The panic created when the plague rippled out from Surat and threatened other parts of the country exposed India's complete lack of resources for crisis control management. In order to combat such emergency situations in future, the government appointed Vullmiri Ramalingaswami, professor emeritus of pathology at the All India Institute of Medical Sciences (AIIMS), in a fact-finding committee for crisis control in epidemics and emergency situations. Ramalingaswami was the ex-director of the Indian Council of Medical Research. Sujata Pandey spoke to him on several aspects of crisis management in emergency situations
Much before the spread of the plague there were warnings. Why did the country's health machinery fail to activate itself? Why did government agencies fail to coordinate after the outbreak?
The situation could have been tackled since India has the capability in terms of scientists and laboratories. The whole thing should have been accepted as a national issue, mobilising all available laboratory facilities and scientific capability. But this was not done. It was entrusted to a single laboratory, which had some limitations; it carried out some physiological tests but did not identify the organisms.
Has the committee tried to chalk out a course of action for the future?
The lesson we learnt from Surat was that whenever there is an emergency, the very best institutions and the very best scientists must be brought into the picture on an emergency basis. We should have a national referral system, by which these facilities are made available as much as possible. If these facilities are complicated and expensive, medical colleges should be identified, where a variety of sophisticated tests can be carried out. We have to have a network of institutions designed to be ready to move when an emergency occurs. This is what we are doing now. We are amending the law to establish a national surveillance system, not only for the plague but also for other infectious diseases.
The fact-finding committee recently submitted its report. What was identified as the main cause behind the outbreak?
The interim reports submitted to the government focus only on Surat, and it is in Surat that we had established that the disease was the plague. There have been doubts. It was very important to establish that it was the plague. As far as Beed is concerned, we still do not have access to the samples that were collected during the outbreak. After the outbreak and the constitution of the committee, we had to go back to preserved specimens of virus cultures, but we have not been able to lay our hands on any of the cultures that were collected in Beed. So nothing can be said about Beed.
In other parts of the country--in fact, in Delhi--there were some people who migrated from Surat and Beed with symptoms suggestive of the plague but there was no evidence that these people had transmitted it to others. In other cities too, there was no evidence of the disease. So it's really Surat and Beed we are talking about.
The outbreak in areas adjoining Beed was reported much before Surat. The committee has only been able to confirm that plague broke out in Surat. Why has it remained silent about Beed?
Well, it cannot be answered on any scientific basis but on an anecdotal basis there were strong similarities between Beed and Surat. In fact when the doctors in Surat, saw the first case of plague on September 19 1994, they commenced symptomatic treatment for pneumonia. They recollected that only a little while before there was plague in Beed. They also recalled that lots of people come from that part of Maharashtra to work in Surat with the diamond and textile industry. Later on at the National Institute of Communicating Disease (NICD), blood samples showed antibodies with plague during tests. So there was a presumptive diagnosis that it was plague. But NICD was not able to make the final diagnosis which must come from isolating the organism yersinia pestis. The fact finding committee had to do this job. There were all kinds of speculations. The New York Times, said that Indian scientists had not been able to identify the bacilli. It was under those circumstances that the committee decided that this issue should be settled first, before looking into the factors responsible, causes of spreading and future course of action. These were our terms of reference. Immediately after the outbreak in Surat, the administrations of several cities went in for major cleaning operations, was the plague outbreak due to urban filth and squalor?
As far as bubonic plague is concerned, it is definitely related to environmental conditions which favour migration of rodents from their habitats deep in the earth to places where there is food and filth. Transmission from the wild to the domestic rodents is the first step in the plague outbreak: what we call from an enzootic to an epizootic situation. The flea of course is essential in the transmission. There are high chances of transmission, from the domestic rodents to humans.
Is the medical community doing anything to educate the people, create awareness that urban filth should be disposed of to stop the spread of epidemics in future?
We should do a lot more. The thing that is really important is not high technology, but simply domestic cleanliness which can protect us from epidemics. Allowing conditions like this today in urban areas can have disastrous results.
What is the condition right now in urban areas of Surat? Are the people still conscious of the horrible environmental conditions they were living in and are their opinions making the local bodies take action to prevent such an epidemic from happening again?
In Surat the outbreak has subsided. Both Maharashtra and Gujarat are still on an alert and they have equipped themselves with abundant supplies of antibiotics and pesticides to meet any exigency. This is only a temporary holding. What we need is a basic ecological and environmental approach to prevent this thing happening again. There are so many countries which are the natural foci of plague, but it remains confined to the wild rodents and it does not spill over into the human habitat. Our attempt now is to be sure that this wild natural foci of plague, called Sylvatic Foci plague, is kept under constant watch.
Have you identified the areas where these plague carrying rodents are found? What measures have been taken to contain them?
In India these rodents are found in the tri-junction, between the states of Karnataka, Andhra Pradesh and Maharashtra. In olden days there were surveillance units in many of these areas to keep a constant watch on these rodents. They must be reactivated.
Is the government implementing schemes which involve local communities in combatting such situaions?
Yes, it cannot succeed without involving the people. Public participation and their understanding of the risks involved is the key. There is a talk about disaster management policy for epidemics. The plague outbreak exposed the lack of preparation to deal with any such situations.
The surveillance system must be coupled with a rapid response. And that is where disaster management comes in. Our history is studded with crises situations and yet institutional memory is very short. For instance we have the most extensive literature written on how to handle famine, in form of the Famine Code of India, during the British days. We also have the old plague outbreak manuals. We are trying to reemphasize that and incorporate new knowledge.
The flight of medicos and hospital staff in Surat during the outbreak did not instil any confidence in the people. Can you comment on that?
I think, it is totally against the medical profession, They had a moral duty, that they stand by and do whatever is possible.
The availability of funds for health and family welfare is dipping. Health infrastructure is being threatened by return of several microbes. What according to you is the need of the hour?
You are now talking about the resources. We are facing a number of uncertainties for the future. But underlying all this is the resource crunch that is getting worse now. The health infrastructure was never something to be proud of in our country. In view of the challenges in a contradictable future, there is an absolute need to increase resource allocation. It is also imperative that we utilise the resources in a cost effective manner. There is a lot of wastage in this sector. A lot more can be accomplished even with the existing resources.