The country of Madagascar is known for its tranquil beaches, exotic wildlife and rich culture. But something else also inhabits the island that is now making headlines: The Black Death.

Perhaps best known as the Bubonic Plague that is generally associated with the Middle Ages when rats, fleas and poor hygiene resulted in the deaths of approximately 200 million people, the disease remains an enduring threat in third-world nations.

Madagascar has been one of the world’s last remaining hotspots for the plague but the illness has been mostly isolated in rural villages and self-contained... until now.

On Friday, Nov. 21, the World Health Organization announced an “outbreak of the plague” in Madagascar, with two people in the country’s capital being infected and one having died from the disease.

Cases have been reported in 16 districts of the seven regions, according to WHO, and the health ministry said there had been 138 suspected cases since the beginning of the year and warned that the death toll was likely to rise in the coming months.

Now that the disease has made it to a densely populated area, a major outbreak seems inevitable. The capital of Madagascar, Antananarivo, houses the prime conditions for a disease such as the plague to spread, similar to those in 14th century Europe – garbage is dumped in the streets and public restroom conditions are terrible. Black rats, which were the primary vector for the disease in the Middle Ages, also roam freely between buildings.

“There is now a risk of a rapid spread of the disease due to the city’s high population density and the weakness of the health care system,” the WHO said in its report, while noting that a national task force has been activated to manage the outbreak.

Contraction of the bubonic plague results in the swelling of the lymph nodes, but can be treated with antibiotics. The pneumonic version, affecting the lungs, can be spread from person to person through coughing. Death can result in as little as 24 hours. The third form of the disease, septicemic plague, is the rarest form and occurs when the blood is directly infected.

Whichever variety of the plague, as the disease progresses its victim lapses into recurrent seizures, Alzheimic confusion, coma and internal hemorrhaging.

The plague is almost impossible to eradicate from Madagascar, due to interaction of natural and sociocultural factors. According to a 2013 report by the US National Library of Medicine, the high percentage of animals carrying the disease lays the foundation for transmission, and social and economic conditions further encourage the periodic leap to humans.

Outbreaks of the plague usually occur in villages at high altitudes in the northern region of Madagascar, spiking between October and April when the warm rainy season keeps temperatures well above 70 degrees day and night.

Without funds coming in from developed nations, the country doesn’t have much to work with to fight the plague. The African Development Bank is allocating $200,000 however, but those resources could quickly dwindle in the coming months. All of these conditions leading up the outbreak mirror those that caused the Ebola virus to spread throughout West Africa.

"Belief in old practices, rampant misinformation, and apathetic, corrupt politicians have combined to make the current outbreak much more widespread than it should be," VICE correspondent Ben Shapiro said in a documentary that was released in September where he helicoptered into a village about 1,000 kilometers north of the capital that was considered a hot zone. "For Madagascar, though, it's unclear how many more people will die of plague before things start to change."

For now, the World Health Organization does not recommend any travel or trade restriction based on the current information available.