The Colonial Response to Epidemics in the Gold Coast

The Colonial Response to Epidemics in the Gold Coast


Anita Johnson
Independent Study Project
UC/EAP at University of Ghana, Legon
9 December, 2008
Advisor: Dr. Laura McGough













Table of Contents
Introduction 3
Key Concepts 4
Introduction 4
The Challenges of Tropical Medicine 5
Sanitation 7
Research 9
Plague 11
Smallpox 15
Malaria 20
Comparative Analysis 26
Curative or Preventative Measures 27
Physical Characteristics 27
Practicality and Public Reception 29
External Forces 31
Conclusion 32







Introduction
Disease in the Gold Coast had wide-sweeping effects throughout the colonies. Numerous diseases, including malaria, smallpox, trypanosomiasis, yellow fever, yaws, tuberculosis, leprosy and others threatened the lives of both Africans and their colonizers. In a similar way, epidemics of European diseases like the plague took their toll on those living in the Gold Coast. “Between 1822-1825, the death rate for civilian and military officials was 450 per thousand…Between 1881 and 1897, death rate of Gold Coast officials averaged 76 per thousand”.1 In order for the colony to develop in accordance with British goals for the colony, disease had to be controlled. However, this task was not easily managed, and prevention measures did not always achieve their desired ends. Several programs and policies implemented in the Gold Coast were successful, and modern Ghanaians do not fear the same illnesses. For example, plague, a disease of rats and insanitation, has not appeared in the area since 1924. Similarly, although smallpox remained a serious threat to health throughout the first half of the twentieth century, it has been eradicated from Ghana and indeed, the entire world. Alternatively, not every policy of disease prevention was successful, even in the longer-term; malaria is still the primary killer of Ghanaian children under five years. What accounts for these varied histories of the disease in the former Gold Coast? How did the different colonial policies towards these diseases contribute to these results? This paper will examine these questions and the issues surrounding public health in the Gold Coast, especially in the first decades of the twentieth century.
Epidemics, widespread outbreaks of disease affecting a substantially larger portion of the population than expected, have the ability to change political, social and economic patterns of an area. Epidemics were major issues in tropical Africa, especially as European powers began to divide up its area into colonies. Stopping epidemics was of the utmost importance for each colony, as developing a colony required healthy officials and at least a minimal level of health for the natives of the colony. Helen Tilley describes the need for an end to medical epidemics in the Gold Coast. While the immediate needs of controlling the epidemic were important, two imperial aims were simultaneously at work motivating each power. “No nation wanted to be trumped scientifically or otherwise by one of its rivals. More to the point, however, the colonial powers believed that, until the epidemics could be stopped, tropical Africa’s economic future hung in the balance.”2 A genuine concern for the well-being of the inhabitants of the colony is notably absent.

Key Concepts
Introduction.
The establishment of medical infrastructure in the Gold Coast occurred much later than it was needed. The Gold Coast became a colony in 1874, but it was almost ten years until the first administrative officers were appointed into service. In response to all of the colony’s health problems, the first Chief Medical Officer, Dr. J. McCarthy was appointed in 1883, and the first medical officer of health, Dr. J. F. Easmon was appointed in 1884.3 Responses to disease in the Gold Coast took several forms: prophylaxis, racial segregation, immunizations, health inspections, educating the public on health issues, improvements on public facilities from latrines to hospitals, and clearing lagoons and other obvious habitats for mosquitoes. In the 1880s Accra was the filthiest city in the whole colony, but as the new capital colonial officials became concerned with turning the tides in favor of Accra. Improvements were needed in the areas of clean water supply, waste disposal, animal control, hospital care, city planning, as well as in disease research, prevention, and control. However, progress and reforms were difficult because of the basic setup of health policy in British West Africa.
Command of health was not a centralized organization like the Colonial Office but was instead in the control of local governors. As each individual governor was different, policies varied greatly, based on who held the power. Governor Gilbert Carter denied the building of a municipal water system because every European purchased water tanks and Africans did not need pure water,4 but a few years later, Governor Guggisberg nobly altered health services in the Gold Coast “from a primitive state to modern, the substantive extension of the service to all Africans, African embracement of modern medicine, major attacks on important prevalent diseases and marked progress in sanitation and environmental health.”5 This unpredictable change in administrative attitude accounts for some of the varied policies in the beginning of the century.
The Challenges of Tropical Medicine
Arguably the two largest problems with handling epidemics of disease in the Gold Coast were a general lack of knowledge of tropical diseases and their treatments, and a lack of European manpower to research and implement policy to solve these health problems in the colony. Academic learning about the diseases that tortured the Gold Coast came in the form of research, from both West African and European nations. During the start of the twentieth century, various institutions were established to research tropical illnesses and ways to combat them. The first Colonial Secretary to actively promote research across the colonies was Joseph Chamberlain, who was in office from 1895-1903. Although Secretary Chamberlain did help to build administration and institutional reforms, his primary aim was the needs of the European officers, and secondary aim to provide for other Europeans, including merchants and missionaries. Similarly, during his term of office, he promoted the attitude that the task of providing sanitary amenities and doctors would be the responsibility of Town Councils. Each would be required to levy taxes and provide these basic health needs for themselves.6
Patrick Manson, termed the “father of tropical medicine”7 was appointed as the Colonial Office’s Medical Advisor in 1897, and began to advocate for increased support for research and institutions, including the creation of the London School of Tropical Medicine. This school would not only centralize medical research, but also train officers for duty in such regions. There was a general lack of desire to work in tropical Africa because of the low pay and high death rate for European officials. For these reasons, by 1908 only one medical officer was making research his primary responsibility. This was also due to the need for medical practitioners to help individual patients, thus taking away time that would have been otherwise used for research. Manson believed that the School of Tropical Medicine would help to attract more officials into duty in the Gold Coast.
Another institution that aided study of tropical medicine for the benefit of British colonies was the School of Tropical Medicine at Liverpool, established by Sir Alfred Jones. This institution focused on research of a few of the most volatile illnesses, especially malaria, instead of training medical officers as the London School.8 In 1901, Chamberlain established the Tropical Diseases Research Fund, which began governmental funding of tropical disease research throughout the British Empire, and inspired the sharing of knowledge of tropical diseases. A controversial step in the availability of officers for work in tropical Africa was Chamberlain’s announcement that all appointees to colonial office in Africa would be required to be trained at one of the Schools of Tropical Medicine. This created a better informed group of officials who worked in the Gold Coast, but it conversely narrowed the field of eligible candidates and contributed to the shortage of medical officers.
In 1902, Governor Nathan proposed the addition of a health department for the Gold Coast, which manifested itself as the West African Medical Service. The formation of the West African Medical Service was a direct attack on the problem of lack of colonial medical officers. It set standards for pay and benefits “in order to make employment in West Africa more attractive.”9 Although the creation of the service did not immediately inspire large numbers of volunteers to come to the Gold Coast, the Service became one of the most prominent advocates for change in health administration in the following decades. A Bureau of Hygiene and Tropical Diseases was formed in London in 1908. The aim of this bureau was to collect the efforts of worldwide sanitary services and to collaborate knowledge into a single place. This bureau from the Colonial Office stemmed from the need to fight sleeping sickness in tropical Africa, but by 1926 encompassed all aspects of insanitation and resulting diseases.10
Sanitation
The state of Accra before 1900 was total disarray. There was no plan for the layout of the city, and no laws to enforce sanitary practices. In 1883, laws were enacted under the Native Jurisdiction Ordinance to create and enforce sanitation procedure. Under this act, chiefs of local villages were given responsibilities in the enforcement of these laws, and most chiefs actually did accept these roles.11 However, public health policy and the resulting progress from organizational and sanitation laws did not begin in earnest until the turn of the century. In fact, the Municipalities Ordinance of 1889, passed by the Colonial Office, stopped all expenditures on public works and sanitation except as necessary to ensure the comfort of European officials;12 any sanitary measures, including water supply, would be the responsibility of each locality to raise the necessary funds. Thomas Gale emphasizes the absurdity of this extraordinary expectation:
It is difficult to see how the authorities could seriously have expected town councils to construct expensive public works projects when no government, even with the full resources of a colony behind it, had been able to provide one town with a satisfactory water, drainage, or sewer system.”13
However, the need for a public health program increased in the 1890s as more Europeans, lacking immunity, arrived. Approximately 40 Europeans died annually from 1895-1897.14 This continually high number of deaths inspired the need for more medical help, as the British needed to keep up appearances in the Gold Coast in order to attract more Europeans to live there.
The turn of the century brought an extremely beneficial combination of new anti-malaria procedures, improved sanitation measures and better infrastructure that brought the death rate for Gold Coast officials down to an average eleven per thousand in 1907-1911.15 However, a lack of these health measures for the majority of the African population created continuous problems for the government of the Gold Coast for the following decades. The West African Medical Service, established in 1902, worked quickly and authorized its own Sanitary Branch in 1908, as Governor Rodger stated that “the only way of securing really efficient and continuous sanitary work is by means of a comprehensive scheme; establishing a special sanitary branch… and the standardizing of the whole system of sanitation.”16 Dr. T E Rice became the first head of this branch, which was controlled by government officials including a minister of health, engineers, and other elected non-officials.17 The formation of this sanitary branch was extremely influential in implementing further sanitary measures, as it provided a more consistent and accurate assessment of the sanitary needs of the Gold Coast regardless of the governor or other administrators in power. The final significant institution of the start of the twentieth century aimed at improving health in the Gold Coast, if only for the European population, was formed in 1912. A Central Health Board with a Principal Medical Officer, entrusted with the power to make, alter, or revoke rules of public health, was established under the Towns and Public Health Ordinance. This further detached the workings of public health from the colonial government, which had already displayed its lack of interest in promoting public health initiatives.
Research
The modern Medical Research Institute in Accra began as a pathological laboratory at the start of the twentieth century, and has been a major actor in researching tropical medicine, preventing disease through the production of vaccinations, and treating illnesses when an outbreak does occur. Laboratory work in pathology was being done as early as 1900, but the existence of an official, government-recognized laboratory did not come until 1908, when an outbreak of the plague prompted a new approach to researching medicine in the Gold Coast. One report claims that the Accra Laboratory began as a Plague Laboratory in 1908 when Professor William Simpson brought equipment and materials to handle the outbreak of the plague.18 Control of the Laboratory was put in the hands of the deputy Principal Medical Officer for a time, but the work of the lab was further hindered by continual changes in leadership. However, the need for vaccines and other products of the lab superseded the problems that it faced.
The first head of the lab, Dr. W. H. Graham, along with assistants Dr. A. Connal and Dr. A. Pickels, worked in both research and clinical investigation, working not only to stop the plague, but to ensure the finality of the last case and ensure that no further outbreaks would occur.19 But the success and value of the Accra Laboratory did not end with the end of the plague. In 1909, the laboratory under Dr. G. E. H. Le Fanu successfully produced an active vaccine lymph for smallpox vaccination. This was an extremely important step in the fight against smallpox, because the smallpox vaccine is not easily transported and is easily denatured by tropical African heat. Production of vaccines began on a large scale in 1910, and the lab began to do a larger variety of tasks from “routine work such as mosquito, slaughterhouse, medico-legal, malaria, and trypanosomiasis work; examination of faeces, urine, sputum and blood as well as post-mortem work.”20
Dr. J. W. Scott MacFie became the first full-time pathologist and medical research scientist in the country in 1914, and re-focused the lab away from vaccine production, to a more research-oriented approach. However, the First World War interfered with the availability of medical officers, and likewise, the plague outbreak of 1917 reverted attention away from research again. There were also problems in acquiring the proper data and ill persons, as the colony was not very populous and had no methods for a systematic collection of specimens for research. Dr J. W. Scott MacFie lamented that “even when something of interest is discovered in a specimen… it is generally quite impossible to obtain either an adequate account of the clinical conditions presented by the patient or any further materials for study from the same case.”21 In 1920, the lab became the Medical Research Institute in Ghana, as declared by the Secretary of State for the Colonies. This provided for a consistent staff force including six pathologists. The construction of Korle Bu Hospital, which opened in 1923, was another step that actively supported medical research in the Gold Coast. Part of this new building was an expanded research institute, and an emphasis on communication between researchers and physicians. Throughout the remainder of the colonial period, similar troubles such as a short turnover for officers and pathologists and changing needs for the colony hindered its capability to do research, but its work at the start of the twentieth century has had the most significant and far-reaching impact.

Plague
Plague, the disease most commonly associated with rats and pestilence, came in the form of an epidemic to the Gold Coast colony in 1908 and 1924. Additionally, a minor, non-epidemic outbreak occurred in 1917-1919. Because of its history throughout Europe and other parts of the world, its progress, including its method of transmission and infection, was already known before it came to the Gold Coast. The disease is caused by the bacillus Pasteurella pestis, and can be bubonic, spread from flea to an intermediate rat to human, or pneumonic, spread from human to human through the bacillus in the air. Epidemics often occur in both forms, beginning with an introduction of the bubonic form into a community. If the bacillus spreads into the victim’s lungs, it can then be spread in the pneumonic form, which is also more lethal. Septaecemic plague, which occurs when the bacillus multiplies in the host’s bloodstream, is the most fatal, but was not witnessed in the discussed Gold Coast epidemics.
Because secondary pneumonia can develop from bubonic plague, thereby becoming highly contagious, control of the disease must take several forms. It is necessary to contain and control both rats and victims of the disease in order to stop the spread of plague. The outbreak of plague in the Gold Coast was not difficult to contain for lack of European experience the disease, and it did not require the development of new tactics or approaches to combating the disease. However, despite these apparent advantages, its effect on the Gold Coast was great. In the case of each epidemic in the Gold Coast, the breadth of the disease remained small, affecting only the Accra area and the distance to Cape Coast. However, the outbreaks are significant because of the high mortality brought by each new infection. In the 1908 outbreak “258 died, giving a mortality of 85%… cases outside Accra with nearly 100% fatality…The cases outside Accra were mostly of the pneumonic type indicating that the spread of disease was effected by humans with secondary pneumonic plague.”22
Colonial response to outbreaks of plague represents a clash between a European disease and medical practices and traditional African societies. Before the plague hit, the Gold Coast administration was unprepared to deal with any major health crisis. The first indication of a serious problem was a rat epizootic in the latter months of 1907, but the effects of this change in life in Accra was not realized until a pneumonic patient arrived at the hospital on January 5, 1908.23 The disease was identified largely by the work of three men, led by Accra’s Principal Medical Officer, Dr. Langley and his Deputy Principal Medical Officer for the Gold Coast, Dr. Garland. On January 9, 1908, instance of plague was confirmed by a post-mortem test performed by Langley’s team. None of Langley’s team had any previous experience with plague outbreaks.24 A first step in qualifying an epidemic instead of an isolated case involved the collection of dead rats in the colony for testing. The team concluded that infected rats arrived in the Gold Coast via the port of Accra. While identification was a positive step in the right direction, it caused unpleasant reaction from the population of the Gold Coast. The existence of such a lethal disease such that had killed millions of Europeans in the Black Death epidemic in the Middle Ages frightened residents, and acknowledging its existence to the international community would seriously hinder trade. However, once the plague was identified, the administration’s task turned to containment.
Dr. Garland suggested to Acting-Governor Major H. Bryan, who was at the head of government while Governor Rodger was in England, to call together all the chiefs of the Accra area, mostly Gas, to inform them of the epidemic and the colonial government’s plans to stop the disease. It was important to have the support of the Ga chiefs, especially because the disease was not endemic to the area, and the chiefs and their medical experts had no previous experience with the disease. Also, since many of the measures taken to combat the disease would be controversial or be of inconvenience to the residents of certain areas, especially that of Jamestown, the chief’s support and cooperation was essential.
Professor William J. Simpsom arrived in the Gold Coast in February, and began to implement measures to contain the disease. Professor Simpsom was an expert in combating the plague, and had led a successful campaign in Calcutta in 1896. His experience was extremely valued, but his effective tactics were also sometimes controversial.25 Because he incorrectly believed that plague could be transmitted via infected food, clothes, or through cuts on the feet in addition to the correct methods of transmission of fleas and their intermediate, rats, he most strongly advocated the burning of villages to create a new, plague-free village. This tactic was often less expensive than fumigation.26 By the time of his arrival, plague had already spread along the important trade route from Accra to Cape Coast. This spread throughout the coast and of more concern, across trade routes, made containment more difficult, and incited the need for further sanitary and preventative measures over a wider area. Containment measures were generally effective, and bubonic plague was not often found outside Accra.27 However, the spread of disease outside of Accra was much more rapid because it no longer involved merely the containment of bubonic plague and its rat intermediary, but the containment of pneumonic plague, spread from human to human, even after death. Previous advancements in transportation and communication, such as the Sekondi-Kumasi railway further facilitated the spread of disease through pneumonic means.28 Simpson’s arrival began an announcement for mandatory vaccinations, and a strengthening of existing sanitary laws. Simpson’s decrees demanded a certification of vaccination in order to pass in or out of Accra; 16,000 people in James Town alone were vaccinated.29 Containment of the plague epidemic was thus aided by the previous knowledge of the disease: because the method of transmission was known and an effective vaccine was already established by the time the 1908 epidemic hit, application of already acquired methods and knowledge were all that was needed to end the epidemic.
Furthermore, sanitary laws were enforced to a greater degree, as local officials were conscious of the method of bubonic transmission, rats. Fear of the disease prevailed over insanitary practices. It was in this time that a West African Medical Service reorganization committee suggested the formation of a Sanitary Branch to deal with the sanitary issues throughout all of West Africa, especially with respect to controlling epidemic diseases like plague that could be spread from colony to colony.30 This branch was not opened until the plague had left the Gold Coast, but it is important to note that the colonial government recognized the connection between sanitary conditions and controlling epidemic diseases. This important step in dealing with the 1908 epidemic also prevented future outbreaks and contributed to improved containment when the did arise. The British government and the Colonial office also knew that study into the plague bacteria was necessary in order to learn more about the current outbreak and prevent future ones. Because of the combination of this need for studying plague and the need to produce vaccines in the Gold Coast instead of in shipments from Britain, the Pathological Laboratory in Accra became the Plague Laboratory in 1908 to cope with the disease.
The 1924 outbreak of plague attacked a greatly changed Gold Coast. Numerous steps in medical and sanitary advancement had been made in the sixteen years, but the introduction of plague from the port of Sekondi challenged these advancements at a time when sanitary laws were at their height. As previously mentioned, ease of communication and transportation aided the spread of the disease, and indeed, the expansion of such systems grew between the two epidemics to make the 1924 outbreak even more difficult to contain. A constant between the two epidemics was the help of Professor Simpson, who was again in the Gold Coast, this time on another medical mission. His presence and expertise on plague greatly aided the attack against the plague. This 1924 outbreak, however, occurred in a much smaller in incidence, although mortality was similarly extraordinarily high. This can be contributed to advanced sanitary and medical laws passed between epidemics to help contain the plague, as well as better acceptance of containment strategies because of previous experiences.
The success of eradicating plague from the Gold Coast indicates that improvements in preventing and containing the disease improved with continued practice in the greater instance of disease. The local government was able to better handle outbreaks of the plague as methods of containment were proven in other parts of West Africa and the world. Although introduction of the plague via outside sources, especially the port of Accra, could not be avoided, advancements in sanitation and governmental bureaucracy made the entirety of the Gold Coast safer and free of disease.

Smallpox
Smallpox was another disease that plagued the Gold Coast at the start of the twentieth century. However, the history of this disease has taken a much different course than other diseases in history; it became the first disease to be eradicated on a global scale in 1977. Smallpox is transmitted only through a virus that can be transported in droplets from the mouth or nose. Inhalation of the virus initiates infection that remains dormant for ten to twelve days. Symptoms include “high fever and aching pains. Two to four days later a rash develops over the face which rapidly spreads to the rest of the body, the extremities being more heavily afflicted. The slightly raised red macular lesions soon fill with fluid and these become deep-seated pustular lesions by the fourth or fifth day. Scabs begin to form by the end of the second week and separate by the third or fourth week.”31 Death occurs most often during the second week of the illness due to the strength of the virus’ infection. In this way, smallpox is highly contagious and lethal. Outbreaks of smallpox ravaged the population of the Gold Coast in 1901, 1925, 1930, 1941, 1942, 1945-48, 1952, and 1953; the highest instances came in 1924 and 1942 with more than 1950 cases.32 The best way to combat the disease is through vaccination before an epidemic breaks out. Once an epidemic breaks it is much more difficult to vaccinate large parts of the area to control its spread. However, officials encountered different problems in implementation, as the African natives already had methods of inoculation that had been practiced for centuries.
From the view of combating the disease, a positive aspect of smallpox is that a survivor retains lifetime immunity. This fact was observed by natives of West Africa, who practiced inoculation in order to halt the spread of disease. However, the practice of inoculation is incredibly controversial. Before European medicine became available, it was the only option to stop the disease. Herbert argues that “inoculation was an empirical rather than a religious or magical intervention… it was used as moments of great peril when isolation of victims and other measures had failed to halt the spread of disease.”33 Some inoculated by traditional methods successfully achieved immunity, but attempts did also result in contagion of the disease and consequent death. This is not to say that inoculation methods were completely ineffective, but instead that several factors contributed to the effectiveness of the inoculation, and methods varied across West Africa; the source of the inoculation material, where, when, and how it was inserted into the healthy person, as well as the individual himself. Herbert summarizes the findings of native West Africans:
It had to be done before the individual was infected naturally (always a problem during epidemics- the only time it was resorted to in Africa because of the impossibility of preserving variola for use at a safer time). There was much less chance of a severe case of smallpox and of secondary infection if the matter was inserted through a superficial scratch than a deep incision. And the best technique of all was to use variola from an inoculation site rather than from a natural smallpox eruption.34
Smallpox was dealt with in this way even before European medicine arrived and the advent of the colonial era. However, it is an unreliable method because the inoculation material, the variola, is not controlled or tested for strength; trust and the experience of the inoculator are the only safeguards against becoming infected with such a lethal disease. Colonial officials noted that often, a single case of the disease created a rush from neighboring villages to be inoculated. Those who came to be inoculated accidentally exposed themselves to the disease by their proximity to the patient, even before receiving the treatment. The inoculation material, usually taken directly from the sores of the patient, did often result in serious illness and death. Conversely, the variola could have been insufficient and immunity not imparted, and the person merely exposed themselves to the disease unnecessarily. Furthermore, an infected person would have already returned to their own village to possibly infect a new population before realizing the negative effects of their inoculation experience. The 1910 Medical and Sanitary Report expresses that there was “no doubt” that native inoculation attempts were to blame for “a large number” of deaths and the spread of the disease.35 The 1920 Vaccination Ordinance attempted to stop this by outlawing traditional inoculation.36
These are the attitudes and actions that British policy attempted to combat with the introduction of the smallpox vaccine. Control of smallpox was a much more psychological and logistical battle, rather than a sanitary or scientific one; the vaccine had already been created and developed. Containment and treatment techniques were met with more resistance as favor in local methods coincided with mistrust of European methods. Local officials had to first obtain the proper equipment to perform vaccinations, but also had to earn the support and respect of the native African population and convince them that European vaccinations were better than local methods of inoculation.
The next challenge that colonial officials faced was vaccine production. Vaccines transported from Britain, because of the difficulty in maintaining high-quality vaccines during this journey, were not sufficiently effective. Furthermore, because the trip was expensive and only a limited number of vaccines could be imported at a time, mass vaccination was only possible when large outbreaks occurred.37 Dr. G. D. H. Le Fanu’s production of a smallpox vaccine at the Accra Laboratory was a significant step in subduing the disease in the Gold Coast. Starting in 1911, the lab was able to produce the vaccine consistently, but the problems of reaching the interior of the Gold Coast without the lymph denaturing, and a lack of acceptance by the African population still existed.38 The first public vaccinator began work in Ashanti in 1911, and led the first coordinated attempt at mass vaccination without the preexistence of a serious outbreak. The success of this project continued, as the number of African public vaccinators increased to five by 1917, operating throughout the country.39 The year 1920 brought the aforementioned Vaccine Ordinance, which forbade traditional inoculation techniques, but also made vaccinations mandatory. Africans were forced to come to grips with their fears about the illness and the Europeans’ anti-smallpox tactics, and “by 1925, Africans… were generally appreciative of the usefulness of vaccination and chiefs and people were in the habit of ‘crying out for vaccination.’ By the 1940s and 1950s, there was general African acceptance of vaccination.”40
However, the existence of a vaccine and the acceptance of that vaccine by the general public is still a distance from eradication of the disease from an area or the entire world. In 1959, the World Health Organization (WHO) implemented a plan to stop smallpox. This was an ambitious goal to achieve what no other medical policy had ever achieved: to see a complete end to an illness that had killed millions. An attempt to eradicate malaria was already in progress, and its failure was less than encouraging for those who set up the campaign against smallpox.41 At that time, an estimated 10-15 million people were contracting the disease in 44 countries every year.42 However, by 1967, it was clear that the campaign was inadequate, and that only a shift in policy would be necessary. The WHO set a new goal to have smallpox eradicated by 1977, with the primary goal of zero cases of smallpox, and not simply majority or even global vaccination. This also required the perfection of the vaccine itself, a goal in itself which took four years to achieve. Even the technique of administering the vaccine went through several years of development before it became perfected. Furthermore, each program was regionally specific, so different modes of attacking the disease were employed throughout the world. This involved not only the team of vaccinators as before, but a team for surveillance and for public relations, ensuring that the community or village was knowledgeable about smallpox, its transmission, the importance of vaccination and identification of persons with the disease. All of these obstacles to the final goal set up a difficult task that took just more than the full ten years and cost more than $98 million. This high price left the mark of financial burden for many years, but this total is still incredibly small compared with the $1000 million that was being spent annually on vaccination and quarantine measures before eradication was achieved.43 A 1978 publication from the Association of Schools of Public Health states emphatically that
Smallpox eradication requires not only the detection of cases (surveillance), but effective control of the disease (containment). Again, a change in the public's attitude was necessary… it is important to recognize the vital contribution of the people of the previously infected countries. International cooperation, national commitment, managerial expertise, and the field workers' dedication were all essential.44
The coordination of worldwide efforts achieved the WHO’s goals. The last known case of smallpox came from Somalia in October 1977, and the WHO declared eradication complete in May 1980.45 This was the first disease to be eradicated on a global scale, and paved the way for other eradication programs. However, while some have made significant gains, none have been entirely successful.

Malaria
The largest barrier to the problem of malaria in the colonial Gold Coast was the general lack of knowledge of the disease. Before the origins of malaria were known, treatment was difficult for lack of proper diagnosis. The symptoms of malaria were often confused with those of other common diseases in West Africa, and quinine was used only as treatment, but not a prophylactic.46 During the 1870s and 1880s, ignited by the discoveries of Louis Pasteur and Robert Koch, the germ theory of disease governed the understanding of disease throughout Britain and her colonies. Attempts were made to apply this theory to multiple diseases, including malaria. This incorrect assumption about the spread of malaria was beneficial in that it resulted in several sanitary measures that did in fact combat malaria. Swamplands were drained, and ideas about the possibility of a piped drainage system developed; these measures helped to destroy mosquito habitats, but the true effectiveness of these measures was unknown. Policy that was created to contain malaria took some of the most varied forms, from effective sanitation policy and inspections and residential segregation.
It was not until 1877 that Patrick Manson found that mosquitoes acted as an intermediary between the parasite and humans, and not until 1898 that entire process of transmission was discovered.47 The female Anopheles is a vector for the parasite to humans, so an adequate habitat, must be maintained for the mosquito to complete its life cycle, of egg, larva, pupa and adult, and transmit the parasite to the human victim . Malaria has been difficult to prevent because of the variety of habitats that mosquitoes utilize, from fresh water in swamps and wells to that in temporary puddles, slowly running water in streams or irrigation, storage facilities, and brackish water. General improvements in sanitation became the most effective steps towards controlling malaria. As knowledge of malaria expanded, and efforts to combat the disease became more concentrated, the disease still continued to take its toll on both European and African populations. Even in the era of highest enforcement of sanitary and anti-malarial measures, the 1920s and 1930s, usually between 6%-9% of all deaths in the colony can be attributed to malaria.48 Even in the 1950s, 15% of all hospital cases reported involved malaria. 49
Water
Water planning was one of the most contested issues between natives and the colonial government. Europeans were provided with safe options for water storage and officials utilized publicly financed metal tanks. The colonial government also worked to eliminate standing water where mosquitoes would be able to breed. However, these sources of water were often necessary for the native population’s water supply, as proper storage tanks were extremely expensive. Similarly, European residences were equipped with drain and sewage systems, while the majority of the colony had none. A plan for a basic system of sewage disposal began in 1893, when the Public Works Department received a boost at the request of officials, merchants, and other Europeans who had been living with only minimal city planning, where any drainage generally went straight into the sea.
In the area of improvements in safe water storage, the Victoria Reservoir was an introduction for the African population to colonial intervention in sanitary affairs, but also to colonialism’s unsatisfactory government programs. The reservoir was designed to allow Africans access to safe water, as opposed to mosquito and disease-laden ponds, but the application of this project created more conflict between the African and governing European populations. A dispatch from Governor Griffith calls the closure of Banya and book ponds in Accra and consequent opening of the Victoria Reservoir “one of the greatest achievements in the sanitary progress of the Colony” but also notes that it was severely opposed by the population to the extent that Governor Griffith was stoned while inspecting the construction project.50 The resulting water from the reservoir, some 3,000,000 gallons, was “potable” but still required precipitation to remove the yellow colour that resulted from the soil over which it flowed.51 However, this optimism was checked by even a government analyst, who described it as “unfit for domestic application” while dead bodies floated in it and other atrocities were connected with it.52 It was not until 1910 that the expensive task of constructing a piped water system in Accra commenced, and 1914 before the system was completed. In 1918, the second city in the Gold Coast, Sekondi, received piped water.53
Another important task of the Sanitary Branch for eliminating mosquito habitats included swamp drainage. This was an extremely necessary precaution, but it ran into dual opposition. The colonial government resisted this for financial reasons while the African population argued to retain their source of water and rebelled against the government’s substitutes like the Victoriasburg Reservoir. Swamps continue to be a problem for lack of financing. The Korle Lagoon reclamation process began in 1929, but when the process was still incomplete in 1950, the project was abandoned. Malaria is still a disease of major consequence in the Gold Coast because of this correlation between expensive tasks and inadequate funds to support the necessary anti-malarial measures.
Segregation
An initial response to the problem of health in the Gold Coast was racial segregation: European civilians were separated from health care officials, and both were segregated from the African population. As much as a quarter mile radius of space around housing was blocked off for the protection of Europeans. Only Africans who worked in the European housing were allowed within this radius. Dr. Robert Koch’s explanation that infants and children in malarial countries were the chief hosts of the parasite, known as the “native reservoir” theory, instigated the policy of segregation.54 Dr. J. F. Easmon began to advocate its use in 1893, and two years later, segregation began for the first time in all of West Africa.55 Members of an expedition to West Africa from the Royal Society of London, J. W. Stephens and S. R. Christophers also affirmed the effectiveness of segregation.56 Dr. Hopkins, the Principal Medical Officer of the colony wrote in 1910 that “it is as dangerous to live unsegregated from the natives in West Africa as it is to live in the immediate vicinity of a smallpox hospital in England” and considered segregation “the most effective and economical solution of the sanity problem of West Africa.”57 This practice continued, and was supported for decades without proof of its effectiveness; into the 1920s, malaria remained the primary cause of morbidity and mortality.58 However, with time, the effectiveness of segregation was questioned, and difficulties with its implementation grew; by the1940s, the policy of segregation ended. Anti-mosquito measures such as the use of mosquito nets and prophylaxis were also taken in conjunction with segregation. However, Stephen Addae argues that “it was clearly impossible to reduce mortality and morbidity among whites by a country-wide programme and campaign to root out malaria and yellow fever, without resorting to residential segregation,”59 while Twumasi asserts that cultural isolation was ineffective.60
The Colonial Office began to make significant gains in the way of medical and sanitary problems with the appointment of Manson as its Medical Advisor in 1897. This brought the realities of malaria in West Africa into the administration of the colonies. However, Manson and his colleague Ronald Ross disagreed on how to approach malaria prevention. Ross proposed continuing the strategy of swampland drainage, and adding the use of larvacides, while Manson advocated the use of “mosquito screens, bed nets, and regular quinine dosage…and he directed that priority emphasis be placed upon individual hygienic precautions.”61 However, swamp drainage and larvacides was an expensive endeavor that would be difficult or impossible to fully complete, but alternatively, Manson’s directives would prove difficult to extend to both the African and European populations. By 1902, the Accra Town Council was helping to educate the residents on hygiene and anti-malarial procedures.
Circulars were transmitted to district and sanitary officers at outstations directing that small depressions should be periodically drained or filled…All loose bottles, tins, shells, or other household receptacles…were to be collected and destroyed; all water storage tanks were to be screened; bush was to be cleared where stagnant water was likely to be concealed; and district officers were to recruit teams for spreading larvacides.62
This is one example of how local governments attempted to aid their sanitation and anti-malarial cause in the absence of intervention from the colonial government. The Sanitary Branch of the medical department, formed in 1910, made significant gains in mosquito control, as it was one measure that aided the demolition of both malaria and yellow fever. In the same year of its formation, the Sanitary Branch established mosquito brigades. This action, in conjunction with the Mosquito Ordinance of 1911 worked in order to “seek, identify, and obliterate all breeding places for mosquitoes in townships and their immediate vicinity…private domestic dwellings in certain designated towns had to submit to authorized entry and larval and general sanitary inspection by sanitary inspectors and their crew.”63 The success of the mosquito brigades did not appear until the 1920s, but thanks to an added element of professionalism, the support of the African population, and a sufficient number of sanitary inspectors, the system remained in place through the 1950s. The Mosquito Ordinance, alternatively, was effective very soon after its implementation, despite fervent resistance from the African population. In the first decade of the Ordinance, the percent of prosecutions per inspections dropped from 16% to 1%.64
Independence
Health policies and the development of anti-malarial campaigns was largely halted by the Second World War. However, the formation of Medical Field Units, begun by Governor Burns in 1947, was a new attempt to bring health to rural areas. These units were very successful, covering both survey and treatment of trypanosomiasis, yaws, smallpox, schistostomiasis, leprosy, onchocerciasis and malaria. In 1960, a new ten-year health program was initiated with the help of the Israeli Dr. D. Brachott. This program focused on a rural health service of hospitals and other medical units, a plan for the entire country and its growing population with consideration of economic capabilities, and a training program for physicians in order to further reduce the population to doctor ratio.65 The Medical Field Units were an important part of this new system. The new plan did achieve many of its goals, especially in the education of rural communities and training of new doctors, but economic limitations and the political instability plagued Nkrumah’s administration limited these advances.66

Comparative Analysis
Epidemics of plague, smallpox, and malaria have been prevalent in the Gold Coast throughout history, but during the twentieth century, they have taken three decisively different paths. Plague has hit the area intermittently; smallpox has appeared more often and with more force, but has been erased from the earth for almost thirty years now; malaria has been a continuous problem and remains a serious threat to Ghana. Several factors explain these varying results. The first is the nature of the disease, from its origin (endemic or imported), to characteristics of its transmission. These features were essential in shaping the individual policies created to combat each disease. However, the success of each policy was also dependent on several factors, including the practicality of the policy, how it was received by the residents of the Gold Coast, and financial backing. Furthermore, external forces, such as the desires of other governments, the general organization of the colony, current sanitation and overall health policies contributed to the effectiveness of these policies. All of these factors combined to give each disease varying degrees of success and failure.
Curative or Preventative Measures
It is important to note the differences in approaches to health, between curative and preventative measures. Colonial health policy was focused on curative, rather than preventative medicine; this began a trend that has continued to modern times. However, it does nothing to help prevent epidemics of disease, only contributes to ending them. When the WHO looked to eradicate smallpox, it was only successful after reorganizing with preventative measures, instead of simply a goal for number of vaccinations. The whole picture of the epidemic must be evaluated, in order to stop the disease.
Physical Characteristics
The physical characteristics and transmission of each disease is extremely important. The characteristics of bubonic plague create different advantages and disadvantages for controlling it. Rat-borne fleas transmit plague, so while it is not immediately contagious from human to human, it is necessary to control direct containment efforts at rats. This creates the need to attack rats and their insanitary habitats. This can be achieved in several ways, from improving sanitation and city planning to fumigation or destruction of the land. The movement of rats is more difficult to track than the movement of humans, as they can travel unnoticed across long distances, significantly on ships to inter-continental destinations. The final and most important physical characteristic of bubonic plague that makes it difficult to control from a healthcare point of view is its tendency to become pneumonic plague, creating the new set of difficulties of human-to-human transmission. However, because of its physical characteristics, it was possible to develop an effective vaccine.
At first glance, pneumonic plague and smallpox would seem the most difficult to contain because they are both transmittable from human to human without an intermediate vector. However, this is an advantage because it means that prevention involves only one target: humans. Smallpox is also only contagious for about three to four weeks, from the time of rash to scabs.67 Identifying a victim is also simple, as victims often have an easily identifiable appearance. The disease is also traceable; because it is transferred directly from one victim to another, it is possible, although generally not easy, to track those who have come into contact with victims. Another positive aspect of smallpox is the immunity that is incurred if the victim survives. It can die out by itself after it attacks an isolated community, after which all members have died or are immune. Also because of the immunity acquired after contracting the disease, a vaccine for smallpox was developed and utilized. This type of vaccine, in which a patient receives immunity from the foreign injection of the virus, was the first to be discovered.
Conversely, the mosquito vector of malaria is an extremely difficult foe to defeat because it involves the defeat of not only the mosquito, but of the most formidable foe of all, the environment of Ghana. The mosquito’s egg larvae has proved almost impossible to destroy completely because of the necessity of storing water and the natural existence of swamplands, lakes, and other large bodies of water. As long as habitats for the mosquito eggs exist, the life cycle cannot be broken and it will continue to spread malaria to humans. It is also possible to contract malaria multiple times in a lifetime, although repeated attacks can bring partial immunity. It is also endemic to Africa, away from developments in European technology. Malaria exists in several different strains, and different species of mosquitoes transmit them, so giving a specific target to “malaria” is extremely difficult. Additionally, mosquitoes, like all other animals, change evolutionarily as a result of their environments, aiding resistance to insecticides and other measures taken to stop their life cycle. This characteristic also prevents the development of an anti-malarial vaccine.
Practicality and Public Reception
The practicality in implementing health policies and the community’s consequent reception often determines its success. The plague epidemic of 1908 was one of the first significant documented epidemics in the colonial era, and as such was a test for the ability of the colonial government to protect the inhabitants of the Gold Coast. Plague is not endemic to the area, so the native population had no previous exposure to the illness, while the British government had access to experts like Professor Simpson. His policies had already been proven successful in India. The measures themselves were not exorbitantly expensive, so the government had the right tools to combat the disease. They were expensive, but attainable within the budget of the Gold Coast, and even helped to prove the need for additional health-related funds. The production of vaccines in the Accra laboratory served the dual purposes of cutting costs and making more and better quality vaccines. While these policies were not popular with the native population, there was no precedent of policy or comparison of the proper way to handle the problem. This did not aid public approval of the measures, but instead resigned local chiefs to comply for lack of alternative measures. Conversely, the local solution to outbreaks of smallpox often made the problem worse. Initiatives taken during plague outbreaks were well-supported by the colonial government because it was seen as a problem with a practical solution, and although the prospect of a spreading epidemic was frightening, there was a greater confidence in the success of these measures. Similarly, the effects of these measures were clearly visible. The destruction of an entire village was not a popular action, but it was a clear indication of the government’s efforts; the containment of the disease to the coastal areas and eventual success at stopping the epidemic testified to the start of positive health policies and practices in the Gold Coast.
Programs aimed at stopping smallpox epidemics encountered the additional hurdle of discouraging native inoculation. Because the practice of inoculation was sometimes successful, it was widely practiced. However, when European vaccination techniques were mandated by the Vaccine Ordinance of 1920 and traditional inoculation practices were outlawed, the law was very much opposed by the majority of the population. Popularity for European vaccines increased in the following decades despite such opposition at the start. The cost of producing and distributing vaccines was cut by their production at the Accra lab, and the colonial government supported anti-smallpox measures as the problems associated with the spread of smallpox were well known already. By the time the global eradication strategy was implemented, public favor had shifted in favor of vaccinations. It is noteworthy that epidemics of smallpox did not drastically alter the nature of public policy other than by implementing vaccinations. Epidemics of plague and malaria each created new policies on sanitation and the development of infrastructure for the Gold Coast, while smallpox, against which European officials were easily vaccinated before they arrived in the colony, did not. The policy of vaccinating only in times of epidemics and a lack of implementing permanent trends in public health contributed to the continuation of epidemics of smallpox in the Gold Coast.
The multi-dimensional program of combating malaria was very well supported by the colonial government. Because malaria was a primary killer of both Europeans and native Africans, the focus in public policy was for the long-term and permanent solutions for water storage. These policies were focused almost exclusively on the European population while natives were not provided with adequate methods for water storage or drainage. Public outcry against the imbalance of resources did little to help the cause because of the expense of anti-malarial projects. As has already been noted, the expense of these projects and a lack of available funds for this purpose has been a key roadblock to their successful implementation. However, while permanent policies of sanitation and water were implemented, along with benefits that lasted for decades, the policies themselves did not stop malaria. The need to stop malaria was of the utmost importance for the Gold Coast, but the same problems that hindered improvement programs in colonial times continue to hinder modern programs.
External Forces
The international community has displayed varied concerns tropical African epidemics, and has appropriated money and other efforts accordingly. The plague was well-understood and international concern was high. Not only did outbreaks of plague hinder economic activity, but other countries were very much aware of its international communicability. The communicability of smallpox likewise facilitated international concern. This took the form of the WHO’s worldwide eradication campaign. Even this program required reorganization and constant attention that only a concentrated, specific, and well-funded program could provide. The financial incentive that global eradication brought was enough to encourage support.
Conversely, global anti-malarial policy has not achieved widespread results. The international community has continued the tendency to be content with meeting the needs of foreigners. As in the colonial era when Europeans were provided with water tanks and other anti-mosquito measures, the availability of quality prophylaxis and effective treatment of malaria is confined to those with the economic and political means to procure them. Macdonald acknowledges the difficulties facing the possibility of eradicating malaria in Africa and other countries with larger problems and smaller budgets, but asks the important question: “Certainly Africa presents greater technical problems than any other land, its administrative systems are poorer, and its sources of skill are shallower. But are these now adequate reasons for failure to start eradication?” 70 The answer to this question is an extensive one, involving political, economic, social and moral factors. However, prioritizing the allocation of global health funds is a continuously shifting balancing act.

Conclusion
The varying histories of plague, smallpox, and malaria cannot be explained as a result of a single factor. As the Gold Coast grew and developed into modern Ghana, health policies similarly grew and developed. A preliminary problem in controlling disease was limited knowledge of tropical illnesses and basic colonial attitudes concerning health and sanitation. However, once research efforts began to reveal causes of illness and consequent epidemics, responsibility for health services was shared between the colonial and local governments. Conflict arose out of who should shoulder some of the expenses, especially the larger ones. However, colonial health policy was a European invention and its imposition on the native population of the Gold Coast was only one of several conflicts resulting from colonial rule.
The introduction of plague from an outside source brought the shocking reality of European problems into the Gold Coast. However, because it is not endemic to Africa, the British colonial government was better prepared to deal with its outbreak. Smallpox brought about greater conflict between European and native African solutions to illness, but vaccinations were indeed more successful than traditional inoculation practices. The WHO’s eradication program was similarly more successful than any effort that the colonial government was able to put forth. Malaria has sadly had the most consistent history. The colonial government, and indeed more and powerful ones likewise, was not able to prevent malaria as a major killer of residents in the Gold Coast.
Tropical diseases have shaped the path that the Gold Coast has taken from its relationship with its British colonial rulers to the continuation of health problems since independence. Stephen Addae expresses the exasperation and need for continual healthcare reform in Ghana because of the prominence of these diseases.
“their grinding effect on morbidity and mortality continued in spite of fifty years’ unending labour of the colonial Medical Department to control them…It is not surprising then that by 1960 the government held the health service one of their foremost priorities. And vigorous steps began to be taken in pursuance of a ten-year health programme.” (Addae 91).
The issue of public health is an issue that every government, colonial or independent, has to deal with. The additional difficulties of colonial rule and tropical illnesses have increased the variation of success and failure of controlling epidemics of disease in modern Ghana.











Notes
1. Thomas S. Gale, “The Struggle Against Disease in the Gold Coast: Early Attempts at Urban Sanitary Reform,” Transactions of the Historical Society of Ghana, XVI(ii) (1995): 185.
2. Helen Tilley, “Tropical Environments, African Trypanosomiasis, and the Science of Disease Control in British Colonial Africa, 1900-1940,” Osiris 2nd Series, Vol 19 (2004): 24.
3. Stephen Addae, The Evolution of Modern Medicine in a Developing Country: Ghana 1880-1960 (Durham: Durham Academic Press Ltd, 1997), 115.
4. Gale p.193
5. Addae, p.66
6. Gale, p.194
7. Raymond E. Dumett, “The Campaign against Malaria and the Expansion of Scientific Medical and Sanitary Services in British West Africa, 1898-1910,” African Historical Studies, Vol. 1, No. 2 (1968): 159.
8. ibid p.163
9. ibid p.162
10. Arthur E. Horn, “The Control of Disease in Tropical Africa: Part I,” Journal of the Royal African Society, Vol. 32, No. 126 (Jan., 1933): 23.
11. Addae p.115
12. Gale p.195
13. ibid p.196
14. ibid p.193
15. ibid p.198
16. Addae p.117
17. ibid p.119
18. ibid p.182
19. ibid p.183
20. ibid
21. J. W. Scoot Macfie, Report of Accra Laboratory 1915 (1916): 6.
22. Addae p.338
23. Jonathan Roberts, “The Black Death in the Gold Coast: African and British Responses to the Bubonic Plague Epidemic of 1908,” Gateway Article Catalogue, http://grad.usask.ca/gateway/archive10.html.
24. Addae, p. 336
25. Roberts
26. Roberts
27. Addae p.339
28. ibid
29. ibid p.338
30. ibid p.118
31. D. A. Henderson, “Smallpox Eradication,” Proeedings of the Royal Society of London. Series B, Biological Sciences, Vol. 199, No. 1134, A Discussion on Technologies for Rural Health (Oct. 19, 1977): 84
32. Addae, p. 325
33. Eugenia W. Herbert, “Smallpox Inoculation in Africa,” The Journal of African History, Vol. 16, No. 4 ( 1975): 558
34. ibid
35. Gold Coast Medical and Sanitary Report (1910), p. 51
36. Addae, p.331
37. ibid p.328
38. ibid p.330
39. ibid p.328
40. ibid p.331
41. D. A. Henderson, “Smallpox Eradication,” Proeedings of the Royal Society of London. Series B, Biological Sciences, Vol. 199, No. 1134, A Discussion on Technologies for Rural Health (Oct. 19, 1977): 86.
42. ibid p.83
43. ibid p.96
44. Stanley O. Foster. “Participation of the Public in Global Smallpox Eradication,” Public Health Reports, Vol. 93, No. 2, International Health (Mar.- Apr., 1978): 149.
45. LSU Law Center’s Medical and Public Health Law Site, “Smallpox Information Project,” LSU Law Center, http://biotech.law.lsu.edu/blaw/bt/smallpox/mmwr46(42)990.htm.
46. Dumett p.157
47. ibid p.159-60
48. Addae p.319
49. ibid p.320
50. Despatch from Governor Sir W. Brandford Griffith, K.K.M.G., 1893, p. 71-2.
51. ibid
52. Gale p.196
53. Addae p.132
54. Dumett p. 171
55. Addae p.41
56. Emmanuel Kwaku Akyeampong, Themes in West Africa’s History, ed. Emmanuel Kwaku Akyempong (Accra: Woeli Publishing Services, 2006), 197.
57. Addae p. 42-3
58. Akyeampong p. 198
59. Addae p.47
60. P. A. Twumasi, The Political Economy of Health in Africa, ed. Toyin Falola and Dennis Ityavyar (Athens: Ohio University Press, 1992), 108.
61. Dumett p.165
62. Dumett, p.168-9
63. Addae p.128
64. ibid
65. ibid p.92
66. ibid p.97
67. Henderson p.86
68. George Macdonald. “Eradication of Malaria,” Public Health Reports Vol. 80, No. 10 (Oct., 1965): 876.
69. Addae p. 91
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