Open Access
Research Article
Historical and Modern Responses to
Plague Epidemics: What Lessons Can Be
Drawn from Case Studies in France, the
United States and Madagascar?
Hugo Carnell
University of Malta; hugo.carnell.20@um.edu.mt
Abstract
Despite its long history, plague has not been an internationally significant disease since the mid-twentieth
century, and it has attracted minimal modern critical attention. Strategies for treating plague are generally
outdated and of limited effectiveness. However, plague remains endemic to a few developing nations, most
prominently Madagascar. The outbreak of a major plague epidemic across several Madagascan urban areas in
2017 has sparked a wider discourse about the necessity of improving global preparedness for a potential future
plague pandemic. Beyond updating treatment modalities, a key aspect of improving preparedness for such a
pandemic involves a process of sophisticated review of historical public health responses to plague epidemics. As
part of this process, this article outlines and compares public health responses to three separate epidemics from
the early modern era onwards: Marseille in 1720–22, San Francisco in 1900–04 and Madagascar in 2017.
Based on this process, it identifies three key themes common to successful responses: (1) clear, effective and
minimally bureaucratic public health protocols; (2) an emphasis on combating plague denialism by gaining the
trust and cooperation of the affected population; and (3) the long-term suppression of plague through the
minimisation of contact between humans and infected small mammals.
Keywords: plague; epidemic control; historical public health perspectives; Marseille; San Francisco; Madagascar
Introduction
Plague is a disease which most lay observers would
associate with history, rather than modern public health.
Looming particularly large in any general understanding
are the estimated 75–200 million people that were killed
in Europe, Asia and North Africa during the Black Death
of the fourteenth century. However, plague outbreaks
occurred continuously across Europe until the end of the
seventeenth century, and the most recent plague pandemic was not brought under control until 1960 (Casey
et al., 2021: 5–6). The mass general improvement in
living standards and health services which has taken
place throughout the twentieth century has strongly
reduced both the prevalence of plague epidemics and
mortality rates after infection (Centers for Disease
Control and Prevention, 2020a). However, it is
estimated that several hundred plague cases, and a
small number of deaths, continue to occur worldwide
every year (Baraniuk, 2020).
Plague remains a diminished public health threat, but
one that is arguably re-emerging. The 2017 Madagascar
epidemic was the first mass outbreak of pneumonic
plague in an urban area in a century, and this has been
characterised as a paradigm shift which signals the reemergence of plague as a major global disease. If a future
outbreak spread from Madagascar into mainland subSaharan Africa, a plague epidemic could be catastrophic
in an overcrowded and unsanitary space, such as a
refugee camp. The development of new clinical
responses to plague has been largely neglected across
recent decades. Although plague is, for now, treatable
with antibiotics, antibiotic-resistant strains of plague
have begun to spread in Madagascar.
It is therefore necessary to identify public health
lessons learnt during past plague epidemics, as plague
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Journal of Humanitarian Affairs Volume 4, No. 2 (2022), 3–11 © The authors
http://dx.doi.org/10.7227/JHA.085
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Journal of Humanitarian Affairs (2022) 4/2
is increasingly likely to become a disease which the
humanitarian sector will consistently engage with in the
coming years. This research article conducts a comparative historical survey of public health responses to three
separate plague epidemics, spanning pre-bacteriological,
early bacteriological and modern eras of public health –
Marseille in 1720–22, San Francisco in 1900–04 and
Madagascar in 2017. Following this analysis is a more
general perspective on the status and possible epidemiological future of plague in 2022, attempting to draw
practical lessons for the humanitarian sector from the
case studies.
Plague: Clinical Profile, Treatment and
Epidemiological History
4
Plague is the result of infection by the Yersinia pestis
bacterium, which occurs in a variety of small mammals.
Although transmission can take place through direct
contact between a human and an infected animal, plague
is normally transmitted from animals to humans when a
parasitic rat flea feeds on its host and then bites a human
(World Health Organization, 2017).
Once infection has taken place, the bacteria colonise
the closest lymph gland, leading to the two key
symptoms: painful round gland swellings known as
buboes and dark-coloured bruises on the skin caused by
internal haemorrhaging (Centers for Disease Control
and Prevention, 2020b). Bubonic plague is fatal when
untreated in about 50–70 per cent of cases, but this rate
drops to 10–15 per cent with treatment (Bandolier, n.d.).
If the bacteria enter the bloodstream, bubonic plague can
progress to septicaemic plague, which systematically
infects the body and is virtually 100 per cent fatal if
untreated (Center for Health Security, 2013).
Alternatively, if the bacteria enter the lungs, bubonic
plague can progress to the highly infectious pneumonic
plague. This condition is characterised by major respiratory shock, aggressive pneumonia and the coughing of
blood. Pneumonic plague can be transmitted human-tohuman through the coughing and subsequent inhalation
of infected droplets. Pneumonic plague is virtually 100
per cent fatal unless treated within twenty-four hours
(Center for Health Security, 2013).
Treatment for all forms of plague is given through a
fourteen-day IV course of antibiotics, usually one or
more of a tetracycline, a fluoroquinolone and an
aminoglycoside (Center for Health Security, 2013).
This is supplemented with general supportive care such
as analgesics.
On a historical level, plague is one of the oldest
diseases known to humanity. DNA evidence indicates
that it has infected humans in Eurasia from as early as
3000 BCE (Rascovan, 2019: 295–6). The Book of Samuel
in the Bible describes a plague epidemic among the
Philistines around 1320 BCE (Khan, 2004: 271).
In terms of plague’s wider spread, it is conventional to
identify three separate historical plague pandemics. The
First Plague Pandemic originated in sub-Saharan Africa
in the sixth century AD, spreading to Europe by 541 and
continuing to ravage the Mediterranean Basin until
around 750 (Keller et al., 2019: 12363–4).
This was followed by the Second Plague Pandemic,
which arrived in Europe from East Asia in the fourteenth
century. Although this pandemic is associated most
strongly with the Black Death of 1347–50, outbreaks of
plague continued to periodically devastate more limited
regions of Europe into the nineteenth century (Spyrou
et al., 2019: 2). Although it is conventionally held that
this strain died out by the nineteenth century, recent
scholarship has argued that modern reservoirs of plague
in East Africa are its direct descendants (Green, 2018:
67–8).
The Third Plague Pandemic began to spread out of
China in the late nineteenth century and was not
suppressed until 1960, spreading to all inhabited continents via ocean-going trade and killing more than
twelve million people in India and China alone (Xu
et al., 2019: 11833–4). Modern strains of plague are
conventionally identified as the descendants of this
pandemic (Earn et al., 2020: 27703).
Building a Comparative Historical
Survey: Pre-bacteriological vs Early
Bacteriological vs Modern Responses to
Plague Epidemics
Public health responses to the broad history of plague
epidemics over time can be effectively assessed through a
process of comparative historical analysis, which has
three core features: ‘concern with causal analysis, the
exploration of temporal processes, and the use of
systematic and contextualized comparison typically
limited to a small number of cases’ (Mahoney and
Rueschemeyer, 2003: 14). Comparative analysis is a
relatively new public health research framework, but
Worboys (1994) identifies it as particularly valuable
because it allows the tracing of common themes, like
diseases and treatment strategies, and their gradual
evolution, across often radically different contexts (89–
90). It has become a mainstream research framework
over the past few decades, incorporating sophisticated
book-length critical studies like the work of McKay
(2017) on the concept of ‘Patient Zero’ in an epidemic.
The onset of the COVID-19 pandemic has cemented
the popularity of comparative analysis. Work like
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(1) Pre-bacteriological epidemics, taking place before the
isolation of the Y. pestis bacterium in 1894 enabled
major advances in clinical understanding and
treatment of plague, marked by an embryonic
and generally ad hoc understanding of medicine
and public health.
(2) Early bacteriological epidemics, taking place
between 1894 and the end of the Third Plague
Pandemic in 1960, marked by a demonstrated and
rapidly developing clinical understanding of plague
but where treatment methods and wider public
health strategies remained relatively experimental.
(3) Modern epidemics, taking place since 1960, where
plague is treatable in a comparatively straightforward and scientifically nuanced way, marked by
public health strategies incorporating sophisticated
international coordination and awareness of plague’s relatively limited prevalence in the modern
world.
By choosing one epidemic from each category, public
health strategies could be traced chronologically, examining how changes in clinical understanding have had
flow-on effects on the development of public health
practice. To enable fair and accurate comparisons
between the three case studies, it was critical that each
epidemic was both well documented contemporaneously
and backed up by a large amount of recent academic
work. Although the three cases are similar, they are not
ideally aligned: the first two case studies are drawn from
large Western seaports, located in countries with a high
degree of contemporary power and authority and public
health systems that were among the best available in their
time. However, plague no longer significantly affects
such areas, and it was therefore necessary to draw the
third case study from one of the relatively poor and
marginal countries where plague remains endemic.
In terms of the first category, it was decided that the
case study had to have taken place since 1700 to ensure
that public health responses took place in the context of
an awareness of the potential role that structured,
professional, centralised public health interventions
could play in combating epidemics. Considering these
factors, the first case study chosen is the 1720–22
Marseille epidemic, as this is particularly well documented, continues to be the subject of in-depth critical study
and debate, and demonstrates an explicit transition
towards the development of public health as a centralised, state-led bureaucratic enterprise.
The second case study is the 1900–04 San Francisco
epidemic, as this is well documented, displays concerted
but flawed attempts to incorporate contemporary medical innovations into public health practice, raises questions about the intersection of questions of race, class and
power with public health interventions, and displays the
efficacy of development-based solutions to plague.
The final case study is the 2017 Madagascar epidemic,
as this is the most recent major plague epidemic on
record, displays mass transmission of pneumonic plague
in an urban area, was treated with a full range of modern
public health strategies, and has been flagged as a
watershed moment potentially representing a wider reemergence of plague.
Historical and Modern Responses to Plague Epidemics
Mooney’s (2020) contextualisation of contact-tracing
has enabled current attempts to map the transmission of
infectious disease to be assessed within a timeline of
similar practices stretching back to the nineteenth
century (1806–08). The innovation of forums like the
University of Oxford’s ‘How Epidemics End’ project,
drawing together specialists from across the natural,
social and formal sciences, has laid the ground for a new
era of complex interdisciplinary study of public health
centred on comparative analysis (Charters and Heitman,
2021: 211–13).
With an awareness of this broader academic context,
selecting a few case studies from thousands of years of
plague epidemics was a complex process. Existing
comparative analyses of plague, such as Bigon’s (2016)
work on early twentieth-century West African
epidemics, have tended towards a more limited
chronological and geographical scope (218–19). The
intention for this study, however, is to conduct a more
broadly ambitious ‘big picture’ analysis of plague: this
analysis aims to demonstrate what responses to plague
epidemics have looked like in the past, how they have
changed in the face of major scientific advances, and
what they look like in the present day, through this
process obtaining generalisable public health lessons
relevant to combating future epidemics. The decision
was made to structure the research by basing case
selection on a tripartite chronological division, using
the following categories of plague epidemics:
Case Study 1: Marseille, 1720
The so-called ‘Great Plague of Marseille’ which lasted
from 1720–22 was one of the very last major outbreaks of
the Second Plague Pandemic. Plague had been a regular
visitor to Marseille in the preceding centuries: eleven
epidemics had been noted in the region in the years since
1560 (Devaux, 2013: 172). However, no epidemic had
occurred since 1650 (Barbieri and Drancourt, 2018: 7).
This has been traced to the creation of successful public
quarantine facilities: Marseille had constructed its first
permanent lazaret, or quarantine station, in 1557, which
allowed disembarking passengers and cargo to be
systemically quarantined. Between 1663 and 1683, the
‘new lazaret’ was constructed: a separate compound with
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6
eighteen large sheds and its own port, managed by a
dedicated staff (Devaux, 2013: 172). By 1720, Marseille’s
quarantine system had developed into a sophisticated
‘tri-polar’ system, where health officials chosen from
among the city’s merchants worked from a dedicated
headquarters, assessing ships for visible signs of disease
before transporting cargo and passengers by rowboat to
the lazaret. The Marseille lazaret was generally
recognised as one of the strictest in Europe, as the
cargo of ships suspected of carrying plague could be
quarantined for up to sixty days (Signoli and Tzortzis,
2018: 219).
The traditional narrative surrounding the eventual
arrival of the plague in 1720 links it directly to ‘the greed
of ship owners’ (Devaux, 2013: 172–3). A ship had
arrived from Cyprus on 25 May 1720. Seven of its sailors
had died suspiciously during the voyage and warning
had been given in advance of its arrival. In accordance
with Marseille’s regulations, the ship should have been
isolated and burned. However, the ship’s owner, a deputy
mayor of Marseille, put pressure on health officials to put
the ship and its cargo of cloth through ordinary
quarantine. On 20 June, the first plague case in the city
was noted (Devaux, 2013: 174–5). Despite the
dominance of this narrative, recent scholarship has
sought to bring it into question. Varlik (2020) argues
that there is no conclusive evidence linking the ship to
the epidemic and the story has more to do with
Orientalist ideas of a ‘sickly Orient’ than any kind of
objective analysis (288–9). This is supported by a recent
reconstruction of the pathogen genome, which has
tentatively linked the strain of plague in Marseille to
older strains which had been circulating in Europe for
several hundred years – raising the question of whether,
in fact, the epidemic arose from an existing European
plague reservoir rather than being carried to Marseille
from the East (Bos et al., 2016: 5–7).
Regardless of its origins, plague took root in Marseille
and spread into Provence by the end of July (Devaux,
2013: 175–8). The French Crown moved swiftly to deal
with the epidemic, in what has been characterised as an
early example of centralised state-led disaster
management. Crisis management was put under the
control of a dedicated Committee of Health led by a
senior army general, which put Marseille under martial
law. Both commerce and travel in and out of the region
were suspended, enforced by a military cordon which
eventually involved up to a quarter of France’s standing
army. The emphasis on movement control included the
construction of a 27-kilometre-long wall blocking off key
transportation routes. The Committee distributed food
and basic supplies, trapped dogs and cats, burned
infected property, buried the dead in mass graves and
conducted regular disinfections of the city with vinegar.
In keeping with contemporary understandings of
disease, cannon shots were used to dispel the ‘miasma’
of infected air thought to lie over the city, and
purificatory religious processions were also organised
(Ermus, 2015: 2–3). Order was imposed through strict
discipline and summary justice: looters of abandoned
homes were punished with death (Devaux, 2013: 177).
Despite these measures, the plague spread rapidly
through Provence, devastating the neighbouring communities of Martigues and Toulon by late 1720 (Devaux,
2013: 178–9). Plague deaths in Marseille eventually peaked
at more than a thousand people per day in September
1720, but this dropped rapidly to around fifty per day by
November. After the almost total suppression of the
disease by the end of 1721, virtually all restrictions were
lifted on Marseille (Signoli and Tzortzis, 2018: 219, 224).
However, a smaller outbreak which started in May 1722
forced the re-imposition of the commercial blockade,
before the epidemic was finally suppressed in December
1722 (Devaux, 2013: 179–80). The plague killed around
120,000 people across 242 affected communities, more
than 30 per cent of the communities’ total population
(Signoli and Tzortzis, 2018: 226).
Case Study 2: San Francisco, 1900–04
Almost two centuries on from the Marseille epidemic,
clinical understanding of plague had progressed significantly. The Y. pestis bacterium was isolated in 1894 by
the Swiss bacteriologist Alexandre Yersin, who proved
that the same bacteria were present in both rats and
plague-infected humans, definitively linking Y. pestis
infection with plague symptoms (Butler, 2014: 202–3).
Based on this knowledge, the Russian-French
bacteriologist Waldemar Haffkine created the first
widely effective plague vaccine in 1897, developing a
heat-killed culture of plague bacteria which was
distributed to several hundred thousand people during
an Indian epidemic (Butler, 2014: 207).
When plague arrived in San Francisco in 1900, in one
of the first epidemics of the Third Plague Pandemic to
spread beyond Asia, responses to plague epidemics based
on a sound clinical understanding were available – as had
not been the case in Marseille (Tansey, 2019: 454–5).
Plague initially arrived on a trading ship from Hawaii in
late 1899, swiftly gaining traction in San Francisco’s
crowded, impoverished Chinatown district. The first
human victim died on 6 March 1900 and was autopsied
by an official city bacteriologist who confirmed the likely
presence of plague (Kinyoun and Wyman, 2006: 16). The
City Board of Health took immediate action, cordoning
Chinatown on 7 March 1900 (Risse, 1995: 1). However,
this was immediately attacked by San Francisco business
interests, who saw restrictive public health measures as a
major threat to commerce (Kalisch, 1972: 116–18). They
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public health strategies for dealing with plague had been
defined and implemented (Stimson, 1939: 122–3). By
1909, in San Francisco, 11,000 houses had been
disinfected and hundreds of thousands of square feet of
concrete footpaths and flooring had been installed
(Stobbe, 2014: 43).
Case Study 3: Madagascar, 2017
Over the next century, the clinical understanding of, and
responses to, plague continued to improve. The Second
Indian Plague Commission proved definitively in 1907
that plague was spread from rats to humans via the
parasitic fleas inhabiting rats (Evans, 2018: 34). The last
major plague epidemic in Europe or North America was
in 1924, in Los Angeles (Viseltear, 1974: 40–1). After the
discovery of effective therapeutic antibiotics in the 1930s
and 1940s, plague became directly treatable and death rates
plummeted (Anisimov and Amoako, 2006: 1465–6).
When the World Health Organization (WHO) announced
the end of the Third Plague Pandemic in 1960, plague was
largely confined to remote areas of Asia, South America
and sub-Saharan Africa, with around 75 per cent of
contemporary plague cases reported to the WHO from
Madagascar (Randremanana et al., 2019: 537).
Despite plague’s endemic quality in Madagascar, the
2017 epidemic took health authorities by surprise. The
normal plague season in Madagascar is from September
to April, but the index case was discovered in August
2017, when an infected highland inhabitant travelled to
the capital of Antananarivo, spreading the disease, before
dying in a crowded taxi on the way to the coastal city of
Toamasina – a place which had no previous history of
plague (Mazumdar, 2017). The epidemic was eventually
confirmed as highly infectious pneumonic plague on 11
September 2017, marking the first major urban outbreak
of pneumonic plague in around a century (Rabaan, 2019:
296). By 14 September 2017, five deaths had been
reported (World Health Organization – Regional
Office for Africa, 2017: 2).
Faced with the prospect of a severe epidemic, the
national Ministry of Public Health launched an immediate response centred around a full range of modern
public health interventions. These included immediate
notification of the WHO, field investigations and
surveillance, contact tracing, distribution of health
information, and spraying of the houses of confirmed
cases with pesticides (WHO – Regional Office for Africa,
2017: 2). However, Madagascar is faced with significant
wider health challenges: it is the fourth most
undernourished country in the world, struggles with
major endemic diseases such as cholera, and more than
40 per cent of the population lives in areas distant from
health centres (Barmania, 2015: 729–30). Additionally,
plague is highly stigmatised in Madagascar due to its
Historical and Modern Responses to Plague Epidemics
were joined in this by many Chinese, who were wary of
the discriminatory treatment they faced from public
officials. White people could leave the Chinatown
cordon, while Chinese were forced to stay (Risse, 2012:
12). Many Chinese were also mindful of a recent public
health intervention in Hawaii, where the burning of
plague-affected houses had led to a major fire in
Honolulu’s Chinatown (Echenberg, 2002: 444). Faced
with overwhelming opposition, the cordon was lifted
after less than 60 hours (Kalisch, 1972: 118).
After plague was formally identified on 11 March
1900, the cordon was not immediately reimposed, but
house-to-house searches were conducted to identify
plague victims (Kalisch, 1972: 119). Chinatown
community leaders were largely uncooperative, and the
bodies of plague victims were regularly hidden to avoid
religiously prohibited autopsies (Echenberg, 2010: 230).
After four new cases of plague were confirmed by 16 May
1900, the federal Surgeon-General ordered the city’s chief
federal quarantine officer to implement comprehensive
public health measures. These included cordoning of the
area, house-to-house inoculations with Haffkine’s vaccine,
the quarantining of suspected cases, comprehensive
disinfection, and the destruction of rats (Kinyoun and
Wyman, 2006: 19).
However, the backlash continued. Reintroduction of
the cordon on Chinatown led to riots (Risse, 2012: 134).
Haffkine’s vaccine was painful and often led to severe
side effects (Risse, 2012: 123–4). The State Governor
blocked most federal public health initiatives, railed
against ‘plague fakers’, and suggested that plague cases
were the result of importing plague samples into dead
bodies (Kalisch, 1972: 127).
Amid the impotence of public health measures, the
epidemic continued to claim lives, with more than
twenty-five deaths by February 1901 (Kalisch, 1972:
127). Faced with a mounting crisis amid an increasingly
visible national lack of confidence in Californian
authorities, the state government was forced to allow
federal intervention under the direct control of the
Surgeon General (Kazanjian, 2012: 1376–7). Under the
leadership of a new local federal quarantine officer, a
public health campaign was launched based on
improving wider sanitation patterns in Chinatown.
Rats were trapped, rubbish was removed, houses and
rat burrows were disinfected, footpaths and flooring
were concreted to minimise contact between rats and
humans, and positive relations between health
authorities and Chinatown inhabitants were prioritised
(Blue, 1909: 8; Risse, 2012: 170). The epidemic was
eventually suppressed by 1904, after 121 deaths
(Kazanjian, 2012: 1377). Although plague would return
to California several times over the next two decades,
notably following a major earthquake in 1906, the basic
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perceived association with poor hygiene, which
hampered contact tracing of the index cases (Alderson
et al., 2020: 428–9). Faced with these barriers, the
Malagasy Government developed a coordinated
humanitarian response in partnership with the WHO,
the United Nations Children’s Fund (UNICEF), the
International Federation of Red Cross and Red Crescent
Societies (IFRC) and major humanitarian nongovernmental organisations, including Médecins du
Monde and Médecins Sans Frontières (Chereau, 2018).
Plague continued to spread widely into early October,
and by 3 October 2017 thirty deaths had been recorded
(European Centre for Disease Prevention and Control,
2017: 1). The WHO airlifted more than a million
antibiotic doses into Madagascar, and the government
launched severe emergency restrictions. These included
a ban on public gatherings, the closing of schools and
universities, the establishment of a toll-free case-reporting
number, and a crackdown on ‘fake news’ spread via social
media (BBC, 2017). The government also suppressed
traditional Malagasy famadihana burial practices. These
involve exhuming the corpse of the dead, rewrapping them
in fresh cloth, and dancing with the body around the
family crypt, a practice which has been linked to the
transmission of pneumonic plague (Sodikoff, 2019: 48).
Many bodies of plague victims were buried in sealed body
bags in mass graves, a practice which scandalised many
Malagasy and led to incidences of plague denialism and
attempted body theft (France 24, 2017).
In the face of these measures, new cases declined over
the course of October, with the last new case recorded on
28 October 2017. By mid-November, having killed 209
people in total, the epidemic was under control. Basic
control measures continued until the end of the plague
season in April 2018 (World Health Organization, 2020).
Discussion of the Situation Today: Why
Is Plague a Threat in 2022?
8
Having assessed more than two hundred years of plague
epidemics, witnessing the gradual development of a
scientific consensus around plague, the end of global
plague pandemics, the retreat of epidemics to a few
endemic areas, and the development of consistently
effective public health interventions and treatment
methods, it must be asked: why consider plague a major
public health threat in 2022, given that other diseases kill
many more people and plague epidemics seem to be
straightforwardly brought under control?
First, plague’s relatively recent confinement to a few
isolated areas may ultimately prove to be an intermission
rather than a full retreat. It has been recently argued,
based on the way the 2017 Madagascar epidemic saw
urban person-to-person transmission of pneumonic
plague for the first time in a century, plague should be
identified as a re-emerging disease (Vallès, 2020: 14). If
plague spread into a location defined by poor sanitation
and mass flows of people, such as a refugee camp, its
impact would be devastating. Fortunately, plague has not
yet widely affected modern refugees, with the only wellreported and significant outbreaks occurring among
South Vietnamese refugees during the Vietnam War
(Whitehall, 2009: 671). Given, however, that both
population density and the numbers of people affected
by absolute poverty have been increasing in plague’s
African heartland, it is perhaps simply a matter of luck
that no recent plague epidemics have coincided with a
significant war, famine or natural disaster (Baril et al.,
2019: 1). If plague is genuinely re-asserting itself, and
there is a real chance that a major refugee population
could be infected, then it is a disease that the
humanitarian sector needs to take wider note of.
Plague has not been studied closely in recent decades.
What studies exist have primarily focused on assessing
plague’s status as a potential bioterrorist threat rather
than as an endemic public health problem, and major
flaws exist in existing clinical responses to plague (Vallès,
2020: 13). Pneumonic plague is difficult to diagnose with
existing rapid diagnostic tests (Mead, 2018: 106–7).
Existing antibiotic treatments often have a poor safety,
cost and availability profile, and existing plague vaccines
are not extensively used because of their dangerous side
effects (Baril et al., 2019: 2–3). Most seriously, strains of
plague with high-level resistance to all first-line
antibiotics have been clinically noted in Madagascar
since 1995 (Galimand et al., 2006: 3234–6).
Beyond treatment, we lack a context-specific ecoepidemiological understanding of how plague circulates
in the environment between successive outbreaks. Why,
for instance, does Y. pestis occur in a variety of small
mammals in Peru, but only in rats in Madagascar (Vallès,
2020: 13)? We are unlikely to be able to understand this
process or develop strategies to mitigate it without
developing our knowledge of the relevant ecoepidemiology.
What Lessons Can Be Drawn from the
Case Studies?
Considering all these factors, the prospect of having to
address a widespread plague epidemic is growing in its
likelihood every year. In preparing to confront it, the
humanitarian sector is armed with treatment strategies
of limited effectiveness and a public health understanding of plague that has not changed substantively over the
last century. Significant research can and must be done
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1. To respond to a plague epidemic, public health authorities
must have centralised, independently effective and
minimally bureaucratic response protocols.
Marseille had a well-established and generally very
effective quarantine service, but the fact that it was
operated by merchants with vested commercial interests
working in their spare time meant that there was clear
scope for the selective non-enforcement of public health
regulations. A central theme of the Marseille epidemic is
the developing realisation that crisis management was the
appropriate domain of centralised state authorities able to
deploy sophisticated bureaucratic systems. However, it
should be noted that lack of clarity within bureaucratic
systems has the potential to sap the effectiveness of such
systems. San Francisco saw its plague epidemic grow out of
control largely because existing federal and state chains of
command had very disconnected priorities. The organised
public health responses became lost in denialism, racist
stereotyping, greed, and bureaucratic wrangling.
Clear and unambiguous public health hierarchies
must, consequently, be put in place and comprehensively
tested long before the outbreak of a plague epidemic. The
Madagascar public health response was certainly an
improvement on those of Marseille and San Francisco.
The epidemic was brought under control within a few
months through the joint intervention of the Ministry of
Public Health and international humanitarian organisations. However, Madagascar’s existing public health
services are not effective enough to respond to a plague
epidemic independently, and massive humanitarian
intervention at the point of an epidemic is not a
sustainable solution. Permanent, development-based
public health solutions to plague epidemics which
meaningfully engage with societal health agendas must
be sought, along the lines of those implemented in San
Francisco. These must develop the ability of individual
public health authorities to act independently in an
epidemic, ideally reducing international humanitarian
organisations to a limited support role.
2. However comprehensive any public health intervention may be, the most important factor in
controlling a plague epidemic is overcoming fear
and denialism by gaining the trust and cooperation
of the affected population.
Over the course of its long history, plague has been
consistently defined by high mortality, rapid spread and
association with poverty. Dangerously, affected
populations may prioritise avoiding the stigma of plague
over responding to it. If plague conflicts with core
cultural values, as with Chinese burial rituals in San
Francisco or famadihana in Madagascar, a population
with limited public health knowledge may dismiss the
plague as ‘mythical’ or ‘perhaps elsewhere, but not here’.
Although a full discussion of the wider ‘humanitariandevelopment nexus’ is outside of this article’s scope, such
denialism can only be effectively addressed through wider
public health education programmes which go beyond
the boundaries of humanitarian health interventions and
become inclusive of broader development strategies.
As has been shown in Marseille, a general and absolute
suppression of civil liberties will, eventually, probably be
enough to suppress a plague epidemic. However, unless
public health authorities present a public health response
to plague as something done with the population, rather
than imposed on them, such responses will be inefficient
and disconnected from local needs and priorities in a
way likely to lead to lasting resentment of public health
interventions. In San Francisco, where the Chinatown
population was able to consistently assert its independence, public health authorities were forced to move
from a narrow approach focused on direct interventions
to a much wider programme of inclusive civic development. If mutually trustful and cooperative interactions
between health authorities and the community are
established before an epidemic’s outbreak, humanitarian
interventions will become much easier. If a plagueaffected community’s first major contact with public
health authorities is during a humanitarian intervention,
humanitarian actors will be forced to build wider
relationships with a potentially mistrustful community
while simultaneously trying to control the epidemic.
Historical and Modern Responses to Plague Epidemics
in this area. However, in the interim, what relevant and
applicable public health lessons for the humanitarian
sector can be drawn from previous responses to plague
epidemics? Three main lessons can be identified.
3. Despite the end of a visible epidemic, plague can
potentially re-emerge wherever there is a stable and
infected population of small mammals.
Plague has the potential to cause an epidemic in any
environment where infected small mammals regularly
encounter humans. Plague’s epidemiological history is
defined, as one writer has pointed out, by ‘its capacity to
move from one region, context, or scenario to another, or
even the emergence or re-emergence in previously free
areas or where human plague has not been observed for
decades’ (Vallès, 2020: 14). Plague bacteria are likely to
survive in some form beyond the end of an epidemic, and
they can swiftly re-emerge following new patterns of
human-animal contact. As we have seen in Marseille, the
plague may have been waiting, forgotten, in domestic
ecological reservoirs for hundreds of years before its
ultimate re-emergence due to unknown factors in 1720.
Consequently, if plague is only combated through direct
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Journal of Humanitarian Affairs (2022) 4/2
public health interventions at the time of an epidemic,
such epidemics will remain endemic. Wider public health
strategies must, in Madagascar and other endemic areas,
move beyond simple patterns of treatment and
population control. They must follow the example of
San Francisco, emphasising the minimisation of humananimal contact through the widespread improvement of
standards of living and sanitation.
Conclusion
Fundamentally, despite its long history and recent diminishment, plague is not nearly as much of a disease of the
past as many observers would like to believe. Recent signs
that it may be reasserting itself may be unwelcome, but
they must not be ignored. Given the re-emergence of
pneumonic plague in Madagascar, and the serious limitations of existing clinical knowledge and public health
strategies, the world may yet see the arrival of a Fourth
Plague Pandemic. Widespread outbreaks in humanitarian
contexts could be devastating, especially if plague becomes
endemic in refugee populations. To forestall this, it is
critical for the humanitarian sector to critically assess the
public health lessons learnt from past epidemics. If there is
a single core lesson from the case studies analysed here, it is
that widely focused public health outreach must start
before the outbreak of disease. Relevant humanitarian
actors must begin to engage in effective and consistent
dialogue with external actors, most prominently their
counterparts in the development sector.
Acknowledgements
I am grateful to Dr Valeska Padovese for sharing her
wide experience, introducing me to public health as a
substantive discipline and guiding me through the
publication process. Additionally, I would like to thank
Haiko Magtrayo and Dr Stephane du Mortier of the
International Committee of the Red Cross, Dr Guy
Thomas of Memoriav and Stephen Duggan, for their
assistance and suggestions at the editing stage.
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