ASHISH KUMAR MUKHERJEE is the Director General of Health Services (DGHS), and as the country's topmost health bureaucrat, was the man in the hotseat when the recent plague outbreak occurred. He took over as DGHS in 1993, and the epidemic was the first major crisis of his tenure. He is now facing a lot of flak for allegedly mismanaging the resources at his command and for a lack of foresight. He spoke to Anirudh Bhattacharyya, at the height of the epidemic, about the outbreak and the measures being taken. Excerpts:
The plague had been virtually non-existent in India for the past 2 decades. What was the cause of the recent outbreak?
One thing should be clear: the plague bacilli were always present in various parts of the country among rodents. Whenever there are ecological imbalances, the plague bacilli will create havoc. But we were quite surprised by the suddenness of this outbreak.
The plague has occurred not only in India; there have been periodic outbreaks in other Asian countries, both North and South America, and Africa. In the us, 13 cases were reported in 1992 and a total of 160 cases reported between 1980 and 1989. The plague has recently also been reported in Vietnam and Myanmar.
If ecological imbalances cause such epidemics, why didn't earlier earthquakes and floods spark off similar crises?
I believe that ecological imbalance was a possible cause of the resurgence of the plague here. But the question is very difficult to answer at this juncture. We are investigating it thoroughly. That is the-reason we have been looking into the entire spectrum: studying rodents and fleas, trying to learn whether contam inated air and water may have been responsible, doing epidemiological studies of people afflicted by the plague.
Two teams from the National Institute of Communicable Diseases (Delhi) and the National Institute of Virology (Pune) are working on it. Only after they conclude their studies, and their findings known, can qua tions be answered.
Did the plague outbreak in Surat have aq connection with the revious cases in Maharashtra's Beed costrict?
Pneumonic plague, does occur in spwq But whether there was independent panei in Surat, or a link between the Surat and FIN outbreaks, is very, difficult to say at moment.
Is the situation now under control?
We expect the peak period to come to end soon. Certainly, within 3 weeks it %al over. Already, there are indications that falling. While during the peak period 90 cent of suspected plague cases were fouil positive, by October 3, the figure had falles I 2.9 per cent.
The recent plague follows a definite tre on which we will base our conclusiodo Between the 4th and 6th day, the number cases soars. Then there is a decline. another 24 to 48 hours, there is another rag because of bad or insufficient treatment, ]owed by a steady fall.
Apparently , the NICD had warned the Union health ministry about a possible outbreak of plague following the earthquake in Latur last September. Why were no preventive measures taken them? Similarly, the Bangalore Plague Surveillance Unit (PSU) had recorded marked increases in the number of seropositive rodents during the '90s. Was we any mechanism in place to combat an eventuality?
The NICD basically investigated and talked mt Latur. Now, Latur is rather far from rd. Yes, the Nici) had gent out a general rm, but it had concentrated on the earthoke-affected area. The NICD only talked mi a possibility - it didn't categorically dict the outbreak.
As for the Pu, we have called for all the epics from Bangalore and we will re-examthe samples here. These samples have to be kfirmed by the Nict). Again, the Bangalore it was really looking more at areas like Karnataka.
No mechanism existed to combat such a wation. We really didn't anticipate it, espeIlly in Surat, where there was no perceptible hil. Fortunately, we have the infrastructure tackle the plague: the NICD has a branch in oplore, state branches in Andhra Pradesh, oil Nadu, Karnataka and Maharashtra, the of the plague. Honestly, we were baffled the Surat outbreak.
Does as the recent plague outbreak show St the Indian healthcare system has failed?
The plague is not a reflection on our khcare system. This is happening globally. [containment measures are a major compo a of healthcare, and in this area we have succeeded.
In Surat, the plague was controlled in hours ,in Beed within 4-5 days, and in Delhi a couple of days. The number of deaths has p relatively small - only 53 (as on October This proves that we have the infrastructure, Kh is responsive and sensible and stands up To a crisis.
Whatis the main strategy adopted by the gft authorities to control the plague?
Right now; we are stressing upon identifison of those affected and their isolation. ides, extensive health education and cleanlia drives have been undertaken.
What have the tests of samples shown?
We have done sensitivity tests. And the mks have been all positive, indicating that I Versinia pestis bacilli are still vulnerable to mc!wJine and other antibiotics.
Was there a lack of adequate quarantine powes in Surat?
No,there was no lack of quarantine meaIm We depended more on treatment. bedy can stop people from moving out.
J%e priority is that every patient must be Mmified and treated. Hospitalisation is necesso avoid complications. Whether sealing required, is a bigger issue involving ilfion residents of that city. And the mof people from Surat did spread the disease.
ButBut the Epidemic Control Act was clamped on Surat after a couple of days of the epidemic, by which time a thk of the population had fled.
Yes, the Act was eventually enforced, when the government felt it was really necessary.
Is it true that a case has been reported in Delhi where the patient developed bubonic plague and maintained he had no contact with any person from Surat?
We are still working on the bubonic plague case in Delhi.
Was the available humanpower and material adequate to combat the disease?
Definitely,We didn't ask for anything from other countries. Many of them actually offered to give us support. In terms ofmaterial, we have enough, althouFh some vaccines were brought in from Russia and some antigens from the us for testing purposes.
It seems that the plague focii map available with the NICD dates back to 1948. Why hasn't it been updated?
But we have been monitoring the situation all the time. Surat was not even on that map. The main pockets on the map were in the South.
Now we will update the map, improve the surveillance system, and try to incorporate other potentially vulnerable areas. But it's difficult: 'ratfall' is an index but is not a necessary condition for the plague to occur.
We will also emphasise on upgrading laboratories and the epidemiology system for a quicker response in such situations.
What accinations for high-risk groups?
We only received the vaccines on Octob 6 from Haffkine Laboratories, Bombay. We will vaccinate the high-risk groups like doctors, nurses and paramedics who are working close ly with plague patients.
Isn't is true that with our sanitation systems in urlan areas failing miserably, health risks have shot up? Doesn't healthcare have to be connected to hygiene?
Definitely. That is what we plan to do. Cleanliness and sanitation are essential, like health education. Your health is in your hands, you have to look after yourself. The masses need to be educated on the importance ofclean air, water and food.
But it is also true that people's habits are difficult to change. For instance, a few days ago, at a hospital where plague patients were being treated, I saw a member of the paramedical staff take off his face mask and spit on the floor. This is one of the habits that have to be given up at all costs.
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