What plagues public health and urban development in India?
Item
- Title
- What plagues public health and urban development in India?
- Creator
- Prabir Chatterjee
- Anand Zachariah
- Madhukar Pai
- Date
- 1998
- extracted text
-
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What plagues public health and urban development in India?
A Review of Public Health and Urban Development: the Plague in Surat by Ghanshyam Shah,
New Delhi, 1997 (Price Rs 395)
,e Publications,
Prabir Chatterjee, Anand Zachartah & Madhukar Pat
Plague in Stunt has been one of the most sensational crisis in this decade. The panic, the exodus,
the disruption of normal life are still fresh in our minds. The beating India's image received still rankles.
Three years after, we are still piecing together the whole story. Was it really plague? How many cases
really occurred? How did it occur? Why was the outbreak sensationalised by the media? These are just
some of the questions still debated. The confusion surrounding plague is tellingly brought out b\ he fact
tlrai there were three official outbreak investigations (by National Institute of Communicable Diseases
(N1CD), WHO International Plague Investigation Team and Technical Advisory Committee (TAC) on
Plague by the GOI.) Ghanshyam Shah's book is the most recent, and arguably the most comprehensive,
look at the Surat outbreak. Unlike the three 'medical' investigations, Shah's book is a sociopolitical inquiry.
Vrlulc technical issues are discussed, the canvas is much wider.
Today, we do know that there was a very small outbreak of pneumonic plague in Surat. Shah's
book tells the story of why and how plague occurred in Surat. The author does this by studying the
political economy of the crisis rather than the microbiological data. By looking at the problem from three
angles - hospital data from Surat, town planning and development, and a sociocultural study, Shah adds an
important, yet ignored piece to the story of plague in Surat A brief summary of the background and the
outbreak, as described in the book, will be useful at this stage.
The Background
Surat’s history goes back to 300 B.C. Its stagnation began after it was taken over by the British in
1759. But it has been growing again since the Und World War and in the last 30 years the population has
increased four times to 14.91 lakhs. Yet in 1994, Surat had no elected Municipality. It was run by a
part-time administrator from Ahmedabad. The traditional business of Surat was -Jari and hand-loom. Jari
continues while the hand-loom industry has been converted into power-looms by a process which made
use of government subsidies and legal loopholes. Power-looms have increased 200 fold to number around
200,000 today. Since 1958 there is also a diamond cutting industry which employs mostly Saurashtrian
Patidars and Prajapatis. The textile industry uses immigrants, especially those from Maharashtra. Wages
are poor, employment is through contractors and unionization is effectively prevented.
Though statistics from Surat showed a felling IMR (22.9 in 1990) the picture was still dominated
by infections like malaria, acute respiratory infections, diarrhoea and TB. Epidemics of malaria, diarrhoea
and jaundice occurred every year. Surat's health budget was 15% of its total budget, comparatively better
than the state governments 2.16%. There were 2 government hospitals - the Old and the New Civil
Hospitals (NCH) with 740 beds in all. Only 60% of these were in use at any given time. Teaching posts
were vacant for years on end. The laundry and the waste incinerator of the hospital were nonfunctional.
There were 8 municipal hospitals with 421 beds. Only 13% of patients used public hospitals. Other
facilities included 12 charitable hospitals with 1095 beds and 288 private facilities with 2788 beds. There
were 713 consultant doctors and 1155 general practitioners in the private sector. Medical facilities were
concentrated in the city centre; the northern areas were underserved.
Background paperfor the MFC Meet, Jan 1998
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The Outbreak
On the 19th September 1994, three patients with high fever were admitted to the NCH. As they
were being treated for malaria, two died. On the 21st, it was found that the third patient had symptoms
more like pneumonia. Earlier reports of bubonic plague in Beed in August 1994 made the doctors suspect
plague. Later sputum microscopy showed the pink 'safety pin' shaped organisms suggestive of Y. pestis.
The municipal hospitals were informed of the diagnosis but told to keep the news a secret This triggered
panic. All suspected plague patients were transferred to the NCH. At first they were kept in the Isolation
Ward. Later the whole hospital was reserved for 'plague' (suspected or real.) Some 68 patients fled the
hospital and finally the Rapid Action Force was posted to prevent any further escape of patients!
On the 21st night itself there was panic. Rumours that the drinking water system had been
poisoned spread in tire city. Since the Muslims of Ved Road had suffered in the 1992 communal riots,
some Hindus thought that the water had been poisoned by die Muslims. Later die Muslims were to
comment that it was Allah's wrath and so Muslims would not be affected by the plague. But these were not
commonly held beliefs.
The most affected areas were the flood prone northern parts of the city. This included an area
called Ved Road with a large population of diamond workers. In the south of the city cases appeared to
have been clustered close to die Navsari Road. Here the textile workers were the most affected. Both the
north and the south were dominated by slums fzoopadpattis' with poor sewage disposal and drinking
water scarcity.) In the crowded Old city and the middle class areas west of the river (places with better
civic amenities) there were only scattered cases.
76% of the doctois fled Surat They were followed by 80% of die residents of 'apartments'
(high-rise) in the north of the city. The government provided 250 buses for those fleeing. By the 29th of
September, one third of die city population had fled. Those who remained started wearing handkerchiefs
as masks. In the rush to protect themselves, 95% of the population bought and consumed tetracycline
capsules (only 5% took die proper dose.) Most social groups responded by distributing medicines, masks
and information regarding garbage disposal. There were also protests against dififerent representatives of
authority and agitation against the government, and against doctors and drug shop owners who failed to
provide the drugs. People felt that the Municipality was responsible for the crisis. Some felt that the flood
was the cause. A few felt that industrialists should pay to clean up the pollution they created. Locals and
outsiders each felt that the other was more responsible. One interesting story written in Gujarati described
a doctor couple; the husband, a private practitioner took their child and fled while the wife who worked in
NCH stayed on at her post to treat the victims. Why did people flee? The doctors probably because they
were unsure of how to handle the epidemic and feared public backlash. Many of those in the city were
from the upper castes and were from outside Surat They also faced pressure from their relatives
elsewhere. The public very likely followed the doctors in a mass panic response. Why the fenr even in
those who stayed back? Only very few would have had family memories of the "Marki Mahamud' in Surat
in 1896. At that time people used to die suddenly of plague. Many in 1896 had left the villages and had
gone to stay at their farms to escape the epidemic. In 1994, some may have read accounts of plague in
novels like Camus's "The Plague" or in Gujarati short stories. Annual floods and the prolonged civil unrest
in Surat in 1992 had promoted uncertainty and frequent migration from the city. All this may have
contributed to the low morale of the city inhabitants.
Management of the crisis
There was striking crisis of confidence in the government among both the rich and poor. Few
believed the official reports and in fact, the government itself tried to keep the lab results "secret" Drug
Background paperfor the MFC Meet, Jan /998
2
V
supply was also erratic. Junior doctors at NCH had to approach private sources for drugs. While the NCH
doctors worked hard during the epidemic, there was much confusion. The hospital worked like a military
establishment; patients were kept back by force. The government was in confusion as to whether to seal
the city. Anyhow they formed a surveillance team who gave prophylactic tetracycline to contacts of known
plague cases and sprayed their houses with BHC. However, they did not get reports of all the deaths from
the private doctors.
Morale among municipal workers was low. Few reported for work. They were seen handling
carcasses and garhnoe without masks & gloves. The government also panicked as the international media
blew up the story, inflating figures and causing panic among business and tourism industries. Local
government officials were made scapegoats. Some were transferred, others retired prematurely. All this
did not restore people's confidence in the government When elections were held 9 months later, the ruling
Congress was voted out of power. Interestingly, the next administrator worked to clean Surat and today it
is reported to be India's second cleanest city!
The way Surat crisis was managed, in many ways, was a striking replay of Bhopal: the
unpreparedness, the panic, the secrecy, the plethora of conflicting reports of the casualties, the lack of
leadership in crisis management, the inability to cut through bureaucratic hurdles and the poverty of
epidemiological data on the health impact of the problem. Though ten years separated Bhopal and Surat,
very little apparently has been learnt from the earlier disaster.
It is possible to look at "Plague in Surat" through the eyes of an epidemiologist One could look at
Agent related factors, Host related factors and the Environmental factors.
Agent related factors: Y. pestis, the plague bacterium, is carried by the rat flea and mainly affects rats.
Large scale displacement and death of rats must have occurred before the outbreak. Usually plague is
carried by wild bandicoots and these must come into contact with domestic rats before the disease enters a
town. In September 1994, the gates of the Ukai reservoir was opened. The resultant flooding of the Tapi
river lead to a flash flooding of Surat Flood water remained in the city for 4 days. The flood displaced the
accumulated filth which the town rats lived on. The Ved-Katargam areas were badly affected. When the
flood waters receded, garbage, dead animals and sewage were left behind.
Host related factors: It was the immigrants who were mainly affected. They lived in slums mostly and
had arrived in Surat over the last 40 years to work in the diamond and textile industries. Their lack of
resources was a result of the policies that keep labour cheap. The efforts to concentrate industry in Surat
compounded the problem of overcrowding. Surat's industry picked up when the textile strike affected
Bombay and business interests in Surat sought to keep migrants divided according to caste and place of
origin. This effectively prevented the rise of worker groups who could demand better amenities.
EnviromneaCal and Developmental factors: Small congested workplaces (diamond work was done in
rooms without windows "to prevent theff) as well as the crowds at the Ganapati festival may have
contributed to the rapid spread of pneumonic plague. In a sense this drives us to the same conclusions as
Shah's. Epidemics are not just medical diseases but a reflection of India's politics, economics and modes
of development. It reflects our national priorities. While agricultural production has increased, land
reforms have lagged far behind. As a result there is an increase in rural poverty and a consequent
migration to the cities. Textile and diamond industries are good examples of how the export-oriented
policy adds to the problem. The profits go to the rich in our country and their partners abroad. This keeps
prices low there while it keeps wages low for the Indian worker here. Who really benefits from increased
exports?
Background paperfor the MFC Meet, Jan 1998
3
>
Our industrial policy gives priority to small scale industry to facilitate rural development Wealthy
families have exploited this by keeping the industry divided into small units in the names of different
family members. By converting hand-looms to powerlooms, the size of the work force has been kept
down. The policy does not deal with workers' incomes, benefits or amenities. Has this industrial policy
actually led to rural expansion? Our Urban Policy is regulatory, not constructive. There are no restrictions
on economic development The elected Municipality in Surat had been dissolved in Surat and there was a
part-time nominated Commissioner at die time of the epidemic. Infrastructure development depended on
state and central government grants. These were always low. Tax evasion keeps the income from property
tax and octroi low. There is a flourishing smuggling and liquor business. A nexus between politicians,
businessmen and lumpens results in land grabbing and the tax evasion. This paradigm of uncontrolled
urbanization - by increasing rural poverty, government subsidies being diverted to the towns, export
orientation not benefiting the workers and poor infrastructure in the city - raises many questions.
Have we seen the last of plague?
Shah's book convinces us that Surat was in no way different from most Indian towns and cities
and what happened in Surat can easily happen elsewhere. Urban decay, collapse of public health and
inappropriate urban development is plainly visible. Wild rodent plague foci exist in many areas and, in the
absence of good surveillance and an effect public health system, it should not surprise us if plague
occurred again. Indeed, plague itself is a mere reflection of the resurgence of many infections in our
country. Outbreaks of malaria, dengue, cholera, leptospirosis and multi-drug resistant typhoid are common
events today. Some of these are even considered ’normal1 or ’usual.’
Plague in Surat warns us of a series of epidemics that we may face due to environmental
degradation and the pattern of uneven development As the author puts it so well, "plague is not merely a
biological disease... it is the symptom of unplanned growth that disturbs the ecology and the environment
and uneven distribution of resources that weakens the social fabric...it is the nadir of urban chaos and
breakdown of the public health system." The current health system is lopsided, hospital based, oriented to
curative services and unavailable to the poor. Only government support can help to reverse these trends. A
rational urban policy is called for. Industries need to pay for the rehabilitation of the migrants they draw to
the cities. Industries depend on these migrants for their profits. Local communities must have power to
control land use, decisions and the planning process. The government should be more transparent in its
dealings. Disease surveillance should be improved. More details of this is to be found in the report of the
TAC on Plague. This along with the NICD and WHO reports for valuable appendices to the book.
Have the middle class and professionals become more self centered in recent years? Is this
self-centeredness, along with 'development,' promoting the occurrence of epidemics; through die lack of
civic sense, the ability to live in a dirty street if our home is clean. Does this self-centeredness affect our
responses in crisis - the urge to flee, the lack of a sense of duty, the desire to control the unwanted from a
distance? Gandhi felt that the problem was older. He spoke of untouchability being the root cause of
"insanitation of our streets and latrines." "It is a matter of sustained education" he says. "Ingrained habits
handed from generation to generation do not yield to persuasion." One may look to the unpleasant past, a
past that even Gandhi rejected, for the reasons. Or one may see in the alienation of people in big cities a
sign of what the future will hold. But whatever your persuasion, it is difficult not to agree with Virchow
who said "epidemics are like signposts from -which the statesman ofstature can read that disturbance has
occurred in the development ofhis nation that even careless politics cannot afford to overlook."
Background paperfor the MFC Meet, Jan 1998
4
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