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.

The Belgian conquest of northern Congo was brutal and protracted, taking several decades as African populations strove to retain their independence. The systematic and ruthless exploitation of the land and people which had begun with Afro-Arab traders in the 1860s and 1870s was further developed by the Belgians, first under the flag of the Congo Free State and then under that of the Belgian Congo. This chapter will provide the background necessary to understand how disruptions to African populations and their physical environment resulted in an ‘ecological disaster’ in northern Congo early this century. Beginning in the late nineteenth century and continuing for some decades into the twentieth, African populations located in what are today the southern Sudan and northern Zaire were subjected to a series of frightful events which, for many of them, resulted in severe malnutrition and lowered resistance to disease. For many, sleeping sickness increased in incidence becoming epidemic in large areas of the north. During the period of their occupation of the Congo, the Belgians believed that most of the northern region of the territory remained free of epidemic sleeping sickness unlike other parts of the colony. This was not true and I will show that for many years a large portion of the north was severely afflicted by epidemic sleeping sickness.

There is no doubt that Belgian conquest and occupation of the Congo was violent and destructive in the early decades of this century and that for many residents of the north the violence continued well into the 1920s.

SLEEPING SICKNESS AND AFRICAN SOCIETIES

Chapters 7 and 8, in discussing at length the main features of the Belgian sleeping sickness campaign until 1930, stressed the proliferation of legislation and directives. The colonial authorities hoped to control the spread of the disease through administration; in the early decades with no cure, the emphasis was very much upon prophylaxie biologique. As early as 1904, a state doctor had claimed that ‘to stop the propagation and diffusion of disease is no longer a scientific problem but simply an administrative problem’.

There is ample evidence with which to piece together the history of Belgian colonial medicine, the history of Europeans in Africa. But what about Zairean history? For instance, how did Zaireans perceive the enormous upheavals between 1891 and 1930? There can be no doubt that for many Africans populations, a significant feature of Belgian conquest and colonisation was increased incidence of illness and death. The ensuing brutal exploitation of the land and people meant that sleeping sickness, previously endemic in regions of the territory, sometimes spread and became epidemic. We can begin to understand the African point of view, firstly, by outlining the major cultural and social factors moulding their perceptions and, secondly, by examining their responses to sleeping sickness and the colonial public health programme. It must be stated at the outset that the major sources for this section are European; nevertheless, as will be demonstrated, a careful reading of the reports and accounts of independent travellers, missionaries, state agents and medical staff reveals much in the search for the African view.

Belgian public health policy was eminently spatial in concept. As has been shown previously, a principal feature of the sleeping sickness campaign was the cordon sanitaire. The Belgians hoped eventually to sterilise the total human reservoir of the disease-causing pathogens, but until such time it was necessary to enforce a strict line of defence around the still uninfected portions of the colony. The health of the African population would be monitored and protected by dividing the entire colony into a pattern of zones designated as either ‘infected’ or ‘noninfected’ by sleeping sickness. A complex set of regulatory measures was produced to control the movements of people among the zones, with particular emphasis on limiting access to non-infected areas, as much of the Uele district was presumed to be. Such a global public health policy, focused on limiting movement, affected every sphere of African life – social, political and economic.

Most Congolese, however, perceived the sleeping sickness policy as simply another feature of foreign domination. Before 1930 the majority of northern Congolese would have had considerable difficulty distinguishing between medical and all other economic and political regulations imposed by the state. Most people were bewildered by the web of administrative edicts and many often found themselves caught in the dilemma of being forced by demands of one colonial department to break the rules of another department. The life of a Congolese was made no easier by public health measures intended to protect him from disease.

The idea of social medicine in the Belgian Congo was born in the special campaign against sleeping sickness. In the words of one colonial doctor, sleeping sickness was a ‘scourge which even an administration as unfeeling as the Congo Free State could not ignore' and by the mid- 1930s most Belgian colonials tended to regard their medical and public health programmes as a form of compensation for the hardships caused by their colonisation of African peoples. But for Congolese populations, the campaign against sleeping sickness had other important implications which affected their existence in ways far beyond the more traditional boundaries of public health. It became widely accepted that the special sleeping sickness campaign was the basis for both the colonial medical service and a public health programme since it was, as in several other African colonies, the first real effort made by the Europeans to deal with the health of Africans. It was during this phase that the real ‘medicalisation’ of the Congolese began. People were systematically introduced to the idea that European doctors and their medications were the solutions to problems of ill health. The Belgian sleeping sickness campaign was elaborated and refined over time until by the 1930s it formed the core of the colonial public health programme. Yet the large-scale campaigns waged against one disease, sleeping sickness, often became so bureaucratised and routine that it was almost impossible to implement important changes in public health policy to deal with other health problems.

Belgian pride in medical services – best in Africa

When their colonial venture came to an abrupt end in June 1960, the Belgians were convinced of the success of at least one aspect of their halfcentury administering the Congo – they were confident that their medical service was outstanding in all of colonial Africa. Many agreed. In 1958 a European Common Market survey described the medical infrastructure in the Belgian Congo as the best in tropical Africa and a 1959 US government report agreed that the Belgian programme was one of the best on the continent with more hospital beds in the Congo than in all the rest of tropical Africa. Most Belgian administrators would have explained that their paternalistic administration had been a resounding success in the area of public health; this success, they would argue was exemplified in part by the near-conquest by medical means of at least one disease, human sleeping sickness.

Sleeping sickness and ‘vertical’ health programme

They believed that their policy of concentrating efforts and resources in a campaign aimed at one disease, sleeping sickness, was responsible in large part for this success. In public health parlance, such concentration of resources is described as a Vertical' model of health-care delivery. As we have seen, their approach to control of the disease, unlike that of the British for instance, had been the attempted medication of the entire population of the colony in order to systematically ‘sterilise’ the human reservoir of the disease-causing parasites, the trypanosomes. The campaigns of mass chemotherapy were aimed at the parasite while the basic ecology of the disease remained unaltered.