Social vulnerability and pneumonic plague: revisiting the 1994 outbreak in Surat,India

The 1994 outbreak of pneumonic plague in Surat, India is revisited and analyzed using the pressure and release (PAR) model. Overviews of the outbreak, of India's experience with plague, and of the disease are provided and the PAR model is used to trace the production of vulnerability via root causes, dynamic pressures, and unsafe conditions and to explain the why, when, and where of the epidemic. The emergence of plague in Surat was an unfortunate amalgam of prior hazard events and of factors generating vulnerability. Root causes include the country's colonial legacy and a complex and pervasive social hierarchy promoting caste and class interests over the common good. Dynamic pressures include: a curative-focused healthcare system; a weak civil society; misplaced spending priorities; and public and private corruption that deprived public health programs of needed funds and which compelled workers to live and labor in unhealthy environments. Unhealthy public, residential and workplace environments; fragile economic conditions; and a lack of surveillance and preparation are immediately linked to the outbreak and to the transmission of pneumonic plague.