"Medieval" Madagascar

"Medieval" Madagascar: Plague and Inequality 

The Current Outbreak of Plague isn't a Throwback, But a Sign of Modern World 

A guest post by Monica H. Green. 
Dr. Green is Professor of History at Arizona State University. 
Follow her on Twitter @monicaMedHist 

I see dead people. That’s my job. I’m a historian.

But in the past five years, I have seen many millions more dead people than I ever thought I would as a historian of medicine. In the past five years, I have had the experience of slowly realizing that the Black Death—the massive outbreak of plague that struck in the middle of the 14th century—likely affected many millions more people than we ever imagined in our wildest nightmares.

In most of the maps we see when we study this period of history, in most of the texts we read, we are usually taught to think of the Black Death as a pandemic that struck only the Mediterranean and Europe. We teach the Black Death through the stories of Boccaccio, telling us of social breakdown from the perspective of elite Florentines who could afford to escape the city, leaving others to their fate. We learn of the Black Death from manorial records in England, which show tenant after tenant having to pay the heriot, a kind of death tax, in order to inherit land from their deceased relatives. We cringe with horror listening to Ibn al-Wardi, writing from Aleppo, recount the terrifying progression of the plague across the Middle East and into North Africa.

But what we haven’t seen or heard, what we haven’t previously perceived, are the many millions of people beyond the Mediterranean who may have also been struck by the disease. Geneticists now talk of a “Big Bang” in plague’s history, a sudden branching out, an explosive expansion of the causative organism of plague, Yersinia pestis, sometime in the late 13th or early 14th century. This expansion of plague created four new branches in plague’s evolutionary tree. One “branch” went westward, reaching the Black Sea and then the Mediterranean. Two branches likely stayed fairly local in central Eurasia, and may have affected wild animal populations more than humans.

Minimum spanning phylogenetic tree of 133 Y. pestis genomes, with major historical events marked. From Y. Cui et al. 2013, fig. 1A, with additions by M. H. Green. Reproduced with permission.

But the fourth branch spread out just as widely as the first. Strains called by scientists 2.MED and 2.ANT can now be found across almost all of Eurasia, from Jilin Province in northeast China to Turkey and even Algeria, from Russia and Mongolia to Tibet and India. Perhaps as much as two-thirds of Eurasia, and maybe even major parts of Africa, were affected by this pandemic, which spawned continuing outbreaks for centuries.

How do we know this? Because strains of plague initially created in the 14th century still exist in the world today. The evolutionary history that I have just given has been made possible by the fact that this organism still persists on four of the five inhabited continents of the world. Plague outbreaks are not a routine experience for most of us today, but that is not because we ever “conquered” the disease. Plague has never been eradicated, and it won’t be. Rather, we have established an uneasy détente with the organism. We know where it lives, we know how it behaves. And we watch it. Closely.

And that’s why those of us who know plague are watching the situation currently unfolding in Madagascar with increasing alarm. The current toll of 1192 cases and 124 deaths already makes this one of the largest outbreaks in years. Equally alarming is the fact that, of the 22 administrative districts in Madagascar, 14—two-thirds—are reporting cases. This is a plague outbreak out of control.

Why is Madagascar suffering from this “medieval” disease? Because it’s part of the modern world. I live in “medieval” Arizona, a state—like most of the American West—where plague has also insinuated its way into the wild rodent population. Plague arrived in Madagascar and the American Pacific coast about the same time, around 1900, and for the same reason: it was being transported all over the world in the holds of steamships coming out of Hong Kong’s harbor. In both Madagascar and America, it spread inland, finding new hosts and taking up permanent residence.

Plague has changed very little in the past 700 years. It hasn’t had to. We control plague nowadays by using insecticides to get rid of the fleas that transmit the disease from host to host and by controlling rodent infestations. But plague never went away. Only our daily awareness of it did.

What is happening in Madagascar shouldn’t be happening. We know how to monitor this terrifying disease and we know how to control it. We know that a standard arsenal of antibiotics can halt an infection, if it is given very quickly after exposure. We also know that, if not controlled, plague has one of the highest mortality rates of any disease in history.

What we have not yet learned is a lesson the microbial world has been trying to teach us since the 14th century: we’re all connected. Madagascar is suffering now not because it is trapped in its medieval past. Madagascar was indeed connected to a larger world in the Middle Ages, but we have no evidence that plague reached it then. Rather, Madagascar is suffering from plague now because of its connections to the modern global economy. The mining, the textile production, even the very vanilla we use everyday has made Madagascar part of this global economy.

I see dead people in the past. And I cannot save them except by recovering their stories. The people of present-day Madagascar, however, are not beyond our reach. Or beyond our responsibility. We are all connected.

Who Knows Anything? - Journalism, Caesarean Section, and the Production of Knowledge

The New York Times ran a story about an amazing c-section survival in 1337. But historians of medieval medicine don't think it happened. 

By Monica H. Green

On Wednesday, 23 November 2016—the day before the Thanksgiving holiday in the U.S.—the New York Times ran what it likely assumed to be a “fun fact” story, a minor historical discovery on a slow news day. Under the category, “What in the World” and headlined “A Breakthrough in C-Section History: Beatrice of Bourbon’s Survival in 1337,” the Times piece recounted how Czech researchers had found “an apparent case” of a Caesarean section performed on the recently married, 19-year-old medieval queen of Bohemia.

The piece would likely have quickly become ephemera had it not been picked up by Twitter. There, the case of Beatrice reached the attention of historians specializing in medieval women’s history and medieval medical history. It immediately provoked skepticism.

In our heightened debates about “Fake News,” we should give more thought to how “knowledge” (“unfake news”) is produced and disseminated. In this case, the curtain that needs to be pulled back is the process of peer review.

To the historian of medicine, the study bears all the pitfalls of amateurish oversight. It takes no account of the past thirty years of scholarly literature in either the history of medieval obstetrics (or women’s history more broadly), nor the history of medieval surgery or anesthesia. Peer review by historians of medieval medicine would have quickly identified these problems. It seems, however, that the piece was only refereed by physicians.

What is peer review?

Peer review involves works being sent out, before publication, to other scholars who work on similar questions to the item under review. They assess the piece in terms of its coverage of the existing literature in a field, the originality of its question, and the rigor of its methods. Based on those criteria, publication (or not) is recommended.

But who are “peers”? In the case of medical history, that is a major issue. Are peers physicians who have been trained in modern medicine, who have treated living patients, excised real tumors, autopsied fresh cadavers? Or are they historians who have been trained in the languages, cultures, archives, and traditions of the past? Researchers who have both MDs and PhDs exist, but are rare. The authors of the Czech C-section study self-identify as a physician, a member of the philosophy faculty, and a historian, all at the Charles University in Prague: an impressive interdisciplinary team. The reviewing process should have involved scholars with a similar range of competence.

The argument of the study hangs on the slimmest thread of evidence, the meaning of the Latin word incolumitate in two versions of a letter sent out under the queen’s name after the birth. Incolumis, according to the Latin dictionary commonly known by its authors’ names, Lewis and Short, means simply “unimpaired, uninjured, in good condition, still alive, safe, sound, entire, whole.” Its medieval usage is comparable. Yet from that single word, and from other accounts written a century or more after the said birth (leaving plenty of time for a private event to have mushroomed into legend), the authors deduce that the queen must have undergone a C-section. Since she clearly survived, the “operation” must have been successful.

There are legitimate grounds to debate the linguistic weight of the word incolumitate, and legitimate grounds to debate the political context in which this still uncrowned queen had to assert her right to the consort’s throne. There are also medical grounds to question the interpretation. Could not incolumitas here mean, for example, that Beatrice, still a teenager, had survived the birth without the crippling damage that obstetric fistula is known to visit upon girls being forced to bear children too young? Unfortunately, neither this scenario, nor many other possible obstetrical outcomes, all of which are well-known from medieval records, are assessed here.

National pride and international spin

The study appeared earlier this year in the national Czech journal of gynecology, meant, apparently, to provide an interesting reflection on national history to the country’s obstetrical specialists.[1] For its original audience, its speculations about the nation’s medieval history were no doubt fascinating. Once its message was amplified internationally by the New York Times, however, it suddenly became “a breakthrough,” a major scientific discovery. Antonin Parizek (“a noted obstetrician and expert on medical history,” according to the Times, and the study’s lead author), seems to be the only person interviewed for the news story. The unsubstantiated interpretation of incolumitate now becomes a fact of history: “Beatrice most likely passed out during delivery,” Parizek is quoted as saying, “and was believed dead … The surgeons opened her only to save and baptize the child. The pain from the operation then likely led to her awakening.”

In short, this is fiction. But, presented as “fact” by the New York Times, it becomes accepted as truth by a world-wide audience. The word “apparent” is the only qualifier given, and other statements—such as the reference to “other archival sources” without clarification that they postdate the birth by anywhere from one to five centuries—mislead the reader.

As noted above, the New York Times piece appears in a section of the newspaper called “What in the World.” This section is meant to circulate news stories coming from other national news outlets, and this one may have been picked up from Czech media. That is certainly a worthy, and indeed, necessary goal in our globalized world. But just as “local knowledge” is needed to interpret the nuances of language and culturally coded behaviors, so local academic knowledge is needed to explain how published work is generated in different professional fields.

The New York Times has given us a prime example of how fake news is generated. In this case, the news is not “fake.” The Czech study really was published. But the implication that it reflected any kind of consensus on what historians believe about women’s medical history was absolutely false.

“What in the world,” indeed.

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Monica H. Green is a historian of medicine and global health. A professor of History at Arizona State University, she has published extensively on the history of medieval women’s healthcare, including her award-winning book, Making Women’s Medicine Masculine: The Rise of Male Authority in Pre-Modern Gynaecology (Oxford University Press, 2008). Many of her works, including her comprehensive bibliography on women and medicine in the Middle Ages, can be found on her Academia.edu page.

[1] Thanks to Roberto Labanti for this reference. Thanks as well to Maaike van der Lugt, Katharine Park, and Fernando Dias de Avila Pires for helpful comments.