truly remarkable achievements of the relief effort – the complete avoidance of any kind of epidemic.” (WHO 2006:81,83) This is in sharp contrast to most other states’ response to public health emergencies and natural disasters. For example, after the recent hurricane in West Bengal, that state’s health authorities’ task was essentially to provide chlorine and other disinfection agents, and medical care<sup>12</sup> ─ not the wide range of relief and disease-prevention activities described above ─ and disease outbreaks followed. After Orissa was hit by a massive cyclone in 1999, a health team from Tamil Nadu was called in to assist with the health emergency in the worst-hit area, where cholera had already set in when they arrived. Even more striking is the example below of Maharashtra and Gujarat states’ response when they were struck by plague.

A different example of anticipatory planning is the fact that in Tamil Nadu, the DDHS deputes a Health Inspector to each government medical college, in order to protect their environmental health conditions. These colleges pose potential health threats, such as the possibility of diseases spreading from them, since they are the top referral points for difficult cases of communicable diseases. The Health Inspector’s tasks include assuring sanitary conditions and vector control. The Directorate of Public Health also takes action if needed in Chennai, if the Corporation does not step up to its responsibilities. For example, when there was an outbreak of leptospirosis in a government medical college in Chennai and the Dean said they had no manpower to control it, the Directorate of Public Health posted Health Inspectors from nearby districts to carry out the preventive measures.

The consequences of not taking this small step are evidenced, for example, in the repeated dengue outbreaks in Delhi and Kerala that originated in medical colleges. This arose from the fact that mosquitoes were breeding in the colleges in ongoing construction sites, or in other places such as water-coolers.<sup>13</sup> Public health experts in Kerala attribute the resurgence of communicable diseases in that state to the neglect of public health services (John et al 2004; Krishnakumar 2009).

# _b. Eradicating diseases and preventing their resurgence_

Tamil Nadu has worked to eradicate diseases, sometimes long ahead of national efforts. For example, it had eradicated guineaworm by 1982, whereas the national eradication program started in 1994.

Even more impressive are its efforts to prevent resurgence of diseases which retain their potential to manifest themselves again. A striking example of this is the maintenance of a state plague surveillance unit, in an area known to have plague foci among wild rodents near the border with Karnataka and Andhra Pradesh states. This is despite the fact that the last episode of plague in South India was in the early 1960s.<sup>14</sup> This unit studies the fleas on wild rats, to detect a threat of a plague outbreak. When the plague outbreak took place in Western India in 1994, a team was sent from this unit to help control the outbreak, along with their plague laborers experienced in finding rats and isolating their fleas. They were amongst the sole remaining repositories in India at the time, of hands-on expertise of how to deal with plague.<sup>15</sup> This is in sharp contrast to Maharashtra state, which also has a known sylvatic plague focus. The state plague surveillance unit was abolished in 1987, because there had been no confirmed cases of plague for decades.<sup>16</sup> When an earthquake took place near the plague focus in 1993, the central government warned the state health department of the possibility of disturbing the wild rats and creating conditions for a plague outbreak, but this was ignored. As Garrett (2000:20-28) summarizes, cases of plague were reported around the earthquake area but not contained there so it spread to Gujarat where it found fertile ground in the spectacularly insanitary conditions prevailing in Surat at the time. Neither the state nor the central governments instituted quarantine until after the outbreak was well advanced, so people were allowed to leave the earthquake area and later flee by the trainloads from Surat to the rest of India. After the outbreak had escalated, vigorous efforts were made to contain it and clean up the city.

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