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Plague in India
Plague
in India
SiR-The recent outbreak of pneumonic plague in Surat city, India, which left more than 50 people dead, came as a surprise, despite the fact that Surat and many cities in India and much of the developing world are dirty and crowded. That apart, there was no reason to suspect that pneumonic plague would break out anywhere since plague has not been reported from any part of India for the past two decades or so. The cases of bubonic plague which started appearing in August in the Beed district, Maharashtra state, fit the classic cycle of natural calamity, rat fall, and gradual appearance of bubonic cases. The sudden explosive outbreak of pneumonic plague in Surat city had no such antecedents apart from heavy rains and flooding in parts of the city during monsoon, which usually leads to rotting rubbish and water contamination. Thus the epidemic in Surat is unusual and needs detailed epidemiological inquiry to understand its
origin. The
has caused mass hysteria and fear in the city, the state, and the whole country, as well as world wide. Within days of the outbreak about 400 000 people left Surat, and all work ceased. Many people even left other cities in the state even though there were no positive cases. Trains were
epidemic
stop at Surat station: no one was prepared to that city. Newspapers played an important part pass through in creating this panic. The news media, including government-owned television, advised people to take antibiotics. As a result of this misinformation people in many major cities including Bombay (which is 250 km south of Surat), rushed to buy tetracycline. Because of lax regulation of prescription drugs, tetracyclines have become available over the counter. The government distributed about 10 million tetracycline capsules. I calculate that at most about 500 000 tetracycline capsules would be needed for prophylaxis and treatment of all suspected cases and their contacts, which shows the magnitude of public panic and government alarm. In many cities people wore masks while on the road, the media having created an impression that plague is spread by air. In some cities the government closed road-side food stalls. Scientific information was provided late partly because young and middle-aged doctors had no experience of plague. The government also seemed to lack correct, concise, and practical information. Because the Indian government usually denies or plays down any epidemic or calamity, it has lost credibility at home. On the other hand, newspapers, which are independent, tended to grossly exaggerate and sensationalise the facts. Fear caused the exodus. With this migration the disease spread to some other cities, but on a limited scale. Many international flights were cancelled to and from various destinations in India that were hundreds of miles away from Surat city, even when WHO had specifically said "there is no restriction for travellers visiting India or passengers in transit in airports for India".’I The Indian prime minister also cancelled his visit to a distant place in the state. Such local, national, and international reactions show that the epidemic was one of fear rather than disease. It has cost Surat, Gujarat, and India very dearly in terms of loss of image and business. But I hope long-term lessons will be learnt by all concerned, including government, media, doctors, lay people, and trade and industry in prevention and management of such epidemics in future. not
allowed
to
Dileep V Mavalankar Indian Institute of
1
Management, Vastrapur, Ahmedabad 380 015,
Vikram K Chand Department of Internal Medicine, Gundersen Medical Foundation, La Crosse, WI 54601, USA 1
Deadly fear. Newsweek,
Oct 10, 1994: 40-44.
SIR-I agree with your Oct 15 editorial that the reason for the plague in India in the international lay press is because it is a disease of poverty and because it is potentially communicable to the people of western nations. It is true that an epidemiologically better approach could have been adopted for investigating the current outbreak. But it must be borne in mind that in India technical resources are much more limited than in the developed world, or that of WHO or the US Centers for Disease Control. The successes of these organisations are mainly attributable to the enormous amount of monetary resources they command and not necessarily to intellectual superiority. It is very easy and unfair to blame the Indian medical and scientific community, but the real reason is the failure of administration to support scientific staff. Few hospitals other than those attached to medical schools have an uninterrupted supply of power and water, adequate stocks of medicines, and good communication systems. India should not abdicate its responsibility to calculate the basic epidemiological figures, as mentioned in your editorial, to any external agencies. Such "assistance" would be a slur to Indian science and would only demoralise the hundreds of clinicians and community physicians who worked day and night during the epidemic in Surat and elsewhere. If India can afford an aircraft carrier, she can very well afford more epidemiologists and the resources they need. It is merely a question of priorities.
sensationalising
Eswar Krishnan Hughes Hall, University
Near-death India
WHO. Plague: WHO Issues International Travel Advice. Press release. WHO/71. Sept 28, 1994
1298
Sir-Your Oct 15 editorial accurately points to the real cause of panic that struck the whole world-namely, poverty. It is also very sad to notice that the members of the medical community both in India and the world over-reacted with such alarm and ignorance. There have been reports in the media about doctors in the city of Surat joining the panicstruck flight of poorly educated masses from the city and its hospitals. But during this exodus there were those who chose to stay behind and fight the public terror by not covering their faces, because this, they felt, was the need of the hour. The epidemic was not only due to plague but also, more severely, to public panic. Even more disappointing is the reaction of the international medical community during these days of uncertainty. New Delhi hosts a major international conference on cancer early in November, but I have come across many oncologists from the western hemisphere who have cancelled their attendance, partly because they are worried, are ignorant of the Indian socioeconomic background, and because they believe that their counterparts from other countries are also choosing not to attend. I hope that we all realise what we are losing in this confusion and what are we going to project to the rest of the world. What are we, the physicians who in most societies do not form part of the poorer section, scared of? Or is it that our practice of medicine is also being directed to the treatment of the rich?
of
Cambridge, Cambridge
CB1 2EW, UK
experiences
SIR-Lempert and colleagues (Sept 17, p 829) record useful showing that induced syncope in healthy adults produces hallucinations similar to near-death experiences data
in India
SiR-The recent outbreak of pneumonic plague in Surat city, India, which left more than 50 people dead, came as a surprise, despite the fact that Surat and many cities in India and much of the developing world are dirty and crowded. That apart, there was no reason to suspect that pneumonic plague would break out anywhere since plague has not been reported from any part of India for the past two decades or so. The cases of bubonic plague which started appearing in August in the Beed district, Maharashtra state, fit the classic cycle of natural calamity, rat fall, and gradual appearance of bubonic cases. The sudden explosive outbreak of pneumonic plague in Surat city had no such antecedents apart from heavy rains and flooding in parts of the city during monsoon, which usually leads to rotting rubbish and water contamination. Thus the epidemic in Surat is unusual and needs detailed epidemiological inquiry to understand its
origin. The
has caused mass hysteria and fear in the city, the state, and the whole country, as well as world wide. Within days of the outbreak about 400 000 people left Surat, and all work ceased. Many people even left other cities in the state even though there were no positive cases. Trains were
epidemic
stop at Surat station: no one was prepared to that city. Newspapers played an important part pass through in creating this panic. The news media, including government-owned television, advised people to take antibiotics. As a result of this misinformation people in many major cities including Bombay (which is 250 km south of Surat), rushed to buy tetracycline. Because of lax regulation of prescription drugs, tetracyclines have become available over the counter. The government distributed about 10 million tetracycline capsules. I calculate that at most about 500 000 tetracycline capsules would be needed for prophylaxis and treatment of all suspected cases and their contacts, which shows the magnitude of public panic and government alarm. In many cities people wore masks while on the road, the media having created an impression that plague is spread by air. In some cities the government closed road-side food stalls. Scientific information was provided late partly because young and middle-aged doctors had no experience of plague. The government also seemed to lack correct, concise, and practical information. Because the Indian government usually denies or plays down any epidemic or calamity, it has lost credibility at home. On the other hand, newspapers, which are independent, tended to grossly exaggerate and sensationalise the facts. Fear caused the exodus. With this migration the disease spread to some other cities, but on a limited scale. Many international flights were cancelled to and from various destinations in India that were hundreds of miles away from Surat city, even when WHO had specifically said "there is no restriction for travellers visiting India or passengers in transit in airports for India".’I The Indian prime minister also cancelled his visit to a distant place in the state. Such local, national, and international reactions show that the epidemic was one of fear rather than disease. It has cost Surat, Gujarat, and India very dearly in terms of loss of image and business. But I hope long-term lessons will be learnt by all concerned, including government, media, doctors, lay people, and trade and industry in prevention and management of such epidemics in future. not
allowed
to
Dileep V Mavalankar Indian Institute of
1
Management, Vastrapur, Ahmedabad 380 015,
Vikram K Chand Department of Internal Medicine, Gundersen Medical Foundation, La Crosse, WI 54601, USA 1
Deadly fear. Newsweek,
Oct 10, 1994: 40-44.
SIR-I agree with your Oct 15 editorial that the reason for the plague in India in the international lay press is because it is a disease of poverty and because it is potentially communicable to the people of western nations. It is true that an epidemiologically better approach could have been adopted for investigating the current outbreak. But it must be borne in mind that in India technical resources are much more limited than in the developed world, or that of WHO or the US Centers for Disease Control. The successes of these organisations are mainly attributable to the enormous amount of monetary resources they command and not necessarily to intellectual superiority. It is very easy and unfair to blame the Indian medical and scientific community, but the real reason is the failure of administration to support scientific staff. Few hospitals other than those attached to medical schools have an uninterrupted supply of power and water, adequate stocks of medicines, and good communication systems. India should not abdicate its responsibility to calculate the basic epidemiological figures, as mentioned in your editorial, to any external agencies. Such "assistance" would be a slur to Indian science and would only demoralise the hundreds of clinicians and community physicians who worked day and night during the epidemic in Surat and elsewhere. If India can afford an aircraft carrier, she can very well afford more epidemiologists and the resources they need. It is merely a question of priorities.
sensationalising
Eswar Krishnan Hughes Hall, University
Near-death India
WHO. Plague: WHO Issues International Travel Advice. Press release. WHO/71. Sept 28, 1994
1298
Sir-Your Oct 15 editorial accurately points to the real cause of panic that struck the whole world-namely, poverty. It is also very sad to notice that the members of the medical community both in India and the world over-reacted with such alarm and ignorance. There have been reports in the media about doctors in the city of Surat joining the panicstruck flight of poorly educated masses from the city and its hospitals. But during this exodus there were those who chose to stay behind and fight the public terror by not covering their faces, because this, they felt, was the need of the hour. The epidemic was not only due to plague but also, more severely, to public panic. Even more disappointing is the reaction of the international medical community during these days of uncertainty. New Delhi hosts a major international conference on cancer early in November, but I have come across many oncologists from the western hemisphere who have cancelled their attendance, partly because they are worried, are ignorant of the Indian socioeconomic background, and because they believe that their counterparts from other countries are also choosing not to attend. I hope that we all realise what we are losing in this confusion and what are we going to project to the rest of the world. What are we, the physicians who in most societies do not form part of the poorer section, scared of? Or is it that our practice of medicine is also being directed to the treatment of the rich?
of
Cambridge, Cambridge
CB1 2EW, UK
experiences
SIR-Lempert and colleagues (Sept 17, p 829) record useful showing that induced syncope in healthy adults produces hallucinations similar to near-death experiences data