Research note: Colonial approaches to sleeping sickness

Romy van de Pol. Show Author details

Sleeping sickness had been endemic to the African continent for decades before European colonisers invaded Africa at the turn of the 20^th century. By invading they destroyed an equilibrium the indigenous communities had created between them and nature, which kept diseases from becoming epidemic (Headrick, 2014). The disease was first discovered by colonisers at the end of the 19^th century, however at the beginning of the 20^th century it had already become epidemic. It took France until 1917 before actual measures were taken in their colonies and a few decades more for the epidemic to do die out. This is relatively late when compared to British Africa, that had the epidemic already under control in the 1910s (Headrick, 2014, pp. 5-6). Why did they differ in their response? This essay will try to answer this question by first discussing their approach to dealing with sleeping sickness in greater detail and then putting forward three factors that can explain their different strategies.

This question is relevant for two main reasons. First, sleeping sickness is still a public health concern in Africa. During the last epidemic in 1998, 40,000 cases were reported and an estimated 30,000 more went undiagnosed. Since then a lot has changed, in 2009 the number cases dropped below 10,000 for the first time in 50 years. In 2019 and 2020 the number of cases stayed below 1,000 a year thanks to bilateral collaboration between the WHO, NGO’s and national policy (World Health Organization, 2022). The second reason is historical: the legacy of medical campaigns has left a big scar in African countries. They were designed and implemented by colonisers in the early 20^th century using coercion to force the indigenous population to undergo painful treatments. According to Lowes and Montero (2021), these campaigns caused mistrust in modern medicine which is still very noticeable today. For example, communities do not access healthcare even when it is available and of good quality. Furthermore health projects of the WHO are not as successful in areas formerly targeted by colonial medical campaigns (Lowes & Montero, 2021).

Sleeping sickness

Sleeping Sickness, or Human African trypanosomiasis, is an illness caused by a parasitic infection. The vector is the tsetse fly, which is native to the African continent and does not exist anywhere else. Its habitat consists of certain bushes (Soff, 1969, p. 262) which thrive in tropical and savannah climate zones (Webel, 2019, pp. 266-267). 

When the fly bites a patient a trypanosome parasite enters the body, causing weakness, malaise, headaches, fever and the swelling of lymph nodes. Eventually it will affect the central nerve system and cause disruptions in the temperature and sleep pattern of its host, with effects as lethargy and insanity. At last, the patient goes into a coma and eventually dies, hence its popular name: sleeping sickness (Webel, 2019, pp. 266-267; Headrick, 2014, p. 1). As described by Headrick (2014, p. 1) the disease consists of two varieties of trypanosomes. The first, and most common, is Trypanosoma brucei gambiense (Worboys, 1994, p. 90) that causes a chronic illness with relatively mild symptoms for months to years before it enters the central nervous system and becomes fatal. The second variety is Trypanosoma brucei rhodesiense and it is much more acute and will be fatal within three to twelve months of infection. 

Epidemics in the colonies

Uganda

In order to discuss the British response, I’ve chosen the Uganda as a case study, one of the most successful colonies fighting against sleeping sickness, which I will discuss more in depth later. Furthermore, the shores of Lake Victoria in Uganda were very much affected by the disease and, therefore, a lot has been written on the region and its response to the epidemic (Worboys, 1994; Soff 1969; Headrick, 2014; Webel, 2019). 

The response from the government in London to the epidemic in Uganda was slow. When in 1902 the epidemic broke out (Worboys, 1994, p. 90) the government decided to set up a research team to search for technical solutions focusing on vector control, but also search for possible therapeutic agents. The progress, which was similar to what we call nowadays biological control methods (Worboys, 1994, p. 92), was slow and in 1906 there were still no answers. 

Meanwhile, the epidemic had been going on for several years costing many lives and the governor of Uganda Hesketh Bell decided to act. He designed a set of measures focused on the vector and the displacement of people. He was initially against the latter since large groups of individuals can be difficult to control and manoeuvre around (Worboys, 1994, p. 91). However, since there weren’t enough technical solutions yet, Bell realised that person control would be necessary. A plan was devised to move communities out of the risk area: a two mile radius from the Victoria lake shores (Soff, 1969). When they encountered people who were infected with the disease, they were sent to isolation camps and often treated with atoxyl (Soff, 1969, p. 263). The forced displacement was met with resistance from these communities. However with cooperation from local leaders, financial compensation and a “long” moving period it turned out possible. 

The implemented measures were a success in Uganda. In 1910 the epidemic had mostly died down and had become such a routine aspect of Uganda medical care that the measures were not enforced anymore (Headrick, 2014; Worboys, 1994). 

French Equatorial Africa

To discuss the French case, I chose French Equatorial Africa (AEF), a federation formed in 1910 that consisted of four French African Colonies: Gabon, Chad, Central African Republic and the Republic of Congo (Thompson & Richard, 1960, p. 12). Since France started effectively treating sleeping sickness after 1910, it makes the most sense to use the AEF as our starting point for my analysis. 

The imperial and colonial government had a hard time with designing and enforcing effective measures to combat the epidemic. However, Dr. Eugène Jamot (director of the Pasteur Institute in Brazzaville) was able to in this situation. In 1917, he created medical teams to be able to travel to villages in order to medically examine and treat people with sleeping sickness. The teams consisted out of French doctors, African nurses trained at the Pasteur Institute, French colonels and African soldiers. The system was an example of vertical health care and thus solely focused on sleeping sickness (Doyle, 2022, pp. 10-11).  

Whereas the British focused on freeing the vector from the trypanosomes, the goal of the French medical teams was to kill the trypanosomes in the entire population in order to protect the healthy (Headrick, 2014, p. 5). Medical teams would travel to villages in order to identify the sick and treat them with atoxyl, sometimes entire villages, even though more effective and safer drugs were already developed at that point. Research had pointed out that atoxyl caused blindness in up to 20% of its patients. Making things worse, after a while trypanosomes even started to build resistance to atoxyl and similar drugs (Headrick, 2014, pp. 3-4). However, the drug was cheap and easy to inject, so the government in AEF disregarded the side effects and kept using it. After Jamot’s success in French Congo he was stationed in Cameroon to implement the same measures. The Colonial administration in Congo opened up a clinic in 1927 specialising in sleeping sickness which eventually replaced the medical teams. The clinic caused a rise in the number of doctors and nurses. Ultimately, the French government finally got a control over the epidemic in 1930. 

Why did the approaches differ?

The responses by both colonial powers were very different. The medical approach used by the French was based on curing patients, most often by injecting them with atoxyl (Headrick, 2014), whereas the environmental approach of the British focused on distancing the vector from the people. Why did they differ? This section highlights the role of three key factors that I elaborate on in the following. 

Scientific influence on policy

The history of tropical medicine is strongly influenced by the history of sleeping sickness, both impacted by growing internationalism and imperial European powers. Indeed, when the aforementioned epidemic began to grow larger and mortality rates kept rising, the interest by imperial governments and researchers grew just as much (Webel, 2019, pp. 267-269). There was little experience and knowledge on tropical diseases at first, so when scientific findings appeared they had an influence on colonial policies. Scientific knowledge and how it was communicated to governments, therefore can be used to explain differences between the sleeping sickness policies of Britain and France.  

Why Britain chose vector control to eradicate sleeping sickness can be partly explained by the role British scientists played. Flies and insects were a popular study subject within the British school of tropical sciences in the 1900s, so scientists soon focused on analysing the importance of the tsetse fly (Worboys, 1994, p. 91). Patrick Manson, founder of the London School of Hygiene and Tropical Medicine, and Ronald Ross, founder of the Liverpool School of Tropical Medicine, had done extensive research before into tropical medicine focusing on insects and flies (Headrick, 2014, p. 2). Manson and Ross played an important role in the research set up by the government; investigating the role of the fly in the transmission of the disease. This vector-oriented research eventually translated into policy when, in the early 1900s, sleeping sickness policy transitioned from a focus on the isolation of the patients to eventually Tsetse Fly control (Worboys, 1994, pp. 92-93). 

But Britain did not work alone on this research, since international cooperation was at that time an important part of scientific findings. Between 1901 and 1913 fifteen medical teams, of which eight British, were sent to the African continent to study the disease. A result of these research missions was international cooperation (Headrick, 2014, p. 2). For instance, British and German researchers and medical practitioners operating in the lake Victoria area regularly circulated information to learn from each other (Webel, 2019, p. 269). A prime example was the work of the Robert Koch, who was stationed in Uganda and worked closely with British researchers. Both Germany and Britain relied heavily on the results of his experiments in the hopes of finding a treatment. In 1906, Koch’s results showed that atoxyl was the most effective and non-toxic treatment (Soff, 1969, pp. 260-261).  

Compared to British scientists, the French focused their research on identifying and eradicating the pathogens (Headrick, 2014, p. 6). Even though the they were the last to send research teams to Africa, they were still part of the scientific race. French scientist namely made breakthroughs in the research of the trypanosomes. Emile Roudbaud and its team of medical entomologists in 1909 were able to unravel the life cycle of the trypanosomes in the digest track of the Tsetse fly (Headrick, 2014, p. 3). A year later, John W. W. Stevens and Harold B. Fantham discovered the second type of human African trypanosomiasis which was caused by a different parasite: T. rhodesiense (Headrick, 2014, p. 3). The focus on investigating the trypanosomes, instead of the vector, can be one of the reasons why France chose a medical approach. 

Colonial political structure

British and French colonies had different administrative structures. Headrick (2014, p. 6) describes how Britain used an indirect way of ruling, appointing native leaders on local administrative and ruling positions. This form of leadership made it possible for Hesketh Bell to act on its own when London was still indecisive on what to do. Bell did not wait on the results of the research, but decided (in the absence of technical solutions) to choose for an environmental approach. He devised measures which he thought were effective but also fair to the communities (Worboys, 1994). In other words, governors and local administrators had some form of autonomy and adapted to and worked with the local political and social systems of indigenous communities (Worboys, 1994, pp. 92-93). The indirect ruling of the colonies made it possible devise a medical approach which was not an one-fits-all solution, but paid attention to what Uganda needed.

France chose a direct way of ruling their colonies. As Headrick (2014) explains, they preferred appointing French soldiers and civil servants at all administrative levels. Medicine was dominated by French army doctors, which was very visible in the composition of the traveling medical teams used to combat sleeping sickness (Doyle, 2022, pp. 10). Whereas Britain was relatively quick to combat the epidemic, France had a hard time with setting up and enforcing effective measures. This can be explained because of the lack of resources in AEF (Headrick, 2014, p. 5). Especially when using direct rule, it can be difficult to generate enough personal and resources to combat an epidemic. Furthermore, the extensive use of force and coercion by the medical teams can be partly explained by the involvement of army doctors and soldiers within these teams. Whereas Bell tried to compensate the communities for their losses and work with them on the solutions. The French forcibly injected entire communities with atoxyl and kept them under inhumane circumstances in isolation camps (Lowes & Montero, 2021, p. 1291). The lack of attention to the humanity of the measures can be contributed to the use of soldiers and the fact that there were no indigenous people who had the power to protest it.

Population density

At last, population density is another important factor that can explain the policies implemented by the British and the French in their colonies. The AEF had a very small population density, especially compared to Uganda, which the calculations below will make clear. Because of this, certain policy measures would not be effective in AEF, whereas the opposite is true for Uganda (more on this below). 

French Equatorial Africa had a large square footage, however it was also thinly populated. It consisted of the current Republic of Congo, Central African Republic, Gabon and Chad. This area had a roughly estimated land are of 2.482.150 sq. km in 1961 (World bank, 2023). Given that the population in the AEF consisted of 6.135.33 people in 1961 (Frankema & Jerven, 2014), population density in AEF in 1961 was 2.47 persons per squared kilometer. On the other hand, Uganda had a population density of 34.95 persons per squared kilometer, which is much higher than in the AEF. Note that the numbers on land area are rough estimates of the land area of colonies which are now independent countries. So borders might have changed a little since independence and therefore have influenced the land area. However this is not so relevant, since the difference between AEF and Uganda is so large, so a small change in land area would not make a difference for our comparison. 

Differences in population density influenced the policy regarding the sleeping sickness epidemic in multiple ways. First, part of the British environmental approach consisted of moving away from the Tsetse fly habitat. However people lived more sparsely in the AEF and not in “enclosed” villages compared to Uganda. Measures focusing on the migration of communities would be considerably more complicated, expensive and less effective in the AEF. Second, the environmental approach also included the destruction of bushes in order to destroy tsetse fly breeding grounds. For the AEF this would have meant working enormous pieces of land which would have had disastrous consequences for the environment. Third, it made sense the French to use travelling medical teams as many were sparsely located. 

Conclusion

Why did the French and British differ in their approach to combat sleeping sickness in Africa? I hypothesize, drawing on the literature, that three factors can be important. 

First, science and scientists influenced policy making. The British school of tropical medicine had a big interest in insects and flies, which tilted policy towards an environmental approach focused on vector control. 

Second, the AEF had a very low population density when compared to the British colony Uganda. Therefore, measures adopted by the British, like communities being forced to move away from the shores of Lake Victoria or destroying the tsetse fly habitat, were undoable and probably not as effective in the AEF. 

And third, the French and British had a very different way of ruling their colonies. London preferred to indirectly rule the colonies drawing on native leaders. France, on the other hand, preferred direct rule. Military doctors were appointed to lead the medical teams and native people were excluded from leadership positions. This sometimes resulted in inhumane measures, such as  using a drug which was proven to be highly toxic, even though alternatives were available. To be sure, the British measures were far from perfect in that aspect, but governor Bell did make an effort to “compensate” the communities and work with them. Whether the compensation offered was fair is something open to discussion. 

Concluding, there was no right or wrong way of treating sleeping sickness, simply methods that came to be because of their time and local constraints.

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