The PEPFAR Paradox

By Katie Paul
Newsweek
December 1, 2009
http://www.newsweek.com/id/224963
As far as storylines go, PEPFAR has had it pretty good so far. Since George W. Bush first introduced the President's Emergency Plan for AIDS Relief in 2003, the program has been able to swing around impressive credentials: more than 2 million people in 15 focus countries have started on antiretroviral treatment and more than 10 million have been supported with overall care. Thanks to the program's promising results, Congress raised the budget of PEPFAR by $4 billion over the course of its existence. With $6.7 billion to its name, PEPFAR is now the biggest public-health initiative in the world.

But after years of steady gains in funding, health experts say PEPFAR's funding will likely flatline under the Obama administration. At the same time, they expect the gap between the number of people who need treatment and the number getting it to widen. With budgets squeezed by the financial crisis, and a growing call in global health circles to move away from "AIDS exceptionalism"-defined as greater funding for AIDS programs at the expense of overall health resources-the jewel of Bush's foreign-policy portfolio is poised to start looking much less shiny.

But even though its results may not look as impressive, the program is as strong and smart as ever. Up until now, PEPFAR was defined by the "E" in its name: emergency. The emphasis was on starting up strong and making a big impact, which often meant bypassing local governments to get as many people on treatment as possible, as quickly as possible. But while that has produced impressive results, the approach is far from sustainable. The program's record on preventing transmission of HIV has been lackluster, and worldwide the number of new infections is drastically outpacing the number of people receiving treatment, according to PEPFAR's published reports. For every two patients put on antiretroviral drugs today, five others contract HIV-a rate that has remained steady even as PEPFAR money made enormous strides in bringing down the death rate.

If that doesn't change-and there is little indication it will-PEPFAR risks becoming a black hole of an entitlement program, committed to funding treatment indefinitely as more and more patients live longer and longer. "The problem is, there's no way you can treat ourselves out of this epidemic," said Dr. Stefano Bertozzi, who directs HIV work at the Bill & Melinda Gates Foundation. "As you newly start people on treatment, you need to maintain those people you started on treatment in previous years. The number of people you're sustaining next year is always going to be greater than the number of people you're sustaining this year." According to a cost analysis from the Center for Global Development, an independent research firm, maintaining present successes for the ever-increasing number of patients would cause U.S. AIDS spending to swell to $12 billion by 2016, consuming half the foreign-assistance budget and squeezing out U.S. spending on other programs, including other health initiatives.

The way out of this conundrum, according to policy experts? Shift more resources over to prevention efforts. Transfer programs to local ownership and put national governments on the hook for delivering services. Monitor and evaluate which programs are working, then report the results.

According to Eric Goosby, the U.S. global AIDS coordinator in charge of PEPFAR, those items are all on the agenda. On the prevention front, PEPFAR is pouring resources into peer-education programs and mother-to-child transmission interceptors. The program is also doubling the funding for monitoring and effectiveness studies, from $23 million this year to $40 million to $50 million in 2010. And in line with the administration's push to broaden global health and development plans beyond one disease-epitomized by a new $63 billion, six-year initiative-Goosby is looking to move away from both reliance on NGO contractors and commitment to a narrow AIDS focus. "Patients are going to need these drugs 20 to 30 years in the future, so we need to focus on sustainability. To do that, we need to work off PEPFAR platforms to expand into a broader constellation of services for each patient," he says.

That position has the support of AIDS advocates, who have had to fight off accusations that AIDS gets too much attention in the public-health realm. "It doesn't make sense for a counselor to have a discussion about contraception with a woman in one building, then have a different program in a different building about HIV prevention. People co-infected with HIV and TB shouldn't have to go to clinics across town to have those problems dealt with," says Bertozzi of the Gates Foundation. In other words: public health isn't a zero-sum game.
Of course, making the change is easier said than done. Politically, the strategy is risky. Improvements on the prevention side, which may produce the best results in the long term, are difficult to measure (you can show how someone caught a bug, but it's tougher to prove a negative and track why he didn't catch it). And while increased partnership with national governments is a worthy goal, it also carries the risk of slow transitions, less impressive results, and a loss of congressional enthusiasm when funding time comes around again. Handing off programs to local control can be a messy process, cautions Peter Navario, a global health fellow at the Council on Foreign Relations who specializes in HIV/AIDS systems in developing countries. In one case he cites, an international NGO that tried to turn over a program to doctors and administrators in South Africa ended up having to resume leadership of the program-twice.

But lower expectations and untidy transitions may be a necessary price to pay. Expensive quick fixes can't work forever; eventually, local doctors are going to need to be trained to take over from their expat counterparts. If, as the experts say, the Obama administration is putting all the right pieces into place to mold PEPFAR into a post-emergency program, then the challenge at home is to make sure congressional support doesn't wane if critics spin the numbers as evidence of ineffective leadership. The new monitoring and evaluation studies should help. They would have helped even more if they had been implemented at the start, say AIDS fund administrators. But so the proverb goes: if the best time to plant a tree is 200 years ago, the second best time is today.

The trial of two alleged Congolese militia leaders charged with war crimes is due to begin at the International Criminal Court in The Hague.

Germain Katanga and Mathieu Ngudjolo Chui are accused of directing an attack on a village in 2003 in which more than 200 people were killed.
They face charges of ordering attacks on civilians, sexual slavery, rape, and enlisting child soldiers.
Both deny the charges and have expressed sympathy for the victims.
It is only the second trial at the ICC in The Hague. The first case - of Congolese militia leader Thomas Lubanga - began in 2008 but has been delayed by legal argument.
Prosecutors say Germain Katanga and Mathieu Ngudjolo Chui led two groups of child soldiers and militiamen who laid waste to Bogoro village in the mineral-rich Ituri province of the Democratic Republic of Congo (DRC).
Many victims were hacked to death with machetes while women were raped and killed or taken as sexual slaves by their attackers, according to the charges.
Chief prosecutor Luis Moreno Ocampo has said that the conflict in Ituri was part of a civil war that raged in DR Congo following the 1994 genocide in neighbouring Rwanda.
Prosecutors plan to call 26 witnesses although 21 of them will testify hidden from public view for fear of reprisals.
The trial is expected to take several months.

By PATRICE CITERA (AP) – 36 minutes ago
KINSHASA, Congo — A U.N.-run radio station says a passenger plane overshot a
runway in eastern Congo and landed in lava, injuring 20 people.

Radio Okapi said the plane was flying from Kinshasa to Goma and passengers
had warned the crew that there were heavy clouds. One passenger told the
station that the plane had landed in lava near Goma's airport.

An official from the U.N. mission in Congo, who spoke on condition of
anonymity because he does not have permission to speak with media, said
there were 117 passengers aboard.

They included the governor of North Kivu province, who was not hurt.

In April 2008, a DC-9 crashed while failing to lift off from Goma's airport
leaving at least 40 people dead. A 2002 volcanic eruption sent lava oozing
onto Goma's runway.


Copyright © 2009 The Associated Press. All rights reserved

Wasn't Ignace Murwanashyaka arrested in Germany before? Or maybe I'm just thinking of when he left the DRC. Either way, the President of the FDLR is now under arrest in Germany for human rights abuses and may be tried under German law.

Someone mentioned today a report that I haven't read discussing the contributions of the diaspora in keeping the conflict in the east alive. It is not surprising, but how can it be stopped?

Last night on BBC, I caught one of the shows during my rush hour commute
that focused on the idea of MONUC withdrawing from DR Congo. The lines were
open to take calls, and opinions ranged from a 5th year student saying that
MONUC has done nothing and should leave, to other Congolese outside the
country and even someone in Liberia saying, you may not see the positive
effects of UN presence now, but you will feel it when they leave. One person
even summed it up this way (paraphrased): "MONUC may not have turned Congo
into heaven, but it may have prevented it from turning into hell."

The local press has been covering the fact that MONUC will still provide
support to Kimia II, an operation undertaken in conjunction with the
Congolese army (FARDC) that has resulted in more civilian deaths in the east
than prior to its initiation. The FARDC has been accused of massacres since
May of this year. The local press is accusing MONUC of covering up
information related to the killings.

Some people calling in to the BBC show thought that removal of MONUC from
the east or other parts of the country would be the only way to encourage
the government of DR Congo to take responsibility for its security
situation, while others disagreed, pointing out that the country is too big
even for the current mission of 17,000 to cover. This size mission cannot
even cover the entire territory in the east where insecurity still reigns.
With or without MONUC, the government of DR Congo must make moves to bolster
the capacity and effectiveness of its uniformed forces to establish rule of
law.

At least three clashes in the east over the past week have been reported via
Radio Okapi, one between FDLR rebels and Mai Mai, one between FARDC and the
Mai Mai Yakutumba militia, and one between FARDC and recently integrated Mai
Mai combattants.

I'm not that great at making new friends but sometimes it's fun, especially when I have nothing to do with it.  I went to meet one friend in DC, who brought her other friend, and these other three people sat down with them and they'd all already made friends before I arrived.  So we drank for half price and talked and laughed and told us the saga of the happy hour at the gay bar across the way and I asked the guy about his freelance photography job, and then they said they were off to a drag show so my friends made plans to meet up with them next week, and I thought, now that's a good day's work.

This week, government doctors went on strike for higher pay, as threatened last week.

I heard on Radio Okapi this morning that they are demanding more money in increases than the current annual health budget allocation.

Here is a summary of local press from the US Embassy re: the strike from September 2:

Doctor’s Strike

“Paralysis in Public Hospitals” is how La Tempete Des Tropiques describes the ongoing doctors’ strike, with a back-page cartoon showing a doctor telling a patient that a nurse will take care of him, then telling the nurse to refer the patient to their private clinic.  L’Avenir announces the end of the strike, but a close read of the article shows that while there might have been progress in talks, an agreement has yet to be reached.  L’Observateur links the doctors’ strike, a potential teachers’ strike, and the recent death threats against government officials formerly linked to Jean-Paul Bemba as “A New Conspiracy against the Republic.”  On its front-page, the newspaper editorializes: “More and more, we are in agreement with those who say that the young Congolese democracy is in trouble.”  According to the newspaper, the strikes and death threats are evidence that “organized forces don’t want the new system … to function properly.”

Apparently there is also a teacher strike on the horizon:

Gathering Clouds

L’Observateur sees the potential teachers’ strike as the fault of the Budget Minister, who claims the government does not have the funds to pay teachers.  “Clouds are gathering in the Congolese sky,” the newspaper comments.  “Those who have the destiny of their country in their hands must assume their responsibilities.  If not, the popular verdict will be unforgiving.  National elections are not far away.”

Here's a link to a couple minutes of footage of the visit mentioned in the press release in the previous post. You can see some views of inside the hospital.

http://www.unmultimedia.org/tv/unifeed/d/13419.html

NBA legend Dikembe Mutombo, UNICEF Executive Director Ann M. Veneman and BD commemorate opening of new center to improve HIV/AIDS treatment in the DRC

http://www.unicef.org/media/media_50959.html

NBA legend Dikembe Mutombo, UNICEF Executive Director Ann M. Veneman and BD
commemorate opening of new center to improve HIV/AIDS treatment in the DRC

*KINSHASA, DRC, 26 August 2009** –* The Biamba Marie Mutombo Hospital and
Research Center (BMMH), in Kinshasa, Democratic Republic of the Congo and BD
(Becton, Dickinson and Company) today launched two Centers of Excellence -
an Immune System Monitoring Laboratory and an Occupational Safety Centre for
Health Workers - at the state of the art medical facility founded by NBA
legend Dikembe Mutombo. The safety center will train more than 300
clinicians, and the new laboratory will improve monitoring and treatment of
patients living with HIV/AIDS.

Mr. Mutombo was joined at the opening ceremonies by UNICEF Executive
Director Ann M. Veneman, BD Executive Vice President Gary Cohen, and the DRC
Minister of Public Health, Mwami Mopipi Mukulumany. The Center is an
expansion of the BMMH, an acute care hospital which opened in 2007 and
provides care to thousands of patients each year in a region of the world
where over five million people have died from violence, hunger and disease
since 1998.

“The doctors and nurses at the Biamba Marie Mutombo Hospital are saving
lives every day and helping improve health care in the DRC which has been
ravaged by more than a decade of war and disease,” said Mr. Mutombo. “These
Centers of Excellence are an important milestone in improving the quality of
life for those who live with HIV/AIDS and in training new health care
workers to help prevent the spread of disease.”

The new Centers will provide laboratory equipment, reagents and training to
improve immune system monitoring, an essential component of treating people
living with HIV/AIDS. To help ensure the safety of healthcare workers at the
facility, DMF will develop a Department of Occupational Health and a
Regional Training Center at the BMMH. BD, in collaboration with the
University of Virginia, will help implement the Exposure Prevention
Information Network (EPINet™) surveillance system to monitor occupational
injuries at BMMH. BD will also provide a range of safety-engineered
injection and safety-engineered blood collection devices as well as
laboratory and occupational safety training for at least 330 healthcare
workers.

“The problems of pandemic disease prevalence and occupational risks to
health workers exist throughout sub-Saharan Africa, but pose particular
challenges in countries emerging from conflict,” said Mr. Cohen. “We are
proud to partner with Dikembe Mutombo, and to support his efforts to provide
essential medical care to the people of Kinshasa and DRC, his home country.”

( Read more... )

Everywhere you go in Sierra Leone's capital, Freetown, there is music. People plays songs from makeshift music shops and watch music videos on small TV screens powered by generators.

Check out Glenna Gordon's fabulous photos and listen to audio featuring local music video producer Ayouba Sidibay.

1. Visit inepd.org to find out what you can do for the global enabling of
poverty development.

2. Visit unfg.org for a great tool for generating gobbledegook for your next
annual report. No joke. For example:

The involvement of different stakeholders in the study resulted in
cross-cutting organisational Education for All policies targeted at
improving enrolment and retention rates amongst marginalized groups.

In the context of decentralization, the Chief Technical Adviser will work to
unlock clusters, through sector-wide reciprocal cost-benefit analysis
frameworks for development assistance planning.
In the context of improving the legal and regulatory framework, the Member
States will develop holistic outcome-oriented feasibility studies of
recommendations for change to be implemented.

Check out Twitter for updates from yesterday's Town Hall in Kinshasa with
Hillary Rodham Clinton:

http://twitter.com/congogirl

GLOBAL: Male circumcision does not protect women

JOHANNESBURG, 17 July 2009 (PLUSNEWS) - New research suggests that
circumcising HIV-positive men does not reduce the risk of their female
partners becoming HIV-infected.

The findings, reported on 17 July in the British medical journal, The
Lancet, emerged from a clinical trial in Rakai District, southern Uganda,
involving 922 HIV-infected men and 163 of their HIV-negative female
partners.

Half the men were circumcised at the start of the two-year trial; the other
half, who made up the control group, were circumcised at the end of it.
Their uninfected female partners were followed up after six, 12 and 24
months to determine whether they had acquired HIV from their male partners.

Male circumcision has become a recommended HIV-prevention strategy since
three clinical trials, one of which was also held in Rakai, showed that the
procedure could reduce the HIV risk to men by as much as 60 percent. Until
now, little was known about whether male circumcision also reduced the risk
of HIV infection in women.

Previous observational studies suggested that the partners of circumcised
HIV-infected men were less likely to acquire HIV, but the trial in Rakai
failed to confirm this. Out of 92 couples in the circumcised group, 18
percent of the women became infected during the study period, compared to 12
percent of women in the uncircumcised control group.

Male circumcision may actually have increased the HIV risk to some of the
women in the intervention group. After six months, women whose partners
ignored advice to abstain from sex for at least six weeks after the
circumcision procedure had an HIV acquisition rate of 27.8 percent,
compared to 9.5 percent among women whose male partners delayed sex until
healing was complete, and 7.9 percent among women with uncircumcised
partners.

( Read more... )

How did I not discover this blog sooner???

http://wrongingrights.blogspot.com/

This snippet is from a blog entry from last week, which continues to briefly
describe the nature of the violence and its results on women's bodies.

http://www.usnews.com/blogs/erbe/2009/07/30/hillary-clintons-congo-trip-will-shed-light-on-sexual-violence.html

"Sexual violence as thought of in the West does not begin to describe what
the Congolese women endure. Not only are they raped repeated and physically
brutalized, they are forced to watch their infants slaughtered upon birth."


Last week, someone told me that 22% of men in the military in DRC have been
raped, and it seems that the militia in the east are raping men at a rate
almost as alarming as that of women, with similar disastrous psychological
and physical ramifications that current aid projects and local resources
cannot begin to address.

The NYT article published yesterday is worth a read but could be
triggering. Here's a relatively neutral summary paragraph:

"According to Oxfam, Human Rights Watch, United Nations officials and
several Congolese aid organizations, the number of men who have been raped
has risen sharply in recent months, a consequence of joint Congo-Rwanda
military operations against rebels that have uncapped an appalling level of
violence against civilians."

http://www.nytimes.com/2009/08/05/world/africa/05congo.html?emc=tnt&tntemail1=y

*Clinton's Africa tour to highlight US
commitments<http://www.google.com/hostednews/ap/article/aleqm5hyyd5hji2indko01yp8hbyxiy1zwd99rokt00>
*
*The Associated Press – August 4, 2009*
Secretary of State Hillary Rodham Clinton's seven-nation tour of Africa
seeks to affirm a commitment by the Obama administration to tackle trouble
spots from Somalia and Zimbabwe to the Democratic Republic of the Congo and
Liberia. Clinton kicked off the 11-day trip — her longest overseas journey
to date as the top U.S. diplomat — by flying Monday night to Kenya where she
will address an African trade and development forum, meet top Kenyan
officials and see the beleaguered president of lawless Somalia's interim
government. …In Pretoria, Johannesburg and Capetown, Clinton will also
underscore the importance of efforts to combat HIV/AIDS and pledge
continuing U.S. backing for health care initiatives in Africa, some of which
have been led by her husband's private foundation.

*Congolese press regarding Clinton visit (Compiled by US EMB Aug 4)*
L’Observateur runs the half-page, front-page headline: “Hillary Clinton Will
Urge More Efforts to Combat Sexual Violence.” Noting that the U.S.
Government is deeply concerned about sexual and gender-based violence (SGBV)
in the DRC, the paper says that Secretary Clinton will highlight U.S.
commitment to helping the Congolese government fight SGBV, and will urge
MONUC to play a more active role in the effort. According to L’Observateur,
Clinton will also encourage DRC Government efforts aimed at consolidating
democracy, eradicating corruption, and implementing sound economic and
budget policies. The paper says that the DRC Government might seek U.S.
support to secure an IMF poverty reduction and growth facility loan in
coming days.

Focusing on the reasons behind Secretary Clinton’s Africa visit, La
Prosperite comments that the choice of countries demonstrates that the tour
is motivated by business concerns, even though “the Obama administration
denies being concerned about China’s increasing influence across the
continent.” The paper says that Secretary Clinton will develop new ties to
regional economic powers such as South Africa, Nigeria, Angola, and the DRC,
as part of a visit that will begin in Nairobi “to alleviate Kenyans’
disappointment,” that the American president delivered his historic address
to Africa from Ghana. Clinton is also expected make her trademark visits to
students, women, and hospital staff, reports La Prosperite.

The independent Le Climat Tempere carries a front-page article titled “An
American in the Congo: Strategic Partnership.” It echoes the widespread
perception that the U.S. was one of the chief instigators behind the Congo
War while hailing a shift in U.S. foreign policy toward the DRC. According
to the article, the U.S. no longer needs to use Rwanda and Uganda as proxies
to protect its interests in the DRC, and the Rwandan Government has
difficulty accepting this new U.S. approach. The Obama administration
“rejects the logics of war,” as it understands “there are no military
solutions to Africa’s problems,” comments the paper. Le Climat Tempere also
runs an editorial arguing that the U.S. is attempting to regain ground it
lost in Central Africa to other powers, including China, over the years
“because of its arrogance and its warmongering.” On the other hand, the
paper urges the DRC Government to present a clear strategic agenda and
demonstrate its ability to govern and defend the Congolese territory in
order to counter attempts to Balkanize it by “those who believe that its
central geographical position and large size are an obstacle to global good
governance.” The weekly newspaper was launched in February of this year by
veteran journalists who want to report news with an independent perspective.

1. Mobiles Help Put a Stop to Drug Stock-outs
http://www.pcworld.com/businesscenter/article/169416/mobiles_help_put_a_stop_to_drug_stockouts.html

2. Perhaps it could be called 'Congo chic'
http://www.globalpost.com/dispatch/africa/090330/perhaps-it-could-be-called-congo-chic

3. Why more young women should start using IUDs.
http://www.slate.com/id/2223840

Local Kinshasa Press Summary 7/30/2009

Secretary of State Visit

Secretary Clinton’s imminent visit made the front page of the pro-government
Le Palmares. Under the main headline “Here are the Secrets Behind Hillary
Clinton’s DRC Trip,” the newspaper continues its tabloid-like coverage of
serious political issues. Despite the fact that no meeting between
Secretary Clinton and President Kabila has been announced, Le Palmares
expects it will be “decisive.” And the paper claims that American policy
toward the DRC has completely changed with the Obama Administration. “After
several attempts to divide and destroy the Congolese nation, all these
international stratagems have only shown that the Congolese giant refuses to
disappear. Finally, in Washington, they understand.”

Citing their erroneous publication in May of an article claiming to detail
the conversation between UN Ambassador Susan Rice and President Kabila, Le
Palmares says, “The day after that meeting, many things began to change
between Kinshasa and Washington.” The paper sees a change in U.S. policy as
it moves away from former allies Rwanda and Uganda, and toward the DRC.
While this perception is not based on facts, it does resonate in certain
quarters of the press and public in Kinshasa.

Violence in the East

Le Potential focuses on Operation Umoja Wetu II, saying it “smells like a
trap.” The front page headline is accompanied by a cartoon showing Rwandan
President Paul Kagame standing at the DRC border, wielding an RPG and
telling MONUC and FARDC soldiers: “Let me help you, I know how to fight the
FDLR. And I have new passports for each of you.” In addition to the
jump-page article, there is also a front page editorial on the latest
MONUC-FARDC efforts against the FLDR. The editorial lays the blame for
violence in Eastern Congo at the feet of Rwanda and the West: “Peace will
not be restored so long as things remain the same in the neighboring state.
Western powers refuse to involve themselves in an inter-Rwandan dialogue
that might bring peace. ‘If there needs to be an inter-Rwandan dialogue,
that’s for Rwandans to decide,’ is what Western diplomats invariably say in
Kinshasa.”

LRA

La Reference Plus reports that a coalition of DRC and Ugandan soldiers
launched a series of attacks on LRA positions in Dungu, Orientale Province,
on July 22-25, killing 23 rebels and dislodging others from neighboring
villages. The article, taken from Radio Okapi’s website, suggests that LRA’s
capability to harm has been greatly reduced as a consequence.

SGBV

L’Avenir runs a half-page, front-page headline: “Sexual Violence: 10 FARDC
Soldiers Get Heavy Sentences.” Although sentenced soldiers include
rank-and-file as well as officers, the paper says that the Government’s
effort to end gender-based violence committed by FARDC troops should be
become a tangible, lasting commitment. MONUC said that this effort should be
supported at the highest level of the DRC government. Le Palmares echoes
MONUC’s call, noting, however, that the UN mission considers the conviction
of these soldiers a sign of progress in the fight against impunity.

Pro-Justice

Le Phare, La Tempete des Tropiques, and Forum des As report on the launching
of USAID-funded “Projustice,” a program aimed at supporting the
establishment of new judicial institutions and promoting judicial
transparency in the DRC. Under this program, civil society’s
justice-oriented projects will be funded at with $210,000 in Kinshasa and in
other cities.

Clinical trials in the Republic of Congo and Democratic Republic of Congo have reached Phase III in a search to develop an effective and non-toxic cure for sleeping sickness, or trypanosomiasis.  

I spoke with Rose Hoban last week, who told me that there has been a successful negotiation with drug company Sanofi to convince them to produce enough of one of the drugs in the combination to make it available for the trial and hopefully to people suffering from the disease in the future.  More info here. 

Sleeping sickness is one of many diseases categorized these days as "neglected and forgotten diseases," those that aren't currently sexy and don't have their own funds named after them.  They affect hundreds of thousands of people a year, but usually there is no incentive for drug companies to produce the cures.  Hopefully the results of this clinical trial will lead not only to protocol changes in national health programs but also to availability of the required drugs. 

New Drug Combo Highly Effective Against Sleeping Sickness
By Rose Hoban 
Durham, North Carolina
09 July 2009

African sleeping sickness is almost a joke in the West. Films depict explorers being bitten by the tsetse fly and then falling into a slumber. But sleeping sickness, or Human African trypanosomiasis, is no joke to the hundreds of thousands of people it affects annually. 

Dr. Gerardo Priotto explains that when the tsetse fly bites, it transmits a parasite into the blood, which, if left untreated, eventually makes its way to the brain. 

"And when this happens, there are a series of neurological signs and symptoms that progress, and they show this sleepiness that gives the name to sleeping sickness," he explains. 

"But also it will progress into severe mental confusion and coma and death, and it will eventually kill all of the persons that are infected by the parasite."

[Follow link for rest of article, link to Lancet publication, and audio report.]