Antananarivo and Central Plateau area, Madagascar.

Considered by the westerners as a mere past chapter of their History, Plague is an ancient flea-borne disease with a case fatality rate of 50-60% if left untreated. Nowadays, plague still represents a public health concern in affected countries in Africa, Asia and Americas.

Despite the surveillance and the prevention measurements implemented, according to WHO over the past 3 years the number of cases in Madagascar has steadily increased, making it the country most severely affected by plague worldwide. Regular outbreaks have been recorded every year since 1983, with peaks in the urban enviroment and in the central plateau during the rainy season (usually from October to April).

Plague is considered the one of most dangerous “neglected tropical deseases”, whose term refers to a group of infectious deseases that prevail in tropical countries and affect more than a billion people. They mainly affect populations living in poverty, without adequate sanitation and in close contact with animals and others infectious vectors.

The explanation for the persistency of plague in Madagascar has to be found besides the enviromental and biological factors: socio-economical causes and cultural beliefs appear to be key determinants. In both urban and rural setting plague is considered to be the “disease of the poor”, affecting those living in poorer, insalubrious, underserved, peripheric areas. This is related to the deep-rooted social stigma associated to the disease, to the patients and to their families.

Even cultural practices have a strong impact on the incidence of plague in Madagascar: the preference for traditional medicine in remote villages can cause delays in the beginning of an effective antibiotic treatment, while funeral ceremonies and ritual corpse exhumations (famadihana) also might favor the spread of plague.