This article originally appeared on MOTHERBOARD.
The filth and government neglect that defined the bulging Indian city of Surat took an astonishing toll 20 monsoons ago, when an outbreak of pneumonic plague racked the metropolis, located in the northwest state of Gujarat. Floodwaters burbled up from sewers and crashed over the banks of the Tapti River, which dissects this low-lying city, home to millions of Indians, before flushing into the Arabian Sea. The floods dumped silt and trash through neighborhoods, nursing rats that hosted fleas that harbored bacteria that delivered an epidemic.
More than 50 Surat residents died from the pneumonic plague that followed, and some 500,000 evacuated the city during two chaotic days. Fleeing doctors and pharmacists took supplies of antibiotics with them, leaving medically defenseless patients behind.
Officials later said that the plague had taken root after monsoon rains flooded poor parts of the city, where trash, waste, and dead livestock were left to fester in the putrid waters, a conclusion supported by medical reports that suggested the plague first took root in one of the city's worst neighborhoods. In a country where a lack of sanitation has been an omnipresent problem, Surat became renowned as a place so exceptionally filthy that the plague could still flourish.
In the nearly two decades since, the local and state governments have toiled to clean up the city and its image. Infrastructure improvements have helped reduce flooding. Slums, for better or for worse, have been demolished. Streets are swept regularly and the swept-up trash is covered for collection by trucks.
To everybody’s relief, the efforts seem to have evacuated the city of its plague problem. Now another bacteria-borne disease is taking its place—a disease that’s also stoked by filth and transmitted by the rats that revel in it. It’s a disease whose symptoms are evolving; some strains now resemble those of the pneumonic plague of old, and deaths are adding up. And while infrastructure improvements haven't benefited the city's slums, officials have blamed a spate of deaths not on a new outbreak of disease, but on victims' poverty-weakened immune systems.
The sister of Vahed Khan, who died in October, holds his picture outside their family home in a poor part of Surat. Image: John Upton
Even worse, these symptoms, which can include widespread hemorrhaging and rapid-fire organ failure, are not just striking down the residents of Gujarat. They're thought to be the result of leptospirosis, a disease that's killing people throughout coastal India as well as in a long list of Southeast Asian, South Asian, and Pacific island countries. Outbreaks have occurred in tropical parts of Central and South America, including in Ecuador, Peru, and Nicaragua.
Leptospirosis is caused by bacteria of the Leptospira genus, which don't typically spread directly from person to person. It’s zoonotic, meaning we catch it from other animals. Most often it is spread by rats, though it can also infect livestock, dogs, monkeys, and other animals. But, unlike the plague, the disease isn’t transmitted by fleas that feast on rats. Instead, it spreads through rat urine.
Lepto, as the disease is commonly called, can be difficult to diagnose, with symptoms camouflaged against a backdrop of less fatal but more common tropical diseases that also ravage developing countries. And the bacteria are difficult for underfunded laboratories to culture and identify.
Because of that, it's not really known how many infections or deaths it causes around the world every year. What we do know is that it’s a major problem. According to the WHO, during outbreaks, as many as one out of every 1,000 people in a community might be struck down, with untreated patients often sinking quickly to a painful death. The problem is worst after floods and monsoon rains.
“When there’s flooding, these rats are everywhere, and leptospirosis will not kill rats,” Delhi-based World Health Organization disease surveillance and epidemiology scientist Gyanendra Gongal told me. “They urinate everywhere. When there is flooding, the floodwaters will take all this rat urine and waste. Then when you swim or drink water, you get leptospirosis. It is a real problem after flooding.”
The much-ballyhooed improvements in Surat during the past 20 years have led some to parrot government claims that the city is now among the cleanest in India. Surat’s post-epidemic “makeover, as if blessed by the plague, is awe-inspiring," India Today gushed nearly a decade ago
But any claim of supreme cleanliness is a farcical one. During recent visits to Surat, it was clear that such claims are made by those who look no further than the tidy streets that line some of the wealthier parts of town, and who pay no heed to the fate of the city’s trash after it’s hauled away from the prying eyes of those with money and influence.
A pile of trash smolders near wetlands at Surat's outskirts. Image: John Upton
Garbage trucks dump their loads in untended piles near wetlands and villages at the city’s outskirts, where they are left to burn. Rats run rampant. Vapors from smoldering plastic scratch at villagers’ eyes and lungs. The city has no recycling program—a broken-down recycling plant rusts near the piles of burning trash. Surat leaders boasted to me that police were ordered to fine litterers following the plague outbreak, but I even saw a police officer toss his trash on the streets.
As in many other parts of India and Asia, the city’s water and wastewater treatment plants remain woefully inadequate. Drains empty from slums and poor neighborhoods into creeks that flow into the river, bypassing the wastewater-treatment plant. The sewage plant discharges its partly treated muck within a couple of miles from the point in the river where water is sucked back up for drinking supplies.
“The drinking water is very dirty; sometimes there will be worms inside,” said M. S. H. Sheikh, a Surat-based community organizer. “Quality water is not available. The sewage is not in good condition. But people are not taking strong action against the government, because the government is giving them cheap water.”
Those who can afford it buy bottled water and electric filters. The poor drink straight from public faucets. Low-income farmers and farmworkers walk unshod over flooded fields, ushering bacteria into their bloodstreams through nicks and cuts.
A newspaper report on a disease that killed Khan and other Kadarshah ni Naal residents in October. A World Health Organization official believes they were victims of lepto. Image: John Upton
Late last year, residents of the tightly-packed Surat neighborhood of Kadarshah ni Naal say six people died within a week following chest-high monsoon flooding. The men’s symptoms resembled those of the 1994 plague outbreak—vomiting, fever, and an hours-long nosedive into an agonizing death, leading some to worry that the plague had returned. Limited lab tests ordered by the government failed to identify the pathogen responsible. The media reported it as a “mysterious illness” because officials denied it was lepto. Death certificates describe symptoms—hemorrhagic fever—but not the cause.
Local officials now say the victims died of miscellaneous ailments, including jaundice and typhoid. This is despite the fact that medical and death reports obtained by Motherboard show the causes of death remain unknown. During an interview, some of the officials criticized the victims for swimming in floodwaters, even though there was no other way for them to reach or leave their homes. They say the victims’ immune systems were weak because they were poor.
One of those killed was 20-year old Wahed Khan, described by relatives as healthy before he was suddenly struck down with pain, fever, and bloody gastro-like symptoms. He was taken by ambulance to an intensive care ward, where he died on Oct. 8. “He was swimming in the floodwaters—the water was up to his chest,” said his brother, Jahir Khan, speaking in Gujarati when I visited early this year. “After the decrease in the flood level, there was no cleanup by the government.”
I asked Gongal, who is working with national and local governments to reduce lepto-related deaths, to review four of the death reports. Based on the symptoms, and the fact that the deaths followed flooding, Gongal was convinced that the outbreak was just another chapter in the lepto horror story.
A child climbs stairs in Kadarshah ni Naal, where poor sanitation is a major health risk. Image: John Upton
“You cannot prevent or control the disease, but you can minimize the risk,” Gongal said. “It’s because of the man-made environment that the disease is coming here. In the past, leptospirosis was a very rare disease.”
The WHO is working with India and other developing countries to health officials identify and respond to lepto, as well as upgrade or build labs to help them diagnose the disease. Some governments hand out prophylactic antibiotics, medicines that at-risk residents, particularly farmers, can take during the wet season as a precaution. The problem with that approach is that it’s expected to help lepto evolve a resistance to the drug.
“Clinical manifestation of leptospirosis is changing in India,” said Gongal. “There is hemorrhaging syndrome, then they may develop jaundice and it will cause fever. They have no appetite. In the eye there may be redness. The body may be yellow in color.”
The problem seems to be getting worse, including in Surat. Data collated by a government medical college in the city show there were about 400 suspected cases in Surat in 2005 and roughly 270 the year after. In 2010, there were 625 suspected cases, and more than 850 in 2011.
Improvements in diagnoses may be partly responsible for the trend, but underlying sanitation problems remain stubborn. And even then, proper healthcare can be elusive for impoverished people stricken by the disease. If it’s caught in time, patients are subscribed doses of antibiotics. If their organs fail—the kidneys and liver are a common target—dialysis may be the only option, which, for the world's poor, isn't always an option at all.