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Terrorism, War, Or Disease (book review)

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  • Terrorism, War, Or Disease (book review)

    (mods please place where you think appropriate. These are some excerpts from a recent book that deals with the history of previous infectious disease outbreaks that have current policy implications)

    This recent book deals with unusual disease outbreaks and allegations of natural or purposeful causes and the complex political, military, legal, and scientific challenges involved in these determinations..

    Terrorism, War, Or Disease edited by Anne L. Clunan, Peter R. Lavoy and Susan B. Martin (2008).

    Part I of the book features empirical case studies from the Second World War to the present, while Part II draws lessons and generates policy recommendations. ie

    Chapter 3 The 1994 Plague in Western India (Human Ecology and the Risks of Misattribution) by Ron Barrett.

    In Chapter 13 Building Information Networks for Biosecurity Anne Clunan explores how national, subnational, and transnational information networks may offer a crucial capacity for timely and accurate attribution of BW use. She assesses policy and trust issues involved in moving from a "need-to-know" limitation to a "need-to-share" presumption to facilitate quick and accurate determination of whether BW has been used and by whom.


    Some excerpts from Chapter 3

    The 1994 epidemic and its aftermath underscore the importance of public trust and a pre-existing public-health infrastructure for the attribution and control of infectious diseases, whether or not they are deliberately initiated.

    Human ecology has been variously labeled as cultural ecology and political ecology. I am expressly avoiding either term to distance myself from academic squabbles between their respective extremes: vulgar adaptationism and vulgar activism, and to use the best of their methods without subscribing to the worst of their agendae.

    Disease investigations are comparable to fire investigations: both require a deep understanding of behavioral and environmental factors. Circumstances can be analyzed in terms of human ecology, approaching the socioeconomic histories of human communities that create selective conditions for and against infectious diseases.

    Earthquakes have long been associated with increases in rat populations, possibly due to the simultaneous disruption of rodent burrows and human granaries.

    A mosaic of different communities and their respective networks formed a pattern of disease transmission in which social proximity had more effect than physical geography. (Members of Surat's working class communities are known to maintain close relationships with extended kin in their natal villages through regular visitation, such as observance of weddings and other life events)

    The re-emergence of plague in western India after nearly three decades was a natural but unintended consequence of deliberate human actions taken in particular biosocial circumstances.

    The rumor claimed that Muslim terrorists had poisoned the wells in revenge for violence received during a major riot in 1992. Events surrounding the 1992 violence may have influenced public response to the 1994 plague. Tensions between Hindu and Muslim communities were high.

    The poisoning rumor persisted for a time even after newspapers first reported that the illnesses were due to plague, for the public had little trust in statements made by the media or government.

    Had the government withheld its descision until all the WHO criteria were met, it could not have acted for weeks into the epidemic. Instead, the government erred in its diagnosis on the side of sensitivity and rapid response, an ?error? that ultimately proved correct. It would not have been realistic to withhold this information anyway, for the existing political conditions were such that even the suspicion of plague could not remain secret for long. The plague epidemic was a crisis of confidence as much as a crisis of public health. Far better to be forthcoming about the pathogen just as it was better to be forthcoming about the negligence from which it emerged. Such lessons apply to defense against future diseases, regardless of whether they are deliberately initiated.

    The need for transparency may exceed the need for security. This is especially the case for public indentification of the disease. It was unlikely that the Indian authorities could have kept the plague a secret for long, and an earlier announcement could have given them the upper hand in the dissemination of accurate information.

  • #2
    Re: Terrorism, War, Or Disease (book review)

    The Surat Plague and its Aftermath
    Godshen Robert Pallipparambil

    In September 1994, plague struck Surat, a city in the state of Maharashtra in western India. The government officials declared an international public health emergency by reporting an epidemic of pneumonic plague. When compared to the bubonic form, the pneumonic plague spreads rapidly and hence caused widespread panic, both locally and internationally. The plague in Surat was mostly pneumonic, though the bubonic form was found in three villages in Maharashtra preceding the pneumonic outbreak in Surat (Ref 3).

    Local Responses
    An excerpt from the newspaper ?The Hindu Universe? dated 25 September 1994, described the situation. ?The people fleeing the affected zones are heading in all directions and taking the hysteria with them. With the discovery of three people afflicted with plague in a Bombay hospital, panic has gripped that city as well. Tetracycline, an antibiotic for plague treatment, has disappeared from chemist shops not only Bombay but also in Delhi?. Because of rumors that Surat would be quarantined and when that action was delayed one-fourth of Surat residents (400,000 to 600,000 people) fled the city within four days of announcement of the epidemic. Among them were people still in the incubation phase of the plague infection. Broad-spectrum antibiotics required to curb the disease had been exhausted due to panic buying of medicines. Physicians and pharmacists escaping the city took with them large amounts of antibiotics for their friends and relatives. At other cities in various parts of India, checkpoints were established at railway stations and airports to monitor incoming Surat inhabitants who were then received by medical teams and quarantined. Hospitals in a number of neighboring cities of Surat were alerted for possible arrivals of plague-infected people. Government had to forcefully stem the exodus with the help of paramilitary forces and prevent the disease from spreading to the neighboring states.

    Because the disease was diagnosed and suppressed quickly, the outbreak did not have the devastating impact originally feared, but it generated considerable anxiety worldwide resulting in a heavy economic toll in the country. In Northern India, Deepavali, the festival of lights is a time for both celebration and business. The plague outbreak occurred just before the festival incurring a total business loss of over US$ 260 million in Surat alone (Ref 2,3,5).

    The incidence in Surat had large impacts on other major cities of India like Delhi and Mumbai. In the capital of New Delhi, the lack of public information on how to deal with the spread of the disease resulted in the large scale purchase of surgical masks and tetracycline. As a precaution, the administration ordered the closure of all schools and public entertainment places. The news of the epidemic and these actions taken by the government alarmed many people. Some chose to stay indoors and others who ventured out did so with masks covering their faces. Schools in Delhi reopening only five days after they were closed illustrated the uncertainty of government officials as of how to proceed with the precautionary measures. In eastern states such as Orissa, thousands of kilometers away from Surat initiated steps to check the plague outbreak. Reports from Rajasthan, which borders Gujarat, stated that the villagers launched an intensive drive to kill rats in their regions. Proper instructions as on how to proceed with the preventive measures were not given to the people. Since the disease was already spreading, killing of the flea host (rats) would force them to switch hosts and result in more human cases. The havoc caused by the epidemic was evident (Ref 4,5).

    On September 23, Surat authorities ordered closure of all schools, colleges, cinema halls and public gardens for an uncertain period. Industrial units, banks, offices and diamond cutting units were asked to shut down until further notice. By this time, plague had been spreading rapidly through Surat's slums for nearly two weeks. People walked in the streets with their faces covered by handkerchiefs, which was not a very effective method because the large weave permitted the entry of bacteria. Several layers of fine muslin would have been a better method.

    Several other decisions and actions influenced societal responses to this event. Health officials in Surat city declared a plague epidemic before it was known if the plague was pneumonic. Daily statistics about suspected plague cases provided by the official agencies added to a mountain of misinformation. The Union Health Minister did not issue any statements to clarify the situation or to calm the country?s or international community's anxieties. Press statements issued by local politicians also did not help the situation. For example, at the time when the plague was considered to be at its peak, the Chief Minister of Gujarat claimed that the plague in Surat was pneumonic and not bubonic, perhaps not realizing that pneumonic plague is far more infectious and less curable than bubonic plague. To emphasize his point he quoted that "rat fall" in Surat was not very high. The local and international media also played an important role in this case. Local newspapers reported highly exaggerated death tolls adding to the confusion.

    Many official press statements were released without assessing the accuracy of the information they contained. People from the plague area with normal fever were labeled as plague cases, and more than 6000 reported plague cases were actually due to other diseases. The actual death cases in Surat were 56. From late August to mid October 1994, a total of 693 suspected plague cases, out of which 488 were from Maharashtra, were reported by India to World Health Organization. In Maharashtra, with the exception of Surat the reported cases were mostly bubonic plague (Ref 1,5,6,7).

    Though there was much confusion in the beginning, the government successfully stemmed the spread. After identifying the plague cases, antibiotics were given to almost everyone in the neighborhood. Fumigation of cargo, clearing of port areas of rat, dusting of insecticides over vast areas to kill rat fleas, helped to control the spread of the disease (Ref 11).

    International Responses
    One of India's major markets (agricultural exports), was jeopardized by a decision by the United Arab Emirates to suspend all cargo transshipment from India. The incident also resulted in the loss of investor confidence. From the exports alone, the total loss suffered was $420 million. In London, Global Depository Receipts crashed after the BBC and CNN media agencies reported the plague situation. In the local stock exchange, the share value of the agricultural products tumbled. An official tour of India by the Mauritian minister for Tourism was postponed. Foreign journalists and tour operators were offered free travel and hospitality to assess the situation, but few responded. More than 45,000 people cancelled their trips to India (Ref 3,5).

    Several countries imposed plague-related travel restrictions on Indian travelers. For example, Indians traveling to the United States from plague-affected areas had to fill out special forms upon arrival. As a result of the Surat plague outbreak, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States by modifying the quarantine protocols and providing information to medical practitioners. Aircrafts were fumigated on arrival at airports in Rome and Milan and passengers were subjected to special health checks. In Moscow, authorities ordered six-day quarantines for passengers from India and banned travel to India. In addition, an estimated 25% of the passengers between India and the Gulf region who are job seekers were stranded; many had their visas extended but the delays in their departures resulted in a loss of jobs to nationals from other countries. The plague cost the Indian economy over $600 million (Ref 3,5,6,8).

    An international response followed in the aftermath of the Surat plague outbreak. The World Health Organization (WHO) announced plans to establish a Disease Intelligence Unit that would function independently when such outbreaks occur to help diagnose the problem quickly. In addition, WHO asked the International Civil Aviation Organization to tighten its health controls at all international airports and to strengthen quarantine measures. (Ref 3).

    The worldwide reaction to the plague outbreaks in India in 1994 reminds us that memories of the sudden spread of disease, from the Black Death onwards are still, understandably, very powerful. The outbreak had severe economic, social, and political impacts. Although the spread of the plague was contained effectively in spatial and temporal terms, societal responses resulted in higher order consequences (Ref 5).

    Was it really plague?
    The WHO team which investigated the plague in Surat, did not find any conclusive laboratory evidence of the disease organism. Even though no scientists were able to get pure Yersinia pestis cultures from the infected cases, this was mainly attributed to inadequate facilities and lack of expertise in the hospitals during the period. But there were lot of supportive evidence of the plague organism, blood tests specific to Yersinia showed positive results, antibodies of Yersinia was found in many infected cases and disease symptoms were diagnostic of pneumonic plague (Ref 2, 9,11).

    After the Surat plague epidemic in 1994, India took several steps to be prepared for such incidents in future. In response to the outbreak, medical school course work has been revised to address plague in greater detail. The National Institute for Communicable Disease's plague research unit has been modernized to make diagnosis easier. In addition to activating plague control units all over the country, the national government decided to set up a more sophisticated national surveillance system. The recent pneumonic plague outbreak in Himachal Pradesh 2002 was quickly and effectively contained. The government took rapid preventive action and there was better flow of information which prevented the unnecessary panic (Ref 3,10).

    Article and refs:


    See also: Comment: Plague in India
    BMJ 1994;309(6959):893 (8 October)
    After decades with no confirmed human plague in India, health authorities there are simultaneously responding to outbreaks of bubonic and pneumonic plague in rural and urban populations of the south central and southwestern states of Maharashtra and Gujurat. A major concern is the spread of disease by travellers from these epidemic foci.1 Worldwide, public health authorities have been trying to prevent the introduction of pneumonic plague within their borders, requiring national disease surveillance and quarantine offices to operate on emergency schedules dealing with a situation with which almost none has any first hand experience.2 Public fascination, confusion, and incredulity have been fuelled by press reports. A mass exodus including hospital patients and even staff themselves has occurred from the epicentre of the outbreak of pneumonic plague despite regular pronouncements by the medical community that plague is readily treated with antibiotics. Assurances of the effectiveness of public health measures have seemed incongruous given the explosive spread of disease, which authorities have been slow to confirm and explain. Doctors and public health workers have quickly tried to educate themselves about a disease they had long considered in the past tense. And everyone asks, “How could this happen?” Plague is caused by infection with Yersinia pestis, a bacterium carried by rodents and transmitted by fleas in parts of Asia, Africa, and the Americas.2 India was one of the countries most affected by the pandemic of plague that began in the latter half of the 19th century, experiencing an estimated 12.5 million deaths during 1889-1950.4 In recent decades plague in India and elsewhere has retreated to rural, natural foci of infection involving …


    Social networks and geographic factors are a small bit of the puzzle. If I told you of the Big Picture behind human Plague, you'd sh*t your pants.

    Gap your forefinger and thumb closely, sir. The planet came within a hair's breadth to Very Bad Karma, in NW India in 1994.

    Comment


    • #3
      Re: Terrorism, War, Or Disease (book review)

      A few more excerpts from Chapter 13 Building Information Networks for Biosecurity by Anne Clunan

      The move beyond hierarchical responses and the traditional intelligence culture toward a "need to share" paradigm involves the second shift: development of networks for information sharing. This shift requires greater understanding of the nature of information networks, and addressing the challenge of establishing trust among members of such networks and between networks and the public.

      As the outbreaks of SARS and avian influenza demonstrated, states have abundant economic incentives to withhold information about the presence or absence of biological agents that are naturally occurring, let alone covert biological warfare programs.

      The issue of information sharing has also occupied social scientists: given that information is an important resource, much scholarship has focused on why actors seek to spread, share, hide, or ignore it.

      Key benefits of networks are timely and flexible access to information, referrals to new sources or verifiers of information and (most importantly for attribution), accuracy, and credibility, as external verification of information helps keep "groupthink" or motivated biases from dominating the attribution process.

      The essential problem at the root of developing networks is helping disparate actors to trust one another enough to share information. Without trust, networks and indeed cooperation more broadly breaks down. Trust has increasingly interested scholars in a variety of disciplines, but the problem of trust is as old as societal organization: it arises whenever there is uncertainty. Trust implies confidence in the face of risk. There are two aspects to building trusted networks for information sharing: trust among the network members, and public trust in the network. Trust is both a cause and a consequence of cooperation, through the development of norms of competency, fairness, and reciprocity.

      As the most difficult challenge is figuring out how to generate trust, by both domestic and international publics, in a meta-network, policymakers would be well-advised to give network norms and scientific and legal standards priority over immediate political gains. The ability of governments to quickly access a meta-network of sources and verifiers of key information about biological agents and events would substantially enhance BW attribution and mitigation capacity.

      Such benefits outweigh the political gains of shaming or harassing geopolitical adversaries through unverified attributions of BW use.

      Comment


      • #4
        Re: Terrorism, War, Or Disease (book review)

        #2:
        "“The people fleeing the affected zones are heading in all directions and taking the hysteria with them. With the discovery of three people afflicted with plague in a Bombay hospital, panic has gripped that city as well. Tetracycline, an antibiotic for plague treatment, has disappeared from chemist shops not only Bombay but also in Delhi”. Because of rumors that Surat would be quarantined and when that action was delayed one-fourth of Surat residents (400,000 to 600,000 people) fled the city within four days of announcement of the epidemic. Among them were people still in the incubation phase of the plague infection. Broad-spectrum antibiotics required to curb the disease had been exhausted due to panic buying of medicines. Physicians and pharmacists escaping the city took with them large amounts of antibiotics for their friends and relatives. At other cities in various parts of India, checkpoints were established at railway stations and airports to monitor incoming Surat inhabitants who were then received by medical teams and quarantined. Hospitals in a number of neighboring cities of Surat were alerted for possible arrivals of plague-infected people. Government had to forcefully stem the exodus with the help of paramilitary forces and prevent the disease from spreading to the neighboring states."

        From this real description it can be seen well the need of individual isolation, meds/ppe/food/water stocks, and the town's mass behaviour in a case of an pandemic.

        Comment

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