STDs and welfare in East Africa
Shane Doyle, University of Leeds (1)
Welfare reform is typically motivated by some combination of altruism and a desire for greater social control. Sexually-transmitted diseases (STDs) are often associated with welfarist interventions of an unusually authoritarian nature, because they particularly threaten both the integrity of the family and the efficacy of the armed forces. Moreover, there has usually existed an easily definable scapegoat, in the form of commercial sex workers, on whom moral responsibility can be placed and compulsory medical examinations and treatment targeted. Given the reputation of colonial rule for illiberalism and a fixation with physical security, one would expect that interventions aimed at preventing the spread of STDs within the British empire would have tended towards the more coercive end of the welfarist spectrum. Yet the introduction of the Contagious Diseases and Military Cantonments Acts in late 19th-century India provoked a storm of controversy, locally and in the metropolis, resulting in an STD policy that was characterised above all by inconsistency. (2) This paper will argue that India was not an exception to the rule, and that imperial welfarism was neither monolithic nor invariably illiberal. It will do so by examining the practice and legacy of colonial STD campaigns in Buganda in southern Uganda.
The story begins in 1907 in Buganda when local missionary fears that the Ganda ethnic group were in danger of becoming extinct won the attention of the colonial governor. Missionary doctors believed that the Ganda's low fertility and high child mortality were due to an epidemic of syphilis, which they claimed infected 80 per cent of the population over their lifetime. An expert in syphilis, Colonel Lambkin of the Royal Army Medical Corps (RAMC), was drafted in, and reported that the disease was indeed hugely prevalent, but that it was Christianity itself which had weakened local norms of morality, by liberating women from traditional patriarchal controls. Missionaries in response blamed social disintegration and degeneration on the colonial government's system of taxation and legal reforms, which, they argued, undermined marriage. (3) Given that it was the missions that provided the bulk of healthcare in the Protectorate, the colonial administration quickly mollified the local religious establishment, by agreeing to support 'social purity' campaigns, while recruiting a number of RAMC officers to begin a programme of treatment.
Over the following years a structure of STD control was established which provided a greater degree of compulsion than could be found anywhere else in the world. Chiefs were paid to report suspected cases, entire villages were rounded up to be examined for syphilis, and patients overdue for an injection of mercury were forced to attend the clinic by the police. The attraction of these procedures to the military clinicians was that they freed the 'patient of all participation in his treatment and the medical officer is independent of his assistance'. (4) This radical system appealed to the doctors because of its efficiency, but was supported by administrators because of their concerns about both moral and population decline. Thus in 1918 the governor reported that the immense mortality caused by recent epidemics of plague, smallpox, measles and meningitis was 'to be expected', whereas the 'deep-rooted injury to the people from venereal diseases is of infinitely greater gravity', even though they accounted for only a fraction of all deaths. (5) STDs provoked a unique emotional reaction because they combined both sin and innocent victims, congenital syphilis being held responsible for Uganda's high miscarriage, stillbirth and infant mortality rates. The practicalities of coercion though caused embarrassment to the Colonial Office when descriptions of the degrading mass public inspection of women reached the London press in 1922. The scandal resulted in the syphilis campaign being subsumed within the general work of the colonial medical department, and the focus of STD policy shifting from enforced treatment to uncontroversial preventive propaganda. (6)
In the late 1930s a new generation of colonial medical officers began to transform Uganda's health service. Less affected by racial preconceptions, and much more research-oriented, they were shocked to find that often 90 per cent of infants were diagnosed as congenital syphilitics at Uganda's rural dispensaries, yet the clinical evidence suggested that '[m]ost of them had scabies, malaria, yaws or kwashiorkor'. (7) Compulsory laboratory testing established a more cautious diagnostic culture, systematic recording of autopsy results indicated that STDs were responsible for only the same proportion of deaths as in the United States, and the first child welfare clinics reported that less than 1.5 per cent of children had congenital syphilis. (8) If greater scientific rigour resulted in a more rational evaluation of the prevalence of syphilis, then the introduction of penicillin in the late 1940s relegated STDs to the second division of Uganda's medical problems. Whereas earlier drugs (mercury, bismuth and arsenicals) had involved such long periods of treatment and unpleasant side-effects that few patients ever completed their courses, penicillin was a one-shot magic bullet that achieved almost immediate, complete cures. Propaganda aimed at controlling STDs became less important as news of the miracle cure created a huge demand for treatment. Fortunately advances in the quality of STD treatment were matched by improvements in the quantity of medical provision. Patients were increasingly likely to have access to a local clinic, as the scale of investment in social welfare in the empire was transformed after the Second World War.
Before the 1920s the British Treasury had insisted that colonial dependencies had to be financially self-supporting, and that investment in the empire was the business of private enterprise. This principle was abandoned with the 1929 Colonial Development Act, but investment was still restricted to projects that would directly increase economic production, any expenditure abroad would have to create jobs at home, and the money available was spread rather thinly. Only £6.5 million had been spent by 1939 across an empire of more than half a billion people. (9) In the late 1930s, research by arch-imperialists like Margery Perham and Lord Hailey found that conservatism and underinvestment had caused the African colonies to stagnate. (10) A new Colonial Secretary, Malcolm MacDonald, convinced the Treasury that Britain's global defence strategy was at risk because of the colonies' economic backwardness and grossly inadequate social services. The loyalty of imperial subjects was in question, Axis propaganda was difficult to rebut, and nationalism fed on frustration and injustice. In 1940, just as France was about to fall, the Colonial Development and Welfare Act committed Britain to an imperial future where colonies' economies would be developed in their own interests and where social development, in the form of investment in education and healthcare, could be justified in the language of humanitarianism as well as productivity. Between 1946 and 1964 the British Treasury provided £506 million in grants and loans for colonial development and welfare. (11) This coincided with a commodities boom linked to European reconstruction and the Korean War, so that cash-cropping Uganda was wealthy enough to plan for a reasonable imitation of a western national health service: by 1962, Kampala's main hospital was superior to many found in the United Kingdom, Uganda's colonial medical service had conducted world-leading research on malnutrition, viral cancers and heart disease; and community-based medicine in Buganda had caused the incidence of preventable disease, including STDs, to drop dramatically. Missionary medicine, by contrast, retained its fixation with syphilis until near the end of the colonial period; as evidence of deepening immorality abounded, decades of propaganda and the wonders of penicillin produced an endless supply of patients demanding to be cured, and STD treatment subsidised other parts of the missions' work. (12)
Independence in 1962 was propelled by welfarism. Better health and education had already fuelled modern Africa's population explosion. By 1959, half of Uganda's population were children, suggesting that colonialism was certain to become ever more expensive. Nationalist politicians' promises of more schools and clinics played on perceptions that colonial governments were reluctant modernisers, while the physical threat behind nationalism was provided by the cohorts of young men who believed that their school certificates merited better jobs than those on offer in the colonial economy. In the event, many of the stresses that split apart the coalition of interests that formed Uganda's post-colonial government derived from the impossibility of satisfying the expectations raised in the run-up to independence. The provision of a hospital in every district in Uganda in the 1960s may have temporarily raised President Obote's popularity, but it nearly bankrupted the Ministry of Health. Shortages of essential drugs intensified during Idi Amin's dictatorship, while repression and poverty drove hundreds of government doctors into exile. As Uganda's emerging welfare state collapsed in the 1970s, so missionary medicine regained its former prominence, as externally-subsidised, vocation-based hospitals were better placed to import medications and maintain staffing levels. STD sufferers could still obtain adequate treatment if they could afford the fees charged by mission hospitals and private practitioners. The poor, however, turned increasingly to black-market injectionists, but their low charges were unfortunately based on low dosages, so that penicillin-resistant strains of syphilis and gonorrhoea grew increasingly common. The 1960s and 1970s saw medical researchers' attention turn once again to STDs, whose incidence appeared to be on the rise. Yet the discovery of the emergence of new high-risk groups, such as truckers, soldiers, police and students, and the recommendations that STD treatment should be more carefully targeted, were ignored by Amin's government, which resumed the old sporadic victimisation of women in general, and morally suspect commercial sex workers and barmaids in particular. In 1977 Amin 'ordered that any woman discovered with an STD should be heavily punished and thereafter be forced to attend treatment'. (13) This reversion to the strategies of the early colonial period would have tragic consequences, as worsening problems of STDs contributed to the rapid spread of HIV in the early 1980s.
Across the world private charity and community support provided the bulk of welfare provision before 1900. In the 20th century, by contrast, welfare became primarily a function of the state in western societies and, to a greater or lesser extent, in the developing world too. In the west, this change completely altered not only the nature of the state, but also the relationship between the individual and government. Welfare brought a new conception of citizenship, that individuals had entitlements to basic standards of living to be guaranteed by the state. In Uganda, Christian missionaries initially took the lead in welfare provision, so that STD prevention and control was particularly aimed at reforming sinful behaviour. Increasing self-confidence within colonial government about its ability to shape African society, and growing concerns about the uneven quality, lack of planning and religious focus of mission provision, initially brought STD interventions that were remarkable for their coerciveness. But in the inter-war period STD policy was liberalised by criticism from humanitarian and women's rights groups in Britain, while diagnosis became less influenced by a presumption of guilt. As independence approached it became clear that welfarism had given the colonial state the ability to change African society but not to control it. Post-colonial governments, aware of the fragility of their power, prioritised their survival. At first, the quest for democratic legitimacy reinforced citizens' belief in their rights to services. By the 1970s, however, in Uganda, a particularly raw politics of ethnicity and patrimonialism made notions of entitled citizenship redundant. The state, left hollow by the end of welfarism, abandoned its sick to the inequities of charity and the black market. It is the poor who have suffered most from the retreat of the state in post-colonial Africa.
Notes:
- Shane Doyle is Senior Lecturer in African History at the University of Leeds. The research on which this paper is based has been funded by the AHRC, the British Academy, the British Institute in Eastern Africa, and the ESRC. His next book, Before HIV: Sexuality, Fertility and Mortality in East Africa, 1900-1980 will be published by the British Academy and Oxford University Press. Back to (1)
- M. Harrison, Public Health in British India: Anglo-Indian Preventive Medicine 1859-1914 (Cambridge, 1994), pp. 72-8. Back to (2)
- M. Vaughan, Curing their Ills: Colonial Power and African Illness (Cambridge, 1991), pp. 132-48. Back to (3)
- Report on venereal diseases 27 Jan. 1909-31 Mar. 1910, The National Archives (TNA), CO/536/33. Back to (4)
- Coryndon to secretary of state, 30 May 1918, TNA, CO/536/89. Back to (5)
- M. Lyons, 'Sexually transmitted diseases in the history of Uganda', Genitourinary Medicine, 70 (1994), 140; Keane, Venereal diseases in Uganda, 1922, TNA, CO/536/120; S. Doyle, Crisis and Decline in Bunyoro: Population and Environment in Western Uganda, 1860-1955 (Oxford, 2006), pp. 152-6. Back to (6)
- R. Barrett papers, Rhodes House Oxford, MSS.Afr.s.1879(9); H. Trowell et al., Kwashiorkor (London, 1982), p. xxiv. Back to (7)
- J. Davies, 'Pathology of Central African natives: Mulago Hospital post-mortem studies', East African Medical Journal, 24 (1947), 180-84; H. Welbourn, 'Notes on differences between Baganda and Luo children in Kampala', East African Medical Journal, 32 (1955), 292. Back to (8)
- D. Meredith, 'The British government and colonial economic policy, 1919-39', Economic History Review, 28 (1975), 484-99. Back to (9)
- M. Perham, Colonial Sequence, 1930 to 1949: a Chronological Commentary upon British Colonial Policy Especially in Africa (London, 1967); A. Lord Hailey, An African Survey: a Study of Problems Arising in Africa South of the Sahara (London, 1938). Back to (10)
- R. Pearce, 'The Colonial Office and planned decolonization in Africa', African Affairs, 83 (1984), 79-93. Back to (11)
- H. Welbourn, 'First impressions' (unpublished TS in the possession of the author, 1946), 6. Back to (12)
- E.g. J. Kakembo, 'A study of the prevalence and incidence of venereal diseases in the Uganda police community' (unpublished DPH dissertation, Makerere University Kampala, 1978); 'President orders women', Munno, 13 July 1977. Back to (13)