The Lungs of the Empire’ – Travel to the Cape for Health Purposes, 1870-1910

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Chapter 4 Cape Town takes the Lead in the Fight against Tuberculosis, 1870-1910

The city of Cape Town was the capital of the British Cape Colony. It is located at the tip of Africa and was the first port of call for ships travelling to the colony from countries such as Britain. It was also the seat of government and had the largest population of any town in the colony. On similar lines to other towns in the Cape, it was structured as a local authority and had the ability to pass and enforce bye-laws.
Cape Town has the longest history of tuberculosis in the country. The disease may have been present in the town from its foundation, although the first recorded reference to it was in about 1780.351
Cape Town had several challenges which made it particularly vulnerable to diseases such as tuberculosis. As a port town it had a large transitory population, a situation which was exacerbated following the discovery of minerals and the opening up of the interior. Accommodation was always in short supply. This was capitalised upon by profiteering landlords who sought to take advantage of the circumstances. This in turn led to slum conditions and severe overcrowding, creating an environment in which tuberculosis thrived. Added to this, there was a high degree of urban poverty and unemployment. Conditions could not have been more conducive for the spread of the disease, as is demonstrated in Table 4.1 below.
In 1875 the municipal authority of Cape Town was paying very little attention to health issues. The town itself was experiencing rapid population growth. During the period 1875 to 1891, the white population in the urban areas increased at the rate of 51,5 per cent, and the Coloured population at the rate of 68,6 per cent.352 Overcrowding became common, and the condition of the town deteriorated to such an extent that in 1881 a number of professional men and merchants petitioned the House of Assembly in the Cape legislature in protest against the neglected state of the town. Their agitation culminated in the election of the ‘Clean Party’ to the town council in 1882, eventually inaugurating an era of greater municipal expenditure and a degree of sanitary reform.
Shortly after coming into office, the new council identified a number of issues which required their attention. These included the provision of a reliable water supply; the improvement of the dwellings of the poor; the taking of steps to prevent overcrowding; and the need to appoint a health officer.355 However, the proposal to appoint a health officer was rejected at the time.
Attitudes towards health matters changed following the outbreak of smallpox in 1882, which caused the death of approximately 1 146 people (in a population of between 40 000 to 45 000).357 The details of the epidemic itself have been discussed in detail by both Van Heyningen and Bickford-Smith and fall outside the scope of this chapter.358 However, the smallpox epidemic was important in several ways because it set the course for the approach to public health for the next two decades and impacted on the way in which tuberculosis was treated.
The changes in legislation and policy following the smallpox epidemic took place within a particular social context. It had already been recognised that there was overcrowding and to deal with the smallpox epidemic and the high levels of filth, the city council appointed an additional thirteen ‘overseers’ to supplement the number of existing sanitary inspectors. It was their task to report on the sanitary conditions of the ‘lower classes’.359 Within days, reports of severe overcrowding were received by the council. For example in Strand Street the inspectors found a dwelling in which nineteen occupants were living in six rooms; and another where there were 26 occupants in eight rooms.360 With such reports appearing regularly in the press, it was no longer possible for the city officials to ignore the living conditions of the poor. These concerns were not necessarily altruistic in nature; they were motivated primarily by the perceived threat of these conditions to the health of the bourgeoisie.361
The discussions about overcrowding and poverty in the town were extended to include a redefinition of who, among the impoverished residents of Cape Town, deserved assistance. Instead of showing empathy, the popular view was that they had brought their misfortune upon themselves and were inherently responsible for their dreadful living conditions – and therefore were not deserving of assistance. This line of thinking was developed further during the 1880s when Cape Town was going through a major financial depression. By this time the new ideology of Social Darwinism had captured the imagination of the bourgeois in both Britain and the Cape Colony. In Britain, London’s dominant class explained the existence of the undeserving poor by means of the theory of urban degeneracy which they believed had resulted from exposure, over generations, to the debilitating urban environment. Within the colonial context this took on a distinctly racial interpretation, with the view among the wealthy and upper middle-class white residents of Cape Town that people of ‘mixed race’ were particularly likely to succumb to degeneration.362 Segregation was seen as the way to ‘protect’ whites from ‘contamination by ‘dirty’ blacks’. Nothing came of the matter at the time, primarily due to lack of consensus about who would pay if segregation were to be implemented.363
The smallpox epidemic also exposed the legislative nakedness of the colony because there were no policies in place which provided guidance on how to deal with the threat. In principle, health care was the responsibility of the Cape colonial office, but the control which the Cape government was able to exercise was very limited. It employed no health officer and the only medical advice to which it had formal access was that of the colonial medical committee. At the time no town in the colony had a health officer and municipal health regulations, where they existed at all, were rudimentary in the extreme.364
It was against this background that the Public Health Act, Act No. 4 of 1883 was passed. Despite its name, it was not a general Public Health Act but rather dealt with the control of infectious diseases. It was this act which was eventually extended to include tuberculosis in 1903.365 One of the major deficiencies of this legislation was that local authorities were expected to pay half the costs of combating an epidemic. This set the precedent in respect of financial contributions for the control of diseases. The result was that this clause guaranteed that the act would never be enforced wholeheartedly.366 Once this precedent had been set it was almost impossible to get the government to deviate from it and this practice continued up to and including the passing of the Public Health Act, Act No. 36 of 1919, proving a major stumbling block in the control of tuberculosis. One of the more positive outcomes of the smallpox epidemic was that it led to the practice of compilation and publication of annual reports on the state of health in the Cape Colony. It also led to Cape Town appointing a municipal medical officer of health and a sanitary engineer (both ‘firsts’ in southern Africa).
The medical officer appointed by the Cape Town authorities was Dr George Henry Bradwell Fisk (MRCS, London), LRCP (Edin.) (1852-1893). He occupied the post of police surgeon and physician to the Free Dispensary prior to his appointment. Fisk was appointed on a part-time basis in May 1883.367 Within days of his assumption of office he issued a report on the sanitary condition of the town.368 In his second report he drew attention to the large number of people who had died of phthisis and other diseases of the lungs. His view was that prevalence of tuberculosis was greatly aggravated by the overcrowded and badly ventilated houses which were so numerous in Cape Town.369 He recognised that the underlying cause of overcrowding was poverty and that the poorer people became, the more they were compelled to subdivide and sublet their apartments to make enough money to pay the rent.370
Fisk mentioned the high levels of tuberculosis again in 1887, when the problem was escalating and had accounted for 176 of 1 317 deaths.371 In 1889, tuberculosis claimed the lives of 139 people, and was second only to ‘convulsions’ as the leading cause of death.372 This number climbed to 188 out of 1 557 deaths in 1892.373 Despite the high death toll due to tuberculosis, these deaths did not attract the same attention as other diseases. Van Heyningen attributes this to the fact that the disease did not impede the economic functioning of the city and so did not demand immediate and drastic action on the part of the authorities.374 Fisk was also at a disadvantage because although death certificates were issued, they did not call for a medical certificate on the cause of death, thereby losing much of their value as they could not be used for the production of reliable statistics.375 Fisk died suddenly in December 1893.376

Dr Barnard Fuller Takes over as Part-time Health Officer, 1894

Fisk was replaced by Dr (Edward) Barnard Fuller, the son of Rev. T.E. Fuller, a Cape Town councillor at the time.377 Rev. Fuller was formerly a Baptist minister in London, and had focused on the needs of the poor. When he moved to the Cape and took up the role of editor of the Argus newspaper, he used this as a platform to highlight the needs of the poor in Cape Town. He was also the author of a pamphlet on the fever epidemic in 1867-1868, in which he drew a connection between the prevalence of poverty and overcrowding and the outbreak of disease.378 He played a pivotal role in the establishment of the Free Dispensary, which later formed an important role in the lives of those suffering from tuberculosis.379 Unlike many of Cape Town’s middle classes, the Fuller family came from a philanthropic tradition, giving them an awareness of the plight of the poor. This stood Barnard Fuller in good stead in dealing with tuberculosis.380 Barnard Fuller was educated at the South African College, and went on to qualify as a doctor at Edinburgh University, graduating with first class honours in 1891. He returned to Cape Town in 1892381 and was appointed as health officer in 1894. Although his appointment was on a part-time basis, he was able to make a significant impact on the council. He wasted no time after his appointment in bringing the attention of the town council to the high number of deaths from tuberculosis, especially among the Coloured population.
In 1894 Fuller reported that there had been 1 520 deaths that year, of whom 922 were Coloured residents; of these, 202 deaths were from phthisis and other diseases of the respiratory system. By comparison, there were only 136 deaths from this cause among white residents. The Coloured deaths from tuberculosis pointed to overcrowding, dampness, and the general insanitary state of the homes of the majority of the Coloured population.382 In the following year the death rate in Cape Town was 36,21 per 1 000 of population, split between 26,83 for whites and 45,70 for Coloureds.383

Consumptives from Abroad

Fuller felt that the majority of the tuberculosis deaths among white people were consumptives who had come to the Cape from abroad ‘for the benefit of their health’. Most of them were in the final stages of pulmonary tuberculosis on their arrival. Fuller felt strongly that advanced cases should never be sent away from their homes because in his view this inevitably led to an early death without comfort and care to ease their last moments. He believed that all medical practitioners should warn their colleagues and the public in Britain and elsewhere of the futility and cruelty of sending those who were showing symptoms of advanced phthisis on long, arduous voyages to other countries. At the same time he realised that it was impossible, nor did he recommend, the complete ban of entry of early cases that could possibly benefit from the climate.384
Consumptives from abroad presented several challenges for Cape Town health officials. As the first port of call for the majority of ships from Britain, it was crucial that a plan be put in place. Those in an advanced stage of the disease were invariably taken directly from the ship to the Somerset Hospital.385 There were others who were suffering from active disease and whose sputum posed the threat of infection to the local population. Because such cases generally sought accommodation in the local hotels and boarding houses, Fuller felt it was vitally important that the proprietors should be educated about the disease, particularly that it was highly infectious. A circular was drawn up in English and Dutch in 1899 setting out the precautions that consumptives should take to protect themselves and others. It also offered precautionary advice to hotel keepers and others about how to clean the rooms which were or had been occupied by consumptives. The hotel keepers were also encouraged to report deaths of consumptives to health officers so that an inspector could be sent out to disinfect the premises. This service was offered free of charge by the council.386
It was Fuller’s intention to educate the public about tuberculosis at every opportunity. The distribution of the circular was a major step in the right direction in educating ordinary Cape Town residents. By wording the circular in such a way as to offer constructive advice, rather than blame, Fuller did his best to ensure that the consumptives themselves were not stigmatised. In addition, by enlisting the cooperation of the hotel and boarding house proprietors Fuller’s staff were able to ensure that the premises were disinfected and made safe for future occupants. By taking this approach, Fuller was able to report that he had never heard of a case where the distribution of the circular had prevented anyone from getting a night’s lodging.387
The constant arrival of consumptives from abroad not only proved a challenge for the city’s health department, it also placed severe strain on the Somerset Hospital. The board of managers reported that consumptives were arriving on virtually every incoming steamer in a hopeless condition, with very little chance of recovery, and often they had no funds to provide for their expenses. The hospital board felt that it was:
… positively criminal and inhuman to send out cases practically in the last stages without fair and reasonable hope of recovery, and thus to expose them to a cruel exile among strangers, culminating in their early death far from friends and home.
It cited an example of a young boy aged 14, who had been sent to the Cape by a philanthropic institution, who had landed in Cape Town in the last stages of the disease with ten shillings in his pocket and without knowing a single person in the country. He had been taken directly to the hospital, which did not generally admit such cases, only to die within a few weeks of his arrival. The hospital board went on to stress that for consumptives to benefit from the climate they had to be in the early stages of the disease upon their arrival, and should have sufficient funds to sustain themselves for at least twelve months. It also added that the seaports were extremely prejudicial to the patients and that they needed to proceed inland as soon as possible. It concluded by stating that the labour market in Cape Town was overcrowded, making it difficult, even for those in the best of health, to find employment. This letter from the Somerset Hospital Board was sent to the Cape colonial secretary, with an appeal for him to bring the matter to the attention of the London immigration agent.388 It was also published in the Cape Times newspaper, the South African Medical Journal (SAMJ), the Lancet and the British Medical Journal (BMJ).389
Fortunately, it was at about the same time that the popularity of the Cape as a health resort started to decline in Britain and Europe. This was largely because of the lack of suitable accommodation and the unsatisfactory sanitary state in most of the towns in the colony, including Cape Town.390 However, while the Cape was no longer popular among well-to-do sufferers, it still remained an important destination for the middle classes from Britain.
Despite Fuller’s best efforts, the death rate from pulmonary tuberculosis continued to climb, and by 1899 it was claiming the lives of one out of every eight people of European descent, and one out of every six Coloured people. It was therefore the greatest cause of mortality in Cape Town.391 What was needed was a new impetus in the fight against the disease. This came, not from the Cape, but from the increased awareness of the disease on the international front and in particular, from Britain’s decision to establish a branch of the Association for the Prevention of Tuberculosis in
1898.392

Increase in Awareness of Tuberculosis

Britain joined the Association for the Prevention of Tuberculosis in 1898 and extended an invitation for the Cape Colony to join the association.393 This was the opportunity that Fuller had been waiting for. He immediately approached the Cape Town council, stressing that the city was in a unique position to play a leading role in the fight against tuberculosis.394 He believed that although the efforts of the council up to that point had helped to keep the Coloured death rate in check, more needed to be done. He added that he felt sure that the ‘council, who have ever shown a disposition to have their Health Department in the van[guard] of sanitary progress, would be anxious to take its full share in helping to reduce the large mortality from tuberculosis’.395 With the buy-in from the council, Fuller was able to tackle tuberculosis with a new gusto.
Fuller was aware that from a practical point of view, there were a number of issues which needed to be addressed. As the identities of tuberculosis sufferers only became available when they died, he needed to know the location of existing patients so that they could be educated on precautionary measures to prevent the spread of the disease. An appeal was sent to all medical practitioners in Cape Town requesting them to notify the city’s health department of any cases that came to their attention so that he could gauge the full extent of the problem, and provide the sufferers with educational material if they did not have a medical practitioner.396
The educational material provided by the Association for the Prevention of Consumption was a cost-effective solution and became the first step in the prevention of the disease.397 However, it was the middle-class white residents who gained the most benefit from these initiatives. It was precisely this group, as the more well-to-do white members of Cape society, who were the least affected by the disease. What was needed was a strategy to deal with other, less privileged residents, in particular those for whom poverty was endemic. It was these people, including impoverished whites, Coloureds and blacks, who were the most vulnerable to contracting tuberculosis.
The most urgent need was to address the social conditions, especially housing. The Cape Town council was aware of the housing shortages in the city. In 1897 this culminated in the construction of labourers’ barracks, which provided accommodation for approximately 200 persons. This building was leased to the Salvation Army and came to be known as the ‘Workmen’s Metropole’.398 This initiative catered initially for the needs of the white, middle-class members of Cape society and made no provision for Coloured people. The Salvation Army also had a night-shelter which was opened in Anchor Street in 1883 providing cheap accommodation for able-bodied, unemployed white people.399 They were further advantaged by educational programmes and public works programmes.400
The provision of employment to these impoverished whites via public works programmes enabled them to obtain better nutrition and an improved standard of living than would otherwise have been the case. Although these measures did not prevent them from succumbing to tuberculosis it did increase their ability to deal with the disease. It was a clear manifestation of who Cape society believed to be ‘the deserving poor’.

The South African War (1899-1902) and the Outbreak of Plague

With Cape Town’s housing shortage already pushed to its limits, the worst was yet to come. By 1898 the colony was already sliding into a depression, precipitated by natural disasters such as drought and the rinderpest epidemic on the one hand, and troubles in the Transvaal contributing to a collapse of the share market on the other.401 Unemployment began to rear its head as indigent refugees from the Witwatersrand began to flock into the city after October 1899 following the outbreak of the South African War. In order to deal with the large influx of refugees, the mayor set up a Relief Fund. Although it was part of a general relief fund and not specifically geared towards the sick, it did provide assistance to a number of white consumptives who were in an advanced stage of the disease.402 By the time the Rand Relief Fund closed down in November 1902, it had assisted 11 800 individuals.403 Added to the refugees, Cape Town also had to deal with the imperial troops, many of whom entered the Cape through Cape Town.
As the war was conducted mainly on horseback it was necessary to import a large number of horses. Forage for their feeding was in short supply owing to the drought so that too had to be imported. The rats and fleas that accompanied the forage carried the plague bacillus and was responsible for the outbreak of the bubonic plague.404 Once the plague broke out in Cape Town in February 1901, the government was sufficiently concerned to take over all plague control and related expenditure in the city.405
One of the first actions of the Cape government was to rush a black township into existence under the Public Health Act of 1883 at a forest station called Uitvlugt (later called Ndabeni), several miles from the town on the Cape Flats. In the midst of the plague during March 1901, some six or seven thousand blacks were moved to this township. By September 1901 the plague had receded in Cape Town. The death toll was high. Of the 807 cases of plague there were 389 deaths, 69 of whom were of white, 244 were Coloured people and 76 were blackss.406
The plague outbreak also had important long-term implications for the public health department because it enabled Gregory to assert its independence from the Cape colonial office. He later admitted that without the epidemic he could not have established a separate health administration.

Anderson Takes over as Medical Officer of Health

Fuller resigned as the medical officer of health in 1901, since he felt that the time had come for a full-time appointment to be made.408 He had held the position for nearly eight years on a part-time basis, and made valuable strides in creating an awareness of tuberculosis, both within the council itself and among the population in general. This impact was not limited to Cape Town. In 1896 he was appointed as the editor of the public health section of the South African Medical Journal (SAMJ), and he used this as a platform for constantly bringing the control of tuberculosis to the attention of medical practitioners throughout the colony.409 As a member of the South African branch of the British Medical Association, he was also able to influence that body by taking an active part in their discussions and providing details of the manner in which Cape Town was dealing with tuberculosis.410 Fuller’s efforts were considerably ahead of those of the public health department of the colony, and paved the way for Cape Town’s city council to take the lead in the fight against the disease in the longer term, right up to and including the passing of the Public Health Act of 1919. Fuller was elected as a member of the city council in 1902 and appointed as the chairman of the health and building regulations committee.411 He was therefore well placed to ensure a smooth transition to his successor.
The person selected to take over from Fuller was Dr (Alfred) Jasper Anderson, who had held the full-time position of medical officer of health for the Blackpool corporation in Britain for the previous ten years. In that position he not only headed the health department but was in charge of the infectious diseases hospitals, slaughter houses and other bodies concerned with public health and for their bacteriological work.412 He was therefore very well qualified for the position in Cape Town.
Anderson soon became aware of the high death rate in Cape Town. The combined impact of the South African War and the poor living conditions that had been exposed by the plague meant that the improvement of sanitary conditions remained a key focus area. His first step was to reorganise the sanitary department. Among their other duties, the sanitary inspectors had the responsibility of moving people suffering from infectious diseases to hospitals (when beds were available) and for disinfecting the premises. Lodging houses and hotels were also routinely checked by the inspectors.

TABLE OF CONTENTS
Acknowledgements 
Abstract 
Preface 
Tables 
Maps 
Photographs and Illustrations 
Abbreviations 
Terminology 
Table of Contents 
Chapter 1: Pulmonary Tuberculosis:  The Disease and early Global History
What is Tuberculosis?
Global History of Tuberculosis
Literature Review
Synopsis of Chapters
Chapter 2: ‘The Lungs of the Empire’ – Travel to  the Cape for Health Purposes, 1870-1910
Promoting the Cape Colony as a Health  Destination
The Role of the Shipping Companies
Ocean Voyages and the Journey Inland
Consumptives in Cradock
Tide Turning against Consumptive  Immigrants
Chapter 3: ‘The Mecca of Consumptives’  Cradock, 1872-1910
The Transformation of the Colony
Tuberculosis in Cradock
Explanations for the Disease
The Relationship between the Public  Health Department, District Surgeons and Local Authorities
Changes in the Medical Profession
Growing Awareness of the Spread of Tuberculosis
Building of a Hospital
Living Conditions in the Townships Prior to the South African War
The South African War, 1899-1902: A Turning Point
The Role of the Public Health Department
Chapter 4: Cape Town Takes the Lead in the Fight against Tuberculosis 1870-1910
Dr Barnard Fuller Takes over as Part-time Health Officer, 1894
Consumptives from Abroad
Increase in Awareness of Tuberculosis
The South African War (1899-1902)  and the Outbreak of Plague
Anderson Takes over as  Medical Officer of Health
Anderson and the Fight against Tuberculosis
Shortage of Hospital Accommodation Reaches a Crisis Point
The Move towards Cooperation between  Municipalities Lack of Government Assistance
The Free Dispensary and Notifications of Tuberculosis
Conclusion
Chapter 5: The Dawn of a New Era in the Fight  against Tuberculosis, 1896-1910
INTERNATIONAL DEVELOPMENTS
The National Association for the Prevention of Tuberculosis (NAPT)
LOCAL DEVELOPMENTS
The Public Health Department and  Tuberculosis
Tuberculosis Declared a Notifiable Disease, 1903
The Association for the Prevention of  Consumption Formed in the Cape Colony
The South African Medical Journal (SAMJ)
Annual Medical Congresses and Mayor’s Conferences
Conference of the Principal Medical Officers of Health, 1906
Dr Neil Macvicar
The Native Health Society (also known as The South African Health Society)
Conclusion
Chapter 6: Transitions: Tuberculosis from Colony to Union; and the Regulation of Tubercular Immigrants 1910-1913
Political Union and Public Health
The Regulation of Tubercular Immigrants
The 1906 Medical Congress, the  Conference of Principal Medical Officers of Health and the 1906 Cape Immigration Act
Regulation of Tubercular Immigrants:  The Debate Continues after Union
Report of the Tuberculosis Commission  regarding Tubercular Immigrants
Parliamentary Discussions on the  Regulation of Tubercular Immigrants,1913
The Immigration Regulation Act,  Act No. 22 of 1913
Chapter 7: The Tuberculosis Commission, 1912-1914
The Commission’s Terms of Reference
Difficulties Faced by the Commission
The Cape
Native Territories (Transkei)
Natal
The Transvaal Collieries
Witwatersrand Gold Mines
Finalisation of the Report
Recommendations on the Measures to be  Taken for the Prevention of Tuberculosis
Recommendations on Public Health Legislation
Conclusion
Chapter 8: From the Tuberculosis Commission to the Public Health Act, 1914-1919
Planning a Brave New World: The 1918  Kimberley Municipal Conference
The Aftermath of the Conference
Central Government Intervenes at Last: The Public Health Conference,September 1918
The Outbreak of the Spanish Flu Epidemic Brings Everything to a Halt
The Public Health Act, Act No. 36 of 1919
Reaction to the Act
Conclusion
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