Overview of Disease in Africa Since 1860

Most of the written sources for the history of dis­eases in Africa since 1860 derive from Europeans, who had very specific interests in health. Their first concern was for their own health and that of fellow Europeans, whereas concern for the health of Afri­cans was extended mainly to those people the Euro­peans needed as laborers or producers.

Certainly it must have seemed so. Early European accounts describe the devastating morbidity and mortality they suffered, but we learn very little about the impact of disease on African populations apart from those employed as porters and soldiers. Non-Eurocentric accounts of diseases and health con­ditions among African populations are rare for the earlier period, and those dating from World War II are also limited in number and scope. Nearly all Europeans in Africa — explorers, traders, missionar­ies, or colonials - were concerned primarily with the diseases that threatened their own health, and this must be borne in mind by anyone looking at early accounts of diseases of Africa.

Between 1860 and 1885 European exploration and trade along with coasts of Africa increased and fi­nally culminated in the full expression of foreign imperialism with formal colonization; by 1920 most of equatorial, eastern, and central Africa had been taken over by Europeans. The result for much of the region was a series of catastrophes in the form of wars of conquest and the initial consolidation of colo­nial rule. The primary motive for colonization was economic exploitation of natural resources and hu­man populations.

Some African societies, like those located along the west coast of the continent, had long been in contact with outsiders and thus did not seem to be as immedi­ately affected by new pathogens and other stresses as were populations in eastern and central Africa, which had been more isolated. For many societies of eastern, central, and southern Africa, however, the period 1890—1920 was so traumatic as to have been described as a time of tumultuous “ecological disas­ter” (Ford 1971; Kjekshus 1977). New diseases were spread to nonimmune populations, and previously endemic diseases became epidemic. It is clear that the great epidemics of human sleeping sickness through­out the Congo basin beginning in the late nineteenth century, which in Uganda produced an estimated 300,000 deaths between 1901 and 1905, were a result of violent disruptions to those regions. In fact, the history of sleeping sickness illustrates well the ef­fects of upheavals in large parts of sub-Saharan Af­rica around the turn of the century. Increased stresses accompanied by reduced nutritional and immune sta­tus led to greatly increased morbidity and mortality for millions of Africans.

During the four decades between 1920 and 1960, colonial rule and economic exploitation of the land and people were refined and greatly extended. Ever­increasing numbers of Africans were drawn, often unwillingly, into colonial economies as laborers and tax payers. Others were forced into an “informal” economy earning cash as prostitutes or petty traders and by providing other services. Highly mobile and most often poorly nourished, these Africans often attracted the attention of colonial authorities, who considered them an important source of disease, espe­cially venereal disease. Military leaders commonly complained about the threat to public health posed by prostitutes and female “camp followers.”

In all colonies, there was constant fear among European colonizers that the new “detribalized” indi­viduals gravitating toward the new urban centers were spreading disease, which in turn contributed to the development of powerful stereotypic images of Africans.

By 1940 many African societies had been literally “restructured” as a result of the need to meet the increasing demands of European industries and mar­kets. Throughout the continent, millions of Africans were forced to migrate annually to labor in unsafe and unsanitary conditions in mines, on plantations, and in public works projects such as road and rail building. In addition to the more apparent effects of heavy labor in harsh conditions on African health were those that attended the proletarianization and urbanization of millions of Africans across the conti­nent. This had the important effect of disrupting and often destroying African forms of social organiza­tion, which also had an adverse effect on the health of Africans.

Migrant laborers, who were usually malnour­ished, poorly clothed, crowded into miserable dwell­ings, and overworked, were victims of a wide range of infectious and contagious diseases. Similarly, men and women left behind in the rural sector were bur­dened with the crushing labor of agricultural produc­tion, which was required by the colonial administra­tors to feed the migrant labor force as well as the rapidly expanding urban populations. The result was that nutrition declined everywhere in Africa, and given the complex interaction of disease and malnutrition we can guess the result.

Large parts of sub-Saharan Africa experience a “hungry” season, which takes place after the long dry season, just as the rains start and food stores are low or depleted. This period is the point in the agri­cultural calendar when intense labor is required, but it is also the time when people are ill.

The two world wars compounded the burden of colonial labor and production for African popula­tions. The wars were also periods of nutritional depri­vation for millions of people. Thousands of men were recruited into military service, and disease and death were rife. Mass recruitment programs during the First World War revealed the poor state of African health to colonial authorities, and as a consequence plans were launched to provide medical services to the masses. The emphasis remained, however, on the curative as opposed to the preventive approach.

Since the 1960s, when most African colonies gained political independence, there has been a con­siderable increase in population throughout much of the subcontinent. This is a subject that in the last part of the twentieth century has become the focus of much study and debate and that in all likelihood will have to wait the next century for an in-depth explanation. While population has increased in many regions, in many African states economic de­cay has been accompanied by a reduction in the immune and nutritional status of large segments of the population. An important cause has been pro­tracted wars of independence such as those in An­gola, Mozambique, Zimbabwe, and Namibia and civil wars such as those in Nigeria, Sudan, and Uganda.

A number of accounts of the overall health of Afri­cans since 1860 have stressed the point that biomedicine and improved public health were the most valuable legacies of the colonial powers. Cer­tainly there were some notable successes starting in the 1920s with the introduction of the sulfa drugs. Yaws, a widespread endemic disease, responded al­most miraculously to sulfonamides; Africans by the thousands eagerly sought injections, and in many regions yaws was almost eradicated. Similarly, sleep­ing sickness, endemic throughout much of eastern, central, and western Africa, was by the 1950s and 1960s under control as a result of sometimes enor­mous campaigns aimed at this one disease. In the Belgian Congo and French Equatorial Africa, the systematic examination and medication of the entire population was the goal, and at the same time all affected colonies practiced some degree of mass re­moval and resettlement of populations thought to be at risk of infection.

Yet even where biomedical solutions have proved effective, the serious problem of their costs remains. Large-scale medical campaigns launched against sin­gle diseases like those aimed at sleeping sickness, yaws, malaria, and more recently smallpox are called “vertical” campaigns and are expensive. More general, or “horizontal,” health programs address a broad spectrum of public health issues such as con­trol of endemic and epidemic diseases, infant and mother care, vaccinations, and primary health clin­ics and are usually far more cost effective in their use of personnel, infrastructure, and supplies.

Nonetheless, by the time of their independence in the 1960s the health of many Afncan populations was considerably better than that of preceding gen­erations. Vaccination campaigns in many countries had become routine. In some regions, more often urban centers, public health programs had imposed a degree of control over malaria. Maternal and child health programs were also well established in many colonies. Large-scale employers such as mines and plantations had expressed some concern for the well­being of their labor forces, and in some regions work­ing conditions were improved. Mortality and morbid­ity rates were lower than ever, and major epidemics occurred far less frequently than before.

Departing colonial administrations took credit for these improvements, which were seen as stemming from the ameliorating effects of those medical ser­vices that, as we noted, many believed to be the most valuable colonial legacy. In other words, it was be­lieved that the incidence of disease had been de­creased through the beneficial effects of Western biomedical staff, infrastructure, and techniques. At that time few would have credited improvements in the standard of living of many millions of Africans for the decreased incidence. Yet as Thomas McKe­own has argued convincingly, it was improved socio­economic conditions, rather than medical therapies, that accounted for the overall improvements in the health of Western populations. Doubtless this also played a substantial if not well-recognized role in ameliorating the health of Africans as well.