Title

Contextualising Plague - A Reconstruction and an Analysis

Creator

Imrana Qadeer

K R Nayar

Rama V Baru

Date

1998

extracted text

■

J

1ST
SPECIAL ARTICLES

Contextualising Plague
A Reconstruction and an Analysis
Imrana Qadccr
K R Nayar
Rama V Baru
A reconstruction of the plague epidemic glaringly portrays the dichotomies in public health and provides lessons foi

I

the future of its practice in this country. The classical approach, which is mainly sanitarian, at best reduces epidemics
to an endemic status. If public health is to go beyond this truncated objective, then it calls for a systemic understanding
of the problem which would involve evolving a muhi-pronged strategy firmly entrenched in the socio-economic context.
to this disease from 1977-88 shows a cop.
there were 250 deaths due to gastro-enieritis.
sistent rise. Diseases like malaria and ka.
Infective hepatitis has claimed several lives
azar arc showing a resurgence despite elabt
in Delhi and a few years ago an epidemic
rate national programmes lor their control
of Japanese encephalitis claimed hundreds
The data on incidence of cholera and death
of lives in Tamil Nadu and West Bengal.
due to it indicate that there has been link­
Several districts in western Rajasthan are
change in the status of this disease since
under the grip of malaria. According to
19X6. Until 19X7. the ministry provides data
reports this epidemic of malaria has claimed
on cholera, gastroenteritis and dysenterover 500 lives and over 60.000 positive
cases of this disease have been detected from
(Table 2). From 19XX onwards the categoric
this region. The worst affected districts arc
include cholera and acute diarrhoeal disease
Bikaner. Barmer. Jaisalmer and Jodhpur.1
and from 1991 the report only includes case
and deaths due to cholera. Given the large
While some epidemics get reported, many
have gone unnoticed. The deaths due to
number of cases of dysentery it could no',
possibly be included in the reporting o!
blood dysentery in Bastardislricl of Madhya
acute diarrhoea for ihe years 1988-91. For
Pradesh and cerebral malarial deaths in
Bikaner district of Rajasthan two years back
the years 1988 and 1990. according to the
are cases in point. Thus many ol the epidemics
ministry reports, there were 82.60.946 cases
that have occurred like kala azar. cholera,
and 7.290 deaths. 95.79.738 cases and 8.63?
gastro-enieritis, malaria and now. plague
deaths due to acute diarrhoea, respectively
have essentially become endemic diseases.
The deaths due to acute diarrhoea was 35
Deaths due to these epidemics often do
times that of cholera deaths in I9XX and 99
not get reflected in the official statistics.
limes the cholera deaths in 1990. The
This is due to inadequacy of the health
significance of this omission is self-evident.
information system which results in under­
Ol the total cholera cases reported, about
reporting and in some cases even non­
88 per cent were reported from the coastal
reporting of certain diseases. This is a serious
states of West Bengal. Onssa. Andhra Pradesh
lacuna ol lhe system. Despite these
and Tamil Nadu Even Delhi, the capital city
limitations, lhe trends in number of cases
with all its amenities has been witness to a
and deaths for certain communicable
steady increase in choiera cases and deaths.
diseases, bused on official statistics arc
Since 1983 there has been a steady increase
revealing.The numberof reported casesand
m the number of cases of gastro-enieritis. In
deaths due to malaria and kala azar has been
I98X there were 14.712 cases and 624 were'
I
showing a steady increase. According to the
confirmed cases ol cholera with 181 reported
Health Information bulletin brought out by
deaths (Table 3). In the Health Information
Resurgence of Communicable
lhe ministry ol health in 1992. the maximum
of India. 1989. however, the recorded deaths
Diseases
number of malaria cases per year were
were reduced to eight.
Over t he last decade, a nu tn her ofepi demies
reported between 1971 and 1976.- After its
have broken out in different pans of the
resurgence, deaths also started rising from
II
country, resulting in thousands of deaths.
1974 onwards. From 1977 lhe number of
Plague. 1994
The number of such outbreaks seem to be
malarial case registered a decline, but the
on the. increase.and. is fast becoming a pan
number of deaths-continued to rise till the
There has been no case of reported plague
of the disease profile of this country. A
mid-XOs. Table I shows that though the
in India since 1967. A few local epidemics
number ol reports have appeared in
incidence of cases seem to have stabilised
were suspected but never officially
newspapers about the repeated outbreak of over lhe mid-XOs. the apparent control over
acknowledged.4 The dwindling resources
epidemics but these very
often do not _
get
_____
the number ol deaths is being lost. The
for public health led to the closure of most
reflected in thcolficial statistics..Outbreaks__ current -••••-"
out“hreqk
in ■Rajasthaoconfirms
this.-— surveillance-units.
Despite warnings
by lhe•'
" -•••*- .<■- •
—.-- - ------------------------------- ----------------- — — I--------------------c---iH -chuiciu and gastro-enieritis have been
/Although the problem of kala azar is mainly
Plague Surveillance Unit in 19X9 endemic
■ reported Iroin Jammu and Kashmir. Madhya
limned to Bihar and West Bengal, more than
states did not improse their surveillance
Pradesh. Delhi. West Bengal and some North
76 per cent of the cases reported are in
systems. Maharashtra had in fact completely
Eastern states. In Jammu and Kashmir alone.
Bihar. ‘ The number of cases and deaths due
closed down its surveillance unit. The signals

NOW that the frenzy of the plague has
waned, it is lime to analyse the socio­
economic and political factors that arc
responsible for the epidemic and the human
suffering it caused. The recent outbreak of
plague cannot be viewed independently of
the recurrent epidemics of communicable
diseases from different parts of the country,
claiming thousands of lives. The immediate
impression that remains in one's mind is the
fear and pathos of human suffering and the
half-hearted response of the administrators
and politicians in dealing with the situation
What is fairly evident is that the government
was much more concerned about the
economic losses incurred, the poor image
presented of India by the western media, the
effect it would have on exports, the tourism
industry and the possible withdrawal of
investments by multinational corporations.
Given these concerns, the government was
more preoccupied with retrieving India’s
image abroad and I ailed to use the principles
of epidemiology to assess, control and
provide relief to alleviate human suffering.
This paper looks al the resurgence of
epidemics over the 1980s and locales lhe
plague epidemic by the stale, based on
newspaper reports and some interviews, in
order to explore lhe complexity behind us
inefficient handling. Finally, the politics of
plague and its consequences arc explicated.

t

Economic anil Political Weekly

November 19. 1994

2981

lor alert by the 17th Inter-State Plague co­
ordination meeting in 1993 thus went
unheeded even though they were based on
lhe findings that rodent positivity for plague
infection was rising.
The earthquake in Latur became the turning
point. There were rat falls and increase in
the number of fleas in Mamla village from
where the first case was reported. By mid­
September Beed district was reporting
bubonic plague. It spread to lhe surrounding
areas, yet all these were insufficient lor lhe
authorities. They did not take nature’s
warning seriously. The continuous rain in
Surat and lhe floods in Tapti inundated
localities and killed catlie. the carcasses of
which were scattered around lhe town. This
could not be passed off as a ‘natural disaster’
even by the administrators and politicians.
By September 20 deaths from plague had
already become a reality. From lhe inundated
areas near the Tapti it spread to lhe rest of
iA:y and forced people to flee. An exodus
oFTiboui 1 million people out of the 2.5
million population was reported. Rifts
between Sums and non-Surtis. lhe moneyed
who could run away and the poor who were
trapped, lhe administration and its workers
were all rooted in lhe fear of lhe dreaded
disease and the suffering of its victims.
Two things that left an impnni on lhe
history of public health in India were the
acute misery and lhe blind fear despite lhe
availability of curative as well as preventive
technologies. Second, the total collapse of
health administration. But for those dedicated
few who stayed and suffered with their
patients, the majority of the personnel
preferred to take leave or run away: For
those who have consistently argued lhat the
existence of technology is reason enough for
being optimistic about lhe future, this should
provide some food for thought.
^Many explanations Jiavc been offered for
t^^alamity in Sural. It is said that lhe fast
growth of the city, its expanding slums (just
next to lhe opulent mansions of lhe diamond
. merchants) its inadequate infrastructure and
the additional strain of lack of resources for
ci vi v services were at lhe root of the disaster.
The succumbing of Sural is thus explained
by its inadequate infrastructures manned by
an apathetic, indifferent and callous admini­
stration. What is not explained is the
behaviourof the capital city. While Bombay
managed to step-up its surveillance and took
lhe possible precautions against plague, Delhi
continued with its false sense of security.
Even though it was clear that lhe fleeing
population from Surat was headed in all
directions, the Delhi administration chose to
ignore the threat.

Delhi Epidemic
While the city administration was still
trying lo get its act together, three suspected
cases were admittedto the Infectious Diseases

2*182

Hospital (IDH), two coming from Gujarat
ment got its first beating Police force was
and one from Bombay. Of these, two
mobilised to gel back lhe absconding pa­
admitted on September 25 tested positive
tients, and armed police also guarded lhe
and heralded the onset ofthc plague epidemic
gates of IDH to ensure (hat no one left the
in Delhi. To control its spread, apart from
hospital without a formal discharge
lhe booths al railway stations and other entry
The government of Delhi invoked Section
points, ten zonal plague control rooms were
385 of the Delhi Municipal Act 1957. under
set-up in the city. All hospitals w-erc directed
which plague has been declared a dangerous
to refer suspected cases to IDH A list of disease. The act empowered lhe government
dos and don’ls was published. Voluntary
to forcibly shift persons suffering from plague
groups were also called upon to educate the
to an isolation hospital and file criminal
public in addition to lhe various official
cases against those who go against the
committees and meetings at the state and
provision of lhe act. After this, there were
central level.
reports of not only police harassment and
Taken aback by the calamity, the health
patients being lifted from their homes without
secretary and the Director General of Health
attendants but also of suspecting neighbours
Services came up with lhe typically
calling control rooms to report non-existent
bureaucratic response. While Mehta, the chief
‘cases’. The use of force came easy to an
minister of Gujarat, denied the diagnosis of administration that knew no other way to
plague in Sural even when people were
reach out to people.
dying, the central health bureaucracy loo
By September 30 it was clear that not all
were reported to have made a press statement
cases of plague in Delhi were from outside.
that cases tested sputum negative could be
Of the 66 cases suspected till 29th. 26 were
called plague.5 Sojne others raised the issue ■ permanent residents of Delhi. Of them 17'
of diagnosis, included WHO’s nonhad neither visited Sural nor met anyone
acceptance of the hacmagglutination test as
from there. Of the 66 cases 25 were from
confirmatory. Fortunately, at that time lhe
Sural, three from Bombay, (wo from
director of the National Institute of Ahmcdabad and one each from Noida.
Communicable Diseases (NICD) clarified
Muzaffarpur and Chandigarh
that a negative sputum is possible in a partially
Another critical factor was that according
treated case. He also clarified that haemagto the reports, "‘all patients from Delhi had
glutination test may not be as sensitive as
symptoms of bubonic plague with well
lhe fluorescent antibody test but it was
developed buboes in the groins and high
reliable. The latter was expensive and needed
fever. Lung infection in all these cases was
costly reagents. Though it was reported that
minimal”? A follow-up of this report, later
the government had ordered lhe required
confirmed by the IDH personnel, pointed
reagent from a Colorado-based US manu­ out that out of the 69 cases among the
facturer through the WHO and it had arrived,
residents of Delhi till October 11. 37 were
no information was available on its use in
indigenous. Of these 37, 14 had palpable
actual diagnosis.
lymph nodes. However, none were fulminant.
On Monday, September 26, Ram Sumer,
Except for the confirmation of one case,
the First case of bubonic plague was admitted
reports for the others are not yet available.
to IDH. The laboratory confirmations of Clinically, lhe diagnosis of bubonic plague
Ram Sumer’s ailment hit headlines on
cannot be ruled out and it is only reports
September 29. By then the total cases of of the buboe aspirate that will confirm the
plague had risen to 35 and admissions to
diagnosis. All these cases were serologically
IDH had started increasing at an alarming
positive for plague.
rate. The possibility of bubonic plague only
With this scare the drive for cleaning the
added to this pressure. When four patients
city was intensified, the Rajan Babu TB
left lhe hospital against medical advice on
Hospital located next to IDH was directed
grounds that the conditions in the hospital
to make 500 beds available to IDH for
were inadequate, the image of lhe govern­ admitting suspected plague cases. Efforts
Table 1: Notified Cases of Cholera, Malaria. Kala Azar and Japanese Encephalitis

Year

1986
1987
1988
1989
1990
1991
1992

Cholera
Cases

Deaths

4211
11423

71
224
215
72
87
150

8957
5044
3704
7088
na

Malaria

Cases

Deaths'

1-792167... 323
1663284
188
1854830
209
2017823
268
2018783
353 .
2120472
421
---- na

Kala Azar

Cases

Deaths

14079+
19179+
22739
34489
57742
61438
na

47+
77+
131
497
606
869

Japanese
Encephalitis
Cases
Deaths
9080
1596
3304
16384
22263
3511
2984
16757
2290
11995
905H^H685*

+ Figures only from Bihar Chief Malaria Office, Swasih Bhawan. Patna; _• Uplill November 1992
Source: GO1, CBHI. Ministry of Health and Familv Welfare, Health injorniaiuiit-of India. New
Delhi, 1993.

Economic and Political Weekly

November 19, 1994

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were also made to make let racy c I i no capsules
available in the market. Despite this, hoarding
and profiteering continued and pharma­
ceuticals made their profits out of the
widespread fear of plague.
Table 4 shows the numbers of suspected
and diagnosed cases in Delhi. The largest
number of patients were admitted between
September 30 and October 4. After this, a
significant decline in admissions indicated
that the peak was over. Till October 11, a
total of 69 cases were diagnosed as plague.
The ultimate picture of spread that emerged
is one where except for some clustering
around one to two kilometres of IDH, the
rest of the cases were scattered. None of the
better off or posh localities were affected.
For example the scattered cases came from
Mangolpuri. Madangir, Okhla. Munirka,
Mohammadpur. Nangloi and Shahadra. The
areas affected around IDH were from
Malkaganj. Azadpur, Jahangirpuri. Santnagar and Mukherji Nagar. The key factors
affecting the course of the epidemic appear
to be the scare which led to early reporting
and timely treatment and extensive use of
tetracycline.
By October 3 plague was overshadowed
by political violence. Media attention shifted
to Uttarakhand and from the head-lines
plague receded to the inner pages and then
into the cradle of the weekly magazines. Il
appeared as if plague was no longer a
problem. The health ministry' officials, who
otherwise express tremendous concern about
information education and communication
(1 EC). never actually set up an independent
information system. The shift of media's
attention was therfore to their advantage and
they did not have to answer uncomfortable
questions. The questions however, remain.

and the Delhi state’s first political rulers.
The All India Institute of Medical Sciences
(AllMS) an autonomous institution directly
under the health ministry, ignored the state
government’s directive to refer all suspected
cases to the IDH. Only when two of the
AIIMS patients died of plague on 25th. the
hospital authorities were forced to acknowl­
edge their reservations. They are reported
to have said that they were waiting for a
formal letter. The hospital was then instruct­
ed by the union health ministry itself not to
admit patients suspected of plague and to
refer them to IDH. When AIIMS did refer
Sushcela Devi, a patient who had tested'
positive tor plague on Friday, the hospital
did not provide her an ambulance and she
never reached IDH. It was only later that
Delhi’s health minister thought of instructing
hospitals to ensure requisitioning of CATS
ambulance to send •patients to IDH. Doordarshan continued to show the garbage
dumps in different parts of the’ eity as a
visual critique of the Delhi state authorities.
It was obvious to the viewers that rubbish
collected over years of neglect could not be
cleared overnight.
The Delhi government on its part kept on
complaining.that their hands were tied as
"the centre docs not allow us to provide
sanitation and develop juggi clusters and
unauthorised colonics".’ According to M L
Khurana. such a directive was 'absurd' and
disastrous for (he city. He may be absolutely
right but it was surprising that il took a
plague epidemic to make him see the
obviousness of his statement. That he had
not bothered to lake up this issue earlier and
was only now planning lo write to the prime
minister (Pioneer, October 2) reflected the
degrce”of his interest in the welfare of 40

lakh people living in jhuggi-jhopns and
unauthorised colonics.
The five-day drive for cleaning the city
taken up by the Delhi government lacked
It was only when people from Surat
a long-term perspective. It only meant
started trickling in. (hat lhe administration
removing garbage from one locality to
woke up to the possibility of a danger. A
another The centrally-located VIP areas got
'red alert* was declared on September 23.
the maximum attention while the peripheries
It essentially meant setting up booths on
of the city collected more garbage. The most
airpons, railway stations and bus stops for
crucial actors in recycling” and reducing the
checkups, alerting the embassies and advising
quantity of garbage - the rag-pickers -were
sprays. The Delhi chief minister’s
banned trom touching it! It was reported Liat
contribution to plague control was setting
they tend to spread garbage hence the police
up a committee to supervise anti-plague
was alerted, informed and told to check rag­
activities under the chairmanship of the chief
pickers. No one bothered to explain how
secretary. The directorate of health services
garbage was critical for the spread of
set up its own cell to monitor plague in the
pneumonic plague or was Delhi ready
country. It was expected that lhe two-would
threatened by bubonic plague? Why garbage
co-operate as far as Delhi's requirements
piled was better than garbage recycled by
were concerned. IDH was spruced-up to
lhe rag-pickers, and which was more
receive cases from all over the city and
dangerous, burning piles of plastic bags
NICD was to do the epidemiological
emitting carcinogens or the possibility of
monitoring and laboratory testing.
...taking tetracycline .in case, of .plague?
The events' over thef'hekfTaniays as they
There was. however, news of the govern­
unfolded revealed that petty political com­
ment exploring possibilities with garbage
petition preoccupied the Central Authorities
recycling foreign companies for setting up'

Administrative. Professional and
Political -Response

Economic and Political Weekly

November 19, 1994

plants in India. If the non-functional Dutch
plant in Delhi is any indication, these
tcchnologiesoffcrnosolution to the problem
of garbage disposal.
Despite of red alert, till as late as September
29 a truck load of people were reported to
have come into the city from Gujarat. The
check-posts were obviously ineffective or
inadequate. It was without any prior notice
or explanation that the schools were closed
on September 30. The explanation later
offered was that surveillance of children was
difficult and they were more susceptible.
However, no attempt was made to stop the
immunisation drive where hoards ofchildren
were collected. Those in charge of the
immunisation campaign went around
advising parents to bring in their babies even
if the child had received a dose two weeks
back. This might be the strategy of a ‘pulse
programme’ but could this be rational under
the threat of a plague epidemic?
In addition to the above, the medical
community contributed to the confusion
through its own lack of confidence. Not only
did they advise different doses of antibiotics,
different modes of isolation and differed on
the most effectivedrug, somealso considered
it wise to raise technical issues regarding the
existence of an epidemic, the accuracy of
tests being earned out at NICD and its
acceptability io WHO. According to NICD.
antibody fluorescent tests could not be
performed on all cases as the reagents were
expensive and unavailable. A number of
suspected cases coming from Surat had
already taken antibiotics and that loo made
Table 2: Cases of Dysentery and
Gastro-Enteritis in India

Year

Cases

1982 8995226
1983 8274724
1984 8469834
1985 8742177
1986 7658399
1987 8741081

Dvsenierv____ Gastroenteritis
Deaths
Cases Deaths

2551
2513
2370
1937
1583
2)09

1015175
1095944

143844
144141 1
1220237
13338594

4076
5796
6688
4996
3580
2109

Source'. NIHFW. National Programme for
Control of Diarrhoeal Diseases. New
Delhi. 1988.
Table 3: Cases of Gastro-Enteritis and
Cholera in Delhi in 1980s
Month/Year

Gastro­
enteritis
Cases

July 1983
July 1984
July 1985
July 1986
July 1987
July 1988

S.26O
9.967
8.805
8.141
6.372
14.712

Confirmed
Cholera
Cases

128
157
57
624

Deaths

67
123
80
90
115
___ 181

Source: V H AI. Ci vi< • Negleet and ILL Health: A
BriefInuuirv into the Cholera Epidemic
in Delhi. New Delhi. 1988.

29X3

7

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pandals’ had been erected and markets
Bombay) received double the amount ol
clinching the diagnosis difficult. In such
were overflowing with unsold goods. Per­
resources in 1991-92 as compared to Delhi,
conditions using strict technical definition
haps under this pressure, schools closed on
in the year 1992-93 the actual allocations
actually amounted to negating the existence
September 30 were reopened on lhe October
were revised For Delhi, it roc and for
ol plague.
4. This decision was taken on October 3. Il
Maharashtra it declined thus further
Through this chaos the central health
is obvious from Table 4. that there was no
narrowing the gap between Delhi and
minister and the director general of health
significant change in the reasons given by
Maharashtra as a whole. Despite Delhi's
services kept telling the public that there was
the directorate initially tor closing schools.
wealth, poverty of initialise, lack of
no cause for concern as they found everything
To add to the disarray, private schools were
administrative cohesion, absence ol a well‘satisfactory' and ‘under control’. Instead of
allowed to remain closed while lhe govern­
worked out strategy, public health
realising that 30 per cent of the suspected
ment schools mostly located in lhe less
incompetence and the callou.-aess ol its
turned out to be positive where there should
privileged and Icssclcuncr surroundings were
political elite are glaring
have been none, they chose to emphasise
ordered to reopen!
that 70 per cent patients reported as suspected
Some Issues
Once the schools reopened plague
cases of plague, proved negative. The
disappeared from the front pages of daily
The epidemic has abated but it has certainly
government, according to them, had done
newspapers. Delhi resumed its false posture
not disappeared. While the pok’.rcal leader­
its best The ministry officials were reported
of normalcy. Thus, even though 306 newship will have to assess the helmsmen it
io have said that 'vested interests’ were
cases were ad ini lied as 'suspected cases’ till
chose for public health, a few simpler admini­
responsible lor the panic within, and over­
October 6 - bring lhe total such cases to 514
strative lessons have to be learned For
reaction outside the country. While the health
according to Delhi‘s chief minister (Pioneer,
example.
minisicr chose to -keep quiet on the issue,
October 6) - lhe health minister claimed that
(i) Public health activities require large
his deputy. Ghatowar was given lhe task of
lhe "disease has been checked".
but active organisations. If the system is not
defending the ministry
WHO too came to government of India’s
geared to go into full action when required
Ghatowar made the best ol a bad job and
rescue. All through it reminded lhe press that
then il loses its public health .significance
made a lew revealing statements. These
plague never was eradicated even in the US
as it is overtaken by events
dearly reflect lhe unn-pcoplc altitude of the
and that it was curable II offered its
(n) Though il appears to be simpler and
government. According to him. "in a country
’expertise' but never commentedon lhe need
cost-effective to centralise services, the
with financial constraints like India we cannot
to guar up lhe infrastructures through which
trouble with the strategy is that it increases
always adhere to whatever the experts
any experts were expected lo function the risk of infection, makes p./.icnts travel
suggested as ideal". He claimed that lhe
Indian or foreign.
long distances and is inconvenient to their
experts hud not warned them of a 'high risk
In briel lhe lethargic reaction of health
families
“Tactor’. Il is obvious then that lhe findings
administrators, its contradictory acts and
(iii) Burden of care on N’ICD and IDH
ol lhe PSU. the warnings ol the meeting of
statements, inability ol most professionals
Inter State Plague Coordination Unit and
would have been lessened i I the city's premier
lo rise up to lhe challenge, lhe obvious
medical colleges and other specialist hosNICD fell on cars that had already decided
efforts of politicians to underplay the problem
to be deal.
became so obvious that even lhe middle
The confusion created by the 'experts’,
Table 4. Reported Cases o.1 St specied
class lost its confidence and panicked.
the inadequacy of practical knowledge of
Plague in Delhi
Under
pressure
of
this
panic
and
the
need
plague among most doctors and lhe fact that
Dale
Daily
Cumuia- Cumula­
to retain some credibility wit hits international
there were till October I only 23 positive
Admis­
tive
donors, the government look some measures
cases, emboldened lhe government to
sions
Total
Total
and was duly rewarded. The US and lhe
underplay lhe calamity. The central governat IDH
SuspeuTested
menl'srepresentative Ghatowar was reported ” European Community look a lenient view - —.
---- ted Ci'cs
Positive .
of the epidemic. Whether it was to let their
to have said that "Plague, gasiro-emerilis.
September 24
I
saleable goods How into the Indian market
cholera are not extinct either in India or in
2
September 25
or to build a political alliance against its
countries such as the US. China. Peru. African
n
September
26
2
states, etc. Gasiro-enteritis is a natural pheno­
perceived ideological opponents (the Islamic
September 27
17
4
bloc) or because of superior infrastructures
menon arising out of contaminated waler,
September 28
13
20
which ensure strategic preventive inter­
bad sanitation, so why ask us. ask the rural
September 29
19
vention is a matter of detail. The real issue
development ministry, the urban develop­
September 30
I 19
I 99
23
ment ministry-wc are doing our best lo cure
is that their benevolence gave the Indian
October I
189
•88
politician yet another chance to get away
25
lhe afflictcd."”Thus he did his best to make
374
October 2
IIS
October 3
with murder.
38
plague look common place, look no respon­
October 4
44
9)
645
The cinema halls reopened on September
sibility for prevention but only for cure and
October 5
SO
70
10 to soothe the short memories of its
pretended as if the failure ol other ministries
October
6
62
>22
50
residents. For the Imai burial of the event,
was not the government’s concern!
October 7
49
an expert committee was set up. Even the
The officials and lhe politician showed
October 8
54
22
ltU3
press has been attacked for its exaggerated
greater concern for dwindling business export
October 9
6
reporting. In short. Delhi has done all it
of food and garments, the "image of India
October 10
12
could, to muddle through the plague
abroad" and the inflow of international capital
October 11
69
epidemic. Its actions become unenviable •••
rather than human suffering and deaths. Thu
Note:
Cumulative suspected cases from October
when seen against the enormous resources
Export and Manufacturers Association
4, 1994 are obvious underestimates as
that il consumes compared to the states of
secretary is reported to have said that the
the daily admissions at IDH alone add
Gujarat and Maharashtra (Table 5).
term plague has a historical connotation for
up lo more than the cumulative cases
In
199
1
-92
Delhi
received?
17.6
lakh
more
our European partners and they panicked.
reported for a day. This may be due to
than
the
whole
of
Gujarat.
In
the
following
There was pressure loo from the smaller,
_______ non-inchision of discharged patients
two years this gap became much larger.' Source: The Times of India. H:mltisltm Times.
business in the capital.- -The season of
Similarly, while Maharashtra (including
Statesman and IDH rufsirts.
festivities was good for their business. ‘Puja

ir-”-"'.7 2984

Economic and Political Weekly

November 19. 1994

pitals had been mobilised. Instead of simply
lo be increased. Second, that public health
eragc norensure regularity of treatment which
criticising the working of these two hospi­ services have been undermined and need lo
is critical lo the Tuberculosis Control
tals they could have been used more effi­ be strengthened. These twin problems of Programme.
ciently.
dwindling resources for health and declining
The Blindness Control Programme also
(iv) An effective public information system
standards of public health are intimately
registered increased outlays. According to
should have been in existence. Information
linked with (a) structural adjustment policies,
lhe government, the emphasis of this pro­
of admitted and discharged patients on a
(b) lhe evolution ot public health in India.
gramme is on cataract surgery" and investing
daily basis along with maps of affected areas
(c) lhe patterns of urbanisation. We briefly
insupcrspecialist.scrvices rather than treating
would have helped people practise prescribed review here, each of these areas.
ophthalmic infections which arc (he second
dos and don’ts better.
major causes of blindness, specially among
S
tructural Adjustment
(v) Though thcmediadid its best to publish
lhe younger age group. Between 1991 and
information, they at limes overdid ii and
The liberalisation policy of the present
1992. the investments in kala azar showed
contributed io the scare among the newspaper government has resulted in the cut-back of a decline of 3.4 per cent and in 1993-94 it
readers. They, however, cannot be blamed,
investments in certain sub-sectors of health.
was merged with malaria control There was
for it was the responsibility of the This trend began even prior to the official
almost a 13 per cent increase in 1993-94
administration to provide detailed, adequate
acceptance of structural adjustment and
outlay for malaria hui this included outlays
and correct information on a regular basis.
investments in health sector have since been
for kala azar and Japanese encephalitis as
(vij Last but not the least, drug control
gradually declining. From the mid-1980s well Even leprosy which was lobe ‘eradica­
of market outlets could have been effective
onwards the government has been culling
ted’ as per the recommendations of the
from the very beginning instead of being an
back on medical and public health with Swaminaihan Committee Report'■ registered
alter thought
increased outlays lor family welfare. During a decline in us proportionate share ot
The epidemiological issues that arise out
the Sixth Plan there was some effort to
allocation despite a marginal increase in
ol the plague epidemic are crucial both for increase outlays for communicable diseases
actual budget.
understanding the epidemic and developing
while the investments in curative services
While reading these plan outlays, two
a strategy lor future. The first and foremost remained stagnant. It is during (his plan
things have lo be kept in mind. Firstly, a
is the diagnostic issue. If plague in Delhi
period that for the first time the government
large chunk of loan from World Bank lo the
was bubonic, then it has serious implications. acknowledged its inability to provide the
health sector has been lied to the AIDS
It means that Delhi loo is carrying a mild
required medical services. Il introduced the
programme. Secondly, lhe over emphasis on
or moderate epidemic in its rodent
idcaol opening up medical services to private ‘AIDS has undermined other communicable
populations which needs to he identified and
and voluntary organisations in order to diseases control programmes What seems
handled along with lheir Ileus. It also partially
supplement government services
to be fairly evident from the trends is that
disprove the assumption that Delhi was
The Seventh Plan not only strengthened
the priorities of the government do not match
.ilfectcd because ol the Surat exodus.
the policies of privatisation of medical care
with the existing patterns ol disease in the
The indications are that plague was bubonic
but in fact raised allocations for family country. Their concern for the National
and the pneumonic manifestations in those
planning by 9 per cent. During this period
Programmes for lhe major communicable
cases were secondary. Il could be due lo the
the investments in medical care remained .diseases is declining while others arc gaining
high rainfall. relatively lower temperatures
stagnant and for communicable diseases, it
priority.
and other climatic conditions in which case actually registered a decline.1"
Evolition or Public Hr.u.ni
it would be with us for some more lime.
During the early 1990s (1990-91) the
To ensure the above, rat fall studies and
health budget was slashed by Rs 32.9 crore
To understand this we have to sec how
Ilea index become indispensable. NICD is
and it was communicable diseases which
public health practice and conteni was shaped
said lo be conducting such studies but the really bore the brunt of this cut-back. Even • in India: Why education and training ol
results are still awaited
, supporters ol lhe new economic policy were ...public health could nol.be. rejuvenated? And
The contusion regarding diagnosis is very quick to point that the indiscriminate cutback
why most diseases of poverty are slowly
critical. The level of sophistication increases on health would further marginalise lhe poor.
sliding down in (he national agenda? A
reliability or detection, but this must noi be
During 1992-93. the outlay lor health was
myriad of factors influenced the content ot
allowed to become an excuse for rejecting
increased by 60 per cent over the previous
public health as it evolved in India, (i) Like
cases in the present situation.
year (Table 5). Much of this increase was
all other professions of that time, public
Social dimensions of the epidemic need due lo a 34 per cent increase for AIDS
health loo was guided by the interests of the
to be focused upon. The vulnerability of the
control with Rs 58 crore being invested lor British. Its concerns were safety of the army,
poor, the implications that excessive fear (his disease alone. There was also a marginal
a select British population and the natives
generated in the middle class, lhe politics
increase for tuberculosis but much of (he
wherever profits were at stake. For example:
of suggestions such as wearing masks m lhe outlay was to be spent on importing a newwhen revenues were threatened, special
buses, instructions to admit all cases set ot drugs for its treatment. Merely committee was set up to examine the possible
irrespective ot the clinical picture and the ’ importing newer drugs without strengthening connection between canal irrigation and
lhe infrastructure will neither improve covMunicipal Act. 1957 are some such issues
malaria.n This was followed by the first
which lead us io examine lhe very scat folding
T
aiii
e
5:
A
nnual
Butxarr
Outlay
ol our mega cities.
t Rs lakhx)
III
. J 993-94.
Year
____ 1.991-92 . _
___ _______
Understanding Chaos
Total
..MNP
Toul
MNP
Total
MNP

There have been two popular responses
to the disaster. First, that the cuts in the
health budget have brought down invest­
ments in this sector from 3.3 per cent in the
-I'trsMww-Five-Year Fktns to-4.7-per-cent in
the Eighth Five-Year Plan and these need

j

i

Economic and Political Weekly

Delhi

Gujarat
Maharashtra

4935.61
2936
6164

1270
4150.76

6500
(6707)
4093
8367
(6433)

7209

1650

4132

6(XX)
(4019)

I06D4

1650
4741

Stiurer-. Annual Plan 1993-94 (Figures in brackets arc revised outlay )

November 19. 1994

2985

i

research' project to control malaria in Mian
multidrug therapy reduces the period of sector. Thus the undermining of secondary
Mir.1* Similarly, public health measures for treatment and increases the possibility of level support structures made achievement
large religious congregations were initiated
intercepting transmission. The working of effective primary- health care even less
plausible. In other words, public health in
despite the well known reluctance to increase group headed by M S Swaminathan knew
government expenditure, because the profits that the treatment ’'effectiveness as a tool for India has suffered due to its substance which
ol private railways companies were linked
achieving early control or eradication of the constrained its practical success and
with promotion of pilgrimage by the natives.1' diseases is yet to be established”. Yet. they undermined its essential infrastructures.
Unlike sanitary movements in Britain, the
launched an expensive programme and the Resources do play an important role but
along with resources the practice and content
socio-economic conditions and living public health experts w-ent along with them.
standards of the people of I ndia never became
Only after successive failures some of public health has to be emancipated.
central to public health. At best practitioners
acknowledged that the strategy was ill
Medical Education
were the army medical doctors who later conceived.”1 Over time then, public health
The relevance of medical education in
manned the Indian Medical Services (IMS).
not only failed to build upon the foundations
The first formally trained public health
laid by the first generation of its practitioners shaping public health is self evident. Bhore
practitioners in India thus got their field
but it also failed to retain what little epi­ Committee in 1946;n visualised the ‘basic
training under these IMS doctors w ho were demiological base they had built. Inclusion doctor’ as a socially sensitive medical pro­
competent technically but did not concern of socio-economic dimensions into an epi­ fessional competent in providing elementary
themselves with the social dimensions of demiological approach remained a far cry.
healthcare. However, the history of evolution
epidemiology.The 'superstitious native’ with
After the country- became independent. of medical education in the country reveals
that not only have doctors been the blue­
his unfathomable peculiar traditions was
IMS was dismantled while IAS continued.
held responsible for the failures for public
As health remained a state subject, the eyed boys in a health team, their education
health efforts while all successes were the experience of public health al grass roots and training also continued to be heavilyachievements of modern medicine and its
levels remained state bound and the centre influenced by western models of education.
There is sufficient evidence to show- that
practitioners.
depended upon medical colleges and other
central institutions for its public health in early 20th century, policies of influencing
The culture of the professionals was carried
medical education in third world countries
into the national programmes of independent
leaders. A scries of director generals with
were consciously followed by the US through
India. They were visions of technical
backgrounds in paraclinical (anatomy,
supremacy which would compensate for the
physiology, pathology) and clinical subjects ns technical and financial support. In China,
lack of social change. The skills needed for such as orthopaedics brought the status of the argument to train personnel to meet the
midway correction through competent
'professional in public health’ lo a level needs of the country was used by the
monitoring were found lacking perhaps due
where they were easily dominated by the Rockefeller Foundation to support medical
to sudden reduction of the professional
IAS officer1'' who invariably had a broader education that trained elite professionals
experience. The bureaucratic control by itself, essential to ’westernise’ the country. This
manpower after the British doctors left.
The foreign 'experts' entered the scene
however, continued to lack public health strategy in fact replaced the foundation's
and the glamour of technology made entry- compcicnce. With the failure of various
previous support to missionaries.21
Similar export of western professionalism
of many vertical tcchnoceninc disease control
health programmes, a new category of
to Asia is also recorded by Goldstein. Not
programmes easy. Malaria was to be
professionals emerged and these were the
controlled through DDT. small pox through
health management experts. Unfortunately, only was aid linked to reforms in medical
mass vaccination, leprosy through dapsonc
these shifts in lhe prolcssional control at the education but also by creating elite insti­
tutions for medical education and insisting
and filaria with hetrazan therapy. Except for top did not contribute io any appreciable
small-pox. which was eradicated after a shift improvement in the working of the on supporting only those, a process of
weeding out all other practitioners and
of strategy’* in the early 70s. all other programmes
•programmes proved inadequate Their
Reported failures in public health efforts - doctors from positions of power and
failures are not the result-of resource
led to a shift in emphasis whereby instead dominance was set in. This led to a generation
constraints alone but of inadequate and
of controlling diseases among people through of physicians who were conscious of their
inappropriate strategies. In the case of a broad-based strategy, the emphasis shi fled own professional dominance and exercised
malaria, it took us two decades to realise that to controlling people themselves - in terms it to become one with the ’‘international
community of scientists”.These elite
it was wrong to create population based
of numbers.
physicians were trained to exercise their
eradication units.The essential factor should
The Sixth and Seventh Five-Year Plans
have been "the terrain and the topography”.
integrated various programmes into the autonomy against their responsibility to the
Il was accepted that without an efficient general health services. This integration, society. They did this through the ingrained
'clinical mentality’ which teaches them to
basic health services, malaria control was however, was limited to the lower echelons
not possible. It was also acknowledged that while at the top Family Planning remained do what they think is best for a single case
conceptualisation of the programme as
the priority. Such an integration pul the without a thought for its implications for the
essentially a rural activity was incorrect.17 entire lower level infrastructure on a platter society at large or even for the family.
In India this conflict started with the British
Even then the programme continued till and offered it to the Family Planning
Programme. Instead of strengthening basic Medical Council (BMC) in the late 19th
1974 when it was finally modified into a
National Malaria Control Programme with' services, integration actually weakened them. century. The issues were of curriculum,
much lowered ambitions.
Peripheral institutions worked for Family language of instruction, training in obstetrics
The other glaring exampleof poor strategy Planning targets at the cost of all other public and integrated education of allopathy and
traditional systems in medical schools?1 The
health activities.
building is in Leprosy. A National Control
Along with liberalisation, medical care medical colleges of independent India
Programme was convened into an eradication
was opened up lo private and hon-govern- continued with their curriculum which were
programme in 1982 by the Swaminathan
menta! sectors. This led to stagnation and evolved under the guidance of BMC. Here
Committee. To any student of public health
loo. Rockefeller Foundation made its inroads
it is obvious that the decision was political undermining of public hospitals as they faced
and not based on scientific knowledge or cuts in their budget allocations and loss of by offering aid and technical assistance.
competent. manpower ..taJhc private .Indian doctors .were no different from those
operational research. The excuse was.lhat...,..t.bcir
.(

2986

Economic -and Political Weekly

November 19. 1994

I

I

of Thailand and China in their concerns.
Majority of the medical students came from
landowning and professional classes24 and
hoped to practise clinical medicine.2-'
Concern for this was expressed by an
official committee on Health Services and
Medical Education in 1975. It recognised
the necessity to restructure the entire
programme of medical education and
acknowledge India's failure to produce the
basic doctor “who occupies a central place
among the di fferent functionaries needed for
the health services”.2'' It recommended a
UGC type of body for medical education to
monitor the needs of the country and assess
the required changes in medical education.
Another official effort was made by Bajaj
Committee which produced an outline of a
National Education Policy in Health Sciences
in 19S9. Fullofcontradictions.thedocument
could not but concede the government’s
failure to reduce the bias in favour of elite
medical education. its inability to tram other
paramedical professions and initiate proper
health manpower planning.27 It called for
the constitution of a medical commission
to regulate medical education but could
not come up with any concrete suggestions
for shifting the emphasis in training
from specialities to basic doctors and of
- strengthening public health training.
As a result of this reluctance to intervene
actively, the government in fact protected
the structures that it had evolved to be a part
ol the international market for professional
skills. India’s educated elite specially its
doctors continued to be more or less inte­
grated into the global economy and thereby
enjoyed the benefits of higher salaries. “The
condition of integration into this international
market was the possession ot internationally
negotiable-qualifications" and this implies
lack ot relation to local needs.2X
It is not surprising then that the initial
efforts of independent India to build
departments of preventive and social
medicine within medical education met the
fate that they did. These departments were
required to deal with the challenge of
highlighting 'local needs' of the vast
populations and find socio-technical
solutions to them. Reasons behind the failure
of these experiments in medical education
were many. Firstly, practising public health
experts were few and the demonstrative
capabilities of the faculty were extremely
limited as no links were developed between
teaching departments of medical colleges
and public health practitioners in the health
care system at different levels. At best these
departments could provide some exposure
to real life situations of cities and villages.
This, in absence of any demonstrative effect
of the success of public health often
convinced students of its futility.
The ’"Sb'Sence of any excitement and
challenge contributed to a vicious cycle

Economic and Political Weekly

- ....

whereby the less successful came to PSM.
Only after the banning of ECFMG. an
examination for screening foreign medical
graduates, which restricted the possibilities
for migration did good medical students pay
any attention to the subject But that was
only for the purpose of leaving the country
e/i route the WHO to be in the same salary
brackets as their seniors.
These departments failed to link their
teaching with that of other departments and
hence became islands in medical colleges
isolated from the rest. Their inadequacy in
developing epidemiology as a discipline in
the Indian context made their isolation a
natural event. They could strive for
recognition only by becoming the victims
of the larger malady - competition for
international acceptance. Therefore, instead
of emphasising local specificities, and
seeking socio-technical solutions to India's
public health problems they were the first
to accept and propagate 'knowledge' that
emerged out of the international centres of
public health.The Indian 'experts' thusjoined
hands with the international ‘expens' in
propagating purely technological solutions
to all public health problems. The ancient
wisdom that most of our diseases are rooted
in the poverty of the people29 was ignored.
Lastly, the inclusion of social sciences in
medical curriculum was reduced to absurdity
under these conditions. The recom­
mendations of ICMR/ICSSR committee went
totally unheeded and the doctors continued
to be trained to think that they alone knew
what was best for their patients' This
assumption came easy to a set who
represented the social elite.

As a result, two things happen. Firstly, when
they think of public health they visualise
only medical technology-based interventive
programmes such as immunisation and oral
rchydration. Secondly, only those diseases
which they experience become their
priorities. Absence of emphasis on others
does not bother them Tneir logical demands
are hospitals, well equipped ternary' case for
heart diseases, blindness, cancer and other
non-communicable diseases. Greater access
to curative institutions and adequate supply
of drugs in the market satisfies them.
The health administrators, policy-makers
and politician who largely come from these
sections of the society are no different in
their thinking. They have also learnt their
lessons from history- that the diseases of the
poor cannot be tackled by technology alone.
The only time they are concerned about this
set of diseases is when they arc themselves
threatened. The mindlessdisposal of garbage
by the plague hit capital's administrators,
the Municipal Corporation of Delhi’s
(MCD's) epidemiological laboratory's full
time involvement with monitoring a single
disease, the handling of the Cholera epidemic
in 1987 are exampcs of such concern. The
rest ot the time they concentrate on.
(i) Removing slum dwellers from amongst
them and creating safer spaces for self­
protection.
(li) Devising schemes lor educating the
poor to be healths without any basic
amenities.
• (iii) Investing more resources in their part
of the city to beautify and keep at bay the
threatening poor.
(iv) Convincing themselves that there is
little that can be done for the increasing
National Priorities in Public Health
menace of death and disease among the poor
who arc blamed for their ignorance and
India’s population control programmes
are yet to be integrated into its health services - reluctance to benefit from modern service.
Implicit in this attitude is the shift of
and hence continue to drain it. Even within
the health sector, priorities remain lopsided. ’ responsibility from the state to the people.
As we have seen the diseases which have
At best the state make some resources
continued to kill and maim the most (such
available to non-governmental organisations
as diarrhoea, respiratory infections, malaria
to run some rudimentary' form of urban basic
and kala azar) arc getting less and less
services. Like poverty, mortality and
attention. Those which arc replacing them
morbidity from diseases of poverty too are
(like AIDS, blindness) arc largely the
now seen as prices that have to be paid for
concerns of either the developed nations or
‘national development’. It is not surprising
of India's elite.
then that these diseases are gradually losing
The reason for this gradual shift is not
the priority they once enjoyed.
far to see. There is no denying the fact that
. Protests against the present policies- are
rare for reasons already discussed. Firstly,
India over the past four decades has built
the knowledge and practice of public health
its infrastructures including a health care
itself has been undermined to an extent that
system. The focus of the infrastructure,
understanding of issues at popular level is
especially for water supply, sanitation,
simplistic. Secondly, in a socio-economic
housing, transport, electricity and public
milieu, where both the.urban elite, and the
distribution system is'iri urban areas. Even
middle classes see its interests tied to the .
within the urban areas the disparities are
process ofeconomic liberalisation and global
obvious. The larger share of the total national
integration, indiscriminate import ol
expenditure is enjoyed by a small elite.
technology is seen as a positive step towards
These basic amenities arc taken for granted
of.a ’development. Thus hi-tech and tertiary
by them, and never seen as part
f
institutions arc^veieomed-and class issue.v
comprehensive public health infrastructure.

November 19. 1994

2987

and primary health can? aic seen as ■primitive’
concepts
The most tragic is the silence of those who
sutler. They remain quiet not only because
ol their helplessness, their negative ex­
periences of raising their voices and lheir
overburdened lives bui also because of lheir
perceptions. The glamour of technology and
ihe acceptance of living from one crises to
another pushes them into dreaming ol lhal
technology. They accept hunger, shortages
and lack of services in everyday life hui in
a crisis, they aspire for what they privileged
classes have. Thus they become easy prey
io me propaganda that more sophisticated
hospitals mean better health care. For the
professional. lhe tact lhal lhe poor seek
technology becomes reason enough io pro­
pagate lheir own model ol tcchnoceniric
health care. With lhe poor on lheir side lhey
lei public health degenerate with impunity.

periphery of Delhi. Bombay. Kanpur, etc.
results in large-scale migration of people
Irom other urban and rural areas. It is possible
io sec the modern industrial city as a human
lai lure, a monster which docs nol lead to any
improvement in total human wellarc. “Most
modern cities are easily perceived as drears
grey wastelands housing dreary, grey,
dehumanised people working as cogs in a
machine which seems to destroy much of
what is good about life"?-' The modern
industrial city may add to material wealth,
and perhaps with lhe changing economic
scenario (his is what the state needs, but it
destroys the very essence of human life. The
people in such cities live under miserable
conditions, similar io the well-documented
stage ol industrial revolution, now con­
veniently lorgoticn. The conditions of life
in such cilics. (he nadii of which is lhe
outbreak of epidemics, should enable lhe
planners io re-examine the pattern of
urbanisation in India
IV
This docs nol. however, mean lhal human
Issues for Urban Health
well-being is a mirage in such cities. This
^^he notcu orthy feature of urbanisation
leads io ihc second issue of quality ol life
in India is the increasing concentration of ol people in cities as against growth, '['his
people in mega cities, industrial cities and
is related to ihc availability of basic services
towns The share ol population of class I
such as health. drinking waler, sanitation
cuius in the total urban population rose
and other utilities apart Irom housing, and
Irom 22.9 per cent in 1901 to 60.4 per cent
transport. There arc isolated cases where
in !9X|. Another conspicuous icaturc is the
even in big cities some degree ol efficiency
l.il: m lhe proportion ol urban population
was introduced for maintaining al least a
in lhe small and medium lowns?"
minimum level ol civic order. Il has io be
In exclusively industrial ci lies like Sural,
recognised lhal utter neglect and callousness
meiropoiiian-cum-industrial city like
ol ihc slate is responsible lor much ol the
Bombay or lhecapital city like Delhi, a large
urban decay.
share ol lhe concentrations and additions in
The case of Delhi, which is ihc national
lhe population consist of migrants. The
capital, is a classic example ol such neglect
apart Irom Surat, of course. This neglect has
characteristics ol such migrants and the
population, ol course, vanes depending on
to be located in the dichotomous organisation
lhe economy of the city. The functional
of lhecity nsell. the garden city for the ruling
specialisation ol cities is an important
classes and (he clue and ihc_shaniy lowns
determinant of lhe characteristics of the
lor (he deprived. The growth rale of Delhi,
population and quality of life in cities. The
in line with the pattern ol urbanisation in
industrial classification of migrant workers
India, is however much more startling. The
^^ral and urban residence shows a higher
decennial growth rule between 1971 and
proportion ol rural migrants in primary and
19X1 was 53 and between 19X1 and 1991.
secondary sector activities, and urban
50.64. Al ter 1961. the growth rale continues
migrants in ternary activities?1 In million
to remain around 50. The density of
plus cities, the sex ratio ol migrants is in
population m Delhi, similarly, is very high
favour of males. The problem ol living space
In 1991. it was 6.319 as against the ali-lndia
in lhe metropolitan cities probably acts
average of 267. It is estimated that by 2001.
against female migration. Il also gives an
Delh’s 10 million population will rise three-,
indication of the type of job opportunities
fold or more.
As the ruling classes rebuild the city for
in such cilics which are male-biased.
themselves, erect skyscrapers and beautify
The pattern of urbanisation in India raises
their surroundings, more and more migrant
several issues for a public health policy
especially in the light of the outbreak of labour is brought in to accomplish this.
However, regarding health services,
plague.
availability of basic services like waler,
First is the issue of economic organisation
sanitation, housing, etc. there is a clear
of cilics in India, whereby increasingly lhe
demarcation between privileged Delhi and
emphasis is on conceniralion of industries
deprived Delhi. There are 44 resettlement
rather than dispersal which lead to human
concentrations and lhe miserable conditions colonies with a population of three million
under which many city people live now. The ' and 4X0 or more unauthorised colonies with
more added every year?' It is estimated that
concentration of industries in cities like Surat.

al least 53 per cent of ihc total Delhi popu­
lation is living in subhuman conditions
While these subhuman population is needed
for maintaining the cozy structures ol the
upper classes, there is total lack of human
. oncern to provide lhe basic services to them.
Surat, similarly, has been oncol (he fastest
growing urban centres in Gujarat. While
Gujarat’s urban population growth was 3.5
per cent per annum in the XOs. Surat grew
Irom 9 lakh in 19X1 to 1 49 million in 1991.
Il has now crossed two million and 2X per
cent of these lives in slums. Unprecedented
growth of small-scale industries in lhe
unorganised sector has significantly
contributed to the rise in population '
The civic amenities have not kept pace
with the rapidly expanding population ol
this town. According to a survey about X()
per cent of the slum households do not have
sanitary facilities. Even before the outbreak
of plague, malaria and hepatitis haveckiimed
a number of lives in this town. Il is fair!v
evident that in a (own which is largely de­
pendent on migrant labour, ihc municipality
can aflord to ignore lhe needs ol this class
as lhey arc not permanent residents of Surat.
The municipal government has tailed to
meet ihc changing need'' ol ihc city.
The reports of lhe plague epidemic in both
Surat and Delhi captured lhe fear and panic
lhal people experienced The major toll of
this epidemic was borne mostly by lhe poor
In Sur.n majority of lhe reported deaths
were Irom ihc slums in lhe low-lying areas
ol the city. From various newspaper accounts
what is lairly clear is that certain areas of
Sural were worse affected than others
although even lhe wealthier pockets were
nol spared. Mostly slums in lhe low-lying
areas, near lhe banks of iheTapu were badly
hn reporting a number of deaths. Vcd road. .
Kalargaon. Randcr. Sanjay \'agar and Rajiv
Nagar of I'dhna industrial area. Ruderpura
and Limbayat were the worst affected.
According to descriptions ol these areas, the
people who resided here were labourers who
where employed in the export earning
diamond and textile industries. Surat is
lamous for these two major industries which
arc both export-oriented and earn crores in
foreign exchange. Majority ol the labour
force of both these industries is constituted
by young male workers from different parts
of the country. The diamond industry
employs craftsmen mainly Irom Rajasthan
and the diamond cullers and polishers belong
to Saurashira. These workers live in slums
like Vcd Gaon and Kalar Gaon. According
to the deputy collector there are-two-lakh —
migrant labourers in Sural and some of them
did lice from Sural io lheir respective stales
when the epidemic broke out.
In Delhi, the majority of the plague cases
were reported from resettlement colonics.
This broadly replicates lhe pattern observed
during the cholera epidemic in I9XX. Most

Economic and Political Weekly
2988

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November. 19. 1994

I

■ 1

ol the cholera deaths occurred in lhe
nailing Mun being its only reserwir (hii|xConclusions
fully) lhe disease could be eradicated.
resettlement colonies and juggi-jhompri
17 Government of India. Ministry of Health
clusters in Delhi. Similarly even during the
The reconstruction of plague epidemic
Family Planning. Works and Housing and
plague epidemic, it is in these places where
glaringly portrays the dichotomies in public
Urban Development. Report id the Special
basic civic amenities are lacking that.cases
health and provides lessons for the future
Commuter to Review She Working ol flu
were reported.
of its practice in this country. Il is evident
Nattimal Malaria Taiidicalitin Pnn>raimm
Even when the rulers arc threatened by
that the classical approach, which is mainly
ant! la Ret tmuneml Measures /ar hnpmve
epidemics, the complexity of the issues of
sanitarian, al best reduces epidemics only io
ment. 1970. Ministry of Health. Family Plan
urban decay arc not realised. The measures
an endemic status. If public health has to go
ning and Urban Development. New I kiln
to control lhe spread of plague, for instance,
beyond ihis limited, truncated objective lhen
(Madhok Committee Report), pp 96-115
IK Tare S Pet al. ’How Far lhe Goal of Ixprosy
was entirely focused on a single-pronged
it calls for a systemic understanding of the
Eradication by 2000 AD is Achievable'.
strategy ol removal of garbage rather than
problem. This would involve evolving a
Swasdi Huai. January. 1990. pp 14-16
visualising epidemics as a-result ol the
multi-pronged strategy firmly entrenched in
19 B.-ineqi D. Decline and Fall ol Public Health
ongoing decay ol urban systems. It .seems
the .socio-economic context. Notwith­
Practice in India'. The Statesman April 13.
lhe earlier outbreak ol cholera in Delhi has
standing the lacl that this would be a harder
19X7.
not provided any lessons.”
option, with the duration between epidemics
20 Government ol India Health Survey and
When the Delhi administration tried to
becoming shorter and the black signal ot
Development ('ummillcr Report. 1946. Man­
'clean up’ the city of garbage, most of the
plague, n could be assumed that the stale
ager ol Publications. Government ol India
ellons were concentrated in the middle and
would initiate positive actions rather (han
Press. Delhi tBhore ('ommiilce Rcpiri)
21 Brown E Richard. Exporting Medical Edu
upper middle pockets of the city with a token
gild lhe pill. The real challenge foe. public
cation:
Professionalism. Modernisation and
effort in the slums. There were reports of
health al this juncture is to rise above lhe
Imjiciialism . Social St truer ami Metin me.
uncleared garbage in areas of lhe slums in
garbage
Vol 13 A. pp 5X3-95
Delhi even a week after lhe announcement
Notes
22 Goldstein S Michael and Peter J Donaldson.
ol cleaning drive.
'Exporting Professionalism. A Case Study of
|Wc would like to acknowledge the help of C K
The third issue which needs to he
Mcdic.il Education'. .1on vital id Health ami
Jagadccsan. Malohika. Siisikar anil Anil Gupta
highlighted is the migratory patterns in the
So<
nil Behaviour. Vo) 20. Dccemlx’i. |97‘»
lor collecting daiu.|
national context. As mentioned earlier, a
PP H2A7
1 The Hindustan Times. October 14. 1994
large proportion or urban agglomerations
23 Jeffery Roger. Western Medicine in ludur .4
2 Government of India. Ministry of Health.
consist of migrants. This adds a new
Casco/ Dcpralrisitmalisaiitm. 1976. Depart­
Health lu/ormatiim. 1992. New Delhi. 1993
ment ol Sociology. Edinburgh,
dimension to the national policies on public
3 Schgal.SandBhatia.KultiA~ar. I9XX.NICD.
24 Madan I' N. ’Doctors in Society' (unpub­
health. Although it is easier io find lhe
Delhi.
lished mimco). 19X0. New Delhi. pp4 4-4.5.
4 Akakicv. Epidemiology and Incidence of
reason for the large-scale fleeing ol people
25 Ramalingaswamt P. Medical Students hnaipPlague in the World - I95X-79. Hidlrlin WHO.
Irom Sural at lhe lit.st information of an
ofPSM. Piildit Health ami('imintuniivHealth
Vol 60. No 2. 19X2. pp 165-69
outbreak of plague in the fear of disease, it
NIIIAE iNIHAE Research Rcpori). New
5 The Pioneer. September 27. 1994
actually is a reflection of lhe all-round decay
Delhi. 14/73.
6 The Pioneer ScplemlKT 30. 1994.
coupied with lhe [X»or state of ci vic amenities
’ 26 Government of India. Ministry of Health and
7 The Pioneer. October 2. 1994.
in the city. It represents the lack of faith of
Family
Planning. Report ol die Commuter on
X Bharat i (’haiurvcdi.. I Talc ol Trash: A Sun rv
the people on state-run machinery.
Medical /u/ur atom ami Support Manpower.
:>! flic Materials. People and l-.cimmmcs
Ministry ot Health and Family Planning New
However, it was lhe upper and middle
Involved in the Recycling Trade in Delhi ,4
Delhi. 1975 (Snvasiavu Committee Report i
classes who managed to use any means
Report. 1994. SRISHTI. New Delhi World
27 Government ol India. Ministry of Health and
Wide Fund lor Nature India.
possible to move out ol Sural. According
Family Planning. National Education Policy
9 The Pioneer. October 1. 1994. to the railway officials nearly 75.0(X) tickets
10 Qadccr Imiuna. ’Structural Re:ni|iisl<iK*ni.......• ...jii Health St ientex. 19X9. Ministry ol Health
had been issued lor Ahmedabad. Bombay.
and
Family Wcllaic. New Delhi tBajai Coni
The Games Nations Play'. Voices. Vol I.
Baroda and Bhusawal. 'lite officials of the
niiuce Report i
No 2. 1993. pp IX-22
district administration who were making
2x Gish Oscar and Mai tin Godfrey. 'A Reap­
I I Government of India. Ministry of Health and
announcements asking people not to leave
praisal of the Brain Dram with Special
Family Welfare. Annual Report. 199.3-94.
lhe city were the first ones to send their
Reference to die Medical Profession'. Social
’Blindness Control Programme', pp 124-26.
families home!
Stiener and Medicine. 1979. Vol'I It',
New Delhi. 1994. Ministry ol Health and
pp
I-I I
In an entirely different context of malaria,
Family Welfare.
29
King Maurice. 'Human Entrapment in India'
the Madhok Committee had drawn attention
12 Government ol' India. Ministry of Health and
National Medical Journal ol Indio. Vol 4.
Family Welfare. Reportol the Working (Iroup
i<» lhe large aggregation ol labour in
No 4. pp 196-201.
on Kniilnainm o/ Improve: Swamimitiimi
construction projects which had sprung up
30 Rao MSA cl al icdsi. .4 Reader in llrhaii
Committer Report. 19X2. New Delhi.
all over the country. It pointed out that
Sm-ioltigv. 1991. Orient Lungman. New Iklhi.
Ministry of Health and Family Welfare
s|K*cnil efforts should be. imide.to provide
I 3 Arnold David, ('ohmisuig the liodx: Mute- ’ p 7«.
adequate provision for health and sanitation
31 Prvmi Mahendra K m Rao M S A el al teds),
Medicine and Epidr nm Disease in Nine­
as a legitimate charge on construction
ibid, pp 105-06.
teenth Century India. Oxford University
projects. * As far as Delhi is concerned, this
Press. Delhi. 199 3. p 53.
32 Murphey Rhoads. The Eading of die Mt mist
is an impoitant lesson where a large
Vision: City and Country in China's Devel­
14 I lai risim Mai k. PuhUt Health m Hrnixh India:
opment. Methuen. London, p 3
Aii.ylo- Indian Preventive Medicine /X’5vpopulation of migrant labour is engaged in
/9/4. Cambridge I ‘nivcrsitx Press, published
33 V||AI. Delhi’ .4 Tale of Two Cities. 1993.
construction activities. The lesson from
— in India by Foundation Books. 1994. New
Voluntary Health Association of India.’Mew..............
plague is (hat migration which forms an
Delhi, p 159
Delhi.
inherent characteristics of urbanisation in
15 Ramasuhlxiii Radhik.i P.adi. Hi tilth and
34 Shah Ghanshyain. 'Economy and Civic
India calls lor an urban renewal with added
Mcditiil Rvxeai iii ot hidia I heir.(Irinin
Authority in Surat*. Ecommuc mid Political
emphasis on ihcs^- sections which produce
I'ndrr die Impui i ot Knimi ( altmnil Policx'.
Weekly. Vol 29(41). 1994. pp 2671-76.
material wealth. Their isolation and
19X2. Siockholni. SAKI.C . p 24
35 Priya Ritu. ’Mr Piiroda Goes io Sunder
quarantine must give, way to an awareness,
16 Small|xix has a y ci v s|K’Cial epidemiological
Nagari'. Seminar. 19X9. 354 .
36 Madhok Cummillrr Report op cit. p 113.
characteristic idjying weak in its ecological
of iheu problems.

l-cimDinii.’ ami Political Weekly

November IV. IV‘)4

29X9