Amsterdam University Press

Chapter Title: Sikkim: Imperial Stepping-stone to Tibet

Book Title: Their Footprints Remain

Book Subtitle: Biomedical Beginnings Across the Indo-Tibetan Frontier
Book Author(s): Alex McKay
Published by: Amsterdam University Press

Stable URL: https://www.jstor.org/stable/j.ctt46n0qk.9

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 2 Sikkim: Imperial Stepping-stone to Tibet

The introduction of biomedicine to Sikkim provides a number of con-

trasts to the rather ad hoc processes that occurred in the Kalimpong-
Darjeeling and western Himalayan areas. The Buddhist state’s reluc-
tance to admit European missionaries into its realm restricted their in-
fluence on medical development in Sikkim. Missionary medicine was
still a significant force in the first two decades of British rule, and Ka-
limpong-trained local staff played a major role in spreading biomedi-
cine from the dispensaries there. But the missionaries were not able to
dominate medical initiatives in this Himalayan state as they had in Ka-
limpong. Instead it was the Indian Political Department’s appointees,
the Sikkim Political Officers and their medical staff, who played the
key role.
Sikkim was, however, primarily of importance to British India as the
gateway to Tibet, and little finance – or effort – was devoted to develop-
ing it. Under the Princely state system, Sikkimese medical develop-
ments were largely funded from state revenue and the medical officers
posted there were not of the highest status. But Sikkim did in many
ways provide a model which the British hoped the Tibetans would
emulate, not least in the medical sphere. It was a secure and stable
state, where steadily growing numbers of Sikkimese resorted to biome-
dicine. There was no apparent resistance to the new system, and its
structures and personnel were so rapidly indigenised that within two
decades of the introduction of biomedicine, Sikkimese medical staff
were being employed in British dispensaries in Tibet.
Sikkim, which became the 22nd state of India on 26 April 1975, is si-
tuated on the northern border of the Darjeeling district of Bengal. It se-
parates the kingdoms of Nepal to the west from Bhutan to the east,
while to its north and north-east is what is now the Tibetan Autono-
mous Region of China. Lying on the main trade route from Calcutta to
Lhasa via the Chumbi Valley, Sikkim today occupies an area of 7,096
square kilometres, ranging in elevation from 300 to 8540 metres. Its
highest point is the summit of Kangchenjunga, the third highest
mountain in the world, and with much of the territory consisting of
steep, jungle-covered inclines or snow-covered mountains, only 20% of
its total area is considered habitable.1

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86 THEIR FOOTPRINTS REMAIN

The earliest known inhabitants of Sikkim were the Lepcha and Lim-
bu tribes, but from at least the 13th century onwards Tibetans began to
migrate southwards into Sikkim. Often referred to as ‘Bhutias’ but
more correctly known as the Lhopo,2 they came to form the bulk of the
elite class. In the 17th century, refugee monks of the Nyingma sect of
Tibetan Buddhism founded a kingdom there, enthroning Phuntsog
Namgyal as Chogyal (‘Maharaja’ or ‘King’) in 1642. This dynasty ruled
Sikkim until 1975,3 but their power gradually declined as a result of
Nepali immigration, which began in 18714 and accelerated under Brit-
ish influence. People of Nepali origin now form a majority of the 1997
population of 406,457,5 but in 1891 Sikkim was home to just 30,458
people.6 Among that number was John Claude White, the British re-
presentative in Gangtok who was appointed to the newly created post
of Political Officer Sikkim in May 1889.7
British relations with Sikkim began as a consequence of the East In-
dia Company’s rivalries with the growing power of the Nepalese state
and they developed as a consequence of the British interest in opening
Tibet. In 1815, British forces entered Sikkim, much of which had been
conquered by the Gurkhas in 1788-89, and gained Sikkimese support
against Nepal in return for the restoration of their rulers and much of
their lost land. By the time of the Treaty of Titalia in 1817, imperial in-
fluence over Sikkim’s foreign relations was formally acknowledged in
return for British protection against Nepal. After 1835, when the reluc-
tant Chogyal was persuaded to cede the Darjeeling hill tract to the Brit-
ish, relations between the two powers deteriorated, culminating in Brit-
ish forces again entering Sikkim in 1861. The Sikkimese were forced to
sign a treaty that gave the British increased access to Sikkim, and
forced to agree to assist in the building of roads up to the Tibetan fron-
tier. In return, the Chogyal received an annual British subsidy. While
Sikkim remained free of resident British officials, imperial influence
on Sikkim henceforth increased. But indigenous opposition to the Brit-
ish grew and to the north the Tibetans became increasingly concerned
by the expansionist European power to the south.
In the Tibetan understanding, Sikkim was a state within its sphere
of influence, and numerous religio-political and cultural links existed
between the aristocracies of the two states; the Sikkimese rulers, for ex-
ample, traditionally took Tibetan brides. Threatened by the northward
advance of British power, the Tibetans finally acted in 1886. They
moved troops to the frontier and fortified a position which in the Brit-
ish understanding was in Sikkim. After lengthy negotiations failed, the
British assembled a force termed the ‘Sikkim Expedition’, which ex-
pelled the Tibetans in March 1888. The Chinese, who claimed Tibet
and thus Sikkim as part of their empire, then entered into talks with
the British over the status of this frontier. These talks between the Brit-

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 87

ish and the Chinese (without Tibetan or Sikkimese participation) cul-

minated in the Sikkim-Tibet Convention of March 1890, which defined
the border and confirmed British authority over Sikkim.
In terms of size and population, Sikkim did not actually warrant a
permanent British Resident. In the western Himalayas, 30 states, sev-
eral larger and more populous than Sikkim, were then grouped to-
gether administratively as the Punjab Hill States under a single Resi-
dent. But a Political Officer was posted to Sikkim because of its strate-
gic significance8 and its potential role as a ‘stepping-stone’ to Tibet.
White, a Public Works Department engineer in Darjeeling, had been
the Bengal Political Officer A.W. Paul’s deputy on the Sikkim campaign
and with Paul involved in the Anglo-Chinese negotiations, White was
appointed to the Sikkim post and stayed on until his retirement in
1908. At that time Sikkim did not have a fixed state capital in the Eur-
opean sense, with the politico-religious authority of the state repre-
sented by the Chogyal’s palaces at Gangtok and Tumlong and the net-
work of Sikkim’s 36 monasteries.9 Having located a suitable plot of
land on which to build a Residency, which was near to (and above!),
the palace at Gangtok, White effectively created Gangtok as the perma-
nent capital of Sikkim.
While he was the dominant figure in this period of Sikkimese his-
tory, White was not highly regarded even by his employers. Though
serving on the Younghusband mission as nominal second-in-com-
mand, and later given official charge of British relations with Bhutan
and Tibet in addition to Sikkim, he was mistrusted by Viceroy Curzon
and effectively ignored in regard to policy. That he was allowed to re-
main in Sikkim suggests the state’s insignificance to the imperial
government. White acted there, as one observer put it, ‘like a little
God’.10 He treated the Sikkimese ruler abominably, exiling him from
his capital for a number of years, and his successor as Political Officer
admitted that:

There can be little doubt that our relations with Sikkim were
mismanaged at this time; too little tact and sympathy, too much
of the hobnailed boot … [in Bhutan and Tibet] people said ‘Sik-
kim has been turned into mud’.11

Through a Durbar (‘Ruling Council’ or ‘Assembly of Ministers’), that

he appointed and controlled, White effectively ruled Sikkim; as he put
it, ‘everything was in my hands’, and the Durbar’s insignificance is un-
derlined by the fact that it did not meet at all in 1905-06.12 But he had
very little support there in terms of finance or manpower and Sikkim
state was impoverished and lacking in most of the structures of mod-
ern government. In 1889, there were no police, courts, or public works,

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88 THEIR FOOTPRINTS REMAIN

and no secular education or public health system. Imperial govern-

ment subsidies for Sikkim were limited to 12,000 rupees per annum.
This was originally paid to the Chogyal, but after his banishment by
White the subsidy went ‘towards the expense of management of the
State by a British officer’13; meaning White used the money as he
chose.14
To counter the shortage of state funds, White initiated revenue-rais-
ing measures to obtain the finance necessary to create state structures.
A land revenue settlement was made, forestry excise measures were in-
troduced and, acting through the Durbar that he dominated, White
was able to introduce the unpopular measure of increasing immigra-
tion from Nepal in order to expand the tax base and raise agricultural
production. Within a decade, Sikkim state revenue had increased from
just over £500 to £150,000 per annum.15 This income enabled White
to begin instituting the development of state structures on the British
model and to encourage the introduction of modernity by financing
the education of Sikkimese youths in British India.
Although White praised his office staff and their ‘efficiency and good
order’,16 his correspondence was invariably tardy and his record-keep-
ing was poor.17 It appears, however, that the first expenditure on medi-
cal matters from the Sikkim budget came in 1895-96; 1,330 rupees
were allocated, presumably to build the civil dispensary that opened in
Gangtok the following year, when 974 rupees were spent on its upkeep
and 145 rupees for ‘sanitation’.18 White’s role here is uncertain. He
noted in his memoirs that he was responsible for all of the depart-
ments – police, education, revenue, and so on – normally under the
charge of a specialist imperial officer and staff,19 but he does not men-
tion public health, where White did, at least initially, have the assis-
tance of a European medical officer.
On the Sikkim Expedition, which remained in the field from January
1888 to January 1890, a Surgeon-Major R.H. Carew was attached to
the British forces and a Surgeon Major G.H. Peevor was in charge of
the Native Field Hospital.20 The biggest health problem the mission
faced was not with men, but with the mules, up to half of which fell
ill.21 The Army had expected harsh conditions and ordered that only
those ‘capable of standing continuous hard work and exposure in a
cold climate’ were to be selected for the mission.22 Imperial battle ca-
sualties were light,23 and although there is no record of the military
providing medical services to the local peoples, the mission doubtless
treated Tibetan battle casualties and local ‘conscripted’ labourers as well
as Indian troops and their British officers.
When White first took up his post in Gangtok, the military medical
staff who had served on the Sikkim campaign remained there on active
duty, now under the command of Dr. J.K. Close.24 After the departure

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 89

of the bulk of the Expedition, a Surgeon-Captain Dr. D.G. Marshall25

was posted to Gangtok in 1891 to act as White’s medical officer, and he
was replaced the following year by Surgeon Captain Dr. A.W.T. Buist-
Sparks.26 In 1893, Surgeon-Captain Dr. G.F.W. Ewens arrived,27 and
he remained in Gangtok until at least 1895.28 There is no record of any
European physician having replaced Ewen, and it seems likely that an
Indian-trained medical assistant served in the Gangtok dispensary. By
1905 it was certainly under the control of the hospital assistant H.N.
Mitra, who remained there for some years.29
These medical officers were the first Western physicians to reside in
Sikkim, and given that two of them later reached the rank of Lieute-
nant-Colonel, and that Marshall had topped the examinations in his in-
take, they must have been among the better-than-average physicians in
the imperial service. Yet there is little evidence of their making any
great impact on the medical world of Sikkim and it is likely that their
services were given only to the army and to White and his staff. With
White effectively exiling the Chogyal from Gangtok until late 1895, it
was impossible to implement the usual imperial medical strategy of
first impressing the ruling elites. Certainly in 1892, the Chogyal’s two-
year old daughter Kumari Kunzang Wangmo was still treated by indi-
genous ‘propitiatory rites, such as burning of incense’, when very ill.30
The early physicians did endure primitive conditions. White refers to
an unnamed medical officer and his wife in this period, ‘who lived in a
two-roomed hut built of wattle and dab’ [sic], where their wooden furni-
ture was liable to sprout in the rainy season!31 The civil dispensary that
opened in Gangtok in 1896-97 must have been very basic, given that
even in the 1960s a Sikkim dispensary was described as; ‘usually …
housed in small sheds. Half of the space is occupied by the medicine
racks and table for dispensing. The remaining portion with a partition
wall is being utilised by the compounder as his residence.’32 However,
such crude structures were only remarkable by European standards
and their very simplicity may have encouraged patient resort. R.C. Cro-
zier has noted that in China, the ‘humble buildings and crude wards
of the early hospitals probably helped by not intimidating simple pea-
sants with an alien and too antiseptic environment.’33
Biomedicine did make some irregular progress in these early years
as the daily average number of patients at the Gangtok dispensary de-
monstrates:34

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90 THEIR FOOTPRINTS REMAIN

Table 2.1 Daily average attendance, Gangtok clinic

Year Daily average attendance
1896-97 6.5
1897-98 7.4
1898-99 7.4
1899-1900 5.9
1900-01 5.3
1901-02 12.8

The sudden increase in 1901-02 is difficult to account for though it

may be a rise related to the regional smallpox epidemic of 1900. But in
June 1902, another state dispensary was opened in Chidam,35 and
around this time a third dispensary opened at Rungpo. The latter was
under the charge of the Public Works Department, suggesting White,
following a common imperial officer’s administrative strategy of divert-
ing funds allocated for one department to another, more needy area,
was able to use PWD funds for medical purposes. Before proceeding
further, however, we may consider the existing indigenous medical si-
tuation in Sikkim.

Sikkimese traditional medicine

Sikkim in the 19th century lacked any state health structures as was the
case elsewhere in the Himalayas. There was also no distinct or system-
ised medical tradition that might be termed ‘Sikkimese medicine’,36 or
any institutionalised centre for the dissemination of medical knowl-
edge. Instead, there existed a wide range of healing practices and un-
derstandings, many of which were associated with particular commu-
nities. The Lhopo aristocracy (who made up the bulk of the monastic
population), had access to the wider Himalayan medical tradition
known as sowa rigpa, which was practised there by monks and less
commonly by amchis.37 These practitioners were often trained in Tibet,
or followed Tibetan lineages of instruction. But in rural areas, where
even today 90% of the population still resides,38 such knowledge was
less accessible and various forms of local healing were the primary
treatment option. Knowledge of medicinal herbs was widespread, while
most villages had a bone setter who applied herbal treatment allied to
the use of bamboo splints.39 Amulets against injury and disease were
also common, along with charms and spells that are reminiscent of
those in the Atharvavedic traditions of the Indian plains,40 although
Āyurvedic medicine was not known to have been practised there until
more recently.
As these latter devices suggest, understandings of disease causation
among the various communities in Sikkim were generally linked to a

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 91

belief in supernatural intervention as a primary cause of human suffer-

ing. Thus there existed a range of community or ethnically based ritual
specialists who operated in the religio-magical sphere to divine causa-
tion and propitiate the illness-causing spirits. These included the Bong-
thing or Muns of the Lepcha tribes and the Nepali Jañkri spirit-med-
iums (who became increasingly important figures in the Sikkimese
medical landscape as the Nepali population grew in the 20th century41).
But there were similar practitioners among the Sherpa communities
and among the Lhopa, many of whom were non-elite villagers with ‘a
very limited understanding of Buddhism’.42 The Sikkimese seem to
have moved easily between these various practitioners.
One other prominent feature of medical practice among the Bud-
dhist population of Sikkim was the emphasis on pilgrimage as a reme-
dy for particular complaints.43 Pilgrimages were, and continue to be,
undertaken to medicinal hot springs that are understood to be located
within a Buddhist sacred landscape.44

Missionary medicine in Sikkim

The posting of a Political Officer in Gangtok marked a significant step

in the northern advancement of imperial power towards its ultimate re-
gional goal, Tibet. It was also of considerable significance to Christian
missionaries, for whom expansion into Sikkim en route to Tibet was a
logical consequence of their work in Kalimpong. But while a mission
was established in Sikkim soon after the establishment of British
authority there (just as it had been in places such as Ladakh, Chamba
and Darjeeling), the advance into Sikkim demonstrated the Political
Department’s increasing reluctance to support Christian missionaries
in their domains. In the wider context, the spread of Christian civilisa-
tion was part of the ideological impetus behind the growth of Empire,
but, in practice, a complex relationship existed between missionaries
and imperial government agents in this region.
Events in India – not least the ‘Indian Mutiny’ in 1857-58 – had de-
monstrated the potentially disastrous consequences of policies and ac-
tions affecting indigenous religious structures and practices. By the late
19th century, Political Officers, even when they were practising Chris-
tians themselves, recognised that missionaries were liable to disturb
and radically change indigenous societies. While that might be accepta-
ble in a ‘tribal’ society among groups such as the Lepcha who lacked
wider political organisation or links to state and national identities, in
wider society of frontier states such as Sikkim the missionaries’ work
could create unwanted political instability. The presence of mission-
aries was also strongly opposed by the local authorities and in acquies-

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92 THEIR FOOTPRINTS REMAIN

cing to their exclusion, the Political Officers strengthened the alliance

of interests with those authorities. Thus, while the missionaries had
been the key agents behind the introduction of biomedicine in Kalim-
pong, in Sikkim they found their efforts restricted by an alliance be-
tween the Sikkimese authorities and the Government of India.
The missionaries responded to those restrictions by making greater
use of local Christians as medical missionaries, with important conse-
quences in regard to the indigenisation of biomedicine. In the early
years, the missions were able to establish three of the first six biomedi-
cal dispensaries in Sikkim and missionary medical efforts were only
surpassed by government initiatives after the first decade of the 20th
century or even later.
The first concrete step in the missionary approach to Sikkim came
in 1880, when Rev William Sutherland arrived in Kalimpong to join
the Church of Scotland mission and was allocated Sikkim as his parti-
cular mission field.45 After several missionary visits to southern and
eastern Sikkim, Sutherland travelled to the Chogyal’s palace at Tum-
long in 1883 to seek permission for a missionary to reside in Sikkim.
But there was no response to his appeal or to a similar request from
Rev William Macfarlane, who travelled through southern Sikkim in
November 1885.46 The Sikkimese government were presumably wary
of provoking further British intervention by restricting the movement
of Europeans and thus reluctantly permitted missionaries to travel in
Sikkim,47 but held out against the permanent presence of Christians.
Macfarlane encouraged another approach. The Lepchas, who were
mainly followers of a ‘Folk’ religion, had proved amenable to conver-
sion in Kalimpong district,48 and the new political borders had not ser-
iously fractured their tribal structures. So he began to train Lepchas in
Kalimpong to spread the Gospel among their fellow tribesmen in Sik-
kim. The project had some success because in 1886 (when Macfarlane
died) there were 26 Christians in Sikkim and by 1888 their numbers
had doubled.49
But the Chogyal was unable to prevent the missionaries establishing
a base in Sikkim in the new political conditions after the 1888 war.
Gangtok itself remained out-of-bounds, but Sutherland selected a site
in Chidam, in southern Sikkim just a day’s journey from Darjeeling,
and a mission house was completed there in 1890.50 This was the
same year that White moved into the new Residency in Gangtok and
the significance of this symbolic convergence of imperial political and
religious power cannot have escaped the attention of the Sikkimese.
Sutherland’s initiative was supported by the Scottish Universities
Mission (SUM) and was administratively separate from the CSM in Ka-
limpong (while numerous individuals worked for both missions the in-
terests of the two groups did not always coincide).51 The Reverend R.

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 93

Kilgour was the first of a series of Sikkim-based SUM missionaries,

but like Sutherland he was an evangelist and not a medical missionary.
During the 1880s, Sutherland had ascertained that while the
Chogyal was opposed to Christian missions he was prepared to allow
the establishment of schools in Sikkim – if these were staffed by indi-
genous teachers. Local Christians who had been trained in Kalimpong
were thus employed and by the end of that decade they had founded
seven schools in southern Sikkim. In addition, many Sikkimese were
educated at the CSM’s Training Institute in Kalimpong; in 1891, for ex-
ample, seventeen of the Institute’s 37 students were Sikkimese.52 These
initiatives produced a body of youths educated on the Western model,
who were thus equipped to become the first generation of Sikkimese
to serve in the new state institutions such as schools and medical dis-
pensaries. The existence of this group was to be crucial to the establish-
ment and indigenisation of biomedicine in Sikkim.
The missionaries’ efforts to gain a foothold in Gangtok continued to
fail. An application for permission for the SUM to be allowed to move
there was made by the Political Officer Sikkim in 1901, but was not ap-
proved by the Durbar.53 Given that White controlled the Durbar, it is
clear that he did not favour a missionary presence in Gangtok (a con-
clusion implied in his autobiography),54 and he presumably made the
request simply to satisfy local Christians. In 1910, Gangtok Christians
themselves drew up a petition requesting that the Maharaja allow them
to build a church there, but again without success.55
After its initial florescence, Christianity seems to have made little
impact in Sikkim, with the number of believers declining between 1913
and 1922.56 The Church blamed the lack of progress on the ‘manifest
hostility’ of the Chogyal’s heir, Sidkeong Tulku, who was reportedly
pressuring local landlords to close the mission schools.57 But despite
his early death, the hostile climate continued and when the Rev Mack-
ean left Sikkim in January 1921, after a total of fourteen years there, it
proved difficult to find a replacement for this apparently unpromising
position. But Mackean, frustrated by the lack of progress, suggested a
new means of stimulating the Sikkim missionary enterprise; he ‘firmly
believed a medical man would be best suited to be his successor’.58
Mackean’s conclusion drew on his experience of the medical dispen-
saries established in Sikkim. In 1901 he had described the mission-
aries’ main activities in Sikkim as ‘evangelistic, educational, and voca-
tional training’, with no mention of medicine.59 But in 1897, the SUM
had opened a medical dispensary at Chidam staffed by a compounder,
Elatji Matiyas, a Lepcha convert to Christianity.60 That it was successful
is indicated by the fact that by 1906 further dispensaries staffed by lo-
cal Christian compounders had been opened at Rhenock, Seriyong,
and Dentan. In 1906, they dealt with 5,734 cases,61 and by 1910 three

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94 THEIR FOOTPRINTS REMAIN

more dispensaries had been opened.62 Additional dispensaries fol-

lowed and by 1923-24 there were a total of eleven mission dispensaries
in Sikkim, including one in Lachung in northern Sikkim opened by
the Scandinavian Alliance Mission, which established a base there with
two female missionaries in 1894.63
It appears that as in so many other regions, the missionaries discov-
ered that medical services were the most effective way to reach the lo-
cal populace. But whereas in Kalimpong there were Europeans in daily
charge of the biomedical facilities, in Sikkim virtually all of the dispen-
saries – and the schools – were under indigenous control from the
time they were opened. While the indigenisation of Christianity (and
its associated teaching and medical programmes), was the missionary
ideal, in practice Europeans tended to retain charge of the missions
they had established, with local converts restricted to managing periph-
eral or isolated mission outposts. But the Sikkimese opposition to the
permanent presence of European Christians hastened the rise of indi-
genous Christians to control over the church and its social institutions,
and meant that Sikkimese were the primary agents and public face of
missionary medicine there.
In this early period, Sikkimese Christians educated on the Western
model seem to have been ‘generalists’, who moved easily between posts
as teachers, preachers, or compounders, while those who had not con-
verted were similarly liable to be employed in a variety of posts, includ-
ing the growing colonial and state government bureaucracy.64 After the
initial period there was a growing specialisation typical of the processes
of modernisation, and the move to state hegemony in regard to health
and education was reflected in the way in which government employ-
ment began assuming greater status than employment among the mis-
sions. There was thus a gradual reversion to traditional social norms
within the state system, something that can be seen as part of the indi-
genisation process along with the assumption of local control over re-
cruitment, training programs, postings, and public health policies.
After Mackean’s departure, a missionary willing to serve in Sikkim
was eventually found; the Honourable Mary Scott. Just as the Reverend
Graham assumed the David Livingston role in Kalimpong, so too did she
fill the ‘heroic’ role in the histories of the Sikkim Church, with her arrival
described as ‘the most important watershed in the history of Christianity
in Sikkim’.65 Born in Scotland in 1877, a daughter of the 8th Lord Pol-
warth, Miss Scott accompanied Rev Graham and his wife to Kalimpong
in 1905 when they returned from home leave. She remained there for
eighteen years and received the Kaisar-i-Hind medal for her medical
services to villagers during epidemics such as the influenza outbreak
of 1918-19. She was clearly a strong individual, one Political Officer re-
ferred to her working, ‘in what some of us considered to be ’insubordi-

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 95

nate co-operation’ with the Church of Scotland Mission’.66 Miss Scott

eventually offered to fill the vacancy in Sikkim, and although her medi-
cal skills seem to have been self-taught, her aristocratic background
and established reputation for good works stood her in good stead
when she arrived in Sikkim in April 1923. She was permitted to live in
Gangtok, ‘a great concession by the Sikkim Maharaja’,67 that seems to
have been a personal tribute to her character and reputation rather
than a result of any initiative by the Political Officer.68
Mary Scott remained in Sikkim for sixteen years, where she was re-
sponsible for all missionary and church activities. Despite her lack of
qualifications, she carried a medical kit and devoted much of her time
to medical matters, supervising the mission dispensaries, organising
medical camps, nursing and relief programs during epidemics, and
caring for the sick in her own home.69 Where Macfarlane and Suther-
land had tried to spread Christianity into Sikkim through the Lepchas,
Miss Scott used a different strategy. While identifying herself with the
Sikkimese to the extent of wearing local clothing and living in simple
quarters in the Gangtok bazaar, she also deliberately set out to gain the
support of the local elites. Doubtless helped by her aristocratic back-
ground, she became a friend of the Maharani, accompanied Sikkimese
royalty on a tour of India, and even acted as a hostess at the palace.70
Before health problems with the altitude forced her to leave Sikkim,
her efforts were rewarded when the Chogyal allowed the opening of a
Christian Church in Gangtok in 1936.71 The Rev Gavin Fairservice and
his wife Ruth replaced her, but were not permitted to reside in Gang-
tok as missionaries,72 and a 1938 regulation requiring Sikkimese to ob-
tain permission from the Durbar to convert to Christianity suggests
the Church’s gains in Sikkim owed more to Mary Scott’s personal influ-
ence than to any great enthusiasm for the new faith by the Sikkimese
rulers.
In the absence of dispensary records or relevant writings by Mary
Scott it is difficult to gauge the impact of missionary medical initiatives
in Sikkim. It does appear that, during the first two decades of a British
presence there, in terms of structures, medical standards, and patients
attracted, the missionaries played at least as significant a part in the in-
troduction of biomedicine as imperial government efforts. Both govern-
ment and missionary clinics were staffed by compounders trained by
the missionaries in Kalimpong and standards, facilities and resources
must have been very similar. The major difference was, as noted, that
European missionaries were largely absent from the Sikkim dispen-
saries, which were staffed by Sikkimese or other local people.
While eventually overtaken by state structures, the missionaries con-
tinued to be important agents for the spread of biomedicine, particu-
larly in remote areas, into the 1930s and ’40s. As in Kalimpong and

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96 THEIR FOOTPRINTS REMAIN

elsewhere, their influence on professional standards and the moral and

ethical boundaries of the medical profession was also significant. De-
monstrating a strong work-ethic and dedication to service, they set high
standards of professional care that their Sikkimese trainees were re-
quired to emulate, although the Christian construct of the ‘compassio-
nate doctor’ and ideals of service to the poor translated without diffi-
culty into similar Buddhist ideals.73 In a small and autonomous state,
isolated from the extremes of Indian society, such standards and ideals
proved easier to maintain in the post-colonial period than they did in
India itself.

State development of biomedicine

In the early years of the 20th century, Sikkim became an important sta-
ging post for the Tibetan Frontier Commission, popularly known as
the ‘Younghusband mission’. John Claude White was preoccupied with
the mission from 1902 until he returned from Lhasa in the autumn of
1904. Gangtok was increasing in size and population and the presence
of numerous military units, each with their own medical officer, in and
around Sikkim as a consequence of the Younghusband mission, was a
reminder of the unsettled state of biomedical development there. The
matter of appointing a permanent European medical officer to oversee
public health in Sikkim was raised in a series of proposals White made
early in 1906. But the discussion over whether the resulting charges
should fall on the military or civil department, which lasted for more
than two years, was not helped by White’s characteristic tardiness in
answering correspondence.74 He initiated the discussion by reporting
that the

want of an administrative medical officer over both civil and

military matters for the Agency is being more and more felt.
There are many pressing questions such as the development
and supervision of existing dispensaries, the opening of new
ones, vaccination, sanitation, etc., and the organization of medi-
cal aid generally, which require special knowledge and which
are now suffering from the fact that there is no medical officer
attached to this Agency. ... All of … [the dispensaries in Sikkim
and Tibet] are under separate management and, although I can
visit them occasionally, I am unable to say if the work in each is
being properly carried on without a medical advisor. New dis-
pensaries are required to be opened in Sikkim and without prop-
er medical advice it is difficult to say where and how they should

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 97

be opened. If all the dispensaries were brought under one con-

trol they would be worked more advantageously.75

White requested the appointment of an Agency Surgeon to administer

both civil and military medical matters in Sikkim. He wanted ‘a man
of experience and tact’, holding at least the rank of Major.76 The Gov-
ernment of India eventually agreed to establish a new IMS position of
Assistant Civil Surgeon at Gangtok to supervise all medical matters in
Sikkim. These included responsibility for the state and missionary dis-
pensaries, jails, schools, and ‘personal attendance on the Chogyal and
his family’.77
This latter duty was a regular charge in the various states under a
Political Officer and does not indicate whether Sikkimese royalty had
adopted biomedicine at that time. The Chogyal Thubtob Namgyal was
now reconciled to British authority, and his Private Secretary, Lobsang
Choden, had served as a British medical interpreter on the Younghus-
band mission. He had been given the British Indian title of Rai Baha-
dur and might be presumed to have spoken well of biomedicine. But
as the Civil Surgeon was given extra allowances (that nearly doubled
his regular pay of 300 rupees a month) in order to compensate him
for the fact that there was ‘practically no private practice in Gangtok’,78
it appears that at that time few if any of the Sikkimese elites had
adopted the new medical system.
The first Civil Surgeon appointed to Gangtok was not of the status
White had hoped. There was a wider context to this. After the Young-
husband mission the British Government reversed the Curzonian poli-
cies of the Government of India, securing agreements with China in
1906 and Russia in 1907 that were intended to stabilise international
relations in Central Asia. China was allowed to regain power in Tibet
and when White retired from Sikkim in 1908 he was replaced by
Charles (later Sir Charles) Bell, an austere and reserved officer who ap-
peared likely to achieve Whitehall’s aim of ‘keeping things quiet’ on
the northeastern frontier.79 That frontier thus became an imperial
backwater, with ambitious officers preferring postings to locations,
such as the northwestern frontier, which were more at the forefront of
imperial attention. In such circumstances, the post of Civil Surgeon
Gangtok had little allure.
The state physician appointed to Gangtok was the Indian-born Assis-
tant Surgeon 2nd class John Nelson Turner (1871-193?), a member of
the Subordinate Medical Department, and not a qualified doctor. Turn-
er, who was probably (like his successors), a Eurasian, has left little
mark in the records. He took up his post on 20 August 1909 and re-
mained in Sikkim until he retired with the rank of senior assistant sur-
geon early in 1920. During World War One, when the IMS suffered a

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98 THEIR FOOTPRINTS REMAIN

considerable shortage of manpower that it alleviated through the use of

the Subordinate service officers, Turner was given the honorary rank of
Captain. But his comparatively low status was underlined by the fact
that he was outranked by the IMS officers then serving at Gyantse dis-
pensary, a potent symbol of the greater importance of Tibet in British
thinking. Only when the Gyantse post was given to a Sikkimese sub-as-
sistant surgeon in December 1915 was that position reversed.
Turner does appear to have overseen a continuing development of
biomedicine in Sikkim. In 1901-02, the government dispensary at
Gangtok had treated around 4,500 patients. In 1908-09, the figure was
approximately 7,500 (including 218 inpatients).80 The reports for the
1912-15 period show ‘a very steady increase’81 in patients at Gangtok to
over 8,000 cases in 1915. Other dispensaries also seemed popular. The
government establishments at Chidam and Rungpo treated a total of
some 6,500 patients in 1908-09, while the three missionary dispen-
saries (to which the state government contributed an annual sum of
250 rupees), treated more than 9,000 patients.82 Peripatetic dispen-
saries were subsequently introduced, which were set up at the fairs that
served as the meeting grounds for Himalayan populations, while the
SUM opened new dispensaries at Vok and Rinchenpong. It was, how-
ever, forced to close Richenpong and Dentam on the dismissal of the
compounder in charge of these sites.83
By 1915, considerable progress had also been made towards the indi-
genisation of biomedicine in Sikkim. The introduction and develop-
ment of biomedicine was a process, one that in the Himalayas required
at least a generation, but from this time on it was firmly rooted in Sik-
kim. This was in sharp contrast to Tibet and Bhutan, which did not de-
velop any significant indigenous biomedical tradition during the Brit-
ish period. While Sikkim state’s closer treaty links to British India and
the political alliance that developed between the British and the Sikki-
mese aristocracy fostered this process, the key factor appears to have
been the number of Sikkimese who had received a Western education.
The government and mission schools in Darjeeling and Kalimpong,
and in Sikkim itself from the 1880s, provided a small but regular sup-
ply of youths from either the Lhopo aristocracy or the Lepcha and Ne-
pali Christian communities, who were educated in the Western sys-
tem.84 Such an education was an essential precursor to the biomedical
training process, imparting the modern scientific worldview necessary
for the understanding of biomedicine. The fact that this education was,
in state schools, essentially secular, and did not require conversion to
Christianity made it more easily acceptable to the Himalayan Buddhist
aristocracy, who from the 1920s onwards came to increasingly occupy
the more powerful positions in the developing medical structures. The
‘native Christians’ and other Christian-educated youths from tradition-

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 99

ally lower status social groups continued, however, to fill the lower
ranks of compounders, dressers, and nurses in disproportionate num-
bers.
During White’s residency no Sikkimese appear to have progressed
beyond compounder qualifications. But his successor Charles Bell
proved to be an astute thinker who sought to encourage indigenous
modernisation in the Himalayan states as a means of strengthening
them, and consequently, the security of British India’s northern border.
He therefore encouraged the education of Sikkimese medical students,
albeit – as will be seen – with the primary aim of employing them in
Tibet. Thus, of the first three students sent from Sikkim to Temple
Medical College in Patna, two were immediately posted to a Political
Department dispensary in Tibet when they graduated. These men were
Tonyot Tsering and Bo Tsering (who were not closely related), both Ka-
limpong educated Sikkimese who graduated as sub-assistant surgeons
in 1913 and 1914 respectively.85 Their contemporary Bhowani Das Pra-
sad Pradhan, however, a member of the Nepali community, remained
in Sikkim after completing his training in Patna. He was placed in
charge of the Chidam dispensary in 1913.86
Thus, as the structures of a state medical system began to be devel-
oped in Sikkim, vacancies were filled by emerging Sikkimese medical
graduates. Their training was financed from the Sikkim state revenues;
we read, for example, that in 1924-25, ‘Lobzang Mingyur, a student
who was sent to the Campbell Medical School, Calcutta, at the expense
of the Durbar, finished his course of studies and was entertained at the
Gangtok hospital as an extra compounder.’87 Associated aspects of the
development of a modern state public health bureaucracy similarly
aided the growth of a Western-educated administrative class by offering
employment opportunities in the new spheres. During the 1920s, for
example, registration of births and deaths was made compulsory, while
a Civil Veterinary Department was established with a dispensary at
Gangtok. Dog licenses were also introduced, with orders given to de-
stroy dogs without the appropriate tags.88 In addition, sanitary mea-
sures were introduced in the Gangtok bazaar.89
As had been the case in Chamba, the steady development of biome-
dicine in Sikkim was stimulated by its patronage under the state’s tra-
ditional ruler. The 9th Chogyal of Sikkim, Sir Thutob Namgyal, had
outlasted White and even generously praised him in the History of Sik-
kim that he compiled.90 With the less dictatorial and more persuasive
Charles Bell as the Political Officer, Thutob Namgyal was increasingly
supportive of modernisation. After his death in 1914, Sidkeon Namgyal
Tulku, who had been groomed for the post by the British, succeeded
him but died after ruling for just 10 months.91 His younger half-broth-
er, Tashi (later Sir Tashi) Namgyal, who had been educated at St Paul’s

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100 THEIR FOOTPRINTS REMAIN

and Mayo College in India, then became Chogyal in 1915 and ruled
Sikkim until his death in 1963.
Tashi Namgyal was, according to British reports ‘deeply interested in
medical affairs’. In the early 1920s, he and his wife (‘the Maharani’ in
British records), made a number of visits to the hospital in Gangtok,
‘and rendered every help possible’. The Maharani even joined the Poli-
tical Officer’s wife in organising classes at which local ladies might pre-
pare garments for patients and so forth.92 This type of patronage con-
tinued into the post-colonial period.93
These symbols of royal approval for, and association with, the new
medical developments had considerable symbolic significance in Sikki-
mese society, bestowing royal authority on the new medical system and
successfully encouraging others to support it. As early as 1905, for ex-
ample, three beds in the Gangtok dispensary were subsidised by the
Indian merchants Jetmull and Bhoraj.94 The landlord class also fol-
lowed their ruler in supporting biomedical expansion and assisted in
its indigenisation. By 1913, it was reported that the Kazis (the predomi-
nantly Lepcha land-owning aristocracy) and thikadars (the Nepali land-
owning aristocracy), were willing to build suitable dispensaries if the
Government would stock them.95
Royal patronage was clearly articulated in the naming of a new
Gangtok hospital built to replace the existing dispensary there. On 24
September 1917, the new Chogyal, Tashi Namgyal, officially opened
the Sir Thutob Namgyal Memorial Hospital.96 Situated on a ridge over-
looking Gangtok,97 it opened with beds for 10 inpatients,98 and charge
of the new facility was given to a state medical officer of Sikkimese na-
tionality.99 The hospital became the centre of biomedicine in Sikkim,
although it was initially poorly-equipped, not until 1923-24, for exam-
ple, did it have a microscope.100 But additional specialist wards were
gradually added; a tuberculosis ward in the late 1920s and, after a
trained midwife was first posted to the hospital in 1929-30, a maternity
ward was constructed in the late 1930s.101
The new hospital did not immediately affect patient numbers at
Gangtok. In 1923-24, just under 8,000 patients came to the hospital,
only a few more than a decade earlier. But in the ensuing decade until
1933-34, Gangtok outpatient numbers doubled to just over 16,000,
although inpatient numbers were inconsistent. They varied from a low
of 317 in 1929-30 to highs of 465 in 1924-25 and 455 in 1933-34.102 The
reasons for the increase in outpatients are not stated in British ac-
counts, but the increasing population, biomedical advances, and per-
sonnel changes must all be considered as factors along with a growing
acceptance of biomedicine by Sikkimese.
On 1 November 1922, John Turner was replaced as Civil Surgeon
Gangtok by the senior assistant surgeon, Dr. John Charles Dyer of the

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 101

Sir Thutob Namgyal Memorial Hospital in Gangtok

Subordinate medical services. Although a Eurasian, as a fully-qualified

medical practitioner, Dyer was of a higher professional status than
Turner and he was a well-regarded medical officer.103 In November
1920, he had accompanied Sir Charles Bell to Lhasa and remained
there for several weeks until Bell’s old friend, the Tibetan-speaking Lt-
Colonel Robert Kennedy IMS was able to join him there.
When Dyer left Sikkim in January 1928, his replacement was sub-as-
sistant surgeon Dr. Kenneth Percival Elloy DCM,104 who remained in
Gangtok until February 1932, when he was replaced as Civil Surgeon
by Dr. W. St. A. Hendricks. Like Dyer and Elloy, Hendricks was a Eura-
sian. But he was described by the Political Officer’s wife as ‘a very fine
GP’,105 and significantly, he was a member of the IMS, the first officer
of the higher service to hold the Civil Surgeon position in Sikkim. The
increased status of the post was a recognition of the fact that Gangtok
was not only growing in population, but was also becoming a place of
some political importance again as the Sino-British struggle for control
over Tibet intensified. The arrival of Basil Gould as Political Officer

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102 THEIR FOOTPRINTS REMAIN

Sikkim in December 1935 saw the Gangtok post upgraded to a 2nd

class Residency, and in August of the following year, Gould led a mis-
sion to the Tibetan capital that became a permanent British Mission in
Lhasa.
Gould placed considerable emphasis on the maintenance of British
prestige as a means of government, and these increases in status were
no coincidence. The political role of the Sikkim medical officers was
now more obvious after some decades of lingering in abeyance. Thus,
the emphasis on the modernity of medical practice in Sikkim in re-
ports on kala-azar, the fever which became an epidemic in Sikkim
every 15-20 years; it was noted in 1939 that treatment of the fever in
Gangtok ‘was in every way in accordance with recent teaching’ and that
the advice of a specialist from the Tropical School of Medicine in Cal-
cutta was being followed.106
Yet Sikkim remained an economically insignificant state. Kala-azar
was believed to be spread by sandflies, but it was noted that, ‘to carry
out efficient anti-sandfly measures in one village would absorb the
whole revenue of the state’.107 Most of Sikkim’s medical costs were
borne from local revenue, including contributions to the mission dis-
pensaries. The contribution of the imperial Government was small; in
1917-18 they gave just 1,500 rupees for medicine, in addition to cover-
ing indirect costs incurred by the PWD dispensary at Rungpo.108 These
economic restrictions acted as a considerable brake on biomedical pro-
gress in Sikkim.
One possible source of income was to charge for medical services
and a step in this direction was taken in the 1920s. Initially, as was the
case throughout all of those regions where British authority was repre-
sented by the Political Department, biomedical services were provided
free of cost (as they were at missionary dispensaries). It was stated in
regard to Sikkim that the ‘established policy of the State is to place
medical aid within the reach of all classes of people in the State’.109 In
the case of the Chogyal and his immediate family, the Civil Surgeon,
as we have seen, received an additional allowance to compensate him
for providing private treatment to the royal family, while all others
could receive free treatment at the dispensaries and hospitals. But just
as the wealthier Sikkimese might choose to consult privately with the
Civil Surgeon on a fee-paying basis, so too, in the 1920s, was there a
demand for private treatment at the Gangtok hospital. A ward origin-
ally built as a TB ward was converted into a paying ward, which
charged a rupee a day for the bigger room and 8 annas (sixteen annas
= 1 rupee) for the smaller. This was made possible by converting the le-
per ward into a TB ward and transferring Sikkim’s lepers to existing fa-
cilities in Kalimpong – with 200 rupees per annum given to that hos-
pice in return.110

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 103

Private medical practice was never forbidden in Sikkim and several

individuals who had trained as compounders in Kalimpong established
practices after initial experience in dispensaries in the region. It was
not, however, until the 1970s that fully-qualified doctors set up private
practice there. Until that time, any Sikkimese qualifying as a doctor
would be absorbed into government service.111

Health conditions in Sikkim

There were distinct local characteristics to the pattern of medical condi-

tions encountered in Sikkim. In the first breakdown of medical condi-
tions given in 1908-09, it was stated that at the state dispensaries, worms
formed around 40% of the caseload. Malaria (15%), skin diseases (12%),
goitre and ulcers (both around 5%), were the other common conditions
recorded.112 Those conditions continued to provide much of the doc-
tor’s caseloads although there were regular outbreaks of epidemics
such as smallpox and kala-azar. But a report in 1913 that 20 Lepchas
in the Ringem Valley had died due to ‘eating excess of raw fruit and
jungle roots owing to a slight scarcity of food grains’,113 hints at the
economic status of rural areas and the extent to which epidemic deaths
may have been swollen by those already to some extent malnourished.
Sikkim certainly suffered heavily in the great influenza pandemic that
followed the First World War and with India also badly affected, it proved
difficult to obtain outside medical aid. Reaching its peak in October and
November of 1918, influenza killed 2,767 people in Sikkim. This was
more than 3% of the population, and the Civil Surgeon reported that ‘it
may safely be said that no one in Sikkim escaped a mild or severe attack’.
Among the dead was the sub-assistant surgeon at Chidam.114
A notable feature of public health in Sikkim was that in contrast to
neighbouring Bhutan and Tibet (as will be seen), venereal diseases
were not a significant part of the medical caseload. Primary and sec-
ondary syphilis and gonorrhoea provided around 1% of the medical
caseload in Gangtok until the late 1920s, when it increased to around
2%. But it apparently remained relatively uncommon, and by the mid-
1960s the figure had declined to 0.1%.115
Imperial biomedical priorities were life-threatening conditions, thus
iodine deficiency disorders were not seriously dealt with in the colonial
period. All of Sikkim falls within an iodine deficient zone and it was
not until 1984 that iodised salt was made compulsory. But even today
around 15% of the population, particularly the poorer rural dwellers
who are less likely to eat imported foods, are still liable to goitre.116 Si-
milarly, as was to be the case in Tibet and Bhutan, no provision seems
to have been made for psychiatric conditions. These were generally

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104 THEIR FOOTPRINTS REMAIN

treated within the local community and not regarded as a medical pro-
blem. After 1947, mental illness cases could be sent for treatment at
an Indian mental hospital in Ranchi, West Bengal, but there remains a
sense that such conditions bring disgrace to a family, and mental pro-
blems were often kept hidden by families.117
Vaccination against smallpox, which will be discussed in depth in
the following chapters on Tibet, was an immediate medical priority for
the British in Sikkim. Despite its comparative isolation, Sikkim lay as-
tride the main trade route from India to Tibet and its borders were also
open to east-west traders from Nepal and Bhutan. Thus it remained li-
able to outbreaks of smallpox introduced from neighbouring regions
and could act as a ‘gateway’ for outbreaks of smallpox to spread across
the Himalayas. Sikkim had little or no protection against the regular
outbreaks of this devastating disease,118 and vaccination was among the
earliest biomedical initiatives there. It appears to have begun in the late
1890s. In a report on medical developments in Kalimpong for the year
1899, one of three local students who had completed medical training
there was stated to be ‘vaccinating in Sikkim’, while the Rev Macara
was sent to vaccinate people in Sikkim during the major regional
smallpox outbreak of 1900, when, ‘over 100 deaths were reported in
one area alone’.119 Funding for this does not appear to have come from
Sikkim state revenues and may therefore have been part of the Bengal
state vaccination program, with missionary assistance.
White stated in 1906 that ‘I started vaccination in Sikkim a few
years ago and am doing all that can possibly be done’,120 but it was not
until 1908, after his departure, that vaccination was made compulsory
in Sikkim.121 Vaccination uptake seems to have been stimulated by the
1900 outbreak and subsequent local epidemics for 4,391 persons were
vaccinated in 1900-01, and 2,331 in the following year (although no de-
tails are given regarding revaccination or success rates).122
Around 1904, Sikkim state revenues began to be used for funding
vaccinations on a systematic basis. The state was divided into eight cir-
cular areas, each with a licensed vaccinator operating there for the five
(summer) months of the year when smallpox was most prevalent. The
new system produced a gradual increase in the numbers vaccinated,
from 3,220 persons in 1904-05 (when there were 182 deaths from
smallpox in Sikkim) and 3,578 in the following year,123 to 5,935 persons
in 1907-08. But in 1908-09, the number declined to a total of 4,884
primary and 768 revaccinations, a decline attributed to ‘the reluctance
of the Bhutias to have themselves revaccinated’.124 No mention is made
of any reluctance to undergo initial vaccination, and it was observed
two decades later in the Sikkim annual report that ‘it is noteworthy that
there is little or no opposition to vaccination’, a statement repeated the
following year.125

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 105

While such statements need to be treated with some caution, for the
reports were designed to be optimistic and reflect well on the medical of-
ficers writing them, resistance to vaccination was noted in medical re-
ports from Tibet. The absence of such references here suggests easier ac-
ceptance of vaccination in Sikkim than in Tibet. But any indigenous cul-
tural resistance may have been overcome in the under-reported 1890s,
and the Sikkimese, in any case, had had close dealings with the Bengal
district of India since the early 19th century and thus had a greater
awareness of Western medicine than the more isolated Tibetans. What
may have affected vaccination uptake was the fact that it was not free.
The vaccinators charged two annas per treatment until the charge was
abolished in 1929-30, at which time the number of vaccinator’s posi-
tions was increased and they were made full-time salaried posts.126
Figures for the numbers of persons vaccinated in Sikkim do show
considerable annual fluctuations that to some extent reflect smallpox
occurrence patterns. In 1912-13, fourteen cases of smallpox were re-
corded in Sikkim, including two in the military barracks in Gangtok.
Six deaths resulted from the outbreak, which was traced to aristocratic
pilgrims returning from Nepal. The number of dead was considerably
less than the regular annual totals of over a hundred just a decade be-
fore. But the efficacy of vaccination was now well-known and the out-
break acted as a stimulus to preventative treatment; 9,580 person were
vaccinated with lymph that year, and 11,195 the following year. In 1914-
15, more detailed figures began to be given. 8,043 people were vacci-
nated (including 5,615 under six year olds), of whom 7,925 were vacci-
nated for the first time, 49 cases failed to react and in 206 cases the re-
sults were ‘unknown’, 118 cases were revaccinated, of which 32 failed,
and in eleven cases the result was ‘unknown’.127
Available figures for the ensuing years are as follows:128

Table 2.2 Sikkimese smallpox records 1917-1934

Year Smallpox cases Deaths Vaccinations Revaccinations
1917-18 3 2 6,163 1,521
1918-19 19 1 6,641 2,432
1922-23 0 0 3,339 not recorded
1923-24 5 unclear 6,676 not recorded
1925-26 19 2 7,010 961
1926-27 23 13 7,137 1,957
1927-28 108 17 9,477 not recorded
1928-29 75 19 7,884 not recorded
1929-30 120 41 5,915 not recorded
1930-31 30 3 8,379 4,517
1932-33 ‘practically no cases’ 2,451 not recorded
1933-34 ‘practically no cases’ 4,677 not recorded

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106 THEIR FOOTPRINTS REMAIN

As these figures indicate, the annual medical reports from Sikkim did
not consistently provide a breakdown into primary and re-vaccinations.
Nor did they always indicate the percentage of these vaccinations that
were successful, the figure for years when they did are as follows:

Table 2.3 Smallpox vaccination success records 1917-1931

Year Total Vaccinations Unsuccessful Result unknown
1917-18 6,163 1,073 212
1918-19 6,641 925 not recorded
1922-23 3,339 49 67
1923-24 6,676 168 74
1925-26 7,010 265 213
1926-27 7,137 926 422
1927-8 9,477 856 863
1928-9 7,884 1,838 553
1930-31 8,379 2,343 1,052

Where vaccinations were unsuccessful, ‘most were revaccinated’,129

while those where the result was unknown were presumably traders,
nomads, and others who did return for monitoring. What is clear is
that the vaccinators focussed on children. In 1917-18 two-thirds of those
vaccinated were children; the following year the figure was 50% and in
subsequent years it often exceeded that figure,130 suggesting that most
Sikkimese adults had been vaccinated and that their children were
being systematically vaccinated. Nor does any particular social group
appear to have been excluded. Uniquely, in 1917-18, vaccination figures
were broken down on communal lines. Of the 6,163 persons vacci-
nated, ten were Christians, 4,678 were Hindus (primarily of Nepali ori-
gin), and 1,475 were ‘Bhutiya’ and Lepcha, figures roughly representa-
tive of the communal diversity.
In 1923 and ’24, it was reported that ‘Every endeavour was made to
push on vaccination throughout Sikkim’,131 yet its eradication was a
long way off. It persisted, particularly in remote districts or those ex-
posed to immigration, trade and pilgrimage. In as late as 1956 there
were still 142 smallpox patients in Sikkim and the disease was not en-
tirely eradicated until the 1970s.132

The post-colonial generation

The indigenisation of biomedicine in Sikkim meant that the departure

of the British had little medical impact there. The last of the imperial
Civil Surgeons, Dr. G.F. Humphreys IMS, was an experienced doctor.

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 107

He had served in Tibet as the medical officer in Gyantse from October

1940-May 1944, and visited Lhasa in 1942-43 as accompanying physi-
cian to two American emissaries. A Eurasian, he remained in Gangtok
until the mid-1950s, providing continuity through the transitional peri-
od. The Sikkimese sub-assistant surgeons who had served in the im-
perial dispensaries in Tibet withdrew back to Sikkim during the 1950s
as the Chinese takeover of Tibet intensified, increasing the pool of ex-
perienced medical practitioners available to the Sikkim state, which re-
tained its semi-independent status from 1947-75.
Biomedical patient numbers continued to increase in post-colonial
Sikkim, the state-wide figures available for the 1954-63 period being as
follows:133

Table 2.4 Sikkim biomedical patients 1954-1963

Year Total patients
1954 115,060
1955 120,637
1956 168,301
1957 176,395
1958 173,083
1961 167,649
1963 188,526

But throughout the 1950s and ’60s, biomedical development was re-
stricted by the limited state revenues available, and continued to rely
on Royal patronage to fund many routine items.134 During this period
the Sikkimese health services were heavily reliant for specialist services
on the variable commitment of Indian doctors employed on short-term
contracts. At the time of the Indian takeover in 1975, there were just
four district hospitals in addition to the STNM Hospital in Gangtok.
The bulk of biomedical consultations took place in rural dispensaries
and primary health care centres staffed by compounders, who thus re-
mained the principle interface between biomedicine and local pa-
tients.135 But an indigenous class of medical specialists capable of ad-
ministering and operating Sikkim’s medical services was developing.
Rather ironically, more indigenous Sikkimese occupy the higher ranks
of the public health service today than was the case in independent Sik-
kim before 1975.
The first generation of Sikkimese biomedical practitioners were not
fully qualified doctors. Men like Bo and Tonyot Tsering held sub-assis-
tant surgeon rank in government service. But by the 1940s, a new gen-
eration of qualified doctors began to emerge. They were largely from
the small group of Western-educated Lhopa Sikkimese who formed a
bureaucratic class serving the Chogyal and colonial governments. This

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108 THEIR FOOTPRINTS REMAIN

class had come to an accommodation with the British, and with their
primary identity being Sikkimese and Buddhist, they were not a part of
the nationalist struggles and religio-political divisions developing in In-
dia. As a cosmopolitan elite at home in British or Tibetan society they
were able to benefit from the crucial role they played as intermediaries
between their neighbouring powers, Tibet and British India. Thus indi-
viduals such as Bo and Tonyot Tsering (who will be discussed in more
detail later), were vital to the British medical project in Tibet, and in re-
turn they gained advanced social status at home through their activities
and employment with the leading regional power.
Among the new generation of medical practitioners to arise from
this class were Tonyot Tsering’s son Dr. Pemba T. Tonyot, who became
the first Sikkimese anaesthetist. Others from this social class were Dr.
Kazi Tendup, who may have been the 1st Sikkimese to qualify as M.
D.,136 and Dr. Tsewang Paljor (a descendent of Raja Tenduk Paljor,
whose estates had extended to Darjeeling), who was the first Sikkimese
to qualify as a surgeon. The close links between members of this class
are illustrated by the fact that the wife of Bo Tsering’s son, Dr. Leki Da-
dul, was the first female doctor in Sikkim, graduating from Calcutta
around 1955.137
The careers of these individuals tended to follow a similar pattern,
and they shared ideals of duty and service that had been reinforced by
the educational and professional structures of British imperial rule. Dr.
Pemba T. Tonyot, for example, was educated at the Gangtok Tashi
Namgyal school. His father had hoped he would follow him into medi-
cine and he did so, ‘being religious minded and seeing it as a noble
profession’. After matriculation Dr. Tonyot obtained a BA in science be-
fore going on to qualify as MBBS in Madhya Pradesh. In 1966, he
graduated as an anaesthetist and was posted to STNM Hospital in
Gangtok, replacing an Indian doctor. He later became a medical advi-
sor to the Government of Sikkim before retiring in 2003.138
His near-contemporary, Dr. Tsewang Paljor, was similarly schooled
in Gangtok and then St Joseph’s school in Darjeeling where he studied
science. Recognising the shortage of medical personnel in his native
land and the opportunity he had to serve there, he then applied to gov-
ernment and was selected for medical training in Andhra Pradesh,
graduating MBBS in 1968. After returning to Sikkim to serve in the
STNM Hospital, he was sent in 1972 to take a masters degree in sur-
gery at the Postgraduate Institute of Medical Education and Research
at Chandigarh, then returned to Gangtok as the first Sikkimese sur-
geon, again replacing an Indian serving on contract.139
But Sikkimese from other social groups also found careers in medi-
cine. Sonam Dorji was not from such a privileged background, but was
selected by the Political Officer Basil Gould to study at High School in

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 109

Gangtok. Then, in search of adventure, he headed off to join the Gur-

khas, fighting at Imphal against the Japanese forces in 1942 alongside
Victoria Cross winner Ganju Lama. On his return to Gangtok, he re-
members that, in recognition of his services, the new Political Officer
Arthur Hopkinson offered him any position he wanted, and he opted
for medical training at Campbell Medical College. He went on to serve
at the dispensary attached to what were now the Indian Government
diplomatic posts in Tibet during the early 1950s and subsequently
served in north Sikkim, before retiring with wife Namgay Dolma in
1989.140

Dr. Sonam Dorji IMS and his wife Namgay Dolma

Dr. Lobsang Tenzing, a nephew of Dr. Norbu who was killed in the
Gyantse floods in 1954, was from a somewhat different background.
Originally from the village of Mangan in north Sikkim, he was the son
of the Christian pastor there, although himself a Buddhist. The Tenz-
ing family placed great emphasis on modern education, and after fin-
ishing second on the merit list in his matriculation at Gangtok , he
was sent to NRS Medical College in Calcutta, completing his MBBS in
1963, the first of his Lepcha-Bhutia community to do so. He was
posted to the STNM hospital that year, and then became medical offi-
cer at the Mangan hospital from 1967-1971. Dr. Lobsang eventually re-
tired as Director-cum-Secretary of Health in 1995, having been the first
local doctor to reach this position.141

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110 THEIR FOOTPRINTS REMAIN

Along with the doctors and licensed practitioners, the (until recently
all-female) profession of nursing also developed in Sikkim, albeit that
the profession is still not of particularly high status. One example of a
nursing career in this period is that of Nurse Sonam Eden (‘Phigoo’).
In 1954, having reached 7th grade in Mary Scott’s school and then at
some fifteen years of age, she and her contemporary Pabita Pradhan
were sent to Kalimpong under the state Five Year Plan to train as
nurses. They trained under the Scottish missionary Dr. Albert Craig, a
man of very high standards who Phigoo remembers as strict and short-
tempered in contrast to the ‘Mother Theresa’ figure of Mary Scott. On
her return to Gangtok, Phigoo was posted to the STNM Hospital where
she remained until retiring in 1995 after 40 years service.142

The modern Sikkimese medical world

In Sikkim today, the Sir Thutob Namgyal Memorial Hospital straddles

a main Gangtok intersection. As of 2000, it was a 300 bed hospital,
with 78 doctors on staff including 36 specialists. In 1999, 351 major
and 984 minor surgical operations were carried out there. Plans have
been advanced for a new 500-bed hospital as patient numbers continue
to increase; to around 140,000 in 1999.143 While Sikkim is part of In-
dia, most of its medical personnel are born in Sikkim. For medical pur-
poses, the state is divided into four districts, each under a Chief Medi-
cal Officer who is also head of the central hospital in that district. A
network of primary health care centres and sub-centres exists in each
district,144 and medical services remain largely free.145 A subjective jud-
gement considering patient-doctor relations, service morale, non-elite
class access, and not least financial probity, as well as numerous statis-
tical indicators,146 would suggest the Sikkimese today enjoy among the
best biomedical services in India.
However, while biomedicine has been indigenised both in terms of
structures and personnel, it has not displaced the local medical prac-
tices, which continue to be the first resort for much of the popula-
tion.147 While medical reports from the colonial period in Sikkim make
virtually no mention of the indigenous practices, as late as 1969 it was
noted of the Sikkimese that, ‘of late they have started realising the effi-
ciency of the scientific treatment as evidenced by their ready accep-
tance of injections and vaccinations and the rising attendance at hospi-
tals and dispensaries’.148 Such optimistic rhetoric is, as will be seen, ty-
pical of biomedical reporting, particularly by newcomers to a region. In
practice, however, medical pluralism is characteristic and in Sikkim it
has been driven by an unexpected source. We have noted the influence
of the compounders as agents of biomedicine, but they may also repre-

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 111

sent traditional medical knowledge and practices; a report from 2001

describes how compounders

are very often also traditional faith healers. In a typical blend of

tradition and modernity; they work in a hospital or health centre
during the day, but perform the traditional tasks of a faith healer
in the evening.149

One other ‘blend of tradition and modernity’ emerges from the use of
techniques from one system by practitioners of another. Thus ‘tradi-
tional’ village bone setters may use x-rays, while biomedical practi-
tioners incorporate local cultural understandings by, for example, al-
lowing patients to choose an auspicious date for elective surgery in
consultation with the appropriate Buddhist monks. Biomedicine con-
tinues to gain acceptance, with modern technologies such as CAT scans
and ultrasound improving diagnosis, and thus treatment and accep-
tance, but non-biomedical systems are unlikely to die away. During the
last decade, medical pluralism has been institutionalised in Sikkim, al-
beit not to the extent known in contemporary Bhutan. But the STNM
Hospital does have an amchi, and outside of the state sector there is
now, in addition to Ayurvedic and Homeopathic clinics, a branch of
the Dharamsala Men-ze-khang.150 This opened in 2004 offering ‘Tibe-
tan medicine’, and there are also private practitioners offering services
in this tradition. Medical pluralism is thus established, but Sikkimese
traditions are under pressure from both Tibetan and Indian Traditional
Medicine as well as biomedicine!

Conclusions

Christian missionaries did make a significant, albeit limited, contribu-

tion to the introduction of biomedicine into Sikkim. During the latter
part of the 19th century, with the imperial government clearly intent on
breaking down the isolation of Tibet and missionary dispensaries being
established in Sikkim, the Himalayan missionaries’ dream of evangelis-
ing in the ‘Forbidden Land’ must have seemed a realistic one. But the
opening of Sikkim and later Tibet did not bring the expected results.
Missionary access to Sikkim was restricted and the Government of In-
dia refused to allow them to cross the frontier into Tibet.151 The CSM
missionary Rev Evan Mackenzie, for example, who had been in Kalim-
pong since the mid-1890s, was allowed to accompany Tibet’s second-
highest religious figure, the Panchen Lama, on his tour of India in
1906-07 to advise on matters pertaining to the Christian religion. But
in 1908, when he requested permission to reside near the Political De-

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112 THEIR FOOTPRINTS REMAIN

partment’s post in Gyantse, it was refused.152 Their continuing exclu-

sion from all but the southern districts of Sikkim must have made it
clear to the missionaries that the imperial government opposed their
presence in the frontier districts, and with the Political Department
making its own educational and medical initiatives in Tibet, the mis-
sionaries services in this regard were not required by the imperial gov-
ernment.
Subsequently, in regard to Tibet, the Political Officer Charles Bell in
1921 recommended that the number of European visitors to Tibet
should be gradually increased, although as any ‘Christian missionary
criticising Buddhism would’, he claimed, ‘be attacked and possibly
killed’, it was agreed that ‘sportsmen, missionaries, and undesirables’
should continue to be excluded.153 But after the Rev Mackenzie had
been permitted to cross the frontier to Yatung in 1922 for the wedding
of the British representative David Macdonald’s daughter,154 and then
to travel on to Gyantse, missionaries were occasionally allowed into Ti-
bet. Mackenzie returned on several occasions, Dr. Graham travelled to
Yatung in 1927, and later Drs Knox, Craig, and others were permitted
to travel on the trade route to Gyantse.155 They were not, however, per-
mitted to evangelise or to establish any permanent structures or insti-
tutions in Tibet, and there is no record of their carrying out any medi-
cal work there.
With the greatly reduced missionary influence, the colonial state
played a greater role in Sikkim than it did in Kalimpong. But having
alienated the local elites in the early years, John Claude White was able
to make little or no political use of medicine. In the absence of any sig-
nificant imperial government funding for Sikkimese public health de-
velopment White had to first transform Sikkim into a revenue-raising
state. Only when internal funding sources were created could the devel-
opment of government structures such as a public health system be-
gin. This meant that biomedicine made little impact on Sikkim in the
final decade of the 19th century.
More sophisticated Political Officers such as White’s successor
Charles Bell recognised that biomedical services could gain support for
the colonial project. Bell followed a policy of befriending the local elites
and encouraging them to gradually transform their state through the
development of modern institutions such as schools and hospitals. The
royal patronage dating from this period provided an important symbol
of Sikkim’s acceptance of biomedicine, and the indigenisation of medi-
cal structures and personnel was to provide a firm foundation for later
development. The existence of a body of Sikkimese educated on the
Western model was crucial to this process, which was to fail in Tibet
where such individuals were virtually non-existent until the late 1940s.

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SIKKIM: IMPERIAL STEPPING-STONE TO TIBET 113

The initial appointment of a low-ranked SMD Civil Surgeon to

Gangtok when the medical officers in Tibet were IMS officers effec-
tively separated medical developments in Sikkim from those in Tibet,
to which the Government of India always devoted greater resources.
Their respective status was also expressed in racial terms; at least from
the time of Dr. Dyer, and probably earlier, the Gangtok Civil Surgeon
was a Eurasian. But in focussing the work of the Civil Surgeon more
on medical rather than political issues, the development of biomedi-
cine in Sikkim may have been stimulated. It was less obviously a for-
eign system, and Sikkimese were, as a result of their education, better
informed as to its conceptual universe than their Tibetan and Bhuta-
nese neighbours.
While there was a significant contribution from the missionaries, it
was the Sikkimese state that largely funded the biomedical develop-
ment process and it was only their shortage of funding that limited –
and indeed continues to limit – the spread of biomedicine. But while
the continuation of traditional medical practices is in part due to the
structural restrictions on biomedicine, it is also a reflection of cultural
survival among the various groups making up Sikkim today. But na-
tionalism, or the nationalist struggle for independence from European
rule, does not appear to be a medical issue that has hindered the
spread of biomedicine in Sikkim. The complex issues of identity in a
multiracial society manifest in many areas, but turning to biomedicine
apparently transcends ethnic and national identities.
This may reflect British colonial understandings and policies in Sik-
kim. With the establishment of an alliance of interests between the
British and the Sikkimese elites, the Sikkimese became something of a
favoured class. They were both liked and rewarded by the British for
their role as intermediaries in Tibet and the Sikkimese found little at-
traction in the Indian independence movement, with their eventual ab-
sorption into India deriving from demographic changes. With the Ne-
pali community owing their presence to British patronage and the
non-elite Lepcha and Limbu largely left to their own devices by the co-
lonial government, biomedicine did not become a political issue in Sik-
kim.
As will be seen in the ensuing chapters, the central themes that arise
from the biomedical encounter in Sikkim were repeated in Tibet and
Bhutan, but only in Sikkim was biomedicine indigenised in the colo-
nial period.

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