Lerer, Leonard B.

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•The data were also analysed to detect whether any of thefactors studied were associated with increased severity ofpneumonia in the index group. There was a moderatecorrelation between chest radiograph score and length ofstay in hospital, but these scores did not correlate withmalnutrition, crowding of sleeping quarters, home pollutionOr current viral infection. The majority of the index patientscould be classified on the basis of WHO clinical criteria1 ashaving moderate AAI, with only 20% having severe ARI, andthis finding may explain lack of correlation between severityand the factors studied.An increased prevalence of recurrent symptoms andabnormal lung function tests has been noted on long-termfollow-up of children who have had lower respiratoryinfections compared with normal controls.1!-11 In the presentstudy all children were monitored by home visits for 18 - 24months to detect any detrimental effect that could beascribed to the respiratory infection, but ill-health was notfound to be commoner in the index group. The frequency ofsubsequent respiratory symptoms and the need to consult adoctor or clinic for respiratory problems were the same inthe two groups. A similar number of children in both groupswas judged to be thriving. Even those with a highradiological pneumonia score did not have more prolongedrespiratory symptoms or a greater need for health carefacilities than those with milder pneumonia. In this stUdy thefinding of equally good health in both groups may bebecause of relatively moderate disease in index children,Which was not severe enough to contrast with controls, andrespiratory sequelae could therefore not be shown to differ.Factors noted in other studies to affect the acquisition orseverity of lower respiratory infection were not demonstratedin this study to be determinants of whether a childcontracted lower rather than upper respiratory infections.Although the children came from a poor socio-economiccommunity, their nutrition was relatively good and homepollution was very similar in both index and control groups.The small sample size might have prevented thedemonstration of crowding as important; both groups livedin grossly overcrowded homes. The evidence of viralinfection was comparable in patients and controls.This study was supported by a grant from the Stella & PaulLowenstein Trust. We are grateful for the co-operation of themedical officers at King Edward VIII Hospital and theDepartment of Virology, University of Natal. We thank Mrs D.Moodley of the University of Natal and Ms E. Gouws of theInstitute of Biostatistics of the South African Medical ResearchCouncil for the statistical analyses.REFERENCES,. WHOIUNlCEF. Basic: principles for comroI of aone respiratory >flfections in childrEnin deYeIoping countries. Indian~rr 1989: 26: 315-320.2. Von SChImding YEA, Yach 0, KIItrl M. Acute res;r.a!ory infectionS as an impol1atltcause of childhood deaths in South Africa.. S AIr Med J 1991; SO: 19-82.3. Chretien J. Holland W, Maddem P. Murray J. WocIcock A.. Ac:ute resprratorylnteenons in crillaren. A glooal public-health ptObIem. N EngI J Med 1984; 310: 982-....4.. EditOrial. Pneumonia in childhood. Umcer 1988; 1: 7~1·743.5. Jame5.!N. Longitudinal study at morbklity of diatrheaI and respuatory infectIOnS inmah'lowished children. Am J Ctin NlJrr 1972; 2S: 690-694.6. Gatdner G, Frank AL. Taber LH. Effects of social and family factors on vir.ll~tory infection and illness IrJ me first year of life. J Eprdemlol Communiry Health1~; 38: 42-48.7. Kossove O. Smoke-filled rooms and lower respiratory disease In infants. S AIr Med J1982; 24: 622--624.B. Editorial. Indoor air pollution and BCl1t@ respiratory infections In children. Lancet1992; 1: 396-391.9. MulhoHand EK. Sirnoes EAF, Costales MOO, McGraltl EJ, ManaJac EM, Gave S.S!anCat'dized dlagnosJS of pneumorua in developing countnes. Ped"larr Infecr Dis J1992: It: 77-81.10. Wesley AG., Coovadia HM. KiepieIa P. Fw1her pn!dictiVe indices of dinlcaI severity 01mea:sles. S Air Med J 1982; 61: 663-665.11. Cout$OUdis A. BroughlOfl M. Coovadia HM. Vrtamn A supplementiltton reducesmeasles morbidity in young African children: A randomCsed pla(:E!bo controlleddouble blind trial. Am J C/in Nurr 1991; 54: 890-<195.12. Spencer MJ. Cherry JO. AdenovlraJ Infections. In: Feigin RD. Cherry JD. eds.Texlbooll of Pediauic Infecrious Disease. Vol 2. Philadelphia.: we Saunder$, 1981:1279-1291.13. Shann F. Etiology of severe pneumonia in children in d@veloping countries. PediarrInfect Di$ J 1986; 5: 241·252.14. ShaM F. Gratten M, Germer S. UNlemann V. HazleU D. Payne A. Mtiology ofpne\lmonia in children in Goroka H05pital, Papua New Guinea. Lancet 1984; 2: 537-54,.15. Hail CB. Hall WJ, Gala CL. MacGiU FB. Leddy Jp. Lon9term prospective Study inchildrefl alter respiratory syncytical virus infection. J Pediarr 1984; 105: 358-364.16. Mok JVQ. Simpson H. Symptoms. atopy and bronchial reactivity after lowerrespiratory infection in infancy. Arc" Dis Child 1984; S9: 299-305.17. Brasfield OM. Stagno S. Whitley RJ, Cloud G. Cassell G, nller RE. Inlam pneumonitisassociated with cytomegalovirus. chlamydia, poeumocystis and ureaplasma: lollowup. p!diatrics 1987; 79: 76-83.Accepted 6 act 199~_HISTORY OF MEDICINE'Neither obscure normysterious' - infantmortality and the KimberleyBoard of Health, 1898-1977Leonard B. LererAnnual reports of the Kimberley Board of Health,established in 1883. provide rich insight into public hearthdiscourse on infant mortality. Commentaries on thedeterminants of infant mortality, especially prior to 1950,largely focus on poverty and interracial disparities, issuesrelevant to current heatth policy.S Afr Med J 1996; 86: 368-370.The debate on restructuring South African health care hasbeen accompanied by renewed interest in the history oflocal pUblic health initiatives and their relevance to currentissues.l.2 Most of the recent documentation has focused onexemplary individuals and institutions and there is a paucityof historical information on the routine public health activitiesof local authorities. Although some of the larger towns anddties have been collecting hearth information since the turnof the century, health service fragmentation and the lack ofan integrated national heatth information system have led toan inevitable decline in the quality of South African healthstatistics.3 The utility of local authority health data wasdemonstrated by Phillips, who used the Reports of theMedical Officer of Health of Cape Town to demonstrateDepartment of Forensic Medicine and Toxicology, University of CapeTownLeonard B. Lerer. M.B. CH.6.• O.FOl'UAEO.• 6.SC. (HONSl (EPlOEMiOL), t.I.MEO. PATH."""ENS.)substantial inter-racial disparities in infant mortality.· Morerecently, Yach analysed local authority data to provideestimates of national infant mortality rates.s The review ofinnovative source material may provide important insightsinto heatth determinants as shown by a study of historicaldemographic data from Moravian Church records in Mamre.'This paper examines almost a century of public healthdiscussion at a local authority level on infant mortality, in thehope that some of the discourse of the past will be relevantto the needs of today.The Kimberley Board of HealthEstablished in 1883, the Kimberley Board of Healthfunctioned for 94 years as a third local authority responsiblefor the provision of comprehensive heatth services. TheBoard was established by the Town Council, with permissionfrom the secretary of the Medical Board in Cape Town, as anurgent response to an outbreak of smallpox. Despitesubstantial changes in health legislation at the beginning ofthis century, Kimberley remained ·the only city in South Africawith an independent health board. The Kimberley Board wasdisbanded in 1977, when the new Public Health Act madeno further provision for its existence;1 its functions weretaken over by the Kimberley City Council. The demise of theKimberley Board of Health was accompanied by increasingState involvement in the provision of district health servicesand the opening in 1978 of a regional office for the NorthernCape by the State Health Department.'The first official report of the Medical Officer of Healthappointed by the Kimberley Board was published in 1898.'This document heralded a long tradition of data,commentary and speculation on a variety of public healthissues such as infectious disease, sanitation and maternaland child health. In his report, Or W. W. Stoney, commentsthat 'it is our infants and young children who are most easilyaffected by circumstances which influence adversely thegeneral health of a community. It is, therefore, to thesickness and mortality rates amongst our infants, that welook as being the most delicate index of general and localunhealthy conditions'. Stoney notes that, although an infantmortality rate of 304/1 000 white infants was unacceptable,this finding had to be viewed in the context of the siegeconditions prevailing in Kimberley at the time. The high rateof infant death was attributed mainly to the quality andquantity of available milk and consequent diarrhoealdisease. While the report does not specifically mention blackor coloured infants, Stoney comments on the 'unsatisfactorystate of the native locations'. Furthermore. he observes that'the huts themselves are frequently very dirlly and are over-croWded, the average number of persons to each hut beingover six'.Stoney's speculation on the mechanisms of infantmortality continue in the 1899 report, where he observesthat 'there is, undoubtedly, some relationship between theprevalence of this disease (fatal infant diarrlloea) and thetemperature of the soil'. He states that public healthintervention addressing improper feeding as a possiblecause of diarrhoea! disease had been undertaken. Thisincluded the distribution of a leaflet on the feeding and careof infants. As to the issue of the high white infant mortalitySAMJARTICLESrate, Stoney mentions that an enquiry into each death wasbeing conducted, with special attention to feeding. By 1901,it was recognised that at least some infant deaths wereoccurring in areas of black settlement. Referring to the'native rooms in Boshof Road', the then Medical Officer ofHealth wrote that 'the wonder is that anyone can live at all inthese places, so crowded and devoid of sanitarysurroundings are they. No windows. in many cases nodoors, mud floors and filth-covered walls go to make up thedwelling so called: Perhaps the most poignant of 1901 'sobservations relates to the 'appalling infant death amongstColoureds; that 160 children out of 220 should die beforereaching one completed year of life is a fact that needsattention, in fact it looks almost as if foul play was going onto do away with helpless infants'.By 1907, some decrease in infant mortality had beenrecorded (Rg. 1) and increasing attention was being paid topossible interventions whereby infant death due todiarrhoeal disease could be reduced further. Infant deathwas often preceded by episodes of diarrhoeal disease which'wrecked the constitution of infants attacked by it, so thataJthough they may recover from it, they are more liable tocontract and succumb to other ailments shortly after, orsuffer from its after-effects for long perlods'. The 1909 reportembraced the 'sanitary theory', emphatically stating that 'thehigher standard of sanitation aimed at and attained in atown, the lower the infantile mortality'. In the 1911 report, aplea is made for better maternal education, breast-feedingand attention to infant cleanliness, and issues such asground temperature, vapours and the virulent properties ofgerms are also explored. As to the role of mothers, it isnoted that 'if a child is to have a healthy life, it is necessarythat its condition be satisfactory before being born and forsome years after, consequently the health and habits of themother are of first importance to the coming child'. Copiousquotations from both British and French public healthsources of the time are included, inter alia the report ofNewsholme from the London Local Government Board.'oWith regard to the role of infant mortality as a public healthindicator, the report states that 'the importance of thesubject cannot be overestimated as it constitutes the masterkey of all public heaith wor!<'.800 ~o=,,=,"::.:,::.:,=,,=w=o::O::.:'::"='="::."::'::.' ~1 1 1 1 1 1 I999999901122335050505SOVIlCf, MfOICll OfFICER OF I;EAl-T"II£POFlTSFig. 1. Infant mortality rates, Kimberley, 1898· 1991.SA.~1J Volume 86 No. 4 April 1996 _By 1920, increasing attention was being paid to themortality rates of under-5-year-olds. This was also the firstyear that black infant mortality was recorded by the Board ofHealth. The provision of housing, including the erection of 'anew township where there would be less public and privateuncleanliness, and the mortality among infants would beless' is proposed. As to the mechanisms of infant mortalitycaused by diarrhoeal disease, the report postulates that'after six months the child is placed on the floor to amuseitself while the mother gossips or gets bUSy with herhousework. The child has a glorious opportunity to get itselfthoroughly dirty in whatever domestic uncleanliness orprivate filth that is to be found. The child contracts summerdiarrhoea and dies of it. The mother attributes it to anythingbut her ignorance or negligence'. A special 'infant bureau'was established in 1922 to institute interventions to reduceinfant mortality_ Volunteers were called for and the reportnotes that 'there is plenty of scope for extension of childwelfare work, especially among the Natives'. The 1923report notes that black mothers were 'very reluctant to bringtheir newly born infants (to the c1inic)_ They were moreinclined to bring those of 18 months and older, and probablyeven then came merely for curiosity'.In 1928, it was recorded that 'the infantile mortality rateamong the Coloureds and Natives is still appallingly high'.This was, to some extent, attributed to the economicconditions of the depression. In his 1943 report, theMedical Officer of Health was clear as to the reasons for theinter-racial disparities in infant mortality rates (black andcoloured rates were 8 and 4 times higher respectively thanthat of whites)_ He writes that 'the reason for this increase isneither obscure nor mysterious. The high Native infantilemortality rate is unquestionably due to social and economicconditions. There must be a radical improvement in theirhousing, nutrition, prevention of over-erowding, hygiene andsanitation in the location'. The local authority responded tothe problem with the construction of a special clinic. 1I By themiddie of the century, the Board reports had becomeextremely sparse in tenns of social comment and interest ininfant mortality. The closure of the Kimberley Board ofHealth in 1977 resu~ed in the City Council's producing astandardised annual report, not very different from that of anumber of South African cities.In the iate 19aOs, the annual reports of the KimberleyPublic Health Department begin to contain comment on theproblems of urbanisation and the proliferation of 'squattercamps'. The more recent reports document an increasingcommitment to proViding basic environmental healthservices and, to some extent, recognition of the de factoexistence of informal settlements_DiscussionMany of the themes in the reports of the Kimberley Board ofHealth are relevant today. These include the relationshipbetween socio-economic status and health, unacceptabledisparities in infant mortality and the role of diarrhoealdisease in infant death. The suspicion of 'foul play' as acause of infant death, contained in the 1901 report, has amodern analogue in the work of Nancy Scheper-Hugheswhich explores 'passive infanticide' or 'benign euthanogenicneglect' in poverty stricken north-east Brazil. I2.13 The role ofvolunteer organisations and special programmes in reducinginfant mortality is discussed in a number of the reports. Thelack of community interest was not an uncommon responseto the interventionist approach and the complaints of theMedical Officer of Health on this particular issue wereechoed by colonial medical officers throughout Africa. '4The recognition, in the 1943 report, that the determinantsof infant mortality are mostly outside the biomedical realm iscongruent with the work of the Gluckman Commissionwhich, just over a year later, reported that 'unless there weredrastic reforms in the sphere of nutrition, housing, healtheducation and recreation, the mere provision of moredoctoring would not bring health to the country' _15 Thehistory of public health interest in disparities in infantmortality rates between various groups should lead us toconcur with Alfred Yankauer who concluded that:'The spirit of public health lives in this conviction that aMure society will authorise the major investment changereqUired to produce an equity reflected in the mortality ratesof its infants' .ISThe author would like to thank the staff of the AfricanaUbrary, Kimberley, for their assistance. The earlier part of thiswork was funded by the Medical Research Council.REFERENCES1. Yach 0, TOllman SM. Public health initiatives in South Africa in the 1940S and1950$: Lessons for a post-apartheid era. Am J Public Health 1993; 83: 1042-1050. -2. Hanison O. The National Health Service Commission, 1942-1944 - its originsand outcome. S Afr Med J 1993; 8:l: 679-684.3. Boma JL. 6tadshaw O. Gonin A, Yach D. The distribution of health needs andservices in South Africa. Soc Se; Med 1988: 26: 845--851.4. Phillips HT. An intel'"--filCial study in SOCial conditions and infant mortality in CapeTown. 11Ie Ali/bank Memorial Fund Ouarterly 1957: 25: 7-28.5. Yadl O. Jrrfa11t mortality rates in urtlan are~ of South Africa. 1981-1985. S AIrMed J 1988: 73; 232-234.6. Katzenellenbogen J, Yach 0, Dorrington RE.. MonaIity in a rul1!l South AfriCanmiSSion. 1837-1 909: AA historical cohon study using church ~ords. Inr JEpidemiol1993: 22:; 965-975.7. Republic of South Africa. Public Health Act. At;t 63 of 1977.8. Start Reportet'". City Board of Health to close down. Diamond Fields Advertiser, 10May 1978. 4(b)9. Board of Health, Kimberley. Reports of the Medical Officer of Health, 1898-1977.10. Ne>NSholme A. Report by the Medical Officer on Child MortaHry. Supplement tothe 30th Annual Aeport of the Local Govet'"nment Board. London. 1910.11. Staff Reponer. New clinics to raise the health standard of the natives. DismondFields Advertiser. 13 August 1946, 9{a),12. Scheper-Hughes N. Social IndlHerence to child death. Lancer 1991: 337: 1144-1141.13, Scheper-Hughes N. Dearh Without Weeping; The Violence of E~erydayUfa InBrazil. Berkeley, CaJlf: Univenity 01 CaJilClrnia Press. 1992.14. Vaughan M. Curing Their Ills: Colonial Power and African Illness. Cambridge:Polity Press, 1991.15. National Health Services Commission. Report of the National Hf!SIth Service$Comm/Uion on the Provi$ion of an Organised National Health Service tor allSections of the People 01 the UniOll of South Africa 1942-1944 {the GluckmanReport}. Cape Town: South African Government Printer, 1945: 24.Hi. Yankauer A. What infant mortality tells us (Editorial). Am J Public Health 1990;80: 653-654.Accepted 6 Jan 1995_Volume 86 No_ 4 !\pril 1996 SAM}

'Neither obscure nor mysterious' - infant mortality and the Kimberley Board of Health, 1898-1977

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'Neither obscure nor mysterious' - infant mortality and the Kimberley Board of Health, 1898-1977

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