Shah G. (1991) Public health and urban development:the plague in Surat, Sage Publications New Delhi, 1991. pp 317, Rs.395

Like a scratched gramophone record, the urban health debate repeats the same catchy tune over and over again. Three notes repeatedly play: the double burden of disease; economic modernisation with a trickle-down effect; and intermediate, community-driven technology solutions. Only occasionally is the discordant note of political economy heard. It is refreshing that Ghanshyam Shah has reasserted political economy in the debate.

Using the 1994 plague epidemic in Surat as his case, Shah provides a harmony that once heard leaves the reader understanding why it is that the poor suffer from a disease burden which is almost exclusively dominated by infectious diseases and premature death. Why, despite Surat’s wealth, many of its population continue to live in the most appalling conditions. And why community participation means more than small-scale mobilisation of communities but requires the commitment of leaders and politicians driven by popular participation. In short, he sings the song of the people, not the rulers.The plague in Surat is Shah’s case. But he does not over-play this disease which for centuries has instilled fear in populations around the world. Rather, he uses his case material to make a broader point: that health cannot be understood from a perspective of medicine, economy, environment or culture alone but must be recognised as an expression of the very social, economic and political material conditions in which people live.

The political economy approach has been side-lined in the health debate in recent years. The ideology of many academics and commentators on urban health is one of neo-liberalism. The rich understanding of health gained from the perspective of political economy is almost consistently forgotten. Shah reminds us of the relevance of this debate in his first chapter and enriches it with his useful interpretation of Said’s Orientalism.

In the next two chapters Shah provides an insight into the living conditions of the people of Surat and the medical services upon which they rely. He describes a city lorded over by a chronically sick, corrupt and disinterested administration, which serves the rich and powerful at the expense of the poor and inarticulate. The description of a medical sector in which private doctors over-prescribe and indulge patients’ whims for modern medicine and an inefficient, weak and inadequate public sector are a sobering reminder of reality. While health indicators have improved, no effort has been made to deal with the daily suffering and sickness of the poor population in this city.

Only in Chapter 4 does Shah return to his case study, the plague epidemic of 1994. Here he analyses the social and demographic data collected from the serologically positive patients he and his research team were able to trace.The analysis is thoughtful, the conclusions credible. Eighty per cent of the plague patients were blue-collar workers.Their working conditions in the formal and informal sector appalling, their living conditions as bad.

The perception and response to the plague was not the same for everyone in Surat. Rumours of water and air poisoning by Muslims spread throughout the city as the number of dead and sick increased. Those with good communications heard these rumours and then the reality, that plague had struck Surat. The same people, with ready cash, packed their bags and fled the city. Seventy per cent of the doctors abandoned their clinics, and their ethics, and fled. Those who were left behind were clear where the blame lay for the epidemic. The poor did not keep their slums and neighbourhoods clean, but the municipal authorities made no attempt either, to ensure adequate rubbish collection, water supply, flood drainage, not even to dispose of animal carcasses rotting in the streets.

The people of Surat from all communities started cleaning the streets. Junior doctors worked tirelessly in the public hospitals. Meanwhile the authorities failed to provide leadership. Health monitoring structures already geared up to monitor the effects of flooding in the city failed to notice unusual deaths four days before the plague outbreak. Reporting systems did not work at all in the private sector. The state and municipal authorities showed themselves incapable of breaking the fetters of bureaucratic inertia and self-importance. Nevertheless, they were quick to pat themselves on the back in a show of sickening political opportunism when only forty were killed in the epidemic. The people of Surat held different views about their leaders. Unable to provide them with adequate health care in normal times, they doubted the capability and sincerity of the state in meeting their needs in the plague. Their lack of confidence was well placed. Ministers and officials flew from Delhi to Surat, adding to the confusion in the city. Essential drugs were not airlifted. The Indian government had to be seen to be doing something, anything. The gestures, it appears, were more for the international investment community than for those at risk from the contagion in Surat.

In the aftermath of the plague Surat has gained the status of the second cleanest city in India.

Populist pressures have forced the municipal authorities to act. In a postscript Shah describes the activities of the health care operation, started in May 1995. Under the leadership of a new municipal commissioner, decentralisation of municipal activities has been undertaken. Road widening schemes have been initiated alongside the demolition of illegal structures, improvements in sanitation, slum rehabilitation and paving. Toilets have been installed and garbage collection doubled. Efforts are being made to address public hygiene. But Shah also notes that pollution and labour laws are being flouted and slum dwellers continue to be treated by the elite and the majority of Surat Municipal Corporation officials as an obstacle in the beautification of the city. There is space within the system for remedial measures. Surat may be cleaner but the improvement in health for many of its citizens has not been addressed.

Shah rightly describes the plague as a ‘symptom of a deep-rooted social disease: the development model that the country is following’, rooted in neo-liberalism. The three notes that chime in the urban health debate are ideological manifestations of this model. All three emanate first from the rich countries of the North and are repeated in the popular press, by policy makers and politicians in India. Shah’s book attempts to redress the balance. He has shown that in Surat, India and internationally, health for all cannot be achieved through narrow and deterministic models of development. It is necessary to address the issue of political economy as well. It is beholden on those involved in the ‘development debate’ to expose the deterministic nature of many of its prescriptions, and map out a future which means fundamental political, social and economic change. Shah has made a valuable contribution to this debate.