We All Fall Down: Reflections on the current plague outbreak in Madagascar

Ring-a-round the rosie,
A pocket full of posies,
Ashes! Ashes!
We all fall down.

Most of us can recall vague memories of studying the Black Death, one of the deadliest recorded pandemics in human history, at some point in our academic careers – even if it was that seventh grade history class you never paid any attention in. Indeed, Ring-a-round the rosie was ruined for me in this very setting, when my teacher informed me that the nursery rhyme was really a nod to a dark history.

If we’ve known about this disease for so long, why are we suddenly watching a modern pandemic of the plague in Madagascar in 2017? Despite the plague being endemic to parts of the island, this outbreak is worse than any in recent history.

The answer isn’t in the science. The plague is no longer a deadly disease in the 21st century – today, it is cured with a course of antibiotics. Cases are still found in countries ranging from Peru to the USA, although roughly 95% of reported cases are attributed to Sub-Saharan Africa or Madagascar.

Image Courtesy of Maurits Vermeulen via Flickr, © 2009, some rights reserved.

      Antananarivo, Madagascar 


But images of rats, of bodies piling up, remind us of our history classes. They conjure an imagined past, a time ‘before’ when people lived in vast cities devoid of basic public sanitation measures. This most recent outbreak of the plague is provoking because we must acknowledge that these images are not so much in the past as they are in the present.

Any number of reasons could be listed to explain why this outbreak is so alarming: cases are largely pneumonic plague, a more aggressive form of the disease that travels from person to person; 167 out of 387 reported cases are in Madagascar’s densely populated capital, Antananarivo; the disease is appearing in parts of the country where it is not endemic. However, these are themselves symptoms of what I believe are two much larger syndromes at hand.

First and foremost is poverty.

Amidst nearly a decade of political instability, Madagascar has become one of the poorest countries in the world, where over 92% of the population live below $2 (£1.5) a day according to the World Bank.

The plague is a disease that flourishes in lack of sanitation. Madagascar is the perfect host; if we recall exactly how the Black Death prevailed in the 14th century, we will remember the role of the city in the transmission of infectious disease. Urban areas present themselves as ideal vectors because of a combination of poor sanitary procedures and population pressure. To make matters worse, Antananarivo suffers from a lack of sufficient healthcare facilities, with hospitals already overcrowded and personnel without consistent access to protective garments to use to guard themselves from infection while treating patients.

Secondly, and perhaps more worryingly, is the lack of a consistent global response mechanism for health crises. Now I hear you say, ‘What about the World Health Organization (WHO)? Don’t they know what to do?’

The answer is yes (most of the time). Unlike in the case of disaster relief, however, there is no governing body with complete jurisdiction over the coordination of relief efforts – WHO or otherwise. While the WHO has delivered 1.2 million doses of antibiotics already, any number of organizations are working in the country to provide piecemeal assistance to communities in efforts to curb the spread of the disease.

WHO Madagascar Representative Dr. Charlotte Ndiaye makes a point of distancing this pandemic from the Ebola outbreak of two years ago, saying in a report that ‘we’re dealing with a different disease in an entirely different setting. Plague is more easily treatable than Ebola if detected early, and with relatively simple interventions.’

As much as the WHO might wish to alleviate concern, this latest incident cannot be entirely removed from the context of the Ebola outbreak of 2013-2016. In a press conference, the Red Cross Federation’s Director of Health and Care Dr. Julie Hall pointed out that lessons from Ebola cannot be forgotten, emphasising that the ‘response needs to be extremely fast in these types of situations, in order to bring an outbreak under control as quickly as possible.’

If we are to learn anything from these two major pandemics, however, it is that location matters. It is no mistake that since both Ebola and now the Plague pandemics have been inherently ‘African’, echoes of centuries of colonial rhetoric about the black body as diseased and black space as dirty are looming in the background. In this discussion, I have chosen to focus on international responses to the crises rather than on the role of the government in an effort to avoid falling back on the classic scapegoat of the development world, the weak state.

Nonetheless, as epidemiologist Katharina Kreppel eloquently states, ‘If an outbreak like this happened in the U.S. or Europe or anywhere else it would be controlled quite fast, because the resources are there.’ In other words, the plague outbreak in Madagascar is no accident, but a product of circumstance; the international community cannot send antibiotics alone, but must aim to remedy a failing system in the meantime, lest we all fall down.