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(7) "The Recolonization of the Lake Shore and Islands."

SIR,

Appendix to above paper:-"Notes upon the Decline of the Sleeping

Sickness Epidemic in Uganda."

Excerpts from despatch No. 218, of the 23rd November, 1906, from Sir H. Hesketh Bell, His Majesty's Commissioner, Uganda, to the Secretary of State for the Colonies.

(1)

24th December, 1915.

I HAVE the honour to submit herewith a series of reports by Mr. W. F. Fiske dealing with his investigations, and also with an analysis which he has made of past records, including native reports. A covering letter to his last report by Mr. Fiske, and my reply thereto, are also enclosed.

2. As stated in my reply to Mr. Fiske's covering letter, I have not yet had time to read all his reports, still less to give so large and important a question the consideration it requires, but I have gathered that Mr. Fiske has discussed at considerable length the bearing of his own and other investigations, in the light of past records and present conditions, on the question of the necessity for the depopulation of the lake shore and islands which has been effected, and the advisability of permitting repopulation at once or in the near future.

3. I have dealt with the requests (1) and (2) in paragraph 3 of Mr. Fiske's covering letter in my reply thereto. I need hardly add that I could not recommend repopulation of the lake shore and islands until the matter can be fully considered in all its aspects, and until funds and staff are available for effective supervision of such a measure if approved.

4. It appears to me that Mr. Fiske bases his arguments and his recommenda- tion for repopulation mainly on the fact that in natural conditions a natural balance, or, as I prefer to call it, an endemic equilibrium, tends to become estab- lished in any epidemic area after a period of years. This means that, so long as conditions remain average or normal in such an area, the death rate shows only minor fluctuations, and may compare not unfavourably with death rates from other epidemic diseases, while the danger to the inhabiting population as a whole may remain comparatively small.

5. Such an endemic equilibrium has been reached in the Nile Valley in Uganda, on the eastern shores of Lake Victoria, and in other parts of Africa. But it is difficult to see how it can have any permanent stability apart from acquired immunity, and it is still doubtful whether this is ever an operative factor in the case of sleeping sickness. Increase in density of population, increase in traffic and communications; in fact the "development" of such an area would tend to increase the danger of infection and to upset the equilibrium.

6. On the other hand, the conditions in any area may be controlled and improved by preventive measures and restrictions so as to reduce the death rate beneath the level it would assume under natural conditions, and I understand that, in the Victoria Nyanza prohibited area, Mr. Fiske does not propose repopulation without restrictions and supervision, and would rely mainly on the measures described by me in 1904 and 1905 as local segregation and local clearing.

7. The main question which he raises for consideration, then, appears to be whether, by artificial measures taken locally on the return of the inhabitants to the prohibited area, it would be reasonably practicable to reduce the death rate in that area to an average which would compare not unfavourably with that from other epidemic diseases, would not render the general death rate unreasonably high, and would entail an infection rate which would not mean serious danger to persons communicating with that area.

8. In considering this question it is to be noted that areas in which an endemic equilibrium has become established under natural, or nearly natural, conditions are those in which conditions favouring a major epidemic were absent from the first. The less favourable the local conditions are to a major epidemic the more favourable are they to the establishment of endemic conditions with a moderate annual death rate which is not liable to intense exacerbations. In areas where conditions are favourable to a major epidemic the converse is the case, and very stringent and carefully supervised regulations would be necessary in order to reduce the annual mortality well below any level it might be hoped to reach in

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natural conditions. The epidemic in the Victoria Nyanza prohibited area was, perhaps, the greatest ever recorded, the natural conditions having been extremely favourable to a major epidemic.

9. Mr. Fiske puts forward the interesting hypothesis that depopulation was neither necessary nor justified by facts, in that the death rate already showed a more or less constant decline, which he attributes largely to the action of local preventive measures already taken. It must, however, be remembered that, at the time of removal, the death rate from sleeping sickness alone, although falling, remained equal to or greater than that for all other diseases, and that, although its fall may be in part attributed to preventive measures, it was no doubt also largely due to the decrease in density of population caused by the previous high mortality. 10. Apart from any question whether the above hypothesis be right or wrong, repopulation at the present time would be a very different undertaking from that of leaving the people where they were in 1907.

11. With regard to Mr. Fiske's deductions from figures supplied by natives,

I would say that these figures have never been put forward as sufficiently reliable for accurate statistics, although, taken in bulk, they are probably sufficiently correct to show the general trend of the epidemic at the time. Any deductions from them require to be taken very carefully, together with all available evidence relating to them.

12. Referring, in his report dated 17th September, 1915, to the local experi- ment in clearing, which I advocated in my letter to you (No. 635/1, of 6th October, 1914), Mr. Fiske states that, in his opinion, whether such an experiment were successful or not, it would affect the general situation hardly at all. I confess that I differ from this opinion. Apart from such an experiment, or a series of them, repopulation would have to be undertaken for the whole area or not at all. Such an experiment would be a step towards ascertaining whether a practical comprehensive scheme can be devised, and, being under close observation and con- trol, the damage done in case of failure would be small, while, in case of success, it could be extended with the aid of the experience which would have been gained in carrying it out.

13. am unable to make further comments without reading carefully all the reports and giving full consideration to all the points raised. I have alluded elsewhere to the special difficulties which exist at present owing to the state of war. I need hardly add that any practical scheme which would secure repopulation of the fertile area under question, without undue risk to the returning population or serious danger to the traffic and communications on which the Protectorate depends for its prosperity and future development, would be welcomed by all parties.

I have, &c.,

A. D. P. HODGES, Principal Medical Officer,

The Chief Secretary

to the Government,

SIR,

Entebbe.

(2)

Uganda Protectorate.

22nd December, 1915. THE question raised by you, that of the repopulation of the lake shore and islands now depopulated on account of sleeping sickness, is one of the first magni- tude and importance.

2. In reply to your memorandum dated 6th December, I regret that I can only confirm the information already given you verbally, to the effect that I have not yet had time to read through all your recent reports on this question nor to give it and them the careful consideration they require, and also that, owing to pressure of work, I am unable to say when this can be done. Further, supposing that the question could be fully considered in the immediate future, and repopula- tion were approved, there are matters in connexion with shortness of funds, and of staff, and with the state of war, which, I feel sure, would prevent any action being taken for some considerable time, and probably for the duration of the War.

1 have, &c.,

A. D. P. HODGES, Principal Medical Officer,

Uganda Protectorate.

W. F. Fiske, Esquire,

Entebbe.