The behaviour of doctors during the pneumonic plague in Surat in September- October 1994 was a blot on the medical profession. It raises several ethical issues related to their responsibility towards society and their profession. This essay briefly describes how the doctors of the city responded to the epidemic.

Medical facilities in Surat
There are 310 hospitals in the city, providing nearly five thousand beds. They include maternity and nursing homes. Of them, ten are government or municipal hospitals, twelve are managed by charitable organisations and the remaining 288 are privately run. There are 2,219 registered medical practitioners engaged in private practice in Surat district. Like elsewhere in the country, they are concentrated in the city. Only 14 per cent of the doctors are in the rural areas, and the majority of them are in taluka towns.

Medical practitioners can be classified in two categories: consultant and general practitioner. The former have a postgraduate degree with specialisation. 713of the doctors in Surat (38%) are consultants. 1,155 (62%) are general practitioners (GPs). There is one consultant for nearly 2000 population and one GP for 1,300 persons. These figures exclude unregistered medical practitioners. The number of medical practitioners in Surat is relatively larger than in many urban areas of the country.

“We try our best”
The city experienced heavy floods before the onset of the plague. As news of the plague trickled in, medical practitioners as a group were the first to flee the city. Like officials of the Surat Municipal Corporation (SMC), they were expecting some kind of epidemic in the post- fiood period. Generally they deal with high rates of infectious diseases in the monsoon. Many consider this their ‘season’ - time to earn. So they were prepared to treat cholera or malaria. When a few of them found that the usual treatment for malaria was not effective and some patients died soon after the onset of the illness, they were perplexed for a while. nut sudden deaths are not unusual, they thought. In the past too, not all their patients were cured. Later, a few GPs realised that X or Y had died because of wrong diagnosis or treatment on their part, but after a while they used to forget such cases. At the most they would console themselves by saying, ‘After all we are not God. Life and death is in His hand. We try our best. What else we can do?’ Therefore, the unusual death of their own patients or that of others was not a very disturbing phenomenon.

News about the death of two patients in the Ashakta Ashram Hospital on 21 st afternoon spread immediately in the medical circles of the Ved Road - Katargam area, where the largest number of the deaths by the plague took place. When news of similar deaths in the New Civil Hospital (NCH) of the Government of Gujarat came in, confusion was compounded. Within no time, imaginary figures of death multiplied on a geometrical scale. One doctor received a phone call saying that ten persons had died in the Ashakta Ashram Hospital; it was the same in the NCH and at Maskati Hospital too. Like people on the streets, some doctors said thirty, some said forty, some said a hundred had died. ‘Why did so many people die so suddenly?’ they wondered. GPs and consultants were frightened because they were not sure about the disease. If it was neither malaria nor pneumonia nor cholera, what could the illness be?

Prelude to the exodus
In the midst of various speculations two doctors got news from the NCH and/ or SMC that the disease responsible for the deaths was plague. Meanwhile, the Deputy Commissioner of the SMC informed the President of the Ved- Katargam Medical Association that ‘a large number of people are dying and it is a plague epidemic. ’

The response of a few practitioners to the information was of interest. ‘Plague! . . Plague!’ they exclaimed. ‘What are the causes of plague?‘, doctors asked each other. ‘I do not know’ was a common answer. Some added, ‘There was plague in the last century and thousands of people died in no time. ’ A GP bewailed: ‘I do not think there is any medicine for the plague.’ Others added, ‘Anything can happen in this city full of flith and dirt. See the heaps of garbage.. Our people are dirty.. They have no sense of cleanliness... In this situation any disease can spread like a wild fire... Nobody can escape.. . After all it is a deadly disease...’ Interestingly enough, even five months after the epidemic and the various discussions about the disease in the media, only one fourth of the doctors could describe the symptoms of plague correctly. For many, practice is the mechanical application of their skills to earn profit. They routinely work for ten to twelve hours a day and they hardly read prof’essional journals. ‘We work from morning to evening and do not have time to read anything except newspapers’, said several doctors. Whatever they learn, they learn through medical representatives who inform them about diseases and medicines. Though they are members of a professional organisation which organise lectures and seminars, they rarely attend them.

Soon after hearing the news about the plague, most of the doctors in the area immediately closed their dispensaries. Patients who were waiting for treatment were asked to go away. They decided that it was of no use staying in Surat. ‘Within no time hundreds of people will die... If you treat a plague patient you would get infection.. . And, there is no medicine or vaccine... Let us go away...’ One doctor telephoned another, some telephoned friends and relatives. A chain of communication commenced. The message was clear, ‘It is the plague and there is no treatment for it. The disease is infectious. It will kill thousands of people. ’ They decided to get out of the city as early as possible.

Those who ran away
On the very first night of the outbreak of plague, around a hundred families of doctors and other professionals from the Ved road and Katargam area alone left the city in their vehicles. The procession of doctors fleeing from the city continued the next day and the day after. According to the survey of general practitioners in the plague affected areas, as many as 76% of the doctors were reported as having absconded from the city. Some returned after a week, by which time the death rate had declined considerably. Others (48%) returned after two weeks. None of them formally confessed that they left the city because of the plague. Almost every one gave one or another kind of pretext. During informal conversation, a doctor said that he and his family left the city because of fear. ‘You know, this is such a dirty and unplanned city. There is no drainage and during the floods garbage was getting rotten in the street. In such a situation anything could happen... One should know that this is a communicable disease passed on from person to person. How can you face such calamity if you are not armed with proper facilities? ’ Another doctor explained, ‘Frankly we did not think much, but as every one was leaving, we followed. Why run a risk? ’

People were angry with the doctors who ran away. A crowd ransacked the clinics of at least six doctors on Ved Road and in Varachha. In the second week of October, one person filed a case against 30 medical practitioners who ran away from the city, alleging negligence of duty. Later on, he withdrew the case. It is alleged that each doctor gave money to the petitioner for deleting his name.

Besides a large number of private practitioners, many doctors employed or attached to the charitable public hospitals also absconded from the city.

Those who continued to serve
Not all doctors behaved in this shameful manner. A few of them were upset by the situation and felt guilty for their inability to intervene in the situation. Among those private practitioners who remained in the city, some kept their clinics or consulting rooms closed for the first four to five days of the epidemic or referred most of the patients to the NCH without even a preliminary examination.

The doctors of the New Civil Hospital were on their toes and many of them worked round the clock. A few attended duty out of fear of suspension from the job. Many, however, performed the duty out of moral conviction. This was against many odds. There was not enough staff in the pathology department and several pieces of equipment were not working. The canteen and mess were closed, so even tea was obtained with difficulty. The doctors in the department of medicine formed an emergency team. The first requirement was that of prophylactic drugs for patients and the staff on duty. NCH did not have enough drugs. Some doctors, on their own, used their own funds and those obtained from philanthropists to purchase the required drugs for the NCH.

Thus, on the first day, the doctors who stayed fought on two fronts: attending to their patients and arranging supplies of the drugs needed. The young ‘junior’ doctors, working on an individual basis, did everything to save lives of the patients.

Many of them underwent personal trauma. Friends and relatives began to keep at a distance from them. Some experienced conflicts within their own families as spouses or parents pressed them to keep away from the hospital. A woman doctor had a dilemma. She had a six- month old baby and was worried about how she could protect the child from the infection to which she was exposed.. At the same time she felt that at this moment her duty at the hospital was more important than anything else. A nurse sent her young children to her village for protection whilst she attended work. A matron living on the NCH campus and performing her duty said, ‘Our staff is honest therefore it is working with sincerity. God has decided birth and death and nobody can change it... If we are going to die once, what difference does it make if death comes by plague or another reason? On the contrary, if we remain alive without performing our duty, we will feel our remaining life is useless. I am a nurse. I believe that I should not run away when my services are required. And, as a matron if I run away it would demoralise the nurses and create chaos in the hospital.’

A few private medical practitioners were distressed by the behaviour of their fellow doctors. ‘We have medical ethics. We cannot run away during such a crisis,’ a GP said. He was feeling helpless. He kept his clinic open despite pressure from his family members and examined patients who never had gone to him earlier. The Katargam Ved Road Medical Association called a meeting of doctors on the same night. It was attended by less than ten doctors. The next day, they distributed medicines to affected persons. But ‘there was not enough medicine and, till the morning of 22nd September, we did not get drugs from the Corporation’, said the president of the association. These doctors met the Municipal Commissioner and leading doctors of the city on 23rd September and discussed the problems of the area. On the 25th, they checked patients in the medical camp organised by the Saurashtra Pate1 Seva Samaj. A few doctors advised people regarding ‘dos and don’ts’ in plague. Padkar, the organisation dominated by medical practitioners, launched a campaign for cleaning certain slums. Leaflets giving information about the disease were published. One doctor wrote a booklet in Gujarati on the plague, and described steps to combat it.

Six doctors participated in a symposium on the plague on the 23rd, organised by the Chamber of Commerce to disseminate information about plague to the people. They explained symptoms, therapy and described preventive precautions. They also pointed out that the disease was not a killer if treatment was taken in time.

An epidemic of unethical practice?
A few, less than five per cent of the private practitioners, consider their profession noble, providing an opportunity to serve humanity. They are disgusted with prevailing practices in the profession. They keep abreast of new developments in medical science by reading professional journals and books and by attending conferences. A majority, but not all, of these are consultants. A few of them occasionally write in the vernacular language about. various diseases, hygiene and general health-related issues of the city to raise consciousness on health in the populace. Some are also involved in the city’s cultural activities.

Classes of doctors
Thus, there are two blocks among the medical professionals. A small section of mixed ages adheres to medical ethics and worked during the epidemic with sincerity. But it is not so with the majority of doctors. On the whole, as with other professionals, profit has become their prime consideration. The concepts of service to humanity and professional ethics are considered by them to be out- dated. They wish to earn money as fast as possible. Money and power (influence) are their obsessions. They provide services only when and where they are assured of such rewards. Self- centeredness is their striking characteristic. Altruism and service are obsolete concepts to them. ‘After all, we have invested a lot of money in our studies, this is not for public service. Why should we not earn?‘, a number of them argue. After initial accumulation of money and recovery of their investment, they invest their savings in industries, shares and estates. Some invest in medical shops. They have become businessmen.

An alarming situation
The present state of affairs of medical services and profession is alarming. On the whole the public health system is increasingly neglected. Gujarat, one of the most developed states of the country, lags far behind as far as its performance in the sphere of public health is concerned. On the one hand the public health system and professionals working therein are systematically denounced and ridiculed not only by those who are engaged in private practice but also by policy makers and intelligentsia. On the other hand, the private health services are expensive, hence cater the needs of a small section of society but, ironically, it enjoys hegemony despite negligence and callousness. (This essay is based on author’s unpublished study entitled, Public health-urban society interface:A study of pneumonic plague in Surat 1996)

Is absolute honesty always a virtue?
In human affairs, crass honesty may not always be the cardinal virtue. Truth must, and often should, yield to discretion, kindness and compassion in the usually irrational realm of human affairs. Naked, sheer honesty as applied to such tricky issues as human values, ethics and human good suffers from the difficulty of discerning, in the human world of noncommensurate values, what truth really is. It may be hard to differentiate honesty of the heart from honesty of the word.

D. Carleton Gadjusek

Gajdusek DC: Scientific responsibility. In: Fujiki N, Mater D (Eds.) Human genome research and society. Proceedings of the Second International Bioethics Seminar. Eubios Ethics Institute, Fukui, Japan. 1992. Pages 205210.

Ghanshyam Shah, Director, Centre for Social Studies, South Gujarat University Campus, Surat 395 007, Gujarat