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 CONFLICT AND HEALTH; Civil conflict and sleeping
sickness in Africa
 Esther Shisoka, MPH student Walden University
 PH 6165-5
 Instructor: Dr. Jalal Ghaemgami
 Winter Quarter, 2009/2010
CIVIL CONFLICT AND SLEEPING
SICKNESS IN AFRICA
TABLE OF CONTENTS
 1. Introduction
 8. Hurdles to Intervention
 2. Disease Definition
 3. Mode of Transmission

 4. Disease Symptom

 5. Treatment
 6. Geographical Distribution
 7. Cases In Point;
 a. South-Eastern Uganda
 b. Angola
 c. The Sudan
 d. The Democratic Republic
of Congo



and Prevention
9. Solutions
10. Breakthrough Treatment
11. Conclusion
12. References
13. Further Reading
IINTRODUCTION
 Sustained political instability
and violence have massive
impacts on the health of the
people affected. Studies show
that more die from treatable
diseases during conflict than
they do from conflict-related
casualties. This is because the
already poor state of
healthcare facilities often
deteriorates to a point where
diseases that require only
basic treatment such as
malaria or diarrhoea cannot
be cured.
 The association between
conflict and infectious
disease are particularly
prevalent in Africa, where
there is ongoing civil conflict,
and where infectious diseased
remain important
contributors to national
mortality.
Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
INTRODUCTION
 Conflict and war have long
been recognized as
determinants of infectious
disease risk.
 Re-emergence of epidemic
sleeping sickness in subSaharan Africa since the
1970’s has coincided with
extensive civil conflict in
affected regions.
refugees.org
news.bbc.co.uk

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and Uganda
in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
boblivolsi.com
alphabetics.info
INTRODUCTION
 Outbreaks and increased disease
incidence have been attributed
to a range of factors associated
with conflict. These include;
 a. decreased hygiene
 b. dietary deficiences
 c. decline of health services
 d. travel insecurity
refugees.org
 e. reduced access of
humanitarian support
 f. reduced veterinary and
zoonoses control
 g internal displacement of
populations into marginal areas.

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general
and Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/17521505-1-6
refugees.org
DISEASE DEFINITION
 Sleeping sickness is a
protozan parasitic
disease affecting
humans, livestock and a
large number of sylvatic
species in much of subSaharan Africa

flickr.com
infosdelaplanete.org
Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
goryfiles.blogspot.com
baggas.com
MODE OF TRANSMISSION
 Sleeping sickness is
transmitted by the tsetse
fly vector
trypanosomiasis.
 There are two subspecies of humaninfectious trypanosomes;
 a. T.b. gambiense
 b. T.b. rhodesiense

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
T.b.gambiense
T.b. rhodesiense
grahamazon.com
grahamazon.com
DISEASE SYMPTOMS
 Stage one symptoms
begin with fever,
headaches and joint
pains, which are often
mis-diagnosed as
malaria.
 If untreated, the disease
slowly overcomes the
defences of the infected
person and then the
parasite passes through
the blood-brain barrier

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
biochem.arizona.edu
DISEASE SYMPTOMS
 Stage two symptoms
include confusion and
reduced coordination,
the sleep cycle is
disturbed with bouts of
fatigue punctuated with
manic periods
progressing to daytime
slumber and night-time
insomnia. Even if
treated the damage
caused in the
neurological phase can
be irreversible

Medecins Sans Frontiers; Switched off: sleeping sickness in conflict
http://www.msf.org.uk/two_doctors_20091030.news
sleepzine.com
dfid-ahp.org.uk
doctorswithoutborders.org
research4development
TREATMENT
 Sleeping sickness
treatment is expensive,
complicated and can be
dangerous for the patient.
 The dominant treatment
for late-stage sleeping
sickness that involves the
central nervous system is
melarsopol, an
organoarsenic compound
with high toxicity and
varying rates of treatment
failure.

medilinkz.org
miyazaki-med.ac.jp
Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular;
answers.com
medilinkz.org
11
TREATMENT
 Sleeping sickness is problematic
because laboratory facilities are
required to diagnose the disease
 A lumbar puncture may also be
needed to differentiate between
stages 1 and 2
 Treatment is relatively less
complicated and still effective
for patients at stage 1. However,
most cases present themselves at
stage 2, this is when the
treatment becomes very
difficult.

Medecins Sans Frontiers; Switched off: sleeping sickness in conflict
http://www.msf.org.uk/two_doctors_20091030.news


Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
Africa: Detecting stealth sleeping sickness; http://www.irinnews.org/PrintReport.aspx
world-countries.net
msf.org
pubs.acs.org
msf.ie
GEOGRAPHICAL DISTRIBUTION
 Sleeping sickness was first identified and
characterized in Africa in the last part of
the 19th century, a period that coincided
with widespread and severe epidemics of
the disease in Kenya, Tanzania, Uganda,
Nigeria, and the Democratic Republic of
the Congo.

medilinkz.org
 The disease was generally brought under
control by the 1960s in much of Africa but
has re-emerged in many countries since the
1970s.
 The re-emergence has been attributed to
post-independence turbulence, unstable
governments, limited public health
resources, and re-allocation of domestic
and international funding towards malaria,
HIV/AIDS, and tuberculosis.
 In areas of Sudan, the Democratic Republic
of the Congo, and Angola, sleeping sickness
occurs in epidemic proportions and is the
greatest cause of mortality

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and Uganda in particular; Conflict
and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
medilinkz.org
CASES IN POINT
 SOUTH-EASTERN UGANDA
 T.b.rhodesiense epidemic in 1976-1990s
coincided with political instability and
civil war during and after the rule of Idi
Amin.
 The civil war influenced the
transmission of sleeping sickness by;
a. Breakdown of veterinary and public
health services
 b. Collapse of vector control, re-growth of
bushy tsetse habitat in abandoned
agricultural fields
 c. Increasing displacement of human and
animal populations into marginal or
swampy areas where they are more likely
to be bitten by flies


Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general
and Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/17521505-1-6
wildgooseministries.org
CASES IN POINT
 ANGOLA
 Sleeping sickness re-emerged in
Angola during a prolonged civil
war following the country’s
independence in 1975.
 Peripheral mining regions were
subject to active insurgencies,
resulting in high insecurity. This
made implementation of
sleeping sickness control
activities logistically impossible.
 In the 1990s two Angolan
diagnostic and treatment
centers had to be abandoned
due to rebel attacks.

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in
general and Uganda in particular; Conflict and Health 2007, 1:6
doi:10.1186/1752-1505-1-6
usaid.gov
CASES IN POINT
 THE SUDAN
 Sudanese health and disease
control infrastructure was
essentially non-operable during
two decades of civil war in the
1970s-1990s.
 By 1997, sleeping sickness had
re-emerged in Sudan with
prevalence rates as high as 19%.
 Outbreaks in the 1990s in
Sudan, have been linked to
abandonment of land, bush
invasion, and increased risk of
exposure for returning internally
displaced people

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
travelblog.org
CASES IN POINT
 THE DEMOCRATIC REPUBLIC OF







CONGO
Re-emergence of disease and new
epidemics were reported in the 1970s and
1980s.
In 2007, the organization, Doctors Without
Borders, opened a sleeping sickness project
in the north eastern part of the country.
This area borders Uganda and Southern
Sudan and has been subject to sporadic
conflict and political tension for many
years.
Since September 2008, the insecurity and
violence has caused almost all DWB
activities to be shut down
It is feared that 5,000 people in the region
will die within the next two years if they
cannot access treatment .
Refugees are entering new regions, raising
the risk of reactivating the disease in places
where it has been eradicated.
Medecins Sans Frontiers; Switched off: sleeping sickness in conflict
http://www.msf.org.uk/two_doctors_20091030.news
cge.aed.org
HURDLES TO INTERVENTION AND
PREVENTION
 Transmission determinants of
sleeping sickness include the
following;
 a. Land cover change i.e.
increased vegetation growth
around homesteads and the
resulting movement of tsetse
flies into peridomestic
environments.
 b. Collapse of essential health
services, and veterinary and
vector control
 c. Reduced surveillance and
treatment in both humans and
animal reservoirs of infection.

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general
and Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/17521505-1-6
 d. Insecurity due to conflict
constrains the capacity of both
national governments and
external organizations to
respond to outbreak situations.
 e. Lack of harmonization and
integration of activities between
organizations trying to control
the disease.
 Absence of appropriate
administrative infrastructures
for program implementation.
SOLUTIONS
 Efforts to prevent and control
sleeping sickness must identify
and integrate knowledge of the
processes by which conflict
affects disease.
 Increased drug development is
needed to identify and develop
newer, safer drugs with more
secure availability and supply to
the African market.
 Active surveillance, early
treatment, and outbreak
prevention can considerably
reduce the burden of disease.

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
 In countries recovering from
recent civil war, rapid reestablishment of essential
health services and active
surveillance and treatment will
be central to reducing sleeping
sickness incidence.
 Resources can be optimized in
the short term by targeting
outbreak locations and areas
bordering countries with high
incidence
BREAKTHROUGH TREATMENT
 NECT (Nifurtimox-Eflornithine
Combination Therapy), the first
new treatment in 25 years
against Human African
trypanosomiasis is now
available. Endemic countries
have now begun the process of
ordering the new combination
treatment and kits through
WHO. NECT cuts the cost of
treatment by half and
significantly reduces the burden
on health workers.
africanhealingjourneys.com

Medecins Sans Frontiers; Switched off: sleeping sickness in conflict
http://www.msf.org.uk/two_doctors_20091030.news
CONCLUSION
 The campaign to eliminate the
tsetse vector from the African
continent will face enormous
hurdles due to continued conflict.
Progress to curb sleeping sickness is
more likely to come from slow
development of national capacity,
policy infrastructure, administrative
integration, and political
stabilization in affected countries.
Local interventions, with localized
infrastructure and rural
development capacity, may be better
placed to provide essential services
during times of intense or
widespread conflict.

Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in general and
Uganda in particular; Conflict and Health 2007, 1:6 doi:10.1186/1752-1505-1-6
 An understanding of areas where
conflict may contribute to increased
disease risk can guide prioritization
of continent-wide as well as
national mitigation programs.
Prevention and control campaigns
should be assessed and evaluated
against the ability of the initiative to
address, mitigate, or alleviate the
conflict-related drivers of disease
risk. Prevention of sleeping sickness
risk in affected sub-Saharan African
countries requires increased
international focus on development
of administrative policy, capacity,
integration, and infrastructure to
implement localized control
strategies.
REFERENCES
 Ford, L.B., (2007). Civil conflict and sleeping sickness in Africa in
general and Uganda in particular; Conflict and Health 2007, 1:6
doi:10.1186/1752-1505-1-6. Retrieved January 20,2010 from
http://doctorswithoutborders.org/news/allcontent.cfm
 Medecins Sans Frontiers(2009); Switched off: sleeping sickness
in conflict. Retrieved January 20, 2010 from
http://www.msf.org.uk/two_doctors_20091030.news
 IRINNEWS (2010). Africa: Detecting stealth sleeping sickness.
Retrieved January 20,2010 from
http://www.irinnews.org/PrintReport.aspx
FURTHER READING
1. Berrang-Ford L, Waltner-Toews D, Charron D, Odiit M, McDermott J, Smit B: Sleeping
sickness in southeastern Uganda: a systems approach. EcoHealth 2005., 2:
2. Moore A, Richer M, Enrile M, Losio E, Roberts J, Levy D: Resurgence of sleeping
sickness in Tambura County, Sudan. American Journal of Tropical Medicine and
Hygiene 1999, 61:315-318.
3. Stanghellini A, Gampo S, Sicard JM: The role of environmental factors in the present
resurgence of human African trypanosomiasis [Role des facteurs
environnementaux dans la recrudescence actuelle de la trypanosomiase
humaine africain]. Bulletin de la Societe de Pathologie exotique 1994, 87:303-306.
4. Jordan AM: Trypanosomiasis control and land use in Africa. Outlook on Agriculture
1979, 10:123-129.
5. Mbulamberi DB: Recent advances in the diagnosis and treatment of
sleeping sickness. Postgraduate Doctor Africa 1994, 16:16-19.
6. Garfield RM and A. I. Neugat: Epidemiologic analysis of warfare: a historical review
Journal of the American Medical Association 1991, 266:688-692