1 Health Promotion Research and Development Office,
2 Executive Research Directorate, Medical Research Council, Cape Town, South Africa.
Correspondence: Priscilla S Reddy, Director of Health Promotion Research and Development Office, Medical Research Council, PO Box 19070, Tygerberg, 7505, Cape Town, South Africa. E-mail: preddy{at}mrc.ac.za
The problem of syphilis in South Africa is so closely related to the development of the country that a study of the social factors responsible for its spread is likely to assist in its control wrote Sidney Kark in 1949 in the South African Medical Journal.1 We would paraphrase: the biomedical paradigm of sexually transmitted infection (STI) relies on the germ causation theory; whereas health promotion theory looks at the multiple determinants (psychological, social, economic, historical and political) which underlie behaviours that result in the spread of STI, and hamper their control.
Venereal syphilis was introduced into the Cape region of South Africa by sailors, army troops and white settlers from the 17th century onwards; but was initially confined to coastal areas.2 Lichtenstein, in 1802 found no evidence of syphilis among the amaXhosa of the Eastern Cape.3 Livingstone, in 1857 could detect little syphilis among the Batswana people;2 but by 1885 Warren noted the natives of Bechuanaland to be badly infected.4
This was as a result of the first major epidemics of syphilis that arose in Kimberley in the 1870s as migrant workers were recruited to the diamond mines; and to the gold mines of the Witwatersrand in the 1880s; and then returned to their home communities in Lesotho and Botswana.5
Today, STI continue in epidemic proportions in South Africa judging by the South African Demographic Health Survey of 1997in which 12% of male adults reported symptoms suggestive of an STI.6
Kark was one of the first to attempt to define the social pathology of syphilis in South Africa; whose determinants are shared with diseases such as tuberculosis, gonorrhoea, chlamydia and human immunodeficiency virus (HIV).
Kark identified social dislocation as a powerful determinant of the spread of ihashe elimhlophe (the white horse)syphilis. Young men in huge numbers were removed from stable systems in the rural areas to the squalor of single sex hostels. Consort with sex workers replaced stable sexual relationshipsfuelled by a profusion of alcohol; and men having sex with men was probably not uncommon. Karks analysis was limited however, by a poor understanding of the nature of relationships between men and women in Nguni societies. The hard forced labour, dirty living conditions, lack of recreational activities or psychosocial support were also conducive to the spread of STI.
Migrant labour results in blurring of the urban/rural divide. The mass movements of the diamond rush and gold rush were the greatest dislocations hitherto experienced in South Africapresaging the forced removals of the apartheid years; which may themselves have played a part in the rapid spread of that other modern day STI: HIV.
These were surplus peopleused in the hard labour of the mines and then ejected when they got sick; thus actively exporting disease; and making it impossible to complete treatment, or trace partners. As a result parts of Botswana had higher syphilis seroprevalence (67%) than South Africa (1225%)a situation mirrored today in HIV where seroprevalence in Botswana at 30% is higher than that in South Africa at 12%.7
Karks paper lacks the moralistic, chauvinist and racist language of much of the medical literature of that time; but some of his conclusions about the psychosocial determinants of syphilis seem suspect; postulating the maladjusted nature of the STI sufferer; whose licentious way of life is an expression of a personality disorder. He does correctly identify however, that in a society that is pathological such as colonial South Africaindividuals belonging to the affected group were adversely affected.
His paper shares the them and us tone typical of medical literature of the time; and which still persists to this day. The Bantu are objects to be studied; a viewpoint inevitable when virtually all the scientists were white (and usually male) and their subjects black.
His paper glosses over the economic determinants of STI in Southern Africa. The impact on health of such shock capitalism could be likened to that affecting the former socialist economies of Europe in which Russia alone suffered half a million excess deaths during the 1980s and early 1990s as capitalism was aggressively introduced.
He also ignores the microeconomic determinantpoverty. The poor have substandard housing in which it is difficult to practise safe sex or sexual hygiene. Their compliance to therapy is likely to be inadequate when they lack the funds to buy medicine, or pay for consultations.
Education was probably also a powerful determinant in the spread and control of STI; particularly as the workers recruited were unskilled. General educational attainment affects the ability to make informed decisions about, for example, attending antenatal clinics. Lack of specific education impinges upon health seeking behaviour; and abstention from sex while infected.
Gender relations are also critical. The discovery that a partner is unfaithful may result in domestic violence, thus inhibiting early presentation with symptoms and partner notification.810
Finally, Kark said little about political determinants of STI. The alienation these workers were likely to feel within this colonial society, and their brutal exploitation by a capitalist system were designed to destroy their self esteem and ensure their compliance. Attendant effects upon the immune system again a stress determinant that may be important in the spread of STI and HIVmight be expected in southern Africa today.
Karks message about the social pathology of STI still goes unheeded. The modern emphasis on syndromic management for STI and on antiretroviral therapy for AIDS demonstrate that the biomedical paradigm still holds sway. Colonial research persists, in which scientists from a totally different culture and language attempt to understand the complex determinants of STI in a tropical setting.
Similarly, the stigma of STI persists, making contact tracing difficultas also pertains to tuberculosis and HIV. Kark would have welcomed the current expansion of access to primary health careincluding free, accessible, concurrent health literacy programmes. As a result syphilis seroprevalence among South African antenatal clinic attendees over the past 6 years has declined from 11% to 2.4%.11
Finally Karks paper again stresses the importance of transdisciplinarity in researching a subject such as STI. In this way the results of such research can better inform control programmes for socioculturally complex diseases, such as the intersectoral programmes adopted by the South African government for the control of HIV and STI.12
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2 Livingstone D. Missionary Travels and Researches in South Africa. London: John Murray, 1857, p. 128.
3 Lichtenstein H. Travels in Southern Africa 18031806. London: Henry Colburn, 1812, p. 252.
4 Warrens Expedition. Official Report. Quoted by McArthur, DC. American Journal of Syphilis 1922;7:569.
5 Report of the Contagious Diseases amongst Natives Commission. Pretoria: Government Printer, 1907.
6 South African Demographic and Health Survey (SADHS), 1998.
7 UNAIDS. The Report on the Global HIV/AIDS Epidemic. Geneva, Switzerland: UNAIDS, 2002.
8 Meyer-Weitz A, Reddy P, Weijts W, Van den Borne B, Kok G. The socio-cultural context of sexually transmitted diseases in South Africa. AIDS Care 1998;10:3955.[CrossRef]
9 Reddy P, Meyer-Weitz A, Van den Borne B, Kok G. STD related knowledge, beliefs and attitudes of Xhosa-speaking patients attending STD primary healthcare clinics in South Africa. Int J STD AIDS 1999;10:392400.[CrossRef][ISI][Medline]
10 Reddy P, Meyer-Weitz A. Sense and Sensibilities: The Psychosocial and Contextual Determinants of STD-related Behaviour. Cape Town: Medical Research Council, 1999.
11 Department of Health, 2000. National HIV Sero-prevalence Survey of Women Attending Public Antenatal Clinics in South Africa.
12 HIV/AIDS/STD Strategic Plan for South Africa 20002005. May 2000.