In the heart of darkness: Sleeping sickness in Zaire

Human African trypanosomiasis (HAT) control programs existed during the colonial era in the Belgian Congo. HAT cases peaked in 1930 at 33,562. They declined gradually to about 1000 cases in 1959. The civil war that erupted after Zaire's independence in 1960 crippled the public health system. During 1960-1967, no active case finding was conducted and notification of HAT cases fell greatly. Mismanagement and corruption maintained a severe social and economic crisis after the civil war. At the end of the 1980s, the number of new HAT cases began to increase from the relatively stable numbers of 4000-6000 during 1969-1981 to almost 10,000. Socioeconomic conditions deteriorated quickly in the 1990s. The withdrawal of foreign aid in 1991 devastated many governmental health facilities that had been dependent on these funds. In much of Zaire, Catholic and Protestant missions were the only health care providers. The breakdown of the health system contributed to epidemics of Ebola fever, dysentery, the plague, and cholera. The specialized mobile teams providing trypanocidal drugs to HAT patients could no longer operate, resulting in drug shortages and thousands of deaths. The teams were somewhat remobilized during 1993-1994, when some foreign aid was again available. A return to neglected areas in 1994 found the HAT prevalence to be 15.4/1000 in the Equator region. In Kimbanzi, Bandundu region, it was 718/1000 among 241 persons examined. Had the teams not arrived when they did, the entire village of Kimbanzi could have disappeared within 1-2 years. The high prevalence rates in neglected areas were the highest rates recorded this century. The neglect brought about an increase in the number of infectious people, an increase in transmission, and a higher cost and toxicity of treatment due to an increase in late-stage HAT cases. The estimated true total incidence of HAT in Zaire in 1994 was about 34,400 new cases. The number of HAT deaths in 1994 was probably at least 80 times higher than that of Ebola deaths in 1995. Proper HAT control methods need to be fully funded and implemented to control this curable disease.