Editorial Commentary: What Is in a Word?

Abstract

The handmaiden to every outbreak of infectious disease is the metaphor it carries with it—a metaphor that has much to do with the way society will view and respond to an epidemic. In Surat, India, in 1994, the word “plague” was uttered in the context of an acute respiratory illness that suddenly blossomed in that industrial town; it triggered the largest mass migration in India since that country was partitioned. Almost 100,000 people (including patients who were ill with the so-called plague) abandoned Surat for other Indian cities, and Surat became a ghost town. Tetracycline became a rare commodity throughout India, insecticides were used indiscriminately, and the economic loss that resulted from India's exports being detained in ports all over the world amounted to billions of dollars. I visited Surat shortly after that outbreak to report on the story [1]. Both then and now, I was unconvinced that the disease was plague. There were no bubonic cases, no large numbers of dead rats (i.e., rat fall), most of the affected people were male, and, for supposed “pneumonic” plague, it was striking that not one secondary case was reported among family members or in other Indian cities. The inability of researchers to isolate the organism or to recover it from sputum, respiratory tract, blood, or other samples was telling and makes it difficult to accept a report [2], made long after the fact, that claimed to find PCR evidence of plague bacillus genetic material in some autopsy tissue. But the scientific question of whether the disease was or was not plague mattered little during those hectic few days in Surat; once the word “plague” had been uttered, the metaphor of the disease had been unleashed, and it could not be bottled up again.