THE COLONIAL HEALTH SERVICE AND THE OVERSEAS PASTEUR INSTITUTES

In December 1890, M. Etienne, Under-Secretary of State for the Colonies, writes to Pasteur asking him to create a centre in Saigon for vaccination against Smallpox and Rabies. At the same time, a senior colonial physician, Albert Calmette*, follows lectures on microbiology given at the Pasteur Institute by Emile Roux. Pasteur convokes him and offers him the post which Calmette accepts immediately. The first links between the Pasteur Institute and the Colonial Health Service date from this historic meeting.

These intrepid pioneers soon make important discoveries. They open the way to an army of builders. Right across the world, these disciples of Pasteur, among whom Yersin* distinguishes himself, multiply establishments, branches of the Paris Pasteur Institute. Their work, concentrated more on applied research rather than speculative research, is an appropriate response to the message of both Pasteur and the Colonial Health Service : "to be always in contact with and in the service of men, especially the poorest and the most vulnerable". The evolution of these institutes in the new independent states took place in perfect accord with "the mother house".

Among the accomplishments, one must remember, notably, the eminent role played by the Institutes in the discovery of anti-venomous serums and vaccines still being used against tuberculosis, plague and yellow fever.

THE PIONEERS

As soon as he arrives in Saigon, Albert Calmette installs his laboratory in an outbuilding of the military hospital. It is the beginning of the Pasteur Institute of Saigon which is inaugurated in 1896.

Constant MATHIS

In 1895, while exploring the Indochinese hinterland, one of Pasteur’s first students, Alexandre Yersin*, who had discovered the plague microbe in Hong Kong the year before, founds a Pasteur Institute in Nha-Trang.

In 1896, A. Marchoux* is given the mission of applying Pasteur methods to the study of microbial and parasitic diseases in Black Africa. He installs, in the premises of the Saint-Louis Military Hospital of Senegal, the first African laboratory of Microbiology which becomes, during the three years of his sojourn, a renowned centre of research. Transferred to Dakar, this laboratory plays a prominent role in the fight against Yellow Fever and is named the Dakar Pasteur Institute, inaugurated by Constant Mathis* on the 1st of January 1924.

Back in France, these pioneers, enriched by their experience in the domain of organizing as well as in that of scientific competency, are given appointments in the Paris Pasteur Institute. They form, together with the few rare specialists in Metropolitan France, the first nucleus of the "Society of Exotic Pathology", founded by A. Laveran in 1908, a meeting point for reflection and discussion, with the publication of a periodic bulletin.

Every year since 1903, the physicians of the Colonial Health Service come to the Pasteur Institute in Paris to follow a course in Microbiology and to improve their knowledge of Tropical Pathology. Since the inauguration, in 1905, of The School of Medical Practice of the Colonial Health Service, microbiology is given great importance in the programme of training for colonial physicians and chemists. The subject is usually taught by physicians in military service who are followers of Pasteur.

THE BUILDERS

Pasteur himself had expressed the wish that his discoveries would be beneficial to the most underprivileged populations and those most vulnerable to infectious and parasitic diseases. Emile Roux and those who succeed him as Director of the Pasteur Institute pay particular attention to the realisation of this wish. In this regard, N. Bernard* and H. Marneffe*, as Vice-Directors of the Institute, play an important role, just as M. Vaucel* does after the creation of an Administration of Pasteur Institutes outside Metropolitan France.

It is to the colonial military physicians thus trained in the school of Pasteur that the responsibility is given for the establishment and functioning of most of the vaccination centres and microbiology laboratories, of which many, just like those in Saigon and Dakar, have later become Pasteur Institutes.

These tropical laboratories of the Pasteur Institute have also contributed towards the scientific and technical training of native collaborators and participated in higher education in the faculties of Medicine and Chemistry.

The activity of colonial physicians and chemists are, above all, oriented towards applied research, faithfully following the Pasteur doctrine, and there is no aspect of tropical medicine nor any improvement in Public Health to which the Pasteur Institutes and the microbiology laboratories they control have not made their contribution.

Pasteur Institute of Dakar "To Pasteur. From grateful Black Africa"

The cultural stamp that France has left in the colonies represents the efforts made by many generations. The Pasteur Institutes have played an important role and the Colonial Health Service, which established and managed most of them, may well be proud of its accomplishment in this domain.

Albert CALMETTE

Albert CALMETTE (1863-1933)

When in 1880 Albert Calmette* began his studies at the Naval School of Medicine in Brest, it was still thought that diseases such as Malaria and Yellow Fever that he, helpless and disappointed, had to contend with on board the Hospital Ship Alceste, in the remote countryside of Gabon, had a telluric origin. Ten years later, in 1890, in Saigon, he shows his astonished fellow physicians how easily Laveran’s haematozoon can be found in the blood of patients suffering from Malaria.

Gradually, he improves the laboratory equipment so that he succeeds, during his sojourn of two and a half years, in preparing sufficient quantities of vaccines against Smallpox and Rabies for the whole of Indochina and even the neighbouring countries.

He succeeds in isolating the yeast that enables the industrial manufacture of rice alcohol. Finally, he begins the researches which will end in the discovery of anti-venomous serotherapy, refined and perfected at the Pasteur Institute of Lille which he directed after his return from Saigon.

It is once again in Lille that the Chief Physician Calmette cultivates, with the collaboration of Guérin, a bacillus to be found in cattle suffering from tuberculosis and treated with bile. It is called the bacillus Calmette-Guérin, better known by its initials BCG. This bacillus is capable of protecting man against the most serious forms of tuberculosis The anti-tuberculosis vaccine which is still used universally had just been discovered.

Alexandre YERSIN

Alexandre YERSIN (1863-1943)

His discovery in Hong-Kong of the plague bacillus is the beginning of a memorable adventure that continues in Indochina.

Yersin* establishes in Nha-Trang a laboratory and, at the same time, a breeding centre for the study of animal diseases and the preparation of an anti-plague serum; then an agricultural centre where he succeeds in acclimatizing the rubber tree which ensures Indochina’s economic development.

Commander Lyautey who meets him at this time writes in 1896 : "This young physician of the Colonial Health Service settled down in Nha-Trang, whose Pasteur laboratory is going to be famous in History… The time we spend in this establishment which is still rudimentary - with this young scientist without any personal needs, uniquely bent on the performance of his task - is quite heartening".

He is the first Director of the Indochina School of Medicine opened in Hanoi in January 1902.

The gradual scarcity of cinchona, a tree that grows in Peru and neighbouring countries, necessitates the cultivation of this plant elsewhere. Only in Indonesia in 1852 and in India in 1872 is there complete success, but a real monopoly comes into being. The increasing demand for quinine, extracted from the plant, to treat the local populations, and its price which rises higher and higher, makes Yersin envisage the growth of cinchona in Indochina.

Yersin, who has already succeeded in acclimatizing the rubber tree there, begins to do the same with cinchona. After many difficulties, he achieves complete success on the hill of Dran. The quinine content of the barks is found to be sufficient to continue cultivation, which leads to a rapid spread of plantations. In 1931, 2 100 tons of cinchona bark are treated. It will be 29 600 tons in 1939, on the eve of the war against the Japanese.

In 1937, the supply pharmacy of Tourane extracts 287 kg of the sulphate of quinine. Two years later, Indochina becomes an exporter of quinine. In 1943, under the direction of Deniel* and Clemensat*, the production attains 3 tons and Malaria declines everywhere.

At the time of his death in 1943, Yersin is aware that Indochina has the means to combat Malaria alone. He is buried in NHA TRANG where his grave is still looked after.

THE ESTABLISHMENTS OF THE PASTEUR INSTITUTE OF PARIS

Between 1890 and 1970, of the 25 associated Pasteur Institutes and Laboratories established in the five continents, 17 have been founded by physicians of the Colonial Health Service, 15 in the ancient colonies and 2 in Iran and China.

Their functioning has been assured by about a hundred colonial physicians and chemists.

Below is a list of Pasteur Institutes established by the physicians of the Colonial health service, the dates of their creation, the names of the founders and first Directors :

1891 - Calmette* - Microbiology Laboratory of Saigon, which becomes a Pasteur Institute (P.I) in 1896.
1895 - Yersin* - Pasteur Institute of Nha-Trang (Vietnam).
1896 - Marchoux* - The Saint Louis Microbiology Laboratory (Senegal) - P.I. of Dakar in 1924.
1898 - Thirough* - Microbiology Laboratory of Antananarivo - I.P. of Madagascar in 1927.
1908 - Martin* G. - Pasteur Institute of Brazzaville (Congo).
1910 - Noc* - Microbiology Laboratory of Fort de France - I.P. of Martinique in 1938.
1902 - Kerandel* - Microbiology Laboratory of Phnom-Penh - I.P of Cambodia.
1913 - Leboeuf* - G. Bourret Institute of Nouméa - I.P. of Nouméa in 1955.
1914 - Leger* M. - Microbiology Laboratory of Cayenne - I.P. of Guyana in 1940.
1917 - Gauducheau* - Microbiology Laboratory of Hanoi - I.P. of Hanoi in 1925.
1920 - Mesnard* - Pasteur Institute of Teheran (Iran).
1924 - Fabre* Microbiology Laboratory of Pointe à Pitre - I.P. of Guadeloupe in 1948.
1936 - Souchard* - Pasteur Institute of Dalat (Vietnam).
1938 - Raynal* - Pasteur Institute of Shanghai (China).
1959 - Gamet* - Pasteur Institute of Yaoundé (Cameroon).
1960 - Chippaux* A. - Pasteur Institute of Bangui (Central African Republic).
1970 - Chippaux* A. - Pasteur Institute of the Ivory Coast.

APPLIED RESEARCH

Faced with the magnitude of the task accomplished by the colonial military physicians and chemists, we shall content ourselves with mentioning some original achievements which, among many others, are particularly striking :

– Plague. The victory over plague is realized in three stages by great figures of the Colonial Military Health Service, all three of them disciples of Pasteur : Yersin* isolates the microbial agent; Simond* identifies the carrier of the disease, the flea; Girard* and Robic* develop a very efficient vaccine.

– Sleeping Sickness : in 1905, G. Martin*, a student of Mesnil, brings to the Pasteur Institute living strains of trypanosomes isolated in Guinea. Following a second mission in Congo, he is given the task of establishing a Pasteur Institute in Brazzaville, which later became a centre for research on Trypanosomiasis. E. Jamot*, the Director of this Institute in 1916, conceives a method of prophylaxis of remarkable efficacy which, applied by the Colonial Health Service, practically eliminated this disease.

– The perfection of vaccines resistant to heat is essential for ensuring their innocuousness and efficiency when they are transported and used in the tropics. The use of the most modern materials and the latest techniques have made the Pasteur Institute of Dakar the unique centre in Africa for the production of anti-rabies vaccine, leading to the decentralisation of the preventive treatment of rabies, and of antiamarillic and anti-tuberculosis (BCG) vaccines, in accordance with international standards. These vaccines are widely used in African states for protection against Yellow Fever and Tuberculosis.

THE EVOLUTION OF OVERSEAS PASTEUR INSTITUTES

In 1970, Jacques Monod, a recipient of the Nobel Prize for Medicine, taking over the direction of the Pasteur Institute declares: "The Pasteur Institute would find it impossible to accomplish the tasks that are confided to it without the support of the military personnel so worthy of praise for their competence and dedication". Going from words to action, it is physicians of the Colonial Health Service that he appoints to the newly-created posts of Medical Adviser to the Director and that of Chief Administrator of the Overseas Pasteur Institutes and Voluntary Service Overseas.

At present, the overseas Pasteur Institutes have become the "international network of Pasteur Institutes and associated Institutes", a title which expresses both the diversity of the statutes of these establishments and the link which unites them. The organisation consists of 22 institutes and the Military Health Service still plays an important role in it. One third of the establishments are directed by military physicians.

For further information :

– L Chambon et A. Rivoalen : L’oeuvre des pasteuriens. Médecine et Armée 1973, T 1, n°2 p 72-80.
– P. Brès and L. Chambon : The Pasteur Institute Worldwide. Trends in Biochemical Sciences.1982 Vol 7 n°3, p 83-84.

RECAPITULATION AND CONCLUSIONS

"If there is something that ennobles and justifies colonial expansion", said Lyautey, "it is medical activity considered as a mission or an apostolate". The objective assigned to medical action in French colonisation is, in 1900, the protection of the health of tens of millions of persons all over the world, distributed over tens of millions of square kilometres.

When it finally ends its activities, has the Colonial Health Service fulfilled its mission and, in doing so, "ennobled" French colonisation ?

An assessment must take into account the means used. They have always been relatively modest. In all, a few thousand physicians, a few hundred chemists and non-commissioned officers doing nursing, some dozens of officers occupied with administration... budgets allocated parsimoniously !

However, in three quarters of a century, from 1890 to 1968, the improvement in health and living standards in the French colonial territories is remarkable.

The latest knowledge and means of procedure are handed over to the newly independent states.

– Scientific discoveries : microbes, biological data, vaccines...
– The establishment of an important system of medical infrastructures of proven efficacy.
– Numerous native personnel in the process of being trained for health service.
– The acceptance by the populations of methods derived from scientific reasoning.

Among the most obvious results, we can mention :

– The decline or disappearance of the great endemics, which was held as the primary objective.
– The progress in health statistics.
– The improvement in the quality of life as a result of better health.

Criticisms have been made and are still being made today, so easy it is to imagine one could have done better. Much more numerous and realistic are the tributes rendered in gratitude for these accomplishments by the countries that have benefited and by foreign experts.

The confrontation of two different cultures being always "a matter of giving and taking" (A. Césaire), the colonial medical practice of physicians and chemists from Europe does not fail to engender positive aspects in their own lives.

In 1960, the handing over of responsibility in health matters to the independent states takes place smoothly.

**School of Medicine and Chemistry inaugurated in Dakar in 1918**

SCIENTIFIC DISCOVERIES

The microbiological revolution is a result of the discoveries of Pasteur, Koch and their students. In a few decades, the pathogenic agents responsible for deadly diseases that decimate tropical populations, the insects that transmit them and the modes of contamination are identified.

Vaccines and serums are invented. The different sections of this website give an account of the medical and scientific discoveries that have permitted the elimination of threats of diseases and to end the reputation these countries have of being harmful to health.

Research workers of all countries have contributed towards this abundant harvest. Among them, the Colonial Health Service has played an important role and is notably responsible for :

– The discovery of the plague bacillus by Yersin*, a worthy successor of another French military physician, A. Laveran, the discoverer of the malaria agent.

– The discovery of the transmission of the plague by fleas in rats.

– The invention of vaccines, especially against two deadly diseases, Plague and Yellow Fever ; and the BCG vaccine against Tuberculosis discovered by Calmette* and Guérin.

– The formulation of serological tests to diagnose Sleeping Sickness and anatomical-pathological tests for other illnesses, in particular Yellow Fever.

– The codification of therapeutic schemas including the study of toxicity and the tolerance of medicines, especially in cases of malaria, leprosy, amoebiasis, trypanosomiasis, etc...

– The selection and the adaptation of widely used surgical techniques.

EFFICIENT MEDICAL INFRASTRUCTURES

With units all over the world, a great network of health establishments was put in place. When Independence dawns, France leaves on the territories where it has exercised influence, more than 4 000 diverse health establishments in full activity. Among them, there are 2 500 dispensaries or health centres, for the most part in rural settings, 600 maternity centres and 216 hospitals of which 41 are great edifices, without mentioning specialised centres, supply pharmacies and educational establishments.

As for the fifteen colonial Pasteur Institutes, they were all founded and kept functioning by members of the Colonial Health Service.

Maternity Hospital in Dakar

However remarkable the legacy of property may be, we must insist on the operational procedures put in place and tested during the colonial period and bequeathed to the new states.

It is, above all, a collective and preventive approach, said to be for the masses, having mobility as its main constituent: travelling around to be in contact with populations and patients. This is the strategy used in the combat against the endemics needing the greatest attention, the Jamot* method, which was conceived in order to fight Sleeping Sickness.

At the time of Independence, the organisation and the means are in place: parking lots for vehicles, depots for medicine, analytic laboratories, necessary material, teams of native personnel, procedures for making populations sensitive to the issues and to attract them, etc.

This mobility is the rule too in the polyvalent training sessions of the AMI. Every week, on fixed days, the physician of the district and the head nurse on duty go out on a tour of consultation around the big villages of the area, which means having vehicles in good condition. Particular attention is paid to maternal and infantile protection.

In all French-speaking African states south of the Sahara, except Guinea, and at the request of the governments, colonial physicians and chemists remained at their posts, long after Independence, while awaiting the taking over of responsibilities by native officials.

EXPERIENCED NATIVE PERSONNEL

It will come as no surprise that French public opinion was quite indifferent towards the work of military health officials sent to the colonies by France to treat the natives. Yet it is thanks to their efforts that populations doubled or tripled and life expectancy was prolonged. These countries which were then considered harmful for the health of Europeans have become popular tourist resorts, destinations for safaris and honeymoons...

Two walls of dead silence have hidden the gigantic progress accomplished, one that pushes it away out of sight and one inspired by discretion. Everybody goes about their business, in all tranquillity, while observing the strictest silence.

With its zeal for education, the Colonial Health Service, concerned about protecting the health conditions of populations always and everywhere, fixes as a priority the training, in the territories, of native collaborators. This is done not with the intention of distributing diplomas or academic knowledge but with the pragmatic purpose of having at its disposal excellent auxiliary workers, experienced in current practice. It opens professional schools where practical know-how takes precedence over erudition.

In the beginning, unskilled workers are trained on the job to do bandages on infected wounds and the frequent varicose ulcers. As schooling develops and the levels of instruction progress, auxiliary nurses are trained with special courses and then, in the schools, male nurses are trained and, some time later, female nurses. Then follow the schools for auxiliary midwives which are branches of the schools of medicine and pharmacy. These, in their turn, become university faculties.

**Eugène Jamot and staff using microscopes**

At the time of Independence, many high-ranking Indochinese, Malagasy and African medical officers are in activity. They have acquired, by contact with colonial physicians and chemists, an enriching experience. In 1961, of the 608 practitioners working in Madagascar, more than two-thirds have been trained in Antananarivo. As for the Dakar School, during its existence, from 1918 to 1953, it awarded diplomas to 582 physicians, 87 chemists and 447 midwives. In most of the territories, native physicians and chemists are more numerous than the French and, everywhere, native midwives outnumber their colleagues from Metropolitan France.

France has set an example in this domain. The historian, H. Deschamps, declares that in the Belgian Congo "at the time of Independence, only thirty Africans hold university diplomas".

More important even than their professional competence, the profound humanity of these practitioners must be insisted on. These schools are real breeding grounds for exceptional individuals. After Independence, many of them become not only Directors of Health Services, Professors or Deans of Faculties, but also parliamentarians, ambassadors, ministers, heads of government and even heads of state.

THE SUPPORT OF THE POPULATIONS

Every health programme implies the active participation of the populations concerned. This action is said to be bilateral. In fact, it is impossible to protect the health of individuals against their will or without their knowledge. In any case, this support is obtained neither at once nor with ease.

**The village of Bangassou (Oubangui Chari 1930)**

Is a village being ravaged by a plague epidemic ? The native witch-doctor and the elders discern in it the wrath of divinities offended by the intervention of evil spirits. How can they be made to understand that, in the opinion of the "Whites", the real cause is an invisible microbe transmitted by a fleabite ? That protection can be obtained not with incantatory rites but by giving pills to those affected ? How can they be forced to submit ? Authoritative measures are followed by slow comprehension and acceptance.

**Vaccination session (Indochina 1927)**

The first teams for vaccination, when they are not greeted with a flight of arrows, arrive in deserted villages. Warned by look-outs, all the adults have fled. The fact is, they have been tormented by the passage of tax collectors and officers bent on recruiting native soldiers, which has succeeded the incursions of freebooters, slave traders and other unscrupulous traffickers.

Little by little, with the intervention of native doctors and nurses, the necessity and the success of these medical tours are acknowledged. The presence of the population at meetings is no longer the result of threats and coercion. Their support is often based on a conciliation between Native and European medicine. "It’s better to have two medicines than one" is a dictum in Black Africa. This does not always have a positive effect. Thus, in a big modern Maternity Hospital, one regrets, from time to time, the occurrence of cases of tetanus neonatarum. The explanation is that the sterile bandage applied by the midwife on the umbilical scar has been removed and then re-applied by the grandmother of the woman who has given birth, in order to comply with the custom of rubbing a lump of ritual substances mixed with clay on the wound, thus infecting the new-born baby.

After decades of rivalry, the conflicts between traditional practices and modern medicine have ceased. At the time of Independence, the quasi-totality of native populations willingly accept the health programmes.

THE DECLINE OF GREAT TROPICAL DISEASES

Some figures and quotations to illustrate to what extent, wrote J.P. Biondi, "health problems were a source of worry". In Saint-Louis, the capital of Senegal, "frequent epidemics of yellow fever decimate the population periodically (1830, 1837, 1848, 1859, 1867, 1869, 1878, 1881, 1883), especially the Europeans". In 1881, the correspondent (from Bordeaux) of the Paris Society of Commercial Geography writes : "The epidemic rages without mercy... The few employees of European commercial establishments who haven’t yet contracted the disease, flee as far as possible. One admires, in the midst of these awful conditions, the devotion of the Head Physician Noury, always at the bedside of patients, full of knowledge, sang-froid and energy (...) In two months, 209 of the 264 patients in the military hospital had expired...".

Sixty years later, French followers of Pasteur in Dakar perfect the first effective vaccine against Yellow Fever, thanks to which the disease will be checked. Since 1940, not a single case of Yellow Fever has occurred in Saint-Louis. In less than twenty years, eighty million doses of vaccine have been administered in Black Africa.

**A group of Sleeping Sickness patients in the course of being treated (Cameroon 1948)**

As M. Martin* writes : "Great pestilential diseases which, until the Second World War, decimated tropical regions are on the decline everywhere".

If Smallpox has become a disease of the past, it is due to the massive vaccination campaigns undertaken from 1900, when this practice was not yet obligatory in the country of its inventor, the Englishman, Jenner.

Plague epidemics in Madagascar have not been able to progress after the invention by Girard* and Robic* in Antananarivo of the anti-plague vaccine.

The decline of sleeping sickness has been spectacular: from 1934 to 1944, forty million Africans were examined and 400 000 cases detected and treated.

Onchocercosis, the sinister agent of "river blindness", shows a distinct decline. In the Lake of Man (le bassin de Man) of the Ivory Coast where 95 % of adults and 50 % of children had been attacked by the parasite, the rate of infection was brought down to less than 1 % in 25 years.

It is the same with most of the other great tropical diseases.

THE IMPROVEMENT IN OVERALL HEALTH STATISTICS

Vaccination in one of the PMI services

In the course of the 20th Century, the population of the French colonies increases considerably, tripling or even quadrupling in certain regions. This is undoubtedly an aspect of a world-wide phenomenon, but it may well be that the health measures taken, by aiding female fecundity, by neutralizing the great endemics and reducing the mortality rate, especially that of children, have also been somewhat responsible.

In 1900, life expectancy in French Africa is around 30 to 35 years. About 1970, it is 48 years and, at the end of the century, 58 years (instead of 75-80 years as in Europe).

According to official statistics, there are, in the French West African Territories (AOF) in 1926, 13 483 000 inhabitants and in 1955, 18 747 000. In the year 2000, the 60 million mark has been passed.

The rate of annual growth is about 2.5 to 3 %, which means a doubling of the population every 30 to 35 years.

Thus in Senegal : 1.7 million in 1926, 4 million in 1960, 9 million in 1999.

The most significant factor is the rate of infant mortality (the number of deaths among a thousand babies during the first year after birth) in Black Africa :

– 1925 : 250 in a thousand (as against 100 in a thousand in France).
– 1965 : 125 in a thousand in rural zones, 70 out of a thousand in urban areas (as against 20 in a thousand in France).

THE IMPROVEMENT IN LIVING AND HEALTH STANDARDS

The improvement in health conditions is not only due to the intervention of the medical services. Thus, in order to reduce unhygienic conditions and the death rate, many undertakings other than the mere establishment of a dispensary are involved. For example, the founding of a school to instruct girls in the rules of hygiene or the building of a road to end the isolation of a village and facilitate food supplies, the sinking of wells to increase water supplies, the developing of agricultural production and the improvement of nutrition... In this way, all the services contribute towards ameliorating standards of living and the quality of life and rightly claim the merit for it.

Capturing rats

Besides, in tropical climates, all kinds of creatures - winged, aquatic and terrestrial - links in the transmission of great endemics - are to be met with. Eliminating them or chasing them away involves considerable work of excavation and deforestation. Thus the marshes where mosquito larvae proliferate are filled up, waste matter is deposited at a distance from habitations, rodents hunted, the foliage that shelters tsetse flies is cleared, etc... The physician indicates what has to be done, but it is the other services that accomplish the tasks.

In towns, the fight against insects and rodents is confided to the hygienic service which tracks down mosquito breeding sites, stagnant pools, defective water pipes... and fines those who contravene sanitary instructions.

In the districts where living conditions have been improved, scorpions, flies and rodents become rarer and rarer. Drinking water becomes available as well as electricity, mains drainage, and septic tanks. Trucks that collect domestic waste circulate. With the advent of the refrigerator, real comfort is attained.

But around the urban centres and the capitals, there remains a circle of anarchic dwellings inhabited by people from rural areas, attracted by the mirage of the city. In these slums, hygiene is worse than in the villages they have come from.

HOMMAGE AND EXPRESSIONS OF GRATITUDE

French and foreign specialists who have had the opportunity of observing the accomplishments of the Colonial Health Service in the overseas territories have written laudatory testimonies :

- 1962 : Professor B.W. Waddy. Institute of Tropical Hygiene (London) :

After spending eight years in the British Colonial Health Service, and having just visited all the West African countries, he declares that in French-speaking countries, "the situation is very different, thanks to the existence of the French Army Colonial Health Service which works, proudly upholding its tradition, with the aid of France, in these countries. Everybody, from the energetic youngster to the qualified professor and the generalist, is a member of the same service (…) which assures the control of diseases such as trypanosomiasis or meningitis that have killed thousands of people and could do so again. The most fragile zones are those where the absence of English physicians have created breaches in the system of defence (…). At the present time, we, (the English), have no reason at all for pride when the French medical efforts are compared with our own in our former colonies" (The Times - 1962).

- 1978 : President F. Houphouet-Boigny, a former student of The Dakar School of Medicine :

"I am steadfastly grateful to these officers of the Overseas Colonial Health Service who have worked so courageously and with so much devotion in the service of the populations of Black Africa. They have trained us to take on our responsibilities with rigour and discipline".

- 1979 : Professor Maurice Payet, Dean of the Faculty of Medicine and Chemistry in Dakar :

"Who has done better and where ?"

- 1985 : Professor François Jacob, Nobel Prize Winner for Medicine :

"The Medical schools of Bordeaux, Lyon and that of the Pharo had succeeded in creating a new type of physician : one who is competent, used to working in difficult conditions, often in the bush, without minding the effort required nor the pain experienced. Many are those who had acquired international reputations... (Sicé or Vaucel, for example). These physicians of the colonial troops played important roles in the Health Service of liberated France (France Libre)... I can see again such personalities as Montfort, Gillot, Chauliac, Chavenon... spending all night operating on wounded patients... Later, at the Pasteur Institute, I encountered another aspect of colonial physicians... They have put up, all over the world, the incomparable network of Pasteur Institutes... I am not sure that France realises the importance of the instrument it has been thus granted... Many people owe a lot to these physicians trained at the schools of Bordeaux, Lyon and the Pharo in Marseille". Paris 1985.

– 1992 : The award by Dr. Milar of the plaque of the CDC of Atlanta at the Pharo School :

My homage to all the physicians of the Colonial Health Service for their active contribution towards the eradication of Smallpox.

Alling the dead at Bordeaux school

This Service prides itself on having been, for the impoverished all over the world, "a beautiful image of the true face of France". While serving indigenous populations, working together with native collaborators, has not its greatest merit been the clear expression of solidarity with individuals and people of different cultures ?

But, above all, the measure of the gratitude of the populations is to be observed in their esteem and appreciation, in the humblest expressions and the smallest presents offered. Graignaire* has passed on these words of an old Cameroonian chief : "The great disease (Sleeping Sickness) arrived... We were all going to die when the doctor (Jamot*) came along with his medicines. Thanks to them, we will one day become as numerous as we were before".

The authorities and the medical staff have not been forgotten, in spite of the unfortunate ups and downs and the sombre times which sometimes preceded Independence. Thus Vietnam, despite the fierce fighting which, during ten years, made it an enemy of France, continues to remember Yersin* and, in March 1991, a symposium was organized in Nha Trang in tribute to his memory.

POSITIVE EFFECTS FOR THE COLONISER

The economic and strategic advantages obtained by colonisation not being ours to comment on, we shall here attempt to show what, on scientific and human levels, the populations colonised brought to the coloniser. First of all, the therapeutic properties of certain Asian and African medicinal plants have been investigated by colonial chemists : the cinchona from which quinine is extracted, the strophanthus , the chaulmoogra, the periwinkle of Madagascar, etc...

In Psychiatry, the trustful collaboration with the native practitioners of traditional healing has helped in the progress of ethnopsychiatry and the discovery of the importance of the socio-ethnic group in determining and treating mental troubles. Europeans thus acquired a new perception of mankind.

By living amidst different peoples, behaviour patterns were acquired or modified. One cannot ignore the extreme courtesy of the Indochinese, the good humour of the Polynesians, the patience of the Malagasies, the laughter and wisdom of the Africans. Take the case of this literate leper who, having lost most of his fingers, replies to the doctor who expresses sympathy : "You know, Doctor, as long as one is in good health !".

The "colonisers" themselves agree that their working conditions, the vastness of the territories under their responsibility, the distance from France, their isolation in the "bush", the urgent problems that must be solved alone - all these things developed their capacity to take the initiative and make decisions and enriched them psychologically. Voelckel* declares : "Lucidity, open-mindedness and tolerance are very often the rewards reaped by being in contact with those who benefited from our activities".

The most essential change and the most profound is in the domain of human relationships. The spirit of solidarity takes over from the individualism so common in Europe. Besides, twenty or thirty years of reciprocal confidence and esteem, gratitude for a cure or the relief brought to sufferers, create permanent bonds of attachment. When a colonist leaves these countries, some part of himself is left behind. Richet*, one of the great colonial physicians, writes to his patients : "We don’t recover from your "enchanted tropics", nor from yourselves. But isn’t there a bit of conceit in our affection for you, not only for what you are but also - and especially - for all the good we have done you ?".

THE HANDING OVER - DECOLONISATION

Most of the newly independent countries are unable to cope with the tasks of ensuring the payment of salaries to all the personnel, making the whole health system, handed over by France, function at the expense of the state and undertaking new enterprises. What has been inherited is difficult to handle. The fight against the great endemics suffers because of it. Less attention is paid to the needs of the populations, all the more as the travelling teams lack regularity in their visits. Buildings and materials too are worn out with the passage of time, without the possibility of being renovated. Due to the lack of funds, the supply of equipment and medicine becomes a problem.

France, at the request of the governments, provides assistance (cooperation). It furnishes subventions to stabilize the situation, sends French staff and pays their salaries, in whole or in part. Towards 1980, twenty years after Independence, French military physicians and chemists are as numerous as they were 1939. In the course of the two following decades, the responsibilities are taken over by native personnel.

At a time when the World Health Organization seeks to stimulate governments into action with the slogan "Health for everybody in the year 2000", health problems increase. A fall in enthusiasm and a lack of means and medicines are the reasons for a fresh proliferation of the great endemic diseases. Thus Lapeyssonie* is annoyed by the rise of Sleeping Sickness : "300 000 new cases every year".

These diseases, said to be re-emergent, remind us that, on the one hand, in infectious pathology, no victory allows us to dispense with vigilance; on the other hand that, though vaccines remain the main remedy, individual and collective hygiene is indispensable for the prevention of diseases.

Many microbes and transmitting insects have become resistant to classical products. New diseases arrive, with AIDS in the first rank, escorted by Tuberculosis.

Whatever the future may hold, the present is extremely worrying.

At the moment, the countries said to be developed are turning towards humanitarianism, towards non-governmental organizations. A young French doctor, a captain in the army, notices the fact and declares in 1996 : "The comprehensive treatment in depth that the Colonial Health Service used to provide has ended. In Europe, one now only demands occasional interventions depending on the circumstances and for humanitarian reasons". One may add "and for funds".

But this is no time for nostalgic reflections. The Colonial Health Service did, at that time, the best that could be done. The final appraisal of its accomplishments provides indisputable proof of its efficacy.

All over the world - and after the passage of several decades - one still awaits a health system that can replace it.

THE COLONIAL MEDICAL CORPS AND PASTEUR’S BREAKTHROUGH

The XIX century was the century of the industrial revolution, but also that of the scientific revolution with microbiology being one of the foremost scientific advances of the time. While complementing each other’s scientific works and discoveries, Louis Pasteur (1822-1895) and his German counterpart Robert Koch (1843-1910) are the founding fathers of microbiology. Once they had been drawn into the sphere of influence of Pasteur’s doctrine, scientists from different countries started to "track down micro-organisms". Whenever they heard of the breakout of an epidemic in a country, they would rush to it. Most of the time it was in an insalubrious and inhospitable tropical country, but this poor reputation had much more to do with the infectious peril than with the characteristics of the climate. It is nevertheless a fact that several scientific researchers who were either physicians or pharmacists ruined their health or lost their life, linking their fate through disease and death with that of native populations.

At this particular point in time France had an advantage over other countries : it had its Colonial Army Medical Corps which was ready to take part in this competition. This Corps was used to implementing military rules of obedience, it was financially supported by the French government which provided a budget allocation. Its medical personnel were scattered across this new colonial domain in the very places where these epidemics were raging. This medical corps together with the Pasteurian Institute schools where young personnel were taught an up-to-date training and a cutting edge technology, can claim the discovery of micro-organisms and thereafter the development of serological tests, of therapeutic sera and of vaccines against the diseases which are caused by them.

Within a few decades the gigantic scientific international to-ings and fro-ings which followed, resulted in making possible the identification of pathogens responsible for nearly all infectious diseases which were then known, and also in figuring out how they were transmitted, and how they could possibly be prevented or treated.

THE MICROBIOLOGICAL REVOLUTION

Louis PASTEUR

At first the identification of a disease is made through its typical clinical symptoms. Discovering its causative agent and its routes of transmission to healthy individuals is usually a long term job. In the ancient times, infectious diseases were thought to be due to mystical reasons : either Heaven inflicted castigation or evil spells. Later on came the time of mythical causes : miasmas and humours. It was not before the dawn of Pasteur’s era that they could be scientifically explained. Advantage was then taken of the renovated scientific way of thinking and of the methods of scientific research which had been initiated by Claude Bernard (1813-1878), undisputed founder of experimental medical science.

During the 17th century A. Van Leewenhoek invented the microscope and in 1878 Sedillot created the word "microbe" for the designation of all living creatures which could not be seen without the help of this device. The word received the approval of Littré, a French language expert and also of Pasteur. With a microscope "infinitely small" creatures could be seen but circumstances which made them appear, and also their role, remained unknown. Over two hundred years the "spontaneous generation theory" had been supported by official coteries and these micro-organisms were not thought to be harmful.

After studying fermentations Louis Pasteur (1822-1895) became convinced that these transformations were due to specific micro-organisms which originated from pre-existing ones. This became known as "the theory of germs".

With the discovery and demonstration of the deleterious role of microbes, of how they proliferate and what were the body’s defence reactions, Pasteur triggered in medical science such a sudden and profound upheaval that the resulting breakthrough is well worth the name of revolution which warrants his being designated as "Mankind’s benefactor". These successful achievements were followed in 1888 by the foundation in Paris of an Institute which at first was dedicated to the preventive treatment of rabies. Pasteur remained at the head of this institution until his death.

Robert Koch (1843-1910) is another founding father of medical micro-biology. Unlike his elder French counterpart, this German scientist was a well travelled MD. After having discontinued his medical practice, he became interested in the new scientific field of micro-biology. As the advisor of his country’s government he was commissioned to go to Egypt, Cameroon, India, Java, New Guinea and so on. Among the bacteria he discovered, two are of a worldwide interest : the tuberculosis bacillus (1882) and the cholera vibrio (1883). He also studied numerous diseases such as Anthrax, Malaria and Amoebiasis.

Koch was a remarkable leader for his followers. In 1891 he was appointed Director of Berlin Institute of Infectious Diseases which is now named after him. He was awarded the Nobel Prize in 1905.

TROPICAL REGIONS AND THEIR POOR REPUTATION

Once they were back home after a long journey to some remote places, European travellers expressed the feeling they had of having come across miserable and unhealthy populations. Upon returning from tropical Africa in 1846, a French explorer named A. Raffenel put the following in writing : "Once I started to hit the trail I could not go through a village without being shown patients afflicted with desperate conditions such as lepers, patients with total ophthalmias, with chronic elephantiasis or with dropsy...".

Highly respected medical authorities upheld the scare and emphasized the dangers of undertaking an adventurous tropical expedition. In 1875 back from Congo where everyone had been impressed by the extensive range of his knowledge, Mahé, Professor of Medicine at the Naval Medical Academy in Brest told his students : "On the stinking shores of the Atlantic Ocean you will meet the sphinx of malaria which should inspire awe and which constitutes a pernicious protean condition, ghost of typhus, the ashen and frosty specter of cholera, and the icteric mask of vomito negro. Watch out ! there is there a poisonous breeze which rises there from earth and water".

Commemorative plate at the Pharo

Still, in 1931 one could read in a magazine named "L’Echo de Paris" : "The very fact that someone was going to the outback in Africa or in Indochina after leaving the homeland, conveyed the idea that there was something he could be remorseful for. No one could understand why a smart and active young man could be foolish enough to show his contempt for good and quiet positions in the civil service and why he would rather live in the tropics where some pernicious fevers could possibly be caught and where he would certainly also get in cahoots with coloured persons".

Mentioning the detrimental effects of hot climates which were found there, or the threat of miasmas and of deleterious principles was absolutely not a deterrent for some strong minded individuals and in fact it was the other way around ! Many were willing to work in these countries with the prospect of helping native populations to achieve better health and living standards. Tribute should be paid among those who were ready to engage in a colonial adventure, to French Naval Officers and to Medical Officers of the Colonial Army Medical Corps dubbed "La Coloniale" who went overseas. As far as Pasteur’s Institute colonial trainees were concerned they could not help dreaming of epidemics to confront.

Still, good health and even life remained in danger overseas. Up to 1960, it was quite impossible to keep working there without having some day an attack of malaria or dysentery. During the 19th century, by the very dramatic times of large epidemics, French colonization was accompanied by the death of a large number of colonists with among them a lot of physicians and pharmacists of the military. The names of those who died in the line of duty are engraved on a commemorative plaque which is displayed on a wall of the Pharo Institute in Marseilles. The largest loss of lives happened during a yellow fever epidemic which occurred in Senegal in 1878. With thirty physicians and pharmacists on duty there, twenty one of them were victims of this epidemic and passed away in Gorée and St Louis. Other pestilential diseases are responsible for other fatalities such as cholera for Guichoux*, plague for Mesny* in 1911, and Bourret* in 1917 and trypanosomiasis for Le Hir* in 1932. Once they had already returned to France a number of them died in the aftermath of a disease which they had caught overseas, but there is no possible assessment of this figure as sometimes their death happened years after they were back and Jamot* is an illustrious example for that. Wives and children also paid a heavy toll to these climates.

Preparation of the virus vaccine (Tannanarive Pasteur Institute 1900)

The British contended that to carry on the ruling of these countries three governors were needed : one in a coffin on board a ship bound back for the UK before being laid to rest, the second one effectively in charge and the third one on his way to take over as the second one was likely to get sick very shortly.

The mortality rate of Europeans living there, provides a good evidence of the risk which was taken : during a three year period of time from 1907 to 1910 among the five hundred of them who were on active duty, thirty two physicians and pharmacists of the Colonial Medical Corps died. In a cohort of men aged 25 to 55, these numbers speak for themselves.

Today millions take advantage of the advances of modern science over ignorance and these accomplishments make a change for the quality of life in these countries, where many tourists can go now without putting their lives at unacceptable risk.

ROLE OF THE COLONIAL ARMY MEDICAL CORPS

France was the only country with an organized formation, the Colonial Medical Corps, ready to fight these epidemics, which had been set up, organized, headed, fostered and counselled by the founders of Microbiology, namely Pasteur and those who succeeded him. Pasteur was not a physician and his ideas were not unanimously accepted by the medical establishment. In 1864, it was the Academy of Science and not the National Academy of Medicine, which was the one to acknowledge officially that he was right and to substitute the "theory of germs" to the one of "spontaneous generation".

A new impetus was given to microbiology but there were also some backlashes well until 1870. Right away physicians of the Military Medical Corps, who did not belong to any medical coterie, joined Pasteur and they cooperated with him. Among them Calmette*, P.L. Simond*, Marchoux*, trained with him and signed up for the Colonial Medical Corps upon its inception in 1890.

Some other students of Pasteur such as Yersin* joined them. The scope of research was then widened and included the whole range of infectious diseases and with Pasteur’s former trainees scattered across the world, Overseas Pasteur Institutes were founded. Working together with the Main Institute in Paris they were assigned to discover new microbes so that the whole of mankind could take advantage of the advances of the new microbiological science.

**Daily testing of rats caught in town (Pasteur Institute, Antananarivo 1900)**

Émile ROUX

They were all servicemen of the Colonial Army Medical Corps which was financed and supported by the budget from France. Moreover inside this Corps, these men had the opportunity of renewing former ties of friendship when they happened to come across their former buddies of the "Ecole de Santé Navale" or of the "Pharo Institute" who had been their fellow students in medical school or for some of them, their fellow trainees in the Pasteur Institute. As a result, there was a feeling of solidarity between them which helped when it came to carrying out as a team a fantastic and fruitful work. Exchanges between physicians who were posted in the outback (bush doctors) and biologists in Pasteur Institutes were going both ways with one giving and the other receiving and vice versa. This, most of the time was done while having the feeling of belonging to a friendly confraternity.

Most servicemen of the Colonial Medical Corps who trained at the Pasteur’s Institute had started their career with one or two tours of duty in medical posts in the outback before having the opportunity of specializing in the field of biology. In 1903 there was an agreement between the Colonial Army Medical Corps and the Pasteur Institute which provided that "micro-biologists" of the corps were accepted as trainees at the Pasteur Institute where they attended Dr Roux’s Complete Course of Bacteriology.

Later on some of them, happened to be the founders of fifteen Overseas Pasteur Institutes. Several of them came back to the Main Institute and were assigned to important positions at the head of scientific departments or at the Institute Management Department.

No other country had such an instrument of scientific research. After the death of Pasteur, the collecting of a considerable amount of data was carried on which included : The discovery of microbes and parasites and the identification of epidemiological chains, some laboratory tests were developed which ascertained the diagnosis of some conditions or led to a presumable diagnosis for some others, the development of vaccines, of therapeutic sera, of specific medications, as well as the discovery and the working out of methods of prevention of infectious diseases for individuals or communities.

The work which was done about plague is a good example of an exclusively French achievement as a few physicians of the Colonial Army Medical Corps are responsible for finding the links between the bacterium which Yersin* had found and the animal reservoir. P.L. Simond* gave evidence of the fact that after biting an infected rat the flea can transmit the disease through a bite to a healthy human being. Girard* and Robic* were the developers of the plague vaccine.

INTENSIVE DATA EXCHANGES BETWEEN INTERNATIONAL SCIENTISTS

By the end of the 19th century the United Kingdom was the other big colonial power of the time and commissioned teams of scientists to go to colonies it was ruling. Some other competitors showed up : Germany, the United States, Russia, Italy, Belgium etc…, and Japan as well.

The competition which followed was a tough one. Then, diseases which now are encountered in the tropics only, struck well beyond those latitudes and occurred at the time in much colder places. The Leprosy Bacillus was discovered in Norway and the parasite responsible for amoebiasis in St Petersburg. We can talk of an "international mobilisation". As soon as they would hear of an epidemic outbreak in some place, scientists and their expeditions would rush there, even if they had to go to the antipodes… but of course at the transportation pace of the time. One can easily find numerous examples of that.

In 1882 cholera was raging in Egypt : Koch, who was German was competing with Thuillier, a French scientist who died after he had caught the disease. Koch attended his funeral and the following year discovered Vibrio Cholerae in Alexandria.

In 1894 plague was present in Hong Kong. Kitasano, a former Japanese student of Koch’s, was at odds with his challenger the French Yersin* as both wanted to be the only one to get buboes which had been taken from corpses of patients who had deceased from bubonic plague. Kitasano thought he was the winner with the discovery of a micro-organism which was not in fact the one involved in the disease but his challenger later found the real plague bacillus.

In 1881 yellow Fever was present in tropical America and Carlos Finlay, a Cuban, took into consideration a previous hypothesis, which made a domestic mosquito (Stegomya) responsible for its transmission. As the epidemic outburst kept spreading , this hypothesis was checked and confirmed in several countries and among those who were involved in this study the names of Marchoux*, Simond*, and Salimbeni, members of an expedition of the Pasteur Institute should be remembered.

In 1926 another outbreak of the disease occurred in Western Africa. And two expeditions worked on it : one of them, from the Pasteur Institute in Dakar and the other, from the Rockefeller Institute. Four members of the latter lost their lives there. Both expeditions succeeded in identifying - for the first time - the virus which is responsible for the disease (Mathis* and Laigret* for the French).

MODES OF TRANSMISSIONS OF TROPICAL DISEASES

The opportunity of studying tropical diseases widened the range of medical knowledge as it gave evidence of the role which either animals designated as "virus reservoirs" or insects or molluscs or "intermediary hosts or vectors" can have in the transmission of human diseases.

The first ones are domestic or wild animals which are very often natural hosts to the microbe or to the virus such as rodents for plague, or forest monkeys for yellow fever.

The latter ones carry the disease from a sick animal to a healthy person after one or two consecutive steps.

These are captivating investigations but also long term endeavours as once the identification of these steps by researchers has been made, they have a hard time identifying the other links, or causative agents.

And it is exactly what happened with Malaria ! The "hematozoaire" was identified in 1880, but nobody knew how it could be transmitted to humans. Clarac* who was a renowned tropical medicine specialist wrote the following in 1887 : "This pathogen lives in the ground and the cause of this endemic disease is related to the nature of the soil". It is only later between 1895 and 1897 that a mosquito bite (Anopheles), was first suspected and then identified as the way of transmission of this pathogen.

As far as Yellow Fever is concerned it was the other way around. In 1881 Finlay showed that transmission of this disease occurred through the bite of a mosquito, named Stegomya but the pathogen remained unknown over the next forty five years and this very fact was a matter of controversy. In 1897 Auvray* asserted : "I am convinced that the annual seasonal flare ups of the disease have a telluric origin. The pathogen keeps proliferating on corpses and contaminates the soil so that the deceased have to be buried between two layers of quicklime in order to prevent the pathogen from proliferating in the surrounding soil". This pathogen is now known to be a virus and not a microbe which does not survive on corpses in the earth.

Now when all is said and done, it can be said that Colonial Army Medical Officers, the "toubibs", heralded French medicine across the world and in so doing provided an important contribution to the spreading of the influence of France across the world. So, after all, the concept of "the French doctors" is not a new one...

MEDICAL ASSISTANCE FOR INDIGENOUS PEOPLES

Straightaway, indigenous medical assistance (AMI), thought of as inherent in the process of colonization, is organized with the aim of offering treatment to native populations, free treatment for the poverty-stricken. With this objective, a network of health services are created which, in peripheral areas, will be under the responsibility of doctors practising in the bush.

The evolution of these services is neither progressive nor harmonious. Their installation requires men and means. The population too has to be convinced that scientific medicine is more efficacious than the traditional magical and empiric practices. It is necessary, therefore, to obtain tangible and indisputable results as soon as possible.

The two World Wars bring with them a degradation of health conditions, even a complete halt of the services. A new start is made with the arrival of native auxiliaries formed on the spot by the Colonial Health Service. But it is only after the Second World War that the AMI in Africa, freed from its combat against great endemics, functions with real efficiency.

This general outline is valid for all the territories with some variations in Madagascar and Indochina.

THE OFFER OF TREATMENT TO POPULATIONS

"It is impossible to describe, in a few lines, all the efforts made to create, develop, animate and assure the evolution, following the progress of medicine, of the different branches of medical assistance, the organization of treatment for preventing endemic diseases, with urban and rural hygiene, vaccinations, the supervision of children in school, together with the very difficult responsibilities like taking care of the lepers and the mentally ill, while not forgetting maternal and infantile protection" (Chippaux*). In fact, everything has to be invented to assure public health in these countries where the absence of hygiene is favourable to the propagation of great endemics and malnutrition the cause of dramatic infantile mortality.

AMI post - Cercle de Gaoua

It is the task of a doctor practising in the bush, isolated in an administrative zone as big as a French department, having undependable means of communication. He goes, after a stay of two or three years, from one colony to another, according to the needs of the service. In Asia, in Africa, in the Pacific or elsewhere, his polyvalent capacities are put to the test. Gradually, dispensaries, maternity wards, little country hospitals are built. In the big cities, the federal capitals of the colonies, hospitals for civilians are opened, admitting the poor for whom hospitalisation and treatment is free. These hospitals evolve in the same way as the great colonial hospitals and their administration and staff are provided by the Colonial Heath Service, working together with the native helpers.

A few decades later, at the beginning of the 1960s, in the territories where it has exercised influence, France leaves more than 4 000 different health services in full activity. Among them there are 2 500 dispensaries, most of them rural, 600 maternity centres and 216 hospitals, without mentioning specialist centres, pharmacies which provide medicines and schools for medical training.

THE EVOLUTION OF MEDICAL ASSISTANCE

To begin with, as missions of exploration progress, military physicians treat native soldiers, porters, interpreters and the civil population that asks for aid. But the changes occur rapidly and one cannot call what follows mere assistance.

In the period that follows immediately, camping is organized and the families of the skirmishers begin to settle down around the military camp or in the neighbouring village. A physician is present in each gathering and gives free treatment to the women and children of these families. He has an infirmary and small premises for hospitalization. At the same time, contact is made with the traditional chiefs and the demand for medical aid increases. But, on the one hand, it remains informal and, on the other hand, it depends on an insufficient provision of health services.

The creation of Medical Assistance to the Indigenous people (AMI) takes place in Madagascar in 1899 with a directive signed by Gallieni, who is advised by a young colonial physician, Lasnet*. This directive initiates the first free health service for the native populations. Its explicit objectives are :

– Medical treatment for civil servants and "as far as is necessary, the European and native population".
– Service in hospital centres.
– Maintaining health standards during epidemics, in hygiene and public health.

These are vast ambitions : in ten years, France has more than twice as many individuals whose health has to be looked after and, of these millions of new "nationals", nearly 100 % are "poverty-stricken" in the most literal sense of the expression.

A few decades ago, Algeria had presented the same problem. It was resolved there by the recruitment of "colonial doctors", practising liberally, employed by the Health Service to treat indigenous people. They are an addition to the Army Health Service. The proximity of France, the number and density of the colonists, encourage the applicants. This solution is tried without success for distant colonies, especially those of Black Africa whose climate has a very bad reputation. It then appears preferable to train native medical staff on the spot to strengthen the Colonial health Service.

We shall describe many periods in the development of this medical assistance. The example referred to will be French West Africa (AOF). The same process takes place in the other territories.

INSTALLATIONS 1905-1914

Pacification is theoretically terminated in 1904, though pockets of resistance persist in Upper Volta, Niger and Mauritania. Roads and railways are opened up, navigable routes are largely used. The physicians of the AMI are, almost all of them, from colonial troops, either detached from military service in the case of two thirds or attached to a military unit and cooperating in the treatment of the populations. The first are free to practise all over the district; the others must remain near their garrison - whence the existence of two types of practices, neither of them being truly satisfactory : either a "stationary" doctor who can be consulted only by those who are close to the medical centre or a "mobile" doctor who moves around and treats a larger number of patients living in scattered villages. The number of physicians and chemists is reduced. It will be rapidly increased because it doubles, on the average, during these ten years.

A gathering of the population

Very often the physician detached from military service and working for the AMI finds himself alone at his post with an assistant nurse to whom he teaches essential tasks. The job is difficult, he can become a victim of dysentery, bouts of malaria. In the rainy season, it is impossible to get about. He is not always available to reply to calls from far and wide. And if he replies, he interrupts his activity. Thus, in 1906, when Dupont*, at his post in Koury, sets out to help his seriously-ill colleague Maupetit* in Gaoua, he closes his dispensary and traverses in unavoidable stages - on horseback, on a donkey, in a hammock - the 300 Km which separate the two large villages, across a land which is still hostile, infested with glossina and other black flies. For three weeks, the dispensary in Koury is closed. Of course this works to the advantage of the local healer whose medical practice has been forbidden by a decree of 1887 but who is always available.

In 1911, a dispensary is finally established in the circle of Ouagadougou, whose surface area is equal to a dozen French departments and whose population is 1 500 000. Two physicians are appointed there, that is to say, one doctor for 750 000 inhabitants !

What sort of medicine can be practised in such conditions ? Everything depends on the doctor, his enthusiasm, his generosity but also the means he has at his disposal. Lassitude, loneliness and disappointment at seeing patients returning to empiricism are the factors that cause discouragement. On the other hand, the discovery of new worlds, the observation of unknown clinical signs in different patients leads to itemizing new diseases, to determine the limits of their propagation, to do the work of a "discoverer".

The situation may seem absurd: on the one hand, France cannot cope with the enormous needs in personnel in the expanding territories (in medicine as in pharmacy, education takes a long time and recruitments are limited); on the other hand, the physicians on the job don’t have a lot of work because the populations are suspicious and techniques in which a scalpel or even a simple intravenous needle is used seem to them fearsome.

In fact, attendance at medical centres falls. In 1906, the physician in Gaoua treats, all in all, 200 patients, that is, less than one a day. In Koury, between October and December 1906, 100 patients come along of whom 7 are hospitalised in the dispensary.

From 1909, attendance increases. Meanwhile the physician has made himself known by going out on campaigns of anti-smallpox vaccination and proving that he had the power of protecting against this disease.

Moreover, it must be admitted that western medicine had only limited efficacy at this time, even if it was superior to the practice of the local healer. Duvigneau* publishes in 1900 "A Medical Guide to Congo and the Countries of Equatorial Africa" in which, except for quinine, anti-venomous serum, purgatives and antiseptics, all the other medicines mentioned have disappeared from medical memory.

A geomancer, in charge deciding the orientation of annamite dwellings (Hue)

A SUDDEN HALT 1914-1924

The First World War brings with it profound upheavals in all the territories.

First the military physicians are called back to the fronts in Europe: in Guinea, they are 20 in 1914 and 10 in 1916. Dispensaries are closed. The physicians who are left are called upon to participate in recruitment campaigns, others accompany the colonists fighting the Germans in Togo and Cameroon. The AMI is weakened, if not completely paralysed. Many years will pass before it recovers its capacity of 1914.

The shortage of staff is a problem; budgetary restrictions make matters worse - the paucity of medicines, of bandages, of material and the total dependence on provisions from metropolitan France. The surgical service of the hospital of Conakry operates only on urgent cases.

The campaigns to recruit skirmishers in 1915 provoke uprisings and lootings in certain regions, particularly in the centre of Upper Volta. Order is established rapidly but at the cost of the destruction of harvests, the abandonment of villages and the displacement of populations. The severe droughts which follow one another from 1910 to 1916 further precipitate the displacement and wanderings of the rural population. So it is at the time when the AMI is at its weakest that the risks of contamination by the cohabitation of undernourished individuals are at their highest. Leprosy and trypanosomiasis are well-known but onchocercosis isn’t as yet, and the first cases of onchocercosis cysts described in Senegal are observed on the bodies of Voltaic recruits, who could become sources for the propagation of this filariasis - which is extremely worrying.

Dispensary of Ségou (Sudan)

It is at the end of this period that "white Russian hygienists" arrive. Forced to leave their country because of the Bolshevik revolution, having become refugees in France where they could not practise because they didn’t have French diplomas, work in the African AMI is proposed to them from 1922 onwards. As they cannot be called doctors, they are given the title of hygienists. They do the jobs of auxiliary physicians.

However, during this dramatic period, the first changes that will give a new lease of life to the AMI are set in place, and this time it will grow into an organisation that is a remarkable instrument for maintaining health.

As early as 1917, the Governor General, Joost Van Vollenhoven, announces his policy of making the well-being of Africans his main preoccupation. If these regions are to develop, their inhabitants must be in good health. He underlines the importance of medical assistance and the maintenance of hygiene.

At the end of 1917, he creates villages for lepers and gives Salomon* the task of organising the fight against the disease. In January 1918, his successor; Angoulvant (Van Vollenhoven is killed in battle in France) signs a decree inaugurating the Dakar School of Medicine, whose graduates are going to give a new impetus to the AMI. The first graduates come out in 1923.

Finally, in this same period, new medicines become available that are efficacious against trypanosomiasis whose proliferation threatens to put black people in peril.

A NEW BEGINNING FOR THE AMI 1924 - 1944

In French Equatorial Africa, from 1921, following the instructions of Jamot*, the fight against the greatest endemic, trypanosomiasis, is no longer confided to the AMI. This does not mean that an AMI doctor does not treat trypanosomiasis when he comes across it during his consultations, not at all. But, whatever the devotion and commitment of the physicians - Le Hir* loses his life in the combat - the immobile dispensaries and the programmed visits cannot check the advance of the disease. From now on, the fight is led by special mobile teams which explore the whole of a territory and open sleeping-sickness asylums where patients found to have the disease are treated. This same procedure is introduced into French West Africa only in 1939. This delay of two decades, in comparison with French Equatorial Africa, is fatal to tens of thousands of patients.

As early as 1924, Daladier, the Minister for the Colonies recommends that the service of medical assistance should be oriented towards prevention and social amelioration. In French West Africa,the Governor General, Carde, with the assistance of Lasnet*, decrees the instructions for its application :

– Every principal town of a colony should have an ordinary hospital sufficiently equipped with services of surgery, radiology, bacteriology, a laboratory and food-distributing centre.
– Every district should have a dispensary with a maternity clinic.
– Medical posts are created in important villages as well as treatment centres and look-out posts for observing the prevalence of endemic diseases.
– Civil status must be established and demographic statistics investigated (that will be more difficult).

The number of physicians increases rapidly and so do the health budgets which are tripled between 1925 and 1927, each colony being invited to contribute from 7 to 12 % of the whole budget.

The Roume Polyclinic in Dakar

At the same time, the first qualified physicians from the Dakar school are ready for employment. From 1939, auxiliary doctors and chemists are more numerous than those in the Colonial Health Service. They are given greater responsibilities.

Complete health benefits will be achieved only several years later, towards 1928-30. Meanwhile, the number of consultations and deliveries double between 1924 and 1931 and the period of hospitalization increases eight-fold, whereas the number of people vaccinated varies little, showing that the campaigns of anti-smallpox vaccination have been extremely active.

Just before the Second World War, the personnel of the AMI of French West Africa (AOF) consist of 165 physicians and 14 chemists of the Colonial Health Service but also 34 civilian physicians engaged with contracts or drawn from the National Health Service, 32 "Russian hygienists" and, above all, 184 African physicians who have been trained and have graduated in Dakar.

THE SPEED OF PROGRESS 1944 - 1960

The Conference of Brazzaville marks a turning point in French colonial policies. One of the most important decisions of the Commission for Hygiene and Health, of which Vaucel* is the spokesman, is the replacement of SGAMS, which is concerned with a single disease, by the "Service général d’hygiène mobile et prophylaxie" (SGHMP), which is polyvalent - that is, it deals also with other great endemics and provides vaccinations. The term "indigène" is no longer used and medical assistance service will receive the epithet "autochtone" (AMA).

A gathering of the population

The AMA devotes itself to curing individuals, to the decontamination of towns and villages where its centres are established. The confidence of the people has been entirely won over and long queues of patients are to be seen in front of dispensaries. The bush doctor is able to exercise his diverse faculties.

In 1949, the AMA has 852 medical centres of which 8 are hospitals.

When Independence dawns, the service functions smoothly without any trouble. The colonial physicians and chemists (who have become naval officers again) stay at their posts (in cooperation with the new administration) and will be disengaged only gradually, to the rhythm of the graduation of national physicians from the African faculties and their recruitment by the new states.

MADAGASCAR

What is novel in Madagascar is the rapidity and precocity with which medical structures to ensure health services to the Malagasy population are set up.

The case of Madagascar is remarkable for several reasons :

– The Malagasy monarchy and government already have faith in Western medicine and when "the big island" becomes a French colony, one sees, together with numerous traditional healers, a physician who has qualified at the Ecole de santé militaire in Lyon, Rasamimanana, and some forty physicians who have graduated from a school of medicine created in 1880 by an English protestant mission, The Medical Missionary Academy. In 1898, Galliéni opens the Antananarivo school for training "indigenous colonial physicians".

– Another particularity is the simultaneous establishment of schools for physicians and schools for midwives. The problems of maternal and infantile protection are taken into consideration from then on. In 1950, there are 356 Malagasy midwives in the medical centre of the island.

– Finally, it must be noted that, straightaway, the young graduates are free to exercise their profession wherever they want to. In the three following years, ten physicians complete their studies and all ten install their clinics in Antananarivo or around it, always on the High Plateaux. The ambition of a medical service covering the whole territory is compromised.

A group of "Indigenous colonial physicians" is then created in 1903. They are recruited when they pass competitive examinations at the end of their studies. The qualified physicians who are not recruited are free to settle where they wish. They are called "free doctors" and can only practise in Madagascar. Besides, they can be called upon to work for the AMI in their town. From 1929 onwards, those who pass the competitive examination can work for the AMI for a minimum of ten years.

In 1950, there are 350 "Malagasy doctors", working in the health services together with 65 physicians, 9 chemists and 9 administrative officials of the Colonial Health Service.

The first graduate "doctors of colonisation" in Antananarivo

Malagasy medical assistance is enhanced at the same time by the increase in medical establishments from 145 in 1904 to 405 in 1924, going on to 662 in 1932, among which there are 57 hospitals, 45 maternity hospitals, 233 "delivery centres", 20 dispensaries, leper-houses and other health centres.

INDOCHINA

In Indochina, from 1903, The Director of the Army Health Service, Grall*, conceives a project of medical assistance for Indochina: "Indigenous Medical Assistance (AMI) will be assured by the physicians of the Colonial Health Service, detached from military service, while awaiting the arrival of recruited French civilian doctors". In 1906, 23 government-paid posts for civilian doctors are set up, of which 14 are granted to military doctors who have resigned or are retired and 9 to civilian doctors from France. It is obvious that this number is insufficient for the needs of the country. So, a large number of posts are given to physicians detached from military service and those in service who are experienced in treating the population.

A novel feature of French colonialism is the attraction exercised by Indochina on French civilian doctors and chemists. Their relative numbers were, from the beginning, higher. However, a good many of them are retired military men who have served their country.

Another feature is the fact that, since Catholic missionary work began a long time ago (the 17th century), there are many church establishments whose activity is also directed towards health and well-being. Their efforts are generously supported by the AMI.

At its inauguration, the AMI depends on the direction of the Army Health Service in Indochina. In 1909, a General Inspectorate of the AMI is created which becomes totally independent of the Military Health Service in 1931, but continues to be directed by colonial military physicians, retired or still active, such as Hermant* (1931-1937), Heckenroth* (1937-1940), Botreau-Roussel* (1940-1945), Doroll* (1945-1950). Members of the staff are still borrowed from the Colonial Health Service.

The number of physicians increases rapidly : 45 in 1907, 115 in 1910 of whom 40 are detached from military service, 128 in 1931 of whom only 26 are from the military. There are 6 chemists, 5 being detached from military service. These figures remain more or less unchanged in the years to come.

In 1902, a School of Medicine directed by Yersin* is opened in Hanoi. The students are engaged for ten years of service at the end of their studies. The first graduates qualify in 1907 and, a few years later, they are more numerous than the French physicians. A Pharmacology section is opened in 1914, then a section for Dental Surgery.

The war of 1914-1918 slows down this evolution during a decade, at the end of which the AMI sets about all its activities vigorously. Anti-smallpox vaccination is generalised with six vaccination centres. Vaccination against rabies, initiated by Calmette* in 1890, is accessible everywhere. The great Far-East cholera epidemic of 1926-1927 is controlled by serotherapy and vaccination (12 million doses are used for a population of 20 million). BCG is administered in all maternity hospitals in Indochina from 1927 onwards.

Beyond this fight against endemics, health protection is extended into the field of water conveyance, the elimination of impure water, in general towards better hygiene. Meanwhile one observes the development of rural hospitalisation. The increase in the number of health establishments bears witness to this : from 336 in 1921, they pass on to become 573 in 1931, among them 127 hospitals, mobile hospitals, lazarettos, 414 infirmaries, maternity centres, 4 institutes of Ophthalmology, 17 asylums and 10 leper-houses, all of which represent 13 860 beds and correspond to nearly 4 million days of hospitalisation. As for consultations, they double every seven or eight years. The fight against tropical endemics is intensified.

In 1936, The School of Medicine in Hanoi is transformed into a Faculty of Medicine. In 1939, 29 chemists, 321 physicians and dentists educated in Hanoi work for the AMI.

From 1940, because of the World War, Indochina is isolated. The production of quinine is sufficient for the needs of the territory; it is even possible to export it to neighbouring countries.

In 1945, the country enters a war that lasts thirty years. The AMI then functions only in the provincial capitals or in the great urban centres. The health service for the colonial troops does its best to satisfy the needs of the civilian population with its own establishments still open to the Indochinese. The Grall Hospital of Saigon, taken over by the French Ministry of Foreign Affairs with its military personnel, remains open to the civil populations until 1976.

THE PLAGUE

Ever since antiquity, mankind has been haunted by the spectre of plague, a terrifying infectious disease with several possible clinical aspects. Considered as a divine castigation, this frightening scourge which triggers terror, has erupted here and there as an epidemic, resulting in deadly pandemic which most often than not has originated. in Asia where it was rampant or endemic, and spread rapidly across the world.

At last, by the end of the nineteenth century the triumph of modern medicine against this terrible scourge started to be outlined and finally this was achieved with the works of four medical officers of the Colonial Medical Corps.

– A.Yersin* who discovered the pathogen in Hong Kong in 1894.
– P.L. Simond* who discovered the "animal reservoirs" and the way of transmission in Karachi in 1898.
– G. Girard* and J. Robic* who developed a vaccine in Antananarivo, Madagascar in 1933.

One cannot help from being struck by the fact that none of these Colonial Army Physicians was awarded the Nobel Prize.

Once a thorough understanding of its epidemiology was obtained, plague could be curbed by putting in place adequate means of prevention. But still today some small foci remain active such as the ones in the United States, in Mauritania, or Madagascar. They are nevertheless kept in check as the discovery of the sensitivity to antibiotics of the involved pathogen known as Yersinia Pestis, and also of the rat flea’s sensitivity to insecticides have been real breakthroughs in the methods of fight and of prevention.

PLAGUE CLINICAL FEATURES

The typical form of plague in humans in that of Bubonic Plague.

After a symptomatic incubation period which lasts between two to five days the onset is very sudden with a large and painful lymphatic node which most of the time is in the groin area. It is escorted with a high grade fever. The patient’s condition deteriorates very quickly progressing to his death with the clinical picture of a sepsis. Nevertheless, this form, the most frequent, remains the least serious, depending on the epidemics, death occurs only in 30 to 80 % cases.

There are two other clinical varieties :

– Pneumonic Plague. The illness starts suddenly and is highly contagious through the inhalation of droplets of expectoration. The outcome is unvaryingly a fatal one when no adequate therapy is available.
– Septicaemic Plague. This variety is characterized by the proliferation of bacteria in the blood stream without any special organ involvement. It is a lightning variety escorted with haemorrhages and known as "Black Death". It used to be lethal, but could be cured in case of early treatment. It is at the acme of all epidemics.

Pulmonary plague is transmitted from a sick individual to an unscathed individual through salivary droplets. This variety is encountered in countries with a cold climate such as Manchuria where a terrible epidemic occurred in 1910-1911 killing many people and among them a young naval Medical Officer by the name of Gerald Mesny* who had been commissioned to go there.

PANDEMICS

Since antiquity there have been three long lasting pandemics which have persisted over several decades and even centuries :
– The first of them, known as the Justinian Plague (Sixth century A.D.) struck mostly the regions around the Mediterranean shores. Most likely it started in the wilderness in Central Africa and later reached Egypt along the Nile River and took a toll of around one hundred million fatalitiess.

Yersin’s shack in Hong Kong (1894)

– The second one named The Black Death or Medieval Plague probably originated in Asia and spread from the Russian steppes and the Caspian Sea region. The whole Europe was struck and nearly half of the entire population died. It peaked in the mid fourteen fifties but continued to run its course with epidemic flare ups well into the eighteenth century such as the one which occurred in Marseilles in 1720.

– The third one called "The Oceanic Plague" started in China and reached all continents aboard homebound ships : India, Japan, East Africa, Portugal, Australia, Philippine Islands, America and Indonesia. Outbreaks scourged the world between 1891 and 1948 and killed roughly twelve million people.

Plague foci across the world by the end of the 20th century

ALEXANDRE YERSIN AND THE DISCOVERY OF THE PLAGUE PATHOGEN

Alexandre YERSIN (1863-1943)

Upon Yersin*’s arrival in Hong Kong in June 1894, this scientist who had been one of the earliest trainees of Pasteur saw that plague was wreaking havoc on the life of the population. More than ten thousand fatalities had been recorded over the fortnight preceding his arrival. Indochina’s Governor General who feared that the disease would spread beyond the Chinese border had commissioned him to get there. Yersin had brought along with him a microscope and an incubator. A Japanese by the name of Shibasaburo Kitasato, who was one of Robert Koch’s former trainees, was already there with some more sophisticated equipment.

Yersin had a shack built for him near the Hong Kong Hospital. He lived and worked there non-stop and as he had not been cleared by the British to see patients he had to make do with patients corpses, taking into account one of Pasteur’s advice "Work on your own and have also your own corpses".

A week into his stay, one of the mice he had inoculated with a sample of pus taken from a bubo on a corpse, died. Its spleen contained "very small, stocky, round tipped bacilli which could be stained only with difficulty". A week later well developed cultures had grown in the test tubes he had inoculated. Yersin sent his report to the Indochina Governor General and shipped a culture of bacilli to the Pasteur Institute in Paris with also twenty pipette tips containing some bubo pus.

No other information is available about this shipment. As a former ship surgeon of the "Messageries Maritimes" a steamship company, we presume that he entrusted some of his former fellow ship surgeons and friends with his precious tubes. This bacterium remained alive during the voyage which was one month long without any need of subcultures.

It did not take long to the Pasteur Institute in Paris to confirm the discovery and this micro-organism was named at first Yersin bacillus or Pasteurelli Pestis. A new genus was later set up and Yersin Bacillus became known as Yersinia Pestis.

The discovery of the pathogen responsible for a disease which had taken a heavy toll on mankind over thousands of years was immediately acknowledged as being an achievement of utmost importance. A few months later, when he came back to France, on November 12th 1894, Yersin was awarded the Legion of Honour by Delcasse who was then Minister of Colonies.

The Chinese press praised the discoverer and requested that his bust be put in the pagoda of the five hundred genii in Canton.

With his inquisitive set of mind Yersin was an innovator in many other fields .He developed the cultivation of the hevea tree in Indochina and subsequently this country became an important latex producer. He also introduced and acclimated the cinchona and in so doing made the region self sufficient for its quinine needs.

He died in 1943. His remains are still in Nha Trang Indochina which is a country he had felt so deeply attached to for fifty three years of his lifespan. The Vietnamese people honour his grave today in the same way as they do for their greatest national heroes.

YERSIN’s grave in Nha Trang

PAUL-LOUIS SIMOND AND DISCOVERY OF THE WAY PLAGUE IS TRANSMITTED

Paul-Louis SIMOND

Since the most ancient times, it had been well known that plague flare ups were associated at least in the early days of an outbreak with an increased rate of mortality in rats. After isolating and investigating bacteria of human and murine plagues, Roux and Yersin concluded that they were facing the same pathogen.

In 1897 P.L. Simond*, arrived in Bombay in order to fight, with the use of Pasteur Institute anti-pesta sera, the terrible plague outbreak of the time, which had already claimed the lives of over thirty two thousand people during the two preceding years. At that point in time the prevailing theory which was supplemented with some additional data in bacteriology provided that transmission occurred through "miasmas". Simond was aware of the fact that the same pathogen was responsible for murine and human plagues.

A few months later he was sent to Karachi where the epidemic was in full swing. In Bombay he had frequently noticed on the skin of patients the presence of a small vesicular lesion which contained multiple bacilli. Therefore he suspected the role of an insect bite, and fleas are biting parasites which are shared by both humans and rats. The digestive tracts of fleas caught on plagued rats contains bacilli while the ones of unscathed rats do not.

At the Reynolds Hotel where he had been accommodated, on June 2nd 1898, he carried out a crucial experiment in the outhouse by placing with extreme care, side by side in a cage two rats which were separated by wire netting : one was plague stricken while the other one was unscathed. He brought uncontaminated fleas into the cage and a few days later he found that the previously unscathed rat was now displaying symptoms of plague. Simond wrote in his diary "I was deeply moved with the inexpressible feeling of having just betrayed a secret which had scared mankind since the early days of plague in the world". He reported his finding to E. Roux who was at the head of the Pasteur Institute and a paper was published in the October issue of the "Annales de l’Institut Pasteur". He devised the strategy which had to be implemented to fight against outbreaks of the disease. Action had to be focused and taken methodically on the three following points : transmitting parasites, rats and humans as both are together "pathogen reservoirs" and victims of the disease.

SIMOND’s experiment displaying the role of fleas (photograph of the Musée du SSA)

This finding was of course disputed. The role of micro-organisms had been well established with Pasteur but the possible role of transmitting insects was then very little known. Twenty years earlier Manson had evidenced that filariosis was mosquito-borne and later Finlay had found that Yellow Fever was also mosquito borne. Bruce had identified the role of glossinas in the transmission of animal trypanosomiasis. Simond altogether with them was then a great innovator.

Shortly after his discovery in August 1898, he had to go to Darjeeling which is a mountain health resort of northern India, to recover from a spell of malaria.

A British medical officer named Ronald Ross had requested an appointment with him which in the end never took place : it was he who had found the role of anopheles in the transmission of avian malaria, and he was later awarded the Nobel Prize in 1902. The King of England subsequently made him a Lord.

Further studies made clear that not all flea species carry the same risk of contamination. In species where bacilli can swiftly proliferate such as the rat’s flea a clot takes shape in the stomach which is a pure culture of Pasteurella Pestis. When the flea feeds again, blood is regurgitated and in so doing boosts the contagiousness of this species.

GIRARD AND ROBIC AND VACCINES

Plague was brought to Madagascar in 1898 aboard a freighter which had sailed from India with a rice cargo. During the ten next years small epidemic outbreaks occurred in coastal regions. Arriving from Mauritius in 1921 it struck again, but this time it reached the Central Highland region, where with colder temperatures pneumonic plague cases occurred, directly transmissible from person to person, extremely deadly.

This scourge remained active during the next two decades. It peaked in 1933 with 3 579 fatalities among the 3 933 diagnosed cases. None of the inactivated vaccines which had been developed so far with killed pathogens by Calmette*, Shiga, Besredka among others, had provided strong and also durable protection.

From 1922 to 1935, in the Antananarivo Pasteur Institute, Girard* and Robic* developed a vaccine from the EV strain (EV, the first letters of Evesque, a European child who died of the plague). It was a live vaccine, developed with an avirulent strain of Yersinia Pestis, like the Calmette’s BCG against tuberculosis. The immunity which appears three months after being inoculated is a strong one but a booster shot is needed once a year.

Georges GIRARD

Jean-Marie ROBIC

The concerned researchers and their staff deserve praise as they carried out the first trials on themselves, at the time when no efficient medication was available once the disease had started.

Over the next few years, the use of this vaccine was widened : thirteen thousand Malagasy people were inoculated in 1934, fifty thousand in 1935 and from 1936 onwards the entire population.

Mass Inoculation was carried out by Colonial Army medical officers and auxiliary Malagasy physicians. The following chart displays the subsiding number of plague cases recorded in Madagascar with five hundred thousand people inoculated each year since 1936 :

Cases of plague in Madagascar

This vaccine has also been used in Argentina, Brazil, in Sub Saharan Africa and Vietnam where it was still produced in the nineteen eighties. It is still inoculated in Kazakhstan in small isolated villages where small foci of plague are still found.

EPIDEMIOLOGY

The spread of epidemics is partly related to fleas mores and to their feeding habits. They are hosted by many mammals and birds. There are numerous species of them and each has a preferred but not exclusive animal host. Males and females feed on blood and abandon their host shortly once it dies.

Three different varieties of plague are to be distinguished :

– Wild rodents plague is a wild rodents disease and this characteristic makes its eradication impossible worldwide. The disease keeps going in natural foci with the survival of bacilli in the most resistant hosts and when a susceptible species is contaminated it comes close to its full extermination. Humans are only exceptionally involved in this cycle and information is available only with making counts of wild rodents.

– Rural plague affects rodents and also rats, which live in human surroundings. This kind of plague foci are still found in Northern India, in Madagascar and in Central America... Rat fleas are not fond of human blood and man is only bitten by mere chance. He will subsequently have bubonic plague but will not transmit the disease unless he is hosting human fleas.

– Urban Plague happens only with human fleas. At all times but especially in cold places there is a risk of seeing the disease shifting from the bubonic to pneumonic variety which carries the most severe prognosis and is directly transmitted from an individual to another.

PREVENTION OF PLAGUE

Very early on, the Colonial Medical Corps advocated and subsequently laid out a rational method of fighting against rats, which are the most important pathogen reservoirs and which also are the ones living close to humans.

In Indochina rat hunters received a bounty. In the nineteen tens around one hundred thousand rats were exterminated each year. Traps were set up to catch rats which could be screened for plague bacilli as a murine plague epizootic precedes a human epidemic.

Capturing rats

In Madagascar, the bounty was awarded upon displaying the rat’s tail and in Antananarivo, children became quickly expert rat hunters.

Later on, poisoned baits were used to get rid of these dangerous commensal animals.

A clinical warning system was also set up in sensitive areas (Madagascar Highlands for instance) so that the first cases could be reported shortly after their occurrence. When in doubt, the post mortem screening of a liver sample had to be carried out as if this scourge kept going undetected during the next fifteen to twenty days it would later be very difficult and nearly impossible to control.

All cases must be notified to Health Authorities according to the rules set up in the International Health Regulations. Each year several hundred cases are reported worldwide and still now a close monitoring of harbours and airports is carried out. There is a periodic implementation of measures to exterminate rats in port cities which are also systematically used for ships arriving from places of endemicity. Rat proof devices which are used on wharves, in houses and attics help to defuse any risk. But wild plague remains beyond all attempts of eradication and remains a threat which populations are equipped to face with antibiotics as the involved pathogen is susceptible to antibiotics and low cost sulfonamides. Moreover killing fleas with insecticides puts in check an outbreak of the disease. Still, a close watch has nevertheless to be kept as there has been a few reports of resistance of the pathogen to antibiotics and also of some instances of flea resistance to insecticides.

The Girard et Robic vaccine has been improved since 1935 and the Pasteur Institute now produces only a new generation vaccine which is made of killed bacteria.

For further information :

– Yersin A. : La peste bubonique à Hong-kong. Ann. Inst. Pasteur 1894,8, 662-667.
– Simond P.L. : La propagation de la peste. Ann. Inst. Pasteur 1898,12,10 626-686.
– Simond P.L. : Comment fut mis en évidence le rôle de la puce dans la transmission de la peste. Rev. Hyg. 1936,58,1-17.
– Mollaret H. : Yersinioses. Encycl. Méd.-chir. Maladies infectieuses 1968. 8-035 D10, 1-12.
– Voelkel J. : La vie et l’œuvre de Simond P.L. 1858-1947. Méd. Trop. 1969,29,429-441.
– Balthasard M : État actuel de la peste dans le monde -foyers naturels-. Bull. Soc. Path. Exo. 1971,64,5,711-713.
– Mollaret M. : Alexandre Yersin tel qu’en lui-même enfin… Nouv. Press. Méd. 1973,2,39,2575-2580.
– Brygoo E.R. : La peste. Etudes médicales. Le Caire. 1974, n°2, 63-111.
– Mollaret H. Brossolet J. : A.Yersin ou le vainqueur de la peste. 1 vol. 321p. Fayard Edit. 1985 "Les Inconnus de l’histoire".
– Lemarchand-Copreaux F. : La vaccination antipesteuse. Pour la science. 2000,273,10-13.

ROLE OF NATIVE PERSONNEL

The training of native healthcare professionals whose standards of expertise grew higher over the years was done over nearly one hundred years by the six thousand physicians and pharmacists of the Colonial Army Medical Corps who were distributed across all continents (with some four hundred of them in 1900 simultaneously working on the field of action, to eight hundred in 1960). These officers made a major contribution in Africa, in Indochina, in Madagascar, in the Caribbean and in the South Seas Islands by setting-up medical teams.

Devising, organizing and leading these teams of workers was the responsibility of European personnel. They were able to take advantage of the help supplied by thousands of native health care professionals such as physicians, pharmacists, nurses and midwives in order to make their missions really successful.

The part which these native health professionals took in the work which has been done, is of the utmost importance. It was really a successful partnership as once they were independent, all French former colonies were able to very smoothly take over their Health Services.

TRAINING AUXILIARY HEALTHWORKERS

The expansion of the Colonial Empire which had been started by the time of of the third Republic (1871-1940) brought to light the absolute necessity of training native paramedics in each territory. Long before health training institutions could be built, in the early nineteenth century Naval medical officers acted on their own as trainers and later in 1863 they opened a medical academy in Pondichery.

In Africa, Madagascar, Indochina, the French language had to be taught first before contemplating any other kind of teaching. At the turn of the 20th century, without any available official population census, about two million people are reckoned to have been living in Senegal which is half as large as France. There they spoke more than a dozen different vernacular languages and this made teaching the French language a time consuming task.

At first at the time they were hired, native aid workers were illiterate. The physician or the pharmacist who employed them had to show them first what he expected them to do. Their training was limited to the only thing they would have to do or to the only task they would have to fulfil. It could be either about taking care of wounds with proper disinfection and bandaging or about using a microscope in a Mobile Health Unit and some of them became very skilled at spotting trypanosomes in human fluids.

Hygiene auxilairy

Later with their grammar school graduation, boys could start nurse training and girls midwife training. They were entrusted with more important responsibilities as they could sort out some patients who were waiting standing in long lines in front of outpatients clinics whom they thought could be in their sphere.

While they were in high school those who had successfully taken an examination named "brevet élémentaire" could be admitted to a native medical academy which had a faculty composed of Colonial Medical Corps personnel. There, they earned a degree either of physician assistant or of auxiliary physician or auxiliary pharmacist.

Those who had completed their high school curriculum and successfully taken the examination named "baccalaureat" could apply for their admission to a medical school in France and later in overseas places where a university with a medical school was built. They could train and earn their medical or pharmaceutical degree there, then becoming fully-fledged physicians or pharmacists.

A Class of student nurses and its "godmother" (1921)

Thus, at all levels, it was the colonial physicians and pharmacists who trained or helped to train these valuable collaborators.

THE MEDICAL TEAM

While he was at the head of a team, a physician was close to his health co-workers and to other workmates as well. According to a Senegalese saying they were "trading their lice" which means that they were in very close contact with one another such were for instance a driver and "his boss". When making their rural rounds they were very supportive of each other but they were also respectful of the hierarchy and of each other’s skills. They shared the same kind of life, travelling in convoys, feeding themselves alike, pushing together their vehicle whenever it got bogged down in the mud and during the heroic ages also exposed themselves together to the risk of dying of plague or of yellow fever. The physician and his team of co-workers could not be split up. After suffering together some hardships, their relationship was bound to become altogether one of friendship, of fondness and of respect.

Getting ready for a round

Either a nurse or a secretary was in charge of translating and this was of the utmost importance as patients had to be asked questions, and they also had to be given some information about their treatment and about prevention. The help of native co-workers was also needed to act in accordance with traditions and to respect taboos. One would be mistaken in underrating the important part taken by these native personnel in the achievements of Colonial Medical Corps.

MEDICAL ORGANIZATION

In a territory or a colony the implementation of health care, which is now known as Public Health, was the duty of the Public Health Department where Colonial Army physicians were assigned to positions of great responsibility or to positions where they had to lead or to boost the action. Altogether these physicians nevertheless were only a minority in the staff.

A few decades after the achievement of the pacification, all public services in French territories were run according to the same pyramidal organization chart.

The French were only found at the head of services and of departments and also indistrict towns. There, they held positions which required the same degrees or the same special skills as in France but this applied only for the highest positions. They had the management, directed and led the actions, set up the training of native personnel, checked and assessed the activities. Gradually some individuals of colonial extraction who had earned the required degrees and skills were posted to these positions.

All the other personnel, by far the most numerous, are natives : Africans, Malagasis, Indo-chinese, etc... From diplomed professionnels to simple workmen. They belong to the so-called "senior communal federal" or local" managers. Or else they are auxiliaries, or even day workers.

In each colony, in conformity with this scheme, the physicians from the colonial troops ((detached from the army) must set up the health service and see to its good functioning. Exclusively civilian, this service is under the authority of the governor of the colonies and of the Ministry of the Colonies. On the other hand, it has no connection with the military authorities of the territory except in hospitals or in small garnisons where "detached" physicians take care of military patients.

For example, just before their independence in the late 1950s physicians of the colonial army made only about 4% of the number of healthcare professionals in Ivory Coast and Togo (physicians and pharmacists, dentists, midwives and nurses). Physicians who were on duty within the frame of the military or who were retired from the military and on private practice there, are not included in the numbers of those who worked for public health services.

Traveling nurses

In Senegal where Dakar was the "capital" (chef-lieu) of French Western Africa , this proportion was higher and reached 6%.

There were also other cogs in the public health services layout : supervisors and management personnel, nurses’ aids, workmen and different kinds of technicians, the second group being mostly African.

Another example is found with the description of a Mobile Health Unit in charge of controlling sleeping sickness in Cameroon in 1939 by J. de Lostalot*. The physician is usually the only "white" in a caravan. They all are on foot : "The physician hit the road with the twenty nurses of the team and also the other mates who balanced on their heads either crates filled with medical equipment and microscopes or chests with the camping equipment, all together there were more than fifty porters".

In the nineteen fifties in sahelian regions trucks were substituted to porters. Mobile Health Units for Treponematoses Control stopped employing as many people as they did before and then beside the physician, there were only 15 to 20 nurses and native workers left.

NATIVE HEALTH CO-WORKERS

As an example we are now going to recall the different categories of native personnel which were found in Black Africa :

– The African medical officer (until 1945 known as auxiliary physician). Most of the time he was older and more experienced than the French physician who had just arrived and he assisted him in all possible ways. He escorted him when doing rounds or remained on duty in the hospital whenever his "boss" was out of town. Some were in charge of an operating theatre, while some others ran a rural medical facility servicing the people of the surrounding countryside.

They were appreciated as go-betweens as they facilitated communication with local populations and chieftains also. They had a much better understanding than Europeans of the hesitations of their patients who so far had been used only to the methods of work of traditional healers. In a reciprocal way they cared for the physician whenever he caught some unavoidable fever or some dysentery.

– The African pharmacist (ex auxiliary pharmacist) assisted the colonial army pharmacist in the management of the Colony Central Pharmacy and of hospital pharmacies, in the shipping of medication supplies to healthcare facilities. He also helped preparing dextrose and sodium chloride solutions which were widely used, in the making of parenteral medications and others, and also in the running of biochemistry labs in hospitals and in Pasteur Institutes. He had also to be in touch with traditional healers.

A visit to the doctor in Tannanarive (1952)

– The African midwife (ex auxiliary midwife) : most of the time a strong minded woman who was in charge of running the maternity, of following up pregnancies, of delivering babies and of supervising the wake of labour. She also had to deal with gynecology issues and to care for infants. In maternities which were in capitals there were a few European midwives who were employed on contract, but all other cities and rural areas were served by native midwives. When there were not enough of them, visiting nurses had to take over and in the back country it happened that empiric midwives were also at work. The physician was only called upon for difficult childbirth procedures. Quite often it happened that the physician’s wife had to give birth in the very place where her husband was posted and the care and concern of the native midwife were at least as efficacious and comforting as those of the baby’s father.

– Most of the nurses were men and as in all other parts of the world, they were an essential cog in the smooth running of health services. They made up to 80 to 90 % of the qualified health workers’ number and there were 8 to 10 times as many of them as physicians. Beside providing the sick and wounded with nursing care they were also assigned to other diverse duties which were more important than the ones of their colleagues in Europe. At the head of rural medical clinics they were responsible for a few dozens of thousand people who lived in several villages : they cared for patients, summoning some to the physician’s visit and referred some others to the hospital. They also supervised the work of the empiric midwife of the village.

The Major Endemic Diseases Control Service Teams were kind of doing assembly line work, with some nurses taking samples of blood or of cerebro-spinal fluid while some others who were branded microscopists were looking at smears. As one of their supervisors put it one day :"Ah ! these microscopists with their eye glued many hours to their eyepiece, they have the same visual skill to find a trypanosome among blood red cells as a hunter who is looking for a bird in hiding, deep in the thick foliage of a tree. Sometimes they fall asleep for good but I figure that they would immediately wake up if eventually a trypanosome showed up".

The smartest ones became medical assistants : for instance a specialization as "Leprosy Inspector" was set up in order to ensure the accurate diagnosis of suspicious spots and nodules and to initiate the appropriate treatment.

The best of them, whom patients often addressed as "doctors" were assigned to more sophisticated duties such as providing general anesthesias, making delicate dressings, performing minor surgery procedures, and even delivering babies.

The list of other kinds of personnel is a long one. One should not forget all the agents involved in management with all secretaries, laboratory technicians, drivers, cooks and handymen.

THE PART TAKEN BY NATIVE PERSONNEL WAS AN ESSENTIAL ONE

Many more levels of the health care system were open to natives where they held positions and worked with competence and dedication, bringing a decisive contribution to the plan of action. They breathed new life into the humanitarian endeavour of the Colonial Medical Corps. As of the mid nineteen thirties, there were many more auxiliary physicians and pharmacists than French physicians and pharmacists and at the time of the independence of these countries, this ratio had even increased.

The Colonial Army physician or pharmacist had to show his expertise and dedication and also to display human touch and tact in order to compel native co-workers’ esteem and devotion. In return, excepted for a very few instances, in the hospital or on the field of action they did not fail to fulfil the duties as "the boss" had expected them to do.

A SUCCESSFUL PARTNERSHIP

Most European physicians and pharmacists were servicemen on temporary assignment overseas "detached", but a few of them were civilians who were employed on contract. There was a very small number only of midwives and management officers.

The number of French nurses was about the same as that of physicians but the size of this workforce was small when compared to that of native nurses they were working with.

On the other hand, "African practitioners", nearly all paramedics, management clerks and auxiliaries, handymen were all natives. By and large, their part in the running of their departments was a decisive one. African auxiliary physicians were sometimes put in the same category as French medical officers, who were fully-fledged physicians. Unavoidable clashes and misunderstandings followed which fortunately do not overshadow the success of this training undertaking.

It is undisputable that on the one hand the conjunction of all these native health professionals who were persistently present on the field with on the other hand the identical training and conception of work of physicians assigned to run medical facilities, who used to take over from one another every two or three years according the duration of their colonial stint, provided the French health services with continuity and good quality.

MALARIA

Known for thousands of years but still active, threatening and affecting two billion people in the world, Paludism or Malaria is a fearsome epidemic of which the agent and mode of propagation are already known at the end of the 19th century.

Spread over different continents, the physicians of the Colonial Health Service study the epidemiological forms and the geographical distribution of the disease. They also help in the work of classifying and understanding the clinical presentations, among which there is the fearsome biliary haemoglobinuric fever.

The therapeutic effects of quinine are strengthened in 1930 with the appearance of synthetic antimalarial products. Moreover, in order not to be dependant on South American production, Yersin* develops the cultivation of cinchona in Indonesia.

The Colonial Health Service is also concerned with the prevention of the greatest of tropical endemics. It does an epidemiological study which leads to health campaigns, completed with campaigns of prevention. The WHO, from the time of its foundation in 1948, launches an attempt to eradicate the disease with the aid of the SGHMP and then, after Independence, with the aid of national organizations. The utopian nature of this project becomes evident in 1969.

THE AGENT AND ITS PROPAGATION

"Intermittent fevers" are known from time immemorial. They are mentioned by Homer and studied by Hippocrates. Their predilection for marshy regions results in the disease being known very early as "Marsh fever" or paludism. Contamination being attributed to "bad air", other authors use the name "Malaria". Until the 19th Century, this theory of "morbid miasmas" is the one that prevails to explain the transmission of malaria.

– 1880 : Laveran, a French military physician and a student of Pasteur, discovers the agent of malaria in Constantine. In 1907 he receives the Nobel Prize for Medicine.

Later, four species of human haematozoon or Plasmodium are identified : Plasmodium falciparum, the most widespread and the most dangerous, which kills (a million deaths a year in the world), Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale.

It must be mentioned that, in nature, other haematozoon affect animals but cannot be transmitted to humans.

From left to right: Plasmodium malariae seen through a telescope, Plasmodium falciparum trophozoite, Plasmodium falciparum gametocyte

– 1897 : Ross, an English physician in the Indian Army, demonstrates that the transmission of bird paludism takes place through mosquitoes. A little later, in 1898, Grassi and other Italian authors and then Manson confirm that it is the same for human paludism, which is transmitted by female mosquitoes (anopheles). Ross receives the Nobel prize in 1902.

This "anopheline theory" is verified in Madagascar between 1902 and 1904 by Clarac* and Bouet* : They observe that the frequency and the gravity of the malaria is proportional to the dispersion and proliferation of mosquitoes and that the destruction of mosquito breeding grounds reduces considerably the spread of the disease. The female mosquito operates nocturnally and the stings are painless. The bloody meal it looks for is indispensable for procreation.

**Breeding ground of anopheles in the Sahel**

The reservoir of the virus is exclusively human. Within the body of the mosquito and then within that of man, the parasite goes through a complex cycle of development with a dozen successive stages.

The parasite, inoculated by the sting, reaches the liver and multiplies there. After a few days, it gets into the blood and invades the red corpuscles.

Another female mosquito, at mealtimes, absorbs parasites from humans and contaminates itself. The man-mosquito cycle is thus continued.

There are many species of anopheles. They do not all have the same appetite for human blood and so not the same role in the transmission of the haematozoon.

Even more important is the fact that the "dangerous" species do not all have the same habits. Thus, to put in place an efficient plan of prevention, a perfect knowledge of these species is necessary. This analysis was the work of the "pioneers" of the Colonial Health Service, those who were followers of Pasteur, doctors or chemists who were entomologists. The list of those who participated in drawing up this inventory would be long.

CLINICAL MANIFESTATIONS

"It struck me like a bolt of lightening... I felt frozen to the marrow... I start to shiver uncontrollably. Malaria ! And then I feel that I’m getting warmer... It seems to me that I am inside a furnace. My temperature is 40.5°; my skull is about to burst... I begin to be delirious... The nurse gives me an injection of quinoforme. In the morning, I have returned to normal... My bed had been flooded with sweat and my attendants had changed my clothes without my being aware". These "torments of malaria" described by a physician, Bonnefond*, have been the experience of all the settlers.

One of the first scientific studies in sub-Saharan Africa is the work of Marchoux* accomplished in St Louis, Senegal. In three years, starting with 350 observations of patients and thanks to a personal method of staining the parasite, he completes the study of the evolutionary stages of the haematozoon and, after autopsies, he describes the engorgement of cerebral capillaries in patients who have died of pernicious fits.

The work of colonial physicians, Thiroux* and Marcel Leger* in Senegal, Bouffard* in Sudan and Sorel* in the Ivory Coast, has largely contributed to the knowledge of the disease.

Besides the typical feverish fits that occur every two days (tertian fever) or every three days (quartan fever), the acute manifestations may consist of a continuous fever having the appearance of typhoid fever, particularly in Indochina, where Grall* speaks of malarial typhoid. Only intermittent fevers are affirmed to be authentic malarial manifestations. From 1834, Maillot*, who obviously ignored the cause of the disease, already believed that all fevers were malarial because they were cured with the administration of quinine.

As F. Blanc* insists, malaria is more frequent after a short stay than during long sojourns and the forms are then more serious, which makes Moretin* remark: "little stay - big malaria". In fact, the force of the parasitic invasion in the case of young subjects arriving in endemic zones brings about what Le Dantec* calls "ship’s boy malaria", which often evolves into a serious form of the disease.

Around 1950 F. Blanc sets about clarifying the different clinical presentations of chronic manifestations, with low fever and the wasting away of the subject who becomes anorexic, anaemic, acquires a grey complexion, which leads to the malarial marasmus described by Quennec* at Nossi-Bé after the events in Madagascar in 1895.

Sometimes, usually after high fever, neuralgic manifestations appear, giving rise to an aspect of febrile coma with convulsions. This is the most brutally destructive form of encephalitis, says Collomb*, affecting mostly young native children and Europeans who have arrived recently and have not received or been badly treated with secondary chemoprophylaxis. Death follows in a few hours or a few days, in spite of the treatment administrated.

A treatise on Malaria by A. Laveran (1907)

The manifestations of the disease already described by Laveran in 1907 in his treatise on Malaria have been studied once again, while according great precision and taking into account new data, by Grall* and Clarac* in 1910, Le Dantec* in 1929, Joyeux* and Sice* in 1936.

Sometimes, in the case of a European, a long-time resident, taking irregular doses of quinine (more rarely in the case of natives) a very serious condition known as "biliary haemoglobinuric fever", which is found all over the empire, suddenly develops. This condition is characterized by high fever, a sallow complexion, cherry-red urine the colour of port wine, almost black, due to the haemoglobin it contains. Urinary secretion slows down and, in one-third of the cases, the patient dies of uraemia. This dramatic circumstance is described in the 19th Century by the naval physicians Lebeau, Dolle, Le Roy de Méricourt, Beranger-Ferraud. As early as 1900, Marchoux* attributes it to the administration of quinine.

Later the patients themselves become aware of the link with quinine and refuse this remedy. Today one knows that this condition is the consequence of the sudden bursting of red corpuscles, resulting in the release of haemoglobin into the vessels, depending on individual sensitivity to quinine. When quinine was no longer used therapeutically, the condition was no longer observed.

THE MEDICINES

In the 17th Century, cinchona bark, used by indigenous people as a remedy against the fevers of the region, is brought from Peru to Spain. In 1820 the French chemists Pelletier and Caventou isolate the active element, an alkaloid called quinine, which revolutionizes the prognosis of the disease.

During the conquest of Algeria, the French military physician Maillot - who has already used quinine in Corsica - is appointed to the hospital in Bône where the death rate of fever patients was nearly 25 %. He uses the new medicine liberally and his success is such that all the patients demand admittance to his ward "where one dies so little".

Maillot determines precisely the patterns curable with quinine; but he is also the initiator of secondary chemoprophylaxis, with the taking of daily doses of this remedy.

Working with a microscope

For a century, from the time of Maillot to the 1930s, quinine salts are the only anti-malarial products used. Presented as a medicine to be taken orally (as pills or syrups for children) and as injectable solutions in ampules, they fulfil all that is required of a curative as well as a preventive remedy.

Towards 1930, efficacious synthetic products appear having a common advantage of being less costly and having a persistent effect in prophylaxis, which permits medicines to be taken no longer daily but weekly. The inconvenience of all these products is that strains of bacteria which resist treatment appear rapidly.

THE EPIDEMIOLOGICAL STUDY

To study the limits and intensity of an epidemic in a given zone, it is necessary to depend on quantitative data and choose the indicators that are the easiest to measure and the most reliable.

Determining the state of the spleen is a rapid and low-cost method of obtaining a view of the present malarial condition of the patient.

It gives an indication, in children less than fifteen years old, of the frequency of the increase in volume of the spleen. Normally this organ is not palpable under the left edge of the ribs. Its volume is increased when malaria sets in and will be increased with each attack until it can be felt by palpating the edge of the ribs; it may reach the umbilicus and sometimes go beyond it.

Palpation of the spleen

The percentage of enlarged spleens permits the establishment of the spleen-condition of a population of children. It is easy to determine because it only requires palpation of the abdomen. It has been widely used by epidemiologists, even if it is less reliable than other methods based on parasite research by examining a drop of blood through a microscope. Taking blood samples is not well-accepted by the population. Performed simultaneously, the two methods have evolved together.

Farinaud* shows that in countries where the endemic exists, 96 % of the children are infected with parasites at the end of their first year. The size of their spleens increases rapidly and reaches a maximum between the ages of two and five. (Meanwhile, from 20 to 40 % of them will be dead). From then on, a stable condition seems to subsist but it is only at the age of puberty that the individual acquires sufficient immunity to resist infection. The large spleens become smaller and almost normal, although the adult himself remains throughout his life more or less under the influence of malaria. His powers of resistance may be overwhelmed in the case of intercurrent diseases or due to usual factors that lead to the diminution of the resistance of the organism. It is thus that the number of patients increase when there is a temporary shortage of food. Women often experience a reawakening of latent malaria during pregnancy and childbirth.

In Indochina, from 1919, Noël Bernard* studies the rate of infection in Indochinese labourers. The investigation is extended into the whole of the Indochinese union. In 1929 the "Anti-malarial Service" is established and directed by Morin*. Its success is dazzling. Workers in plantations and mines are protected. L.A. Robin*, Marneffe* and Farinaud* distinguish themselves particularly during these campaigns.

THE WIDE-SPREAD NATURE AND THE GEOGRAPHICAL DISTRIBUTION OF MALARIA IN FRENCH COLONIES IN 1937

Geographical distribution of Malaria of the type Plasmodium Falciparum

From the beginnings of colonialism, Health Service physicians are conscious of the terrible tribute children in the first years of life pay to this scourge. Among them, the overseas followers of Pasteur undertake studies to hold back this massacre while their colleagues in the AMI try desperately to treat - but one at a time - the afflicted patients. In Indochina, in 1938, M.E. Farinaud* establishes that, in the region of the Mountainous Plateaux highly infected with malaria, of 1 000 births, 31 % of the children die before the age of one and 80 % of these deaths are due to Malaria. Other studies have confirmed these observations in the AEF (French East Africa) and in the AOF (French West Africa)...

It is the most widespread disease in the world, causing every year nearly two million deaths of which more than a million are those of children. 40 % of the world’s population live in malarial zones. Its economic cost is estimated to grow by 1.3 % every year.

At the peak of the French Colonial Empire, Vogel* and Riou*, the authors of an annual report established by the Direction of the Colonial Health Service, declare that in 1937 : "Malaria remains, as always, for the whole of our colonies, the most fearsome epidemic".

– In the whole of Indochina, the disease is the cause of 20 % of the consultations and 16 % of the hospitalizations. Its widespread character and its severity justify the creation in Annam and Tonkin of an "anti-malarial service" made responsible for searching people suffering from the disease and pursuing anti-malarial investigations.

– In Madagascar, the disease is the cause of 27 % of the consultations and 16% of the hospitalizations.

– In the AEF, with only 3.6 % of the population arriving for consultations, one begins to think that the disease is less prevalent. In fact, numerous investigations in the area reveal a higher rate of infection : thus, in the Mid-Congo (Moyen-Congo), in the department of Pool, the Pasteur Institute of Brazzaville finds, during that same year, in the villages, blood rates (said to be due to plasmodium) between 45 % and 100 %, the average in the region being 75 %, which corresponds to a strong hyperendemic situation.

– In the AOF, systematic investigations made in Guinea establish the figure for affected spleens as 80 %.

– In the group West Indies-Guyana, the disease rages more actively on the continent, in Guyana, where a large proportion of the patients are Europeans in penitentiary establishments.

– In India, only Chandernagor is concerned, the disease being rare in the other trading posts.

– In the Pacific, Malaria exists neither in New Caledonia nor in Polynesia while it is hyperendemic in the New Hebrides.

**Antimalarial Campaign notices (China 1938)**

On the whole, one estimates that many millions of Malaria patients are treated every year in establishments of the French Colonial Health Service. At the time of Independence in 1960, Malaria is clearly on the decline.

THE ORGANIZATION OF THE COMBAT AGAINST MALARIA

Until 1948, outside Indochina, there is no "Native Health Service" to combat Malaria for the indigenous people. It is integrated in the polyvalence of the AMI.

Catching anopheles

– Curative and individual medicine :

All the patients are treated one by one in the dispensary or admitted into hospital. In general, those who have fever are given quinine systematically, later quinacrine and then chloroquine. Before the term is invented, it is what will later be called "presumptive treatment".

– Prophylactic mass measures :

They are preceded by an epidemiological investigation to evaluate the intensity of the epidemic by establishing the condition of the spleen in the case of children and adolescents. They are examined in some villages by the bush doctor and systematically in schools. Moreover, the Hygiene Service and the Pasteur Institute try to identify local mosquitoes and their habits. From 1948, confided to the SGHMP, the mass anti-malarial combat takes on another dimension.

PRACTICAL MEASURES TO COMBAT MOSQUITOES (ANTI-VECTORIAL)

As early as 1903, Rangé*, the inspector of Health Services in the AOF recommends the suppression of larvae breeding grounds, and the elimination of stagnant water spots is organized by the hygienic services directed by a colonial physician that the populations nickname "Mosquito Doctor". One of them, at the end of his career as a hygienist, knew how to find motionless mosquitoes in the most unlikely hiding places. His African collaborators said of him: "He has learnt to reason like the mosquitoes !".

Until the end of the Second World War, the combat against vectors is limited to :

– The drying up of larvae breeding grounds.

– The installation of earthenware or concrete draining material, water-flowing facilities in river networks, in Indonesia from the 1930s (Pleiku, Phu Qui) then in Madagascar (Ivato in 1937).

– The spreading of fuel (which asphyxiates larvae) over shallow waters that cannot be drained away. Around Dakar, attention is paid to market-garden and garden wells and to creeks, which are sprayed with mineral oils derived from petrol.

The fight against larvae

– The introduction of larvae-eating fish of the species Gambusia or Girardinus into ponds and water spots where anopheles foregather.

– Visits made by "the brigades of the hygiene service" to houses with the possibility of fines if larvae-breeding places are discovered. For example, in 1937, in Dahomey: 270 158 visits lead to the discovery of 3 436 breeding places of anopheles.

– The spraying of the walls of houses with insecticides, pyrethine and other "fly-tox".

A series of "minor measures" which have great efficacy, on condition that they are rigorously observed :

– The use of mosquito nets at night, the installation of metallic wire mesh on windows or the application of Citronella, palm oil, etc..., on the skin, protects one from mosquito bites.
– Certain indigenous practices prove to be efficacious. Thus Bouet* in 1903 advises "that the Malagasy custom of living in huts filled with smoke from the kitchen fireplace should be allowed to continue and the native should not be obliged to build a kitchen outside his dwelling". In Madagascar, from 1902 to 1904, under the authority of Clarac*, the natives are advised not to fill paddy fields with stagnant water after the harvest but to let them dry up. In sub-Saharan Africa, the combat is led all the more vigorously as the Health Service is, at the same time, active against the Aedes, the vector of Yellow Fever.

In 1905, Le Moal* initiates in Conakry a very efficient plan of action. A follower of Pasteur, a student of Mesnil, he directs the hygiene service in Conakry. Malaria is the cause of decimation among Guinean children. Le Moal* gets the pools dried up, the ditches filled up and cavities in trees sealed … His mosquito control programme is adopted in the other capitals. His career will be short: he dies in 1908 in Kindia (Guinea) at the age of 32. His statue, paid for by public contributions, is inaugurated in 1914 in Conakry where his memory remains legendary.

After the Second World War, the advent of DDT, the first of the organo-chlorates, insecticides with residual effects, marks a decisive step in the anti-vectorial combat, at least in urban areas.

It is used in the form of pulverisations, in dwellings and in hedges and foliages along public roads. Two inconvenient factors soon appear: on the one hand, the high cost of these pulverisations; on the other hand, from 1956, the appearance of species of anopheles that can resist these products.

PRACTICAL MEASURES FOR CHEMOPROPHYLAXIS

Bust of Maillot

From 1840, Maillot advocates taking quinine to avoid malarial manifestations. In 1893, the Dahomey expedition is a great success on the level of health, the troops having observed the recommendations.

In 1895, the Madagascar expedition is a disaster because the hygienic recommendations and the rules for protection were completely unsuitable. Le Dantec* writes in 1929 : "that generally 20 or 30 cg of quinine sulphate are taken every day for many successive years without any trouble. The prescription must indicate a daily dose and not a weekly one as it sometimes does".

Chemoprophylaxis does not concern adult natives, considered as semi-immunised after adolescence. The programme is designed to protect Europeans systematically, civil servants and native children thanks to the free distribution of quinine and, later, chloroquine. In the 1930s, synthetic antimalarial products taken weekly as prophylactic doses are widely used. The results prove to be satisfactory notably in 1937 in Chad, Madagascar, Cochin China and in Annam. There is significant reduction in the size of spleens. In Togo, in Sokodé, the comparison between areas that have dispensaries and those that do not shows that the former have 26 % bad spleen conditions and the latter double that figure, that is to say, 52 %.

As soon as it is discovered, chloroquine supplants other products rapidly. In 1948, a great chemoprophylaxis campaign aimed at civil populations is set up in Indochina, in the mountain plateaux in the centre. Directed by Choumara*, "an autonomous mobile service of antimalarial prophylaxis" is created. At the end of 18 months, three protocols, when compared, show equivalent results. The infant mortality rate is reduced by half. The populations prefer the spraying of DDT (every six months) to the daily distribution of chloroquine. Other protocols are tested by Farinaud* and Choumara* until 1953. At the end of these five years of study, it is confirmed that the best prophylaxis consists of an association of the combat against vectors with chemoprophylaxis.

ATTEMPTS TO ERADICATE THE DISEASE

Leaning essentially on the combat against vectors, the WHO and international organizations decide in 1956 to attempt to eradicate Malaria in the world. Experimental zones are designated in order to test methods and evaluate the results.

The SGHMP has had a "Malaria section" since 1948 and two "experimental zones" are chosen by the WHO in French West Africa (AOF), one in Senegal, in Thiès, which is put in charge of R. Michel*, the other in Upper Volta, in Bobo-Dioulasso, confided to Ricossé*. Divided into sectors, these zones are submitted to different protocols, the combat against vectors with DDT being used alone or in association with chemoprophylaxis. Although the epidemic has diminished significantly after five years of the programme, chemoresistance spoils hopes of progress : that of anopheles vis-à-vis insecticides (Hamon and Choumara* in Upper Volta in 1957) and that of haematozoon vis-à-vis chloroquine in 1960 (Ricossé*).

Loading insecticide sprayers

Once it becomes independent, Senegal decides to preserve the experimental zone of Thiès by creating an "Antimalarial Service" (SLAP) which continues to be directed by Michel* and is integrated on the regional level into the OCCGE. Because of its cost, the spraying of insecticides is reduced, whereas health education and chemoprophylaxis are given greater importance. The results remain very satisfactory : serious Malaria disappears and children are in better health.

In 1969, the WHO acknowledges officially the failure of the project to eradicate Malaria from the planet.

For further information :

– Laveran A. : Traité du paludisme. 1 vol. 622p. Masson et Cie Edit. Paris 1907.
– Joyeux Ch. Sicé A. : Le paludisme.p.779-889, In Précis de médecine coloniale. Masson et Cie Edit. Paris 1937.
– Vaucel M. : Paludisme. p.655-806, in Médecine Tropicale. Editions médicales Flammarion. Paris 1952.
– Groupe d’auteurs : Le paludisme. Rev. Prat. 1977,27,37,2339-2418
– Groupe d’auteurs : Le paludisme. Méd. Trop. 1982,42,363-462.
– Groupe d’auteurs : Le paludisme. Rev. Prat. 1988,38,18,1149-1187.
– Groupe d’auteurs : Le paludisme. Rev. Prat.1998,48,3,251-297.

MATERNAL AND INFANTILE PROTECTION (PMI)

At the beginning of the twentieth century, maternal mortality and infantile mortality rates are catastrophic in tropical countries. Cultural reasons don’t incite people to ask for treatment in this domain at a time when, moreover, Health Service physicians consider as a priority the duty of fighting the spread of endemic diseases.

After the 1914-1918 war, the service for the protection of mothers and children (PMI) is set up. It depends on the training and the participation of native female collaborators, first of all midwives but also visiting nurses who, going out to meet pregnant women in their dwellings, maintain a link with the health services. Besides, especially in rural areas, the traditional midwives or matrons receive, as often as possible, some training and are subjected to controls. A service for the protection of indigenous mothers and children comes into being.

After 1950, the PMI is modernised. Centres are established in towns, qualified personnel are appointed there. Maternal protection and infantile protection make considerable progress. The extended programme of vaccination initiated by the WHO strengthens these results. When Independence is granted, well-adapted plans of action are already in place.

MATERNAL MORTALITY RATES

In the absence of global statistics, the results of many fragmentary investigations are concordant : maternal mortality is very high (Lefrou* for the period 1921-1930 at Saint Louis in Senegal, Heckenroth* in 1929 in Dakar and, for the whole of the French colonies, Thiroux in 1931, Sorel*, Martial and Beaudiment* in 1939). At the beginning of the 20th century, it is impossible to determine statistics because most of the childbirths take place outside the control of the state authorities. At the end of the century, the mortality rate is estimated as thirty times higher than that observed in Europe.

The principal causes of death are the very young age of the mothers, who are often anaemic and suffering from food deficiencies, as well as labour complications, especially over-infection and haemorrhages due to insufficient supervision.

THE INFANTILE MORTALITY RATE

In West Africa, even in 1960, prenatal statistics confirm the fact that 80 to 85 babies are born alive in 100 pregnancies.

The knowledge of child mortality (the proportion of deaths of children during their first year for every 1 000 babies born alive) is relatively recent because the reliability of these figures depends on the establishment of a dependable census, which is not the case until the teams fighting the great endemics establish it themselves, that is from 1925 in French Equatorial Africa (AEF) and 1939 in French West Africa (AOF).

When in 1938, M.E. Farinaud* begins the first anti-malarial campaign on the mountainous plateaux of central Indochina, he devotes the first year to taking a census of the population for the study of mortality rates, which enables him to determine that infant mortality is 310 in 1 000. Twenty years later, in a region of Upper Volta which is just as much ravaged with Malaria, Raba* notes the figure of 130 in 1 000. In France, at the same time, the infant mortality rate is 27 in 1 000.

This infant mortality rate doesn’t mean much in tropical countries. The major illnesses that a child suffers occur in the second year also, when the immunities transmitted by the mother have disappeared. The mortality rate then is just as high as during the first year. Malaria is the worst affliction and Farinaud* attributes 80 % of the deaths to that disease in a zone where many endemics are rife.

In 1957, in Upper Volta, at the end of an inquiry into 4 528 births in Lobi country, Mazer* shows the ill-effects of precocious weaning. When a mother who is still breast-feeding gets pregnant again and stops giving mother’s milk to her baby, letting him consume family food instead, it is a way of sentencing him to death. In 15 % of births, the child would have been weaned before the age of ten months, which has had the effect of tripling his chances of dying before the age of two, in comparison with children who have been breast-fed for more than 18 months. Is there a better way of showing the necessity of increasing the intervals between births ? Convincing couples of this reality will be one of the objects of those concerned with infantile protection.

THE CULTURAL REFERENCES

Pregnancy and the coming into the world of a child are at the heart of every culture. Every society has its rites and superstitions, its rules and interdictions concerning the pregnant woman, the care given to the baby, the destination of the placenta and the diet of the mother and the child.

In 1939, Giordani* writes: "Pregnancy being considered a normal state, the natives in our colonies don’t understand why a woman’s activity must be diminished during this period, no more than they can understand why the help of a physician is necessary at the time of delivery".

In the French colonies, the recourse to maternity hospitals and pre and post-natal consultations, in the 1930s, varies from one country to another and even from one ethnic group to another. In Niger, the Muslim population refuses to allow a European physician to examine pregnant women and to deliver babies. In the French coast of the Somalis, Islam "forbids women to show themselves to foreigners" during pregnancy and the forty days after childbirth because evil spirits are at work. Neither the woman nor the child should leave the house during this interval... In Pondichery, for Muslims as well as for Brahmans, a man is dishonoured when his wife gives birth in a maternity hospital. At the same time, in the maternity hospitals of Laos, for every 1 000 childbirths, Laotian women are "an infinitesimal number", nine out of ten of those giving birth in hospitals being Annamese.

In 1933, the "Most Beautiful Baby Contest", organised by the Red Cross in Dakar, attracts the Animists but not the Muslims who are convinced that "winning the contest would bring bad luck to the baby".

ORGANIZING PROTECTION

According to a report by Bouffard* in 1930 on the situation in the Ivory Coast, the authorities give a lot of attention to the protection of mothers and children. The plan of action has many stages :

– All the urban centres, capitals of federations or colonies which have a hospital are provided with a well-equipped maternity ward with their three basic activities : pre and post-natal consultations, deliveries with the possibility of surgical intervention and care for the infants.

– In other conglomerations such as principal towns where a doctor and a midwife are present, a "maternity dispensary" is foreseen. In addition to deliveries, pre and post-natal consultations are organized for mothers and children. A visiting nurse will be available.

– In rural areas, where there is a medical centre managed by a nurse, the doctor or the midwife from the principal town makes regular visits. They get to know the rural matrons in order to train and supervise them.

– Medical inspections in schools complete the programme, making it possible to detect transmissible children’s diseases or great endemics prevailing in the region. Students of the Medical schools participate in this activity.

Distribution of milk

– Mention is always made in official reports of "private organizations" which are an invaluable complement to administrative action. Some are secular like the Red Cross and its branches which are here called "Goutte de lait" (Drop of milk) and "Berceau africain" (African cradle), mostly concerned with infant care (weighing babies, distributing milk, soap, clothes...) and confining their action to townships. Others are Christian organizations, present even in "the most distant villages". These private bodies are often subsidized by the government and, in Indochina, supported by municipal and provincial contributions. Finally, in many capitals, there is an orphanage called "Foyer des métis" (Home for half-breed children) with many abandoned children in them.

As can be seen, very high achievements are aimed at, for the territories are extensive, the populations widely spread and sometimes reserved. Giordani* writes in 1939 : "We control only 30 or 40 % of the births declared in most of our colonies". Let us remember that, at this time in France, the majority of pregnant women and almost all of those living in the countryside give birth at home with the assistance of a midwife.

MIDWIVES

In the colonial empire, European midwives, when they are not public employees, work as "colonial midwives", recruited by the Colonial Ministry. They are few, engaged to work with the European population. They work only in the hospitals, for, in the beginning, European women are rare and reside only in important colonial centres.

Weighing babies

In 1939, for the whole of French West Africa (AOF) with 10 or 12 million inhabitants, there are only ten midwives of whom 4 are in Senegal and 3 in the Ivory Coast. There is not a single one of them in many of the colonies of the federation. There are also two in Indochina and one in Madagascar.

The advent of native midwives is a turning point. For example, the school for midwives in Dakar opens in 1920 and the first midwives arrive in the Ivory Coast in 1923. Five years later, in 1928, they are sixteen, and three-quarters of the territories are provided with midwives. In the course of 32 training courses, 447 midwives qualify from the Dakar school. Bouffard* is full of praise : "These young women or girls are perfectly capable of performing the task that is set them". The aim is to appoint one midwife to every principal town of a territory where there is a maternity hospital.

VISITING NURSES

This new category of nursing staff has only been used in French West Africa and in Madagascar, from 1930 onwards. They are at an intermediary level between the native nurses and midwives and they are trained at the Midwives’ Schools of Dakar and Antananarivo. This new branch of the nursing staff is used for about fifteen years. Concentrating on paediatric nursing and prevention rather than on the care and treatment of patients, they form a connecting link between the maternity hospital and the population. They have nothing to do either in the delivery rooms or the wards of the hospital. Their role is to be in contact with the families, have interviews with expectant mothers, control the number and quality of the deliveries performed by the matrons, direct sick infants towards dispensaries, give diet instructions to young mothers... They are the forerunners of "Health Instructors" (éducateurs sanitaires).

Through this nursing staff, one observes the qualities of mobility and closeness to the people which characterizes the action of the Colonial Health Service when assisting the population. To help them to get about more easily, especially in Senegal, these agents are provided with bicycles.

In spite of their success, visiting nurses have not been used consistently in other French territories. In French West Africa, for example, perhaps because women have become less reluctant to consult physicians, the recruitment of visiting nurses ends in the 1940s.

In 1953, a government circular creates in French West Africa (AOF) a body of social workers and helpers for the medico-social service of the PMI. The following tasks are confided to them: "Visiting dwellings, following the progress of patients, discovering new patients and directing them to centres of consultation or vaccination". But their principal activity remains the education of mothers, especially in the matter of food for children. They take over from the "visiting nurses".

The Colonial Health Service is the inventor of "social paediatrics", which goes beyond the treatment of individuals and pays attention to problems of the community, where preventive measures are more important than curing illnesses.

TRADITIONAL MIDWIVES OR MATRONS

From time immemorial, everywhere in the world, matrons have practised there profession in the sight and knowledge of the whole community from whom they receive gratitude and consideration. Sometimes this profession is hereditary. The French coloniser, after having tested their aptitudes, decides to include matrons in the official health plans, without, however, making them salaried employees.

In the 1930s, in Africa, the training of matrons becomes one of the priorities of obstetrics in rural zones. These women follow, at the nearest maternity hospital, a training period whose length varies from two to six months according to the colonies. Then, when they return to their village or urban area, they remain under the supervision of the midwife or visiting nurse who has trained them. A bonus system, depending on their activities and the results, is helpful in encouraging them to use the knowledge they have acquired. They may receive a midwife’s instrument case (scissors, forceps, compresses, eye lotions...). Later, UNICEF participates in these emoluments. The matrons do their work in the home of the woman in labour or in an enclosure for childbearing, when the villagers have constructed it.

In Indochina (Cochin China and Tonkin), rural midwives are called "Bâ-mû". They are very efficient, their average accomplishment in 1939 being 187 and 120 childbirths per year in Cochin China and Tonkin, respectively. Khmer "nursing midwives" of Cochinchine, recruited from among the minority Cambodians, are a local feature. They follow a six-month course and pass an examination, after which they practise in their ethnic group.

Bathing babies (Cholon)

It must be mentioned that these matrons are present in the towns and even in the big cities where there are public and private obstetrical clinics. Thus in densely-populated Dakar in 1960, one-third of childbirths take place at home with the assistance of a matron. It is true that the number of beds for expectant mothers in the hospitals is insufficient.

THE PROGRESS OF MATERNAL AND INFANTILE PROTECTION

– The Health Service sets up important units. Giordani* establishes a summary in 1939.

1) Health Services whose activity extends to the PMI :

– 433 maternity centres of which 364 are in hospitals and 69, mostly in Indochina, are independent establishments.
– 158 paediatric nursing dispensaries of which 117 are in Tonkin.

2) Personnel :

– 171 European midwives and 9 European visiting nurses.
– 925 native midwives and 187 native visiting nurses.

Many thousands of qualified matrons practise in rural areas and in the towns.

This plan of action has considerable effects. Sudan illustrates its efficacy :

– The percentage of premature babies is 8 times less when the pregnancy is supervised.
– From 1936 to 1939, prenatal consultations increase by 22 %, assisted childbirths by 27 % and treatment of babies by 41 %.
– Another example, for the AEF as reported by Robert* :

Prenatal consultations
1935: 1 516
1945: 19 208

Supervised childbirths
1935: 900
1945: 8 000

Treatment for infants (0 to 2 years)
1935: 31 980
1945: 278 891

After the Second World War, the PMI is created in France by the edict of 2nd November 1945. It is established in the colonies on a new basis at the beginning of the 1950s. This is not an inferior version of the plan for Metropolitan France. On the contrary, a circular dated 1953 makes it clear that there are important differences, especially in what concerns children. In France, the PMI confines its activities to prevention and stop these activities at the age of six, the age of obligatory schooling. In the colonies, the PMI is responsible for the care of all children up to the age of six but also all those children between the ages of six and fourteen who don’t go to school, that is to say, the majority of the children.

The activities of the PMI must be, especially in tropical zones, an element of the public health service. Mothers and children are the most vulnerable members of the population. The staff in charge of these activities are physicians and social workers. The most effective measures to be taken to protect the population are not the multiplication of PMI centres but, as Farinaud* proposes in 1943 in Dakar, the provision of drinking water, the evacuation of faecal matter and the fight against Malaria - three health projects whose results will be immediately evident.

The Colonial Health Service creates in 1957 a special Paediatric Service. One of the first colonial paediatricians, Guignard*, after having served overseas and then directed the Rabat Paediatric service, will occupy the important post of Director of the International Child Centre in Paris.

At the beginning, social workers are very few (one or two in a colony) assisted by native helpers. Their duties are not at all bureaucratic. On the contrary, they have a role to play in the countryside, by visiting dwelling places. They take over from the "visiting nurses" but with greater competency.

THE PROGRESS OF MATERNAL PROTECTION

The intended plan of action develops thanks to the financial support of national and, after the Second World War, international organizations, in particular the FIDES (Fonds d’investissement pour le développement économique et social).

The schooling of girls and the alphabetization of women making progress, new maternity hospitals and PMI centres are built. The old ones are renovated. But there is a time-lag between developments in towns and the situation in the bush, and even between colonies. Madagascar with its very old School for Midwives is more advanced than Black Africa, especially the AEF.

Consultation in town

While continuing obstetrical treatment, maternity clinics also detect endemic diseases.

Young mothers are particularly exposed to infectious complications among which puerperal infections are especially serious. Bad aseptic conditions contribute towards infection. Early detection and immediate hospitalization have a good chance of leading to healing without after-effects.

An unexplained characteristic is revealed by the physicians : the rare occurrence in native women of phlebitis of the lower limbs, fairly common in Europe. On the other hand, they are more exposed to cerebral thrombophlebitis. In Pondichery, Guicheney* shows the Indian Union physicians the frequency of postpartum cerebral phlebitis in their country. He demonstrates the decisive role, much debated at the time, of heparin in the cure of serious cases of this disease.

In rural areas, the matron remains the only possible source of aid. Knowing that the usual birth rate for natives is 50 for every 1 000 inhabitants, it appears that only a quarter of the pregnancies are controlled by the Colonial Health Service. At the beginning of the twenty-first century, international organizations esteem that this rate is 50 %. The development of the medical network cannot keep up with the demographical increase. The training and supervision of matrons becomes absolutely necessary.

In Nairobi in 1984 the movement "Maternity without Risk" is launched. However, far from becoming lower, the rate of maternal mortality rose from 400 000 to 600 000 in the year 2000. The demographic growth can be given as one reason for this increase, all the more as more than 98 % of these deaths occur in tropical countries. These figures indicate that the suppression of all risks is still far in the future.

THE PROGRESS OF CHILD PROTECTION

The protection of children has two fields of combat : the nutritional dangers and the dangers of infection.

– Nutritional dangers are estimated with the observation of child mortality. Deprived of the excellent proteins and vitamins in mother’s milk, the weaned infant is incapable of building up any solid immunity. Bergeret* in Dakar, as early as 1948, insists on the importance of adding milk to the diet of the weaned child to compensate for the loss of proteins and vitamin deficiencies. Later, the ORANA specifies the necessary food complements : fish paste, Soya, groundnut cakes… all of which are available in the tropics. They are tested in hospitals and in the villages of the Dakar region used for experiments.

Anti-smallpox vaccination

These studies engender the programmes of nutritional supplements enriched with local foodstuffs; and baby food is produced industrially in many countries by United Nations agencies and, in particular, by the UNICEF. These products are distributed by the PMI centres to children in nurseries, kindergartens and schools. But they can also be consumed at home. The education of mothers in nutritional matters is a fight against interdictions and errors rather than food shortages. Private organizations participate in this campaign. Thus in 1953, the "Goutte de lait" (drop of milk) in Dakar provides the whole ration or complementary ration for 250 children every day.

– The dangers of infection can be observed in the numerous digestive and respiratory infections that prevail. To these must be added the great tropical endemics, Treponemal diseases, measles and, above all, malaria. The advent of effective medicines and, principally, vaccinations render these illnesses controllable.

ADAPTED PLANS OF ACTION

- In towns :

The modern PMI services are installed in the principal colonial towns after the Second World War. The finest example is in Dakar and it has three branches :

– A new "PMI Centre" established in 1953.
– A "Mobile PMI Service" that visits dispensaries. The team consists of a social worker who supervises the nurses and a midwife who takes over the prenatal consultations.
– A hospital service, still lacking beds for all patients.

After the establishment of the Dakar University, this plan of action becomes the responsibility of an academic, Professor Sénécal, who occupies the chair of Paediatrics which will eventually bring him international renown.

- In rural areas :

The action in rural areas has three aims : nutrition with the ORANA, mass vaccinations, and the fight against the great endemics, especially Malaria.

The total birth rate in French West Africa (AOF) increases in thirty years from 40-45 in 1930 to 50 (for 1 000 inhabitants) in 1960. The populations of tropical countries double every 30 or 35 years. As long as under-development persists, there will continue to be underprivileged rural areas where infantile death rates will be the double of those in the towns, which are better equipped against diseases. Finally, even in towns, we must bear in mind the deplorable situation in the slums and the emergent phenomenon of "street children".

YELLOW FEVER

Yellow fever is an acute infectious disease which flares up with dreadful epidemics. It mostly targets the liver and kidneys. Jaundice, fever, hemorrhages (mostly nose and gum bleedings), rarefaction or discontinuation of the urine output are the most characteristic symptoms of it.

The amaril virus is the pathogen which is involved in Yellow fever and it is transmitted to man through a mosquito bite. In fact this is a disease that affects monkeys which live in forests and in the wilderness of Sub Saharan Africa and of tropical America, these are the only places where this disease is rife.

No specific therapy is so far available and whenever a patient survives, he is permanently immune to the disease and this explains why vaccination is such an efficacious one.

Medical officers of the Colonial Medical Corps were confronted to yellow fever and had to endure its scary epidemics. With the help of their native co-workers they intervened in the field of action and also in the Overseas Pasteur Institutes laboratories and especially in Dakar.

– These practical experienced men identified the disease, detected it, provided care to those who were sick and helped to prevent it.

– They took a part in shedding light on the role of mosquitoes and in the isolation of the amaril virus.

– They improved the way of diagnosing the disease in their labs.

– They developed an efficacious vaccine and made all necessary arrangements for its production.

– They kept watching out for the amaril risk in Sub Saharan Africa and in Tropical America.

EPIDEMIC OUTBURSTS

Monument in Goree

Scary flare ups of yellow fever occurred with the death of half of the ones who had been sickened until the turn of the twentieth century. It was graded a pestilential disease and later a quarantinable one. There are however many "flu like" or milder cases with a much lower fatality rate as it is in the 10% range.

In 1648 the Spaniards in Yucatan were the first to report the disease. They named it "plague" but this must be considered as an archaic term which at that point of time was given to many different medical conditions.

As they scoured Tropical America, the Caribbean and also Sub Saharan Africa the French happened to come across this scourge. In 1778 in St Louis, Senegal which is a city located at the mouth of the Senegal river, J.P. Schotte gave it the scholarly but short lived designation of "Synochus Atrabilosa".

In 1763 already, colonization of French Guiana had been confronted with Yellow Fever which was then named "amaril typhus". Survivors fled to the Devil Islands, which are located in the open sea, east of Kourou and afterwards, these islands became known as the Refuge Islands ("Iles du Salut").

During the nineteenth century three epidemics were widely talked about :

– In 1802 Napoleon assigned his brother in law General E. Leclerc with his thirty thousand men to Dominica to quell Toussaint-Louverture’s uprising. Only a small number of them were able to make it back home as they were the only survivors of an outbreak of yellow fever which had claimed Leclerc’s life.

– The 1878 outbreak in Senegal among others claimed the life of 21 physicians and pharmacists. There was only one who survived. Two steles, the first one in St Louis, Senegal, the other one in the island of Gorée which is in the open sea, west of Dakar, are there to show the respects which are paid to physicians who fulfilled their duties among populations and at the bedside of patients to such an extent that they finally wound up as victims of the disease.

– In 1889 the Panama Canal digging had to be given up by the French because of Yellow Fever.

CONTRIBUTION OF CLINICIANS

The forerunners of colonial physicians reported the symptoms of the disease and identified it in the maze of many other tropical fevers. In infirmaries, mobile field hospitals and lazarets, Navy medical officers showed the kind of painstaking and skilled clinicians they were. Their reports are still today high valued ones.

Dutrouleau*’s written works supplemented by those of Beranger-Feraud* are still accepted as standard reference works. As far as the common case is concerned they identified two successive phases in the course of the disease :

– The red one when the patient is running a fever, is restless and crippled by pain. His face and eyes are flushed and red.

– The second one dubbed the yellow or the icteric one, gave its name to the disease (amarillo means yellow in Spanish). It starts on the fifth day. The patient’s eyes turn yellow, he throws up blackened blood dubbed "black vomit", his urine becomes scarce or even absent because of renal failure and the ensuing death occurs sometime between the 4th and 11th day after the onset.

This disease was a cause of concern for all physicians who were on assignment in Sub Saharan Africa but especially those posted in rural areas as they had to treat or to prevent it. It did not happen to all of them to have to live amid an epidemic focus but through their presence and vigilance they were sentinels who kept watching out for epidemics.

In his lonely medical facility a young physician who was posted in the outback ("bush doctor") carried out the examination of patients, especially those who were running a fever and made authorities aware of any unusual number of fatalities in a village. In so doing he was providing an epidemiological watch. As soon as the Dakar Pasteur Institute vaccine became available, then this physician became in charge of carrying out the combined immunization program of the district’s whole population with both yellow fever and smallpox vaccines which had been mixed together before their inoculation. Later on, the Major Endemic Diseases Department took over the implementation of these programs of vaccination.

Finally the Public Hygiene Department which was concerned by malaria as well as by yellow fever had to look after the sanitation of villages by the destruction of mosquitoes and through seeking out the places where they had laid their eggs such as stagnant water pools and home water tanks.

Vehicles Mosquito Clearing

Should we remind our browsers that any loosening in these vaccination programs or of the sanitation enforcement made the region at risk of going through a new outbreak ?

THE ROLE OF MOSQUITOES AND THE VIRUS ISOLATION

In 1884, Carlos Finlay in Cuba suspected the role which mosquitoes could have in the transmission of the disease to humans. It should also be noted that thirty years earlier in 1854 a French and Venezuelan physician named Louis Daniel Beaupertuy (1807-1871) in Venezuela had already claimed that yellow fever was mosquito borne and therefore he had recommended the use of a mosquito net at night. He was the grandson of "an apothecary" and the son of "a medical officer" of the French Royal Navy who both had been on assignment at the military hospital in the Guadeloupe Island. The Academy of Sciences in Paris did not attach any value to Beauperthuy’s works which he published, among some other journals, in the academy’s own magazine but finally his claim went unnoticed.

In 1901 a US mission which was headed by Walter Reed confirmed Finlay’s assumption and designated a mosquito belonging to the Aedes genus as the transmitting agent. Around the same time France had commissioned P.L. Simond* and E. Marchoux* to go on assignment to Brazil for a four year long scientific mission. They also confirmed the role of this mosquito and beside their research work, these Colonial Army medical officers took an active part in the fight against an epidemic which was then in full swing in Rio de Janeiro. Marchoux was awarded the distinction of "Honorary Citizen" of the town.

As far as the isolation of the virus is concerned it took place simultaneously in 1927 with a British scientist named A.Stokes in Ghana and with C.Mathis* and J.Laigret* who were two French researchers of the Dakar Pasteur Institute.

Jean LAIGRET

LABORATORY DIAGNOSIS

Informing the international community of any case of yellow fever is an obligation so that one has to be fully aware of both the importance and the severity of this diagnosis. It is based on laboratory tests with mostly the examination of a liver sample by a pathologist after it has been taken from the corpse of an individual deceased with suspected yellow fever. This sample has to be shipped from the place in the outback where it was taken to the main city.

During the 1965 Senegalese epidemic, R. Camain* at Dakar Pasteur Institute had the opportunity of updating the data regarding the hepatic lesions which are specific to yellow fever and in particular those which are found at the initial stage of the disease.

The second way we have to be absolutely certain of the accuracy of the diagnosis is with the isolation of the virus from a blood sample or from tissue samples which have been taken during the autopsy. This has to be done in a laboratory which is supplied with the adequate equipment.

There is now a serology test which provides a result within a few hours but virus isolation remains the only internationally accepted standard for claiming that there is somewhere a yellow fever focus.

In the Dakar and Abidjan Pasteur Institutes, Lhuillier* developed a test for a quick identification of IgM antibodies in a blood sample taken from a patient who is suspected with yellow fever. Within one hour or so the diagnosis is confirmed or at least deemed very likely or it can be ruled out. This can help to sketch the frontline of an outbreak and to concentrate prevention and vaccination efforts in places which are endangered.

DEVELOPMENT AND PRODUCTION OF THE AMARIL VACCINE

An American scientist named Max Theiler succeeded in adapting to mice the viral strain which Mathis* and Laigret* had isolated in Dakar in 1927. The development of the first vaccine took place subsequently with the cooperation of Laigret* and of another American scientist by the name of A.W.Sellards.

In 1939, M. Peltier* C. Durieux*, H. Jonchére* and E. Arquié* developed a more efficacious one which was better tolerated and it became known as the "Dakar Pasteur Institute Vaccine". Its administration through a skin scarification was easy and it could be associated with the smallpox vaccine. During the nineteen forties with the implementation of programs of immunization among the whole populations in the African colonies, yellow fever vanished. Unfortunately the use of this vaccine was accountable for severe and even lethal cases of meningo-encephalitis. Its use was at first limited to individuals who were over twelve years of age and later in 1967 it had to be abandoned.

Vaccinating nurse

It was replaced by one which is still used today which is the "Rockefeller 17D vaccine". It was also developed by Max Theiler and is still considered as a perfectly valid one. It is delivered to individuals who are over the age of one through a subcutaneous injection. Its tolerance is excellent and it induces a long-lasting immunity which lasts at least ten years. As its inactivation by heat is a drawback, now it has become standard practice to supplement it when it is manufactured at the Pasteur Institute in Dakar with an excipient which was developed at the Paris Pasteur Institute (Barme) which supplies an excellent thermo-stability. With its own production the Pasteur Institute in Dakar is now able to provide all facilities in French speaking countries of Africa with all the vaccine they need and in so doing brings its contribution to the protection of this continent. Immunization with the same vaccine dubbed the amaril vaccine is now required by international regulations for those who travel to Sub Saharan Africa or to Tropical America.

THE AMARIL RISK

Studying the outbreaks which took place across the world supplied the information relevant to the means of circulation of the virus. Yellow Fever is a disease that affects monkeys. It is transmitted from an infected animal to the next one through mosquito bites and this is known in French medical literature as the "cycle in the wild" and as "jungle yellow fever" in the English one with the following pattern :

Infected monkey ---> Mosquito ---> Healthy monkey.

Areas of amaril endemicity

This "jungle yellow fever" cannot be eradicated and humans are intruders in this cycle. After a non immunized individual is bitten by a mosquito carrying the virus on the occasion of a trip to the wilderness, or with the intrusion of an infected monkey in a village where it gets bitten by a mosquito, then the first human cases occur and mosquitoes will spread the disease.

Vaccination provides a protection which lasts over ten year. After a vaccination campaign, populations are no longer receptive to the disease and are fully safe, so that epidemics become rare and whenever one occurs it is going to be short-lived. There are still some flare ups which persist as according to the data compiled by the WHO, each year there are two hundred thousand non vaccinated individuals who catch the disease with thirty thousand fatalities.

Raising Aedes Mosquitoes

All measures to be taken for Yellow Fever control have been codified in a text which is known as "the International Sanitary Regulations" which has been passed by the international community.

Protection of the world implies that specialized facilities which are located in affected areas keep watching out. For many years now, the Dakar Pasteur Institute has been one of the four "WHO Regional Reference Centres" which are in charge of keeping the disease under control. Today the monitoring system which was started by the time of colonization is still in operation.

Teams of Scientists of the Pasteur Institute and of the French Institute for Overseas Scientific Research are in charge of monitoring the virus circulation among humans and monkeys with serial serum testing and also with catching carrying vectors with traps and human baits. In 1965 Pasteur Institute scientists who were members of the Colonial Medical Corps have set up procedures and practical programs of action.

Across Africa many colonial biologists took an active part in the programs to fight the disease.

The vaccine which is in use now, is efficacious against all strains of the amaril virus. Research has nevertheless to be carried on in order to sequence the virus as accurately as possible and to develop new vaccines. The Tropical Medicine Institute of the Armed Forces with the Institute of Molecular Biology at the Pharo in Marseilles take an important part in this high tech research program (Nicoli* and Coll*).

On the grounds of his fame, a colonial Pasteur Institute alumnus by the name of P. Bres*, was assigned to the head the Arbovirus and Yellow Fever Department of WHO, in Geneva, which he ran from 1970 to 1981.

Vaccination with the Ped-o-Jet Device

The achievements of the Colonial Medical Corps were largely successful as within its range of influence there has been no flare up similar to the ones of the nineteenth century. As long as the same kind of coverage of populations which was provided by the Corps is carried on, reports of large epidemics of Yellow Fever will be found only in history textbooks. But since 1965 there is a lack of regularity in the implementation of the vaccination campaigns, small epidemics can occur now. There are an estimated two hundred thousand cases a year with around thirty thousand fatalities.

For further information :

– A.F. Dutrouleau : Traité des maladies des européens dans les pays chauds. 1 vol. 607 p. Edit. Baillière Paris 1861.
– L.S.B. Béranger-Féraud : Traité théorique et clinique de la fièvre jaune. 1 vol. 985 p. Edit. Doin Paris 1890.
– E. Marchoux et P.Simond : La fièvre jaune. (Rapport de la mission française) Bull. Inst. Pasteur 1904,2,1-10 et 49-52. Ann. Inst. Pasteur 1906, 20,16-40,104-148,161-205.
– Ch. Joyeux et A. Sice : La fièvre jaune. In Précis de médecine coloniale p.701. Collection de précis médicaux, Edit. Masson et Cie Paris 1937.
– P. Navaranne : Une épidémie coloniale ayant tourné à la catastrophe épidémiologique : Saint-Domingue. Thèse n°59, 10 juin 1943, Montpellier.
– M. Peltier : La fièvre jaune. In Médecine tropicale par M. Vaucel . p. 959. Edit. médicales Flammarion. Paris 1952.
– R. Camain et D. Lambert. Une épidémie de fièvre jaune au Sénégal en 1965 : Histopathologie des foies amariles prélevés post-mortem et par biopsies. Bull.OMS. 1967, 36, 129-136.
– M. Sankale et I. Diop-Mar : La fièvre jaune. Conc. méd. 1976,98,8,1047.
– F. Rodhain : Arboviroses Encyclopédie médico-chirurgicale. Maladies infectieuses, 8-062-A 10. 1995, 16p.
– J.P. Digoutte, M. Cornet, V. Deubel, W.G. Downs. : Yellow fever. Kass handbook of infectious diseases. Exotic viral infections. Edited by Porterfield J.S., Chapmann and hall medical p.67-102.

TUBERCULOSIS

Universal and very ancient, a social disease par excellence, Tuberculosis is infectious, contagious and due to Koch’s bacillus (BK). Person to person transmission takes place through the atmosphere, from infected lungs.

Having progressively perceived the infection and the disease of tuberculosis, the physicians of the Colonial Health Service study the geographical extent of the disease and analyse its epidemiology. One of them, Calmette* and his collaborator, Guérin, invent the anti-tuberculosis vaccine which is called BCG.

Following their lead, the colonial Pasteur Institutes distinguish themselves in the intensive fabrication and perfection of BCG vaccines, easily handled in the tropics. The prophylaxis of the disease then becomes possible.

From 1944 onwards, the discovery of anti-tubercular antibiotics brings about a revolution in the treatment and prognosis of the disease. The plan to combat tuberculosis overseas becomes more and more efficacious. However, even if until the advent of AIDS the regression is clear in developed countries, the scourge remains terrible in the third world. At the present time, between two and three million people still die of tuberculosis every year in the world.

THE MICROBE AND ITS PROPAGATION

In 1882, on examining the saliva of patients suffering from fever, loss of weight and chronic coughing, R. Koch isolates a microbe of which he obtains pure cultures. These microbes induce tuberculosis in those used as guinea-pigs. This Koch bacillus or BK is Mycobacterium tuberculosis, the agent responsible for tuberculosis in humans, a disease known for a long time and recognised as contagious. Almost all the organs can be attacked. Person to person transmission is due to droplets emitted by the coughing of a person suffering from pulmonary lesions.

For a long time, it is thought that there is only one variety of human BK. In the 1960s, in Dakar, Boiron*, studying colonies of isolated BK in patients systematically, notices in more than half of them original characteristics, intermediary between human and bovine tuberculosis bacilli. This new variety is the object of much research at the Pasteur Institute of Dakar (Sarrat*), at the end of which, from 1973, this bacillus is recognized as a species : Mycobacterium africanum. This discovery leads to the notion of the geographical distribution of BK colonies. Thus, besides the Dakar variety, a Cameroon variety is isolated in its turn, two Rwanda varieties and, beyond Africa, an Indochina variety.

Moreover, Koch isolates from the cultures a substance, tuberculin, to which he mistakenly attributes therapeutic properties. Later, Von Pirquet and then Mantoux observe that the intradermal injection of tuberculin causes an allergic reaction which is a sign that the subject has had a previous encounter with BK. Since 1907, the cutaneous reaction (and the intradermal reaction since 1909) permit a different approach to the epidemiology of the disease.

TUBERCULAR INFECTION AND TUBERCULAR DISEASE

All the subjects who, having inhaled the tubercular bacillus, carry it in their organisms are not said to be tuberculous. In the case of the majority, the bacillus, neutralized by the defensive reactions of the individual, remains harmless. The cutaneous reaction to tuberculin confirms the contamination : it is the primary infection. These subjects, while remaining infected with BK, are not contagious and are apparently in perfect health.

X-ray of a case of pulmonary tuberculosis

On the other hand, if the BK regains its virulence or if, as a consequence of superinfections, the defence mechanisms are unable to cope, the bacilli attack one or the other of the subject’s viscera. Then the infection becomes a disease and the patient tuberculous.

In Europe the lungs are the seat of the disease. In one third of the cases, evolution is "slow and progressive", punctuated with the spitting of blood (haemoptysis). More unusually, one observes organs other than the lungs being affected : ganglions, bones, kidneys, digestive apparatuses, meninges...

In the tropics, physicians note that the predominant clinical forms are not the same in the cases of city dwellers and rural inhabitants. The former, exposed to BK since their youth, develop a certain immunity or resistance to the disease. Attacks on the lungs are the most frequent. The latter, following the dispersion of the population, contracts the malady later, in general about the age of 20 or over. Because of the absence of immunity, the disease is going to break out violently, a phenomenon which some have chosen to call "tuberculosis of the virgin races" ("la tuberculoses des races vierges") where the disease is located in other organs than the lungs and manifest extremely acute developments.

The forms observed in the big cities of the colonies and in Indochina (where the Annamese have been victims of tuberculosis for centuries) are not at all different from those to be found in Europe. But on the other hand, in Black Africans and Malagasies, extrapulmonary forms are observed, which evolve rapidly with the generalisation of the infection.

THE EPIDEMIOLOGY

The opinion has long prevailed that tuberculosis is a disease of temperate zones, introduced into the colonies by Europeans. Moreover, a Black person settling in Europe - worker, soldier or student - is fragile and falls prey to this ailment and, when back in his country, contaminates those around him.

The reality of the dissemination of the disease by such people coming from Europe, especially trained native soldiers, is indisputable. But it has been established that, for thousands of years, an autochthonous tuberculosis has been present in Africa as well as in Madagascar or in Indochina. In the 19th Century, it is observed in South Sahara, in AOF, notably in Niger, Sudan, Cameroon, etc.

Botreau-Roussel*, in the 1930s, finds that skin tests reveal positive results in the case of 84% of young recruits from the Ivory Coast, people who have not had previous contact with whites, which leads to the supposition that they are from ethnic groups particularly affected by the ailment.

At the beginning (tuberculin tests not having been discovered yet), the figures gathered by Kermorgant*, the Director of the new Colonial Health Service, makes him declare in 1905 that "the affliction exists … in most of our colonies". Taking into account only the cases of tuberculosis identified accidentally in health training centres, the official reports give derisory figures such as 2 791 cases declared in 1938 in all the colonies (Grosfilez* and Lefèbvre*). Diagnosis is made almost exclusively by the examination of spit and, in general, without having recourse to X-rays. Twenty years later, with the use of more rigorous methods, the figures are multiplied by 50 or more.

X-ray examination

– In Indochina, in 1895, dozens of patients are detected, especially in Saigon and Tonkin. The mortality rate is high. Cambodia and Laos seem to be spared. The most affected are the Annamese. In 1903, Hénaff* writes that in Cochin China, the disease is very ancient, known by the name of "binh ho lao" (cough and consumption disease). In fact, he says, loss of weight is such that "these unfortunate native sufferers of tuberculosis look like wizened spectres". Among the circumstances that favour transmission, one mentions the promiscuity in Annamese schools, the mouth to mouth passage of opium pipes and insalubrious brushes (which contain food and saliva).

– Clarac* has said that in Madagascar in 1905 the disease is "more frequently to be observed in large conglomerations than in the countryside". Certain ethnic groups seem to be strangely spared.

– In Black Africa, the disease is reported in all the territories. Kermorgant* notices two facts : "on the one hand, its rapid extension since the beginning of colonization"; on the other hand, the scarcity of the phenomenon as one gets further away from the ports, "as the contact with Europeans diminish". In 1913, after the discovery of tuberculin tests, Calmette* establishes a vast investigation to determine the degree of tuberculous impregnation in African populations. In French East Africa (AEF), the statistics reveal an average of 15% positive reactions in adults. It is also confirmed that the figures are proportional to the extent of European penetration in these territories.

The comparison with the data obtained in this primary investigation makes it possible, later, to quantify the incessant progress of the disease. Thus, around 1950, with the absence of mass vaccination, positive skin tests increase by 30 to 40% in these same regions.

THE ANTITUBERCULAR VACCINE

Albert CALMETTE (1863-1933)

At the beginning of the 20th Century, intensive research is undertaken to find protection against the disease with a vaccine. Calmette*, a colonial physician, and Guérin, proceeding from a bovine tubercular bacillus, invent an anti-tuberculosis vaccine which is named after their initials, BCG (Bacille Calmette Guérin) and which is still used. Administered to a young child in 1921, it is recognized as the best means of combating tuberculosis and the least expensive.

In 1924 in Senegal, Mathis* becomes the first to administer it to new-born babies at the Maternity Hospital in Dakar. That same year, BCG is introduced into Indochina and systematically administered in the Maternity Hospitals of the big towns : in 1930, more than 100 000 new-born babies were vaccinated. The preparation of BCG soon becomes one of the most important tasks of the colonial Pasteur Institutes which adapt the product to tropical climatic conditions.

– The initial vaccine of Calmette* and Guérin called "fresh", administered orally, is fragile because it is inactive when there is heat and light.

– From 1936, a new version is administered subcutaneously.

– Towards 1950, Boiron*, at the Pasteur Institute in Dakar, uses a form that is frozen and dried, administered by scarification in a solution of gum Arabic.

– In 1970, Chambon*, at the same establishment, perfects a lyophilised vaccine, injectable by intradermal means, which tolerates heat and can be preserved for many months. It is rapidly adopted all over Africa.

THE FIGHT AGAINST TUBERCULOSIS

This combat is undertaken simultaneously in the domains of preventive medicine and curative medicine.

In the big towns an important plan of action is established in the 1930s.

– Systematic detection using skin tests with tuberculin is the rule in PMI (Maternal and infantile protection) dispensaries, especially for children who have lost weight, who are coughing or have fever. It is also practised by the Hygienic Services and in medical schools. Some mobile teams assure x-ray detection. The first of these appear in Indochina at the end of the 1930s, in Africa ten years later.

Fairground consultation (Gabon)

– Epidemiologic investigations by intradermal reactions to tuberculin observed in children under 15 are multiplied. In Senegal, in 1960, the rate of positive contamination is 15% before the age of 7 and 46% at the age of 14. The disease is certainly "a public health problem", as defined by the WHO. This is confirmed by the mobile teams performing pulmonary x-rays and the repeated bacteriological examination of saliva. This same year, a total of 150 to 200 new cases of tuberculosis are detected every month in Dakar (of which a good proportion come from the interior of the country).

– BCG vaccination is the most important prophylactic measure but it is only used in the case of children. The new-born receive it in the maternity hospital and bigger children are vaccinated at home by visiting nurses who keep an eye, at the same time, on the families of tuberculosis patients. Vaccination comes to be used generally and, from 1973, it is included in the PEV (Extended Vaccination Programme).

– The treatment given to patients is disappointing. Until 1944, it consists of means that seem derisory today : cod liver oil, creosote preparations both revolting and tonic… then choline, finally gold compounds which are more tonic than effective. Collapsotherapy is in vogue until the Second World War : "Artificial pneumothorax" is the process of injecting air periodically into the pleura to compress the affected lung and thus to render relief to the lesions underneath. These treatments are given only in the big towns, for those who are not hospitalized, at the anti-tuberculosis dispensary, at the Institute of Social Hygiene or in the hospital. The tuberculosis ward is separated from the wards for other contagious diseases. Only Indochina disposes of a few sanatoriums. With this plan of action, some patients are cured but they are a minority; not more than 30%, a figure that corresponds to that of spontaneously favourable evolutions.

BCG vaccination

From the 1950s, the modernization of health equipment and the spectacular efficacy of new medicines against tuberculosis (streptomycin, isioniazide, etc...) increases the statistical figures, all the more as patients now crowd into specialized services. The death rate is frightening. At that time, in the paediatric services of the Dakar Hospital, one death in eight is due to tuberculosis. The combat which ensues involves, on the one hand, the evaluation of needs and, on the other hand, the establishment of means to fight the disease.

The treatment of patients is assured in specialized institutions: the anti-tuberculosis dispensary in Antananarivo, the phthisiology service of the Institute of Social hygiene in Dakar. These establishments possess x-ray installations and laboratories and are stocked with active anti-tubercular medicines. They are directed by phthisiologists of the Colonial Health Service.

In 1959, more than a million new patients are treated in Dakar, half of them severely affected. The greatest number, after brief hospitalization (often refused) are followed as non-hospitalized patients while the least curable (usually the most contagious) remain hospitalized for a long time in wards where there are always an insufficient number of beds. Running away is not rare while interrupted treatment facilitates the production of tuberculous bacilli resistant to treatment. It becomes possible to practice thoracic surgery on the spot.

Finally, the combat against tuberculosis is registered as an element in regional coordination: the tuberculosis section is created inside the OCCGE in 1969.

In Madagascar a sanatorium is established in Fenoarivo, on the central plateau.

Social action completes medical action. Public services are supported efficiently by benevolent associations (The Red Cross, the Anti-tuberculosis League) whose action in the Ivory Coast, through the impetus given by Delormas*, proves to be particularly invaluable.

The results obtained reflect modern progress. Thus in 1959, in Antananarivo, Bordas* and Mistrot* obtain, respectively, a cure and a distinct improvement in 54% and 21% of the tuberculosis patients treated.

For further information :

– Kermorgant M. : Rapport au congrès de la tuberculose en octobre 1905. La tuberculose dans les colonies françaises. Ann. Hyg. Med. Col. 106,9,220.
– Calmette A. : Enquête sur l’épidémiologie de la tuberculose dans les colonies françaises. Ann . Inst. Pasteur. 1912, XXVI, 497.
– Mathis et Durieux : Considération sur la tuberculose en AOF. Bull. Soc. Path. Exo. 1930,5,533
– Sanner L. : Tâches et problèmes de santé publique en AOF: La tuberculose Rapport de 1954.
– Menu P. Rivoalen A. Revil H. : La tuberculose : Endémie africaine. Méd. Trop. 1956,16,187.
– Brochard H. : La tuberculose des noirs transplantés. Rev. Prat. 1965,15,221.
– Sankale M. : Aspects actuels de la tuberculose pulmonaire du noir africain transplanté en europe. Mars. Méd.1980,221, octobre/1,31.

SMALLPOX

Smallpox is an infectious eruptive viral disease which is strictly limited to humans. It is a highly contagious condition which is transmitted either directly from one individual to the next one or indirectly through tainted items where the virus survives over a long period of time.

Clinical findings include a rash with characteristic features and this condition has a stereotyped development over two week. The prognosis for healing is poor with many fatalities. When cured, survivors are protected for their life time.

Before Jenner’s findings, the fight against smallpox was rather unsuccessful as there were repeated outbreaks of the disease.

In the early nineteenth century, shortly after the time of Jenner, the role of medical officers asserted itself very swiftly and from 1890 onwards immunization institutes were set up in the French colonies. The Colonial Army Medical Corps had a role which was essential as vaccination through scarification is very efficacious. A spectacular breakthrough was made with the development of a dried vaccine which within a few decades brought about the worldwide eradication of the disease. A few questions remain still unanswered regarding pock diseases which are due to related viruses.

CLINICAL FINDINGS

By the end of the symptom free incubation period, between 12 to 14 days, the disease starts with sudden shivers and a high grade fever (in the 104°), and with severe head and back aches.

Around the third day the rash starts on the face and proceeds rapidly down the body. Pustules break and scab after drying leaving the patient with indelible scars. These blackish crusts are highly contagious material which can stick on different items and clothes.

Smallpox vesicles

The fatality rate is between 10% to 50% of the sick according to the outbreaks.

JENNER’S FINDINGS

The disease, which has been known since the early times of history, spreads terror wherever it shows up. In past centuries outbreaks became more frequent with the development of expeditions across the world and with soaring numbers of individuals travelling.

Patient with Smallpox

In the old days in China, prevention of the disease was attempted with the inoculating into healthy individuals of variolous vesicles dried crusts which had been collected from patients with mild cases : beside an ensuing risk of death this procedure contributed also to spread the virus. The best mean of prevention remained the isolation and quarantine of patients.

Jenner* observed that women in farms who used to milk cows were resistant to smallpox after they had caught cow-pox : this disease of cow udders can be transmitted to humans and its clinical effects are only mild. In 1796 he gave evidence of the reality of this protection against smallpox with volunteers who had been inoculated with material from cow-pox lesions. This is how vaccination was discovered.

THE ROLE OF FRENCH MEDICAL OFFICERS DURING THE NINETEENTH CENTURY

Jenner’s vaccination through scarification became progressively standard practice with the immunization of Napoleon’s "Great Army" which was vaccinated at Boulogne Camp, and with him and his son also receiving the vaccine together in front of the public in 1811.

As early as 1831, Chevreau started a vaccination campaign first in Algiers and then in all other big cities of Algeria. Medical Officers experienced major difficulties in implementating this vaccination campaign, since passing pustular material from the arm of an individual to the next did not always result in immunization and was also sometimes unsafe.

In 1864 Chambon succeeded in obtaining vaccination material from heifers and then a medical officer by the name of Vaillard was able to set up in Paris, at the Val de Grace Hospital the first vaccination institute for the military which used vaccine pulp which had been preserved with glycerol.

**Nurse care for patients with smallpox**

In spite of these efforts during the 1870-1871 war with Germany, immunization in the armies was not adequate as two hundred thousand smallpox cases occurred with twenty three thousand fatalities.

SETTING UP VACCINATION INSTITUTES IN THE COLONIES

Up to the end of the nineteenth century this condition was spread worldwide. Later on it became limited to tropical regions and then with the help of Colonial Army Medical Officers whose role was a decisive one, it started to subside before it could finally be eradicated.

Their forerunners who were Navy Medical Officers had already started to undertake smallpox vaccination campaigns in Indochina and Cambodia shortly after their arrival. On Dec 26th 1867 a Vaccine Board was set up by Admiral de la Grandiere in Saigon. From 1860 to 1890 individuals were vaccinated with the "person to person" procedure which was provided in dispensaries or by travelling physicians.

In 1890 a vaccination institute was set up in Saigon to which Pasteur and Roux assigned Calmette*. Unfortunately the vaccine which had been manufactured in France fared poorly with the heat, so that Calmette had to innovate with the development of a glycerol preserved vaccine pulp which had been prepared from buffalo skin and which was kept in sealed tubes. This shift from "the person to person" procedure to "the skin scarification" made vaccinations much easier.

Patient with smallpox

As early as 1891, 120 000 people had been vaccinated or revaccinated with this procedure which was then swiftly widespread across Tonkin and Indochina. This became much more feasible after 1904 with the availability of vaccination personnel, who had just earned their degree of "Indochinese auxiliary physicians". This entitled them to work as specialized native medical technicians. Multiple vaccination institutes had to be set up as, long distances, heat and also a need of large quantities of vaccine constituted major hurdles which had to be overcome to fight the disease.

After the First World War, there were six vaccination institutes all across Indochina which were located in Saigon, Hanoi, Hué, Xieng Kouang, Vientiane and Luang Prabang. A boost to the fight against smallpox had to be given as the disease was still rife with flare ups. Mobile teams of health workers who belonged to the Natives Medical Service (AMI) were assigned to this fight. These teams were headed by physicians who had a district posting or by Indo-chinese auxiliary physicians. One decade after, smallpox had nearly disappeared from Indochina.

In 1897 Thiroux* with the help of Clarac* inaugurated the Vaccine Institute of Madagascar. The last case of smallpox which was reported there, occurred in 1921.

In French Occidental Africa vaccination institutes were set up by Marchoux* in Saint Louis, Senegal in 1895, by Martin* in Guinea in 1905, by Bouet* in Ivory Coast and Dahomey in 1908, and also in French Equatorial Africa by Kermorgant* in 1908.

Just like in Indochina heat and long distances constituted major impediments to the vaccine stability. Both Joyeux* in Guinea in 1909 and Sorel* in Ivory Coast in 1911 strove to stabilize the vaccine but these attempts were not conclusive as the uneven quality of batches was still an issue.

THE DEVELOPMENT OF A DRIED VACCINE AND THE GLOBAL DECLINE OF THE DISEASE

Fasquelle who had trained with Vaillard at the Val de Grace Hospital and who later succeeded Chambon at Paris Vaccine Institute made a real breakthrough with the development of the freeze-dried vaccine. As this dried vaccine is thermo-stable and as it could be carried anywhere in sealed tubes with no loss of its protective value, it took over the glycerol preserved vaccine.

From 1919 onwards the Colonial Army Medical Corps decided on bringing this dried vaccine into widespread use in every colony and a global recession of the disease occurred after ten million doses were used each year.

Vaccination through scarification

Many other regions of Africa had been left without any systematic vaccination program and this applies particularly to territories which were ruled by the United Kingdom and so across the whole continent the total number of smallpox cases between 1928 and 1966 fluctuated between 15 000 and 40 000. It peaked in 1943 and 1947 (55 000 cases), as this vaccination policy had been somewhat on the backburner during the Second World War.

From 1939 onwards the Yellow Fever vaccine which was prepared with the Dakar strain was successfully associated to the dried smallpox vaccine. Systematic vaccination campaigns were run in rural areas by the Major Endemic Diseases Department and in large cities by Public Hygiene Services.

ERADICATION OF THE DISEASE AND RELEVANT PERSISTING ISSUES

From 1960 onwards, smallpox started to recede everywhere and at the same time yellow fever as well. It remained confined to a few regions of Africa such as Ethiopia and Somalia and Bengladesh in Asia. In 1967 WHO contemplated its eradication with taking action in still infected regions and with a close monitoring of other regions. Pasteur Institutes and all physicians assigned to Major Endemic Diseases Departments took part in this eradication campaign and to the epidemiologic watch.

The official acknowledgment of this first example of eradication of a worldwide disease took place in 1980 three years after the report of the last Somalian case of 1977 and this had been made possible with a truly archaic vaccine. Later smallpox vaccination was given up.

Since that time pox virus diseases have occurred among animals in the endemo-sporadic mode, such as the "Monkey Pox disease" also called "Monkey’s smallpox". Despite the fact that so far there has been no identification of any threat, adaptation of this virus to humans or another pox virus should be considered as a possible risk for the future. Small outbreaks have been reported with a few human cases over the few last years. Clinical findings are the same as for smallpox but contagiousness and mortality rate are much lower. The epidemiologic watch has to be carried on at all times, all the more carefully that smallpox virus is considered as a most likely weapon in a bacteriological war.

Eradication of smallpox was achieved by the work of all those involved in this action but medical officers of the Colonial Army Medical Corps and their co workers played a major role in Africa, in Madagascar, and in Indochina.
One should be reminded of the tribute paid by the CDC in Atlanta in this respect.

Photograph of the CDC tablet given to the Pharo Institute by Dr Milar in 1992

For further information :

– Fasquelle R. Fasquelle J. : Vaccin desséché et campagne de vaccination dans les pays chauds. Bull. panamerican sanatary bureau. Washington, 1949,28,1118.
– Fasquelle R. et Barbier P. : A propos de la dessication sous congélation. Sem. Hôp. Paris 1950,26,92,4762-4766.
– Foege W.H. Miller J.D. et Henderson D.A. : Bull. de l’OMS. 1975, 52,209-222.
– OMS.- Final report of the globalk commission for the certification of smallpox. Genève 1979.
– Chronique OMS.- Courbe de cas notifié 1928-1966 sur 40 ans. 1980,34, p.43.
– Breman J.G. Kalisa-Ruti, Steniovski M.V. Zanotto E. Gromyko A.I. Arita I. : Le monkey pox chez l’homme 1970-1979. Bull. de l’OMS 1980,58,6,849-868.
– Ferchal F. : Orthopoxvirus : variole et vaccine. Encyclo. Méd. -chir. Paris. Maladies infectieuses 8-050-j10-1995.

HUMAN AFRICAN TRYPANOSOMIASIS (SLEEPING SICKNESS)

Sleeping sickness which is also called African human trypanosomiasis results from the invasion of a human organism by an unicellular parasite called Trypanosome. It is conveyed from one human to the next by glossinas which are dubbed "tse tse flies". The outcome is invariably a fatal one when the disease is left untreated. The most efficacious medications are also very toxic ones and implementing a full course of treatment is often difficult with the frequent scattering of human settlements in rural areas.

The Colonial Medical Corps grasped right away the severity of this endemic disease. Physicians described their clinical findings and innovated in setting up programs of prevention and of mass treatment.

Rules of prevention are easy ones to lay out but implementation of these rules happens to be much more difficult.

Eugéne Jamot* (1879-1937) outclasses all others in the history of prevention of this disease as he developed a doctrine of action which he carried out vigorously in Cameroon with outstanding and successful results.

But Jamot was misunderstood and with his relegation to the sidelines trypanosomiasis was once again rife and this is now known as the "after Jamot period". As there is no way to get away from inescapable facts, shifting back to Jamot’s doctrine implementation finally achieved the control of trypanosomiasis in French Western Africa. A few years later a major tribute was paid to the doctrine when its implementation was widespread and when its scope was broadened to other endemic diseases.

Unavoidable changes had to take place with decolonization and Jamot’s doctrine had to be modified. Here and there trypanosomiasis is now classified as a re-emerging disease.

TRYPANOSOME and TSÉ-TSÉ FLY

Trypanosomes which are spindle shaped micro-organisms are together elegant and extremely mobile. Their cells are as long as three or four red cells lined up and move around with the help of their flagellum. Two British scientists by the names of Forbe and Dutton discovered them in 1901 in Gambia.

Trypanosomes in the blood

In Western and Central Africa they are parasites of humans but also very likely also of swines. Another species is found in Eastern Africa which is slightly different but as harmful as the other one as it is a parasite of both humans and animals mostly antelopes but also giraffes and wart hogs, and this fact precludes any possibility of eradicating the disease.

The "Tsé tsé fly" which is an exclusively African insect conveys the disease while biting a patient, feeding on his blood and picking parasites which will be later transmitted to a healthy individual on the occasion of the next feeding bite.

Glossine or tsé-tsé fly

DEVELOPMENT OF THE DISEASE

There are two different successive stages in the course of this condition :

– During the first one parasites are found easily in patients’ lymph nodes and blood stream. Symptoms which are quite commonplace include a high grade fever, enlarged cervical lymph nodes and a few spots on the skin... none of these clinical symptoms is an enticement to resort to medical care.

– A few months later with the second stage the patient starts having neurological disorders. Impairment of the brain may result in paralysis, convulsions and sensory disorders which make using tools such as keys quite painful : this is known as the "Kérandel symptom" (by the name of the colonial physician who described it first hand when he was suffering from the disease). There are also mental disorders which keep worsening with an irrepressible need to sleep which is a relevant explanation for the name of this medical condition. During this stage trypanosomes are found when tapping a cerebro-spinal fluid sample.

Last stages of trypanosomiases

Shortly after experiencing an important loss of weight with considerable wasting, the patient is going to pass away : the period of time which elapses between the infecting bite and his death is sometimes less than a year long.

MEDICATIONS

During the first half of the twentieth century there were very few efficacious medications. The only one which was known and used at first was an arsenical by-product named Atoxyl It had to be administered over a several week period of time through courses of subcutaneous injections. As it was a swift killer of trypanosomes roaming the blood stream, its use during the first stage prevented the risk of transmission with new fly bites. But as this medication does not pass through the meningeal barrier it is not efficacious against trypanosomes which are already present in the cerebro-spinal fluid so that the disease can continue to progress in patients who are experiencing the second stage of this condition.

In 1926 a new arsenical by-product named Tryparsamide became available. It is given intravenously once a week over a few weeks. This medication has a great advantage over Atoxyl as it penetrates into the cerebro-spinal fluid. It is therefore a medication for the second stage of the disease. But nevertheless about 20 % of all patients are not going to recover and their outcome will be a fatal one.

Discovering a sick person

When mass therapy campaigns against Trypanosomiasis got started, only these two medications were available. They are arsenical by-products with deleterious side effects for the optic nerve, as a result, most of the time patients are cured but some complain of ocular side effects and may even wind up fully blind. The need of repeated injections is another shortcoming as it is difficult to have patients stick to the program unless they are inpatients over two or three month period of time. And then also, incomplete treatment courses give rise to strains which are resistant to these medications. These first generation arsenical drugs are obsolete now and not used any longer with the availability of new molecules which were developed through research and development.

During the nineteen thirties an urea by-product by the name of Suramine or Moranyl became available without any detrimental ocular side effect but its use may impair the patient’s renal function. It is administered intravenously over 5-10 weeks and is only efficacious during the first stage of the disease.

Diamidines which are very efficacious arrived later, but they do not pass the meningeal barrier. In 1946 in Western Africa Le Rouzic* and Combescot* laid out the rules for their use in mass campaigns. Accidents with this therapy are rare but usually severe. One injection of this medication provides a healthy individual with a several week long protection but this is too short a time anyway to warrant systematic prophylactic campaigns which had been contemplated at first.

A new arsenical molecule by the name of Melarsoprol became available in 1947 which Jonchére* tried out. It came out that this medication is efficacious during both stages of the disease and provides the cure of ninety five percent of all patients. Unfortunately 5-10 % of all patients who happen to be treated with it experience severe side effects of the toxic encephalopathy type which too often result in a fatal outcome. Melarsoprol was banned for a while but had to be reintroduced as no substitute could take over. Therefore in 1998 in spite of these very detrimental side effects, WHO stated that "melarsoprol was the only medication which was available for patients during the second stage of the disease".

TRYPANOSOMIASIS AS AN ENDEMIC DISEASE

Geographical distribution of African human trypanosomiasise

This disease has been always been present among populations of Sub Saharan Africa and over the past centuries slave traders were aware of it. The disease flared up with the arrival of European colonizers who built roads, brought peace to tribes, and facilitated the movements of humans and the traffic of goods.

– In French Equatorial Africa and Cameroon :

Around 1880 a member of the Savorgnan de Brazza’s expedition reported it and later in 1895 Couvy* and Carmouze* reported an epidemic which had occured in the region of Loango which is situated south west of Brazzaville. Kerandel*, Heckenroth*, Millous* identified other foci in 1906 in the Lower Congo region. The Geographic Society assigned G. Martin* and P. Leboeuf* together with E. Roubaud who was an Entomologist, to investigate this issue in French Equatorial Africa. They happened to come across some Colonial Army medical officers who were posted there. They were able to make their own assessment of the situation in the Lower and Middle Congo regions which they considered as a very serious one.

Without any means of penetration and with no availability of any population census, any medical undertaking remained incomplete and the epidemic kept gaining ground. Between 1905 and 1910 organizations dedicated to the study of tropical medicine became deeply concerned with the problem. More than half of the papers which were published in the first issue of the bulletin of the French Society of Tropical Medicine were about this condition. In 1913 in the Northern Oubangui region, which is one thousand miles away from the Lower Congo Region which was supposed to be the primary focus of the disease, among the twenty thousand people whom he screened, Ouzilleau* was able to diagnose seven thousand patients with Trypanosomiasis. He tackled the task of restraining the spread of the epidemic while using Atoxyl.

In surrounding districts his fellow physicians such as Aubert* and Monfort* in the Sangha region of North Congo and Heckenroth* along the banks of the Lower Oubangui River performed amazing feats but they could not carry on as they had not been provided with any additional means of action. The epidemic kept on spreading and in 1926 Muraz* found over eleven thousand patients around Fort Archambault in Chad. Cameroon which had been a German colony until 1916 was not spared. This western epidemic swell met up in eastern Africa with the one that had come from the Anglo Egyptian Sudan (today called Sudan). The origin of the latter is found in the memorable epidemic which wreaked havoc on Uganda between 1902 and 1905 with the death of above two thirds of the total population in one of its province. Over the next two decades the disease flared up in the whole French Equatorial Africa.

As of 1910 the Germans who then were the rulers of Cameroon laid out plans to fight this scourge shortly after beginning to assess with accuracy the scale of the problem. Emphasis was made on the need of policing borders, of supplying health passports, and of setting up treatment facilities where patients could be gathered. In 1913 systematic screening of populations by itinerant teams of health-workers, bush clearing to get rid of tse tse fly habitat and training of specialists for this action were due to start. An allocation of funds in the amount of several hundred thousand marks had also been earmarked for the years 1914-1915 but war played havoc with these plans. Later when France took over Huot* had to implement them according to the same blue-print… but then without any allocation of money. It had been assumed at first that the disease was only found in dense forests and along river-banks in the hinterland. Over a twenty six month long period of time Huot* diagnosed 8 548 patients among the seventy thousand people who were screened. In fact this scourge was everywhere but so far, there had been no correct assessment of the scale of the disaster.

In the former Belgian Congo, now Zaire, as early as 1911, E. Lejeune diagnosed and treated thousands of patients who were suffering from the disease. In 1913, Elisabeth, Queen of the Belgian People, donated some of her own money to set up in Leopoldville which is now Kinshasa, a facility dedicated to the training of native health worker aids which would enable them to diagnose the disease according to standard instructions. The British and the Portugese who had made the same epidemiologic findings did not implement any similar plan of itinerant action.

– In French Western Africa :

Meanwhile some physicians who were members of the Colonial Medical Corps such as G. Martin*, Thiroux* and Bouffard* brought evidence that the disease was present in all territories. In 1908 Bouet* and Roubaud ’s mission roamed the Federation and charted the epidemic which had spread from its epicentre in the Volta Rivers region. In 1925 Hérivaux* came across a very active focus of the disease in Northern Togo, which had already spread beyond the border with North Western Dahomey, heedless of any political boundary line. Dabbadie* reported that an epidemic was rife in Southern Upper Volta and later Montestruc* who had taken over reported that the frontline of the epidemic had been moving eastwards and had reached the banks of the Niger River. Senegal and Guinea were also infected. Just like twenty years earlier in French Equatorial Africa, there was no coordination of the action. The Director of the Public Health Services of the Federation was a medical officer with the rank of a General who tried to minimize the importance of the danger. In each territory there was a director of Public Health and a Governor so that policies were different from one territory to the next. The situation which prevailed in Sudan which was the last territory to acknowledge the presence of Trypanosomiasis has to be compared to the one in Togo which had been under French mandate since the end of WWI and where an appropriate institution set up in 1925 had helped to keep the disease in check.

PRINCIPES OF PREVENTION

Upon Jamot’s arrival in Africa the principles of a preemptive fight against sleeping sickness had been specified and the two weakest points in the epidemiologic chain had already been identified which were the tse tse fly on the one hand and the trypanosome on the other one. But these were only theoretical principles !

Fight against glossinas was then impossible as there are in fact several different species of them with some living in forests, some others in forested savannahs, and others also in sahelian areas along river banks. The latter use to move around during the wet season. At this point of time there was no availability of insecticides nor of glossina traps.

Fight against trypanosomes had to be delayed until the first arsenical by-products which wipe out trypanosomes in infected humans, became available. Flies become harmless once they do not come across anyone who is parasite carrier.

It is quite easy to deal with such a problem theoretically but tackling this objective on the field of action is much more difficult. It took about two decades to overcome together the reservations of authorities, the lore and fears of those who were interested in this endeavour and finally all the obstacles which are come with any innovation.

This achievement required the energy, conviction, doggedness, eloquence, charisma of a Colonial Medical Corps Officer : E. Jamot who had also a non conformist set of mind altogether with an ability of being good at organizing things. His associates who displayed great courage and dedication, paid a heavy toll to Trypanosomiasis : some of them were stricken twice while some such as Le Hir* in the Upper Volta territory died of it.

Eugène JAMOT (left) and his first collaborators (1930)

The aims of prevention are clear cut :

– The requirements to achieve the sterilization of the virus reservoir are the following :

The availability of an efficacious medication which can be used in locally prevailing conditions,
the need of diagnosing all existing patients,
which have to be systematically treated as soon as they are diagnosed : the first injection is aimed to wipe out roaming parasites and then afterwards all subsequent care is given according to standard procedures over the next few months. An uncompleted course of treatment can result in a disastrous failure for the patient first but also for his community.

– To diagnose all patients one must :

Go and meet the people where they live and screen everybody with the help of itinerant teams of health workers who must be able to work anywhere swiftly and efficiently.

**Working in the bush : lumbar puncture**

Census records should also be made available. One of the provisions of the law was that chieftains at the head of districts had to provide a makeshift record of inhabitants but most of the time this document was forged as it was in use also for the assessment of taxes which the village had to pay. Therefore as soon as they could, itinerant teams made their own census.

Call again at places which had already been visited according to a planned schedule and advertised in advance in order to ensure that everybody could be screened with no one left behind and also in order to diagnose new cases which might have broken out since the last visit.

– In order to work swiftly and efficiently There was a need for :

Teams of health workers with a good experience of the job and of the procedures which are implemented. These auxiliary health technicians were chain working according to standard procedures they had been trained for in health assistant training institutions.

The adhesion of populations which also had to subscribe to this program with everyone reporting to the screening. The first step which had to be taken was at first to convince Chieftains of villages and districts. In Western Africa Sleeping Sickness was viewed as a defect which was shaming the patient and his relatives. One had be able to assess the unfortunate necessity of resorting to "the indigenous code" which provided penalties for those who broke the law and who endangered public health through their unruly behaviour.

Successful achievements had to be heralded so that chieftains and populations could become aware of them.

DESIGNING JAMOT’S METHOD

Upon arriving in Sub Saharan Africa in December 1910, Eugéne Jamot* was assigned over the three next years to one of the battalions in charge of pacifying Chad. When he returned to France he signed up for a training course at Paris Pasteur Institute where he got the opportunity of being introduced to Mesnil who directed him to research the trypanosomiasis issue. In July 1914 he sailed back to Congo where he was assigned to the Brazzaville Pasteur Institute. Fifteen days later war broke out and he became a medical officer in the French and Belgian force which was in charge of confronting the Germans in Cameroon .When he returned to Brazzaville in 1916 he was assigned to the running of the Pasteur Institute.

On the occasion of his stint in Chad, it is likely that he got sharply acquainted with the issue and that he became convinced of the need of setting up itinerant teams of health workers in the African hinterland. Furthermore while making his way from Brazzaville to Yaoundé he had crossed the region which had the largest number of patients suffering from trypanosomiasis so that he could not have missed seeing these staggering people who were severely wasted by the disease looking like skeletons with their eyes similar to those of deceased people. Anyhow this situation clearly looked like a real medical emergency and as director of Brazzaville Pasteur Institute he strove vigorously to fight the disease.

As early as November 1916 the colonial government became aware that a trypanosomiasis epidemic was flaring up across French Equatorial Africa. In April 1917 the Colonial Hygiene Board in Brazzaville set up "The Sleeping Sickness Monitoring and Prophylaxis Centre". Each territory was divided into districts and Jamot insisted that the colonial administration be entitled to decide with a request of the physician in charge, which places populations had to report to for the need of their mandatory medical screening. This undertaking aimed at taking a census of the people, opening medical files and starting treatments.

It quickly turned out that physicians in charge of itinerant teams of health workers had to go along with them to carry out the screening of entire populations and to immediately implement the treatment of those who had been diagnosed so that trypanosomes could be stopped from spreading.

A round in the hinterland

Jamot’s venture began with an itinerant team which he had set up with two European and seven African auxiliary health technicians. The first two were in charge of day to day chores while the seven others belonged to different ethnic groups who spoke different dialects. Over a several month period of time they had been intensively trained to carry out one or several specific procedures : lymph node puncture, screening of lymph node juice or of blood samples for trypanosomes, performing Atoxyl injections and so on...

The area which had been selected for this mass screening was the corridor connecting the Oubangui and the Chari basins. They hit the trail in Bangui and walked north, until they reached the border with Chad which was around six hundred and fifty miles away. This trail in the wild at first crossed forests with clearings, then savannahs which had a vegetation which became scarcier and scarcier from one day to the next. Two microscopes, two hand powered centrifuges and a few syringes made up the basics of their equipment. They travelled by boat or canoe, sometimes they rode horses but most of the time they had to go on foot.

Over an eight month long campaign which spanned from June 1916 to February 1917, they diagnosed 1 959 patients among the 18 874 people who were screened. They were identified, registered and treated while their medical file was drawn up. Only one village among the seventy seven villages which they screened was unscathed.

Once he was back in Brazzaville, Jamot strongly advocated carrying out this kind of action all across French Equatorial Africa. During the next two years seven itinerant teams were set up, each one in charge of a district. Muraz was at the head of the Nola district, which is a place located at the southern tip of the Oubangui Territory and dubbed "the post of death", and later, he went to Fort Archambault, Chad. He diagnosed and treated thousands of patients but he also became imbued with Jamot’s doctrine which, twenty years down the road, he implemented successfully when he was at the head of the SGAMS. Prior to that, in 1926, he was assigned to run the Sleeping Sickness Control Department of French Equatorial Africa.

IMPLEMENTING JAMOT’S METHOD

In March 1922, by the time Jamot was posted to Cameroon which the Society of Nations had entrusted to France, this country was in a desperate plight as a quarter of its population had died. In some villages 97 % of the people were stricken by the disease. It can be claimed that bites of the tse tse flies were accountable for a true human genocide !

At this point of time his staff had been beefed up with four young medical officers named Corson*, Euvrard*, Odend’hal* and Marquand* and with also seventy five auxiliary African health technicians. He undertook to assess the situation and he found places in the central region of the country which were a few hundred miles away from Yaoundé, where 30 % of the people were suffering from trypanosomiasis. During the following year this screening endeavour brought Jamot and his team close to Yaoundé, but they were repelled by the colonial government. Flare ups of the disease deep into the hinterland were acceptable but the assumption of having this scourge close to the capital was really ill chosen and foolish !

Palpation of lymph nodes in the neck

From September 1924 to February 1925, Jamot screened northern Cameroon : the infestation was also there but was not as serious. When he went back south he found that in the meantime there had been a further deterioration of the situation. Among the 663 000 people who were screened, 115 354 were diagnosed with the disease which makes a infestation rate of 17 %. In September 1925 Jamot sailed back to France on regular leave.

In June 1926, Calmette*, who then was deputy director of the Pasteur Institute, introduced him to the fellows of the "Association Colonies-Sciences". Its president, General Messimy, a former Minister of colonies, who had become famous during WWI, was also at the head of the Colonies Committee at the Senate. As a result of Jamot’s natural eloquence combined to his description of what he had been through, a lot of people felt drawn to him. He gave a number of lectures, and he was easily granted audiences by cabinet staff members and even by ministers, and furthermore he received directly an allocation of funds in the amount of eight millions francs which today in the year 2000 would account for 4.5 millions euros. He was the only one who was accountable for the use of these funds. But while directly addressing "lay persons" he had become guilty of bypassing altogether three different hierarchies which were the military, the medical establishment and the colonial administration. Some people never forgave him.

Anyway he had already achieved a lot : As early as 1926 Jamot’s prophylaxis mission was granted its full-fledged autonomy in Cameroon and French Equatorial Africa. He set up fourteen Special districts and fourteen subsidiaries. His strike force consisted of eighteen medical officers of the Colonial Medical Corps, thirty six French health technicians and four hundred Cameroonian medical auxiliaries. Some teams had up to fourteen microscopes at their disposal. The Ayos facility had become the training institution for staff members.

Blood testing

By the end of 1928 all over Cameroon 663 971 people had been screened out of the 800 000 who were listed and 115 354 patients had been diagnosed and treated. Bedridden and crippled patients were cared for as inpatients in sleeping sickness facilities while the other ones reported to outpatients care centres or expected the visit of an itinerant health worker in their village. The outcome was a good one with the full recovery of seventy five percent of them.

While Jamot was in Paris on the occasion of the 1931 Colonial Exhibition his fame grew higher as political authorities displayed their appreciation of his feats in Cameroon. He gave interviews and lectures one after another and this time showed the kind of great communicator he was when he resorted to cinema which was then the most recent media available. Marc Allegret shot a film in Cameroon which recalled Jamot’s own challenge ten years earlier "I will re-awaken black Africa". Hence its title : "The re-awakening of a human race" (Le réveil d’une race). This movie was a hit and Jamot became a French nominee for the Nobel Price for Medicine.

But this was too much. He was then charged of being accountable for a technical error which had been made by one of his co-workers who was posted in Bafia. Several hundred people had become totally and permanently blind with an overdose of Tryparsamide. While he was sailing back to Cameroon he was notified that his assignment to Yaoundé had been cancelled and that he incurred a blame. After disembarking in Dakar he stayed there and waited for his new assignment which was delayed over the next seven months.

Finally in July 1932 he was assigned to run the French Western Africa Department for Sleeping Sickness Prophylaxis and was requested to determine the limits of distribution of this endemic disease. He got sixteen Cameroonian nurses to come with him with some recruits from the Upper Volta. He set up his headquarters in Ouagadougou which is in the centre of the Upper Volta.

Until March 1935 he roamed the immensely large French Western Africa territory and found trypanosomiasis everywhere except in Mauritania. Villages vanished everywhere and census figures were sharply declining. The fatality rate was 25 % higher than the birth rate. One cannot avoid feeling strongly impressed when taking stock of the achievement : in less than a three year period of time Jamot and his teams diagnosed sixty eight thousand patients. The situation there, was similar or even worse than the one he had found ten years earlier in French Equatorial Africa.

His advice was the same as in Equatorial Africa : an independently functioning institution dedicated to the fight against the disease had to be set up. But his detractors were the ones who held power and they denied the efficiency of his doctrine and challenged its merits. The statement which his medical superiors issued was that "Any epidemic comes to an end some day or the other and even if Jamot had not been there the successful results he claims for, would have been achieved anyway in Cameroon or in the French Equatorial Africa". The administrative hierarchy added : "any department which is granted an autonomous running, becomes an independent state of its own". Jamot was shattered by the news, and he had also been deeply affected by the blame he had been informed of upon his arrival in Dakar. He was also worn out. He knew that he was right and in 1935 as he was a man with a sense of honor, he resigned and retired in France in the Creuse region where he passed away two years later.

THE SITUATION AFTER JAMOT

By issuing a decree, the inspector physician Couvy*, head of public health in French Western Africa, brings the fight against trypanosomiasis back to what it was in 1906. The main motto of his reform is "versatility". Screening and treatment teams are turned into general consultation teams, and treatment centres have become permanent centres for consultation. In other words, itinerant teams return to the structure of Native Medical Services (AMI) which deals with all the health problems of the populations.

It’s a fairly good idea, and anticipates the recommendations which WHO formulated at the Alma Ata conference in 1978, but it deprives trypanosomiasis of its priority statute. The specific training of the personnel is not guaranteed anymore, the therapeutic protocols are ignored, the additional tests are neglected. For instance lumbar punctures are not systematic anymore. In fact, from 1935 to 1938, trypanosomiasis starts to flare up again. Patients in their second stage of the disease are more numerous.

It upsets some people. In particular Lefrou* who gets a blame. Shortage of everything settles, shortage of vehicles, shortage of material, shortage of medicine, and also shortage of enthusiasm. Oddly enough, the administrative hierarchy has become aware of the danger, while the higher spheres of the medical hierarchy (inspectors and directors of the health in the territories) remain locked to the notion of versatility that empowers them with authority over everything.

Finally, it’s the general governor of French Western Africa, De Coppet who, on January 20, 1939, with the help of Couvy’s successor, manages to obtain from the new minister of the colonies the creation of the general service of the sleeping sickness (SGAMS), the direction of which is given to Muraz*.

BACK TO JAMOT’S METHOD

Right away Muraz* made all arrangements to avoid some of Jamot’s shortcomings as the latter had never shown any interest for administrative work nor any consideration for hierarchy. Jamot cared for his subordinates the same way as he did for friends. He gave his instructions only by word of mouth during informal conversations or through private mail. Upon taking over from his predecessor, a medical officer who was assigned to the head of an itinerant team could not find any record relevant to the proper use of medications which had as many toxic side effects as therapeutic properties.

With Muraz it was the other way around as he issued "technical instructions" where both screening and treatment procedures were codified, unified and updated. Everything has been anticipated in these documents, they have been recorded and they are the permanent reference for the head of the sector.

Muraz who took advantage of the achievements, relied on regulations, decrees and orders which had been issued by the government. He made sure he was fully trusted by decision-makers in Paris and Dakar. Instead of Dakar he set up his headquarters in Bobo Dioulasso in the Upper Volta right in the centre of French Western Africa.

Thirty two districts were set up in French Western Africa, which were run by Colonial Army Medical Officers. On the one hand they had at their disposal one or several itinerant teams, with an auxiliary native physician at the head of each one who had trained at the African Medical Academy in Dakar and on the other hand they had team technicians for agronomic prophylaxis that were in charge of wiping out glossinas habitat while taking advantage of recent advances which had been made in the knowledge of the life cycle of these flies. From 1940 to 1945, 4 025 bush clearing sites were set up by SGAM which achieved the clearing of three hundred and forty square miles. Itinerant teams had still kept some versatility as they were also in charge of vaccination campaigns.

Several steps were taken which boosted the success of this Service. For instance patients who steadily reported for their treatment, were exempt from paying the capitation tax. Districts and villages chieftains were granted an allowance when all their people could be gathered.

And then success was back. Between 1939 and 1945 despite of the war and later in 1942 when ties had been severed with the mainland, four times as many people were screened as before and the rate of new contaminations declined sharply as it was twenty times lower. Among the forty million people who were screened four hundred thousand were diagnosed with the disease and most of them fully recovered after having been treated.

JAMOT’S METHOD USED WORLDWIDE

Eugène Jamot (1879-1937)

In 1944 with the Brazzaville conference, versatility was brought back to the forefront and updated. Trypanosomiasis which had been curbed was no longer considered as a commonplace medical condition which could be left to the care of Native Medical Services (AMI). On the contrary broadening the scope of activities of the "Autonomous General Service for Sleeping Sickness Control" which had kept its independent course was contemplated in order to include the fight against some other major endemic diseases. They were selected among those which were the most dreadful but also which could efficiently be treated. While vaccination programs were still carried on, new tasks were progressively assigned to these itinerant teams with the fight against Leprosy, Malaria, Trepanomatoses, Cerebro-Spinal Meningitis, Onchocerciasis dubbed also River Blindness and other disabling ocular diseases such as Trachoma. An assessment of the results is found in the chapter relevant to each of these conditions.

Because of all these changes the SGAM was renamed and became the "Itinerant Hygiene and Prophylaxis General Service" (SGHMP) which Le Rouzic* kept running till 1948. Headquarters were kept in Bobo Dioulasso at the "Muraz Centre" where the different departments and laboratories of this institution were located. As a follower of Jamot* and Muraz*, Le Rouzic* kept on favouring the fight against trypanosomiasis which within the ten next years wound down as a minor endemic disease. Thus in 1953, in the previously most severely infested region of French Western Africa, 6 092 patients only were diagnosed among the 5 407 376 people who were screened, and most of them had been contaminated in Gold Coast which is now Ghana.

In French Western Africa together with Togo there were seventy five special districts and forty four subsidiary ones which were run by medical officers of the Colonial Medical Corps. French Equatorial Africa and Cameroon were divided into some thirty districts. In the nineteen sixties which was the time when their activity peaked, itinerant medical services in Africa which altogether employed several thousand people, had the use of more than eleven hundred vehicles and the figure of their 1956 expenses would be valued at ninety four million euros (figures in 2000).

After the independence of these countries the legacy of the "Itinerant Hygiene and Prophylaxis General Service" was bequested to African international institutions known as OCCGE and OCEAC.

But it should be kept in mind that beside political and economic issues the independence process involved also psychological and sociological ones. Along with the new citizenship status came a feeling of emancipation from the administrative tutelage.

With this newly gained freedom, the obligation to report to gatherings could not be enforced any longer as it was now viewed as a constraint which had been brought by colonizers. Requiring the people to report and to stand in line during several hours before they could be screened, without any privacy for the identification of patients, turned out to be difficult. Jamot’s doctrine had to be implemented with some coercion in order to warrant its full efficacy with everyone reporting to the itinerant team. But still today, just as yesterday, a patient who is left undiagnosed on the occasion of the population screening can be responsible for the contamination of ten or twenty people over the next few months.

Beside all these considerations, these countries with limited means cannot afford to continue the implementation of this doctrine. International help and scanty humanitarian grants are not up to the needs. Some governments do not pay their share to international common organizations any longer. Rounds of itinerant teams are less and less frequent today.

And the unavoidable consequence is that trypanosomiasis is classified as a re-emerging endemic disease now but this time without any qualified auxiliary health worker left and there is still no new medication which can be used for mass treatments. In 1998 WHO assessed that there were fifty five million people who were at risk of catching the disease with only four million of them who could take advantage of an appropriate screening. Moreover, wars and political unrest wreck all health programs.

ADAPTING JAMOT’S DOCTRINE

This method as it had been originally designed has to come to an end. English speaking specialists refer to it as the "French system" which achieved the right thing at the right time. The entire scientific community admired the successful achievement. French Africa was spared a demographic disaster.

Sleeping Sickness in Central Africa

But now it has to be adapted : the concept of itinerant teams with each member assigned to a task for which he has been specifically trained is still in use. The first injection which has to be given immediately to achieve sterilization of the virus reservoir remains an essential measure of prevention. Absenteeism is today the most important difficulty which has to be overcome and awareness programmes should take over obligation. It is only when the people are fully aware of the risks which are incurred that one can expect to change their standpoint. Absenteeism will decline with good education and information and efforts which should be specially directed toward women and girls, but anyway, this will require a lot of time.

Fortunately by the end of the twentieth century a few new possibilities are coming out and a more efficacious fight against glossinas can now be envisioned with the availability of organochloride insecticides, of insecticide impregnated traps and with the release of irradiated sterile males.

Screening can now be done with fewer health-workers than before, as after taking a blood sample at a finger’s tip a serologic test can be done immediately. The results are immediately interpretable and this makes a quick sorting out of the people possible. Individuals who test positive have to undergo a thorough medical check and are searched for trypanosomes. Those who are finally diagnosed with the disease are cared for either by itinerant treatment teams or in treatment centres. Anyhow and forever the keyword of this fight against trypanosomiasis will be "itinerant team" and Jamot will also remain forever in everyone’s recollection as the one who had this bright idea. Research and development departments of the pharmaceutical industry should become interested in the development of new trypanosome killing medications which would be easier to use than the present ones. No new medication has been developed over the last fifty years which could now take over Melarsoprol in mass campaigns.

For further information :

– Martin G. Leboeuf et Roubaud. : Rapport de la mission d’études de la maladie du sommeil au Congo français -
1906-1908. 1 vol. Masson et Cie Edit. Paris 1909.
– Laveran et Mesnil. : Trypanosomes et trypanosomiases. 1 vol. Masson et Cie Edit. Paris 1912.
– Jamot E. : La lutte contre la maladie du sommeil en AEF et au Cameroun L’Illustration 4330, 27 février 1926,200-202.
– Jamot E. : La prophylaxie de la maladie du sommeil In "les grandes endémies tropicales" Tomes I et II ; Vigot Frères Edit. Paris 1930.
– Jamot E. et Coll. : Rapport sur la maladie du sommeil. Journées médicales coloniales : 23 07 - 05 08 1931. Rev.Med.Hyg.trop. 1931,23,190-192.
– Jamot E. : La lutte contre la maladie du sommeil au Cameroun. Ann. Institut Pasteur. 1932,48,481-539.
– Jamot E. : La maladie du sommeil en AOF. Bull.Acad.sci.Outre-mer.1935,265-273.
– Dutertre J. : Médecine d’Afrique noire. 1968, n°4, 147-177. Numéro consacré à la trypanosomiase humaine africaine.
– Ann. Soc. Belge Med.trop. 1977,57,4-5,191-479. Nombreux articles.
– Médecine tropicale, 2001,61,4-5. Numéro entier : Maladie du sommeil : le renouveau.
– Lapeyssonnie L. : "Moi, Jamot" Le vainqueur de la maladie du sommeil 1 vol. 210 p. Les presses de l’INAM. Edit. Plaisir 1987.
– Lapeyssonnie L. : La médecine coloniale. Mythes et réalités. 1 vol. 310 p. Seghers Edit. 1988.
– Bull. Soc. Path. Exo. 2002,95,5,331-344 Numéro entier : Hommage au Médecin général Lapeyssonnie.

LEPROSY

Leprosy is a slowly progressing condition which maims and cripples patients. It is said to be as old as Mankind. It is caused by the Leper Bacillus which is also called Hansen Bacillus. It is a strictly human medical condition with cutaneous, mucosal and associated nerve lesions which are responsible for paralyses, sensory losses and mutilations of limb extremities.

In all colonies the Colonial Medical Corps had to face the disease but its most successful achievements took place in Sub Saharan Africa, which was a major region of endemicity. In the early days of the fight against this scourge the name of Marchoux* (1862-1943) stands above all others, when as early as 1923 he spoke in favour of humanizing Lepers Hospitals. He suggested the building of a Leprosy Research Centre which opened up in Bamako and became later named after him. It is presently be known as the "Marchoux Institute".

In 1944 the fight against Leprosy was re-organised in order to achieve a better coordination.

For their part Colonial Corps Surgeons with Carayon* and Bourrel* innovated and developed surgical procedures which intended to bring some relief to patients.

Now in Africa supranational organisms (OCCGE and OCEAC) carry on the fight against Leprosy with the help of physicians of the involved nations. WHO coordinates the fight and every country of endemicity runs its own program which is financed through charities.

This condition is expected to gradually subside with poly-chemotherapy regimens which are now put in place and implemented with the hope that this disease will not be any longer a concern for public health.

HISTORICAL FACTS ABOUT LEPROSY

China and India are probably the most ancient focuses of the disease which made its way after to Mesopotamia and to the Mediterranean shores and then spread easily across the Roman Empire. It peaked in Europe during the twelfth century just after the Crusades and declined after. Segregation of patients who were isolated in lazarets in order to minimize contagion are possible explanations for this decline but the most likely reason is probably found in the advances of hygiene standards.

During the nineteenth century Virchow and Hansen with their works reported important relevant pathological and bacteriological data. In the early twentieth century Mitsuda supplied the first immunological information and developed an invaluable intra-dermic test.

Lepromatous variety

Leprosy spots

Tuberculoid variety

Today this condition holds on to the tropical world. Its main strongholds are located in Africa, in Central and South America and in the Far East. Protein deficiency, promiscuity, the lack of hygiene, ignorance combined all together with the immuno-depressive action of many medical conditions contribute to its upholding. From a worldwide distribution during the Middle Ages, Leprosy has now turned into a specifically tropical disease.

In France the few hundreds cases which are known are all imported ones and no native case has been reported now for decades.

Over the last thirty years the number of lepers has been dropping from thirty millions to less than one million people the world over but two or three million of them remain disabled even if their disease is cured.

THE PATHOGEN AND TRANSMISSION OF THE DISEASE

This uniquely human condition which develops over a long period of time is due to a bacillus which was discovered in 1873 by a Norwegian named Hansen. The slow development of this micro-organism explains why the disease breaks out several years only after contamination. Even after it breaks out the disease develops slowly. Worsening developments are followed by respites which can sometimes extend over several years. Most of the time this disease constitutes a chronic and crippling condition but it is not directly responsible for the death of the patient.

A Cluster of Hansen Bacilli making a Globi

For each case the way of contamination remains unclear. Most of the time it dates back to childhood while inhaling sputters of an infectious leper. It can also occur with a leper’s mucus tainting skin ulcers or an open wounds and with the use of soiled items such as linen, mats or pillows. All these possible ways of transmission entail close and durable contacts such as the ones which occur in the close settings of family life. There is no known hereditary transmission but congenital transmission remains possible.

As fleas, mosquitoes and other insects are entailed in the transmission of other tropical diseases Marchoux* with the help of Bourret* started contemplating the hypothetical but possible role of an insect, but this was to no avail except for the occasional and exceptional case of domestic flies passively carrying the pathogen.

LEPROSY ENDEMISM OVERSEAS

As M. Leger* put it in 1920 : "In the French colonies Leprosy is far from being the most contagious and deadly infectious disease. It should nevertheless be considered as a most afflicting scourge (…) which may constitute an impediment for the economic development of a country".

Native populations stuck to their forebears’ traditions with the building of segregation villages and the French authorities followed suit. A plan of action against leprosy was laid out and included on the one hand setting up lepers hospitals and "agriculture settlements" and on the other hand restricting patients movements and barring them from some occupations. But it did not take long for physicians to behold that villages were kept empty at daytime as patients were begging in villages which were all around so that enforcing segregation was only a fiction. At the turn of the century some Public Health Supervisors such as Kermorgant* in 1905 and Grall* in 1910 made several comprehensive reports on leprosy.

– In Indochina the illness had been present there for a long time and was rife everywhere but distribution of the cases was uneven with two main focuses :Tonkin and Cochin-china. According to counts made by colonial physicians around 1900 there were several hundred patients in Laos and Cambodia but they acknowledged that these numbers made only for a small part of the total figure as most of the time those who were included were the ones who had reached an advanced stage of the disease. Tonkin with its overpopulated delta was a very active region. Many lepers were hiding but their number was assessed to be around five thousand in Cochin-china and about a thousand in Annam. In 1912 Governor Sarraut set up a Department of Lepers Hospitals.

Some forty years later in 1938 in their annual report Grosfilez* and Lefevre* reported 8 104 lepers in the Indochina Union with 4 132 of them in Cochin-china and 2 772 in Tonkin. And their comments were very similar to the previous ones : "This figure (….) is probably inferior to the real one. Great efforts are still to be made to screen and segregate new cases".

– In Africa Bernard* who had the support of Dabbadie*, the Public Health Director of the time, assessed that several thousands lepers were living in the Upper Volta and added that many patients kept hiding out to avoid being segregated. In 1955 after conducting a thorough screening of entire populations the The General Service of Mobile Hygiene and Prophylaxis (SGHMP) gave a ratio of two hundred patients for every ten thousand people. For the whole continent their number was figured to be above five million with one million of them living in French speaking Africa.

– A few other examples :

In 1939 eighteen hundred patients were recorded in the French Trading Posts of India. There was a few hundred of them in Martinique also where Montestruc* reorganised the fight against the illness and committed himself also to the study of leprosy characteristics in infants and children. At the same time in French Guiana, Floch beefed up the plan of action against leprosy where this condition had already been reported in 1887 by Simond* with his doctoral dissertation on the issue.

In summary Leprosy was present in every part of the French Colonial Empire and was a real cause of concern. No efficacious medication was available before the time of sulfones around nineteen fifty. As soon as a patient had been diagnosed and identified he had either to hide out or to be deported to a facility for the care of lepers or to a village for lepers. Depending on their ethnic group and culture, patients could be accepted or repelled from their communities with no mercy.

CLINICAL FEATURES OF LEPROSY

Leper with multiple disabilities

Cutaneous lesions break out on the skin of young adults consisting in discoloured or bronzed spots on dark skins or slightly reddish ones on light coloured skins. The edge of the lesions is more or less marked and distinct. According the patient’s defence reactions specific clinical aspects develop later from this first lesion which is called "the undetermined one". This was made accurately clear by J. Languillon* in the early nineteen sixties and then by Ridley and Jopling.

Whenever the patient’s resistance is strong and stable, he develops the so-called Tuberculoid Leprosy with characteristic cutaneous and nerve lesions. This leprous neuritis strikes preferentially some nerves such as those of the cervical plexus, and also the ulvar and median nerves, and the external popliteal nerve. This neuritis results in paralyses and in an impaired trophicity. Bacilli are scarce and found clasped into dense inflammatory tissues and the patient is not contagious.

With an individual who has no resistance, a special variety occurs which is called Lepromatous Leper. The patient displays infiltrated cutaneous lesions called "lepromas". Neurological disorders are unobtrusive and there are frequent visceral lesions. Bacilli are easily found and the patient is contagious.

Between these two well characterized varieties ,there is a wide range of others which are named "intermediate varieties" because of unstable and fluctuating defence reactions.

Since the nineteen sixties, in order to achieve a better standardization of the therapeutic rules, the varieties of leprosy are categorized by WHO as follows :

– Multi-bacillary varieties which include lepromatous and intermediate forms.
– Paucibacillary forms which fit mostly with the tuberculoid variety.

HUMANIZING LEPERS QUARANTINE

Quarantine of all lepers was recommended by the "French Tropical Medicine Society" in Paris when it got started (in 1909) as this was considered as one the most basic measures which had to be taken to secure prevention. This had already been required by the first International Leprosy Conventions. During the proceedings Marchoux*, but to no avail, had expressed his reservations. The instructions were to record the patients’ numbers and to segregate them after. The "native legal code" provided a term of imprisonment for those who did not report to mandatory screening for endemic diseases.

Tropical Leper Hospitals had a poor reputation : these facilities which had low standards of hygiene and no efficacious medications were considered as places where to die in spite of the dedication of the nurses who were in charge (mostly in Indochina) and who belonged to religious orders. Still these facilities aroused envy among a few people who tried to be illegally admitted there.

In 1923 the Third International Leprosy Convention opened up in Strasbourg with Marchoux* as its General Secretary. He advocated the cause of lepers and rose up against rounding up patients in special villages. With slowly changing attitudes, coercive segregation was abandoned while leper hospitals kept on running and ambulatory treatment became standard practice with the use of chaulmoogra oil. In Bamako, lepers who had been kept in seclusion in Djikoroni were set free by Laigret* who incited them to report on a regularly basis to the outpatient clinic in order to carry on their treatment. The same was done in all other territories.

But at this point of time, some patients were still in the need of living in lepers communities where they could be treated. Today, there are still some "therapeutic villages" but now there is absolutely no coercion, such as in Lambarene for the one A. Schweitzer set up in 1953, and for one close to Bouake Raffier* built in 1963, and another built in Samanko close to the Marchoux Institute by Languillon* in 1966. Most severe cases wish to remain in their community with their relatives close to them while having medical and surgical care and being fitted with a prosthesis when they need one. They are free and they volunteer to live in these villages which nevertheless have lost today most of their relevance with the implementation of poly-chemotherapy.

THE MARCHOUX INSTITUTE

In December 1930 "The Leprosy Special Society" of the Society of Nations convened in Bangkok. Internationalizing the fight against leprosy was on the agenda with the implementation of the same rules of action and with deciding upon consensual and standard therapeutic procedures. A worldwide network of Research Centers was designed with four cities which had already their own centre : Calcutta in India, Culion in the Philippine Islands, Honolulu in Hawai and Rio de Janeiro in Brazil. Tokyo also in was on its way to have its own.

The determination of Marchoux* who had the backing of F. Sorel* convinced the French government to have a Central Institute for Leprosy built which was renamed "Institut Marchoux" after his death in 1945. In January 1932 at the Ministry of Colonies in Paris a "Consultative Commission for Leprosy Prophylaxis" was set up and Marchoux became its president.

This institute had a triple calling :
– It was first a regional operations centre against leprosy,
– But also a clinical and therapeutic research centre which was integrated in the worldwide network,
– And a training and specializing centre for healthcare personnel.

The institute was in charge of setting up, of standardizing and coordinating all actions taken against leprosy in French sub Saharan Africa. In fact the Institute did not remain in charge of these duties over a long period of time, as they were transferred to the SGHMP when chemotherapy became available.

It is only in the early nineteen fifties after sulfones had started to be widely used that screenings became really efficacious and in the meantime leprosy endemism started to decline. This decline became quite spectacular with the introduction of poly-chemotherapy.

We are indebted for the development of these protocols to the teams of health-workers working at the Marchoux Institute led successively by Laviron*, Kerbastard*, Languillon* and Saint André*. Within forty years the lepers ratio dropped from 200/10 000 to 5/10 000 people. In the meantime eight hundred thousand patients have been diagnosed and treated by the Colonial Medical Corps.

ORGANIZING THE FIGHT

The need for coordinating the fight against leprosy became of utmost importance at the level of each federation of colonies. It was not achieved before making a series of trials.

In 1931 the Leprosy Prophylactic Service of French Western Africa was set up in Bamako. It was assigned the duty of compiling a register of patients and of treating them while monitoring the outcome of their treatment. In fact, each colony, part of the federations, had its own Health Service which was independent from the others and the directives of the local Supervisor had to be implemented there, so that there was no possible coordination yet.

In 1939 the Autonomous General Service against Sleeping Sickness (SGAMS) was set up. As a federal service which was independent from the government of each colony. It typified beforehand what an institution had to be like for the needs of coordinating the action against a transmittable disease.

In 1945 SGAMS became SGHMP which became in charge of organizing the fight against leprosy on the field of action outside of Dakar and Yaounde. The Marchoux Institute and its research centre which was carrying out therapeutic trials and training of personnel was incorporated to this new institution.

Départ d’une tournée de traitement (AEF 1956)

In 1953 with the availability of sulfones in French Equatorial Africa, and later in 1955 in French Western Africa Richet* breathed new life into the screening and the therapeutic plans as he got an important support from international organizations such as WHO, UNICEF, FISE, FIDES, and also from humanitarian organizations which were brought together in the International Federation of Associations against Leprosy. Two of them had a preponderant role in the former French colonies : the Order of Malta which subsidised the Applied Leprosy Research Institute in Dakar and also the Raoul Follereau Foundation which among other programs, subsidised the Marchoux Institute.

At Richet’s* and Labusquiere’s* instigation an original framework was set up in 1956 which was an application of Jamot’s* doctrine : "daisy-shaped rounds " were put in place with assistant nurses who had to ride a few dozen miles on their bicycle each day along a petal shaped round for the distribution of sulfone tablets. They also updated patients’ records, and referred to the physician they had to report to any suspected new case they had come across. Detection and treatment of hundreds of thousand patients has been made possible with this arrangement.

From 1945 to 1960 most of the fight against Leprosy has been carried out by physicians of the Colonial Medical Corps who were assigned to this duty when they were at the head of districts of the SGHMP and later after 1960 by national physicians who gradually took over. A most remarkable national framework was set up in Ivory Coast by Maurice Rive* and in the Upper Volta by Labusquiere*.

Handing out sulfones in Madagascar during the nineteen fifties

But insufficient or irregular intakes of sulfones resulted in outbreaks of resistance to sulfones which was diagnosed in 1964 and this became a major impediment. But with the development of some other major medications leprosy started to lose ground with a scarcity of contagious cases and with the bacteriological sterilization of lesions. This happened together with the improvement of hygiene and living standards.

By the time these countries had won their independence, they understood that their fight against major endemic diseases with leprosy among them, had to be a common undertaking which led to the creation of the OCCGE and the OCEAC.

SURGERY FOR LEPROSY

As a complement to medical therapy, surgery for leprosy which has sometimes to be followed by physical therapy and prosthesis fitting can prevent many paralyses from being irreversible and can bring down the number of disabilities related to leprosy neuritis.

During a long period of time surgeons performed only ulceration cleaning procedures and amputated infected or necrotizing extremities.

Leprosy plantar ulcers (uncomplicated and complicated varieties)

When sulfones became available which could stop any further development of the disease, two new types of surgical procedures became available to surgeons :

– On the one hand curative procedures such as the ones for progressing neuritis in association with medical therapy. They consist either in draining inter-fascicular leprous abscesses or in a procedure named neurolysis which releases all intra or peri-fascicular inflammatory adherences. In 1953 Lassiera was the first who attempted to perform such decompression procedures which were later in 1957 refined by Carayon* and are now known as "fascicular neurolysis".

Ulvar nerve pinched in the elbow area

– On the other hand palliative procedures aiming to offset the consequences of paralyses. In 1953, with Carayon*, the foot extensor muscles revival procedure took over the foot arthrodesis procedure which had been so far standard practice. But it is mostly about hand paralyses that surgeons strove to imagine more and more surgical procedures.

In 1958 Languillon* had a surgical department for leprosy set up at the Marchoux Institute where Bourrel* had most of these repairing procedures streamlined, improved and codified in order to make them feasible by "general surgeons" working in district hospitals or by surgeons who had been commissioned to get there on temporary assignment.

In 1997 WHO endorsed this strategy with the publication of "Surgical Procedures for Leprosy in district hospitals".

LEPROSY TODAY

Currently, the use of new medications stands out in the evolution of this condition with among them :
– Rifampicine which has been used since 1968 is an exceptionally efficacious medication with bactericide properties. As it is an expensive medication it has to be taken under close supervision.
– Clofazimine which has been used since 1972 is a non toxic molecule which comes at a high cost.
– Thalidomide which is used to control some varieties of leprosy reactions.

Therapeutic plans and duration of treatment courses have been completely changed. Poly-chemotherapy has really disrupted the development of this condition as transmission of the disease is prevented by a swift sterilization of the existing lesions. Paucibacillary varieties undergo a six month long treatment course and multibacillary leprosy has to be treated over a two year long period of time. Healing is now the usual outcome but disabilities which were already present by the time the therapeutic course was started, such as paralyses, trophic disorders, plantar ulcers and stumps remain and this underscores the need for having patients cared for as soon as possible.

WHO ’s objective is to achieve the elimination of leprosy as a public health issue. This will happen with a ratio of patients lower than one for ten thousand people. In fact eighty percent of all Lepers who are recorded across the world, are found in these only five countries namely Nigeria, India, Myanmar, Indonesia, and Brazil.

Around the world, six to seven hundred thousand patients are diagnosed each year. There are still hundreds of thousand disabled lepers who are in the need of surgical care.

International aid which is supplied among others by the Raoul Follereau Foundation and by the Malta Order Hospital Charities, makes that the situation is swiftly improving. Public Health authorities should keep on striving and researchers should look forward to developing new and more efficacious medications and one can dream also of having someday an efficacious vaccine.

In the meantime watching out for any potential resurgence of the disease is imperative and disabilities have to be mended or made up for. As far as Leprosy and some other medical conditions are concerned, the expertise of the Colonial Medical Corps is fully acknowledged by international organizations. Sansarricq* was appointed to the head of the Leprosy Department at the WHO headquarters with the charge of designing the outlines of poly-chemotherapy regimens for leprosy, while Daumerie* an other former colonial medical officer is in charge of supervising the WHO program against leprosy.

For further information :

– Beaudimont A. et Laviron P. : La lèpre. in Médecine tropicale p. 1395 M. Vaucel 1954 Flammarion et Cie Edit.
– Joyeux Ch. et Sicé A. : La lèpre. in Précis de médecine coloniale p.540 Masson et Cie Edit. 1937.
– Bourrel P. : Chirurgie de la lèpre chez l’africain. Expérience personnelle de 580 interventions. Med. Trop. 1969,29,1-32.
– Bourrel P. : Place de la chirurgie dans la prévention et le traitement des infirmités lépreuses. in Précis de léprologie Languillon . p 251-279. Pré-presse Pastel-Créations,1999, Lavaur.
– Carayon A. : Les névrites lépreuses. 1 vol. Masson Edit. 1986 Paris.
– Languillon J. : Précis de lèprologie 1 vol. 1999 Lavaur.
– Sansarricq H. : La lèpre 1 vol. Ellipses 1995 Paris.