Plague: A Challenge for Urban Crisis Management

-:--------46 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT FIELD REPOR T Plague: A Challenge for Urban Crisis Management Harshit Sinha" 'We think according to nature, we speak according to rule, we act according to custom' (Francis Bacon). • Indian Institute of Management, Vastrapur, Ahmedabad, 380015, India. E-mail: HARSHIT (q' CC LAN .iimahd. emet.in Volume 8 Number 1 The need for crisis management emerges when any natural or man-made disaster occurs and disturbs the normal routine life of people. Considerable intelligence, co-operation and concerted effort are required to tackle such an sudden incident. Such are the abstract concepts for very concrete events which, in a moment, can plunge a community, a nation or the entire world into a state of chaos. Social harmony and/or conflict among various groups, the virtuous or vicious face of the society and, along with the capabilities of the individual, concerned social groups and political systems emerge to face the crisis. It is these very concrete events that bring back memories of fear, political deception, sorrow and, yes, even anger. One always seems to ask why did it happen? What could have been done to avoid the disaster? Who is responsible? However, answers are frequently incomplete, evidence is not made to the public and the public forgets quickly (Rosenthal, Charles, and 't Hart 1989: 4). The outbreak of Plague in Surat city, located in the March 2000 I I The return of Plague, an unforgotten scourge of mankind, once again reminds us that it continues to smoulder in populations of wild rodents in natural foci throughout the world. Its occasional outbreaks remind one of the devastation it caused in the past. The 1994 outbreak in Surat caused local panic (mass hysteria) and international concern, leading to the imposition of travel and trade restrictions by a number of countries. The authenticity of the crucial decision in declaring the epidemic as 'Plague' and, later, different institutional initiatives taken for isolating the germ (Y. pestis) were subject to many controversies. The uniqueness of an extra band in its protein profile created much speculation among the media. This gave momentum to various notions, as to whether the disaster was natural or man-made. In spite of all these short-comings, the decision. came to identify the epidemic as Plague and the entire catastrophic incidence was controlled within a week, with a low mortality rate. This paper traces the chronological evolution of the Plague epidemic and analyses the critical issues of its management, undertaken by various authorities and individuals, including a common citizenary. The emerging key issues of this catastrophic incident are discussed and an anatomy of the crisis is presented. The lessons learnt are put towards a model for strengthening long-term planning against any such sudden natural or man-made disaster. Introduction I I western state (Gujarat) of India, is a prime example of governance of the crisis in an urban area. This was the fourth consecutive crisis that the city experienced in less than two years. The outbreak of Plague struck at a time when the city had not yet recovered from the devastating communal carnage, of December 1992, that continued intermittently for over six months. In between, the supposed forecast by an unidentified astrologer that the Ukai Dam, upstream of the river Tapi (8 km from Surat), was to break led to an exodus of people. Then, a flood came in early September 1994 and, as its aftermath, the outbreak of the Plague in the city. Though it was controlled within a week, the gravity of the problem remained unresolved for a long period of time. Though such crises occur only rarely, it warrants (or forces) a great amount of expenditure and attention of managerial expertise. Intrigues of politics, financial bungling, poor management, ineffective planning and numerous other shortcomings simultaneously come to the forefront, aggravating already intricate problems. Thus, there remains a dire need for the accurate understanding of such critical situations. Incorporating personal experience, in field surveys during the crisis period in the city, were © Blackwell Publishers Ltd 2000, 108 Cowley Road, Oxford OX4 IJF, UK and 350 Main Street Malden, MA 02148, USA I I I I I I I I I I I I I 43 Table 1: Mortality from Plague in India Period Total deaths from Plague SM rate per Per cent of all deaths 10,000 Population 1898-1908 1909-1918 1919-1928 1929-1938 1939-1948 1949-1958 1959-1968 1969-1993 60,32,693 42,21,529 17,62,718 4,22,880 2,68,596 59,059 942 183.3 133.8 51.9 11.7 6.8 1.8 0.2 0.0 4.32 2.32 1.34 0.33 0.21 0.55 0.01 0.00 Source: Chakraborty, Rangan, and Uplekar (1995: 167) observation and discussions with managerial authorities, medical experts and intellectuals. Thus, efforts are being made to give the chronological order for the entire Plague epidemic. The critical issues of the management process undertaken by various authorities and individuals (including common citizens), are analysed under the realms of crises management. The emerging key issues of this catastrophic incident are discussed. The lessons learnt from this experience are put towards a model of how political, administrative and social institutional systems interact during the critical time of any disorder. Plague in the Past Plague is a severe infectious disease caused by bacterium Yesrsina pestis. Three pandemics have swept across the world, claiming many millions of lives and causing untold misery. Looking back, the only large, known epidemic of primary pneumonic Plague in history has occurred among marmot trappers in Manchuria, in China, and Mongolia during the early part of this century (Christe and Corbel, 1990). While the first recorded outbreak of Plague in India occurred in the year 1031-32 AD, many subsequent ones are estimated to have caused 12.5 million deaths during 1889-1950. The disease continued to be a major health problem until the mid-1940s. Thereafter, it began to decline speedily (Table 1) as a result of the large- scale application of DDT for the purpose of malaria control (Sehgal and Bhatia, 1991). However, reported outbreaks of pneumonic Plague in India (1898-1911) had occurred as part of the bubonic Plague epidemic (Seal, 1987) and pneumonic cases constituted a very small proportion of total cases (2-13 per cent). The last human case in India was reported in 1967 from Karnataka state. Since 1966, a few suspected outbreaks have occurred, especially in the historic Plague endemic areas of South India and Himachal Province in North India. However, none of these could be confirmed to be Plague. One of these outbreaks in Himachal, in 1983, was very similar to pneumonic Plague and, of the 22 cases, 17 died (WHO, 1989). In 1994, Plague suddenly re-emerged after a gap of twenty-seven years, first with bubonic cases in the Beed district of Maharashtra state and, later, in Surat, where pneumonic cases appeared suddenly. It spread to other states of India as indicated in Table 2. Issues For Analysis The outbreak of Plague in Surat raised several important issues in the field of cnS1S management. The following questions can provide a useful analytical focus for discussion: • Under what circumstances did the epidemic of Plague occur in the city? What was the urban setting at the time of the outbreak? Table 2: Cases and Deaths Due to Plague in India: 26 August to 5 October 1994. Name of the State Maharastra State (Including Bombay) Gujarat State (Including Surat) Delhi State Other State Total of India Suspected Cases Seroposive Cases 2793 1391 749 169 5150 79 35 44 09 167 Total Deaths o 49 40 o 53 Source: WHO (1994) © Blackwell Publishers Ltd 2000 Volume 8 Number 1 March 2000 46 44 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT • How did the public, media and scientific community react in the atmosphere of panic and fear and what roles were initiated and what mechanisms evolved to cope with the crisis? • How did inter-organizational and political systems perceive and respond to the complexity and impending disaster from the crisis? • What were the strengths and weakness of the concerned combating authorities in the management of coping with the crisis situation? • What impact had it caused in different strata of society at regional (local), national and international levels? •. How did communication networking help in either controlling or aggravating the crisis situation and mobilizing the resources at the crucial juncture? • What mechanism was involved in detecting and declaring the epidemic as Plague? • What regulatory responses does the Plague epidemic of Surat suggest to the authorities of the local, national and international levels? • Can there be implications for a model as to how political, administrative and social institutional systems interact in a disaster? Urban Setting Surat city lies on the golden corridor of the Ahmedabad­Bombay national highway on the southern bank of river Tapi, in the vicinity of the Gulf of Cambay, that confluence in the Arabian sea. The city of Surat has a glorious history dating back to 300 BC Earlier, it was under the reign of the Hindu monarchy and several Muslim dynasties. Later, the East India Company started trading and commercial activities. Thus, the transition of Surat city from a small trading centre to a sprawling metropolis has been a complex process spread over several hundred years. Thus, today, Surat has emerged as a major force in the textiles, diamond, chemical, plastic, engineering, petrochemicals and fertilizer industries. This, on one hand, has opened employment opportunities and economic prosperity and, on the other, has created, scarcities for usual amenities of life. The entire urban waste of Surat is discharged through wide open nullahas (sewerage) into Tapi. This, along with rain water, goes underground during monsoons, polluting the underground water table. The consequences of crowded living in industrial areas, with the associated squalor, filth, piles of rotting garbage, pools of over­flowing sewerage and an absence of latrines had turned Surat, the 'Silk City', to the 'sick city'. Extreme congestion, air and water pollution and deteriorating public health services led to Volume 8 Number 1 March 2000 frequent outbreaks of various diseases every year, culminating in the outbreak of Plague in September 1994. Chronology of the Plague Outbreak in 1994 The origin of the first outbreak of Plague in India during 1994 (21 September) appears to lie in the ruins of the earthquake that struck Maharashtra two years earlier, killing thousands of people and demolishing the burrows of millions of rats harbouring Pasteurella Pestis ­ the Plague bacterium. It was first noticed on 5 August 1994, with a complaint of a flea nuisance from the sarpanch (village head) of Mamla village (of Majalgoan Taluka) in the Beed district. On the same day, the first suspected case of bubonic Plague was reported from this village (WHO, 1994). After two days, the state government had sent a high­level delegation of health professionals to this village. Preventive measures were only suggested, but surprisingly, the option of isolating this village was neglected. Thus, the movement of people from Mamla to surrounding villages continued undeterred. Even the 5 August rat­fall did not alert them to the possibility of a Plague outbreak. Later, on 25 August, when 36 more potential Plague cases were identified with swelling in the groin (classic symptom of bubonic Plague), the local authority sprayed Benzene Hexachloride (flea control powder) in about 300 villages and distributed Tetracycline to the residents of the affected villages to be used as chemoprophylaxis (WHO, 1994). Further, on behalf of the central authority, The National Institution of Communicable Disease (NICD) team from Banglore rushed to take a serum sample. However, media reports have highlighted irregularities in this regard (Sharma, 1994). The second outbreak occurred when reports emanating from Surat. prior to detection of Plague, had revealed that water was poisoned. On hearing this rumour, the entire population was out on the street on lhe night of 18 September. The local authority, Surat Municipal Corporation (SMC), reacted sharply to counter the rumours by announcing that the water was uncontaminated. They never tested the water because Plague cases came only from some parts of the city, while other parts, sharing the same water source, did not report any cases. As the number of cases increased, with similar clinical symptoms, and resulted in sudden death (some within an hour), the local authority came to action. At Sural Government Medical College (SGMC), the head of the department of medicine called an emergency meeting of senior doctors. Explaining the clinical picture and reviewing the © Blackwell Publishers Ltd 2000 I I I I I I I I , PLAGUE bubonic Plague outbreak in the neighbouring Maharashtra state, and the population movement (mostly labour) across the border between Surat and different parts of Maharashtra, a clinical diagnosis was made by local experts of the New Civil Hospital (NCH). Detecting the 'safety pin' organism on Wayson stain in sputum smear, they took an immediate decision. After exhaustive discussions and referring to numerous literature, 1 finally, the entire group of medical experts declared the epidemic as 'Plague'. However, after an initially high toll. the fatality' rate came down as indicated in Table I. Mounting Pressure and the Chaotic Situation in the City The panic about Plague spread faster than Plague itself. On 21 September 1994, the news hit the front pages of all the newspapers, the numbers of reported Plague deaths ranged from an exaggerated 200 (local Gujarati medium) to 2,000 (International News Agency on satellite channel), with a provocative headline embellished with a picture of snarling rats and skuUs with crossbones. The majority of them highlighted garbage as the potent source of infection. Orders to isolate the affected areas and to shut down all shops, business complexes, industrial and vendor units, made people reticent in procuring essential commodities. The slightest fever and vomiting or coughing of any family members, scared others. Each cough or fever created restlessness among them. Within a few hours, the entire city engulfed in panic, leading even to the coUapse of administration. It was first the elite class that ran away, followed by three-quarters of the doctors. It crumpled the confidence of the common mass. This led to a phobia-induced mass exodus. The minds of the escapists reeled between fad and fiction. Nearly one-third.' of the houses of Sural were closed. Emigrants constituted the larger number among the fleeing population. Most of them disposed of their belongings and ran away. Railway stations and State Transport Corporation (STC) bus stands were overcrowded. The STC provided nearly 200 buses especially to take people out of the city. Soon, panic gripped the entire Gujarat state and, later, the entire country, as well as the world. The atmosphere of panic, as noted by World Health Organization (WHO), revealed a total of 5,150 suspected pneumonic or bubonic Plague cases and 53 related deaths from the eight states of India (Table 2). Further, the international news agencies (especially in Europe), through satellite channels, showed images of people fleeing from © Blackwell Publishers Ltd 2000 45 this epidemic. In spite of a WH0 3 declaration that the risk of Plague to international traveUers was extremely small, many governments, relying on media reports, reacted with 'knee jerk' measures to protect themselves. Restrictions on travel and trade caused massive losses to the economy of India. The situation at New Civil Hospital (NCH) was tense as the majority of private doctors had fled and aU other Government and Trust owned hospitals were asked to direct suspected Plague cases to one nodal centre. With rumours of the spread of kil1er disease, more than 700 suspected Plague cases arrived at NCH, often sick with fear as well as disease. As perturbed doctors shouted between patient and relatives in an atmosphere of mounting panic and pressure, the correct results of diagnosis and the addresses of patients were not noted properly in the requisite records. Besides, some deaths occurred on the mid-way to hospital and those who died at home of similar symptoms were off the record. There was no pathologist traceable in the hospital. similarly was the case with more than half of the paramedical staff. Only 200 staff members were attending, willingly, to their respective duties. Even several doctors and nurses had contracted the killer disease and many others tried to avoid their assigned duties. The confirmed cases of Plague were kept in specifically-made isolated wards and admission criteria became more and more restrictive with pathological and other medical tests. To combat the situation, the required logistic support in the NCH in Surat was either absent or out of stock and that present was not in working condition. Besides, constant intervention from higher-up in the state capital led to chaos and confusion that hindered the process of admission and treatment. As a result, the entire combating staff of the hospital (including doctors) threatened to go on strike in protest against the state authorities. The shortage of essential drugs in Government hospitals gave momentum to the chaotic situation. With the announcement that medicine such as Tetracycline, Septron or related drugs were effective against this disease, black marketing soared. This situation forced authorities to order such medicine from other places, while a handful of people found an alternative to these medicines with other type of therapy." Those who could not get any of these, expressed their anger against the fleeing doctors (private) by resorting to arson and looting their clinics. The panic was so deep-rooted that, despite excess production of Tetracycline in the country, the panic-ridden department of Revenue of the Union government exempted aU the medication intended for Plague patients from all types of custom duty (India Today, 1994a). Furthermore, bulk imports of the drug were also exempted from all types of duty. Volume 8 Number 1 March 2000 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT 46 There was so much politicization of the incidents that it was very difficult to arrive at any definite conclusion during these crucial days. This was very much evident on two occasions; first, when the first Plague case was detected at the Ashakta Ashram (Trust hospital), the municipal authorities asked that hospital authorities remain tight­lipped till further orders and, secondly, when the first batch of serum samples of the Plague­affected patients were found missing en route to the national capital. It was also noticed that coordination among the research institutions (NICD­Delhi, Haffkine Institute­Bombay and Institute of virology­Pune) was totally absent. On one occasion, the report of Pune institute was found to contradict the reports of the NICD­Delhi (Mehta, 1994). Seeing the pathetic condition of the civil hospital, many raised objections about the procedure adopted in collection and pathological testing of serum of victims. Even the state committee report on Plague did not make any definite statement (Table 3). The central and state authorities remained silent, hiding the facts in order to divert attention of the people, media, and world community as a whole. This created much chaos and confusion, giving birth to several misperceptions. Many believed it to be a natural disaster, while others have identified it as a man­made disaster. Some people believed it as a curse of Allah owing to the demolition of the disputed structure at Ayodhaya in December 1992, with outbreaks of communal riots as repercussion. Others felt it a revenge against the losses borne by the minority community during the communal riots. Among experts, confusion and lack of coordination created much controversy regarding the nature of this epidemic occurring under odd epidemiological circumstance. Doubts were raised about the possibility of 'Plague'. Some pronounced it as some other disease, like Hania Virus (Dhar. 1994), Melodises (Jacob, 1995), or Plasmodmonas Pseudomallei (Bharadwaj, 1994). In effect, many, seeing the low death toll (56 deaths only), were not ready to accept this epidemic as Plague (Paneth, 1994). The media began speculation based on reports Table 3: The Dilemma For the Surat Epidemic Why Not Plague? Why Plague? 1. Primary 1. Highly 2. 2. A reported 'excellent' response to treatment with Streptomycin, Tetracyclines and 3. 4. 5. pneumonic Plague is highly uncommon (only one large epidemic of primary pneumonic Plague is known to have occurred in Manchuria in 19101912, causing some 60,000 deaths). A classical Plague epidemic follows the Bubonic Plague ｾ pattern of rat­fall ｾ pneumonic Plague, which does not seems to have happened in Surat at all. Also, typically, total number of pneumonic Plague cases does not exceed 10 per cent of total Plague cases. Primary pneumonic Plague is highly infectious, while here the contagiousness is very low. Also the age and sex distribution here is not typical. Research indicates that the mortality of a given case of pneumonic Plague is very high whereas, in Surat. the comparative mortality is very low. The children and elderly patients seems to have escaped lightly here. In Surat, an uncommon occurrence. 6. Conflicting data regarding cross analysis of matching gram stain positively, Symptomatology and X­ray pictures. 7. A reported flea index of 0.21 only in Surat. suggestive symptomatology of LRTI­Pneumonitis, of short duration with positive radiology, occurring in a very short time amongst vast population. Chloramphenicol. 3. Possible containment of outbreak by massive use of prophylaxis, curbing the mortality to some extent also. 4. Reported occurrence of an epidemic of bubonic Plague in nearby Maharastra state. 5. Occurrence of natural disasters like floods in Surat and earthquakes in neighbouring state of Maharastra, causing a probable ecological imbalance causing displacement of rodents. 6. Reported occurrence of cases of bubonic Plague in Surat also. 7. Corroborative bacteriological and serological data from Surat (through highly unsatisfactory). Source: Mehta (1994) Volume 8 Number 1 March 2000 ttl Blackwell Publishers Ltd 2000 PLAGUE of the extra band of protein in molecular analysis of the serum samples. Earlier, many experts commented that the Surat Plague was exacerbated by the negligence of the civic authorities. The flood was assumed as one of the possible reasons for the epidemic that enhanced the chain of infection which later went out of control (Mehta, 1994; TAC, 1995; Shah, 1996). Several questions were raised among experts about the origin of the Plague organism (The Times of India, 1995a). Some theorized that it was caused by genetically engineered microbe intended for biological warfare (The Times of India, 1995b). Since the Surat stain was not Indian, the possibility of purchasing the Plague virus from Kazakhisian by militant groups (belonging to another country) was also suggested (The Times of India, 1995b).5 Some scientists believed that this outbreak was an experiment done by a developed country aiming to study how the government, the people and the scientific community would react in the event of a real attack. In the US, the invention of Biological Integrated Detection System (BIDS) for detecting germs in the air and the simultaneously sudden rise in the expenditure for germs defence programme in 1994 (which was 54 per cent more than the previous year) raised many possibilities as it was not difficult to transport the germ (Prasannan, 1995). To date, the incident is a matter of debate as to whether it was a man-made or natural disaster. Measures of Control and Relief Where a section of the city's inhabitants, in a state of utter chaos and confusion, opted for exodus, others dared to stay within the city, keeping their life and fortune at the mercy of the Almighty. Young dynamic people took initiative in helping social workers bum the garbage, sweep the roads and spray insecticides. Some of them worked day and night to rescue flood victims, while others arranged to procure medicines from all possible sources and distribute to affected localities. After the local authority had declared the epidemic as 'Plague', it was conveyed to all administrative offices of the city, state headquarters and national capital. For better communication, a wide network wireless system was set up throughout the entire city connecting SMC centred and zoning offices with the civil other district administrative hospital. departments and with the state (Gandhinagar) and national capital (Delhi). Recognizing the gravity of the situation, the State government, with the support of the municipal authorities, prepared an action plan (Figure 1) (SMC, 1994). Under the Essential Services Act, strict action lQ Blackwell Publishers Ltd 2000 47 was enforced against the absentees during these days. To execute the plan, a rapid action force, along with eleven companies of State Reserve Police (SRP), intensified 24-hour patrolling. The local authorities had prepared forty multidisciplinary survey teams, including doctors, nurses, spray workers, teachers and some voluntary workers. Serious efforts were made for early detection, referral services, providing prophylactic treatment, spraying of insecticide, health education and preventive measures against the disease. Unfortunately, during the outbreak of Plague, there was no publicly elected body in the SMC and the majority of doctors had run from their responsibilities. At this crucial juncture, a few members from the Chamber of Commerce, in association with a few private doctors, had set up a 24-hour camp distributing medicines and organized several information sessions. In order to guage the prevailing panic and terror among the fleeing people, some useful aspects of the discussions were video-taped and telecast in the city. From the very first day of the epidemic, the President of Indian Drug Manufacturers Association gave an assurance to meet the demand for the present crisis and future consequences. As a result, by the first week of October 1994,55 million capsules were supplied (Down to Earth, 1994). At the central level, the matter was taken seriously and the supply of drugs was assessed at a meeting of the drug producers. It was found that the country had more than sufficient supplies of drugs (Coval, 1994). As thousands of people from Surat continued to reach different destinations, the adjoining districts of Gujarat and the neighbouring states to which migrants belonged, including the capital city (Delhi), were declared Plague threatened (The Times of India, 1994). The measures taken in these districts included medical examination of incoming persons, distribution of Tetracycline, alerting medical staff, cleaning the garbage and so on. Such measures were also adopted by the authorities at railway stations and all national and international airports. The state government appointed a senior officer as the chief co-ordinator for Plague control measures. The Chief Minister of the Gujarat State held a high-level meeting with the Additional Chief Secretary of Health and the Chief Co-ordinator, who all reviewed the situation for allocating the relief grant. However, field surveys revealed the reality of the absence of any such assistance to the victims (Shah, 1996). Besides, an international response towards the relief activities was totally absent. Many representative of domestic political parties and voluntary organizations did a remarkable job rendering their services. Volume 8 Number 1 March 2000 48 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT Locating Point of Threat Isolating the Indexed area 1 Isolation Ward Control room at New Civil Hospital South West Zone Zonal Office ｾ ｾ ｾ 3 Teams EachTeams Consists of a M.O MPHW LHVIFHW SI SprayWk. Driver 5 Teams EachTeams Consists of a M.O MPHW LHV/ANM Vaccinator Spray Wk. Driver 1 Teams Each Teams Consists of a M.O MPHW LHVIFHW DSI Spray Wk. Driver ｾ ｾ 4 Teams Each Teams Consists of a M.O LHV Vaccinator Spray Wk. Driver ｾ ｾ 2 Teams Each Teams Consists of a M.O MPHW FHW PHNIPMA Spray Wk. Driver ｾ 3 Teams Each Teams Consists of a M.O MPHW FHW SHIIPHN Spray Wk. Driver ｾ Objectives Early detection, Referral Service, Providing prophylactic treatment, Spraying of insecticide, Health education, Preventive Measures against this disease. Action Plan for Survey Work by School Teachers With the Help of Local Authorities List of Activities Brief meeting of the planners Collection of Electoral Roll & its division Brief meeting of Head Masters & traini ng regarding survey 1 1 1 Deputy Comm. of Health Election and Census Officer Distribution of survey activities 1 Deputy Commissioner of Health & Supported by R.D.D. & M.O.H Election and Census Officer Conduction of Actual Survey 1 Concerned School Teachers along Supervisor Collection of the Survey Forms Scrutinising of the forms and further actions 1 1 Concerned Head Master & H.S. Dy. MOH DC (HHj Supervisor Who is responsible? Figure 1: Action Plan of the Surai Municipal Corporation Against a Plague Epidemic Volume 8 Number 1 March 2000 © Blackwell Publishers Ltd 2000 PLAGUE Origin and Nature of Disease Much later, at state­level, it was decided to appoint a high­level expert committee for investigating the Plague epidemic. This was followed up by a Federal Government decision to appoint a Technical Advisory Committee (TAC) in connection to the outbreak of the Plague. As the Defence Research and Development Establishment (DRDE) gave a controversial clue to the nature of the disease, the samples were sent (India Today, 1994b) to the Centre for Disease Control and Prevention, Fort Collins (CDC) laboratory and the Pasteur Institute in Paris for sample confirmation and to Stavarapol Anti­Plague Research Institution in Russia, for molecular characterization. This controversy ended with the declaration by these three WHO collaborative institutions that the Sural Yersinia Pestis was unique and was never recorded anywhere else in the world (Laney, 1995). Confirming the uniqueness of the protein profile, the Russian Institute, on the basis of an additional test, reported that Sural strain was a weak Pathogen. The new strain has been classified under group'S'. Further, since many theories were associated with the outbreak of the Plague, the central authority took a keen interest in finding the origin of the germ through a team from Defence Research Development and Organization (DRDO) under the leadership of renowned scientists. Anatomy of the Crisis Tracing the chronology of the events in the process of managing the crisis, many pitfalls and irregularities were found in the action and decision­making processes adopted by the authorities. Summarised details of the actions and decisions related with the management of this epidemic are indicated in Table 4. Neglecting initial warnings in the Beed district, the consequence of ratfall and the non­isolation of the village Mamla resulted in an increase in the number of Bubonic cases from 16 to 32 and the spread to neighbouring villages. However, the Maharashtra health infrastructure, with immediate preventive measures, restricted the disease from developing into Pneumonic­type, without any fatality. In Surat. the delay in removing the carcasses of dead animals, due to flooding from the low­laying areas, gave momentum to a chaotic situation. The possible impact created a congenial atmosphere conducive for the growth and transmission of Eurasian Pestis from wild to domestic rodent. As a result, more fatalities occurred in these areas. However, with the barest facilities available to the authorities, the wisest decision came in © Blackwell Publishers Ltd 2000 49 detecting the epidemic as 'Plague'. Thereafter, the measures taken to break the chain of infection gathered tremendous momentum. It is a different matter that within their own country they were always questioned about the procedure adopted in detecting this disease. The action plan, together with a proper communication network, co­operation, realising individual responsibilities and with the unmatehable zeal of fighting sprit, restricted the death toll to a mere 56. On the other hand, many technical irregularities were observed while forming the team for survey during the action plan. Absence of an epidemiologist and an entomologist in the survey team retarded the knowledge about the ecology of the rodents for Plague. Thus, many questions regarding the nature of the disease, its origin and mode of transmission remained unanswered. Procedure and format, adopted for maintaining records, created much difficulty in locating the victims for follow up. Constant harassment of the victims for their serum sample (as used for bacteriological examination) encouraged them not to co­operate with authorities. They failed to educate the victims regarding the significance of the pathological examinations. Besides, sudden closure of vendor shops, industrial units and private hospitals, enormous dumpings of insecticide and administering chemoprophylaxis to all, created much panic among the masses. Instead of providing the correct information on the nature of the disease, the authorities arranged for about 200 buses to evacuate people. In a multi­layer system of bureaucracy (Stephen, 1979), the victims were supposed to be largely dependent upon the state and central authority." Making the NCH as the nodal point for the treatment of Plague cases, and immediately creating an isolation ward, prevented the diffusion of the infection to other parts of the city, but confusion prevailed in setting clear case definitions for admitting the victims ­ as large numbers of cases being suspected as Plague victims were admitted. From the very first day, the initiatives taken by doctors for looking after the patients, arranging for drugs and also exploring useful contacts from all possible resources, were the right steps in prevention and control of such diseases. The absence of other preventive kits (mask, gloves and so on) generated the risk of infection among the staff, many of whom have suffered for it. The combating team failed to supply drugs and vaccines during the first three days when fatality rates are normally higher. The blanket decision for exemption made on import duty for the medication (related to this disease) had no impact during the crucial days (or hours) of the Volume 8 Number 1 March 2000 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT 50 Table 4: Analysis of the Sural Epidemic Under the Realms of Crises Management The Irregularities/Wrong Actions/Delayed Decisions 1. The delayed action of civic authorities 2. 3. 4. 5. 6. 7. in removing the carcasses from flood affected areas (North Zone) of the city. Confusion in setting clear case definition for admitting the victim. The inability of the hospital authorities to provide for protective measures (hand gloves) and proper record keeping system. Unable to confirm the correct laboratory diagnosis of the disease. Lack of co-ordination among the various department of the hospital. The constant interventions of "higherup" disturbed not only the working procedure but demoralised the combating staff. The survey team does not include an epidemiologist and entomologist. 8. The local authorities fail to sustain confidence and information regarding the disease among the people. 9. The local authorities fail to take action against absentees, including doctors and also against media for exaggerating the situation. 10. Since the disease is air borne, excessive sprinkling of insecticides on road without chemoprophylaxis created much panic among the people. 1 1. Delay in procuring the medicine and vaccination at the crucial hours of these crises. 12. No swift action for follow-up on victims. crisis. Constant interventions by distant bureaucrats in technical aspects not only deteriorated the situation in the hospital, but created frustration among staff. It was not so easy for the senior doctors to motivate all the remaining employees to put their efforts together with the barest infrastructure. In spite of many irregularities and lack of co-ordination among various department at the NCH, the doctors of the NCH performed their duty remarkably well, against all odds, including several limitations of infrastructure and other related facilities. The young doctors (interns), on an individual basis, and paramedical staff did everything to save the lives of patients. The strain undertaken during these crisis times by the Volume 8 Number 1 March 2000 The Regularities/Right Actions/Positive Decisions 1. Identifying the epidemic as Plague. 2. Locating the point of threat at the earliest moment. 3. Isolating the infected area from rest of the city. 4. Establishing isolation ward and gathering all victims at one treatment centre. 5. Establishing a survey team and information network system. 6. The team sprit, patience, dedication and courage shown by the hospital staff members in treating the Plague victims. 7. Seeing the magnitude of the problem, the initiative taken up with the spirit of team work was very much appreciable. 8. The Plague epidemic diverted people's attention not only towards hygienic living condition (solid waste management) but consciousness towards civic sense and other essential amenities. 9. The media mobilise immediate government action. 10. Seeing the pathetic condition and irregula- rities, faced during the crises time, draws attention of the health planners towards health infrastructure. 11. Draw attention of the planners towards consequent problems of rapid urbanization and industrial growth. 12. Draw government attention in preparing Disaster Management Plan, doctors and entire paramedical staff, including class IV employees, was unmatchable. The local authorities diverted popular attention towards the garbage pile-up which was considered the sale source of infection. Thus, public and local authority gave much importance to 'Operation Clean'. This was also witnessed in most of the major cities of India (Laney, 1995). During the early days of the epidemic, the political pressure delayed the decision to declare the epidemic as Plague. Even the State Plague Investigating Committee did not make any definite statement. Thus, hiding the evidence had not only created confusion and chaos among the masses, but failed to justify their verdict during crucial hours. This led to the (9 Blackwell Publishers Ltd 2000 PLAGUE 51 formulation of many theories for the ongm of the epidemic. Fortunately, the germ (Y. pestis) was detected at Defence Research and Development Establishment (DRDE), Gwalior, and proved beyond doubt that the epidemic was Plague. The action taken by the state and central government to set up an inquiry committee for the two Plague epidemics was too late to be of any use. The exaggerated reports by the vernacular newspapers further enhanced panic among the masses. The government's response to the misinformation and exaggeration by the print media was weak. Thus, lack of accurate information in the print media contributed to mass hysteria and fear. The only positive aspect of the press coverage was that it did mobilize lhe government into action. Such catastrophic incidents become issues of international politics, especially in developing countries. At the international level, the adverse comments made toward India in connection with this epidemic showed the biased nature of the developed countries against India. Since 1986, WHO estimated reported annual death figures due to Plague outside India have crossed the 100 mark every year. Even in a Western country, such as the US, between 1970­1991 the Plague mortality was 4.5 per cent. These incidents pass almost unnoticed by the world community; whereas India remains the butt of adverse comments on the Surat Plague. The international support for the victims in rehabilitation process was limited due to stigma associated with this disease. All international passengers and their commodities from India were looked as Plague suspicious cases. Thus, in the atmosphere of panic and fear. people and the media, from different countries, behave in the same manner. Lessons For the Future Cities do grow and crises are a constant result of this. Plague is an example of a series of medical disasters that could erupt at any time, with changing ecology, environmental degradation and uneven population growth. The situation in Surat resembles other millionplus cities of India, revealing imbalances between rural and urban developmental programmes. The former, being neglected, leads to the influx of large numbers of migrant to cities. These uneven life-styles of migrants and main dwellers, lack of co-ordination between urban planning and public health may cause sudden natural or man-made disasters, plunging the public health system into chaos. It draws the attention of state authorities towards uneven distribution of resources between rural and urban region. Thus, in order to attain sustainability in development programmes, the widening gap between these ｾＧｂｬ｡｣ｫｷ･ｬ Publishers Ltd 2000 regions should be narrowed. It is time that India formulates a national urban policy and also sees that it is being practically enforced. In Sural, the uneven industrial and urban growth, dumping of industrial waste, environmentally destructive suburbs with pathetic lifestyles, without any public amenities, draws attention to the fact that basic services to the urban poor have to be provided on a priority basis. Simultaneously, the Pollution Control authorities must enforce strict laws against unauthorised industrial growth and their outgoing waste. The Plague epidemic highlights that governments have to deal with the main social cause of the disease, rather than adopting a symptomatic approach as a 'fire fighting' exercise. The fragmentary approach to economy and health has to be replaced with an holistic approach. Prompt action to identify the causative agent in an outbreak is of utmost importance in the control of infectious disease. In India, several earlier attempts have been made, however, it remained as a major weakness in the management of all public health action programmes (Sinha, 1997). Thus, a well functioning surveillance system, with appropriate diagnostic capability at health centres, hospitals and clinics, backed by supportive referral institutions, must be given high priority in India and other developing countries. The media can do more damage than the Plague. In Sural, the media failed to disseminate correct information among the masses. This, in turn, had swayed the minds of the people between fact and fiction. As all national and international code of ethics of journalism were violated, strict and firm laws should be framed so that media exaggeration during crises could be penalised under law. In this regard, the role of 'Ombudsman' becomes essential in order to help maintain proper understanding between media, government and the masses. New infectious diseases continue to emerge, yet there is no clear strategy for managing them. A model response should be devised in the light of past events, such as the recent US outbreak of a previously unknown Haniaoirus (Gellert, 1994). Epidemic of Plague is similar to past, devastating events occurring in Surat. This epidemic revealed many conflicting attitudes of individuals while combating the real-life situation. The absence of a clear, distinctive role of an individual for technical and administrative tasks during crises has never been specified. Besides, the power and associated politics within the working hierarchy become a major hurdle in normalizing the tense situation. Looking at this conflicting nature, proper and appropriate guidelines for management of crisis have to laid down. Irrespedive of the nature and the type of crisis, a common model may be adopted as given below. Volume 8 Number 1 March 2000 I 52 JOURNAL OF CONTINGENCIES AND CRISIS MANAGEMENT Future Model awareness and interest and to encourage societal forces to influence public policy and resource mobilization. Implications of such a model could be strengthened with proper interaction with the media and the public. Seeking their assistance would be of utmost importance in the management of any crisis. Thus, such models should be implemented by a joint venture of State and Central Government in all major cities of India, at different levels of governing bodies. The suggested model may be useful in the field of crisis management, in imperilled cities, for long­term planning to combat natural or manmade disasters. The above difficulties in such catastrophic incidents draws experts' attention to prepare a common minimum disaster management plan, as shown in Figure 2. The disaster site(s), being directly linked to the control room, are later connected with the various levels of administrative bodies. It is advised to set up two parallel divisions with a control room. These divisions will ensure that the technical decisions are taken by technical experts and administrative decisions taken by appropriate administrative authorities. To ensure the regular supply of the essential commodities at the disaster sitets), the control room should command the logistic support division. This will help to identify the requirements of any present crisis and its future consequence. The other division would be involved in rehabilitating the victims and disseminating the correct information through the Information, Education and Communication (IEC) activities. Such activities are being conducted by various individuals at different levels. All these activities should be governed and controlled through a control room. This model would help to avoid confusion and reduce fear and panic in the community. Further, this would guarantee that the necessary assistance reaches victims on time. Information has an important advocacy role to increase public Conclusion Whatever controversies may persist as to the outbreak of the epidemic in the Surat city, people, in general, wanted immediate action from the authorities. The local authority reacted quickly but failed to disseminate the correct information. As a result, mass exodus took place from Surat. It, of course, created many problems in other parts of the country. Correct information was lagging and the media ignited the entire crisis situation to such an extent that various ill­notions, psycho­fear and panic gripped the minds of people, even doctors. The only positive aspect of the media was to r r REHABILITATING DIVISION I I ADMINISTRATIVE DECISIONS r r ADMINISTRATIVE DIVISION TECHNICAL DIVISION I 1 LOGISTIC SUPPORT DIVISION DISASTER SITE .. CONTROL ROOM ｾ 1 .. IEC DIVISION TECHNICAL DECISIONS I Disseminating Correct Information I r ｾ VICTIMS I I I I I I I r LOCAL I I 1 STATE HEAD QUARTER 1 NATIONAL HEAD QUARTER r f-----. l: Ｎｾ PEOPLE I Ｎｾ DISTRICT HEAD QUARTER ｾ ｾ NATIONAL MEDIA I I Ｎｾ I I INTERNATIONAL I Figure 2: Disaster Management Plan Volume 8 Number 1 March 2000 © Blackwell Publishers Ltd 2000 PLAGUE mobilise the government into action. On the other hand, many voluntary organizations played a significant role individually and, along with the local authority, helped to minimize the entire crisis. The expert and scientific communities had their own perceptions and were confused about the facts regarding the outbreak. The non­availability of high­tech facilities in the civil hospitals created much controversy and confusion in passing technical judgement. In spite of these shortcomings, a wise decision was made in declaring the epidemic as 'Plague'. However, politicization of the event had delayed the decision in declaring the epidemic as Plague. Overall, the joint efforts made by all combating authorities, at various levels, with proper action planning and efficient communication networks, caused the fatality rates to decline rapidly and the entire catastrophic situation was brought under control within a week. 53 religiosa), Bhel (Aegle marmelos) and Tulsi (Ocimum Sanctuml/basiiicum L) in boiling water proliferated. 5. 'Dr. A.P.J Abdul Kalam, Defence Science Advisor, is personally looking into matter with the help from Scientists of Defence Research Laboratory in Gwalior, who have specialised knowledge in the field of biological and chemical agents... , The decision taken by Dr. Kalam at a meeting he held with defence scientists at midnight last night is not known' (The Times of India, 1995b: 1). 6. A multi­layer system in India, permits (indeed encourages) such calculation of state versus central as well as local versus state interests. The union government is always concerned about its international reputation as well as domestic perceptions of its assistance to a stricken state. The victims were found caught between the need to bargain with union authorities for assistance support, and the central responsibility towards local leaders and bureaucrats who must bear the brunt of implementation. Finally a crisis may occur in a political environment in which there is a already a prescription to exploit available issues (Stephen, 1979). Notes 1. The studies made by Park (1972) and Evans and Feldman (1982) were available at the department's library. These highlighted the clinical features of pneumonic Plague, as described by Tiggertt (1982: 712). In pneumonic Plague, the onset may often be with a chill followed by fever, cough and splinhn of the chest, with the production of sputum that soon becomes bloody. Focal lung lesions are present, as manifested by dullness, decreased breath sounds, and roetgenographic evidence of infiltration, Mediastinal lymphadenopathy may be evident. Without effective therapy, progress of the disease is rapid, with extensive lung consolidation, septicaemia, prostration, mental confusion, subcutaneous haemorrhages due to intravascular coagulation, and shock, with death ensuring in 2 or 3 days. 2. According to a survey carried out by the Sural Municipal Corporation (SMC), on 29 September 1994, 'Nearly 33 per cent of the houses of Surat were closed. Among those who fled away, a majority were entrepreneurs, medical practitioners and other professionals and members of the upper middle class. A large number were migratory population.' 3. 'WHO does not recommend change in individuals' plans to travel to India, but advises caution in travelling to the city of Sural. There is no restriction for travellers visiting India or passengers in transit in airports in India. Surat is the only locality declared an epidemic zone. It is prudent to advise travellers from potentially infected areas that any illness presenting within six days of leaving the areas should be brought to the attention of a doctor, who should be informed of the travel that has taken place.' (WHO Press release WHO International Team on Plague calls for an end to restrictions, 28 September 1994.) 4. Homeopathic medicine such as Crotalus Horridus: Ayurvedic Medicine mixing leaves of pipal (Ficus © Blackwell Publishers Ltd 2000 References Bharadwa], R. (1994), 'Outbreak of Plague­Like Illness Caused by Pseudomonas Pseudomallei in Maharastra, Letter to the Editor', The Lancet, Volume 344, 3 December, p. 1574. Chakraborty, AK, Rangan. S. and Uplekar, M. (1995), Urban Tuberculosis Control: Problems and Prospects, Foundation For Research and Community Health, Bombay. Christie, A.B. and Corbel, M.J. (1990), 'Plague and Other Yersinial Diseases', in Smith, G.R. and Easman, C.F.5., (Eds.) Topley and Willison's Principal of Bacteriology, Virology and Immunity: Volume 3, (8th Edition), Edward Arnold, p. 400. Dhar, L. (1994), 'India: Is It Plague?, Letter to the Editor', The Lancet, Volume 344, 12 November, p. 1359. Down to Earth (1994), 'Mystifying the Plague', 31 October, p. 2. Evans, A. and Feldman, H. (Eds.) (1982), Bacterial Infections of Humans, Plenum Medical Book Co.. New York. 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