Betrayal of Trust: The Collapse of Global Public Health by Laurie Garrett

From Barnes & Noble

Pultizer Prize winner Laurie Garrett made the world sit up and take notice with The Coming Plague. Betrayal of Trust grew out of the conviction that the only way to deal with potentially devastating plagues would be a strong public health infrastructure. To her dismay, Garrett discovered that public health around the world is on the verge of collapse.

From the Publisher

In this meticulously researched and ultimately explosive new book by the Pulitzer Prize-winning journalist and bestselling author of The Coming Plague, Laurie Garrett takes on perhaps the most crucial global issue of our time. She asks: Is our collective health in a state of decline? If so, how dire is this crisis, and has the public health system itself contributed to it? Using riveting detail and finely honed storytelling, Garrett exposes the underbelly of the world's globalization to find out if it can still be assumed that government can and will protect the people's health, or if that trust has been irrevocably broken.

Foreign Affairs

This book is a twin, in many ways, of the author's best-selling The Coming Plague -- interesting, sprawling, heavily anecdotal, and amply footnoted . . . Once extracted, however, the message remains an important one old scourges tuberculosis and syphilis are alive and all too well and newer ones AIDS, most notably have yet to abate their force . . . a useful warning that globalization may have a very dark side indeed.

Publishers Weekly

On a par with Rachel Carson's Silent Spring, this chilling exploration of the decline of public health should be taken seriously by leaders and policy makers around the world. Garrett, a Pulitzer-Prize winning journalist for Newsday (The Coming Plague: Newly Emerging Diseases in a World Out of Balance), has written an accessible and prodigiously researched analysis of disaster in the making in a world with no functioning public health infrastructure.

Journal of American Medical Association - Thomas J. Coates

Prescient is the right word for Laurie Garrett's Betrayal of Trust. It would be an understatement to say that the US response to anthrax deaths has left much to be desired. Worse yet, those deaths and the specter of bioterrorism have exposed all of the weaknesses in the public health system that Garrett has documented in her usual meticulous and intelligent style. Her thesis is that the health of the public is part of the compact between citizens and their governments and that governments have broken the compact; hence, they no longer deserve the essential trust of those citizens. Furthermore, she documents how the solutions to today's major health problems are nontechnological and that the local is linked intimately with the global.

Publishers Weekly

On a par with Rachel Carson's Silent Spring, this chilling exploration of the decline of public health should be taken seriously by leaders and policymakers around the world. Garrett, a Pulitzer Prize-winning journalist for Newsday (The Coming Plague: Newly Emerging Diseases in a World Out of Balance), has written an accessible and prodigiously researched analysis of disaster in the making in a world with no functioning public health infrastructure. In India in 1994, neglect of public health for the poor led to an outbreak of pneumonic plague; the once-dreaded disease is now easily treatable with antibiotics, but the failure of Indian authorities to quickly reach a diagnosis and provide accurate information resulted in a worldwide panic. The former Soviet Union, for all its flaws, according to Garrett, assured every citizen access to health care. After the U.S.S.R.'s breakup, the Russian economy collapsed. With no funding left for health care, Russia was overwhelmed by a tuberculosis epidemic. Even the U.S., historically a pioneer in public health (this commitment was demonstrated by New York City's quick and successful response to an 1888 cholera epidemic, as well as the tenement reform movement of the early 1900s that helped eliminate diphtheria), is lagging today. During the Reagan administration, Garrett says, budget cuts dramatically weakened public health while also denying poor Americans access to medical care. The author believes that the medical challenges posed by the epidemic spread of AIDS in Africa, by drug-resistant microbes carried from one country to another and by the danger of biological warfare can be met only by a cooperative global movement dedicated to strengthening public health infrastructures. Garrett sounds the alarm with an articulate and carefully reasoned account. Author tour; NBC Today appearance. (Aug.) Copyright 2000 Cahners Business Information.

Library Journal

Turning her attention to the frightening condition of public health throughout the world, Pulitzer Prize-winning science reporter Garrett repeats the call for action she initiated in her tremendously successful The Coming Plague. Re-emerging diseases, antibiotic-resistant superbugs, and biological terrorism are increasing threats that can only be conquered through significant attention to worldwide public health. Garrett provides an in-depth look at public health programs in several different geographic areas and analyzes their successes and failures. The author shows clearly that successful public health programs require a fragile bond of trust between the people and their government, and she details the critical effects of politics and economics on public health infrastructures. Her endnotes, which might constitute a book in themselves, offer a tremendous resource for additional research. Completely readable for general readers and experts alike, this reasonably priced book is highly recommended for all libraries.--Tina Neville, Univ. of South Florida Lib., St. Petersburg Copyright 2000 Cahners Business Information.\

New York Times Book Review - Fitzhugh Mullan

These are lurid, disturbing and well-documented images that are not easily dismissed as alarmist. . . . But it is Garrett's observations about the United States that are the most disturbing. . . . [Her message] is a momentous one that is delivered persuasively.

Business Week - Arnst

In this spectacularly well-researched and well-argued follow up (to 1994's The Coming Plague) Garrett details how poorly prepared the world's public health-care systems are to deal with outbreaks of disease.

Product Details

• Table of Contents
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Table of Contents

Read a Sample Chapter

Chapter One

FILTH AND DECAY

Pneumonic plague hits India
and the world ill responds.

This town is coming like         a ghost town No job to be found         in this country. Can't go on no more,         people getting angry. This town is coming like         a ghost town. This town is coming like         a ghost town. This town is coming like         a ghost town. This town is coming like         a ghost town. This town is coming like         a ghost town. From "Ghost Town" —The Specials, 1981

No one else got off the train. Thousands got on.

    Even before the aging Indian locomotive lumbered its way into Surat passengers began scouring their sacks and suitcases in search of rags or scarves to wrap around their faces. Protesting children wailed, but mothers, speaking Hindi, Tamil, Punjabi, Bengali, or English, sharply insisted.

    "You must wear this, child. It will protect you," they said. And as the train approached the city the children's dark eyes widened above their impromptu masks and therocking passengers grew silent.

    The only Westerner aboard gathered her bags and, to the obvious astonishment of fellow passengers, exited the train, stepping into the torrid September heat of Surat. Throngs of masked Suratis, encumbered with bags and infants, elbowed their ways onto the train, shouting and jostling for seats. Though they had tickets, most would gladly stand for hours if need be, relieved to get far away from the monsoon-soaked city.

    Far away from the plague.

    In less than a week 500,000 residents of Surat had fled, forming a diaspora of Suratis that, thanks to India's vast train system, now stretched from the Himalayas to Sri Lanka. An estimated 600,000 day workers and business travelers who normally visited the gem and fabric districts of Surat stayed away. Thus, less than half of Surat's typical daily census of 2.2 million remained. They were the poorest of the Gujarat State's poor: lower caste citizens who could no more conjure the seventy rupees (or $2.50) for a lower class train ticket than $500 for a seat on a jet.

    As the chugging sound of the departing train dissipated, a near silence, punctuated by occasional motorbike rickshaws, reigned. Four train cars remained, painted with large red crosses and signs saying ACCIDENT MEDICAL RELIEF. The grounds around the cars were chalk white with thick layers of DDT pesticide powder.

    Trash and garbage blew about the streets, inspected by foraging cows sacred to the largely Hindu population. Roads that usually resonated with the high frequencies of diamond polishing devices and 300,000 power textile looms were silent. Boards, loosely hammered in place, sealed shut the pharmacies, private medical clinics, and nongovernmental hospitals. Those citizens who remained moved quickly, rags or masks wrapped about their noses and mouths.

    Only the prostitutes near Ved Road flaunted their faces (as well as their figures), calling out from brothel balconies to would-be customers. And, perhaps surprisingly, there were customers, despite the plague.

    "This came as a sudden grip, a blow from the sky," declared Gujarat's Minister for Health Subash Shelad. "I wish there weren't so much panic."

    But panic had, indeed, taken hold, and Surat was a ghost town. At the sprawling new Holiday Inn a visitor could have any room she pleased, as all of the rest were empty. Meals were a bit limited, as farmers were afraid to bring their goods into the plague-ridden city. And it took some time for the turbaned Sikh doorman to find a rickshaw taxi willing, even for the equivalent of a normal month's wages, to take a visitor about town.

    Amid the squalor of open sewers, ramshackle crowded houses, and roaming livestock emerged a cluster of poor Surati men shouting, "Plague! Plague! Plague!" The terrified men raced about madly, waving wooden clubs and shouting for all the world to hear. Kicking up a cloud of dust they settled into a tight circle, staring at the ground. And cowering in terror, trapped between human feet, was a brown rat, its beady eyes blinking in the bright sunlight.

    "Plague," a man reiterated, waving his club menacingly at the rat. Yet so great was the collective fear that the men of Ved Road dared not hit the sorry rat lest it might give its assailant a retaliatory bite. After a moment the rodent made its escape, scurrying down a garbage-strewn hillside and disappearing into a DDT-coated hole.

    The men looked sheepish. When told that the fleas that may carry Yersinia pestis plague-causing bacteria usually inhabit Ratus ratus—black rats—the cluster feels its manhood restored, each man puffing up his chest and sternly vowing to kill the first ebony-colored rat he sees.

    In September 1994 all of India resonated with plague panic, coupled with a near universal condemnation of a filthy Surat.

    "Surat is perhaps the most decrepit, unlivable, and unmanageable Indian city of its size," wrote the Telegraph. The Calcutta newspaper was typical of India's major media as it decried the Surati "bankruptcy of administration, the decadence of society and the collapse of basic civic amenities."

    Nothing shamed the nation's commentators and intellectuals as deeply as world attention to India's rats, and the urban filth in which they thrived. While politicians wagged their fingers scoldingly at Surat's local government, the nation's intellectual elite found in the symbolic rat reason to denounce the most fundamental aspects of Indian economics and politics. Typical of the perspective were the views expressed by Nikhil Chakravartty, who noted that the vast Indian nation was ruled by a strong federal hand during the decades of colonialism. But since independence, Chakravartty continued, the centralized federal government had weakened and local administrations had taken over rule of every aspect of Indian life, with disastrous results.

    "In short, a fearsome underworld has surfaced in all the metropolitan centres and larger municipalities. The plague menace, we are warned now, spreads through garbage piling up on which rats thrive," Chakravartty wrote. "Come to the best of our urban centres and you will see garbage-piling has become a common feature. In Calcutta, garbage reaches mountainous proportions before it is touched by municipal authorities. Bombay may be better off in the posh superrich pockets, but things are no better in the densely populated areas.

    "It is fashionable nowadays to talk of globalisation, of getting into the world currents. But if our municipalities and district boards are in a state of disuse and become the inevitable breeding ground of epidemics, what sort of economic miracle are we going to bring about?"

    Like their American and European counterparts in the late nineteenth century, India's intellectuals in 1994 cried out for sanitation and hygiene, the absence of which they blamed not only for the plague, but also for every imaginable failure in their society.

    On such a note of hand-wringing, J. N. Dixit wrote that "this crisis should impel us to ruminate on the economic and social implications of such an epidemic. Speaking of crises, at times, one is pushed to superstitious apprehension, even para-psychological paranoia about India's fate!"

    But the focus of plague paranoia was nothing as surreal as parapsychology but rather the mundane, eyesore-inflicting, nose-offending filth that filled the streets and alleys of India, having long since become the single most familiar and reliable feature of her urban landscapes.

    "It's as if a medieval curse is upon us. But the hex is self-inflicted. We are our own worst murderers. Because we are the practitioners of filth. The emperors of garbage," read one editorial in India Today. "As in all societies that have made progress, a groundswell of public opinion against dirt and disease has been the backbone of fundamental reform because it is a simultaneous upheaval against endemic corruption and fatalism. Ultimately, the health of a nation is also its wealth. There are dramatic movements in this country in the fields of entrepreneurship, economic modernization, science and technology. But unless this collective lurch toward progress is accompanied by a vision of a cleaner and more hygienic life, India will never quite qualify in the eyes of the international community as a modernising nation. Nobody wants to invest in the dark ages."

    And so by the fourth week of the epidemic, fires burned in every city in the nation, filling the air with the putrid smell of flaming garbage. Herds of day workers built mountains of awesome height made entirely of filth, doused them in gasoline, and with these pyres hoped to set India on a course from Plague to Progress. In perhaps the most vivid symbolism of the day, city administrators in Bombay hired Irula tribesmen from the southernmost state of Tamil Nadu to hunt rats in the city of some fourteen million humans crammed so densely that an average of 130,000 souls lived in each square mile. Famed for their rodent-catching skills, the Irula tribesmen had for centuries eaten rats, which comprised their major dally source of protein. Bombay told the Irula they could eat all they wanted, and actually get paid for their feasting.

    But, despicable as Surat's verminous filth was, the stench, garbage, and rodents of the city played little, if any, role in the start or spread of the nation's plague epidemic. While it may have sparked a long overdue urban beautification campaign, the plague in Surat had much more to do with horrid housing, human panic, and bereft health care than Ratus ratus.

    It didn't even start in Surat. And flea-ridden rats in the Gujarati city weren't responsible for its spread.

    The epidemic began hundreds of miles to the southeast in a rural part of Maharashtra State, the capital of which is Bombay.

    The earthquake hit while villagers slept, striking with a Richter force of 6.4: not enough to topple well-constructed freeway overpasses in Los Angeles, but quite sufficient power to level the mud and brick homes of the Beed and Osmanabad Districts. The September 30, 1993, earthquake's epicenter was the eastern Maharashtra city of Latur, in which tens of thousands of homes were leveled. Surrounding Latur some ten thousand villages were obliterated, one million homes destroyed, and more than ten thousand people killed.

    For days afterward aftershocks of up to Richter scale 5.0 rocked the Osmanabad and Beed Districts, prompting a human exodus of survivors who fled the earth's rage. The peasants of Beed, being practical sorts, hastily harvested their crops and locked the food inside whatever structures had outlasted the earthquake before decamping the region.

    The Indian government, with about $30 million in financial aid from the World Bank, erected prefabricated houses, sprinkling the structures where Latur's villages once had stood. And the residents trickled back into the region during the summer of 1994.

    No one in India had seen a case of plague in more than thirty years. During the 1980s, convinced that Yersinia pestis bacteria had disappeared from India, state governments one by one shut down their plague stations, stopped looking for cases, and eventually even ceased random rat and flea checks.

    On August 26, 1994, Yashitha Langhe, a man from the village of Mamala, located near Beed, returned to his earthquake-ruined home. He opened doors sealed for months behind which he had hastily stored harvested grains before fleeing the tremors eleven months previously. And he was overwhelmed by a cloud of black fleas that seemed to leap from the decrepit storeroom, biting at every millimeter of his body. When he looked down it seemed that the very ground on which he stood was moving.

    At his feet, and all about the Mamala man, were black rats, grown fat and populous, thriving on the stored grain bounty. The Mamala man's experience was repeated that week in village after village, in Beed, outside Latur, as earthquake refugees returned to their hamlets to lay claim to new government-built houses and retrieve their caches of grains.

    Yersinia pestis is a bacterium that can survive for extended periods of time in an apparently dormant state in soil. This capacity was overlooked when Indian officials decided to abandon all plague surveillance programs. In Maharashtra State, plague public health programs were eliminated in 1987; the last officially certified human case appeared in nearby Karnataka State in 1966.

    The bacteria can also hide in the guts of fleas, causing no harm to the insects, quietly reproducing and passing their offspring off to subsequent generations of fleas.

    But when conditions change—in ways no one clearly understood even by the end of the twentieth century—a genetic signal is triggered in the bacteria's DNA. A gene called hms (for hemin storage) switches on, causing the secretion of proteins that essentially shift the Yersinia pestis population from acting as a benign commensal thriving in the gut of a flea into a superdangerous bacterial collective that invades the insect's foregut. There, the microbes block the movement of food, and the flea begins to starve.

    The starving flea shifts its diet and, frantic, becomes far more aggressive. It will then in a frenzy assertively attack any warm-blooded creature, living off the blood that it extracts from the animal's body. Rats, particularly those of the black Ratus ratus species, are primary targets. And aboard the rats the fleas are protected by the rodent's fur and are highly mobile, carried energy-free by the scurrying creatures.

    When humans come in proximity of the rats the plague-carrying fleas are capable of leaping distances that are orders of magnitude greater than their own size, landing on Homo sapiens skin to feast on 98.6°F blood.

    Yersinia pestis then has other tricks in its genetic bag. The bacteria have a slew of special genes—at least twenty of them—that give the organism unique powers over the cells of humans and other animals. The instant Yersinia come in contact with human cells these genes switch on, causing production of a lethal cascade of chemicals.

    The first set of chemicals drill a microscopic hole in the protective membrane of the human cell. Then another set of genetically coded proteins becomes a transport tube carrying chemicals from Yersinia into the victimized cell. These chemicals swiftly incapacitate the targeted cell.

    Meanwhile, Yersinia also secretes a set of proteins into its immediate environment that blocks defensive efforts of the human's immune system. Mighty macrophages—large immune system cells that usually gobble up invading microbes—are rendered impotent by the Yersinia chemicals. The effectiveness of this stunning and complex system of attack lies in the fact that these genes, and the proteins they encode, are not originally of bacterial origin. They are animal genes, stolen millenniae ago through unknown means and put to deadly, effective purpose by the bacteria. Thus, a protein system originally intended to serve an entirely different purpose—a benign role—in animal cells has evolved into one of the most complicated and efficient offensive weapons apparatuses in the microbial world.

    If Yersinia takes hold in cells of the skin and lymphatic system a disease called bubonic plague results. As colonies of Yersinia grow, the human's lymph nodes swell, often to enormous sizes, and ugly pustules form on the skin, oozing yellow, viscous liquid.

    In the villages around Beed people began by late August to develop precisely these symptoms. And on September 14, 1994, Indian Union Health Secretary M. S. Dayal confirmed that there were four cases of bubonic plague in Mamala, Beed District, Maharashtra State.

    Two days later the Maharashtra State authorities announced that 10 percent of the village population of Mamala were suffering bubonic plague, and India's National Institute of Communicable Diseases issued laboratory confirmation that the ailments of the Beed District were caused by Yersinia pestis.

    While even a handful of cases of bubonic plague would have been justified cause for mass panic in India or anywhere else in the world six decades earlier, there shouldn't have been serious alarm in 1994. After all, Yersinia could be defeated with the cheapest and simplest of antibiotics: tetracycline and doxycycline. If administered in the first stages of illness, or simply after suspected exposure to infected fleas, these drugs were usually 100 percent curative.

    Once illness was established, however, treatment became more problematic. Yersinia could move into the red bloodstream, causing septicemia and ravaging the heart and liver. Or it could colonize the lungs, producing pneumonic plague. That was the most contagious and dangerous form of the disease, for once Yersinia inhabited the convulsed, coughing lungs of a human being it no longer required rodents or fleas to spread, creating contagion. A microscopic mist of exhaled droplets was sufficient to pass the bacteria from one person to the next.

    Untreated, or improperly treated, Yersinia easily claimed 50 percent of all infected human beings. But it was inconceivable that any nation in the world at the end of the twentieth century would fail to stop a bubonic plague outbreak, preventing the less easily controlled pneumonic form from emerging.

    So on September 16, the Beed District's Health Secretary R. Tiwari told local reporters that "there is no need to panic." Help, he insisted, was on its way. Maharashtra State Health Minister Subash Salunke further insisted that all Beed District plague reports were "wildly exaggerated." But he admitted that Yersinia might have surfaced after its long hiatus, because the bacilli, he said, "could live in the soil for ten to fifteen years."

    In Bombay, Dr. V. L. Yemul of the Haffkine Institute opined that the region's earthquake had disrupted the ecological niches of long-hidden Yersinia colonies, opening up previously hidden soils. Further, he said, in the aftermath of the quake populations of rival rat species grew and fought over the stores of grain left by frightened villagers. Their blood fights attracted fleas, allowing for a surge in that insect population. Thus, he argued, what was seen in the tiny village of Mamala, population 375, was likely to also be occurring in earthquake-ravaged villages throughout the region.

    The earthquake had disrupted the health care infrastructure of the region, leveling clinics and driving physicians and nurses from their homes. So local authorities were hard-pressed to identify and treat all the bubonic plague cases. And further exacerbating the problem was the monsoon, which in 1994 was the most powerful one anyone could recall. Roads were washed out, turning even a short distance into a severe, lengthy journey. A reporter who attempted to travel the roughly 400 kilometers (or 240 miles) of roads from Bombay to Latur had to give up after fourteen grueling hours of dodging elephants, diesel trucks, sacred cows, and other vehicles on a road frequently narrowed to less than a truck's width of passable pavement.

    But in truth, India would have had difficulties no matter where Yersinia had surfaced, for the country's public health infrastructure was stretched beyond limits. At a time of record-breaking economic growth, India was slashing its public health expenditures, shifting responsibilities from the federal to state levels, and seemingly washing its hands of all responsibility for the people's health. By 1991 to 1992, federal public health spending, which included hospital services, was a mere 0.04 percent of the national budget, or more than tenfold less than was spent in the previous decade.

    Bad as that might have been, the 1992 to 1993 federal budget saw a 20 percent further reduction in public spending. And few states compensated by increasing their local public health expenditures. None increased spending by more than 5 percent.

    In 1992 only three nations—Brazil, Mexico, and the Russian Federation—were carrying more than India's astounding external debt of $77 billion. Foreign investors had steadily increased their confidence in India, but even with annual growths during the 1990s, private foreign investment in the country was less than $1.5 billion in 1994. The Indian economy grew steadily in the early 1990s by a rate of 4 percent a year—a genuine speed demon pace for India, but a crawl by regional standards. Pakistan in contrast grew by 9 percent annually, South Korea by 10 percent.

    Despite its massive external debt and comparatively slow economic growth, India was considered a promising financial state, heading toward a free market and rapidly eliminating former laws that rigidly controlled its industries and limited outside investment. With an estimated 1994 population of 900 to 950 million people and a gross national product (GNP) per capita of $310 per year, every sector of the Indian economy was growing in the early 1990s at rates well above those seen in most of Africa, Eastern Europe, or the Americas. Value-added manufacturing in 1991 was an impressive $40 billion—one of the largest seen in the third world. So the country was easily able to service its national debt and still meet its annual expenditure needs.

    The boom was felt especially strongly in India's southern and western states, where trade deregulation prompted entrepreneurial zeal. In Bangalore, for example, industrious Karnatakans created a vast computer software manufacturing empire. Bombay swiftly became the core of capitalistic enthusiasm in India. And to its north Surat almost overnight was transformed.

    Between 1971 to 1991, the population of Surat grew by an astounding 151.61 percent, with most of that increase representing impoverished migrant workers who toiled in the $600 million textile or $1 billion diamond industries. As the population grew, so did the number of horrendous slums—up from ninety in the 1960s to three hundred by 1994, inhabited by some 450,000 people. There were no formal sewage or water systems in these slums; housing was slapdash lean-tos, even tents; malaria and hepatitis were epidemic; and no one apparently enforced even India's weak labor and safety regulations in the businesses along Ved Road.

    What drew industry to Surat was precisely the weakness of its government, lack of health and pollution enforcement, eager, unskilled labor force, and a virtual tax-free environment. By 1994, one out of every three diamonds mined in the world were polished in Surat.

    "Perhaps the greatest irony," wrote the conservative Business Standard of Bombay, "is that the epidemic has hit one of the economically most active areas of the country in a state which is considered to be the most business friendly.... What is more, the Gujarat government has gone out of its way to be more accommodating to business than most and has in turn been able to reap the benefits of a rapid industrialization which is not the case with the rest of the country. But somehow down the line, the need for good municipal services was forgotten. Businessmen who were busy making money cared little about minimum civic services or the basic quality of life that says no filth, mosquitoes, flies, fleas, and rats. And when the epidemic hit, they were the first to pack their Maruti 1000s and run. India today has clearly got its priorities wrong."

    The problem, indeed, was priorities. In 1992 India spent twenty times more on its military than on health. And for a decade, India secretly toiled on a massive, hugely expensive effort to create nuclear weapons. The public health sector was at its lowest rank of any major spending category. Just ahead of it was education, which was so poor in India that only 50 percent of adult males and less than a third of females were able to read, placing India below not just the global literacy average, but subaverage for the poorest nations on earth.

    In 1994 nearly a quarter of all Indian children hadn't received their full battery of UNICEF-recommended vaccinations, infant mortality rates were more than ten times those seen in Europe and North America, life expectancy was about fifty-nine years, and more than three humans were born annually for every one that died, guaranteeing that the nation's population explosion would persist well into the twenty-first century.

    Meanwhile, India was eager to move swiftly toward a free market and away from its formerly state-regulated socialist economy. It was privatizing many sectors, including health. More than 75 percent of all care was, by the mid-1990s, provided by private physicians, and the essential public health infrastructure was rapidly disappearing.

    "Instead of moving forward to meet the newer health challenges, the situation is sliding backwards," Dr. Alok Mukhopadhyay, chair of the Independent Medical Commission on Health in India, said, noting that public health in his country was in a state of "gradual but sure decay."

    Against that backdrop, compounded by earthquake and monsoon, Maharashtra's key official, Salunke, and local Beed and Latur health officials struggled in mid-September to keep the bubonic plague epidemic under control. Quick surveys revealed a twentyfold increase in the Latur rat population, with similar rodent explosions counted in Osmanabad. A scouring of local records found that the first complaint of flea infestation was filed, but unheeded, on August 5, and the first human plague case occurred on August 26. Even more disturbing were national plague data released to the media: though India saw no human plague cases from 1966 to 1988, Yersinia did, despite prior claims to the contrary, make its comeback in 1989 with three human cases. And in 1991 with fifty. And in 1992 with 135 plague cases nationwide.

    Given India's history with plague it seemed a substantial oversight to have dismissed this upward trend in cases. Plague broke out in Calcutta in 1895 and raged across India until 1918, killing more than ten million people. After that Yersinia was endemic in India for five decades, claiming more than two and a half million additional lives between 1919 and 1968.

    Yet the state governments had all ignored plague surveillance for years. And amid the outbreak in Maharashtra State, officials continued to downplay the situation, telling inquiring journalists that everything was under control.

    A key exception was Dr. Syamal Biswas of the Plague Surveillance Unit in distant Bangalore. After investigating the situation around the Beed District of Maharashtra, he pronounced conditions "extremely favorable" for a pneumonic plague epidemic. His warning was ignored.

    By that time 317 human bubonic plague cases had been identified in six districts of Maharashtra State. Though officials, including India's Minister of Health G. Shankaranard, continued to insist that there was "no cause for concern," newspapers in Bombay began attacking Maharashtra Governor Sharad Pawar and his government, accusing them of neglect.

    "But now that it has happened I say don't worry," Maharashtra's Salunke insisted. "We have beautiful antibiotics. This is not the Middle Ages. We have pesticides. We have surveillance. I promise you, there will not be one death in Maharashtra. Not one."

    But plague had already spread and was quietly erupting with lethal impact some six hundred kilometers to the northwest in Surat.

    Filthy, ramshackle Surat reeled from the monsoon of 1994. For eighty-seven days rain poured on the city, dropping a record eighty-one inches. The Tapti River swelled and overflowed its banks, flooding the ghettos and slums of the city. Along the notorious Ved Road, considered Surat's most abominable slum, Tapti floodwaters rose perilously, reaching rooftops by the end of August. Tens of thousands of Suratis fled during early August, seeking housing in dry parts of the city. It was not uncommon during August to find a dozen people crammed into a shack that normally housed four, or to espy migrant workers sleeping on the floors between the textile looms or diamond polishing machines on which they toiled during the days.

    Even during the dry season Ved Road was a horror. Most of its residents were migrant workers, 10 to 20 percent of them were usually from the Beed and Latur districts of Maharashtra. They crowded into houses and shared a handful of toilet facilities. There were 150 people per toilet, open sewers, and a constant stench.

    Thanks to the August monsoon the Tapti waters didn't recede from Ved Road until the second week in September. As if to validate the miracle of Ganesh Chaturthi, the rains stopped on September 10, the Tapti receded below its banks, and the mud of Surat began to dry by September 15. It was cause for genuine joy and celebration, as befits the Festival of Ganesh.

    Ganesh, the elephant-headed Hindu god, was a favorite of the poor and disadvantaged, for he had heroically overcome tragedy. Reunited after years of forced separation Ganesh greeted his mother, showering her with hugs and kisses. Upon seeing and mistaking the intent of their warm embraces, the mother's new husband flew into a rage, grabbed his sword, and sliced off Ganesh's head.

    "What have you done," cried the mother. "You have killed my son!"

    Shamed, the slayer searched frantically for a way to bring Ganesh back to life. Spotting a passing elephant, he chopped off the animal's head and placed it upon Ganesh's neck. And Ganesh became one of the greatest of gods, fun-loving, filled with great fortune, concerned about the poor.

    Traditionally Ganesh's saga is celebrated on September 18 with jubilant festivals. Neighborhoods and households compete, each trying to outdo the other with their elephant statues of Ganesh. Amid dancing, singing, and drinking, the statues are paraded about for hours, eventually dumped into a body of water. In Surat, the Ganesh statuary found itself in the Tapti River.

    Weeks of monsoon had left much of the Tapti's banks unstable, so the usually spread-out celebrations were concentrated, the crowds of festive poor jam-packed into small spaces. They carried their elephant god high, his four arms and trunk waving to the masses.

    Somewhere in those crowds was at least one person from Maharashtra. A plague carrier whose infection had gone untreated and moved into his lungs. He coughed as he celebrated.

    And three days later, seven feverish, pneumonic celebrants sought help from Dr. Pradeep Gupta and his staff in the emergency room of Surat Civil Hospital.

    "By twelve-thirty we found that seven had been admitted," an exhausted Gupta recalled three days later. "Two had died. They all had bilateral pneumonia and blood in their sputum. And their history of illness was short—certainly less than four days. Then there were other admissions and by Thursday [September 22] by 11:00 A.M. we had thirteen. And seven of the first thirteen were dead."

    The first wave of patients all came from the slums of Ved Road.

    By then, six weeks after Yashitha Langhe had come down with bubonic plague in far-off Mamala village in Maharashtra, the federal government was insisting that less than seventy people in India had plague, all of them suffering the easily treated bubonic form.

    Gupta, a young, energetic civil service physician, suspected instantly that his dead and dying patients were victims of pneumonic plague, a disease he knew only from textbooks. He took his suspicions to Dr. B. D. Parmar, who examined sputum samples from the dead under a microscope. A professor of medicine at the Medical College of Surat, Parmar was typically consulted when Civil Hospital physicians found puzzling infectious disease cases.

    "I diagnosed the first case here on September 20," Parmar recalled. "The patient was admitted for malaria that developed suddenly. I ordered an X ray which showed bilateral pneumonia. We treated that case as pneumonic plague, since there are some cases reported from Beed District of bubonic plague. We suspected pneumonic plague since the symptoms were fast-developing over a period of six hours. And the patients developed blood in the sputum and respiratory failure within no time, with bilateral pneumonia."

    Parmar's first case was a thirty-five-year-old migrant worker from Maharashtra.

    "He had an X ray done at a private hospital," Gupta said of that first patient. "That was at 8 P.M. It looked completely normal. Then he developed a high fever at midnight. On taking his X ray here an hour later, we saw violent signs of pneumonic plague. Violent. He died that night. That indicates the virulence of the organism."

    "Was that frightening to you?" a visitor asked.

    "Definitely!" Gupta exclaimed, his voice muffled by the three respiratory masks he wore, one of which was designed to protect workmen from chemicals.

    "Definitely," he repeated, shuddering.

    On September 20, Parmar and Gupta cornered their new boss, the recently appointed medical supervisor of Civil Hospital, Dr. Dinesh Shah. A middle-aged man accustomed to the reins of authority, Shah wanted to see the lab work himself. After examining under the microscope smear samples from the patients, he said, "Yes, looks like pneumonic plague."

    Shah ordered smears sent to the National Center for Infectious Diseases in New Delhi and contacted local authorities. But privately he was troubled by seemingly odd aspects of Surat's outbreak. There were no plague-dead rats in the city; all of the first cases were adult men, which seemed strange; there were no initial pediatric cases, which violated patterns seen historically.

    "It's very surprising," Shah told his staff. "No ratfall. This just came in straight to the city in pneumonic form. Did someone from Beed come here? Maybe.

    "Or maybe," he continued with a chill, "Yersinia has mutated."

    Professor Parmar was also concerned about the apparent oddities in Surat's epidemic. And he told Shah that without help from the city's 137 private physicians, "This will spread like wildfire. It's a Black Death."

    The civil doctors, fully supported by the Gujarat State Minister of Health Subash Shelad, did their level best to calmly spread word of the apparent plague outbreak, hoping to solicit assistance from the city's private physicians.

    They were totally unprepared for what followed.

    The private doctors panicked. Eighty percent of them fled the city, closing their clinics and hospitals and abandoning their patients. The fear in those physicians' eyes did not go unnoticed by the populace, and rumors of a great impending disaster spread swiftly among the largely illiterate masses. Surat's middle class discreetly packed their bags and slipped out of town.

    Then, on September 22, Surati and Bombay newspapers carried banner headlines declaring, "Surat Fever!"

    "Over eighty people are feared to have died following the outbreak of a mysterious fever here last night," read the lead of a typical Bombay newspaper article that morning. "Dr. Mahendra Gandhi, a private practitioner in the city, has confirmed forty-five deaths and said the toll is likely to cross eighty."

    It was only the opening salvo of a barrage of wildly exaggerated reports that would hit the world's media, most of them relying on panicked private physicians for their information. The BBC, which is hugely popular in India, echoed these reports, saying on September 22 that a mysterious deadly fever had broken out in Surat.

    The exodus began.

    Within twelve hours of the BBC broadcast an estimated 100,000 Suratis boarded trains headed in every imaginable direction across the Indian subcontinent. Because Surat had no unemployment it had attracted workers from as far away as Bangladesh, Tamil Nadu, Delhi, Uttar Pradesh, Punjab, even Nepal. Now they fled homeward, potentially taking with them infectious microbes.

    Friday, September 23, found an estimated 300,000 more Suratis, handkerchiefs wrapped about their faces, queued up for trains. By then the Civil Hospital had seen thirty-one pneumonic plague deaths and its wards were packed with plague and with the worried well. Officials declared Surat a "ghost town," and five states, including Gujarat and Maharashtra, went on emergency health alert status.

    News reports across India ran the gamut from the Times of India's calming headline that day ("Disease is infectious, but curable") to the Daily's claim that more than 250 Suratis were dead, and 10,000 had the plague. One report had it that half the population of tiny Kattar village in rural Gujarat were dead, all plague victims. Still another account had it that all of Surat was "disease affected."

    Bombay was in a frenzy. Most of the Surati exodus came south to India's huge Arabic Sea metropolis, and local radio, television, and newspapers buzzed with rumors of dead rats and people within the city limits. It was said that eight people had died of plague the previous night in the Bombay suburbs of Borivili and Dadar.

    So far the only clear casualty of the epidemic was truth. So expansive was the misinformation, government prevarication, and media frenzy that Indians from the Himalayas to the islands of Goa were almost to a one convinced the plague was among them. The reality would later seem disappointingly mundane as most of the ailing were, at least at first, laying in Surat's Civil Hospital.

    But the federal government took no actions, made no effort to slow the Surati exodus, and did not offer any concrete assistance to the beleaguered medical staff of Civil Hospital. At the Bombay end of the Maharashtra State government similarly lacked a clear strategy. It seemed helpless to stem the monumental flow of Suratis who poured out of Bombay's several train stations in enormous human herds, quickly disappearing into the suburban and slum crowds of the densely packed metropolis.

    Hysteria was further fueled by India's unique perspective on medicine. Few societies on earth in the late twentieth century were as culturally complex as India. Outsiders often noted that India was like an onion: one peeled layer after layer, often finding cause to weep in the process, but upon reaching the core discovered another onion inside. Each of India's many religions demanded all-encompassing devotion from its followers, affecting every aspect of their lives. And India's experiments with democracy had to avoid granting dominance to any particular religious view. Failure to walk that delicate balancing act usually resulted in mass outpourings of violence.

    Medicine and health are, in Western tradition, based primarily in a scientific tradition that requires proof not only of logical theorem but also of practice. The body is a concrete set of molecular and organismal systems. Illness is reversed through a host of interventions which seek to repair failing systems or obliterate invading microorganisms.

    That Western medical discipline was widely practiced throughout India, and the Indian Medical Association adhered to scientific traditions that roughly mirrored those professional standards in place in England.

    But on official, equal footing under Indian law were ayurvedism, homeopathy, yoga, Tibetan treatments, and a host of other health care traditions that viewed the human body and its illnesses in fundamentally different, usually spiritual, ways. While plague might in 1994 be easily treated with tetracycline under Western allopathic care, antibiotics played little or no role in ayurvedic or other ancient Indian practices.

    The result was that nearly anyone could hang up a shingle, declaring himself a physician, and the nation's medical providers represented a mind-boggling blend of genuine healers, crackpots, and exploitative charlatans. More than 75 percent of all health care in India was delivered by "private" physicians, most of whom lacked serious training in either allopathic or other healing traditions and were likely to offer treatments that would certainly be illegal in nations that practiced Western medicine. The new free market atmosphere that reigned over health care in 1994 only exacerbated the problem, pitting charlatans with no medical training in any tradition against legitimate physicians who had devoted more than a decade of their lives to the vigorous study of either allopathic or traditional medicine.

    The competition was fierce, and the hardest-fought battles took place in India's largest cities, where physicians practicing all traditions of health care went after the hearts, minds, and rupees of the growing middle class. By 1994 it was glamorous to be an antigovernment physician who decried the stupidities and corruption of state and federal authorities. It was fashionable to declare as lies most government public health declarations. And intra-physician competition often echoed this antiestablishment theme, making the most outrageous of "physicians" chic among the middle and upper castes.

    Indeed, India's Minister of Health B. Shankaranand was not a physician, but a businessman who faced indictments on mishandling of public funds during his previous service as petroleum minister. Shankaranand and his predecessor in the Ministry of Health supported an unusual medical paradigm: daily consumption of one's own urine as treatment for cancer or AIDS.

    So from the first moments of Surat's epidemic the Indian public was deluged with at least as much misinformation as actual facts. And while it was tempting to blame the media for its lack of accuracy and for yellow journalism, India's health care establishment had to share credit. The information schism—between truth and fantasy, accuracy and exaggeration—would prove disastrous for India in coming days.

    But in Surat itself there were few citizens left who could be misinformed, and nearly the entire medical profession, save the dedicated nurses and physicians of Civil Hospital, had flown the coop.

    One exception was Dr. Lalgibai Patel, who on the morning of Thursday, September 22, anxiously paced the halls of Civil Hospital, distraught. His wife, Durga Watideri, had come down during the night with a nasal drip. That seemed pretty minor, Patel said, but rapidly worse symptoms appeared as the night wore on. Her throat began to burn so badly she couldn't swallow.

    "And then I discovered she had a serious problem," Patel, who was at his wits' end, recalled. "She had chest pain, vomiting. I took her to a hospital for treatment, a private hospital. But the hospital was closed. By then she was vomiting blood. So then I brought her here." No sooner had twenty-eight-year-old Watideri taken to bed on the Civil Hospital plague ward than Patel's seven-year-old son and twenty-two-year-old brother also came down with the disease.

    "Being a man of medicine I was confident of recovery," Patel said. "But then when I saw the horror of it I was terrified."

    It would be weeks before Patel's family would recover, though all would, thankfully, live to tell tales of the Plague of '94.

    Throughout the hospital nervous families related similar stories, describing sudden illness marked by vomited blood, loss of breath, chest pains, stomach pains, and high fevers. They spoke from behind masks, careful to stay out of the way of exhausted medical personnel. Occasionally tempers flared among the small remaining staff of sleep-deprived doctors and nurses: loud shouts of disagreement rang out in sporadic, brief bursts of rage.

    Along the hallway leading to the plague ward masked lower-caste women, dressed in colorful saris, swept the floor and scrubbed the walls as if such cleanliness would prevent spread of Yersinia inside the hospital. The ward, separated in half by a long curtain, contained about eighty steel beds, white paint peeling off their rusty frames. Female patients were on the left side of the curtain, males on the right. With all the beds full, additional patients lay upon gurneys. Despite the crowd, there was little sound, as most of the patients were too sick to talk or even moan.

    Behind thick isolation doors in two sealed chambers were the most dangerous patients—those who were actively coughing up Yersinia-contaminated blood and sputum. The nervous Dr. Gupta, still wearing three masks at a time, moved among the patients, checking their antibiotics, fevers, and pains. His manner betrayed three sleepless days as he stumbled and slogged his way from bed to bed.

    The following Friday India began to pay what would eventually be an enormous price for its epidemic. The United Nations Security Council demanded a full accounting of India's plague control efforts amid quiet threats of boycotts of Indian goods. That put the plague on Prime Minister Narasimha Rao's agenda. He dispatched Health Secretary M. S. Dayal to Surat. Dayal, a graying, bespectacled civil servant, was the top bureaucrat in the Ministry of Health. He flew into Surat Friday morning, returning that afternoon to Delhi, and telling journalists and Prime Minister Rao that 44 Suratis had died of pneumonic plague and another 174 cases were in treatment.

    "The situation in the affected area is well under control," Dayal claimed, adding that Surat health officials were commencing door-to-door surveys throughout the city, searching for additional cases?

(Continues...)