Diseases of Sub Saharan Africa since 1860

Africa was long characterized as the "dark continent," impenetrable, disease-ridden, and dangerous. To many Europeans, Africans personified degeneracy and suffering, and their environment seemed a hothouse of fever and affliction. Europeans had good reason to connect sub-Saharan Africa with disease. For centuries, their attempts to penetrate the coastal fringes of the continent had been effectively frustrated by diseases against which they had little or no resistance (Carlson 1984). In the early nineteenth century, Europeans arriving in West Africa suffered appalling mortality from disease (most often yellow fever and hyperendemic malaria) at rates of between 350 and 800 per 1,000 per annum (Curtin 1968), and the West African coast became known as the "white man's grave." With such mortality rates, it is no surprise that Europeans believed that Africa was more disease-ridden than other parts of the world.

In fact, many continue to believe that tropical Africa has a well-deserved reputation as a vast breeding ground and dispersal center for dozens of diseases and thus would subscribe to the recent assertion that "Africa is a sick continent, full of sick and . . . starving people" (Prins 1989). This view has been reinforced by scientific speculation concerning the appearance of so-called exotic new diseases like Ebola, Marburg, and Lassa fevers in the 1960s and 1970s (Westwood 1980; Vella 1985). The HIV viruses that cause the acquired immune deficiency syndrome (AIDS) are the most recent additions to this list.

Recent technological advances, especially in electron microscopy, coupled with the rapidly expanding specialties of molecular biology, genetics, and immunology, have given rise to an equally rapid expansion of virology. Scientists are now on the threshold of making important new discoveries that it is hoped will lead to cures for viral infections to equal those available for many bacterial, fungal, and parasitical infections. Unfortunately, however, the identification of Africa as the home of "exotic new diseases" has reinforced the widespread view of that continent as a major source of disease-causing germs.

Disease has been an important factor in the history of sub-Saharan Africa since 1860. Across the continent people have been under constant attack by endemic diseases in their struggle for survival, and epidemic diseases have decimated millions. In 21 countries, life expectancy today ranges from only about 44 to 56 years according to I. Timaeus (personal communication). In some countries, mortality rates have grown recently, and in most regions they remain high. Increases have occurred in Angola, Ethiopia, Mozambique, Niger, Nigeria, and Rwanda. In the first three there were 250 to 299 deaths per 1,000 live births, and in Gambia, Sierra Leone, Mali, and Malawi child mortality rates were more than 300 per 1,000 (United Nations 1987). The direct causes of this mortality in most developing countries are the following: diarrhea, malnutrition, malaria, measles, acute respiratory infections, tetanus, and other neonatal causes. Now AIDS reminds us of the potential havoc of an epidemic disease in Africa.

Nevertheless, other countries have experienced an appreciable decline in infant and child mortality in the past 20 years. In Kenya in the late 1950s, the child mortality rate (for children less than 5 years of age) was 265 deaths per 1,000 live births, whereas in 1989 it had declined to 150 per 1,000 (Blacker 1989). It must be made clear that in some regions of Africa there have been significant increases in population growth, whereas other regions such as Kivu in eastern Zaire have been densely populated for many decades. African demography is a rapidly expanding field of study among social scientists and members of the medical and scientific communities, and there is a continuing debate concerning the relationship between biomedical provision and morbidity and mortality rates in sub-Saharan Africa. Some observers contend that over the past century, medical provision has been the major factor in lower morbidity and mortality, whereas others believe that improved socioeconomic conditions, more than medical provision, have resulted in less illness and death among

Africans. Proponents of this view refer to the apparent paradoxical situation in some regions of the continent in which populations have increased in spite of the quite dramatic disintegration of health care delivery systems that were inherited from the colonial period. We shall probably have to await the twenty-first century for satisfactory explanations of the dynamics of African demography and its history.

An analysis of disease environments can be made in terms of both natural factors and socioeconomic considerations. Natural factors, crucial to proponents of the "determinist" school of disease causation, include such items as altitude, temperature, rainfall, humidity, and soil, as well as the proliferation of potential disease hosts and vectors like animals, birds, insects, and parasites. Epidemiologists describe three major disease patterns in sub-Saharan Africa roughly akin to the three main climatic zones: damp uplands, damp lowlands, and savanna regions with a long dry season. Damp uplands include the Kenyan highlands, southwestern Uganda, mountain slopes of eastern and western Africa (mounts Elgon and Kilimanjaro), and parts of Rwanda and Burundi. The much vaster damp lowlands include coastal West Africa and the massive Congo basin, which are the regions of Africa that most readily fit the popular notion of "the tropics." The third and most extensive climatic pattern is identified by a limited rainy season and a longer dry season. At one extreme in this climatic pattern is the Sahel, where the dry season dominates, but the pattern pertains to savanna regions as well (Bradley 1980).

Disease patterns vary immensely throughout these three zones, yet generalizations can be made. In the damp uplands, including the Kenya highlands, the southwestern tip of Uganda, parts of Rwanda and Burundi, and the southern Kivu district of eastern Zaire, population densities are high and the predominant infections are respiratory and diarrheal, both largely diseases of poverty and poor sanitation. In the damp lowlands with their prolific insect vectors, malaria dominates the disease pattern, with almost every person infected within the first year of life. Yaws, hookworm, the diarrheas, typhoid, infective hepatitis, and numerous viruses are also common. The third disease pattern, that of the savannas, is again dominated by malaria, with diarrheal diseases and waterborne diseases predominating. The latter include schistosomiasis and dracunculiasis (guinea worm), whereas another devastating disease, sleeping sickness, is especially prevalent along waterways, the haunt of many tsetse flies, which transmit the disease. Another im portant disease of this environment is cerebrospinal meningitis.

Analyses of disease patterns that focus more on the role of social, cultural, political, and economic factors emphasize the dynamic relationships that exist between humans and their total environment. This is the approach of those concerned with the "social production of health and disease" (Turshen 1984). Only rarely do analyses of disease patterns combine both the deterministic and the socioeconomic approaches and thus reveal the complex interrelations between natural and socioeconomic factors (Blacker 1989). John Ford's (1971) brilliant study of the tsetse problem is an example of a successful combining of the two.

Yet in the case of Africa, climate and geography are less important determinants of health than are the social, economic, and political factors. (The majority of sub-Saharan Africa is not the sweltering, humid tropics of popular imagination but is rather temperate savanna or forest.) Medicine has only a limited role in ameliorating the health of populations (McKeown 1979), and upon closer examination, it can usually be shown that the root causes of ill health are embedded in social and economic structures. Indeed, in much of sub-Saharan Africa, it is precisely because of social and economic upheaval that we have recently seen a rapid increase in morbidity and mortality, and medical services in some regions have deteriorated so seriously as to be nonexistent (Dodge and Wiebe 1985).

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