The social pathology of syphilis in Africans

Sidney L Kark

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. Few countries can have a higher incidence of the disease than has South Africa. Table 1Go indicates the extent of the problem.


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Table 1 The incidence of syphilis in various African groups studied in South Africa
 
The data include sample studies of men, women, children and babies. They indicate the extent which syphilis has spread to urban and rural areas. In the school children examined by Kark and le Riche5 in 1938–1939, the incidence of definitely positive Wassermann tests in the total urban group was 23.6%, and in all rural areas it was 23.28%. Cluver’s figures,2 as well as those of the Polela group,6 also indicate that syphilis is probably as widespread in rural areas as it is in urban areas.

Gale10 estimated that the rate of infection per year in Pietermaritzburg Africans was 2620 per 100 000 as judged by the occurrence of early cases under treatment. A sample study, carried out by the author at Polela6 in 1942, indicated the annual rate of infection in adult women to be 3.27%, estimated by the incidence of known cases exhibiting primary and secondary manifestations, with a recent history of infection. At Springs11 the rate of new cases coming to the notice of the Medical Officer of Health (1940) was 2061 per 100 000, of which 577 per 100 000 were early cases.

Purcell,11 after briefly reviewing the incidence of syphilis in various groups of Europeans and non-Europeans in South Africa, indicated that ‘the incidence of syphilis in the Union is enormous’. Our present review indicates that not only are we dealing with a large mass of latent syphilis in the African populations, but also with a very high incidence of new infections each year. This process is taking place in highly urbanized areas, as well as in the more remote rural districts.

A study of the social pathology of the disease must, therefore, include an historical analysis, as well as an assessment of present trends which are maintaining the spread of syphilis.


    Historical
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 Historical
 The shifting nature of...
 General discussion and...
 References
 
Before Europeans came to South Africa,*

syphilis was unknown among the Africans.12 The Zulu have no specific name for the disease other than isifo sabelungu (disease of white men) or isifo sedolopi (disease of the town).

The first permanent European settlement in South Africa had very little close contact with Bantu-speaking Africans, and the contact for many years thereafter was casual and temporary.13,14 In spite of wars and repeated minor conflicts between frontier groups of Europeans and Africans, very close relations between masses of these two races did not develop until the discovery, in the last half of the last century, of diamonds at Kimberley and gold on the Witwatersrand. Large numbers of European and African immigrants were then attracted to these areas. From then on, syphilis became an ever-increasing problem, not only in these newly proclaimed mineral fields, but throughout the country. The two races worked together under conditions which were far from ideal.

Results of the discovery of diamonds at Kimberley in 1867
The diamond fields which developed, ushered in the Industrial Revolution of South Africa—a revolution which continues to the present day. By 1877, the population of Kimberley was 18 000 (8000 Europeans and 10 000 non-Europeans). Within the short space of 10 years, Kimberley, a relatively unpopulated and barren area, had become the second largest town in South Africa.

Some 10 000 Africans were employed on the mines each year, and between 1871 and 1895, about 100 000 came to the mines and returned to their homes. The men came as temporary unskilled labourers, leaving their families behind them. Migrant labour on a large scale had begun. This mass movement of population was far greater than anything South Africa had experienced before, as far as European–African contact was concerned. In terms of numbers of people involved, the Great Trek and the Voortrekker villages that resulted, were far smaller: e.g. in 1852 Bloemfontein, then the largest village north of the Orange River, had about 70 houses with some 300 Europeans; and Smithfield, the second biggest of these villages, had 42 homes and about 200 Europeans.

The living conditions of the Africans in the Kimberley area were conducive to the spread of syphilis. Drunkenness was common; compounds were often filthy and there was a rapid movement of men to and from the diggings. In the beginning they would remain for from three to five months and by 1889, up to nine or occasionally even 18 months. The striking feature was that a large group of men were living under abnormal social conditions, because very few, if any, had their wives and families with them. This resulted in promiscuity, prostitution and the sure spread of syphilis.

Some idea of how far the disease, contracted at Kimberley, could be spread, is obtained when one realises the extensive area from which this labour came. Van der Horst14 quoting the Cape Blue Book on Native Affairs (1885), presents the following figures for ‘new hands’ registered at the Kimberley mines in 1884:


Shangaans 681
British Basutos 195
Sekukuni Basutos 2215
Zulus 815
Portuguese Zulus 446
Bakhatlas 56
Matabele 120
Colonials 375
Bakwenas 33
Batlapings 277
Swazis 11
Bamangwatos 56
Barolongs 115
Korannas 6
Griquas 3
Batlaros 21
Transvaal Basutos 47
West Coast 2
Dramara 1
Mosambiques 1
Total 5476

These men from various tribes came from all parts of South Africa—the Cape Province, Natal, the Orange Free State, the Transvaal, Basutoland, Swaziland, Rhodesia and Portuguese East Africa.

The results of the discovery of gold
A far more important factor in the spread of syphilis emerged soon after with the discovery of gold on the Witwatersrand in about 1884. Urbanization under abnormal social conditions which started at the diamond fields, continued on a far greater scale on the Witwatersrand. These social changes resulted not only from the direct recruitment of labour for the mines themselves, but the gold industry also became the main stimulus for the development of other industries, e.g. coal. It led to the development of ports such as Durban, Port Elizabeth, East London and Cape Town, for export and import, to satisfy the growing needs of the ever-increasing numbers of consumers in the mining areas. It gave rise to secondary industries for clothing, feeding and housing the population, and finally to the commercial and distributive enterprises needed for all these activities.

All these developments required labour, and the bulk of the unskilled labour was provided by African men.

From the beginning the main sources of labour were from the Native rural areas. The men who came to work left their homes in the rural areas. Their period of work was limited and they, as well as their employers, regarded their stay in the towns as temporary. After a variable time they would return to their homes.

Housing
Housing and other facilities necessary for the development of a family life and a stable community were not provided. The compound system prevailed. The development of family life, which leads to more stable sex relations between men and women, thus never became a feature of the gold mining industry. It is only in recent years that urban African family life has become an accepted fact in our towns; but such family life is dependent for its income on other fields of employment than the mining industry.

Table 2Go indicates the number of African and other Coloured men concerned in the gold mining industry from the years 1904 to 1939.


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Table 2 The number and distribution (according to area of origin) of men employed in the mining industry of the Transvaal*
 
All the areas of South Africa are involved to a varying extent, as well as the neighbouring territories of Basutoland, Swaziland, Bechuanaland, Portuguese East Africa and tropical areas such as the Rhodesias and Nyasaland. The migration of so many young adult men must necessarily disturb social conditions in the area to which they go, unless there is a very large stable population with facilities for social life. It becomes necessary, therefore, to analyse the distribution of population in the towns of this country to see whether there is any opportunity for this group of men to live a fairly normal social and sexual life.

Distribution of the African population according to the 1936 Census17
This Census was the last full Union-wide census of which details are available. Table 3Go indicates the urban and rural distribution of African and European populations as extracted from the 1936 Census.15


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Table 3 Urban and rural distribution of Africans and Europeans of the Union of South Africa
 
The proportion of total males to total females for Africans in Urban areas is greater than 2:1; whereas this proportion for Europeans is a fraction under 1:1. The proportions in rural areas are relatively normal for both groups. These figures, although they indicate an abnormal Bantu population distribution in towns, do not indicate the true state of affairs. Firstly, by taking the total of all age groups, the figures do not show the proportion of adult male to adult female. Secondly, they do not indicate the shifting nature of the African population. Thus there is no indication of the numbers who are permanent urban dwellers, as distinct from those who are temporarily in town, with their homes and families in the rural areas. A further analysis of these factors is indicated in Tables 4GoGo and 5Go.


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Table 4 Proportion of adult males to adult females (Africans) (a) All urban areas: the proportion of African male and female persons, according to age, in the urban areas of South Africa
 

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Table 4 Proportion of adult males to adult females (Africans) (b) Leading industrial areas: the distribution of African males and females, according to age, in some leading industrial areas
 

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Table 5 The proportion of African men and women between the ages of 21 and 49 years in the Transkeian Territories (according to the 1936 Census)
 
The greatest preponderance of males over females is during the most virile period of life, viz. the age group of 20–49 years. If the figures for some of the leading industrial areas are analysed, we find an even greater preponderance of males over females, as indicated in Table 4bGo.

In none of these towns was the proportion less than 3:1. The range for various age groups in Johannesburg was from about 31/2 to over 4 men per adult woman; in Springs from 5–12 men: 1 adult woman; in Krugersdorp from about 4–9:1 and in Durban from 3 to 7:1. It is likely that this state of affairs in urban areas influences the position in rural areas.

Rural areas
It has been noted above (Table 3Go) that the total rural distribution of African males to females was a little less than 1:1. Such a distribution would allow for a normal social life were it to obtain in all areas. These figures are, however, for the total rural areas of South Africa and do not necessarily express the state of affairs in various parts of the country.

Furthermore, the analysis is based on the figures for all age groups and does not, therefore, present a picture of the proportion of adult males to adult females in various areas. The distribution of Transkeian Territories indicates a different state of affairs from that which obtains in the general rural population (Table 5Go).

The position in the Transkeian Territories (which is more like that of other ‘Native Reserve Areas’ than is the total rural areas inclusive of the vast European-owned farming area) is the reverse of that which exists in the urban areas. There is a relatively high proportion of women to men, ranging from about 1.3 women to 1 man in the age group 45–49, to 2.5 women to 1 man in the 21 to 24-yea0r age group.

Conclusions
(a) In the urban areas there is a preponderance of adult males over females most marked in the age group 20–40, where it is over 3:1. In the more industrialized urban areas this preponderance is even greater.

(b) The effect on the rural African reserves is to upset the balance in the other direction, resulting in a preponderance of women over men.


    The shifting nature of the population
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 The shifting nature of...
 General discussion and...
 References
 
The development of the diamond and the gold mines led to a considerable number of persons, more especially adult men, going to work in the towns and returning to their homes periodically. The census only shows the position at a particular moment in time and does not indicate the total turnover of population in various places. It thus excludes an important demographic problem in the study of syphilis, viz. movement of people. Table 6Go summarizes certain sample studies of the extent of migratory labour.


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Table 6 Summary of sample studies of the extent of migratory labour in various areas of South Africa
 
Conclusions
Very few adult men have not been away from their rural homes to work in some town or other. In a number of areas the majority of men are away during the course of each year. A number of them remain away for lengthy periods of two or even more years. While these figures do not adequately convey the exact picture in all rural and urban areas of the Union, they do indicate that at any one particular moment of time, some 40% to 50% of men are away from their homes and that during the course of a year, between 40% and 80% of the men might be away.

The marital status of adult African men and women in rural and urban areas
In terms of social relationships the data of Table 7Go indicate the following:


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Table 7 Marital status of Africans over 21 years of age (according to 1936 Census)
 
Urban
The total number of unmarried men over 21 in urban areas is 218 400 (i.e. those never married, plus the widowed and divorced). It will also be noted that 346 281 men are stated to be married as compared with 119 682 married women. If we assume that all married women are with their husbands, then 226 599 men are married but are not with their wives. By combining this figure (226 599) with that of the total number of unmarried men (218 400) we reach a figure of 444 999 unattached men in the towns. This gives a proportion of approximately 4 unattached men to each one attached.

The total number of unmarried women over 21 was 71 068, a proportion of 1 unattached to 1.7 attached, assuming again that all the married women are living with their husbands in town. If the 119 682 married couples are accepted as being faithful to one another, there are 444 999 unattached men with only 71 068 unattached women, i.e. a proportion of over 6:1.

Rural
The number of unmarried men over 21 is 299 508, a proportion of 1 unattached to 2.4 attached. The number of unmarried women over 21 is 422 290, of whom no fewer than 291 505 are widowed. There are also 909 629 married women and only 713 181 married men. There are, therefore, 196 448 women whose husbands are not with them. This figure excludes the incidence of polygamy. For purposes of this analysis it may be assumed that some 10% of adult women are in a state of polygamous marriage. That leaves a figure of approximately 175 000 temporarily unattached, married women. The total number of unattached women over 21 in the rural areas would therefore be 597 290, a proportion of 1 unattached to 1.2 attached. Assuming again that men and women, when together, are faithful to each other, there are 299 508 unattached men with 597 290 unattached women, i.e. a proportion of 1:2 for all rural areas in South Africa. In the Transkei, this proportion is roughly 1:7.

One further important comparative set of data is the proportion of never-married to married women over 21 years of age:

In towns: 40 474 to 119 682, i.e. about 1:3

In rural areas: 121 252 to 909 629, i.e. about 1:71/2.

The relatively high proportion of unmarried adult women in the towns should be noted.

Conclusions from these data
In the towns the number of unattached men is four times greater than that of attached men, and six times greater than that of attached women. Over and above this a large number of these unattached men are not permanent residents in the towns. Where there is such a high proportion of virile adult men as compared with women, the results are likely to be undesirable. The men will seek their social and sexual life in shebeens and brothels. Prostitution and alcoholism are well-established immediate causes of syphilis and require no further discussion. Furthermore, the temporary nature of the sojourn of these men in urban areas is not conducive to the development of a moral social code, which might influence behaviour, as it would be in the case of a stable community.

The additional factor to be dealt with in South Africa is the movement of men so infected in the towns, to their homes in the rural areas. In this way venereal disease has been brought to the most remote corners of the country. A limited study carried out in the Polela district indicates that this is the main source of infection of the rural population (Table 8Go).


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Table 8 Epidemiological study of 76 cases of primary and secondary syphilis and acute-gonorrhoea (carried out at the Polela Health Unit in a rural area)
 
The Polela study indicates that the majority of married women (29 out of 32) patients were infected at home by their husbands, who had recently returned from work in a town. No fewer than 23 of the contacts who had infected these 32 women had been infected in town.

The position of married men is somewhat different. Few (2 of 20 patients) were infected by their wives. The majority were infected during an extra-marital union. A number (10) were infected in their home area. Like the married men, single men are frequently infected while away from their homes (six out of ten cases).

The majority of girls and single women (13 of 14 patients) were infected in their home district by contacts who had contracted the disease in the area, as well as while away from the area. Not infrequently these contacts were married men.


    General discussion and conclusions
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 Historical
 The shifting nature of...
 General discussion and...
 References
 
Social pathology may result from two broad types of disorder.21 In the one, the individual person may be so maladjusted that he is unable to order his life according to the folk ways and mores of his particular group. Such maladjustment may be due to an abnormal domestic life or to a disordered personality resulting from a multiplicity of causes. Whatever the cause may be, the maladjustment is essentially one of individual personality pathology and the therapy required is that for the individual. Should such a maladjusted person develop syphilis as a result of a licentious way of life, it becomes necessary to regard the syphilis as an expression of a personality disorder, and the diagnosis established, as well as the therapeutic programme developed, must include consideration of this social maladjustment.

The other type of disorder is that in which the pattern of society does not allow for the healthy development of the individual. Here we are dealing with a process in which the society itself is pathological. The disturbance in social relationship may not affect all groups or communities to the same degree, but the individuals belonging to the affected groups are likely to show evidence of this pathology.

The industrial revolution in South Africa, commencing with the discovery of diamonds and continued with the large-scale mining of gold, led to the development of an urban life which has profoundly disturbed the family stability and sexual mores of several million African people. Urbanization as a process is bound to disturb patterns of living which have been developed in a rural society, but urbanization in South Africa has taken a particularly disturbing direction as far as the African is concerned, as it has developed mainly on the basis of migratory labour. This system of migratory labour of adult men has led to instability and pathology in family relationships.

The code of morals of the men who have been to town appears to have arisen through the realization of a new, free, sexual life, one that does not regard sexual intercourse in a serious light, but as a cheap commodity for temporary pleasure. This results in adultery and intercourse with single girls at rural homes—a state of affairs which the work at Polela indicated to be not uncommon, despite the fact that the tribe as a group frowned upon such activities.

In addition, the very large number of widows (over a quarter of a million) and the many women whose husbands are away at work from the rural areas, comprise a group already used to sexual intercourse. In the old days a widow would become the ‘wife’ of her late husband’s brother and have children with him. This still happens today (but not as often as before) and it is probable that this group of women will present an ever-increasing problem in the spread of syphilis. The other group, whose husbands leave them, will often also indulge in extra-marital intercourse, more especially if their husbands remain away for long periods. Examples of such cases grow more and more frequent in the African reserves. Details of a particular case study of this type have been reported.22

Thus we have on the one hand a set of conditions in urban areas ideal for the spread of syphilis, and on the other hand, a migrant labour force which successfully spreads this urban disease to the rural areas where social conditions are also suitable for its reception.

All this has been going on at an ever-increasing rate since the diamond digging days, producing great changes in Bantu social customs, breaking down a system of rigid moral standards, destroying the old concepts of right and wrong, cheapening relations between men and women and bringing with it syphilis.

Without an understanding of the economic factors involved and the historical development of the vast social pathological changes brought about during the last 70 years, no treatment will save the spread of syphilis in South Africa. Treatment of individual personality disorder or attempts to inculcate a re-orientation towards a healthy sexual and family life cannot succeed in any but a few cases. The first line of treatment must be to remedy the unhealthy social relationships which have emerged as the inevitable result of masses of men leaving their homes every year. This pathological process is at the root of the disturbed social relationships and successful therapy requires the establishment of African urban and rural communities based on a stable family life. With the development of such family life in our urban areas will emerge a set of mores which, among other benefits, will gradually control the spread of syphilis. In such ordered urbanization lies the answer to the problem of the social pathology of syphilis.

I have to thank the Secretary for Health for permission to publish this study, and my wife, Dr Emily Kark, for her assistance and comments. To the late Dr David Landau I am especially indebted for his criticism and advice in this study.


    Notes
 
Training Scheme for Health Personnel, Ministry of Health, South Africa. Reprinted with permission of the South African Medical Journal. Kark SL. The social pathology of syphilis in Africans. S Afr Med J 1949;23:77–84.

* Much of the historical material presented here has been obtained from CW de Kiewiet’s History of South Africa13 and ST van der Horst’s Native Labour in South Africa.14 Back


    References
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 Historical
 The shifting nature of...
 General discussion and...
 References
 
1 Drew FS (1932). Cited in the Report of the Native Economic Commission (1930–1932), p. 214. Pretoria: Government Printer.

2 Cluver EH (1932). Cited in the Report of the Native Economic Commission (1930–1932), p. 214. Pretoria: Government Printer.

3 Rauch JH and Saayman LR (1938). S Af Med J 12,885.

4 Pijper A (1921). S Af Med J 19,302.

5 Kark SL and le Riche H (1944). Manpower 3,1. Pretoria: Government Printer.

6 Annual Reports of the Medical-Officer-in-Charge, Polela Health Unit, to the Chief Health Officer, South Africa (1941–1946). Unpublished.

7 le Riche H (1943). A Health Survey of African Children in Alexandra Township. Johannesburg: Witwatersrand University Press.

8 Annual Report of the Medical Officer to the Local Health commission (Natal) for the year ending 30 June 1946.

9 Annual Reports of the Medical Officer of Health, Municipality of Springs, Transvaal (1938–1944).

10 Gale GW (1939). S Af Med J 13,265.

11 Purcell FWF (1940). S Af Med J 14,23.

12 Gluckman H (1931). Lectures on Gonorrhoeal and Syphilitic Affections, p. 5. Johannesburg: Hortor’s Limited.

13 de Kiewet CW (1941). A History of South Africa. Oxford University Press. London: Humphrey Milford.

14 van der Horst ST (1942). Native Labour in South Africa. Oxford University Press. London: Humphrey Milford.

15 Census Report of the Union of South Africa (1936). Pretoria: Government Printer.

16 Schapera I (1934). Western Civilisation and the Natives of South Africa, p. 45. London: George Routledge and Sons Ltd.

17 MacMillan WM (1930). Complex South Africa. p. 178, London: Faber and Faber Ltd.

18 Krige JD and Krige EJ (1941). Unpublished Data on Family Budgets in a Native Reserve (by kind permission of the authors).

19 Hunter M (1936). Reaction to Conquest. Oxford University Press. London: Humphrey Milford.

20 Report of the Basutoland Census (1936). Pretoria: Government Printer.

21 Gillin JL (1946). Social Pathology. New York and London: D Appleton Century Company Inc.

22 Kark SL and Kark E (1945). Clin. Proc 4,5.





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