‘enemy within’ were the trade unions and her ‘enemy without’ the Argentinians during the Falklands war, many fear that Modi’s ‘enemy within’ will be the Muslims and his corresponding ‘enemy without’ Pakistan.

Modi’s alleged economic success in Gujarat has also come into question.  Since 2002, he has steered his rhetoric away from Hindu nationalism and towards a more inclusive agenda based on economic growth.  Before Modi came into power in Gujarat the growth rate was 4.8% compared to a national average of 3.7%[i].  In the 2000s it was 6.9% compared to a national average of 5.6%.  Not a huge difference.  Social development indicators in Gujarat also remain poor, with 44.6% of children below 5 suffering malnutrition and 70% anaemia, making Gujarat below even Uttar Pradash and Bihar on rates of malnutrition[ii]

From a macro, strategic point of view, however, Modi’s success – like Thatcher’s – might also be seen in terms of the demands of global capitalism.  While India remains a country with shocking levels of inequality, corruption, a woeful lack of basic infrastructure such as education, sanitation and public health, it remains a country difficult in which to do business.  Global capitalism demands a state willing to invest in the necessary infrastructure (including health care and education), the rule of law to enforce contracts, an efficient civil administration – together with free trade agreements - to provide the workforce and environment necessary for effective capital investment.  India cannot prosper on the world stage until its lack of infrastructure is addressed.  Until then, it will be more attractive for its English speaking educated middle classes to seek employment abroad – perhaps India’s most successful export to the Middle East, UK and US - and one which primarily benefits the host country, not India.

Whether Modi can create an inclusive agenda and conditions for India to truly prosper remains to be seen.

 

[i] http://www.theguardian.com/commentisfree/2014/mar/13/modinomics-narendra-modi-india-bjp. Accessed 17/05/2014

[ii] India Human Development Report 2011

TV Review: The Birth of Empire – The East India Company

The BBC has at times a fascination with India and almost every few months it seems a BBC television crew is in Calcutta. Notably Rick Stein has been there, and Ian Hislop began a Great Railway Journey at the Calcutta Club. One of my favourite programmes on India was Alexander Frater’s Monsoon where he ended up in Cherrapunji, reputedly the wettest place on earth. For me it invoked memories of Assam where I spent a monsoon as a child. I much enjoyed Brian Cox’s Jute Journey where he focussed on the Dundee Scots who made their working lives in Bengal managing jute factories. Recently Anita Rani drove around in India on Four Wheels. There have been some TV misses as well: Paul Merton in India and Caroline Quentin: A Passage Through India come to mind although these weren’t BBC productions. Nevertheless I did look forward to The Birth of Empire.

Sitting down to watch this two-partner presented by Dan Snow I waited for my first cliché and sure enough it came: “The Jewel in the Crown”.  It is always remarkable that a small European country of 4 million people managed to colonise an entire sub-continent then of 190 million and producing perhaps one quarter of the world’s output.

The facts of the East India Company are well-known: a joint stock company given a monopoly by the English Crown to pursue trade in India at the start of the seventeenth century. Company employees find cloth, spices, tea, diamonds, pearls and pepper on the Coromandel Coast near modern day Chennai (Madras) after setting up a trading post in 1639. Ships journey to and from India, trade increases, the company makes vast profits, and consolidates its positions. More trading posts are created, there were 22 in the eighteenth century, with new warehouses and citadels, and the foundations of Bombay and Calcutta created. The East India Company and not the British government is the sovereign power, forging agreements with the local princes, overseeing justice, raising taxes, and maintaining probably what was then the largest standing army in the world.

Fabrics in particular are the major commodity comprising 60% of the Company’s revenues. And the Company begins to practice the concept of listening to the English customer who prize hand printed chintzes, and their brilliant and fasted colours. The initial period saw the beginning of a hot drink culture, tea and coffee, and the influence of spices, which of course leads to the situation today when chicken tikka Masala is almost an indigenous UK invention. Calcutta becomes the centre of British India and remains so till 1911 when the Bengalis are agitating for independence.

The programmes have a strong focus on the East India Company employees who arrive in India, with jobs oiled by nepotism and corruption – plus ca change in India today. The employees were allowed to engage in private trading which made many of them enormously rich by contemporary standards.

But while great wealth was a possibility the risks were high. Huge numbers died because of the heat and diseases like dysentery and malaria. In one year one-third of the Europeans in Calcutta during monsoon perished.  Snow spends some time at the Park Street Cemetery in Calcutta. The Company sent out wine which was supplemented by local brews of toddy and arak. It was discovered that quinine which was soon used to make tonic for gin and tonic mitigated the chances of catching malaria. Soon hard-drinking together with gambling and brawling became the norms of behaviour.

What exasperated the authorities in London was the numbers of employees who had “gone native” and taken up with local women often setting up households with multiple women. There were also relationships with the daughters of Portuguese traders and missionaries. But efforts to limit these relationships by sending out British women ended in failure.

The East India Company was very skilled in playing off one group of Indians against each other, and would only engage in battle if absolutely necessary. At the Battle of Plassey, which sealed the preminence of the Company, Clive was outnumbered 10 to 1, but won the battle thanks to local traitors. There were relatively few British soldiers supplemented by local volunteers who were trained in British methods.

Despite some employees having gone “native” the Company was at times surprisingly callous about the demands of the various religions. The Mutiny of 1857, known as the First War of Independence in India, was sparked by rumours that pig fat and cow fat, respectively anathema to Muslim and Hindu soldiers, were used as grease in gun cartridges.  The rumours, whether true or not, managed to unite Muslims and Hindus against the British. With brutality and horrors committed by both sides, the revolt was eventually put down.

The Mutiny of 1857 sparked widescale changes with overall control of India passing to the Crown. Reforms prompted by Macaulay sought to Anglicise the native population and he defeated proposals to maintain an Asiatic approach. The object was to create “Indians in colour and blood, but English in taste, opinion, morals and intellect.” To exemplify this Snow visits La Martiniere School in Calcutta and talked to students who suggest that they only speak English most of the time. Macaulay also proposed the creation of a professional well educated Indian Civil Service, initially of Britons only, to run the administration, and a UK based legal system.

What Snow fails to mention is that while 1857 saw the beginning of the Anglicisation process it was probably also the start of more entrenched British attitudes, with more white women coming out to India thus limiting inter-racial relationships, and the development of a British cultural, moral and racial superiority mindset. Many of the earlier settlers recognised a unique and compelling culture within India, and that appeared to have been forgotten later.

The East India Company was seen as the exemplar of the modern multi-national corporation maintaining control from long-distance, with shares issued in London, an accounting system, and rules of corporate governance. Comparisons with modern day companies might have been instructive.

Dan Snow was an engaging presenter who looked to have done his background research, but I do have the feeling he is more of a military historian which is where he made his name. At times the programme moved back and forth to the UK, with contributions from academic talking heads and visits to sites in London such as warehouses and the Lloyds Building.

The two hours went quickly but I felt there were issues and themes that could have been explored further. First the question of why the UK was in a position to dominate a large alien country, particularly in an era when other European countries were looking to develop their own colonies. Some comparisons with other European countries such as France and the Netherlands, which had their own East India Companies, might have been apposite. Could India in other circumstances have been divided into British, and larger Francophone, Dutch and Lussophone zones as Africa was? There were French and Portuguese enclaves but they were relatively small and ultimately never a serious threat to British hegemony in India.

Were the British more benign than say the French, or the Spanish as colonialists? I might contend that apart from the Mutiny and isolated incidents such as the Amritsar Massacre there was little overt brutality.

The lives of Indians in this period and their interactions with the East India Company were almost completely ignored. In addition the long term effects on India after 1857 were glossed over. Was India a better place following the rule of the Company and the British Raj?  There is the implication that India has benefitted enormously from exposure to the English language both as a unifying force and as a driver to enable global trade. If English were not an option then perhaps Hindi might be more widely spoken. Amongst the elite knowledge of near perfect idiomatic English is almost a given. Anecdotally if one approaches a hotel reception and speaks in a language other than English the reply will invariably be in English. And, for example, interviews during the Indian Premier cricket League are almost always in English. But whether fluency in English has been an enabler to world trade and soft power is difficult to assess. Japan, South Korea and China have, for example, not found trading difficult despite poor language skills although that is changing. One very rarely finds Indian diplomats making statements about world affairs. Fluency in English amongst the elite may hinder the domestic economy as many, including my father, and for example many Indian students and businessmen in the US, find it easy to leave India and take up new roles. But despite the position of the English language India has still not achieved any real impact in world trade except in some industries like software.

While The Birth of Empire was a compelling narrative it would have benefitted from greater exposition and analysis. Most of the background on the Company could have been compressed into an hour giving sufficient time to explore other issues.