By Nathaniel Hill
The ongoing COVID-19 pandemic, known colloquially as the Coronavirus, has set a substantial challenge for the global health system. The COVID-19 virus has put East Asia, Western Europe, and the United States on lockdown and sent the global economy into a free fall. Previous global health crises, the 2009 Swine Flu pandemic (H1N1), the 2014 Ebola Crisis, and the 2015 Zika Virus have all shown how globalisation has affected the global health scheme. However, the effects of all these previous viruses seem to pale in comparison to what is happening with COVID-19 . Despite the paranoia and the pandemonium surrounding this virus, plagues and viral outbreaks are no stranger to humanity. Advances in modern medicine have rendered horrific plagues, such as measles, scarlet fever, polio and dozens of others, distant vestiges of the past. However, epidemics and health crises are frequent occurrences in the global south and poorer areas of the world. Only if they affect or transmit to the West, do they get anything close to extensive media coverage or a focused international response?
One of the most under reported cases of the 21st century is the series of outbreaks that have rocked the island nation of Madagascar. What is even more surprising is that, the disease in question was a bubonic plague. The bubonic and/or pneumonic plague is one of the diseases caused by Yersinia Pestis bacterium found in fleas. The bubonic plague is responsible for the worst pandemic in human history, colloquially known as the Black Death. For over two decades, the Black Death killed more than 200 million people in Europe, Asia, and Africa. Initially transmitted through sea and caravan routes, the plague had an unprecedented effect on the economic, environmental and social aspects of the world for decades. The bubonic plague now only exists in the fringes of society, in the untamed and unmonitored wildlands of the Congo, the Amazon and Asia.
Only a few hundred cases are reported every year and even fewer deaths are as a result of the isolation of these cases. In the far-flung corner of Madagascar, there have been frequent outbreaks of pneumonic plague, a more deadly and resistant form of the bacteria. From 2014 to early 2018, Madagascar saw a swath of outbreaks, and around 300 known deaths from the plague were recorded. News of the outbreaks rarely reached the international media level and for the most part, the response was effective at curbing the spread of the disease. The epidemiology of the plague in Madagascar is useful in examining how diseases spread to areas of poverty and how the world responds to these outbreaks. As the COVID-19 escalate in some parts of the world and winds down in others, it is crucial to look at responses and cases of previous outbreaks, even if they did not capture the global spotlight.
Bubonic/Pneumonic Outbreaks in Madagascar
Madagascar has frequent cases of the plague, typically when the rainy season occurs from November to October. In 2014, a man from the Italian region in central Madagascar contracted the plague. This one vector managed to infect over 100 other people, and 40 were confirmed to have died from the disease. This was the first wide-scale spread of bubonic plague in Madagascar. The epicentre for this, and the subsequent 2017 outbreak, was the central and northern highlands of the island. These regions are some of the most remote places on the island. Most of the population lives in remote and scattered villages, high on the plateau that is at times only accessible by helicopter. Most residents subsist on agriculture as subsistence or travel to urban areas such as the capital Antananarivo, to seek work. The more widespread outbreak in 2017 saw over 2200 cases and 200 deaths.
The 2017 Epidemic saw a substantial response from the international community. The World Health Organization (WTO), the Institut de Pasteur and the Madagascar Ministry for Public Health had a concentrated response to the outbreak. Organizations deemed the plague’s ability to spread outside of Madagascar into a global pandemic unlikely; given the country’s isolation and the plagues early treatability. Despite the low risk to those outside Madagascar, the way the plague spread and dispersed among rural and urban Malagasy was shocking. Firstly, widespread poverty inhibits both the government’s ability to administer healthcare and people’s access to it. 70 percent of Madagascar live under the poverty line and after the political crisis of 2013, the government’s stability has hampered its efforts at providing adequate public health.
Other factors contributed to the plagues spread, such as illegal deforestation of the highlands, which forced many rats from their homes in the forest down to the city. The Malagasy burial practice of Famadihana, which involves taking corpses out of tombs and parading them with music around town, was also seen as a contributor to the spread of the plague. Additionally, the packed urban slums in Antananarivo and other urban spaces often involving high-density populations living next to open sewers and refuse piles, offered ideal setting for the plague to spread.
One lesson out of hundreds we can learn from the COVID-19 outbreak is that, the public and more importantly governments, need to become more receptive and aware of potential and real epidemics, even if they are far away on the other sides of the world. The West may have the tools and resources to easily combat a large-scale outbreak of bubonic plague, but Madagascar and the surrounding countries clearly do not. Indeed, without a quick response from the global community, the casualties of the 2013 and 2017 epidemic could have been much higher. Furthermore, the strains of plague in Madagascar, known as pneumonic plague, are passed through air particulates and can be extremely aggressive in its infection, which if left untreated has a mortality rate of almost 100 percent. The coalition of organizations fighting the plague focused on improving sanitary conditions in rural and urban populations, education about proper sanitation techniques and plague symptoms, and engagement with local leaders to identify potential cases. All these efforts succeeded in halting the spread of the plague in Madagascar and reducing the number of casualties.
Africa so far has not experienced the large scale societal effects of COVID-19 as observed elsewhere, yet the WHO and others urge African leaders “to prepare for the worst.” The perennial African challenges of food insecurity, water access, state stability and low literacy, could compound the situation to make Africa the next epicentre of COVID-19. Policymakers, civil society and business need to join together in a concerted effort to avert a COVID-19 worst case scenario in Africa.
Part 2 of this blog will update and chronicle the current state of Covid-19 preparedness and containment approaches by selected African governments.