White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa / Edition 1

by Randall M. Packard

Overview

Why does tuberculosis, a disease which is both curable and preventable, continue to produce over 50,000 new cases a year in South Africa, primarily among blacks? In answering this question Randall Packard traces the history of one of the most devastating diseases in twentieth-century Africa, against the background of the changing political and economic forces that have shaped South African society from the end of the nineteenth century to the present. These forces have generated a growing backlog of disease among black workers and their families and at the same time have prevented the development of effective public health measures for controlling it. Packard's rich and nuanced analysis is a significant contribution to the growing body of literature on South Africa's social history as well as to the history of medicine and the political economy of health.

Product Details

ISBN-13:	9780520065758
Publisher:	University of California Press
Publication date:	11/06/1989
Series:	Comparative Studies of Health Systems and Medical Care , #23
Edition description:	First Edition
Pages:	416
Product dimensions:	6.00(w) x 8.80(h) x 1.20(d)

About the Author

Randall M. Packard is Asa G. Chandler Professor and Chair of the History Department at Emory College. He is the author of Chiefship and Cosmology.

Read an Excerpt

White Plague, Black Labor

Tuberculosis and the Political Economy of Health and Disease in South Africa

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By Randall M. Packard

University of California Press

Copyright © 1989 Randall M. Packard
All right reserved.
ISBN: 9780520065758

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Introduction: Industrialization and the Political Economy of Tuberculosis

Tuberculosis was the number one cause of death in Europe and America from the late eighteenth to the early twentieth century.1 Although the disease was by no means unknown before this time, its impact on human populations increased tremendously during the early years of the industrial revolution. The rise of industrial development and the growth of cities in both Europe and America produced ideal conditions for the spread of the disease. The men and women who flocked from rural communities to find employment in the factories and mills of Manchester and Birmingham, Lowell and Fall River had little prior contact with tuberculosis and as a group possessed limited resistance to it. To this inherent disability was added the physical insults of industrial life. Long hours, intolerable working conditions, atmospheric pollution, overcrowded living quarters, the absence of sanitation, and inadequate diets composed largely of bread, cheap tea, and "drippings," marked the daily lives of the newly industrialized workforce. These conditions undermined the abilityof workers and their families to resist TB and facilitated the rapid dissemination of infection among them. Though the disease recognized no class lines, attacking some of the most gifted intellectuals and artistic talents of the day including Keats, Shelley, Emily and Charlotte Bronte, and Chopin, it clearly took its heaviest toll among the laboring classes. The spread of the disease was so great and hope of recovery so small that tuberculosis became known as the "great white plague," an allusion to both theblack plague of earlier centuries and the characteristic pallor of victims of the disease.

As industrialization spread from its early centers in Europe and America, so too the white plague found new populations to attack. The correlation between early industrialization and tuberculosis is clearly evidenced by the TB mortality curves of major U.S. cities.2 In each case, the rising tide of TB parallels the growth of urban industrial development and the recreation of conditions that fostered the disease's spread. So strong was the association between early industrialization and rising TB mortality that tuberculosis became seen by many medical authorities as an almost inevitable cost of industrial growth.

The rise of TB in the newly industrialized societies of Europe and America was followed in every case by a long period of gradual decline. This decline, as Dubos,3 McKeown,4 and others have noted, was largely independent of medical intervention. In fact, there was little that medical science could do to control TB prior to the 1950s. It appears instead that improvements in housing, working conditions, and nutrition from the middle years of the nineteenth century played a critical role in the decline in TB mortality. At the same time, the proportion of hereditarily susceptible families in industrial populations declined as a result of their higher mortality rates.5 This selection process contributed to the overall ability of industrial populations to resist the disease.6

The downward trend in TB mortality was not continuous, however. Wartime conditions including malnutrition, physical and mental stress, and overcrowding led to sharp upward trends in TB mortality throughout Europe, overriding whatever level of acquired resistance European populations had previously achieved. Immigration was another cause of TB resurgence. Grigg7 argues that the immigration of Europeans to Boston and New York, and the movement of blacks from the rural areas of the American south to cities such as Chicago and Cleveland during the nineteenth and twentieth centuries, introduced new populations of susceptibles to these cities and thereby increased TB mortality rates in them. This "immigration effect" was no doubt generated as well by the ghetto conditions under which many immigrant populations lived during their early years of urban settlement.

Despite these setbacks the general trend of TB mortality in the west since the middle of the nineteenth century has been downward, so that by the time effective treatments for the disease were discovered following World War II, the disease was no longer the dreadful killer it had been a century before. Like the association of TB with early industrialization, the subsequent downward trend in TB mortality has been so widespread in western medical experience that it is often described as part of the natural history of the disease.8

Tuberculosis and Colonial Development in Africa

At the end of the nineteenth century, the industrial revolution began to expand outward from Europe and America into the third world under the banner of imperialism. While commercial capital led the way, industrial centers began to emerge in a number of European enclaves in Latin America, Africa, and Asia. The development of gold mines in South Africa, Zimbabwe, and Ghana, copper in Zaire and Zambia, and tin in Nigeria drew large numbers of African workers to emerging industrial centers. At the same time, the expansion of agricultural production and the growth of port cities like Accra, Lagos, Dakar, and Mombassa, geared toward the export of Africa's mineral and agricultural wealth, also drew thousands of Africans into an expanding urban environment. As in Europe and America the growth of industrial and urban centers in Africa was accompanied by sharp rises in TB mortality.

Nowhere was the correlation between industrial and urban growth and TB more evident than in the booming industrial and commercial centers of South Africa. The discovery of gold and diamonds attracted tens of thousands of Africans to the mining centers along the Rand and in Kimberley at the end of the nineteenth century. The mineral discoveries also stimulated the growth of African populations in the port cities of Cape Town, East London, Port Elizabeth, and Durban. The rural populations who flocked to these centers in search of employment, like their counterparts in Europe and America, had limited prior experience with TB and thus little resistance to it. Moreover they entered an environment that in many ways resembled the conditions of London and Manchester during the early nineteenth century. Overcrowded housing, low wages, inadequate diets, and lack of sanitation were the common welcome of newly industrialized African workers. Predictably they suffered extremely high rates of tuberculosis, in some cases exceeding 15 deaths per 1,000 residents per year.

Yet the experience of newly industrialized workers in South Africa has not been identical to that of their European and American counterparts. To begin with, the TB epidemic in South Africa did not fall evenly on the working class as a whole. Rather it fell most heavily on Africanworkers.9 Although many white workers fell victim to the "white plague," at the turn of the century their mortality rates were uniformly lower than those of African workers. Second, while the TB epidemic among white workers paralleled the experience of their counterparts in Europe and America, with both mortality and morbidity falling off dramatically after an initial epidemic wave, rates for blacks have shown little sign of replicating this downward trend.

African TB mortality did decline dramatically in South Africa, as in most of Africa, following the development of effective antitubercular drugs in the early 1950s. There is little evidence, however, that this decline in TB deaths reflected a significant reduction in the level of TB morbidity. Although South African medical officials claim that a real decline in the incidence of TB has occurred over the past twenty years, the evidence for this claim, as we will see, is of questionable reliability. In fact there are those who have argued that given inefficient treatment programs, chemotherapy has simply produced a growing pool of half-cured and therefore potentially infectious cases that have contributed to a rising tide of TB.10

South African medical authorities have tended over the years to attribute both the high incidence of TB among Africans during the early years of industrialization and the failure of Africans to develop resistance to TB to their inherent susceptibility. It was not, they have argued, that the conditions under which Africans lived and worked were so much worse than those experienced by white labor, but that whites have had a long historical experience with both the disease and the conditions of urban industrial life. This experience accounts for both the lower initial rates and the more rapid decline of the disease among white workers. Africans conversely were said to have had little or no experience with either the disease or the conditions of industrial life. They were in effect a "virgin" population and therefore more susceptible to TB. These arguments, as we will see, have been presented in a number of different forms since the beginning of this century and, like the disease itself, have reflected changing political and economic interests within white South African society. The message underlying these explanations, however, has remained constant: the experience of Africans with TB has been different from that of whites because Africans are themselves different.

Critics of South Africa's apartheid system have been equally vocal in arguing that the disparity between the experience of whites and blacks with TB has been a product of racial discrimination in South Africa.

Racism caused the squalid working and living conditions associated with the early industrialization of Europe and America to be reproduced among black workers in South Africa, but not among white workers. Racism and the resulting inequitable distribution of resources needed to sustain health similarly account for the persistence of TB among blacks when the disease has nearly disappeared among whites.11

Though these two explanations of the South African experience with TB (the "virgin population" theory versus the racism theory) are clearly at odds with each other, they are similar in one important respect. They both define the South African experience as fundamentally different from that of the west. In one case, this difference is attributed to the racial susceptibility of South African blacks. In the other, South African society is defined as different from western society because of its racist policies.

In contrast with that view, this book will argue that while South African experience with TB has been affected by the particularistic contours of South African history, both the epidemiology of the disease and the history of efforts to control it can best be understood in terms of the same set of political and economic factors that have shaped the history of the disease in the west. More specifically, the history of TB in South Africa and the west has been shaped by the changing alignment of political and economic interests within a rapidly expanding capitalist industrial economy. What is unique about South Africa is the specific way in which these alignments have evolved.

The Political Economy of Tuberculosis in England

Looking at the history of TB and industrialization in England, it is clear that both the rise of TB and its subsequent decline were directly linked to changing political and economic interests within English society. The growth of industrial capitalism in England was preceded and preconditioned by the reorganization of agricultural production accomplished through enclosure and estate clearances from the fifteenth through the eighteenth centuries. This process transformed English agriculture into a market-oriented system of capitalist production in which much of the land passed out of the control of independent owner—occupiers into the monopolizing hands of wealthy landlords, and where large numbers of farm laborers lost control over their own lives to their employers and the poor laws. This transformation meant that the landcould not absorb the great increase in rural population that occurred in the late eighteenth century.12 The resulting surplus labor force fueled the growth of industrial enterprises. It also created the political and economic context that largely defined the conditions under which newly industrialized workers lived and worked within the urban and industrial centers of eighteenth- and ninteenth-century England.

It may be true that neither the municipal authorities nor factory owners of the country's growing industrial towns could foresee the health costs of industrial development during the early years of the ninteenth century, that they were faced, as Anthony Wohl has recently observed, "with a set of problems that were novel not only in their form but in their magnitude."13 It is equally clear, however, that as the century wore on the persistence of these conditions reflected in large measure the unwillingness of either capital or the state to enact the reforms that were necessary to alleviate the suffering caused by the exploitation of labor.

From the viewpoint of capital the surplus of labor generated through the transformation of agricultural production vitiated the need to initiate reforms that would ensure the reproduction of the workforce. It also undermined labor's ability to press for such reforms.

The state, for its part, was dominated prior to 1832, and only to a slightly lesser degree afterward, by the landed interests that had played a crucial role in generating the industrial workforce. As a class they had little immediate interest in the conditions developing in the squalid urban centers of the country and were concerned primarily with keeping down expenditures for poor relief. Given this alignment of political interests the main response of the state to popular pressure for reform was repression. The long list of brutal laws designed to deal with wandering poor produced by enclosures, and the repressive character of the poor laws, attest to the state's efforts to deal with the social and economic costs of industrialization through social control rather than reform.14

In short, the great white plague that ravaged the working and non-working poor was not an inevitable cost of industrial development but a result of the specific pattern of primitive accumulation that laid the basis for industrial growth and for the exploitation of labor, and of the alignment of political interests within the state. As Dubos has noted, TB was "perhaps the first penalty that capitalistic society had to pay for the ruthless exploitation of labor."15

Conversely, falling TB rates during the nineteenth and early twentieth centuries did not result from some natural progression of modernsociety or from the triumph of scientific rationalism, or even from the energetic work of such Victorian reformers as Edwin Chadwick and the Earl of Shaftsbury. They reflected instead the effects of "natural selection" and a growing convergence of class interests within English society around the issue of worker health.

The very conditions that laid the base for the exploitation of labor probably played a significant role in ultimately decreasing the force of the TB epidemic that accompanied early industrialization. The fall in TB mortality rates in England dates from the beginning of death registration in 1838. Although it is impossible to know what the incidence of the disease was prior to registration, it was almost certainly higher. Thus the disease was probably decreasing in its impact throughout the nineteenth century. This pattern cannot be explained by improvements in material conditions, which, as we will see, remained appalling through most of the century.16 It is likely instead that the early decline of TB in England, and probably in America, was brought about by a rise in overall resistance produced by the early elimination of genetically susceptible families and the survival of more resistant families. This experience, common to the natural history of many infectious diseases, should not, however, be seen as an independent biological process. It was clearly encouraged by the creation of a more or less permanent class of urban working and nonworking poor who lived in constant contact with the TB bacilli. Had the extent of land alienation been less, and the movement of labor into industrial centers more temporary in nature, it is likely that this "seasoning" process would have been delayed.17 In effect, the so-called natural history of TB was shaped by the degree to which workers were fully proletarianized.

Whereas natural selection appears to have played an important early role in the decline in TB in England, the downward trend was hastened by gradual improvements in working and living conditions. These reforms resulted from a combination of the growing bargaining power of labor and an increase in the concern of employers for improving the efficiency of the workforce during the nineteenth and early twentieth centuries.

The middle years of the nineteenth century saw a dramatic increase in labor organization and the growth of trade unions. Populist calls for reform were further crystalized in the Chartist Movement, that, despite its ultimate demise, galvanized the ruling classes into enacting moderate reforms designed to counteract populist demands.18 Pressure from below, therefore, contributed to better working conditions and wages,which slowly led to some improvement in the overall ability of working-class populations to resist the onslaught of the tubercle bacillus. It is certainly no coincidence that meaningful reforms did not start, however, until after the Second Reform Act of 1867, which began the process of enfranchising the working class; nor a fluke that reform remained largely unsuccessful until the more broad-based political participation of labor was achieved after World War I. It is clear, too, that working-class pressure by itself would not have produced the reforms begun in the middle nineteenth century without a wider convergence of class interests committed to health reform.19

The growing importance of industrial and commercial capital within English society led to a shift in the distribution of class interests represented within the state, marked by the enfranchisement of the middle classes in the First Reform Act of 1832.20 This shift in political power paralleled a growing awareness by the middle class of the need to improve conditions of health among the urban working classes.

The industrial and commercial interests enfranchised by the 1832 reforms represented not capital as a whole but an elite segment of capital, the major manufacturing concerns whose origins can be traced to the sixteenth century.21 The interests of this group were not always the same as those of small-scale manufacturers of relatively recent origin. Specifically, established industrial interests were more attuned to the tremendous carnage the ruthless exploitation of labor was having on the industrial workforce and came to see it as being in their interest to discipline capital by reducing the demands on labor in order to increase its efficiency. This was not simply an act of noblesse oblige but also of self-interest. Reforms such as the ten-hour day and restrictions on the use of child labor not only helped to ensure the health of labor but also contributed to the rationalization of capital. Such reforms hit small-scale, often undercapitalized enterprises the hardest and thus reduced their competitiveness.

Self-interest no doubt also pushed the parliamentary representatives of major manufacturing families to work for reforms in other areas of working-class life. Housing and sanitation reforms were viewed as essential to protect the middle classes from the ill-health of workers. As Dickens put it, "the air from Gin Lane will be carried, when the wind is Easterly, into May Fair."22 Four cholera epidemics between 1830 and 1866 demonstrated the reality of this observation and played a significant role in getting Parliament to pass the Public Health Act of 1848.23 Although implementation of the act was seriously impeded by a subsequent reduction in the power of the General Board of Health established to supervise it, the act represented a significant movement away, though by no means a complete break,24 from the repressive Poor Law approach to the working-class conditions that had dominated public welfare laws prior to 1848.25

One should not of course see the development of reforms in health and in the workplace as evolving easily out of a combination of worker pressure and capital's self-interest. The drive for reform was long and hard, with each effort to improve conditions deflected by a range of conflicting economic and political interests.

Housing reform was symptomatic of the difficulties urban reformers had in improving the conditions under which the working poor lived. Through much of the second half of the nineteenth century housing was a focus of debate by local and national authorities. This debate produced a number of housing reform acts designed to remove the dangers of overcrowded slums. Yet the unwillingness of local and national legislative bodies to provide funds for the creation of alternative housing, together with obstacles created by the nature of land ownership in cities like London, often meant that housing reform resulted in increased overcrowding in areas adjacent to those cleared and did little to reduce the overall problem.26

Improvements in nutrition also came slowly. Although McKeown27 has argued that improvements in food supply were a major contributor to the decline in TB during the nineteenth century, these improvements do not appear to have had much effect on the diets of the working class before the last quarter of the century. Most diets prior to that time lacked the needed protein and vitamins, let alone adequate calories, to hold off infections.28 In the end, it is safe to say that improvements in urban living conditions came very slowly and only achieved significant improvements from the 1880s. It was not in fact until after World War I when labor gained a greater voice in the control of the state, that conditions of housing and nutrition improved sufficiently to curtail the spread of TB.

Despite the sluggish pace at which reform occurred, there nonetheless can be little doubt that the demise of TB in England from the middle years of the nineteenth century was encouraged by a convergence of class interests around health. If capital and labor had different agenda, their interests coincided in the need to ensure the reproduction of theworkforce and to eliminate the causes of diseases that refused to recognize the social boundaries separating the lower and upper classes of English society.

The Political Economy of Tuberculosis in South Africa

Changes in the alignment of economic and political interests have also shaped the history of TB in South Africa. As in England, changing patterns of agricultural production and the alienation of peasant farmers from the means of production generated the industrial workforce needed for the growth of industrial capitalism in South Africa.29 It is clear, however, that during the period of early industrialization, from the end of the nineteenth century through the 1920s, the process of primitive accumulation was slow and uneven. As a result, the proletarianization of the peasantry was less complete than in England. This more limited transformation of the rural economy resulted from a combination of factors. Landed interests, in this case white farmers, while seeking to transform relations of production within the rural economy and having a significant political voice, faced a more resilient precapitalist social order than existed in England and lacked the coercive force needed to transform this order. Many white farmers, moreover, lacked the capital needed to rationalize agricultural production on their lands and were, therefore, dependent on African farmers who obtained access to land in return for payment in kind or labor.30 In short, white farmers were either unable or unwilling to follow the lead of landed interests in England in alienating the peasantry from the land and thus in laying the groundwork for the development of a proletarianized industrial working class.

For its part, industrial capital did little more to encourage the development of a proletarianized urban workforce. During most of its early history, the mining industry was handicapped by the high cost of capital investments required for mining operations and by a low and inelastic price for their product on international markets. As a result, mine owners were under considerable pressure to keep down labor costs.31 During the early years of the mining industry this requirement made it difficult for mines to attract labor. African farmers had few incentives to engage in what was seen as a dangerous occupation. When they chose to do so, often at the behest of local ruling elites, they only stayed for short periods of time.32 This resistance began to decline during the first decade of this century as a result of the state taking a more active role in encouraging African participation in labor markets, through the imposition of taxes, the control of desertions, and, ultimately, through the passage of legislation that began to restrict African access to the means of production. These policies, combined with the creation of effective mine recruiting organizations, began to ensure a steady, if pulsating, flow of labor to the mines.

By the time this occurred, the mining magnates had come to recognize the value of a migrant labor system in which the African worker retained a rural base. The retention of a rural base, in fact, came to be seen as an essential element in the financial structure of the mining industry. For it saved the industry from having to pay for either the reproduction of labor or for the welfare of workers who were too old, sick, or injured. The need to secure a rural base for migrant workers conflicted with the practice of generating labor by restricting access to the means of production and, we will see, produced a fundamental contradiction in the development of labor policies in South Africa. It led the mining industry, nonetheless, to support the creation of native reserves, constituted by the 1913 Native Land Act, and fueled their consistent opposition after 1913 to policies that would lead to a more complete proletarianization of their African workforce.33

The less complete proletarianization of the African workforce and the development of the system of labor migrancy affected the epidemiology of TB in several critical ways. First, the pattern of labor migration, which characterized early industrialization in South Africa, caused the urban-based TB epidemic to spread into the rural areas of South Africa at a more rapid rate than occurred in Europe or America. In fact, by the late 1920s, over 90 percent of the adult population of some parts of the Ciskei and Transkei had been infected with TB.34 This spread, as we will see in chapter 4, reflected not only the high turnover of labor but also the forced repatriation of workers who were sick or deemed to be unproductive, as well as the gradual impoverishment of rural populations in the face of declining access to the means of production and low industrial wage policies. This impoverishment undermined the ability of rural Africans to resist diseases, such as TB, which were transmitted by returning migrants.

Second, in contrast to the history of the disease in England, labor migrancy may have delayed the development of resistance to TB. Though a sizable population of more or less permanent African urban residents emerged in the major cities of South Africa following WorldWar I, most workers were temporary sojourners, particularly in the mining industry, and thus there was a high turnover of African workers. In the gold mines, the turnover rate in any given year was nearly 100 percent. This pattern may well have retarded the development of a stable balance between African urban populations and the TB bacilli and thus prolonged the TB epidemic.

By contrast, white workers from the beginning of the industrial revolution formed a more settled industrial population and had a longer prior experience with TB. This may well have contributed to a more rapid adjustment to the disease. The steady flow of white Afrikaners into urban centers following the South African War, however, probably had a retarding effect on this adjustment similar to the arrival of immigrant populations in the United States.35

Finally, the fact that African workers were less proletarianized than either their English counterparts or white workers in South Africa, limited the ability of African labor to push for health reforms.

The more rapid decline of TB among white workers than among Africans was not, however, a simple reflection of different levels of proletarianization. It was instead the product of fundamental differences in the alignment of political and economic interests in South Africa over the question of health reform. In the case of white workers, a convergence of class interests around health, similar to that which occurred in England, evolved during the first decades of this century following a period of intense struggle.36 By contrast, although there have been moments when the interests of African labor, certain segments of industrial capital, and the state have converged over the question of health reform for urban Africans, these have been temporary in nature, fragile in terms of the level of commitment exhibited by either capital or the state, and weakened by the opposition of other powerful sets of economic and political interests within white South African society. As a result, much less reform has been achieved or even attempted in the conditions that contribute to high rates of TB among African workers and their families.

The achievement of health reform for white workers and their families did not evolve easily. However racist South Africa was to become later in the twentieth century, the alignment of political and economic interests at the beginning of the industrial revolution did not automatically ensure white privilege or white worker health and safety.

Political power during the period of early industrialization, prior to the South African War, lay primarily in the hands of farming and commercial interests. This was particularly true in the Transvaal where the discovery of gold had created a boomtown environment along the Rand. The Kruger government represented the interests of Afrikaner farmers in the Transvaal and moved slowly to accommodate the expanding industrial complex on the Rand. Like the landed gentry who dominated English politics in the early nineteenth centry, the farming interests in the Transvaal had little reason to implement health reform or other improvements to insure the well-being of the rapidly expanding industrial workforce, and they were primarily concerned with maintaining order and with rent-seeking activities.37

For its part, capital, working under severe financial constraints, had no more inclination to invest in the health of white workers than in that of Africans. Silicosis took a dreadful toll among white mineworkers during the early years of underground mining.38

After the war, the Milner administration proved much more sympathetic to the interests of industrial capital.39 In the absence of any perceived need by capital to improve working and living conditions, however, this led to few improvements. The mine owners continued to treat all labor with equal disdain when it came to health and safety. In the end, the ability and willingness of white workers to mobilize and fight for reforms, their representation within the state, particularly after 1924, and the mine owners' fear that failure to provide improvements for white workers would lead to the development of a broad-based multiracial labor movement, encouraged the mine owners to gradually develop a discriminatory system of wages and benefits.40 They did so with the support of the state, which was committed to the ideal of a white settler society in South Africa. This led to the emergence of the color bar in industrial relations and to a growing disparity in the working and living conditions of white and African workers.41

In effect, the needs of white labor, capital, and the state came together in an uneasy alignment of political and economic interests which, while not completely crystalized until the political empowerment of white labor had been secured in the 1920s, ensured that improvements were instituted in white working and living conditions.42 As a result, TB among white workers exhibited the same downward trend experienced by workers in England following a similar convergence of political and economic interests. In fact the TB mortality rates of white workers in South Africa dropped much more rapidly than those of their European counterparts, reflecting the shorter history of their struggle with capital and their more rapid empowerment within the state.

For Africans there was no such convergence of interests. Although the withdrawal of African labor from the mining industry, in the face of declining wages and expanding opportunities outside of mine employment, created a labor crisis on the Rand following the South African War, the crisis did not encourage self-interested reform on the part of mine owners. This was because, as mentioned above, the state chose to support the mining industry by permitting the introduction of Chinese labor, and later by facilitating the development of a more efficient and geographically expansive labor recruitment system based on migrant African labor.43 These actions, combined with a decline in non-mine employment after 1906 and the crushing of the Bambatha rebellion, which pushed thousands of Zulus onto the labor market, contributed to the creation of a labor surplus that undermined African labor's ability to organize and push for reform. Mining capital, as a result, was neither impelled nor drawn to make reforms that would have ensured the health and reproduction of the African workforce. The mining industry did make some reforms in order to cut down on mortality rates, for which they became financially liable, and to increase the productivity of the workforce. Yet as we will see in chapter 6, these reforms left a good deal to be desired in terms of both working and living conditions.

The interests of the state did not always coincide with those of industrial capital. As the industry continued to grow, however, the two sets of interests seldom conflicted to a degree that undermined the ability of capital either to acquire labor or to make profits. In the area of health reforms especially, the state, despite much rhetoric on the part of the Native Affairs Department (NAD), only rarely intervened to enforce improvements in working and living conditions in the mines prior to World War II. The most dramatic, and in fact the only, time in which the state seriously defended the interests of African labor, was when appalling death rates among tropical workers became a political embarrassment just prior to World War I (see chapter 6). For the most part, the state, regardless of its political complexion, was sympathetic to the needs of the industry that was seen as the backbone of the South African economy.

In the absence of strong pressure from African workers, of self-interested reform on the part of the owners of capital, or a willingness of the state to enact legislation that might harm the mining industry, the only voice advocating urban and industrial health reform prior to World War II—other than that of the emerging African bourgeoisie, who lacked political power—came from the white residents of the growing urban and industrial centers of the country and from middle-class white reformers.

Like their middle-class counterparts in England during the middle nineteenth century, white urban residents were enfranchised and increasingly vocal about the danger posed by the ill health of poor, and in this case black, workers. This fear was heightened by the plague epidemic of 1902 and later by the Spanish influenza epidemic of 1918. As we will see, both episodes, like the cholera epidemics in nineteenth-century England, led to calls for urban reforms. In theory, these reforms were suppose to benefit African workers by providing them with better housing in regulated "Native locations."44 But South African housing reform in practice resembled its counterpart in England during the 1890s in that it involved little more than the removal of black urban workers from the centers of white settlement. Little effort was made to actually ameliorate the conditions of African life, and in many cases conditions grew worse in the overcrowded locations that grew up around the white-dominated urban centers following the implementation of sanitary segregation. Slum clearance was in fact little more than a rationalization for racial segregation based on the metaphoric equation of Africans with disease.

The white urban middle class showed even less concern for the health of the rural population from which they drew their labor. Removed from the view of most white voters, the rural reserves were seen as primitive and yet essentially healthy backwaters from which an endless supply of cheap labor could be drawn. This view belied a growing reservoir of poverty and disease within the reserves and by doing so laid the basis for the future expansion of TB within the urban and industrial centers of the country.

Not all whites shared these views and, as in England, there were middle-class reformers—medical men, missionaries, certain officials within the NAD and other state agencies, and Joint Councils of Europeans and Africans,—voluntary associations founded in the 1920s "to promote interracial co-operation and to investigate, and make representations on, matters affecting the welfare of Africans, under the aegis of the liberal South African Institute of Race Relations,"45 During the 1920s and 1930s these reformers were highly critical of the conditions under which Africans were forced to live and work. Their numerous commissions produced reports that clearly identified the problems faced by African workers and their families and made recommendations for eliminating them. Yet the recommendations of these advocates receivedlittle support. The white electorate resisted any reforms that would threaten their own economic interests, either directly through taxation or indirectly in the form of competition from an increasingly stable African workforce.

Lacking a mandate for reform and facing significant opposition from the white electorate, the state either did nothing or enacted policies, such as the Native Urban Areas Act of 1923 and the Slum Clearance Act of 1934, which were riddled with contradictions and ineffective as instruments of urban reform. Such reforms, like the white electorate whose interests they reflected, continued to ignore conditions in the rural areas.

During the late 1930s and early 1940s the conditions that had inhibited a convergence of political and economic interests over the question of social reform began to change. This change reflected transformations in both the supply of labor and in the nature of industrialization in South Africa. By the mid-1930s contradictions embedded in the system of capital accumulation which had developed over the previous half century were becoming apparent. The rural support base, meant to provide for the reproduction of labor, showed signs of breaking down under the stress of policies that had been designed to generate labor. As we will see in chapter 4, malnutrition and disease were becoming widespread in the reserves, and employers began complaining about the falloff in a healthy labor supply.46 The structure of industrial development began at the same time to change from extractive industries dominated by mining to manufacturing. This shift, which started following the Depression and accelerated during World War II, necessitated the establishment of a more skilled and permanently settled African workforce.

Combined with the failure of earlier reform efforts, these changes resulted in the movement of thousands of African workers and their families into urban centers that had made little effort to accommodate them. This set the stage for a major rise in black TB mortality and led to increased recognition by industrial capital and the state that the new labor force could not be created without significant improvements in the conditions under which African workers lived and worked. At the same time, African labor found itself for the first time in a position to organize and apply pressure for reform. Much of the pressure was focused on the issue of housing, which as we will see was woefully inadequate for the growing African urban population. Highly politicized squatters' movements emerged and were involved in disturbances and riots in several major cities.47 In short, the period during and immediately after World War II saw the emergence of converging class interests around health and welfare issues paralleling those that had emerged in England during the second half of the nineteenth century and among white workers of South Africa at the beginning of the century, in both cases contributing to health reforms and a declining mortality rate.

This coalition of interests, however, despite a great deal of discussion about health reform that culminated in the recommendations of the Gluckman Commission for the creation of a National Health Service, produced very few substantive changes in the area of African public health, housing, nutrition, or sanitation. The reasons for this failure will be discussed in chapter 8, but the basic cause lay in the existence of significant class interests in opposition to the underlying assumptions of urban health reform and in the failure of the coalition of interests advocating reforms to mount a significant challenge to the structural basis of ill-health. The white electorate continued to view African urbanization as a threat to their interests and refused to support the reform movement. White workers feared increased competition for employment, and the landed interests in the platteland decried the loss of farm labor. In contrast to nineteenth-century England, these rural interests remained dependent on large bodies of cheap labor and opposed policies that threatened the security of that workforce. Even more moderate middleclass whites, concerned by the growing radicalization of African labor, were less than enthusiastic about policies that threatened the tradition of urban segregation. In addition, whereas large-scale manufacturers advocated the creation of a more stable African workforce, many smaller, undercapitalized employers, even in the urban sector, were unprepared to pay the cost of such a move. Finally, the mining magnates were opposed to any reform that would interfere with the migrant labor system. In the end, the Smuts government was unwilling to oppose these interests and failed to provide resources needed for health reform.48

Following the war, the electorate turned its back on the reform agenda of manufacturing capital and the Smuts government and rejected the demands of African workers, choosing instead to side with the Nationalist Party and increased repression in the 1948 election. The Nationalist victory halted the drive for meaningful health reform and replaced it with a renewed commitment to the policy of urban segregation and labor control designed to relocate the problems of African ill-health rather than eliminate them. To placate capital, the state worked to reestablish the supply of cheap African labor through the creation of a system of more efficient state-run labor bureaus and the expansion ofrecruiting areas. By this action, the Nationalists were able to win the support of manufacturing capital for their apartheid policies and undermine industry's earlier commitment to meaningful health reform. In addition the expansion of mining capital into manufacturing, combined with the continued dependence of the former on migrant labor, may have deflected pressure toward urban reform on the part of manufacturers. Finally, by reinstituting earlier patterns of labor migrancy, undermining labor movements, and cleaning out squatter camps, the state greatly reduced the structural basis for popular dissent and thus reduced grassroots pressure for reform.

The withdrawal of the state and, to a large degree, industrial capital from the limited coalition of class forces pushing for health reform, and the repression of labor movements symbolized by the state's crushing of the 1946 African mine workers strike, meant that effective reforms that would have provided a base for the decline of TB and other diseases among blacks were not enacted. The state, to the contrary, can be seen to have resurrected earlier models of disease control based on sanitary segregation. This time, however, it was carried out on a much greater and more tragic scale through the policy of grand apartheid.

This turning back the clock was facilitated by the development of medical technology that promised to solve major health problems. The late 1940s and early 1950s saw the development of INH, streptomycin, PAS, and other effective weapons for fighting TB. It also saw the introduction of DDT in the fight against malaria and typhus. These developments raised the possibility of a relatively simple solution to three major health problems. They were solutions, moreover, that could be implemented without massive investments in social and economic reform and thus freed the state and capital from some of the costs inherent in reducing the disease burden undermining the efficiency of labor. This reliance on medical technology consequently deflected the drive for environmental reform that had arisen during the war. Medical science, in effect, ameliorated and disguised some of the health costs of the Nationalists' political and economic agenda. It did not, however, eliminate those costs. TB control efforts as we will see in chapter 9, have been seriously hampered by the wider social and economic policies of the Nationalist government. Moreover, the government's failure to enact more broad-based reform has meant the underlying causes of TB have gone largely unchecked, resulting in the production of new cases at a rate that equals or in some areas exceeds the rate of patients being cured.

Although recession and the rising labor militancy of the early- andmid-1970s spurred capital and the state to push for limited reforms in working and living conditions and triggered a resurgence of African labor movements, the resulting fragile convergence of interests produced only limited improvements for a small percentage of African workers. Failure to make more broad-based reforms, together with efforts to further restrict the majority of Africans to the so-called homelands, has limited these benefits to a few while the vast majority of Africans continue to live in abject poverty with all the health costs this condition entails. The health reforms of the mid-1970s were in reality part of a wider strategy designed to preserve the privileges of the white minority rather than to bring about a radical transformation in African health.49 The consequences of this failure of the state and capital as we will see in the epliogue to this study, is a rising tide of rural disease that is beginning to spill over into white South Africa.

Conclusion

By arguing that the history of tuberculosis in South Africa resembles its earlier history in England in that both histories have been shaped by the changing alignment of political and economic interests associated with the early growth of industrial capital, the present study suggests that the South African experience with TB has not been produced by a unique set of social and biological phenomenon (either the racist state or the racially susceptible African). It must be seen instead as a product of a particularly pathological intersection of political, economic, and biological processes that have a much wider distribution.

This book builds, then, on the insights provided by earlier studies that have explored the political economy of health within the context of expanding capitalist relations of production in Africa and elsewhere.50 These studies have highlighted the complex ways in which changing patterns of sickness and health are linked to the emergence of specific sets of political and economic interests operating at the local, national, and international level. In doing so, they have revealed the inadequacies of more narrowly defined approaches to understanding the causes of ill-health and the development of health care. With few exceptions, however, these linkages have been painted with broad strokes and lack specificity in terms of the historical development of specific health problems. For example, except for John Ford's classic study of trypanosomiasis in Africa,51 there have been no sustained studies that have tried to relate the history of a specific disease to broader patterns of political and economicdevelopment in Africa over an extended period of time. More often studies on the political economy of health have dealt with a number of health issues with limited attention to the specific linkages that exist between biological and social processes. The political economy of disease literature has, in fact, been stronger on political economy than on the linkages between political economy and specific disease patterns.

A number of studies have linked the history of specific disease episodes—malaria epidemics,52 outbreaks of typhus,53 or of small pox,54 —to wider patterns of political and economic change. Yet in limiting their time frame they have been unable to describe how these linkages have evolved over longer periods of time and how realignments in specific sets of political and economic interests have shaped the longer history of both health and health care.

The present study attempts to overcome the limitations of earlier works by exploring in depth the evolution of both a specific health problem and efforts to control it within the changing political economy of South Africa from the middle of the nineteenth century to the 1980s. It is hoped this book will thus provide a richer and more nuanced analysis of the changing relationship between health and society, not only in South Africa but more broadly within industrializing capitalist economies. At the same time, by linking the history of health and disease with the wider study of political and economic development in South Africa, the study throws fresh light on the changing contours of this wider history and, more specifically, on the high cost in human lives this history has inflicted upon the black population of South Africa.

The degree to which this or any study of health and disease is successful, of course, depends to a large measure on the availability of data on the changing health status of the population under view. In dealing with the history of disease in Africa this is a particular problem. The collection of vital statistics in most of Africa has been at best uneven and at worst nonexistent. In South Africa, the longer history of western medical care has meant that there have been more people collecting data over a longer period of time and that there is, in fact, a richer data base than is available in the rest of sub-Saharan Africa. The distribution of this data has been highly skewed, however. We know a great deal about health conditions in the mines, somewhat less about changing health patterns in the cities, and virtually nothing about the health of rural blacks. This distribution of data is not haphazard but, as will be suggested at several points in this study, is like the health problems the data describes, a reflection of changing political and economic interestsin South Africa. For example, although the mining industry and other sectors of industrial capital were concerned about the health of their workforce within narrowly defined limits having to do with the efficiency of labor, they showed a studied disregard for the health of workers' families who lived in the rural areas of South Africa. When the deepening impoverishment of these families began to threaten the reproduction of labor in the 1930s, however, they initiated a series of investigations into health conditions in the rural areas and funded, to a limited extent, the development of rural health services. These studies provided the first clear view of the state of rural health.55 In the urban centers of the country, similarly, we have health statistics for diseases among the whites and those Africans, coloreds, and Asians who fell within the narrowly defined statistical boundaries of "white" cities, but only occasionally do we get glimpses of health patterns in the segregated townships and peri-urban slums that surrounded these cities. Such momentary flashes of light have not been serendipitous but corresponded either to a growing self-interest among white residents over the threat of black ill-health or, as noted above, to broader transformations in the nature of capitalist development during the 1940s and then again in the mid-1970s, which necessitated the creation of a more permanent, and therefore healthy, workforce.

The exclusion of the majority of blacks from the statistical record has been part of an effort to remove black health problems from view. As we will see in the history of TB control in South Africa, there has been marked effort to eliminate the problem through the application of exclusionary policies that both physically removed blacks from centers of white settlement and expunged any record of their sickness from official health statistics.

As a result of the unevenness of the health record, it is impossible to explore the complex relationship that evolved between changing sets of political and economic interests, on the one hand, and patterns of sickness and health, on the other hand, with the same degree of specificity for all areas and all times. For some areas and periods of history, and especially for the rural reserves or bantustans during much of the period under study, we are often looking through a glass darkly. Occasionally, however, we are able to pierce the darkness created by the biased distribution of South African health resources and statistics and explore, in some detail, the ways in which political and economic development have intersected with biological processes and given rise to the white plague in South Africa.

Continues...

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Excerpted from White Plague, Black Labor by Randall M. Packard Copyright © 1989 by Randall M. Packard. Excerpted by permission.
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Table of Contents

	List of Tables and Graphs	ix
	Abbreviations	xii
	Preface	xv
	Introduction: Industrialization and the Political Economy of Tuberculosis	1
1.	Preindustrial South Africa: A Virgin Soil for Tuberculosis?	22
2.	Urban Growth, "Consumption," and the "Dressed Native," 1870-1914	33
3.	Black Mineworkers and the Production of Tuberculosis, 1870-1914	67
4.	Migrant Labor and the Rural Expansion of Tuberculosis, 1870-1938	92
5.	Slumyards and the Rising Tide of Tuberculosis, 1914-1938	126
6.	Labor Supplies and Tuberculosis on the Witwatersrand, 1913-1938	159
7.	Segregation and Racial Susceptibility: The Ideological Foundation of Tuberculosis Control, 1913-1938	194
8.	Industrial Expansion, Squatters, and the Second Tuberculosis Epidemic, 1938-1948	211
9.	Tuberculosis and Apartheid: The Great Disappearing Act, 1948-1980	249
	Epilogue: The Present and Future of Tuberculosis in South Africa	299
	Notes	321
	Select Bibliography	367
	Index	379