Civil conflict and sleeping sickness in Africa in general and Uganda in particular

Abstract

Conflict and war have long been recognized as determinants of infectious disease risk. Re-emergence of epidemic sleeping sickness in sub-Saharan Africa since the 1970s has coincided with extensive civil conflict in affected regions. Sleeping sickness incidence has placed increasing pressure on the health resources of countries already burdened by 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 first or second greatest cause of mortality in some areas, ahead of HIV/AIDS. In Uganda, there is evidence of increasing spread and establishment of new foci in central districts. Conflict is an important determinant of sleeping sickness outbreaks, and has contributed to disease resurgence. This paper presents a review and characterization of the processes by which conflict has contributed to the occurrence of sleeping sickness in Africa. Conflict contributes to disease risk by affecting the transmission potential of sleeping sickness via economic impacts, degradation of health systems and services, internal displacement of populations, regional insecurity, and reduced access for humanitarian support. Particular focus is given to the case of sleeping sickness in south-eastern Uganda, where incidence increase is expected to continue. Disease intervention is constrained in regions with high insecurity; in these areas, political stabilization, localized deployment of health resources, increased administrative integration and national capacity are required to mitigate incidence. Conflict-related variables should be explicitly integrated into risk mapping and prioritization of targeted sleeping sickness research and mitigation initiatives.

Figure 1

Distribution of sleeping sickness in Africa and map of Uganda showing the case study area. The approximate location of the 'Luwero Triangle' is shown; this is where much of the conflict and violence was concentrated during Uganda's civil war (1979–86). Sleeping sickness status data from WHO (2001).

Figure 2

Sleeping sickness epidemics and major political events in Uganda, 1905–2000. Cases from 1936 onwards include south-eastern Uganda only. Sources: Sleeping sickness data 1905–36 deaths [62], 1925–36 cases [62], 1937–58 cases [63], 1960–71 cases (Unpublished report, 1992, Mbulamberi, D. B. The sleeping sickness situation in Uganda: past and present. National Sleeping Sickness Control Program, Jinja, Uganda), 1972–75 cases [54], and 1976–2001 cases (Ministry of Health, Uganda); Political time-series [56, 64, 65].