Two cases of plague contracted in a Yosemite campground have made headlines nationally and internationally. In part, the shock value of the story is due to the assumption that plague has been subdued by civilization. But the truth of the matter is, that the United States experiences numerous cases of plague each year, most ocurring in the southwest, where plague remains endemic in rodent populations. About half of the cases of plague in the United States occur in New Mexico, where it has caused ten human fatailities since 2010. In 2014, Colorado reported eight cases and earlier this summer reported its first two fatalities due to plague since 1999. And it isn't just human cases. The 2014 cases in Colorado were tied to a dog, which died of plague like symptoms As the students in my Politics of Global Health class know, rodent populations are key to forcasting incidences of plague. Prairie dogs, squirrel and chipmunk populations have been hard hit during the latest plague season --- and entire colony of prairie dogs was wiped out in Utah in July.
While there is debate about the scientific explanation for recent increases in plague, the real novelty of the story is the non-response to plague in the United States. Because plague is viewed as controlled and subdued, there is little domestic concern and no international response. In contrast, outbreaks of plague in developing countries often result in severe international response.
For example, in 1994 seven patients with pneumonic plague-like symptoms in Surat, India led to local panic. Under the International Health Regulations (IHR) countries are required to notify the WHO of cases of epidemic-prone diseases of special concern. In the midst of public panic, India notified the WHO of a potential outbreak and implemented all recommended regulations, prior to confirmation that the outbreak was plague. Before a single case of plague was confirmed, several countries had stopped importing Indian foodstuffs and Italy placed an immediate embargo on all goods from India. Likewise, Canada, France, Germany, Italy, the UK and the USA all issued travel warning to their citizens. Not only was travel to India discouraged, Indians traveling abroad were subjected to unwarranted measures that are prohibited by the IHR. The result was a loss of at least 2.2 million tourists and quantifiable losses of over US$2 billion. (See Deodhar, Yemul and Banerjee's "Plague that never was" in Journal of Public Health Policy, 1998 for more). Only after the Indian Ministry of Health reported the outbreak under control, did the WHO issue a statement that there was evidence of a limited outbreak in Surat, but not of person-to-person. Morevoer, a follow-up report indicated that no case of plague was confirmed on the basis of WHO bacteriological standards.
The difference in responses to US outbreaks and those in India or other developing countries are part of a larger pattern. Countries have long struggled with the dilemma of reporting outbreaks or not. While reporting outbreaks ensures international action to prevent disease spread, it may also results in severe economic losses. Early treaties intended to prevent the spread of disease were frequently discarded because of disparities in their application. While richer countries implemented quarantines and embargoes in response to reported outbreaks in their poorer trade partners, poorer countries were unwilling to implement such measures against their richer trade partners for fear of economic losses. The IHR is intended to overcome this dilemma. In addition to required reportingof specific health threats, the IHR identify and limit acceptable measures that other states can implement to prevent the spread of disease in order to minimize disruptions to trade and travel.
In the Indian case, the swift and severe international response caused additional and unnecessary harm. That response was in part due to panic among the local population. While the lack of ability to confirm cases as plague may have contributed to panic, the lack of confirmation should have resulted in calls for calm and restraint by other countries. Ultimately, the primary cause of the exaggerated response was the continued power dfiferential between developing and developed countries --- behaviors the IHR was created to prevent. However, the usefulness of the IHR rests upon three key factors: 1) maintanence of public calm; 2) accurate and timely scientific information and; 3) the willingness of other countries to wait for scientific information --- all of which were lacking the the case of India's outbreak.
Similar responses have been seen throughout the recent Ebola outbreak. Authorities at various levels in numerous countries opted to implement a variety of measures and restrictions ranging from temperature readings to mandatory quarantines and full travel bans. While some travel restrictions were important for disease control efforts, the effectiveness of the most drastic of these measures and their impact on the general disease control effort has been widely debated. Without a stronger deterent to hasty reactions, disproportionate responses will likely continue. However, a question remains: how do the harms associated with disproportionate responses affect future health and disease control in the country of origin?
While there is debate about the scientific explanation for recent increases in plague, the real novelty of the story is the non-response to plague in the United States. Because plague is viewed as controlled and subdued, there is little domestic concern and no international response. In contrast, outbreaks of plague in developing countries often result in severe international response.
For example, in 1994 seven patients with pneumonic plague-like symptoms in Surat, India led to local panic. Under the International Health Regulations (IHR) countries are required to notify the WHO of cases of epidemic-prone diseases of special concern. In the midst of public panic, India notified the WHO of a potential outbreak and implemented all recommended regulations, prior to confirmation that the outbreak was plague. Before a single case of plague was confirmed, several countries had stopped importing Indian foodstuffs and Italy placed an immediate embargo on all goods from India. Likewise, Canada, France, Germany, Italy, the UK and the USA all issued travel warning to their citizens. Not only was travel to India discouraged, Indians traveling abroad were subjected to unwarranted measures that are prohibited by the IHR. The result was a loss of at least 2.2 million tourists and quantifiable losses of over US$2 billion. (See Deodhar, Yemul and Banerjee's "Plague that never was" in Journal of Public Health Policy, 1998 for more). Only after the Indian Ministry of Health reported the outbreak under control, did the WHO issue a statement that there was evidence of a limited outbreak in Surat, but not of person-to-person. Morevoer, a follow-up report indicated that no case of plague was confirmed on the basis of WHO bacteriological standards.
The difference in responses to US outbreaks and those in India or other developing countries are part of a larger pattern. Countries have long struggled with the dilemma of reporting outbreaks or not. While reporting outbreaks ensures international action to prevent disease spread, it may also results in severe economic losses. Early treaties intended to prevent the spread of disease were frequently discarded because of disparities in their application. While richer countries implemented quarantines and embargoes in response to reported outbreaks in their poorer trade partners, poorer countries were unwilling to implement such measures against their richer trade partners for fear of economic losses. The IHR is intended to overcome this dilemma. In addition to required reportingof specific health threats, the IHR identify and limit acceptable measures that other states can implement to prevent the spread of disease in order to minimize disruptions to trade and travel.
In the Indian case, the swift and severe international response caused additional and unnecessary harm. That response was in part due to panic among the local population. While the lack of ability to confirm cases as plague may have contributed to panic, the lack of confirmation should have resulted in calls for calm and restraint by other countries. Ultimately, the primary cause of the exaggerated response was the continued power dfiferential between developing and developed countries --- behaviors the IHR was created to prevent. However, the usefulness of the IHR rests upon three key factors: 1) maintanence of public calm; 2) accurate and timely scientific information and; 3) the willingness of other countries to wait for scientific information --- all of which were lacking the the case of India's outbreak.
Similar responses have been seen throughout the recent Ebola outbreak. Authorities at various levels in numerous countries opted to implement a variety of measures and restrictions ranging from temperature readings to mandatory quarantines and full travel bans. While some travel restrictions were important for disease control efforts, the effectiveness of the most drastic of these measures and their impact on the general disease control effort has been widely debated. Without a stronger deterent to hasty reactions, disproportionate responses will likely continue. However, a question remains: how do the harms associated with disproportionate responses affect future health and disease control in the country of origin?
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