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      The Hot Zone: Black Death Returns to Madagascar

      August 7, 2014
      Benjamin Shapiro

      By Benjamin Shapiro

      Senior Editor

      Malagasy plague specialists perform an autopsy on a potential plague rat. Photos by Lucian Read

      I sat in a helicopter as it banked around and down toward a clearing in the center of Beranimbo, a village of 80 or so palm-thatched huts tucked away in the emerald mountains of Madagascar’s Northern Highlands. My pilot, a blocky German expat named Gerd, had already made one attempt to touch down the shaky single-engine copter, but he’d aborted the landing after the rotor blades kicked up enough dust to cause a brownout.

      A few hours earlier, when we’d set out for Beranimbo—a three-hour journey from the Malagasy capital of Antananarivo—Gerd had seemed excited. He doesn’t normally get jobs like this, typically making his money flying film crews around the countryside to shoot B-roll for ecotourism documentaries, usually about lemurs. “You want me to do a pass?” he asked, and before I could find out what he meant, we were swooping low through the hills. My stomach lurched upward; from this altitude we could see the spiny forest vegetation, tall ravenala trees, and great gaping wounds in the countryside, scars of systematic deforestation.

      We were there because, in the fall of 2013, Beranimbo had been an epicenter of a black plague outbreak that resulted in nearly 600 cases and more than 90 deaths across the country. Madagascar reports the most instances of the disease in the world. Depending on which century you’re talking about, it’s perhaps best known as the plague—a scourge generally associated with the Middle Ages, when rats, fleas, and poor hygiene resulted in the deaths of between 75 and 200 million people. The disease remains an enduring threat in third-world nations; public-health watchdogs report up to 2,000 cases a year.

      In the 1930s, the rise of antibiotics dampened and then nearly extinguished the clinical threat of the disease, at least in the developed world, and it lost its status as a global killer. But for years, epidemiologists have warned that Madagascar is particularly vulnerable to widespread rural and urban contagion. I wanted to find out just how dangerous this medieval disease is in the 21st century, and why it persists in this corner of the world. That search led me to Beranimbo.

      When we arrived, Gerd’s nervousness was apparent. “This may be too dangerous,” he muttered into his headset intercom as he tried to land the helicopter. Gerd’s concern wasn’t for his own safety, but rather the security of 200 people gathered around the makeshift landing pad below. Any one of them could have easily lost an eyeball to a pebble or twig whipped upward into the air. Helicopters are rare in Beranimbo and always attract attention, as they usually carry aid workers from the Red Cross. When we finally found a suitable spot to land, villagers ran from the dusty complex of huts to greet us.

      On the ground, I was introduced to the village elder, a thin old man in a light jacket and safari hat. To celebrate our arrival, he had organized the slaughter of a zebu, a type of domestic cattle with a large, camel-like hump, for a celebratory lunch. “The sacrifice of the zebu marks our friendship,” he told me. “I can’t express enough our happiness. Enjoy it with all our gratitude.” The animal’s neck was cut, and I was taken to meet Rasoa Marozafy, a 59-year-old father of seven who’s spent his life in the village. Rasoa is a plague survivor, and part of the reason I’d come to this place.

      Like his fellow villagers, Rasoa is of slight build and visibly, chronically malnourished. His limbs are knobby, like twisted sheets. He peered at me closely, looking me up and down before extending a hand for the traditional Malagasy handshake, a greeting with the left hand wrapped around the right wrist, then a quick flip into an open-palmed clasp and back down again.

      I introduced Rasoa to my translator, and he recounted his brush with the Black Death.

      The isolated village of Beranimbo, the epicenter of the plague that gripped Madagascar’s Northern Highlands in September 2013. Photo by the author

      In September 2013, at the outset of the hot and rainy season, Beranimbo was gripped by an enigmatic pestilence. The index case was Rasoa’s cousin, a maize farmer, who suddenly took ill and died. Following tradition, his body was carried into the center of town and left unburied for a week while funereal arrangements were made.

      Rasoa’s troubles began a few days later. The horror started with a high fever and searing chest pains, which jetted out from his trunk in red-hot strands. A day later he was coughing violently, spitting up black gobs of blood. Smooth, painful lesions appeared on his armpits and groin, and within 24 hours, his wife, Veloraza, had developed the same symptoms.

      When the local healer took ill, Beranimbo devolved into open panic. Sick and dying villagers staggered into the countryside toward neighboring settlements they thought were uninfected, thus spreading the unknown disease throughout the Highlands. By early October, a full outbreak had ensued, and Beranimbo had become a hot zone. Rasoa and Veloraza, fearful of spreading the unknown disease any further, walked into the jungle together to die.

      The sickness continued to rage unchecked through the countryside for weeks before a handful of villagers limped into Mandritsara, a nearby city and commune. Preliminary tests conducted by local doctors found the general risk factors associated with rural living: low body weight, chronic malnourishment, lack of sanitation. But the sick tested positive for Yersinia pestis, the bacterium that causes the black plague.

      Regional coordinators of the Red Cross were alerted and dispatched on October 5. When the aid workers arrived, Rasoa and Veloraza were still in the forest, waiting for death, so volunteers instructed villagers to search for them. It took a day, but the couple were located and carried back to the village, where they were administered injections of tetracycline and streptomycin, two strong antibiotics. They were on the verge of death and severely underweight. But within days, the mysterious illness vanished.

      After a few weeks, Rasoa and Veloraza recovered. “Now we will never separate,” Veloraza told me, sitting next to her husband, tears welling in her eyes. Until she was treated, she had never heard of the plague. I took a deep breath of dry air and asked her what consequences the disease had had on the village.

      “Consequences?” she snorted in traditional Malagasy. Her anger didn’t need translation. “It killed people,” she said. “Those were the consequences. It killed. We thought we were going to die.”

      The villagers prepare a zebu for lunch.

      I was born in the Year of the Rat. As a kid, scanning the printed mats beneath serving plates of dumplings and pork lo mein at Chinese restaurants, I was proud to be a rat. It’s the first in the Chinese zodiac, like Aries, my sun sign. I interpreted its character less as smarmy, filthy vermin than as industrious, instinct-driven survivor. Still, most people don’t think of rats that way. It takes a low position in the animal kingdom to qualify as vermin. Although I might reasonably argue that rats grade higher than cockroaches on the human scale of animal tolerability, they’re clearly below crows, bats, and even pigeons, and musophobia dates back to the earliest stages of civilization, when rats first crept into grain silos and contaminated food supplies.

      Since then, they’ve been feared for spreading a mind-bogglingly vast array of illnesses, like rat-bite fever, cryptosporidiosis, viral hemorrhagic fever, leptospirosis, and, of course, the plague, by far the most horrifying of the great epidemic diseases. Over the course of history, the plague has earned a handful of aliases that convey its potential for destructive power (Black Death, black plague, Great Mortality, Great Pestilence, Great Plague, Red Death), but most know it as the bubonic plague and have a set of knee-jerk associations with it: fleas, nomadic packs of crazed flagellants whipping themselves, the Brueghelian triumph of death, Monty Python, and, naturally, disease-spreading rats.

      Of course, there’s way more to know about the plague than most people care to learn about—it really just depends on how curious you are. Like many fantasy-obsessed middle schoolers, I became interested in the Middle Ages. And that led to a specific interest in the plague for a very specific reason: its status as the single most catastrophic killer in human history. Since it was first reported among the Philistines in 1320 BC, it has caused an estimated 300 million deaths, and there is currently no reliable vaccine. The Y. pestis bacterium has proven itself impossible to eradicate, and by all accounts it will be around long after our species is dead and gone.

      “It’s a disease for a time and place,” Dr. Tim Brooks, a British epidemiologist who specializes in the plague at Public Health England’s Rare and Imported Pathogens Department, told me over the phone before my trip. “But, in fact, its time is not now.” While it may not be the plague’s moment, that doesn’t mean it’s not biding its time in the waiting room. There have actually been three global pandemics of the disease. The first happened in the sixth century, then there was the Black Death of 1347, and finally there was the so-called Third Pandemic, which began its march in the 19th century and, depending on how cynical your epidemiologist is, may still be happening in small numbers on all continents today. It even crops up in the United States, which reports about seven cases every year, mostly clustered around the western side of the country. Just last month, the Colorado Department of Public Health and Environment reported that a Denver man and two others had contracted pneumonic plague, while a fourth person had contracted a milder form. (It most likely originated from fleas that bit the first man’s dog.)

      The number of actual cases in the 21st century is, admittedly, low. Cheap antibiotics like doxycycline, the same stuff the doc gives you for a urinary-tract infection, will treat the plague almost every time. My doctor explained what to do if I thought I might have contracted the plague while assuring me that I almost certainly wouldn’t die from it if I took immediate action.

      The “almost” is what got me. I imagined what the last days of my life would be like if I somehow caught the plague in a remote village in Madagascar and became sick so quickly that I’d be unable to seek help. It’s not the job of a disease to recognize or respect human dignity, but to me, the plague seemed engineered to degrade and agonize its victims. Here’s how it works: In most untreated cases, an incubation period of two to six days is followed by the sudden onset of violent flu symptoms. Painful, rose-colored lesions often develop around the groin, armpits, or neck. Gangrene turns the extremities black, and blood is coughed up and vomited.

      Bubonic plague is the most common form, taking its name from the inflamed swellings, or “buboes,” which in turn reference the Greek word for “groin” (boubon). Pneumonic plague can be a direct consequence of the bubonic form, occurring when the disease reaches the lungs and begins spreading like the flu. The third form of the disease, septicemic plague, is the rarest and occurs when the blood is directly infected.

      Whichever variety of the plague, as the disease progresses its victim lapses into recurrent seizures, Alzheimic confusion, coma, and internal hemorrhaging. Without treatment, the bubonic plague has a 40–60 percent mortality rate within four days. The pneumonic form, which spreads like the flu, has a much higher fatality rate (close to 100 percent) and works faster than its bubonic cousin, killing its human host within a few days if left untreated.

      The condition most commonly associated with the plague is, of course, the buboes: swollen lymph nodes that have been described throughout history as kernels, pimples, wheals, and biles. Giovanni Boccaccio’s generally accurate description from The Decameron of 1353 poetically sums up what it’s like to experience the plague:

        In men and women alike there appeared, at the beginning of the malady, certain swellings, either on the groin or under the armpits, whereof some waxed of the bigness of a common apple, others like unto an egg, some more and some less, and these the vulgar named plague-boils. From these two parts the aforesaid death-bearing plague-boils proceeded, in brief space, to appear and come indifferently in every part of the body; wherefrom, after awhile, the fashion of the contagion began to change into black or livid blotches, which showed themselves in many [first] on the arms and about the thighs and [after spread to] every other part of the person, in some large and sparse and in others small and thick-sown; and like as the plague-boils had been first (and yet were) a very certain token of coming death, even so were these for every one to whom they came.

      In 1894, during the Third Pandemic, Alexandre Yersin, a French physician and bacteriologist, determined that the plague was caused by the previously unknown bacillus pestis. As is common in scientific practice, the bacterium was later named in his honor: Yersinia pestis.


      Infographic: A Recent History of the Plague.
      Click to enlarge

      Before my trip to Madagascar, I assumed the bare and chilling facts of the disease would allow the story to write itself. When I spoke with friends and colleagues about the story, I would get one of two contradictory responses—confusion as to what the big deal was (it only kills a few thousand people a year. How bad is it, really?) and shock that it is still around at all.

      In Madagascar’s cities, everyone knows about the plague. They know it constantly threatens to disrupt the social order of the country’s towns and villages. They know it just takes a perfect storm of filth, fleas, garbage, rats, and diminished immune systems to set off an epidemic that could potentially make it off the island and spread to the African coast.

      As history has taught us, by the time there are enough people with the plague to classify it as an “outbreak,” it’s already too late. Something about Madagascar has made it the most vulnerable country on the planet for a serious outbreak at this moment. I wanted to know what that something was.

      Rasoa Marozafy and his wife, Veloraza, who both contracted plague in the fall of 2013. Photo by the author

      When I arrived at the Ivato International Airport in Antananarivo, the first thing I noticed was the smell. It’s not an odor, exactly, more a general ruddiness in the air that followed me throughout my trip. There were moments when it was overpowered by brassier fragrances—the sick-sweet curdle of garbage, or fried-egg fart-wafts of human sweat—but it remained the bass note of every olfactory chord, as if the entire country were housed inside a potter’s lathe.

      “In shape,” wrote Sir Mervyn Brown, Britain’s ambassador to the country in the 1970s, “Madagascar resembles the print of a gigantic left foot with an enlarged big toe pointing pigeon-toed slightly to the right of north.” Almost the size of Texas, the country is 1,000 miles long, 350 miles wide, and tropical along the coasts, with a warm, wet summer and a cool, dry winter.

      Some 88 million years ago the island broke away from the supercontinent of Gondwana, eventually being pushed 250 miles off the coast of Mozambique. It is one of the rare places on earth that has preserved its own unique ecosystem. More than 75 percent of Madagascar’s flora and fauna are specific to the island, although many of these species have been eradicated, mostly due to local slash-and-burn farming techniques introduced by the island’s first settlers and still practiced to this day.

      The country is populated by dark-skinned inhabitants, descendants of ancient Indonesians who arrived on the island around the ninth century, having sailed nearly 5,000 miles across the Indian Ocean in elegant outrigger canoes. They don’t consider themselves African and speak a traditional Malagasy language and French, a holdover from colonial days. At the turn of the 20th century, France unified the island under a single regime. The first recorded instances of the plague followed soon after, worming its way aboard merchant ships and into the port city of Toamasina. By 1921, the disease had become endemic in the rodents and small mammals of the Highlands. Since then, the plague has flared up here and there, mainly as a rural phenomenon with occasional urban epidemics.

      The plague is almost impossible to eradicate from Madagascar, thanks to a complex interaction of natural and sociocultural factors. According to a 2013 report by the US National Library of Medicine, the high percentage of animals carrying the disease lays the foundation for transmission, and social and economic conditions further encourage the periodic leap to humans.

      Outbreaks of the plague in Madagascar usually occur in villages above an altitude of 2,600 feet and can be linked to the activities of farmers. The agricultural infrastructure of the Highlands provides three distinct habitats for the plague to thrive: hilltop houses, hedges planted around livestock enclosures, and the irrigated rice fields of lower-lying areas. Food shortages and farming can serve as triggers that cause the rat population to drop significantly while, inversely, fleas flourish. Without the rats as a primary food source, fleas are forced to look for other mammals—such as humans—to serve as hosts.

      In northern Madagascar, the plague spikes between October and April, when the warm rainy season ensures that the temperature rarely drops below 70 degrees. The sustained humidity acts as an incubator for Xenopsylla cheopis, better known as the Oriental rat flea, the primary vessel for the plague.

      Compounding the difficulty of controlling the flea population during the rainy season, new research by the US National Library of Medicine suggests that the plague bacterium can quite literally persist underground between outbreaks via rats that infect themselves by burrowing into contaminated soil. While research is still in the preliminary stages, it has been demonstrated that Y. pestis bacilli can survive underground for at least 24 days under optimal conditions.

      While vermin are the natural scapegoat for the plague, humans are the true culprits. In villages, crops are often stored inside houses to prevent robbery, attracting rats and fleas. Deforestation by illegal loggers, a timeless but growing problem in Madagascar, forces rats from the forests and into the villages. From there, impoverished living conditions and migrants fleeing those conditions can quickly result in outbreaks in previously uninfected communities.

      Even more chilling, traditional Malagasy funereal practices help to ensure that the plague can continue to spread even after the victims have been buried. Most of Madagascar’s dead are interred in vaults and are exhumed from time to time for the Famadihana ceremony, which roughly translates to “the turning of the bones.” Upticks in plague activity are sometimes reported following these exhumation ceremonies, and it is enough of a problem that the Ministry of Health has recently recommended instituting a seven-year period between the death and exhumation of plague victims.

      Despite these considerations, and evidence that instances of the plague may be increasing, the Malagasy government stopped tracking metrics on the plague in 2006, due to financial constraints. Today there remains only one reliable source for medical and biological data on the spread of the plague in Madagascar: the Unité Peste, or Plague Unit, of Antananarivo’s Institut Pasteur de Madagascar.

      Evolving out of the Bacteriological Institute established by the French colonial government at the turn of the 20th century, throughout its various iterations the Institut Pasteur has long been crucial to the tracking of communicable diseases in the country. The health organization’s subsequent privatization has assured autonomy and, in an economically depressed Madagascar, its status as the last line of defense against the plague. A visit there was crucial if I hoped to understand just how bad things could get.

      Andavamamba, a slum in Antananarivo whose name means “the Crocodile Mouth”

      "There is a flea!” Michel Ranjalahy, a young lab technician with the Unité Peste, shouted from the deck of an open-air autopsy table. He’d just broken the neck of a rat with a pair of gleaming, silver tongs. He then cut open its carcass with a scalpel and scissors, using tweezers to extract its liver from a tightly packed coil of organs.

      While he was scraping at the gutted rat’s fur with a pocket brush, the flea had fallen into a small basin. Some of the technicians instinctively backed away, raising their hands in morbid respect for the potential devastation this tiny flea was capable of causing. I asked Michel whether it was plausible that this particular Oriental rat flea carried the plague. “Yes,” he said, “because it drinks the blood of the rat, which may contain the plague bacterium.”

      At its essence, the Unité Peste is a rogue team of die-hard rat catchers who conduct their work with lethal seriousness. As the only official group dedicated to fighting the plague in Madagascar, they have quite possibly the worst job in the country. Their days consist of traveling to remote, at-risk areas where the primary objective is to catch potentially infected rats and perform autopsies on them to search for signs of the highly virulent disease.

      After a tour of the facilities, I was invited to tag along on one of Unité Peste’s search-and-capture missions. Within hours I found myself crawling on my hands and knees through the undergrowth around Antananarivo, hunting for rats that may or may not have been infected with one of the most devastating diseases known to man. Our field gear consisted of a pen and paper for note taking, sliced tilapia for bait, and two-door rattraps made from rust-resistant mesh cages that the team hides in the undergrowth, where they are left out overnight. With any luck, there would be live rats trapped inside when we checked the following morning.

      Everyone I spoke to in Madagascar had heard of and expressed concern about the plague. I sensed an underlying fear that, if the disease were to reach the capital, the results would be catastrophic, as crowding could cause it to spread far more rapidly than in the countryside. This sentiment was echoed by the entire Unité Peste, including their boss, Dr. Christophe Rogier, a cheerful man with a thick French accent and a close-cropped buzz cut who serves as the director of the Institut Pasteur.

      “There is an urgent need for funding the control of this neglected disease,” he told me when I visited him in his office in Antananarivo. “Because it is happening in neglected areas, where no politicians are going, and where no physicians want to go, since it’s too remote. The disease is dangerous for the population. But because people are moving, in fact, it’s dangerous for everybody. There are more rats in the city than in rural areas. The rats are in closer contact with the population, and the houses are overcrowded, so we can imagine that the spread of the plague from human to human would be faster in the cities than it would be in the country.” Suddenly the Black Death, which decimated Europe’s largest cities in the Middle Ages, didn’t seem so unfathomable.

      The slums of Antananarivo share many characteristics with the densely populated medieval cities that were virtually wiped out in the mid 1300s. Among a total population of around 2 million, tens of thousands of Antananarivo’s most impoverished families live under ramshackle lean-tos fashioned from tarps and bamboo shoots with little or no access to clean water or indoor plumbing.

      “If the plague were to hit the slums,” Rogier told me, “there could be dozens, hundreds, or thousands of cases.” It is a situation that has the potential to push the already troubled country off a cliff and further into failed statehood.

      Michel Ranjalahy, of the Unité Peste, holding a potential plague rat outside the Institut Pasteur. Photo by the author

      Antananarivo’s earliest known inhabitants settled atop the highest hills in the city, which spread out into three ranges that form the shape of a Y. This area wasn’t chosen for the nice views; rather, it offered a 360-degree tactical advantage over hostile invaders. As the city grew and developed, it sprawled down the mountains and into their low-lying valleys. As real estate on the mountain became increasingly scarce, the hillside communities became slums and have continued to grow unabated. An outbreak of the plague here would be catastrophic to the local population.

      Just as they have for centuries, the men and women of Antananarivo walk barefoot through the streets, which are little more than mud ruts lined with open sewer systems clogged with trash and human waste. The latticework of canals that crisscrosses the city is also backed up with garbage. I watched as small bands of children waded and swam through the fetid sludge, hunting for anything worth selling that might be floating in the muck.

      The day after I returned from the Highlands, I was given a private tour of one of the worst-off slums in the city by a 28-year-old security guard and father of three named Andriambeloson Solofo Pierre, who goes by Billo. He met me in a dilapidated café in the neighborhood of Andavamamba, which translates to “the Crocodile Hole.” (The settlement is built on top of a swamp, and local legend holds that the first people who moved into the area would often slip and fall into the deep pits where crocodiles laid their eggs.)

      Billo earns between $3 and $5 a day. Like most people in Madagascar, he and his family cannot afford any real form of health care. “I fear for my family,” he told me, watching the sun setting over a canal choked with garbage.

      He pointed to a group of children playing in the viscous water. “We’re located in an inner-city slum, so no one pays attention,” Billo said. “The roads are not repaired, and the projects to fix pathways and irrigation are gone since the coup. I know that politicians aren’t going to change things very much.”

      The coup Billo referred to took place in 2009 and, like many of Madagascar’s most notable political moments, was a disaster for the country. When the French colonized the region in 1885, they set to work stripping the area of its resources and slaying more than 100,000 Malagasy who fought against the exploitation of their land. After a monitored independence was initiated in 1960, the country quickly devolved from the hope of autonomous democracy into total anarchy, and after that a failed Marxist utopia.

      This all changed when President Marc Ravalomanana was voted into office in 2001. For the first time in the country’s modern history, Madagascar seemed poised to enjoy a degree of stability. The economy soared, bolstered by the land’s rich mineral wealth, which includes bounties of gemstones, nickel, and iron, and land-lease agreements with foreign investors like the Korean industrial giant Daewoo.

      But this political and economic optimism was short-lived. In 2009, the Ravalomanana government was ousted in a bloody (and, many Malagasy believe, French-backed) coup, led by a former DJ and media entrepreneur named Andry Rajoelina, who at the time was serving as the mayor of Antananarivo. He immediately set up the so-called Fourth Republic and dubbed himself president of a fantasy regime called the High Transitional Authority.

      As a result of Rajoelina’s coup and the dissolution of the elected government, foreign aid to the country, which formerly accounted for 70 percent of the national budget, evaporated almost overnight. A month later, Madagascar’s economy was in shambles. The country was suspended from the African Union, and according to a report by the Organization for Economic Cooperation and Development, it was the most under-aided country on the planet.

      Rajoelina’s junta countered by slashing public expenditures across the board, specifically in the irrigation, transportation, communication, and health sectors. These cuts affected virtually every facet of the Malagasy economy and evaporated the fragile middle class. The cost of Rajoelina’s coup will continue to be paid by average citizens for years, if not decades, to come.

      The plague’s relationship to the country’s tangled political situation became apparent to me after I met Dr. Jean-Louis Robinson, the former minister of health who was ousted by the coup. We spoke at his compound, a lavishly decorated home overlooking a cluster of urban farms. A stout man with darting eyes and a hairpiece, Robinson told me that after Rajoelina took power, more than 400 health-care centers were closed across the country.

      His main concern, like the Institut Pasteur’s, is that Madagascar’s urban population could be a conduit for a plague epidemic the likes of which the country has never seen. “There used to be established structure and control programs,” he said. “In the inner-city slums, there are no sanitation programs. Public restrooms are insufficient; garbage is not picked up regularly.” Everyone I spoke with who was in a position to do so identified these same sanitation issues as a potential tinderbox of widespread, communicable havoc, but there are few tenable solutions to such a problem when there’s no money to clean up mounting piles of garbage.

      On December 20, 2013, following a series of political debacles surrounding the presidential election, Rajoelina and his High Transitional Authority lost control of the presidency to his former finance minister, Hery Rajaonarimampianina. Almost immediately, the US Department of State lifted all remaining restrictions on aid to Madagascar. But while this no doubt opened the door to an improvement of the country’s financial and public-health situations, according to a report issued by the Bertelsmann Stiftung’s Transformation Index, these democratic elections should not “be expected to resolve the profound weakness of institutions and, particularly, the deeply eroded capacity of the state to govern, enforce, and regulate through critical sectors,” such as public health.

      For his part, Billo told me, all he can do is wait for the next plague season, which begins in October. As we wandered through the throngs of bodies crowding the streets of Andavamamba, he wondered aloud about the chances of the plague reaching the capital—and how many might perish if it did.

      Two girls in Beranimbo, firsthand witnesses to the plague outbreak

      On one of my last days in Madagascar, I met a traditional healer named Dadafara who runs a small private practice out of a two-room hut off a dusty side street on the outskirts of Antananarivo. The exterior was lined with horned zebu skulls, and inside was a variety of plants and herbs in jars, and rainwater collected from the 12 sacred hills of Imerina, a cluster of mountains that surround the capital. In Madagascar, when people get sick, they generally consult people like Dadafara, although wealthier citizens refer to them as witch doctors and shun their practice. His frail body was clad in a traditional sari and topped with a worn baseball cap.

      I wanted to know what sort of treatment a traditional healer would administer were he presented with a case of bubonic plague, and Dadafara agreed to consult with and treat me as if I were a sick patient. He explained to me how the consultation would work. First, I would tell him my symptoms. Then he and I would do a bit of chanting and invoke the ancestors to seek their advice. Dadafara held a small mirror up to the light. “This is my camera,” he told me. “I’m looking at everything through this and communicating with the ancestors. When I read a person through this, it’s like I’m watching a TV.” After we’d communicated with the spirits, they would tell Dadafara what my treatment should be, and he would prescribe some sacred water or boil herbs to treat me.

      When we were ready to begin the ceremony, Dadafara asked me to tell him my symptoms, and I obliged. “I’ve got a fever of about 104 degrees,” I said, “and my groin and armpits are covered in smooth, open sores about the size of chicken eggs. I’m vomiting blood, I have a headache and painful muscle aches, and I’m experiencing violent, recurrent seizures. Also,” I added, “I live in an area that has no clean water and is infested with rats.”

      My fixer told Dadafara what I’d said, and when he responded, she started to laugh. “What?” I asked. “What did he say?”

      Dadafara crossed his arms as the translator gave me a deadpan stare. “He said, ‘You have the plague. You need to go to a doctor immediately.’”

      A freshly chopped zebu head

      Last month, in a scene reminiscent of Albert Camus’s 1947 masterpiece, La Peste, Yumen, a northwestern Chinese town of 30,000 people, was sealed off after a man died of bubonic plague. Police set up roadblocks on the perimeter and told motorists to find alternative routes around the town.

      At the end of Camus’s novel, the protagonist, Dr. Bernard Rieux, surveys the Algerian city of Oran as its people celebrate the passing of a deadly plague and return to their old customs and habits. “He knew,” Camus writes, “what those jubilant crowds did not know but could have learned from books.

      “The plague bacillus never dies or disappears for good… It can lie dormant for years and years in furniture and linen-chests… It bides its time in bedrooms, cellars, trunks, and bookshelves; and… perhaps the day would come when, for the bane and enlightenment of men, it would rouse up its rats again and send them forth to die in a happy city.”

      Look for our documentary about the persistence of plague in Madagascar, coming soon.

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      Topics: plague, the plague, bubonic plague, black plague, Madagascar, Africa, rats, death, Africans, travel, diseases, deadly diseases, deadly bacteria, dying, guts, Blood

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