The lessons of history

Shah Ebrahim, Co-Editor

Kark’s paper reprinted from an issue of the South African Medical Journal of 1949 deals with the problem with syphilis in South Africa. The opening sentence provides a clarity of purpose too often lacking in more recent work:

"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."

The tragedy is that the same adverse social factors that caused syphilis to rip its way through Africa half a century ago remain firmly entrenched and have shown themselves more than equal to providing a fertile soil for the modern plague of human immunodeficiency virus (HIV) and AIDS.

Kark distinguished clearly between the ‘maladjusted’ individual and the situation where the ‘society is itself pathological’, and the impossibility of dealing with the epidemic of syphilis by treating the individual was obvious to him. Kark’s diagnosis was that the economic possibilities of the discovery of vast wealth—diamonds and gold—so dazzled the mine owners and dazed those being exploited by them that a social pathology was born. This pathology of apartheid went deep—beyond the inadequate housing for families, the single men trapped in urban settlements with few recreational outlets, and the women separated from their menfolk—the indicators Kark used to illustrate social pathology.

The underlying pathology of apartheid has been dismantled —so what went wrong? Why has this history lesson come back to haunt us with its too obvious cipher for HIV/AIDS? The failure of social medicine has been in its inability to marshal the necessary political will and resources to mount large scale population interventions. In South Africa, that failure in the face of syphilis was probably compounded by the, oh so effective, magic bullet of penicillin that provided an intervention for individuals that was sufficiently powerful to produce a population effect. It was easier and more convenient to simply treat infections as they arose than deal with the growing edifice of apartheid and its increasingly complex regulations. Kark had courage and ability, and so do his commentators, published in this issue. Read this set of papers.

In a different vein, history provides us with data to answer contemporary questions. Bengtsson and Lindström’s paper aims to examine whether the decline in old-age mortality is due to economic and social conditions obtaining during old age itself—i.e. period effects—or due to long-term influences of circumstances operating around birth—cohort effects. Using data from four parishes in Sweden for the period 1766 to 1894, they explore the possible effects of infant mortality, food prices, season of birth, and socioeconomic position on old-age mortality. They find a seasonal effect in their data, with old-age deaths being associated with winter and summer births which they attribute to airborne infectious diseases—a view disputed by our commentator. The lesson here is an easier one to learn—never throw away data, as you never know when they will be put to good use.