While some people talk about the elimination of sleeping sickness across Africa, in less than two months one MSF team has identified more than 160 people with the disease in Dingila in the Bas-Uélé District of Orientale Province. Dingila, a cotton-growing town, borders Ango District where, as in neighbouring Haut-Uélé, the Congolese population has been subjected to more than two years of attacks by rebels from the Lord’s Resistance Army (LRA). The situation likely is not unrelated to the southward spread of the disease.
This morning Jean-Dedieu M., a young teacher at a middle school in Ganga, a health area 37 km south of Dingila, could never have imagined how his day would go. He felt fine, and nothing other than the desire to visit two colleagues in the hospital and a little bit of free time would have caused him to go to the hospital so early.
A curious man, Jean-Dedieu walked over to a group chatting under a mango tree and suddenly found himself busy all day. “They told me about sleeping sickness,” he explains to me while having his blood drawn for the initial exam. “You never know….”
Since 20 September more than 8,700 people have been “screened” at the hospital. “During the first phase of the project, we’re researching trypanosomiasis only among people who voluntarily come to the hospital,” says Josué Amici, the project’s medical director. Among those, more than 160 already have turned out to be infected by human African trypanosomiasis (HAT), the disease’s scientific name. “That’s a large number,” emphasizes François Chappuis, the referent doctor for trypanosomiasis in Geneva who also points out the disease is fatal when left untreated.
Jean-Dedieu exits the room set up to conduct the first test, the CATT, which uses an agglutination technique to signal, or not, the presence of parasites in the blood. He heads for the second step in the screening process, a sign that he is already suspect. Jean-Pierre Kango, who oversees the MSF team charged with raising awareness, joins us. “Efforts to raise awareness among the population began well before 20 September. They really contributed to the intervention’s success,” he tells us. “The local administrator helped us enormously. That’s no surprise. MSF saved his life in Bili….”
Bili, another cotton-growing village located farther north in Bas-Uélé, was the site of MSF’s previous trypanosomiasis project in Orientale Province. The project had to be closed in March 2009 following the attack on and looting of MSF’s treatment centre farther east in Banda by an unidentified armed group. Today Caroline Madamu is a nurse in Dingila, but she was in Banda when the attack occurred. “What hurts most,” she says, “is the thought of all those who we left behind, still sick. Thankfully, many people were able to flee this far.” Indeed, many believe those displaced people brought the sleeping sickness parasite here.
Morning wears on, and Jean-Dedieu continues to make his way through the screening maze. Finally he breathes a sigh of relief. After examining Jean-Dedieu’s neck, Dieudonné Gomete, the lab assistant who specializes in trypanosomiasis research, did not feel the swollen glands that are characteristic of advanced sleeping sickness—and the possibility of detecting the parasite in the cerebrospinal fluid, denoting stage 2 of the disease. More detailed blood tests follow, with extremely fine tubes from the centrifuge being studied under the microscope.
Jean-Pierre Tshibangu is also a lab assistant with considerable experience in treating sleeping sickness. For five years he has worked in many different MSF sites in DRC, the country where he was born. He oversees the flow of patients. “We’re entering the treatment room for patients with stage 1, meaning trypanosomiasis has not yet affected their nervous system,” he explains, opening the door to the nearby “HAT wing.” About 15 people of all ages are lying on mats. They are quietly awaiting their daily Pentamidine injection. “Patients come to the hospital every day for seven days. They must lie down for a good hour under medical watch.”
Jean-Dedieu is now alone on a bench outside the lab. He appears to be thinking. Jean-Pierre joins him, and they talk. Jean-Pierre explains that now it is necessary to confirm that he does not have trypanosomiasis in the cerebrospinal fluid. Jean-Dedieu tries hard to avoid the lumbar puncture by claiming a meeting, but finally gives in and follows Jean-Pierre to the exam room.
I take the opportunity to catch up with Josué. The MSF medical director leads me into the second room in the HAT wing where confirmed cases of stage 2 are hospitalised. “We’re using NECT, a new treatment that lasts ten days and requires strict medical monitoring,” explains Josué. “Given the success of passive screening, people on the waiting list will have to wait 20 days because all the beds in the hospital are already occupied. With that in mind, we’re going to postpone active screening for the moment and test only those people who come to the hospital.”
Active screening is the greatest challenge of trypanosomiasis programs. It is the only approach guaranteed to interrupt the tsetse fly’s chain of transmission. Indeed, only by meeting with people living in villages deep in the forest can we effectively find those who are infected, especially in areas where people have forgotten about the disease’s existence. “That’s exactly the case here,” asserts Dominique Amisi, the lead doctor for the Dingila health area. “Prior to 1960 there were campaigns to find infected patients. Doctors went looking for swollen glands. We live in an endemic region, but everyone has forgotten this.” Everyone here believes the population movements that follow the attacks by armed groups farther north have reignited the fire.
I don’t see Jean-Dedieu when I leave the HAT wing, so I inquire about him. Jean-Pierre leads me right to him. Jean-Dedieu must lie on his back for a good hour after the lumbar puncture and is on a mat with several other patients not far from the exam room. “I didn’t pass my last test. They say I’m stuck at stage 1,” he says, half jokingly. “I’m going to have to leave my students for a week, but that’s not too much to ask to save one’s life!”Sleeping sickness really has taken hold in Dingila.
MSF has two trypanosomiasis projects in the DRC’s Orientale Province: Dingila, which is turning out to have a potentially greater number of infections than expected, and Doruma, which is now expanding into areas that had not been monitored previously. In Doruma 390 cases of sleeping sickness have been treated since the beginning of the year.
The fragile nature of these interventions still lies in the insecurity linked to the presence of armed groups. Insecurity, combined with inadequate public health services, is one of the greatest obstacles to the potential elimination of sleeping sickness.