India’s Epidemic History: From Asiatic Cholera to Modern Outbreaks

India’s relationship with epidemic diseases stretches back centuries, but the story that shaped global public health begins in 1817 – the year cholera left the riverbanks of Bengal and went on to become the world’s first truly global pandemic. From that point forward, India found itself at the centre of one health crisis after another: plague, influenza, smallpox, and more recently, swine flu, Nipah, and COVID-19. Understanding this history isn’t just an academic exercise – it reveals how public health policy, sanitation infrastructure, and disease surveillance systems evolved under pressure.

The origins of Asiatic cholera 🔗

Cholera-like symptoms have been described in Indian texts for over 2,500 years, and Greek physician Hippocrates wrote about a similar illness around 2,400 years ago. But the disease we now specifically associate with the bacterium Vibrio cholerae did not become a global concern until the early 19th century.

The first cholera pandemic (1817-1824) originated in the Bengal region of India, near Calcutta (now Kolkata). Cholera was endemic to the lower Ganges River, where pilgrims frequently contracted the disease during festivals and carried it back to other parts of the country. In 1817, a particularly severe outbreak struck the town of Jessore – located between Calcutta and Dhaka – and then spread rapidly across India. By 1818, it had reached Bombay on the west coast, and by the early 1820s, cholera had spread via trade and military routes to Southeast Asia, the Middle East, Eastern Africa, and the Mediterranean coast.

This was unprecedented. Earlier cholera outbreaks had been confined to limited regions. The first pandemic killed thousands of British soldiers and hundreds of thousands of Indians, drawing European attention to the disease for the first time. Colonial Kolkata, situated in the Ganges delta, would later be described as the “homeland of cholera” – a label that persisted for nearly two centuries.

How cholera became a global killer: seven pandemics in 200 years 🔗

The first pandemic set a pattern that would repeat itself six more times. Each new wave of cholera followed expanding trade routes, military campaigns, and mass pilgrimages – carrying the disease from India to the rest of the world.

The second and third pandemics (1826-1860) 🔗

The second pandemic (1826-1837) was the first to reach Europe and the Americas, aided by advances in transportation and increased global migration. During this period, different theories about cholera’s transmission clashed across nations. In the West, the dominant “miasma” theory blamed bad air and unsanitary conditions. Russians believed the disease was contagious through person-to-person contact, Americans blamed Irish immigrants for bringing it, and French doctors attributed it to poverty and unfavourable climate.

The third pandemic (1846-1860) was widely considered the deadliest of all. It extended to North Africa and South America for the first time. Russia was severely affected – roughly 23,000 people died in Great Britain alone in 1854, and Russia experienced devastating mortality across multiple provinces. An estimated 15 million Indians died during just the first three pandemics between 1817 and 1860.

The fourth and fifth pandemics (1863-1896) 🔗

The fourth pandemic (1863-1875) originated once again in the Bengali Ganges Delta. It spread through Mecca with Muslim pilgrims travelling for the Hajj – a recurring pattern that would link cholera to the pilgrimage for decades. Mecca was later described as a “relay station” for cholera as it moved from East to West; 27 cholera outbreaks were recorded during pilgrimages between the 19th century and 1930.

The fifth pandemic (1881-1896) started in India and spread to Europe, Asia, and South America. This period saw significant fatalities: more than 5,000 people died in Naples in 1884, 60,000 in Spain’s Valencia and Murcia provinces in 1885, and an estimated 200,000 in Russia between 1893 and 1894. However, by this time, a major scientific breakthrough had occurred – Robert Koch identified the cholera-causing bacterium in 1883, and the first cholera vaccines were being developed.

The sixth and seventh pandemics (1899-present) 🔗

The sixth pandemic (1899-1923) was especially lethal in India, Arabia, and North Africa. Over 500,000 people died from cholera in Russia during this period. The pandemic’s impact on Western Europe was limited, however, thanks to improved water supply and sewage treatment systems that cities had invested in since the mid-1800s. The sixth pandemic killed more than 800,000 people in India alone.

The seventh pandemic, which began in Indonesia in 1961 with a new strain called El Tor, is still officially ongoing according to the World Health Organization. It reached India by 1964 and has since become endemic in many developing countries. In 2024, 60 countries reported cholera cases to WHO, with over 560,000 cases and 6,000 deaths – driven by poverty, conflict, climate change, and inadequate water and sanitation infrastructure.

Beyond cholera: bubonic plague and the crisis of 1896 🔗

While cholera dominated the 19th century, bubonic plague struck India with devastating force starting in 1896. The epidemic began in Bombay (Mumbai) and rapidly spread throughout the country. Between 1896 and 1914, plague killed over 8 million people in India – and this is considered a conservative estimate.

Unlike cholera, which by then was somewhat familiar, plague triggered unprecedented public panic. It prompted massive state intervention, including intrusive house-to-house inspections, forced hospitalisation, and segregation measures. These heavy-handed tactics provoked fierce resistance from Indian communities – riots, attacks on European officials, and mass flight from cities. Around 1,000 people fled Bombay daily at the epidemic’s height in early 1897, spreading the disease further across colonial India.

The plague crisis was a turning point. It exposed the glaring inadequacies of colonial public health infrastructure and the tension between authoritarian disease control measures and community trust – a dynamic that echoes in public health debates to this day.

The Epidemic Diseases Act of 1897 🔗

It was directly in response to the plague that the British colonial government enacted the Epidemic Diseases Act of 1897. The Act was designed to provide the legal framework needed to contain the outbreak when ordinary laws proved insufficient.

The Act is remarkably brief – just four sections – but its provisions are broad. It empowers state governments to take special measures during an epidemic, prescribe temporary regulations for the public, and mandate inspection of travellers. The central government was given authority to inspect ships and vessels arriving at or departing from Indian ports and to detain passengers if necessary. Violations of regulations under the Act are punishable under Section 188 of the Indian Penal Code.

Though created during the colonial era, the Act has been invoked repeatedly in independent India – to control smallpox outbreaks in the 1950s and 1960s, the Surat plague of 1994, the swine flu outbreak in 2009, and most recently and notably, during the COVID-19 pandemic in 2020, when it was used alongside the Disaster Management Act to impose lockdowns and movement restrictions. In April 2020, the government amended the Act to include provisions protecting healthcare workers from violence, with penalties of up to seven years in jail for attacks on medical staff.

The Act’s longevity – over 125 years and counting – speaks both to its functional utility and to criticism that India has not yet developed a more comprehensive, modern public health law suited to 21st-century challenges.

The 1918 influenza pandemic: India’s deadliest epidemic 🔗

If cholera defined the 19th century for India, the influenza pandemic of 1918-19 – commonly known as the Spanish Flu – defined the early 20th century. In sheer mortality, it was the worst epidemic India has ever experienced.

The pandemic arrived in Bombay in June 1918, likely carried by soldiers returning from World War I in Europe. From Bombay, the disease spread through India’s roads and railways, reaching the entire country by August. The outbreak coincided with a severe drought in the central provinces, which caused famine and left large portions of the population dangerously vulnerable.

The pandemic hit in three waves, with the second wave (September-December 1918) being the most deadly. Conservative estimates place India’s death toll at 12-13 million people, while more recent studies suggest it may have been as high as 18.5 million. These figures represent roughly 5% of India’s population – the highest death toll of any country worldwide. The decade between 1911 and 1921 was the only census period in which India’s population actually declined.

The colonial government’s response was widely criticised. Doctors had been deployed overseas for the war effort, leaving Indian hospitals severely understaffed. Despite the epidemic, food grains continued to be exported to support the war, worsening the famine. It was NGOs and community organisations – not the state – that took the lead in providing care to the afflicted.

Other major epidemics in India’s history 🔗

Beyond cholera, plague, and influenza, several other diseases have shaped India’s public health landscape:

Smallpox was endemic in India for centuries, with the goddess Sitala worshipped as the deity of the disease in many parts of the country. India played a major role in the global eradication of smallpox, with the last naturally occurring case in India recorded in 1975, followed by global eradication declared by WHO in 1980.

Malaria was arguably an even bigger killer than plague during the colonial period. Between 1896 and 1921, malaria may have killed 20 million people – twice as many as plague in the same period.

The Surat plague of 1994 caused a nationwide panic when pneumonic plague cases were reported in Gujarat, leading to mass migration from the city and significant economic disruption.

Modern outbreaks have included the re-emergence of cholera with the O139 strain in 1992, chikungunya and dengue outbreaks, the H1N1 (swine flu) pandemic in 2009, Nipah virus outbreaks in Kerala (2018 and 2023), and of course, the COVID-19 pandemic beginning in 2020. India navigated COVID-19 with a combination of the colonial-era Epidemic Diseases Act, the Disaster Management Act, and a massive vaccination drive that eventually became the largest in the world.

Lessons from India’s epidemic history 🔗

Several recurring themes emerge from India’s long encounter with epidemic diseases:

Sanitation and water access remain foundational. From the first cholera pandemic to the seventh (still ongoing), the link between unsafe water, poor sanitation, and disease spread has been consistent. The WHO continues to emphasise that safe water, basic sanitation, and hygiene are the only long-term solutions to cholera.

Pilgrimages and mass gatherings are epidemiological amplifiers. Cholera’s spread along Hajj routes and through Hindu bathing festivals like the Kumbh Mela demonstrated early on how mass movement of people accelerates disease transmission – a lesson that remained relevant during COVID-19.

Colonial-era laws are still in use. The continued reliance on the 1897 Epidemic Diseases Act – despite widespread acknowledgement that it is outdated and insufficient – highlights the need for comprehensive, rights-based public health legislation in India.

Poverty and inequality determine mortality. Every major epidemic in India’s history has disproportionately killed the poor – from the famished villagers of 1918 to the migrant workers stranded during the 2020 lockdowns. Structural factors like malnutrition, crowded living conditions, and lack of healthcare access have consistently amplified the toll of infectious disease.

Science matters. From Waldemar Haffkine’s pioneering cholera and plague vaccines developed in colonial Calcutta to Hemendra Nath Chatterjee’s formulation of oral rehydration salt therapy in the 1950s, Indian scientists and institutions have made contributions that saved millions worldwide.

Where India stands today 🔗

India’s epidemic history offers a sobering but also hopeful narrative. The country has eradicated smallpox, nearly eliminated polio, and managed multiple modern outbreaks with increasing sophistication. Yet cholera remains endemic, with India still reporting hundreds of cases annually, and new threats – from antimicrobial resistance to climate change-driven disease patterns – continue to emerge.

The history of epidemics in India is not a closed chapter. It is an ongoing story whose next developments will be shaped by investments in public health infrastructure, equitable access to healthcare, updated legal frameworks, and the political will to prioritise prevention over reactive crisis management.

What do you think? Given that India still relies on a colonial-era law from 1897 to manage epidemic responses, is it time for a comprehensive, modern public health act? And what lessons from India’s cholera and plague history should inform how we prepare for the next pandemic?

References

1. https://www.britannica.com/science/cholera/Cholera-through-history
2. https://en.wikipedia.org/wiki/1817%E2%80%931824_cholera_pandemic
3. https://en.wikipedia.org/wiki/Cholera
4. https://en.wikipedia.org/wiki/History_of_cholera
5. https://www.who.int/news-room/fact-sheets/detail/cholera
6. https://www.cambridge.org/core/books/abs/epidemics-and-ideas/plague-panic-and-epidemic-politics-in-india-18961914/0C7AD36256D3711FF139E179A43E5E92
7. https://www.theindiaforum.in/article/manufacturing-epidemics
8. https://ruralindiaonline.org/en/library/resource/the-epidemic-diseases-act-1897/
9. https://www.gktoday.in/epidemic-disease-act-1897/
10. http://ijme.in/articles/the-epidemic-diseases-act-of-1897-public-health-relevance-in-the-current-scenario/?galley=html
11. https://en.wikipedia.org/wiki/1918_flu_pandemic_in_India
12. https://www.gatewayhouse.in/1918-flu-india/
13. https://pmc.ncbi.nlm.nih.gov/articles/PMC3160492/
14. https://www.ecdc.europa.eu/en/all-topics-z/cholera/surveillance-and-disease-data/cholera-monthly