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

African trypanosomiasis, or sleeping sickness, is a fatal disease caused by a protozoan hemoflagellate parasite, the trypanosome. It is transmitted through the bite of a tsetse fly, a member of the genus Glossina. Sleeping sickness is endemic, sometimes epidemic, across a wide band of sub-Saharan Africa, the so-called tsetse belt that covers some 11 million square kilometers. Although the disease was not scientifically understood until the first decade of the twentieth century, it had been recognized in West Africa from the fourteenth century.

The chemotherapy to combat trypanosomiasis has remained archaic, with no significant advances made and, indeed, very little research done between the 1930s and the 1980s. Most of the victims are poor, rural Africans, which has meant that there is little or no economic incentive for pharmaceutical firms to devote research resources to the disease (Goodwin 1987). However, in the mid-1980s field trials of a promising new drug, D1-alpha-difluoromethylornithine (DFMO), demonstrated the drug’s efficacy in late-stage disease when there is central nervous system involvement. In addition, there have been exciting recent developments in the field of tsetse eradication with the combined use of fly traps and odor attractants (Hall et al. 1984). And, the World Health Organization’s Special Program on Tropical Disease is trying to overcome the research problem resulting from the reluctance of pharmaceutical firms to get involved.

Following are some of the more relevant items of legislation and instructions which pertained to human trypanosomiasis in northern Congo. It can be observed that the medical service itself was a direct outgrowth of the campaign against sleeping sickness.

The historian can approach the subjects of disease and medicine in a number of ways. More traditional historians of medicine concentrate on the impressive scientific achievements in Western medicine, beginning their story with medical knowledge and practices of the ancient Greeks and Romans. Other medical historians are concerned with the social history of medicine although their focus remains on technical and scientific achievements. They discuss societal relations in connection with the development of medical science and they tend to be more critical and analytical than their more traditional colleagues. Both of these groups of historians are generally of the opinion that Western biomedicine is the correct path to pursue in the effort to salve and solve the ills of mankind. A number of twentieth-century works have dealt with the history of medicine in the African context. Most have been written by former colonial or missionary medics who often follow the more traditional approach and take the form of a celebration of man's intellectual advance as demonstrated by his increasing ability not only to comprehend his environment but to shape it to suit himself. Titles such as Gelfand's Tropical Victory and Ransford's Bid the Sickness Cease espouse this notion.

What is needed now is for historians to begin to put such work back into its historical context. The study of medicine in history can result in a much richer view of man's past by pulling into the analysis the subjects of disease and medicine as two of the factors among many in the overall process of historical change. In this way, the roles of disease and medicine are fully integrated in historical explanation.

In revising my Ph.D. thesis for publication, I have tried to draw out the relevance of the study to public health issues in Africa today. While I do not concur with the view that history is prescriptive, I do believe there is much that can be learned from the past which can be of help with present-day issues. The history of medicine and public health in Africa, particularly during this century, can assist greatly in understanding some of the issues and problems confronting health workers today. The histories of epidemics, such as those of sleeping sickness, are especially helpful, highlighting as they do a broad spectrum of issues ranging from purely medical ones to political and economic considerations. In this way, the history of sleeping sickness in a region of colonial Belgian Congo, now known as Zaire, has an importance reaching far beyond the confines of African history but is of relevance also to the wider history of health in the developing world. The present epidemic of AIDS has once again reminded us of the complexities involved in monitoring health on a global scale as well as those involved when attempting to intervene in the highly sensitive and deeply entrenched cultural realm of human responses to disease. As I discuss in this volume, the declaration of an epidemic is very much a political act, but not as widely recognised are the political aspects of public health programmes.

The scientists

On 23 September 1903 the team of scientists from Liverpool arrived in the Congo Free State to begin assessing the public health situation, particularly with reference to sleeping sickness. The Twelfth Expedition of the Liverpool School of Tropical Medicine consisted of Doctors Joseph Everett Dutton, 28, John Lancelot Todd, 27, and Cuthbert Christy, 40, each of whom recently had taken part in previous trypanosomiasis research expeditions in Africa. Dutton had participated in the Third Expedition concerned with malaria in Nigeria in 1900 and in two expeditions dealing with trypanosomiasis, in 1901 and 1902, both to Senegambia. Cuthbert Christy, a most difficult and irascible man, had been briefly attached to the Royal Society's first sleeping sickness commission to Uganda in 1902. When they reached the Congo Free State, the British team was joined by Dr Inge-Valdemar Heiberg, a reserve captain in the Norwegian army, who was one of the many non-Belgian military doctors employed by the State. Heiberg's career of six terms spanned nearly twenty years. Beginning as a médecin d'expedition in the Lado enclave, he became director of the first sleeping sickness lazaret at Ibembo in 1907 and the first médecin en chef of the Congo on 28 January 1911. As an illustration of the small number of tropical health specialists at the time, Dutton and Todd were already acquainted with Heibert whom they had met in Liverpool where he had completed the new tropical medicine course in May 1903. Dutton explained, ‘We were delighted when he told us that he was put at our disposition and was to act as a guide, aide-de-camp and everything else.’

Late-nineteenth-century European concepts and practices concerning epidemic disease deeply affected the lives of millions of colonised Africans early this century. This was especially true in the Belgian Congo. The term ‘epidemic’ can be highly emotive, even political, evoking images of catastrophic mortality involving millions of deaths such as those caused by plague in early modern Europe and by the great influenza pandemic this century. Between 1901 and 1905 a sleeping sickness epidemic caused the deaths of over a quarter of a million people in Uganda. Depopulating entire regions of the country, that devastating epidemic altered for many decades the demographic pattern of the northern shores of Lake Victoria.

The decision to declare an epidemic is influenced by political factors as much as purely scientific ones as it is most often the state which declares a disease to have reached epidemic proportions. This fact was borne out in the early colonial history of parts of sub-Saharan Africa. For instance, the declaration of an epidemic could provide a new and understaffed colonial administration with important control mechanisms as there would be a rationale for the introduction of a range of highly authoritarian measures. In the Belgian Congo, sleeping sickness legislation became, in fact, a clear example of an attempt at ‘social engineering’ in Africa.

The impressive discoveries of the mid- to late-nineteenth century in the fields of bacteriology and antisepsis had a profound impact on the prevailing theories of the epidemiology of disease which had evolved over the long centuries of plague and more recent cholera epidemics.

Belgian colonials produced much rhetoric on the subject of their ‘civilising mission’ in Africa and they often rationalised, even justified, their presence in the Congo by referring to their duty to instill and nurture in Africans the European, bourgeois values of education, hard work, moral duty, selflessness, courage and patriotism. These values were not only to be taught in the abstract in schools but were to be acquired by Africans in the process of practical works. Congolese would become civilised by labouring for Europeans. But it was often to prove difficult to obtain African labour, the supply of which remained a major issue during the entire colonial experience. This was an enormous problem as the mise en valeur, or economic exploitation, of the Congo in the early decades of its existence depended almost entirely upon obtaining sufficient numbers of African labourers. The earliest instructions to state agents had stressed the significance of labour as the pivot of the Belgian ‘civilising mission’.

As we have seen, the conquest of the northern Belgian Congo was protracted and costly for African societies, but military conquest was only the beginning of many decades of real stress for many people. Administrative policies strained societies in ways which for some populations culminated in famine, disease and death. State demands for labour and tax were particularly onerous and began almost immediately upon establishment of each state post. The relationship between labour recruitment and deployment and the overall upheaval experienced by northern Congolese, especially before 1920, is crucial to an understanding of outbreaks of sleeping sickness.

In 1904, sleeping sickness was declared to be epidemic in some parts of the Congo Free State. This was the conclusion of a team of British scientists invited from the Liverpool School of Tropical Medicine to conduct a survey of health conditions in central Africa. They advised the state authorities to take immediate action to control the further spread of sleeping sickness. It was certainly not the first time the disease had been reported. The ‘sleepy sickness’ had been noted in the region in the early 1880s, and fresh outbreaks were confirmed by missionaries and travellers. But, by 1901, a terrible epidemic had spread around the northern shores of Lake Victoria and neighbouring islands in the Lake in the region of Busoga, in the adjoining Uganda Protectorate.

The declaration of an epidemic was a watershed in the history of public health for Africans in the Congo; for, more than any other one factor, sleeping sickness prompted the development of the Belgian colonial medical service. This medical service was consciously used by the Belgians as a form of ‘constructive imperialism’, with which they hoped to establish European influence. The provision of health services was considered by the Belgians to be a central feature of what they called their ‘civilising mission’ in Africa.

In discussing sleeping sickness in Africa in the early twentieth century, there are three important points. First, there was a direct link between sleeping sickness and the rapidly expanding new field of tropical medicine.

Third phase: World War I

The period of the First World War can be considered as the third phase in the campaign against sleeping sickness in the Belgian Congo. Unfortunately, the war began just at the time when the colonial administration was in the process of addressing the problem of a medical service and public health policy in the Congo. An outstanding feature of the period of the war was the manner in which the colonial administration contradicted its own public health policy and, in fact, aggravated human sleeping sickness in northern Congo. The reprise of the Congo in 1908 had not been widely popular amongst Belgians at home but the war revealed, for perhaps the first time, the fact that their government needed the labour and resources available in its colony. Evacuated to Britain because of German occupation, the Belgian government looked to its African colony for material assistance in the war effort. North-eastern Congo was suddenly of great importance for three reasons: gold, rubber and labour. We can get some idea of the effect of the war by examining the figures for gold production in northern Congo during the war. In 1913, the total sales from Kilo-Moto amounted to 4,676,852 francs, but by 1918, the sales were 12,394,256 francs and in 1919, 19,796,000 francs. In six years, the sales had quadrupled.

But the constantly increasing demands for gold, rubber and men forced the colonial administration to contradict much of its own recent public health policy in the north-east. The labour demands required an intensification of the movement of population throughout the northeast, and that meant that the recently imposed cordon sanitaire became a hindrance to the war effort.