by Genese Sodikoff
Recent outbreaks of the bubonic plague in Madagascar offer a glimpse into the dynamics of past outbreaks, the Plague of Justinian (sixth to eighth centuries), the Black Death (fourteenth to seventeenth centuries), and current wave of “Third Pandemic” plagues that began in the nineteenth century. Over the past few years, genetic studies of the bacillus, Yersinia pestis, have revealed why the pathogen was so devastating, killing tens of millions over centuries. Yet much about it remains mysterious.
Tracing the plague's dynamics on the ground raises hard-to-solve questions, hard because of the material conditions in countries of Asia and Africa, where most of today's epidemics erupt. Impassible roads, lack of equipment, broken-down communication networks, proximity to rats in homes, and traditional healing and mortuary practices enable the plague to persist and evolve. Antibiotics contain the plague, but these are not always easy to get, nor are the proper dosages always consumed, in poor, remote areas.
I have just returned from a trip to Madagascar, where I visited the site of the August 2015 plague outbreak (14 cases and 10 deaths). I have a lot to learn, but my burning questions concern how long Y. pestis can survive inside a corpse or underground. For medical workers there, answers could help control outbreaks. And if it turns out that the dead are only ephemerally infectious, an overhaul the current policy on burials and funerary rites would be welcome news. The policy is a source of major anxiety for relatives of plague victims, who are prohibited from burying their kin in family tombs for seven years. For most, accumulating enough money to be able to transfer a body over a long distance is an enormous burden, so the seven years may stretch out indefinitely. Those who die of plague in the hospital may not receive the customary funerary rites from their family. All told, plague victims are unable to transform into proper ancestors. They are lost souls.
Until a few of years ago, scientific accounts of the plague held that the bubonic form, highly deadly but survivable, spread from black rats (and possibly gerbils) to humans through flea bites, and that it was only contagious between people if a person came into contact wit the bacteria-laden pus that oozed from a ruptured lymph node. The bubonic plague infects the lymph system, causing nodes to swell at the groin, neck, and armpits into lumps (buboes) that blacken and sometimes burst. For the patient, the discharge of fluid from the buboes may have been a good thing, setting them on the road to recovery, according to some texts.
Today, antibiotics kill off the infection before it reaches this advanced stage, unless—and this too is a muddled issue—the bacteria breach the respiratory system to become the fast-acting pneumonic plague, long considered rare. In Madagascar, it appears that most of the fatalities of the 2014 and 2015 outbreaks were cases of pneumonic plague, and healthcare workers feared that isolated bubonic plague cases would spread by rats, people, or fleas traveling over roads, and that it would become pneumonic and sweep into the densely-populated capital, Antananarivo.
It confused me to read plague literature that stressed the rarity of airborne plague in light of recent outbreaks in Madagascar, where the pneumonic form manifests quickly. Medievalist historians and scientists had also been hard pressed to reconcile the massive death tolls of the past plagues with what we know of the limited transmissibility of bubonic plague between people. This led some to postulate different diseases at work, such as anthrax or some hemorrhagic fever virus, like Ebola.
In 2011, scientists reconstructed the genome of Y. pestis, the plague bacterium, from remains taken from a fourteenth century plague pit in East Smithfield, London. They proved that Y. pestis was indeed the pathogen responsible for the great plagues.
In 2014, Y. pestis was extracted from a tooth of a fourteenth century skull from Charterhouse Square, north of London. Scientists compared to a sample from Madagascar's 2014 plague outbreak (resulting in 335 cases and 79 deaths). The strains were nearly identical, suggesting that human beings had become the sources of contagion during the past plagues. Rat fleas surely lit the fuse, and bubonic plague did continue to circulate, as evident in the enduring descriptions of black buboes and black patches of skin in victims. But the incidence rate of the plague climbed rapidly due to people infecting one another by coughing up bloody sputum and vomiting. The discovery validates the skepticism of those who doubted the high communicability of bubonic plague.
These revelations about the prevalence of pneumonic plague gibed with what I was hearing in Madagascar by family members of plague victims, some of whom survived after treatment. 
What I was hearing sounded so different from bubonic plague, I wondered too whether it some other disease. The plague diagnosis was certain. Doctors at the Moramanga hospital had rapid test kits to confirm, and samples of the patient's sputum or lung fluid (if deceased) were then sent to the Pasteur Institute in the capital for further confirmation.
One couple in the August 2015 plague zone, (I will call them Jules and Botine), lost seven relatives, including their son, to the disease over the course of three days. A curse seemed to have struck their family to have lost so many, and they believed sorcery was at play. Something to do with a bitter ex-husband of one of Jules' relatives intent on harming his whole family by laying cursed charms in a nearby spring. What else troubles them now is the seven-years rule prohibiting the transfer of bodies to the family tomb. If someone dies of plague in the village, and several had in August, people ignore the policy and carry out the usual rites. But if a patient manages to get to the hospital–a herculean effort to go on foot when ill–and succumbs anyway, hospital orderlies handle the burial unceremoniously.
The seven-years policy combines cultural and scientific logic. Throughout the island, Malagasy people bury their kin together in a family tomb on their natal territory. If a person dies far from this place, the family saves up for the day when they can bring the body home. Malagasy are renowned for the famadihana, the ceremony where they exhume deceased kin after several years, unwrap the white funerary cloth and rewrap the skeletons in new cloth. In some regions relatives dance with the bodies held high before returning the remains to the tomb.
The plague has disrupted famadihana plans for families of plague victims. In some plague-hit localities, authorities are establishing separate cemeteries, which I think has less to do with quarantining the bacteria in the soil than making it easier to identify plague victims and prevent kin from exhuming them, implying anyway that the soil or the human remains are infectious.
From region to region, and even from village to village, specific details of funerary rites in Madagascar vary. Within the Betsimisaraka ethnic population of eastern Madagascar (the same population hit by the 2015 outbreak), people believe that the dead can transmit certain diseases or deformities to one another underground. In one village I lived in between 2000 and 2002, individuals who died of leprosy, lameness, or polio were buried in the forest near, but separate from, the stone-covered cave or dugout in which ancestors' bones lay. Why only these but not all infectious diseases? No one could tell me explicitly why, so I interpreted the selection as having to do with impaired mobility. Since walking is essential to subsistence farming in the mountains, the separation in death of weak and strong walkers would protect the able-bodied from immobilizing, postmortem diseases.
At this point, I assume that the seven-year rule against interring plague victims in family tombs expresses the state's concern for the wellbeing of Malagasy ancestors. Scientifically, the rule implies that jostling human remains will loose plague bacteria into the air and possibly infect people. Although seven years is a long time, better safe than sorry.
Dr. Lynteris tells me that during the colonial period in Africa, the French held onto centuries-old theories of soil plague-infection longer than the British or scientists elsewhere, so the current policy may be a colonial holdover. If the bodies and soil could be analyzed and found safe, maybe Jules and Botine could recuperate their dead and make them ancestors. This would ease their conscience.
They saw apparitions at night of Jules' mother and sister, who scolded them for leaving them buried far from home. In Madagascar, if the living fail to properly care for deceased kin, if they leave no gifts of tobacco or rum in the folds of the white cloth, if they exile them from the family tomb, then the deceased grow resentful and haunt the living in dreams. They may seek vengeance, which manifests in a variety of forms, such as the death of a child, the death of a cow, a paltry rice harvest.
Jules and Botine guided me and my collaborator, Dieudonné Rasolonomenjanahary, to the communal pit at the side of a dirt road, where four of their relatives lay: their son, Jules' sister (her husband had died of plague in the village), Jules' nephew, and his brother-in-law, all of whom made it to the Moramanga hospital, but too late. Jules' mother was buried alone at another site near town.
The footpath leading to it was steep and overgrown with bramble. The couple had been present at the burial (the doctor had allowed that much), but no rites were performed and no offerings left. The couple was distraught at the idea of the bodies being covered by only a shallow layer of earth and exposed to the wet and cold. Jules' dead nephew was too tall for the body bag and his feet stuck out. They fretted about that. The couple took it upon themselves to buy a blue plastic tarp. They covered the four bodies and shoveled more dirt on top to weigh down the tarp. As we left the pit that afternoon, Botine spoke softly behind me to her deceased kin, making promises, trying to comfort them.
How it all started, the identity of Patient 0, is still unknown. Did it begin with Arnod, a man who got the bubonic plague and died in a nearby village in April 2016? Was the epidemic four months later instead triggered by Dimilahy, the brother-in-law of Jules, who had attended Arnod's wake and burial in April. Why the four month interval between infection and illness? Had Dimilahy taken a partial course of antibiotics to ease painful symptoms, not suspecting the plague, and did that work to tamp down the bacteria multiplying inside him? These are a few pieces of the puzzle we are trying to find in one family's story, and the bodies of the dead, now underground, may have something to tell us.