The Surat Plague and its Aftermath
Godshen Robert Pallipparambil
In September 1994, plague struck Surat, a city in the state of Gujarat in western India. The government officials declared an international public health emergency by reporting an epidemic of pneumonic plague. When compared to the bubonic form, the pneumonic plague spreads rapidly and hence caused widespread panic, both locally and internationally. The plague in Surat was mostly pneumonic, though the bubonic form was found in three villages in Maharashtra preceding the pneumonic outbreak in Surat (Ref 3).
An excerpt from the newspaper ‘The Hindu Universe’ dated 25 September 1994, described the situation. “The people fleeing the affected zones are heading in all directions and taking the hysteria with them. With the discovery of three people afflicted with plague in a Bombay hospital, panic has gripped that city as well. Tetracycline, an antibiotic for plague treatment, has disappeared from chemist shops not only Bombay but also in Delhi”. Because of rumors that Surat would be quarantined and when that action was delayed one-fourth of Surat residents (400,000 to 600,000 people) fled the city within four days of announcement of the epidemic. Among them were people still in the incubation phase of the plague infection. Broad-spectrum antibiotics required to curb the disease had been exhausted due to panic buying of medicines. Physicians and pharmacists escaping the city took with them large amounts of antibiotics for their friends and relatives. At other cities in various parts of India, checkpoints were established at railway stations and airports to monitor incoming Surat inhabitants who were then received by medical teams and quarantined. Hospitals in a number of neighboring cities of Surat were alerted for possible arrivals of plague-infected people. Government had to forcefully stem the exodus with the help of paramilitary forces and prevent the disease from spreading to the neighboring states. Because the disease was diagnosed and suppressed quickly, the outbreak did not have the devastating impact originally feared, but it generated considerable anxiety worldwide resulting in a heavy economic toll in the country. In Northern India, Deepavali, the festival of lights is a time for both celebration and business. The plague outbreak occurred just before the festival incurring a total business loss of over US$ 260 million in Surat alone (Ref 2,3,5).
The incidence in Surat had large impacts on other major cities of India like Delhi and Mumbai. In the capital of New Delhi, the lack of public information on how to deal with the spread of the disease resulted in the large scale purchase of surgical masks and tetracycline. As a precaution, the administration ordered the closure of all schools and public entertainment places. The news of the epidemic and these actions taken by the government alarmed many people. Some chose to stay indoors and others who ventured out did so with masks covering their faces. Schools in Delhi reopening only five days after they were closed illustrated the uncertainty of government officials as of how to proceed with the precautionary measures. In eastern states such as Orissa, thousands of kilometers away from Surat initiated steps to check the plague outbreak. Reports from Rajasthan, which borders Gujarat, stated that the villagers launched an intensive drive to kill rats in their regions. Proper instructions as on how to proceed with the preventive measures were not given to the people. Since the disease was already spreading, killing of the flea host (rats) would force them to switch hosts and result in more human cases. The havoc caused by the epidemic was evident (Ref 4,5).
On September 23, Surat authorities ordered closure of all schools, colleges, cinema halls and public gardens for an uncertain period. Industrial units, banks, offices and diamond cutting units were asked to shut down until further notice. By this time, plague had been spreading rapidly through Surat's slums for nearly two weeks. People walked in the streets with their faces covered by handkerchiefs, which was not a very effective method because the large weave permitted the entry of bacteria. Several layers of fine muslin would have been a better method.
Several other decisions and actions influenced societal responses to this event. Health officials in Surat city declared a plague epidemic before it was known if the plague was pneumonic. Daily statistics about suspected plague cases provided by the official agencies added to a mountain of misinformation. The Union Health Minister did not issue any statements to clarify the situation or to calm the country’s or international community's anxieties. Press statements issued by local politicians also did not help the situation. For example, at the time when the plague was considered to be at its peak, the Chief Minister of Gujarat claimed that the plague in Surat was pneumonic and not bubonic, perhaps not realizing that pneumonic plague is far more infectious and less curable than bubonic plague. To emphasize his point he quoted that "rat fall" in Surat was not very high. The local and international media also played an important role in this case. Local newspapers reported highly exaggerated death tolls adding to the confusion. Many official press statements were released without assessing the accuracy of the information they contained. People from the plague area with normal fever were labeled as plague cases, and more than 6000 reported plague cases were actually due to other diseases. The actual death cases in Surat were 56. From late August to mid October 1994, a total of 693 suspected plague cases, out of which 488 were from Maharashtra, were reported by India to World Health Organization. In Maharashtra, with the exception of Surat the reported cases were mostly bubonic plague (Ref 1,5,6,7).
Though there was much confusion in the beginning, the government successfully stemmed the spread. After identifying the plague cases, antibiotics were given to almost everyone in the neighborhood. Fumigation of cargo, clearing of port areas of rat, dusting of insecticides over vast areas to kill rat fleas, helped to control the spread of the disease (Ref 11).
One of India's major markets (agricultural exports), was jeopardized by a decision by the United Arab Emirates to suspend all cargo transshipment from India. The incident also resulted in the loss of investor confidence. From the exports alone, the total loss suffered was $420 million. In London, Global Depository Receipts crashed after the BBC and CNN media agencies reported the plague situation. In the local stock exchange, the share value of the agricultural products tumbled. An official tour of India by the Mauritian minister for Tourism was postponed. Foreign journalists and tour operators were offered free travel and hospitality to assess the situation, but few responded. More than 45,000 people cancelled their trips to India (Ref 3,5).
Several countries imposed plague-related travel restrictions on Indian travelers. For example, Indians traveling to the United States from plague-affected areas had to fill out special forms upon arrival. As a result of the Surat plague outbreak, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States by modifying the quarantine protocols and providing information to medical practitioners. Aircrafts were fumigated on arrival at airports in Rome and Milan and passengers were subjected to special health checks. In Moscow, authorities ordered six-day quarantines for passengers from India and banned travel to India. In addition, an estimated 25% of the passengers between India and the Gulf region who are job seekers were stranded; many had their visas extended but the delays in their departures resulted in a loss of jobs to nationals from other countries. The plague cost the Indian economy over $600 million (Ref 3,5,6,8).
An international response followed in the aftermath of the Surat plague outbreak. The World Health Organization (WHO) announced plans to establish a Disease Intelligence Unit that would function independently when such outbreaks occur to help diagnose the problem quickly. In addition, WHO asked the International Civil Aviation Organization to tighten its health controls at all international airports and to strengthen quarantine measures. (Ref 3).
The worldwide reaction to the plague outbreaks in India in 1994 reminds us that memories of the sudden spread of disease, from the Black Death onwards are still, understandably, very powerful. The outbreak had severe economic, social, and political impacts. Although the spread of the plague was contained effectively in spatial and temporal terms, societal responses resulted in higher order consequences (Ref 5).
Was it really plague?
The WHO team which investigated the plague in Surat, did not find any conclusive laboratory evidence of the disease organism. Even though no scientists were able to get pure Yersinia pestis cultures from the infected cases, this was mainly attributed to inadequate facilities and lack of expertise in the hospitals during the period. But there were lot of supportive evidence of the plague organism, blood tests specific to Yersinia showed positive results, antibodies of Yersinia was found in many infected cases and disease symptoms were diagnostic of pneumonic plague (Ref 2, 9,11).
After the Surat plague epidemic in 1994, India took several steps to be prepared for such incidents in future. In response to the outbreak, medical school course work has been revised to address plague in greater detail. The National Institute for Communicable Disease's plague research unit has been modernized to make diagnosis easier. In addition to activating plague control units all over the country, the national government decided to set up a more sophisticated national surveillance system. The recent pneumonic plague outbreak in Himachal Pradesh 2002 was quickly and effectively contained. The government took rapid preventive action and there was better flow of information which prevented the unnecessary panic (Ref 3,10).
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