Mada­gas­car’s grave dilemma

The pneu­monic plague is forc­ing the is­lan­ders to aban­don their tra­di­tional burial rites

Mail & Guardian - - Africa - Ra’eesa Pather

In the streets of Mada­gas­car’s cap­i­tal city, the plague is a ghost. Pa­tients stay hid­den away in hos­pi­tals or are at home, where some are keep­ing their ill­ness a se­cret. They fear death but, more than that, what hap­pens after death — the anony­mous mass grave that many pa­tients be­lieve is their in­evitable fate.

The pneu­monic plague — a rel­a­tive of the bubonic plague, or Black Plague, but not ex­actly the same thing — is a bac­te­rial dis­ease spread from per­son to per­son by droplets in the air. It can kill in as lit­tle as 24 hours if left un­treated. Over the past few months, there have been more than 1900 sus­pected cases in Mada­gas­car, and 143 deaths.

But the pneu­monic plague is pre­ventable and cur­able if treated early, ac­cord­ing to the World Health Or­gan­i­sa­tion (WHO). The med­i­ca­tion is free in Mada­gas­car. Yet many Mala­gasy refuse to seek help.

“Some peo­ple have the plague and they don’t know. They are afraid to go to the doc­tor be­cause even a sim­ple cough can be di­ag­nosed as plague and peo­ple are afraid of that,” says Fan­ja­soa Ran­javelontsalana (50), a com­mu­nity vol­un­teer.

Ran­javelontsalana has just be­gun work­ing for the Mala­gasy Red Cross So­ci­ety. She hails from a ru­ral area called Ah­bo­himi­adana Sud, which is just out­side An­tana­narivo.

Al­ready, one case of pneu­monic plague has been con­firmed in her com­mu­nity and there is an­other sus­pected case. There could be oth­ers, but Ran­javelontsalana may only find out when it is too late.

An­other fac­tor de­ter­ring peo­ple from seek­ing help is con­cern about what hap­pens to their body if they die from the plague.

Fu­ner­als here are ex­tremely im­por­tant: burying the dead is ac­com­pa­nied by a host of rites. Among many Mala­gasy, there is a cus­tom known as famadi­hana, when the bodies are pe­ri­od­i­cally re­moved from the fam­ily crypt. Loved ones clean the re­mains and reshroud the bodies in new cloth. With the bodies of their an­ces­tors readorned, the Mala­gasy then dance with the dead around the crypt.

But sci­ence and cul­ture have col­lided with a dev­as­tat­ing con­se­quence in Mada­gas­car: the Mala­gasy can no longer per­form this sa­cred rite if a loved one has died from the plague. The gov­ern­ment has made this clear.

“If a per­son dies of pneu­monic plague, and is then in­terred in a tomb that is sub­se­quently opened for the rit­ual, the bac­te­ria can still be trans­mit­ted and con­tam­i­nate who­ever han­dles the body,” says Willy Ran­dria­maro­tia, chief of staff for the health min­istry.

Search­ing for dig­nity

An­tana­narivo is scat­tered with snaking side streets. Colour­ful block houses and shops are jum­bled on top of one an­other along the pave­ments. It is a city that ap­pears to have been cre­ated by ac­ci­dent. And its health­care sys­tem seems just as chaotic, ham­pered by a lack of re­sources.

Plague out­breaks are not un­usual in Mada­gas­car. But this year, it has struck the cap­i­tal with un­usual force: in this sprawl­ing city there are 194 wards known to be in­fected with pneu­monic plague for the first time in their his­tory.

Con­trol­ling this ur­ban out­break is hard enough — but the sen­si­tiv­i­ties about what to do with the corpses makes it even more dif­fi­cult.

“The prob­lem you have now among com­mu­ni­ties in Mada­gas­car is that most fam­i­lies don’t want to give back the body. The po­lice come to take the body. This is ter­ri­ble. It is re­ally ter­ri­ble,” says Char­lotte Ndi­aye, the WHO rep­re­sen­ta­tive in An­tana­narivo.

The WHO and the United Na­tions Chil­dren’s Fund (Unicef) have sup­plied the Mala­gasy gov­ern­ment with body bags that can be sealed to keep the dead safely con­tained.

Unicef is also pay­ing hy­giene of­fi­cials em­ployed in the re­gional gov­ern­ment’s wa­ter and hy­giene de­part­ments to help to dis­in­fect the dead.

“It’s an ex­tremely sen­si­tive ques­tion in Mada­gas­car be­cause it is a fun­da­men­tal part of Mada­gas­car cul­ture, so there is not yet any of­fi­cial cir­cu­lar with what to do,” says Jean-Benoît Man­hes, the deputy rep­re­sen­ta­tive of Unicef in Mada­gas­car.

The lack of an of­fi­cial plague burial sys­tem does not mean no method ex­ists. Bodies of the dead are tested and, if they are even sus­pected of be­ing pneu­monic plague vic­tims, a hy­giene of­fi­cer will come bear­ing chem­i­cals, such as a chlo­rine so­lu­tion, to kill off any bac­te­ria.

The body is then placed in a sealed body bag. But the grave in which it is buried is noth­ing like tra­di­tional fam­ily tombs.

“When some­one dies from plague the of­fice of hy­giene comes to your house or hos­pi­tal, takes the body and pre­pares the body in or­der to put the body in a com­mon grave,” says Ndi­aye. “For Mala­gasy tra­di­tion, it is some­thing very dif­fi­cult to ac­cept.”

It re­mains un­clear how long the bac­te­ria sur­vives in a corpse. Man­hes says that not enough stud­ies have been done to con­clude how long bac­te­ria stay alive in a ca­daver, but that a dance with the dead may be less con­ta­gious than a dance with the liv­ing.

“Dead peo­ple are less con­ta­gious be­cause they don’t move. But they are still con­ta­gious if you touch their flu­ids,” he says.

In the Mala­gasy Red Cross So­ci­ety, Izaka Rabe­son has been work­ing through­out the weeks to com­bat the plague. The Red Cross runs one of three hos­pi­tals in the cap­i­tal that has a ded­i­cated unit for plague vic­tims, he says.

What has struck him is that this dis­ease, so eas­ily treated with an­tibi­otics, has been al­lowed to vi­o­late the sanc­tity of a dig­ni­fied burial. Some fam­ily mem­bers, he says, have even gone as far as at­tempt­ing to steal the bodies back.

“What’s shame­ful about this epi­demic is that we can cure plague. And that’s what we are try­ing to do,” he says wearily, sit­ting in his of­fice in the city.

A dis­ease that haunts

While the world gasps at the hor­ror of a plague epi­demic on the is­land na­tion, life in An­tana­narivo car­ries on as nor­mal. There were a few weeks of dis­rup­tion when school hol­i­days were ex­tended, but now schools have re­opened. Health work­ers re­main vig­i­lant, but it is be­lieved that the epi­demic is slow­ing down.

The plague is not ob­vi­ous. There are no peo­ple wear­ing sur­gi­cal masks to pro­tect them­selves. The only place where th­ese can be seen is at the air­port, when ner­vous tourists — in­clud­ing one Amer­i­can spot­ted with a chee­tah-print de­sign — ar­rive wear­ing them.

Even be­hind closed doors, the dis­ease is kept in the shad­ows. The sick won’t speak for fear of a fosse com­mune (lit­er­ally trans­lated is a pau­per’s grave), and the cured won’t talk be­cause they are afraid their neigh­bours will treat them like out­casts. They are all haunted by a dis­ease that will con­demn them to an un­sanc­ti­fied burial.

But Man­hes said the re­spon­si­bil­ity should fall squarely on the min­istry of health to come up with a dig­ni­fied burial method. As yet, the gov­ern­ment knows the mag­ni­tude of the prob­lem and it is re­luc­tant to take con­trol, Man­hes says. Unicef has sub­mit­ted a po­ten­tial burial pro­to­col and is await­ing feed­back.

“No one re­ally wants to take re­spon­si­bil­ity [for is­su­ing a fi­nal reg­u­la­tion on buri­als]. We have com­mu­ni­cated with churches, with the health ser­vices, but it should be the min­istry of health after global con­sul­ta­tions with all ac­tors,” he says.

Ran­javelontsalana helped to save the life of the man in her com­mu­nity who be­came ill. He prays with her in her church and thanks her for her help in rais­ing aware­ness of how plague can be treated.

Even though the plague is cur­able if treated quickly, she says peo­ple have one fear: “They be­lieve they will die. They are es­pe­cially afraid of not be­ing buried in the same fam­ily vault. It is sa­cred for Mala­gasy to be buried in the same place.”

While the world gasps at the hor­ror of a plague epi­demic on the is­land na­tion, life in An­tana­narivo car­ries on as nor­mal

Out­break: Work­ers (left) clean and dis­in­fect tents at a plague triage and treat­ment cen­tre. Some Mala­gasy are tak­ing steps (right) to pre­vent in­fec­tion as the pneu­monic plague spreads rapidly in ur­ban ar­eas across Mada­gas­car. Pho­tos: Ri­ja­solo/AFP and Hen­it­soa Rafalia/Anadolu Agency

Con­ta­gion: Over the past few months 143 peo­ple have died from pneu­monic plague and more than 1 900 sus­pected cases have been reg­is­tered in Mada­gas­car. Photo: Hen­it­soa Rafalia/Anadolu Agency

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