African Diseases

Vivax malaria probably arrived in the blood of the first Europeans and, although a relatively benign form of the disease, nonetheless joined in the slaughter by claiming its share of Indian lives. As the Indian die-off progressed, the'Spaniards found themselves forced to look elsewhere for hands to put to work colonizing the Americas, and they chose the black African. By 1518 the transatlantic slave trade was under way, which almost immediately opened a conduit for the transatlantic flow of a much more deadly form of the disease: falciparum malaria.

The circumstances surrounding the introduction of yellow fever from Africa are less clear: Although it is now generally accepted that the anopheline mosquitoes that spread malaria were on hand in the New World to do just that, the Aedes aegypti vector of yellow fever most probably was not. Thus both vector and virus had to be imported and to reach human populations dense enough to support them. A case has been made that all of these conditions were met by 1598 at San Juan, Puerto Rico, and there is absolutely no question that they were met by 1647 when yellow fever launched assaults on Barbados and Guadeloupe, before continuing on to Cuba and the Gulf coasts of Mexico and Central America.

The slaves had lived with both of these tropical killers for eons and in the process had developed a relative resistance to them. But in addition, they were also accustomed to most of the other Old World illnesses that had proven so devastating to the Indians. The ironic result of this ability to resist disease was that it made blacks even more valuable as slaves. The Indians died of European and African diseases, the whites died of African diseases, but the blacks were able to survive both, and it did not take the Europeans long to conclude that Africans were especially designed for hard work in hot places.

This view was not limited to the Spaniards, although they had been the first to discover the blacks' din-ability. Other Europeans had begun trickling into the Caribbean, impelled from their mother countries because of wars, religion, politics, crimes committed, or just outright lust for adventure and riches. They settled first on the islands of the eastern Caribbean, which had been left relatively untouched by the Spaniards, and brought disease to, and ultimately an end to, the surviving Caribs.

If at first these new arrivals grew any "cash crops," they grew tobacco in small plots, which the Dutch, by then ubiquitous in West Indian waters, marketed for them. All this changed abruptly, however, when the Dutch, who had moved into Brazil, were driven out, taking with them the secrets of sugar production. These they gave to the small planters of the eastern Caribbean along with financial assistance, and the sugar revolution was under way. Tobacco growers became sugar planters, small tobacco plots were consolidated into large sugar plantations, and the demand for black labor soared. The Dutch met that demand with their slave ships, which brought African pathogens as well as Africans, both of which had heretofore only trickled into the Caribbean and now began to pour in.

In addition to yellow fever and falciparum malaria came the filarial worm, also carried by mosquitoes, to create the infamous disease "Barbados leg." It seems to have broken out on that island first, but soon was widespread throughout much of the Caribbean, although always strangely absent in Jamaica. The Africans also carried with them the misnamed hookworm Necator americanus, which found the West Indian sugarcane fields an especially favorable habitat. That dracunculiasis was rife among them could be noted as Guinea worms poked their heads out of slave legs to be patiently wound on a stick by the victim until all of the worm was removed. In addition, yaws blossomed on the bodies of slave youngsters, leprosy assaulted the adults, and onchocerciasis invaded the eyes of both. Indeed, even smallpox began arriving from African rather than European reservoirs, and the Caribbean was transformed practically overnight into an extension of an African, as opposed to a European, disease environment.

Paradoxically, the increasing dangers of such an environment paralleled the increasing value of the West Indian Islands in the eyes of the capitals of Europe. As colonies that sustained a slave trade, purchased products from mother countries, and supplied sugar for processing to those countries, the islands fit marvelously into - indeed helped to shape - the prevailing mercantilist philosophy, a part of which prescribed grabbing as many more islands as possible from European competitors.

The political consequence was that Europe's wars of the seventeenth and eighteenth centuries were fought out in the islands as well as on the continent. The epidemiological consequence was the slaughter of tens of thousands of nonimmune soldiers and sailors sent to do that fighting who died, not from battle, but from yellow fever and malaria. During the years 1793-6, for example, the British lost 80,000 troops in the West Indies, the bulk of them to this pair of tropical killers. Much of that mortality had been sustained during the British invasion of San Dom-ingue, where the slaves were revolting against French masters. Because of their ability to resist the disease, the ex-slaves had a strong ally in yellow fever, as the disease counterattacked the British with deadly effect.

Next came the French attempt to retake San Dom-ingue. Briefly they met with success. Then they met with yellow fever and within 10 months of landing had lost some 40,000 men including 1,500 officers and their commander, Napoleon's brother-in-law.

Yellow fever flourished in the Caribbean wherever the virus discovered a sufficient number of nonimmune persons to host it, for the A. aegypti is a domesticated mosquito that lives close to and feeds on humans and breeds in rain-filled gouges humans have made in the earth or in any of the discarded accoutrements of civilization that hold water. Anoph-eline mosquitoes that carry malaria, however, are not so tied to humankind and consequently are not spread evenly across the Caribbean. Thus August Hirsch (1883-6) identified Cuba, Jamaica, Santo Domingo, Guadeloupe, Dominica, Martinique, St. Lucia, Grenada, Trinidad, and Tobago as the places where the disease was most prevalent. He termed malaria "rare" in the Bahamas, Antigua, St. Vincent, and Barbados, where today we know that for a variety of reasons anopheline mosquitoes had difficulty in breeding successfully.

It should be stressed that, although yellow fever and malaria were the chief killers of whites in the West Indies, the victims were generally newcomers. Old residents, by contrast, usually suffered from yellow fever while quite young, at an age when the malady is relatively gentle with its victims, and in the process earned a lifetime of immunity against another visitation. Similarly, resistance to malaria was gained by repeated bouts with the disease although this was not so perfect an immunity as that acquired against yellow fever.

Blacks, on the other hand, although remarkably resistant to these diseases, suffered greatly from other illnesses that generally bypassed whites, and their resulting experience with disease was so different from that of whites that physicians were moved to write whole books on the subject. They identified one of the most fearful diseases of slave infants as the "9-day fits," which today would be diagnosed as neonatal tetanus triggered by an infected umbilical stump. Another example of a presumed black disease came from the same source. Plantations were littered with the droppings of horses and oxen containing tetanus spores, so the almost always fatal illness struck hard at slaves with open wounds resulting from frequent accidents with machinery, and because almost all went barefoot.

Poor nutrition, however, was probably the biggest destroyer of slave life, either directly because of nutritional diseases or indirectly because it left slaves less able to combat other ailments. Their basic diets of very little salted fish (jerked beef in Cuba) and lots of manioc and other root crops, plantains, rice, and corn produced symptoms of frank beriberi (related to thiamine deficiency) and pellagra (related to niacin deficiency) among slaves all across the Caribbean. Of the two, beriberi had the greatest demographic impact because thiamine deficiency is passed along from mother to infant in her milk, and infantile beriberi has proved historically to be almost invariably fatal.

Another major disease of the slave young was protein-energy malnutrition (PEM) brought on by a lack of whole protein in the diet. Slave infants were nursed by their mothers for about 3 years and were thus safe from the disease, which struck after they were weaned to a diet of pap almost totally devoid of good-quality protein. Some developed marasmus, a symptomatic pole of PEM in which the child simply wastes away. More often, however, they developed the swollen bellies of kwashiorkor, which are evident in physicians' descriptions of slave children. The prevalence of PEM in Barbados can be assumed from the conclusions of an investigation of the teeth of excavated slave skeletons, which revealed considerable nutritional stress at the time of weaning (Handler and Corruccini 1986).

The term dropsy was very frequently recorded as the cause of slave deaths, and doubtless when a child died of kwashiorkor, this was called dropsy. Similarly, the fluid accumulations of wet beriberi would have been called dropsy. Other dropsy cases were probably the work of hypertensive heart disease. Apparently in the largely salt-free environment of sub-Saharan Africa, black bodies had developed an ability to retain the mineral that is crucial to life itself (Wilson 1986). In the West Indies, however, slaves received an abundance of the mineral in their salted fish or beef, and in addition, were issued a great deal more as a condiment. For a people with the knack for retaining salt, this must have provoked much fluid accumulation and frequently proved deadly.

Dry beriberi's symptoms are remarkably similar to those of a mysterious illness of the slaves called the mal d'estomac in some islands and hatiweri or cachexia Africana in others. Physicians first thought that the lack of energy, breathlessness, and nerve problems including an unsteady, high-stepping gait - the symptom constellation of mal d'estomac — were caused by dirt eating; later investigators have suspected that the cause was hookworm disease. But because, as will be discussed shortly, blacks of West African origin are very resistant to the ravages of hookworm infection, dry beriberi remains the best explanation for this particular ailment.

Another disease that remained a mystery at least until recently, and which struck white troops as well as slaves, was the "dry belly ache." But research by Jerome Handler, Arthur Aufderheide, and others (1986) has made it clear that this ailment was actually lead poisoning; the lead being ingested in nonaged rum made with distilling equipment containing the metal and from molasses and sugar whose production also involved the leaching of lead from some of the equipment.

The successful slave revolution in San Domingo brought ruin to one major sugar-producing area of the Caribbean, whereas the abolition of the British slave trade in 1807, and then of British slavery in 1833, severely damaged most other sugar islands. This left the field to Cuba, which developed a flourishing contraband slave trade, and became the new focus of such African diseases as filariasis, leprosy, and yaws while at the same time achieving the unhappy distinction of becoming the nineteenth-century yellow fever capital of the hemisphere.

Other diseases also became prevalent during this period. Typhoid, for example, was an increasingly serious health problem in the West Indies throughout the century, although in part this trend doubtless reflects nothing more than better diagnosis as physicians learned to untangle typhus and typhoid from each other and both from the whole bundle of fevers that bedeviled the region. Because the fouled water supplies that brought typhoid were serious problems everywhere, it was predictable that the islands would pay a steep price for this condition when the pandemics of Asiatic cholera reached them. This first occurred in Cuba where, during the years 1833-6, the disease wiped out at least 8 percent of the slave population.

The 1850s, however, were the real cholera years for the Caribbean during which as many as 34,000 slaves in Cuba perished, between 40,000 and 50,000 individuals died in Jamaica, another 20,000 to 25,000 lives were lost in Barbados, and at least 26,000 succumbed in Puerto Rico. Cholera returned a final time to Cuba in 1867, where it claimed a few thousand more lives before leaving the region forever. In its wake, however, it left a far greater percentage of black than white victims. Because there is no racial predisposition to cholera, the best explanation for this lies in the impoverished circumstances of blacks on the one hand and lesions of nutrition that deprived them of gastric acid to fight cholera vibrios on the other (Kiple 1985).

The fact that tuberculosis waited until the nineteenth century to fall on blacks with the fury that it did is less easy to explain. Tuberculosis was not one of the Euroasian diseases that blacks had experienced in Africa, and they proved to be extraordinarily susceptible to it when exposed. That such exposure was so long delayed suggests that the plantation probably served as a kind of quarantining device. After slavery, however, the disease exploded among them as many impoverished blacks crowded into the cities. In Havana, for example, the disease generated mortality rates approaching 1,000 per 100,000 population.

Nonetheless, although tuberculosis continued to rage, it was during the last half of the nineteenth century that much of the region began to experience a significant decline in mortality. Certainly some of the decline was due to nothing more than the end of slavery. But empirical observation also played a considerable role. Cholera had drawn attention to the dangers of bad water, and the last decades of the century witnessed important efforts to improve water supplies, with a resulting decrease in the prevalence of typhoid and dysentery. Empirical observation had also established once and for all the efficacy of quinine against malaria, and its regular use also brought important mortality reductions.

Cuba, however, was largely exempted from the mortality decline enjoyed elsewhere during this period. No sooner had the contraband slave trade come to an end, capping the pipeline of disease from Africa, and no sooner had cholera receded than the Ten Years' War (1868-78) erupted. Soldiers arrived from Spain to extinguish the rebellion only to introduce smallpox and be extinguished themselves by that disease in tandem with yellow fever and malaria. A few years later, this pattern was repeated as Spain once more sent soldiers to Cuba to quell the rebellion that began in 1895. In both instances, yellow fever and malaria claimed far more lives than did bullets, with war and disease slashing Cuba's population from about 1.8 million in 1895 to 1.5 million in 1899 - fully a 15 percent reduction in less than 5 years.

VII. The Geography of Human Disease The Twentieth Century

The twentieth century has been a time of a tremendous mortality decline in the Caribbean as it has in much of the rest of the underdeveloped world. Improved nutrition, great strides in public health and sanitation, and the increasing sophistication of modern medicine have all played significant roles.

Yellow fever's Caribbean career came to a close during the occupation of Cuba by the United States when the theory of Cuban physician Carlos Finlay that the disease was mosquito-borne was proved correct by a Yellow Fever Commission headed by Walter Reed. Ensuing mosquito control measures were successful in throttling the long-dreaded malady in Cuba, and, armed with this new epidemiological understanding of the disease, William Gorgas was able to eliminate yellow fever in Panama where the canal was under construction. The disease flared up one last time in Cuba in 1905 but, after that, retreated from the whole of the Caribbean.

The public health activities of the U.S. Army also brought sweeping sanitary reforms to Cuba, which in Havana resulted in a decrease of "close to 30 percent in the crude death rate in that city by 1902" (Diaz-Briquets 1983). Similarly the annexation of Puerto Rico, and the occupation of the Dominican Republic and Haiti by the United States, although deplorable, nonetheless brought important health benefits to these countries in the form of cleaner water supplies, adequate sewage disposal systems, mosquito control, and medical treatment.

Just at the time when one African disease, yellow fever, was conquered, however, another African malady was revealed. In Puerto Rico, the Puerto Rico Anemia Commission discovered a hookworm problem estimated to be causing one third of all deaths on the island. War was declared on this disease, as well as on malaria and yaws, in much of the Caribbean by the Rockefeller Sanitary Commission and later by the Rockefeller International Health Board. The Rockefeller physicians in the West Indies and in the southern United States discovered that black people were resistant to hookworm disease although not to hookworm infection, whereas pockets of poor whites and Asians in the West Indies living side by side with blacks suffered severely from the disease.

Tuberculosis receded among Caribbean blacks as mysteriously as it had appeared, and it had ceased to be much of a health problem long before the end of World War II when medicine finally got its "magic bullet" against the malady. Yet the greatest gains in reduced mortality have taken place among the very young. Infant mortality rates, which were as high as

303 per 1,000 live births in Barbados earlier in the century, have plummeted in most places to rates of 20 per 1,000 or below. Exceptions are the Dominican Republic and especially Haiti, where age-old problems of neonatal tetanus, malaria, yaws, and other African diseases still linger.

Less satisfactory have been improvements in the nutrition of the young, and it is quite possible that fully half the deaths that have taken place among the age group 1 to 4 years in Hispaniola and Jamaica in recent years are the result of PEM — the same disease that proved so devastating to the slave young of yesterday. Other problems or potential problems left over from the disease ecology of that period also remain. Yellow fever is still very much alive in its jungle form in the treetops of South America and, with the present lax mosquito control measures, could easily return to the Caribbean as it in fact attempted to do in Trinidad during 1954. Indeed the ever increasing number of dengue epidemics that have taken place of late in the region show just how vulnerable the West Indies are to yellow fever, because the same mosquito spreads both diseases.

Similarly the pockets of falciparum malaria that still exist may also suddenly expand, as happened in Cuba during the 1920s when tens of thousands of Haitian and Jamaican laborers entered the country bringing the illnesses with them. Haiti, in particular, remains a focus of the infection, as an epidemic there in 1963 so vividly demonstrated by assaulting some 75,000 individuals.

Filariasis has not been completely eradicated. In fact, the people of Puerto Rico were found to have a surprisingly high rate of infection during a survey in the 1960s. In Barbados, however, where the disease was once notorious, the malady (or at least its most notable symptoms) has become rare. Schistosomiasis may still be found in some of the Lesser Antilles, and small endemic foci have been located in the Dominican Republic as well, and intestinal parasites remain widespread across the Caribbean region. In addition, another new, seemingly African disease - AIDS -has surfaced in Haiti, although the extent to which this threatens the rest of the Caribbean remains to be seen.

One of the greatest assaults of late mounted on remaining health problems in the region has taken place in Cuba, where the government of Fidel Castro has made improved health a top priority. The extension of health services to the countryside, mass vaccination campaigns, and important advances in sanitation have allowed the Cuban people to attain a life expectancy considerably more favor able than that enjoyed by those in most other developing nations.

Yet it is ironic that today the greatest threat to the health of West Indian people is their own relatively good health. With the tremendous strides made in reducing infant and child mortality, populations have mushroomed in alarming fashion. In the past, much of the excess population of the region migrated to Great Britain or to the United States; that safety valve has been shut down by the recent restrictions both of these countries have placed on immigration from the islands. And they are islands, which by definition means a limited area of land. If, as is the case in so many of them, land is put into sugar instead of foodstuffs, then the latter must be imported. Thus, swelling populations can only threaten the level of their nutrition while placing perhaps impossible pressures on the ability of governments to continue to deliver essential medical and sanitary services.

Kenneth F. Kiple

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