Medical technology’s impact is predicated on accessibility: even the most effective of treatments are rendered pointless when out of reach. Formidable diseases that may have been deadly a few short centuries ago are often now easily treatable with simple prescription medications or even completely avoidable with routine vaccinations. However, as close as we might otherwise be to achieving the eradication of numerous deadly pathogens of the past, we are not at all close to ending poverty, a major obstacle to medical access and predictor of disease-related risks [1]. The frightening role of poverty as a tourniquet restricting the flow of vital resources to vulnerable populations has paradigmatically come to a head in Madagascar, where a deadly reincarnation of medieval monster Yersinia pestis currently looms.

Although many consider the plague to be an anachronism, it still resurfaces seasonally in Madagascar, the Democratic Republic of the Congo, and Peru [2]. This year’s outbreak in Madagascar has become remarkably deadly, with roughly 194 cases and 33 deaths recorded as of October 7th [3]. Most of these cases have taken the form of pneumonic plague, especially dangerous in its easy transmission and characteristic pathology of rapid, fatal decline [3]. The pneumonic plague can also arise from the bubonic form, likely covered in your elementary history class. This form is characterized by the presence of enlarged lymph nodes, or buboes, and can spread to the lungs undetected. All types of the plague can be cured easily with antibiotics like Gentamycin but for most patients, the primary barrier to recovery boils down to timely access to medical care [4].

Preventable disease is especially pernicious in its ability to simultaneously claim countless lives and minimal attention.

Weathering the effects of political crises following controversial changes of government, extreme weather, and a global increase in food prices, over 92 percent of Madagascar’s population lives off of under two dollars each day [5]. According to an NIH study, “the maps of those living on less than two dollars a day and the epidemiology of HIV/AIDS, malaria, tuberculosis (TB), and many other infectious diseases coincide nearly exactly” [1]. Although significantly more treatable than many other infectious diseases, the plague’s ability to induce sudden decline makes it extremely deadly, especially when prolonged by hesitation in seeking treatment on account of “denial,” “stigma,” and “economic disincentives,” which are shockingly common  in some parts of Madagascar [3].

Complete plague prevention, while ideal, presents its own challenges. No standard vaccination currently exists; while some have been developed and used, their efficacy against pneumonic infection is unproven [6]. The approach of targeting rat populations, incubators for Y. pestis’ primary vector, the flea, is productive in theory but difficult to carry to completion due to rats’ ubiquity and persistence. Dr. Daniel Bausch, director of the UK Public Health Rapid Support Team, points out that “even much richer cities with more resources” could not achieve such a feat and that, while tempering rat populations may be achievable to an extent, the elimination of rats creates a higher demand for humans as alternative hosts, actually increasing disease transmission [7]. Bausch also notes that ensuring hygienic conditions to limit interactions with rodents is another strategy potentially not feasible for those in poverty, since “things like storing your food out of reach of rodents and not having any garbage around your house isn’t necessarily a given” [7].

Bausch also speculates that the apparent preponderance of similar outbreaks in recent history, such as those of Ebola, could stem from a variety of factors ranging from increased awareness of crises to global warming [7]. While “financially-strapped health systems” and the most impoverished groups within those systems remain among the most vulnerable to emerging outbreaks, they also have attracted minimal attention from health groups in the past [1]. Poverty, not qualified as “a disruption of normal physiologic function,” is a problem often cast outside the domain of both scientists and physicians, and resources allocated to tracing and diminishing its causes tend to be “sparse” or misguided [1]. Aid efforts must move toward an increased recognition of the multi-faceted nature of disease, drawing approaches from social as well as biological spheres.

Cycles of poverty-linked disease can unfold in a manner that “[reverberates] through generations” and, if not addressed, can continue to fester while organizations scramble to apply temporary bandages to emerging outbreaks [1]. Although long-term, foundational problems do not command attention of the same magnitude as more urgent ones given limited resources, partially on account of their perceived intractability, their resolution arguably is more important than that of sensationalized, temporally localized, and often corollary issues.

Preventable disease is especially pernicious in its ability to simultaneously claim countless lives and minimal attention. Millions of children die from preventable diseases each year, according to the WHO [8]. Why does society tend to be more accepting of death that occurs through lack of action than through direct action? While some may claim that issues like global poverty are impossible to remedy from afar, it is difficult to deny that even relatively small contributions to poverty-related efforts can have incredibly meaningful impacts. For example, the Against Malaria Foundation, often championed by advocates like philosopher Peter Singer, offers donors the option of preventing a case of malaria and thus potentially saving a life for $2.50, the cost of a mosquito net [9]. While countless other opportunities to save lives exist, we somehow continually justify their neglect through emphasis on the fact that we are not directly responsible for the problems the impoverished confront. Harm by omission or inaction can be considered morally equivalent to harm by action from a consequentialist viewpoint. However, omission allows for a false loophole in which responsibility to intervene in a situation is sidestepped by denying that indirect action– or, in this case, lack thereof– remains action. While society is often eager to rally funds in support of imposing, aggressive efforts like those of war and defense, chronic, deeply harmful and deeply ingrained issues including those stemming from poverty are continually allowed to suppurate without much recognition or remorse.

The WHO sent 1.2 million doses of antibiotics in response to Madagascar’s recent plague outbreak [10]. As they appeal for $5.5 million “to effectively respond to the outbreak and save lives,” the scope of their aid appears very clearly confined to containing this particular outbreak [10]. The question of how overall disease outbreaks will be decreased in the affected impoverished population, among others, remains.

In a sense, infection with Y. pestis is not only disease, but a symptom of far-reaching socioeconomic problems that continue to plague Madagascar. It is urgent that more long term solutions be formulated in order to prevent similar outbreaks in the coming years. Specifically, solutions must address social risk factors for disease as equally valid as biological ones. Increases in disease transmission serve as notably destructive byproducts of inequality and, wherever we allow such cycles to continue, we allow human rights to disintegrate.

 

References:

[1] Alsan, M. M., Westerhaus, M., Herce, M., Nakashima, K., & Farmer, P. E. (2011). Poverty, global health, and infectious disease: lessons from Haiti and Rwanda. Infectious Disease Clinics of North America, 25(3), 611–22, ix. http://doi.org/10.1016/j.idc.2011.05.004.

[2] Plague fact sheet. (2017). In World Health Organization Media Centre. Retrieved from http://www.who.int/mediacentre/factsheets/fs267/en/.

[3] Eltagouri, Marwa & Wootson, Cleve R. Jr. (2017, Oct. 7). Rats used to spread the black death. Now, poverty plays a role. The Washington Post. Retrieved from https://www.washingtonpost.com/news/to-your-health/wp/2017/10/05/black-death-outbreak-strikes-madagascar-killing-30-and-triggering-panic/?utm_term=.1f3d98dac53e.

[4] Plague: Resources for Clinicians. (2015). Centers for Disease Control and Prevention. Retrieved from  https://www.cdc.gov/plague/healthcare/clinicians.html.

[5] Madagascar: Measuring the Impact of the Political Crisis. (2013). The World Bank. Retrieved from http://www.worldbank.org/en/news/feature/2013/06/05/madagascar-measuring-the-impact-of-the-political-crisis.

[6] Plague Vaccine. (1982, June 11). Centers for Disease Control and Prevention MMWR, 31(22), 301-304. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/00041848.htm.

[7] Bichell, Rae Ellen. (2017, Oct. 12). Ask The Disease Specialist: Why Is It So Hard To Beat The Plague? National Public Radio. Retrieved from http://www.npr.org/sections/goatsandsoda/2017/10/12/557358712/ask-the-disease-specialist-why-is-it-so-hard-to-beat-the-plague.

[8] Child mortality. (2011). In World Health Organization PMNCH News and Media Centre. Retrieved from http://www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/.

[9] Against Malaria Foundation. (2017). Retrieved from https://www.againstmalaria.com/.

[10] WHO provides 1.2 million antibiotics to fight plague in Madagascar. (2017, Oct. 6). In World Health Organization Media Centre. Retrieved from http://www.who.int/mediacentre/news/releases/2017/antibiotics-plague-madagascar/en/.