History and Geography

The history of sleeping sickness in Africa is long and complex, stretching across millennia to threaten millions today. The complicated ecology of the trypanosomiasis, involving the human host, trypanosome, tsetse fly, wild and/or domestic animal reservoir, climate, and geography has dramatically affected demographic patterns in sub-Saharan Africa. The parameters and density of human settlement have been limited in many regions until the present time, while the trypanosomiasis have prevented cattle-keeping across vast regions of the continent, thereby seriously affecting the nutrition of entire populations.

The "African lethargy," or "sleepy distemper," was well known to Europeans in West Africa from as early as the fourteenth century, through good descriptions given by Portuguese and Arab writers. For centuries slave traders rejected Africans with the characteristic swollen cervical glands, for it was common knowledge that those with this symptom sooner or later died in the New World or North Africa (Hoeppli 1969). In 1734 an English naval surgeon described the disease along the Guinea coast, and in 1803 another English doctor described the symptom of swollen cervical glands, which came to be called "Winterbottom's sign" (Atkins 1735; Win-terbottom 1803). As European exploration and trade along the West African coast increased between 1785 and 1840, the disease was reported in Gambia, Sierra Leone, and western Liberia, whereas between 1820 and 1870, it was also commonly noted along the Liberian coast.

Colonial Period

Certainly the disease was an important factor in the history of colonial Africa. In the beginning, colonial administrators were concerned mainly with the health of Europeans and those few Africans in their service. But the threat of epidemics of sleeping sickness eventually forced colonial authorities to take much more seriously the health of entire African populations.

For many Africans the disease occasioned their first, often traumatic, encounters with their new political masters, while epidemics enabled many colonial authorities to increase their political hegemony through public health measures. In those colonies affected by sleeping sickness, medical services often developed in direct response to this one disease, which resulted in the development of "vertical" health services — programs aimed at controlling a specific disease, while neglecting other crucial public health issues. Although the colonial powers have departed, as recently as the 1970s the World Health Organization urged developing countries to move toward "horizontal" health services that take into account the multifactoral nature of disease and health.

Research in Parasitology and Tropical Medicine. Sleeping sickness, along with malaria and yellow fever, played an important role in the development of the new specialties of parasitology and tropical medicine. In 1898, Patrick Manson, the "father of tropical medicine," published the first cogent discussion of the new scientific discipline. He explained that tropical diseases, those present in warm climates, were very often insect-borne parasitical diseases, the chief example being trypanosomiasis (Manson 1898).

Trypanosomiasis at the time was very much on the minds of colonial officials. In the decade between 1896 and 1906, devastating epidemics killed over 250,000 Africans in the new British protectorate of Uganda, as well as an estimated 500,000 residents of the Congo basin. Understandably, the new colonial powers, including Britain, France, Germany, Portugal, and King Leopold's Congo Free State, perceived sleeping sickness to be a grave threat to African laborers and taxpayers, which in turn could dramatically reduce the utility of the new territories. Moreover, the fears were not limited to the continent of Africa; the British also speculated that sleeping sickness might spread to India, the "jewel" of their empire (Leishman 1903).

Thus ensued one of the most dramatic campaigns in the history of medicine, as scientific research teams were dispatched to study sleeping sickness. They began with the Liverpool School of Tropical Medicine's expedition to Senegambia in 1901 and the Royal Society's expedition to Uganda in 1902; other expeditions followed until World War II.

Many of these were sent by new institutions espe cially designed to investigate the exotic diseases of warm climates. The British, for example, opened schools of tropical medicine at Liverpool and London in 1899, while other such schools came into being in Germany, Belgium, France, Portugal, and the United States. This new field of scientific endeavor, tropical medicine ("colonial medicine" for the French), offered the opportunity for bright young men to gain international acclaim and a place in the history of medicine. According to John L. Todd of the Liverpool School of Tropical Medicine in 1903, "Tryps are a big thing and if we have luck, I may make a name yet!" (Lyons 1987).

It should be noted that sleeping sickness was not the only disease to receive such attention as Europeans sought to establish themselves permanently in regions of the globe where health conditions were difficult and mortality was high (Carlson 1984; Bradley 1986). There were major discoveries by Manson, who was the first to demonstrate insects as vectors of human disease (filariasis); and by Ronald Ross, who found that the malaria parasite was transmitted by the Anopheles mosquito. Yet, despite the fact that endemic malaria was probably the cause of far more morbidity, the trypanosome and trypanosomiases attracted much attention in the new field of tropical medicine for the next 2 or 3 decades. Indeed, obsession with it dominated the first issue of the Transactions of the Society of Tropical Medicine and Hygiene in 1907.

Quite literally, sleeping sickness captured the colonial imagination (Martin 1923). International meetings were convened to discuss sleeping sickness, beginning with one at the British Foreign Office in 1907. As the number of "tryps" specialists increased, sleeping sickness became a key factor in the international exchange of research findings in tropical medicine. The Sleeping Sickness Bureau was opened in London in 1908 to facilitate communication of research findings on all aspects of the disease. Its work continues to the present time as the important Tropical Diseases Bulletin.

After World War I and the formation of the League of Nations' Health Organization (the antecedent of the World Health Organization), two major conferences in 1925 and 1928 were convened to focus on African sleeping sickness. These conferences, following the pattern of the nineteenth-century sanitation and hygiene conferences, sought international collaboration and cooperation in implementing public health solutions. In Africa, special research centers on tsetse flies and sleeping sickness appeared in many colonies including Uganda, Kenya, Tangan yika (now Tanzania), Belgian Congo (Zaire), Nigeria, Ghana, and French Equatorial Africa (Chad, Central Africa Republic, Congo-Brazzaville, and Gabon). Sleeping sickness thus became an important catalyst for cooperation among the colonial powers in Africa, which in turn aided the rapid growth of tropical medicine as a field. In fact, sleeping sickness early in the twentieth century attracted international attention to Africa with an urgency that was repeated in the early 1980s with AIDS (Kolata 1984).

Response to the disease occurred within the private sector as well. Concerned at the possible loss of increasingly important African markets, the European business and commercial community encouraged and sometimes initiated research into tropical diseases. For example, the principal founder of the Liverpool School of Tropical Medicine in 1899 was the influential and powerful capitalist Alfred Lewis Jones, chairman of a Liverpool-based shipping line that plied a lucrative trade along the West African coast (Morel 1968). He was also a personal friend of the notorious King Leopold of the Congo Free State. The businessman shared the imperialist's dismay at the potential devastation that could be caused by sleeping sickness, and together they were keen to support attempts to prevent the decimation of African populations.

Politics and Epidemiology. The politics of colonialism often reflected contemporaneous perceptions of the epidemiology of sleeping sickness. By 1900, for example it was widely accepted that the disease had been endemic in West Africa for centuries but had only recently begun spreading into the Congo basin and eastward. H. H. Johnston, the English colonial expert, popularized this view by arguing that sleeping sickness had been spread eastward across the Congo basin in 1888-9 by H. M. Stanley's Emin Pasha Relief Expedition (Morris 1963; Lyons 1987).

From the earliest days of colonial settlement, it was not uncommon to blame sleeping sickness for the abandoned villages and depopulated regions that Europeans encountered during their push into the interior. It usually did not occur to the intruders that in many cases Africans were withdrawing from areas because of the brutal nature of colonial conquest, and half a century would pass before researchers began to examine the deeper socioeconomic and political causes of the dramatic changes in the African disease environment that had resulted in the spread and increased incidence of sleeping sickness.

The word "epidemic" is a relative term that in volves many factors. The declaration of an epidemic is most often made by an authority with the sanction of the state. Epidemics are social and political, as well as medical, events and their declaration can serve a variety of needs (Stark 1977). Early in the twentieth century, the declaration of an epidemic could provide a pretext by which to control unruly populations suffering the traumas of colonial conquest. For example, in response to threatened epidemics of disease, African populations could be recognized and relocated for ease of political control and administration. On the other hand, declarations of sleeping sickness epidemics also enabled public health and medical service personnel to implement measures designed to contain the incidence and spread of the disease.

Medical experts at the turn of the nineteenth century tended to favor the theory of circumstantial epidemiology, which held that diseases were spread mainly through human agency within specific sets of circumstances. Lacking effective treatments, the principal methods of control of epidemic disease consisted of segregation or isolation and disinfection with acrid smoke or strong fumes such as sulfur and vinegar. Disease was perceived as an invader to be demolished. This view accounts for much of the imagery and idiom of war used in early public health campaigns. A major adjunct to this theory was the belief that once the circumstances had been identified, most diseases in Africa could and would be controlled, even eliminated, with techniques and technology developed in Europe. The European colonials assumed that they would succeed where Africans had failed and that they would transform the continent by conquering the problems of tsetse and the trypanosome, among others. Most colonists believed that much of the backwardness they saw in African society was attributable, at least in part, to endemic diseases such as sleeping sickness that could, they thought, help to explain the lack of the use of the wheel and the attendant need for human porterage, as well as the lack of animal-powered plows, mills, and the like.

Powerful notions of the potential of Western technology for solving health problems in Africa, sleeping sickness among them, have survived until quite recently. Rarely, if ever, did colonial authorities consider the possibility that Africans not only possessed some ideas about the ecology of sleeping sickness but had gained fairly effective control of their environment. An example of one such African strategy was the warnings to early European travelers not to travel through certain regions during daylight hours when tsetse flies were active and might infect their transport animals. Moreover, throughout the tsetse-infested regions, there were instances of African residence patterns that allowed coexistence with the ubiquitous tsetse flies yet avoided population concentrations conducive to epidemic outbreaks. It was, according to John Ford (1971), a curious comment to make upon the efforts of colonial scientists to control the trypanosomiases, that they almost entirely overlooked the very considerable achievements of the indigenous peoples in overcoming the obstacle of trypanosomiasis to tame and exploit the natural ecosystem of tropical Africa by cultural and physiological adjustment both in themselves and [in] their domestic animals.

European colonizers, by contrast, often disrupted - or destroyed — indigenous practices and survival strategies with the result that endemic sleeping sickness spread and sometimes became epidemic with disastrous effects. For example, from the late 1880s through the 1920s, the Belgians forced Congolese individuals to spend ever-increasing amounts of time searching farther and farther afield for sources of wild rubber with which to meet tax demands. In northern Zaire, rubber vines proliferated in the gallery forests, and such galleries were, and remain, superb ecological niches for the vector of gambiense sleeping sickness, G. palpalis.

The colonial powers, however, held their own version of the history of sleeping sickness and its evolution (Morris 1963; Burke 1971). Prior to their arrival, ancient, intractable foci of the disease had existed in West Africa and in the Congo basin around which, from time to time, the disease would flare into epidemic proportions. Colonials believed that it really began to spread only after the European newcomers had suppressed local wars and slave raiding among African peoples and established law and order. This in turn allowed many Africans, for the first time ever, to move freely and safely away from their home regions. Protected by Pax Brittannica, Belgica, and the like, the increased movements of Africans carried sleeping sickness from old endemic foci to new populations. There was some basis for this hypothesis, especially in West Africa such as in Ghana and Rukuber of Nigeria (cf. Duggan 1970). This widely accepted notion of the spread of sleeping sickness had an important consequence in the enormous effect expended by the Europeans in trying to regulate African life at every level, and especially to limit strictly any freedom of movement.

Ford, the British entomologist who spent over 25

years researching sleeping sickness, was one of the first to challenge this "classical view" of the pacification of Africa and the spread of the disease. He argued that it was not the pacific character of European colonization but, on the contrary, its brutal nature, that greatly disrupted and stressed African populations (Kjekshus 1977). In particular, the balanced ecological relationships among humans, tsetse flies, and trypanosomes were disrupted by European activities with the result that endemic sleeping sickness flared into epidemic proportions. Vivid examples of the results of such ecological upheaval were the sleeping sickness epidemics in Uganda and the Congo basin that had killed hundreds of thousands.

Public Health Initiatives. Epidemics continued throughout much of the colonial period, especially prior to World War II when there were serious outbreaks in both West and East Africa, which occasioned a great deal of morbidity and mortality (Duggan 1970). Public health regulations proliferated to control the disease that affected other areas of administration such as taxation, labor supply, and freedom of movement across international frontiers. In some colonies, sleeping sickness programs became so extensive and bureaucratic that they came into conflict with other colonial departments, exacerbating competition for scarce staffing and financial resources within colonial administrations. In addition, sleeping sickness regulations were often responsible for confrontations between the private and state sector as members of the former found themselves increasingly hindered in their attempts to exploit the people and resources of Africa.

Two major patterns emerged in the colonial campaigns against sleeping sickness. In one, the focus was on tsetse eradication, whereas in the other, the focus was on the medicalization of victims. Both approaches, however, involved varying degrees of brush clearance as a prophylactic measure, and in reality, most campaigns were a combination of features from each approach. For instance, it was pointless to think of successfully destroying tsetse habitat in the rainforest conditions of the Congo basin or much of French Equatorial Africa. Nevertheless, in some areas combined campaigns of brush clearance, resettlement, and medicalization were carried out.

Within this framework, national variations emerged in the colonial campaigns. The British took a more broadly ecological approach to control of the disease, whereas the French and the Belgians took a more "medical" approach to the problem of human infection. British policy was to break the chain of sleeping sickness transmission by separating people from flies. Thus, while British administrators implemented social policies aimed to protect people from disease, the scientific community, especially the new entomologists, searched for solutions to the "tsetse fly problem" in Africa (Ford 1971). The compulsory mass resettlement of Ugandans, which probably helped save lives, from lakeshore communities in Buganda and Busoga in 1908, and the huge Anchau (northern Nigeria) scheme begun in 1936 are good examples of breaking transmission chains. Likewise, in some regions where it was ecologically feasible, Belgians resettled groups of people such as those along the Semliki River in eastern Congo.

Unfortunately, in the context of recently conquered and colonized Africans, who had rural subsistence economies, and whose culture and tradition were intricately linked to locale, compulsory relocation sometimes had calamitous effects on those it was meant to protect. In the Belgian Congo an extraordinary amount of legislation and effort was directed at the control of populations in relation to sleeping sickness. In some places people found themselves forbidden to go near rivers that were designated "infected" with the disease. They could not fish, cross the rivers, use their rivercraft, or even attend to cultivations along the banks. It is not surprising that many Africans regarded sleeping sickness as the colonial disease because of the sometimes overwhelming amount of administrative presence it elicited (Duggan, personal communication; Lyons 1985).

French and Belgian efforts were directed chiefly at "sterilizing the human reservoir" of trypanosomes through mass campaigns of medicalization, or injections. To achieve this, they conducted systematic surveys of entire populations, hoping to locate, isolate, and treat all victims. Eugène Jamot, a French parasitologist, developed this method in Ubangui-Chari (French Equatorial Africa), and later introduced it to affected parts of Cameroon and French West Africa (Jamot 1920). In 1916, he organized an ambitious sleeping sickness campaign based upon mobile teams, which systematically scoured the country for victims of the disease to be injected.

A grid system was devised to ensure complete surveys, and the mobile teams worked with true military efficiency. Between July 1917 and August 1919, over 90,000 individuals had been examined, and 5,347 victims were identified and treated. Jamot's design for a sleeping sickness service was soon adopted by the Belgians in the Congo, and by

1932 there were five such teams operating annually in northern Congo alone. Admirable as it was for its sheer scale of organization, the policy of mass medicalization did not affect the fundamental ecology of the parasites; indeed, this approach had the effect of removing the store of antibodies from humans that had been built up through long contact with the parasites (Lyons 1987).

Sterilization of the human reservoir was made possible in 1905 when the first trypanocidal drug became available in the form of an arsenical compound, atoxyl. Discovered by the German chemist Paul Ehrlich, and adapted for use with sleeping sickness by Wolferstan Thomas of the Liverpool School of Tropical Medicine, atoxyl, alone or in combination with other compounds, remained the only chemotherapy for 2 decades. Atoxyl was toxic for 38 percent of patients, with dreadful side effects suffered by those whom it did not kill outright, among them the blinding of 30 percent of those injected. By the early 1920s, new drugs - suramin (1916-20) and tryparsa-mide (1919-25), and later in the early 1940s, pentamidine - were in use for early-stage rhode-siense and gambiense disease. Melarsoprol, a most problematic arsenical with serious side effects, including up to 5 percent mortality, was and is used for second-stage disease. Together with suramin and pentamidine, these three have remained the drugs of choice since the 1940s.

Postcolonial Period

In the early 1960s, which saw independence for many African territories, colonial rulers concurred that human sleeping sickness was under control in Africa. But political upheavals in many countries following independence, accompanied by the breakdown of medical infrastructures and large-scale population displacements, once again seriously affected the epidemiology of sleeping sickness. Some countries - Zaire, Uganda, Sudan, and Ivory Coast, for instance - witnessed epidemics of sleeping sickness, and it has been estimated that by 1969 there were up to 1 million sleeping sickness victims in the Congo alone (Mulligan 1970).

Sleeping sickness continues to afflict unknown numbers of Africans. Epidemics occurred in the 1980s in old, well-known foci located in those regions of Africa experiencing disorder and decay of public service brought about by socioeconomic and political conditions. In fact, some areas are experiencing a disheartening replay of events earlier this century, while other areas are experiencing the introduction of the disease for the first time.

Tsetse flies and the trypanosomes that cause sleeping sickness will continue actively to shape the future of humankind in Africa. Because the most effective means of control is continual and thorough surveillance and treatment with available chemotherapy, present-day health planners and administrators must be aware of the history of this disease and the ease with which that history can repeat itself.

Maryinez Lyons

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