Episode 80: Colonial Medicine and STDs in 1920s Uganda

Today we’re going to take a look at syphilis and the politics of mercury in colonial Uganda from 1906 to 1922. Specifically you’ll be talking about the politics of colonial public health through commodity history, by taking mercury as a unit of analysis, correct?

Yes, absolutely.

Why don’t we start off by giving some background on colonial Uganda and the role of public health in colonization?

Colonial Uganda was a British colony. It became a protectorate and so that came with a certain set of policies wherein there were colonial supervisors but to a large extent the populations that were already there were supposed to be more or less left alone within certain government frameworks. I really want to see colonial Uganda in the early 20th century in kind of the benevolence of the civilizing mission, at least as the colonizers saw it. It was about raising these populations who were behind that of Europe out of their situation and exposing them to new sciences and cultures, and of course the indigenous populations didn’t really have much of a say in this, it was just presumed that they would want this.

And this is the story across much of colonialism in general. In particular public health was seen as an investment in the colonized peoples but because of what’s at stake in public health, you have the general health of the population, this also has economic effects in terms of the labor force, in terms of the ability for colonizing education to be effective because of what’s at stake there it took a really malicious form in reality where it came to enforcing that civilizing mission and that public health.

So when did the syphilis outbreak begin in Uganda and about how many individuals were affected? Did it spread rapidly or was it more contained?

Where you really start to see a surge of this documented is right around 1879 where you have colonial reports of the Baganda who were the major ethnic groups in the area and these reports were just full of references to syphilis. And I do want to note that it’s what appears to be syphilis because there’s actually an interesting twist that kind of comes at the end of this story. But by 1897 and so we’re crossing decades and the syphilis is sort of festering at this point because they’re recording accounts of it but there’s nothing really being done about it, but the church missionary society actually initiates a formal survey and concluded that nearly 80% of the people they were testing were testing positive and that was then applied to the larger population so the Baganda, in particular, it was reported that they had about 700,000 people in the area, so if you think about 80% testing positive that’s pretty insane levels.

So when they were receiving these reports and surveys, what kind of relief operations did the colonial British officials in Uganda conduct at the beginning of the 20th century?

In 1906, the governor calls in a man named Col. Lampkin who was the army medical corps’ top veneriologist at the time so Lampkin comes in, he confirms the earlier findings about the rates of syphilis in the protectorate and frames this in his reports as a preeminent threat to the colony and this went right alongside with governor’s concerns and kind of fueled the response in the colonial metropolis in Europe that this was a problem that really needed to be tackled head on. So Lampkin was given full rein to design an entire relief strategy and the British government kind of told him we will spare no expense in dealing with this problem within reason, just tell us what we need to do, and so the strategy was designed in 1906 really took effect in 1908 and was active from that point until the mid 1920s or so.

Can you tell us a little bit about what this treatment campaign entailed and was it Lampkin who headed the entire campaign between 1908 and the 1920s or did it shift hands throughout?

It actually did end up shifting hands so while Lampkin designed the strategy, he was not really the person who enacted it. The person, also from military background, his name was Capt. Sparks, and he’s actually the individual that kind of marks the maliciousness of the history of this campaign over all because he’s the person who’s really enacting what I’m about to describe. In 1908, he comes in he sets up a couple of very small buildings and oversees an effort that includes a prescribed 21 month series of painful injections right in the stomach muscle and so those injections, which were mercury, were also followed by a topical cream, which included mercury as well and so mercury was the main strategy that was recommended by Lampkin.

I do want to note that mercury was probably the low end in terms of quality treatment. It was just the most expedient the easiest to get to the protectorate and the cheapest and so there were obviously a lot of fears over mercury because as you can imagine it started to result in some very visible negative consequences that came from the treatment regime and so the indigenous population were not all that keen to voluntarily go and get treated especially since there was already a lot of background of distrust from the colonial effort in general.

There are actually some fantastic primary source documents, in which there are accounts of Capt. Sparks publicly injecting himself with the full dose of liquid mercury actually far more of the dosage than were being injected into the indigenous populations. This was meant to calm the population’s fears about the dangerousness of mercury. However this actually wasn’t effective. It was just more of a spectacle because by the end of 1909 only a year or so after the actual campaign picked up, only about 2500 indigenous patients voluntarily came to be treated. And again this was just from one of the dominant populations out of the group of 700,000. A lot of historical accounts will say that this is attributed to 9 patients who very publicly and violently died at Sparks’ treatment clinics. There were reports of seizures and foaming at the mouth, utter incomprehensibility in terms of language and so this was a very public event and this had a huge effect on indigenous fear of these treatments.

What ends up happening is not everyone was going through with the full 21 month series, so you had people who would come for 3 or 4 months and don’t come back, people who come for one month and don’t come back, people who will just appear very 6 months or so because their symptoms of the actual disease that’s being treated are resurging, but among all this you have other accounts that are floating around the indigenous populations. There are miscarriages that are happening. There are blood disorders that are being acquired during the treatment series and here was actually an account that these mercury injections were injections of fire and that’s the way in which this treatment series was being spoken about by the indigenous population and so by 1913 the colonial records that we do have report that about 2000 of the 5000 patients treated by Sparks had died as a result of the mercury treatment.

So there are still records from the colonial side that perceive mercurial treatment as a suitable treatment as late as 1953. So there’s a real distinction in the perspectives of what the indigenous population is saying and what the colonial population is saying and of course if you were a white individual in the protectorate who was diagnosed with syphilis, you had access to much higher quality medications. So there is an interesting disconnect in the stories that are coming out depending on who you’re looking at.

Before we get into the politicized response that you mentioned, can you talk a little bit about the timeline of early 20th century medicine that Sparks was working in?

Absolutely, it’s interesting because the actual scientific timeline is quite different from the historical timeline in the use of these treatments. Mercury and arsenic based treatments for syphilis were some of the oldest ones and they were actually far outdated by the time mercury was being used in Uganda. But in the early 1910s or so Paul Ehrlich developed Salvarson, which had a slight arsenic component to it but much less than the earlier treatments that were primarily arsenic based. It was popularly heralded as the magic bullet for dealing with syphilis at the time it was generated. A couple of years later you have sulfa tablets, which are also seen as effective have much fewer side effects than the earlier treatments and then a bit later in the story in 1928 you have Alexander Fleming coming up with penicillin but as I said previously you had documented cases of mercury being seen as legitimate treatment until the 1950s. You look at the difference in these dates and its just astounding.

What we see in terms of Ugandan timeline and the African timeline in general in a lot of cases is that the treatment is delayed anywhere from 20 to 30 years due to colonial calculations about the difficulty and cost of transporting the treatment supplies and the idea of population health by aggregate among the indigenous populations so what I mean by that is the colonial interest in having a healthy population beyond the rhetoric of the civilizing mission was that the colonized had to constitute a healthy labor force. So if we lose a certain proportion of that labor force to a treatment with significant side effects, that’s ok as long as the aggregate health is still at a level where productivity continues. The people who die as a result of that are just considered acceptable casualties. Whereas you look at the white populations in the area that became afflicted with syphilis, they have access to the sulfa tablets later or the penicillin they have access to the best medication because at the end of day they are seen as more valuable on an individual level.

So as with any controversial medical testing done on human subjects, what kind of political meanings did these test garner in terms of ethics?

In general British scholars and contemporary scholars more recently have often viewed colonial populations as difficult to integrate into public health campaigns. So at the time British scholars were writing about this and the reality of the racism behind this has been developed by scholars more recently where the British scholars at the time saw these populations as primitive, to put it plainly. They saw the idea of medical discipline, of returning for all 21 months of the series of injections, of taking the medication, of practicing sex in the way that they deemed safe under public health, as fundamentally affiliated with indigenous primitiveness and beyond their capacity. This is why mercury really comes into play here because at one level the colonial government isn’t going to spare the expense of the high-end medication on this population that it doesn’t view as worthy, quote unquote, of these medications. At a second level British scholars are responding to Lampkin’s recommendations and saying that the mercury injections aren’t going to work, they’re not going return for their entire 21-month series etc. Lampkin actually responds to these claims and argues that the political structure of the Baganda people actually made it an ideal context in which to carry out these treatment campaigns.

What he meant by this was that in the Baganda governing structures there was a monopoly of the chieftaincy so if Lampkin and Sparks who would end up carrying this out could get the chieftaincy to agree to this and then force this then this provides an entirely solid structure within which the medical campaign could work, and given that Lampkin was making the claims he was making and that he was highly esteemed within British public health and British governance structure and the colonial governance structure, this faith began to spread among the colonial administration. Combined with the just innate fear of losing this labor population they kind of signed on to his plan and it ended up becoming one the most coercive public health campaigns in all of colonial history. But, of course, as with the civilizing mission, it was very clearly framed as charity and bringing public health to the colonial administrative periphery.

How did these ideas of paying off chiefs and chiefdoms to bring social order play into British authorities’ ideas of political control?

It certainly capitalized on the monopoly of the chieftaincy. A couple of ways it did this more specifically, British officials paid chiefs for reporting sexual disease cases so it engaged this entire surveillance state within the indigenous governing structure. This was a pretty widespread campaign where every single case of syphilis that was reported to the colonial government was rewarded and so there was a lot of economic flow back into the chieftaincy. It’s also important to note that because of the shock of colonialism, as hands-off as it may have been in these cases, compared to other cases, the chieftaincy was losing a little bit of authority within its own populations and so that financing was very Important for the chiefs in terms of holding on to their own power. While this was widespread in about 1915, Sparks and some of the people advising him had deemed that this was not enough, they still weren’t seeing the amount of treatment that they wanted. Locals were very clearly still avoiding the treatment and syphilis was still very much an issue, and so the colonial officers from the documentation that I’ve seen very clearly appear indignant.

Their reaction is that of someone who provided a gift that was refused, which was very much the way that they were conceiving of the public health that they were bringing to these people. This is where the coercion aspect really comes in. The 1886 Contagious Disease Acts in Britain had been dismantled by women’s group’s decades before but a similar variant of it got completely re-implemented in Uganda at this time. It’s important to note that up until this point, all of the public health campaigns in the Ugandan protectorate are being carried out by army medics and so there is a huge military component that, regardless of if its being enacted, is still underlying all of this and so you have under this re-implemented Contagious Disease Act the idea of compulsion really framed clearly. There are cases where entire villages are rounded up by colonial police forces to undergo compulsory examination and compulsory treatment. Despite all the fears and the very obvious pain that had been communicated previously these colonial police also hunted down people who didn’t complete their injection series and there are documented cases in which clinics saw about 60 women an hour. They were very publicly stripped naked and it was almost like processing these women like they weren’t even people. It’s actually quite horrifying to delve into.

Based on my understanding of similar outbreaks across the world, I know these outbreaks tend to have linkages to prostitution, the “uncontrollable” female desire and other gendered tropes. Was this also the case in colonial Uganda?

It’s important to note that this context is seated in an era in general when syphilis was associated with “degenerates,” “deviants,” prostitutes, etc., and whether or not this was true, this was at the height of ideology about what it meant to be civilized and what Victorian modernity meant and so there was this huge fear of locals, especially in the colonial context, corrupting white populations in particular. It wasn’t just about the physical infection but also the fact that there may have been a sexual encounter between a white person and a black indigenous person. There was a lot of syphilis that was actually going around Europe at this time as well and so there was huge anxiety about the degeneracy of the white race so to speak. And so, combined with the association of syphilis with miscarriage, stillbirth, infant mortality, women especially became the targets of these campaigns. There’s a lot of rhetoric of the women in Europe having been tamed and controlled but the women in the colonial sphere needed to be brought under that same sort of control and there’s a lot of talk of the quote-unquote female passion. So unfortunately women did become very much victimized in this dynamic and this also again coincided with anxiety in the chieftaincy where women were seen as claiming more power in those particular chieftaincies and so chiefs were very often glad to comply with mercury to reassert their own internal dominance regardless of the problems it may have caused for their own populations. This sustained the campaign until sometime in the 1920s.

To wrap up, after the 1920s what changed and moreover what lessons can be learned from the response to the syphilis outbreak that can be applied to other situations such as the current crisis of HIV and AIDS?

Women ultimately undid the compulsory element of this campaign. Women’s groups in London, a lot of the same ones that helped take down the 1886 Contagious Disease Acts in Britain, caught wind of news reports of this coercive regime in the Ugandan protectorate and immediately began protesting against these campaigns. So, for example, one female doctor who traveled to Uganda to take a look at the campaign ended up circulating an anonymous report in the British Parliament, which said, “the campaign was the worst and most abusive public health campaign in our history.” General outrage ensued among European populations at large. There were references to the Uganda campaign as barbaric and outdated and eventually you see a shift away from the militaristic regime of public health where the colonial medical department actually takes over all public health and the army medical corps fades into the back. Capt. Sparks is no longer affiliated with this campaign and then you eventually have newer medications integrated.

Where you see African troops really becoming involved you have much more of an interest, still a little bit in having aggregate health, but each life seems to be a little more valuable, and so all across Africa, in fact, you have cases in Ghana where these troops have access to sulfa tablets instead of mercurial treatments. Ultimately I think that we find that mercury as a product itself occupies a space of huge political significance both from the imperial anxieties it was utilized to relieve and the fear instilled in compulsion but also from its spelling its own downfall. Mercury creates a context in which it is able to thrive as the main product of use but it also creates a context in which it’s no longer sustainable for obvious reasons.

And so I think that one thing that’s really important for looking to contemporary context, you mention HIV/AIDS, is that sometimes at least historically looking at the disease itself is not necessarily the bet course of action for understanding how a dynamic may be functioning. What I’ve done is focus the attention on the commodity of the treatment itself. And actually with HIV and AIDS, if you look at anti-retrovirals or you look at preventative measure as far as the commodities go and how those commodities are traveling, how they’re being received, how they’re being integrated, how they’re being funded. It gives us a very interesting set of questions that are different from the questions that would arise from looking at the disease itself. I think if anything speaks to the power of mercury as a product as opposed to syphilis as a disease, the fact that research in the 90s actually showed that the vast majority of the cases that were diagnosed in the Ugandan protectorate for syphilis actually turned out to be yaws which is a similar disease but not the same and necessitates a different treatment regime. And so I think the fact that these surveys got the disease entirely wrong, it has some significant implications for the story itself.