The prisons are overcrowded and unsanitary. Overrun with vermin, it is the fleas on the rats which spread the disease to the convicts. When they are released, or when family members leave after their visits, they spread the plague into the community. The public health system itself is in poor condition, so although the infection can be treated to lower the mortality rate, hundreds have died. Where are we? In Europe in the Middle Ages? No. This is occurring in modern Madagascar.