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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