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Venereal disease in East Africa
642
TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL /~EDICINE AND HYGIENE. Vol. 59. No. 6. November, 1965.
VENEREAL DISEASE IN EAST AFRICA BY
J. W. K I B U K A M U S O K E
Mulago Hospital, Uganda Recently much attention has been devoted to the problem of venereal disease and there is little doubt today that its incidence is rising in many parts of the world. KING et al. (1960) and WATT (1961) observed a definite rise in the United Kingdom; DESCHIN (1961) and BEERMAN et al. (1962) recorded a similar trend in the United States. The world Forum on Syphilis and Other Treponematoses held in Washington D.C., U.S.A., left no doubt about the upward trend of venereal disease in many countries. The association of the young age groups with the increase (WATT, 1961; DESCI-IIN, 1961) raises a new and increasingly important question of teenage behaviour towards sex. The incidence of venereal disease has always been known to be high in Africa, and Cook (1901) wrote commenting on this fact. A study was therefore undertaken at the Venereal Disease Clinic of the Mulago (University College) Hospital to verify the magnitude of the problem and to assess the many factors that may be responsible for the high incidence.
Materials and methods 1,000 consecutive venereal disease patients were studied between 7 September and 28 October 1961--a period of 7 weeks. Detailed histories were taken from them and these included details of social history. Appropriate specimens were taken for diagnosis and these were examined by the usual methods. The presence of urethral stricture was estabfished by the use of urethral bougies. The clinic is a busy one, running 6 days a week and dealing with about 10,000 patients (approximately 10% of the entire out-patients) a year. It serves an estimated population of 500,000-750,000 people. 3 mission hospitals are also present in this area in addition to a number of medical aid units, nursing homes and medical practitioners, all of whom treat venereal disease patients.
Social background The high incidence of venereal disease in East Africa can be related to certain social and historical factors. The Ganda tribe is the largest in Uganda, and its influence is felt widely throughout East Africa. It had a well organized form of government before the advent of Western influence at the close of the 19th century. Slave trading, carried on by the Arabs, had taken place in the area for some time, and legend has it that gonorrhoea was introduced into the country during this time. The reigning monarch acquired the disease and so, in order to remove the stigma attached to it, a slogan was coined and spread from the king's court that "he who was without gonorrhoea was impotent." This acted like a strong force to spread the disease throughout the country. Ganda attitudes and behaviour in relation to sex and venereal disease, as now observed, are probably a legacy of those times. BENNETT(1962) found that certain social factors were important determinants of the spread of gonorrhoea. Prominent among these were the multiplicity of tribes, which led to a breakdown of tribal ethics, the differing
J. W. KIBUKAMUSOKE
643
o o
Map. The incidence of urethral stricture in East and Central Africa. The large dots represent 5 or more cases per annum, and the small dots figures below this. 07 O
O O
O O
sex ratios of these segments of the population with a large proportion of young male migrant labourers from many parts of East Africa, the curiously abnormal age composkion of the population, and the large extent of rural-urban migration. Social and economic pressures exert their influence to promote prostitution and promiscuky (SOUTHALL and GUTKIND,1956; CARLEBACH,1962). As a matter of fact, there is a wide range of differing types of sexual relationship: short-lived lover relationships, concubinage and prostitution--the latter ranging from barmaids, dance-hall partners and brothel girls to street corner prostitutes. In a study of juvenile prostitution in Nairobi, Carlebach emphasized the part played by prostitutes in the urban transmission of venereal disease. With these factors in mind it would not be difficult to appreciate the size and extent of the problem of venereal disease as currently seen in East Africa. ....
A n a l y s i s o f cases
1,000 consecutive cases of venereal disease in patients attending Mulago Hospital
644
VENEREALDISEASEIN EASTAFRICA
between 7 September and 28 October 1961 (a period of 7 weeks) were analysed The tabulated results are briefly presented below. TABLE I.
An analysis of 1,000 consecutive V.D. cases at Mulago Hospital.
Acute gonorrhoea
Other manifestations of gonorrhoea
i 540
Stricture (Presentation)
1st attack
97 (18%)
2nd attack
243 (45%)
3rd and over
124 (23%)
Relapse
54 (10%)
Others
22 (4 ~o)
Orchitis
25
Sterility
5
Prostatitis
2
Ophthalmitis
2
34
Gonorrhoea 665 (66%)
91
History
45%
Bougie
21%
Cystitis
7%
Perineal abscess
9%
Acute retention
6%
Bilateral hernia
6%
Fistulae
5%
Incontinence
1%
Syphilis (all primary)
41
Balanifis
25
Lymphogranuloma venereum
36
Cystitis (30 had had urethritis 6-12 months before, 12 of them probably gonorrhoeal)
33
Non-specific urethrifis
44
Reiter's syndrome
3
Granuloma inguinale
1
Chancroid
99
Genital neurosis (impotence in majority--anxiety and introspection prominent)
51
Yaws
(Table I).
2
J. W. KIBUKAMUSOKE
645
540 cases of acute gonorrhoea were seen (about 50% of the patients in the entire series). 18% were having their first attack, 45% their second, and 33% their third or more. One subject had had 7 attacks. The average age of these patients was 26 years--the extremes being 17 and 41. In 10% of cases the wives were infected, and these required treatment at the female clinic. 4 complications of gonorrhoea were seen in the series: orchitis, prostatitis, sterility and ophthalmitis. There were 5 cases of sterility; in 4 of these the sperm counts were very low--between 3 and 5 million per c.mm. In one case it was normal (19½ million) but all the spermatozoa were morphologically abnormal; in the others the percentage of abnormal forms was 75 or more. In all cases the sperm motility was 30% or less and smears revealed pus cells and gonococci in every one of them. Only 2 of these patients complained of impotence; one of them showed testicular atrophy as well. 300,000 units of procaine penicillin in 2% alumininm monostearate (PAM) were given intramuscularly in a single dose on diagnosis. All but 22 (4.0%) patients responded satisfactorily. These 22 responded to a second injection of PAM of similar dosage. The patient with 7 attacks also required two doses of PAM for complete reponse. The strictures There were 91 cases of urethral stricture, in all of which there was an undoubted history of chronic recurrent and neglected gonorrhoea. The average age was 49.2 years--the extremes being 30 and 74. The average "incubation period" for stricture, taken from the history, was 14.7 years, but when estimated from the calculated average age of the two groups, gonorrhoea and stricture in this series, it appears to be 23.2 years. This difference is significant but appears to be largely due to the reluctance so commonly met in our venereal disease patients in accepting the blame for reporting late for treatment. In fact, the average period for which patients experienced difficulty in micturition before reporting was 2.4 years. Only 25% of the subjects with stricture volunteered a history of difficulty; persistent enquiry unveiled 20%, and 21% were discovered by urethral exploration with a bougie in those in whom the history left doubt in the questioner's mind. These were particularly patients with a persistent watery discharge or "frequent relapses" of urethritis. The rest of the stricture cases presented as follows: cystitis 7%, perineal abscess 9%, acute retention 6% (but many more presented to the surgical service for emergency relief), bilateral inguinal hernia 6%, scrotal and perineal fistula 5% and overflow incontinence 1%. There were 41 cases of syphilismall primary. This averaged one per day during the period. The incidence of cystitis was high--33 patients, of whom 30 had suffered urethritis 6-12 months before; about half of these were secondary to non-specific urethrifts. Cystitis is a recognized complication of non-specific urethritis (EvANs, 1961) but does not appear to have been reported in connexion with uncomplicated gonococcal urethritis. Mid-stream urine cultures taken in 6 of these cases yielded no growth of organisms. However, all cases appeared to respond well to sulphathiazole. 36 cases of lymphogranuloma venereum were seen, most of them presenting with buboes in the groin. In about a third of the cases the small genital ulcer was still to be seen. Only 3 cases of Reiter's syndrome were seen. All presented with symptoms of mild muco-purulent urethritis, and conjunctivitis and arthritis were or had been present. Keratoderma blenorrhagica was not seen. A moderate but significant number of cases of non-specific urethritis were seen. The striking feature of these was the disproportion between dysuria and discharge from the urethra. The latter was small in amount and often presented as a small amount
646
VENEREAL DISEASE I N EAST AFRICA
of dried scum at the mouth of the urethra. The discharge was more easily obtainable on getting up in the morning. The patient was issued with a glass slide and instructed to take a smear on getting up. No treatment was completely satisfactory for these cases, though sigmamycin and albamycin-T appeared to offer some benefit. There was a high incidence of chancroid, 99 in all. In the United Kingdom this disease is confined to seaports, and even then is very uncommon. The reason for the high incidence was not clear. 51 cases of genital neurosis were seen, usually associated with anxiety states; most of the patients complained of impotence.
Keloid formation among venereal disease patients It is generally known that the incidence of keloid is very high in people with dark skins. It was therefore considered important to investigate the part this tendency might have in stricture formation. 400 cases were examined for keloids (Table II). The incidence of scars of any sort was very high (48%) and the incidence of keloids in the entire group was 11.5%. Only 2 cases of stricture, however, were found among those with keloids. It therefore appears that the keloid tendency is not a factor o f much consequence in the formation of urethral stricture. TABLE II.
Keloid formation among venereal disease patients. Scars from burns
Other
No. without scars
Total 162
Percentage 40- 5 ~o
No. with scars (not keloids)
63
129
192
48.0~o
No. with keloids
33
13
46
11.5%
Total
96
142
400
The incidence of scars is very high and many are due to bums. Most of the keloids developed in scars from burns. The ratio of keloids to burn-scars is 1 to 3 (34%).
The incidence of gonorrhoea in Uganda and East Africa Table III was compiled from the Annual Reports of the Ministry of Health, Uganda, to show the incidence of gonorrhoea in males in the different parts of the country. There is a relation between the incidence of gonorrhoea and stricture, and inversely the general fertility rate; stricture is most frequently seen where gonorrhoea is commonest. The figure for Buganda is more than twice as high as that for the Eastern Region. The reason for this appears to rest in the presence of gonorrhoea in Buganda 20 years before it reached the Eastern Region. The general fertility rate is lowest where gonorrhoea is most frequent. In an investigation into sterility among the Baganda, R I C H E S and REINrNG (1952) found a very high incidence: 31~o of women over the age of 45 never having h i d children. A survey of the incidence of urethral stricture in East Africa and Central Africa (see Map, after D. P. Burkitt) reveals a very interesting distribfltion--the highest being in Buganda. The reason for this appears to be historical, Buganda being the area where gonorrhoea has probably existed longest.
647
J. W. KIBUKAMUSOKE
TABLE III.
Incidence of gonorrhoea in Uganda.
Populadon
Males with gonorrhoea
Stricture total
General fertility rate (1949)
42,122
674
170
Buganda
1,834,300
Eastern Region
1,873,000
67,432
284
182
Western Region
1,497,500
12,939
183
202
Northern Region
1,245,000
12,210
30
215
Totals
6,449,800
134,703
1,171
l
A direct relation exists between the incidence of gonorrhoea in the area and the stricture total, and an inverse relation with the general fertility rate.
Discussion Venereologists have appreciated the significance of social factors in the spread of venereal disease for many years, but perhaps never so vividly as during the last few years. These social determinants operate all over the world and there is little doubt today that the underlying factors depend to a very large extent on the disruption of the code of social ethics. Intermixture of tribes, races, or people of different nationalities in a crowded society creates a situation conducive to disruption of this code. Such conditions exist in urban societies, particularly in large cosmopolitan cities. The impact of this disruption is greatest on the younger generation, for whom factors of family responsibility do not exist; this has been the experience in diverse parts of the world. The numerical size of the problem is not the prime factor in the dissemination of venereal disease, although this has undoubtedly something to do with it. Medical advance will certainly help in control but must be complemented by the correction of social factors if total eradication is to be achieved.
Summary 1,000 consecutive cases of venereal disease have been analysed, and the social factors facilitating the spread of this group of diseases are examined and discussed. It is suggested that the latter assume a very significant role, and that any effective eradication programme must take social factors into consideration. REFERENCES BE~.gMAN,H., NICHOLAS,L., SCH~IBERG, I. L. & GREENBERG,M. S. (1962). Arch. intern. ll4ed., 109, 323. BENNETT,F. J. (1962). E. Afr. reed. ft., 39, 332. CARLEBACH, J. (1962). East African Studies No. 16, E. A. Institute of Social Research. Makerere University College. COOK, A. R. (1901). 3:. Trop 2t'Ied., 4, 175. DESCHIN, C. S. (1961). Teenagers and Venereal Disease--A Sociological Study--U.S.A. Public Health EVANS, M. D. (1961). ft. Urol., 86, 4, 409. KING, A. J. & WISDOM, A. R. (1960). Roy. Soc. Hhh. ft., 80, 412.
648
VENEREAL DISEASE I N EAST AFRICA
LESLIE WATT (1961). Brit. med. J.~ 2~ 858. Proceedings of the World Forum on Syphilis and other Treponematoses. Sept. 4-8, 1962. U.S. Dept. of Health, Education and Welfare. RICHARDS,A. J. & REXNING,P. (1952). 20.8/31b. East African Institute of Social Research Makerere University College. SOUTHALL, A. W. & GUTKIND, P. C. W. (1956). East African Studies No. 5. E.A. Institute of Social Research, Makerere University College.
TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL /~EDICINE AND HYGIENE. Vol. 59. No. 6. November, 1965.
VENEREAL DISEASE IN EAST AFRICA BY
J. W. K I B U K A M U S O K E
Mulago Hospital, Uganda Recently much attention has been devoted to the problem of venereal disease and there is little doubt today that its incidence is rising in many parts of the world. KING et al. (1960) and WATT (1961) observed a definite rise in the United Kingdom; DESCHIN (1961) and BEERMAN et al. (1962) recorded a similar trend in the United States. The world Forum on Syphilis and Other Treponematoses held in Washington D.C., U.S.A., left no doubt about the upward trend of venereal disease in many countries. The association of the young age groups with the increase (WATT, 1961; DESCI-IIN, 1961) raises a new and increasingly important question of teenage behaviour towards sex. The incidence of venereal disease has always been known to be high in Africa, and Cook (1901) wrote commenting on this fact. A study was therefore undertaken at the Venereal Disease Clinic of the Mulago (University College) Hospital to verify the magnitude of the problem and to assess the many factors that may be responsible for the high incidence.
Materials and methods 1,000 consecutive venereal disease patients were studied between 7 September and 28 October 1961--a period of 7 weeks. Detailed histories were taken from them and these included details of social history. Appropriate specimens were taken for diagnosis and these were examined by the usual methods. The presence of urethral stricture was estabfished by the use of urethral bougies. The clinic is a busy one, running 6 days a week and dealing with about 10,000 patients (approximately 10% of the entire out-patients) a year. It serves an estimated population of 500,000-750,000 people. 3 mission hospitals are also present in this area in addition to a number of medical aid units, nursing homes and medical practitioners, all of whom treat venereal disease patients.
Social background The high incidence of venereal disease in East Africa can be related to certain social and historical factors. The Ganda tribe is the largest in Uganda, and its influence is felt widely throughout East Africa. It had a well organized form of government before the advent of Western influence at the close of the 19th century. Slave trading, carried on by the Arabs, had taken place in the area for some time, and legend has it that gonorrhoea was introduced into the country during this time. The reigning monarch acquired the disease and so, in order to remove the stigma attached to it, a slogan was coined and spread from the king's court that "he who was without gonorrhoea was impotent." This acted like a strong force to spread the disease throughout the country. Ganda attitudes and behaviour in relation to sex and venereal disease, as now observed, are probably a legacy of those times. BENNETT(1962) found that certain social factors were important determinants of the spread of gonorrhoea. Prominent among these were the multiplicity of tribes, which led to a breakdown of tribal ethics, the differing
J. W. KIBUKAMUSOKE
643
o o
Map. The incidence of urethral stricture in East and Central Africa. The large dots represent 5 or more cases per annum, and the small dots figures below this. 07 O
O O
O O
sex ratios of these segments of the population with a large proportion of young male migrant labourers from many parts of East Africa, the curiously abnormal age composkion of the population, and the large extent of rural-urban migration. Social and economic pressures exert their influence to promote prostitution and promiscuky (SOUTHALL and GUTKIND,1956; CARLEBACH,1962). As a matter of fact, there is a wide range of differing types of sexual relationship: short-lived lover relationships, concubinage and prostitution--the latter ranging from barmaids, dance-hall partners and brothel girls to street corner prostitutes. In a study of juvenile prostitution in Nairobi, Carlebach emphasized the part played by prostitutes in the urban transmission of venereal disease. With these factors in mind it would not be difficult to appreciate the size and extent of the problem of venereal disease as currently seen in East Africa. ....
A n a l y s i s o f cases
1,000 consecutive cases of venereal disease in patients attending Mulago Hospital
644
VENEREALDISEASEIN EASTAFRICA
between 7 September and 28 October 1961 (a period of 7 weeks) were analysed The tabulated results are briefly presented below. TABLE I.
An analysis of 1,000 consecutive V.D. cases at Mulago Hospital.
Acute gonorrhoea
Other manifestations of gonorrhoea
i 540
Stricture (Presentation)
1st attack
97 (18%)
2nd attack
243 (45%)
3rd and over
124 (23%)
Relapse
54 (10%)
Others
22 (4 ~o)
Orchitis
25
Sterility
5
Prostatitis
2
Ophthalmitis
2
34
Gonorrhoea 665 (66%)
91
History
45%
Bougie
21%
Cystitis
7%
Perineal abscess
9%
Acute retention
6%
Bilateral hernia
6%
Fistulae
5%
Incontinence
1%
Syphilis (all primary)
41
Balanifis
25
Lymphogranuloma venereum
36
Cystitis (30 had had urethritis 6-12 months before, 12 of them probably gonorrhoeal)
33
Non-specific urethrifis
44
Reiter's syndrome
3
Granuloma inguinale
1
Chancroid
99
Genital neurosis (impotence in majority--anxiety and introspection prominent)
51
Yaws
(Table I).
2
J. W. KIBUKAMUSOKE
645
540 cases of acute gonorrhoea were seen (about 50% of the patients in the entire series). 18% were having their first attack, 45% their second, and 33% their third or more. One subject had had 7 attacks. The average age of these patients was 26 years--the extremes being 17 and 41. In 10% of cases the wives were infected, and these required treatment at the female clinic. 4 complications of gonorrhoea were seen in the series: orchitis, prostatitis, sterility and ophthalmitis. There were 5 cases of sterility; in 4 of these the sperm counts were very low--between 3 and 5 million per c.mm. In one case it was normal (19½ million) but all the spermatozoa were morphologically abnormal; in the others the percentage of abnormal forms was 75 or more. In all cases the sperm motility was 30% or less and smears revealed pus cells and gonococci in every one of them. Only 2 of these patients complained of impotence; one of them showed testicular atrophy as well. 300,000 units of procaine penicillin in 2% alumininm monostearate (PAM) were given intramuscularly in a single dose on diagnosis. All but 22 (4.0%) patients responded satisfactorily. These 22 responded to a second injection of PAM of similar dosage. The patient with 7 attacks also required two doses of PAM for complete reponse. The strictures There were 91 cases of urethral stricture, in all of which there was an undoubted history of chronic recurrent and neglected gonorrhoea. The average age was 49.2 years--the extremes being 30 and 74. The average "incubation period" for stricture, taken from the history, was 14.7 years, but when estimated from the calculated average age of the two groups, gonorrhoea and stricture in this series, it appears to be 23.2 years. This difference is significant but appears to be largely due to the reluctance so commonly met in our venereal disease patients in accepting the blame for reporting late for treatment. In fact, the average period for which patients experienced difficulty in micturition before reporting was 2.4 years. Only 25% of the subjects with stricture volunteered a history of difficulty; persistent enquiry unveiled 20%, and 21% were discovered by urethral exploration with a bougie in those in whom the history left doubt in the questioner's mind. These were particularly patients with a persistent watery discharge or "frequent relapses" of urethritis. The rest of the stricture cases presented as follows: cystitis 7%, perineal abscess 9%, acute retention 6% (but many more presented to the surgical service for emergency relief), bilateral inguinal hernia 6%, scrotal and perineal fistula 5% and overflow incontinence 1%. There were 41 cases of syphilismall primary. This averaged one per day during the period. The incidence of cystitis was high--33 patients, of whom 30 had suffered urethritis 6-12 months before; about half of these were secondary to non-specific urethrifts. Cystitis is a recognized complication of non-specific urethritis (EvANs, 1961) but does not appear to have been reported in connexion with uncomplicated gonococcal urethritis. Mid-stream urine cultures taken in 6 of these cases yielded no growth of organisms. However, all cases appeared to respond well to sulphathiazole. 36 cases of lymphogranuloma venereum were seen, most of them presenting with buboes in the groin. In about a third of the cases the small genital ulcer was still to be seen. Only 3 cases of Reiter's syndrome were seen. All presented with symptoms of mild muco-purulent urethritis, and conjunctivitis and arthritis were or had been present. Keratoderma blenorrhagica was not seen. A moderate but significant number of cases of non-specific urethritis were seen. The striking feature of these was the disproportion between dysuria and discharge from the urethra. The latter was small in amount and often presented as a small amount
646
VENEREAL DISEASE I N EAST AFRICA
of dried scum at the mouth of the urethra. The discharge was more easily obtainable on getting up in the morning. The patient was issued with a glass slide and instructed to take a smear on getting up. No treatment was completely satisfactory for these cases, though sigmamycin and albamycin-T appeared to offer some benefit. There was a high incidence of chancroid, 99 in all. In the United Kingdom this disease is confined to seaports, and even then is very uncommon. The reason for the high incidence was not clear. 51 cases of genital neurosis were seen, usually associated with anxiety states; most of the patients complained of impotence.
Keloid formation among venereal disease patients It is generally known that the incidence of keloid is very high in people with dark skins. It was therefore considered important to investigate the part this tendency might have in stricture formation. 400 cases were examined for keloids (Table II). The incidence of scars of any sort was very high (48%) and the incidence of keloids in the entire group was 11.5%. Only 2 cases of stricture, however, were found among those with keloids. It therefore appears that the keloid tendency is not a factor o f much consequence in the formation of urethral stricture. TABLE II.
Keloid formation among venereal disease patients. Scars from burns
Other
No. without scars
Total 162
Percentage 40- 5 ~o
No. with scars (not keloids)
63
129
192
48.0~o
No. with keloids
33
13
46
11.5%
Total
96
142
400
The incidence of scars is very high and many are due to bums. Most of the keloids developed in scars from burns. The ratio of keloids to burn-scars is 1 to 3 (34%).
The incidence of gonorrhoea in Uganda and East Africa Table III was compiled from the Annual Reports of the Ministry of Health, Uganda, to show the incidence of gonorrhoea in males in the different parts of the country. There is a relation between the incidence of gonorrhoea and stricture, and inversely the general fertility rate; stricture is most frequently seen where gonorrhoea is commonest. The figure for Buganda is more than twice as high as that for the Eastern Region. The reason for this appears to rest in the presence of gonorrhoea in Buganda 20 years before it reached the Eastern Region. The general fertility rate is lowest where gonorrhoea is most frequent. In an investigation into sterility among the Baganda, R I C H E S and REINrNG (1952) found a very high incidence: 31~o of women over the age of 45 never having h i d children. A survey of the incidence of urethral stricture in East Africa and Central Africa (see Map, after D. P. Burkitt) reveals a very interesting distribfltion--the highest being in Buganda. The reason for this appears to be historical, Buganda being the area where gonorrhoea has probably existed longest.
647
J. W. KIBUKAMUSOKE
TABLE III.
Incidence of gonorrhoea in Uganda.
Populadon
Males with gonorrhoea
Stricture total
General fertility rate (1949)
42,122
674
170
Buganda
1,834,300
Eastern Region
1,873,000
67,432
284
182
Western Region
1,497,500
12,939
183
202
Northern Region
1,245,000
12,210
30
215
Totals
6,449,800
134,703
1,171
l
A direct relation exists between the incidence of gonorrhoea in the area and the stricture total, and an inverse relation with the general fertility rate.
Discussion Venereologists have appreciated the significance of social factors in the spread of venereal disease for many years, but perhaps never so vividly as during the last few years. These social determinants operate all over the world and there is little doubt today that the underlying factors depend to a very large extent on the disruption of the code of social ethics. Intermixture of tribes, races, or people of different nationalities in a crowded society creates a situation conducive to disruption of this code. Such conditions exist in urban societies, particularly in large cosmopolitan cities. The impact of this disruption is greatest on the younger generation, for whom factors of family responsibility do not exist; this has been the experience in diverse parts of the world. The numerical size of the problem is not the prime factor in the dissemination of venereal disease, although this has undoubtedly something to do with it. Medical advance will certainly help in control but must be complemented by the correction of social factors if total eradication is to be achieved.
Summary 1,000 consecutive cases of venereal disease have been analysed, and the social factors facilitating the spread of this group of diseases are examined and discussed. It is suggested that the latter assume a very significant role, and that any effective eradication programme must take social factors into consideration. REFERENCES BE~.gMAN,H., NICHOLAS,L., SCH~IBERG, I. L. & GREENBERG,M. S. (1962). Arch. intern. ll4ed., 109, 323. BENNETT,F. J. (1962). E. Afr. reed. ft., 39, 332. CARLEBACH, J. (1962). East African Studies No. 16, E. A. Institute of Social Research. Makerere University College. COOK, A. R. (1901). 3:. Trop 2t'Ied., 4, 175. DESCHIN, C. S. (1961). Teenagers and Venereal Disease--A Sociological Study--U.S.A. Public Health EVANS, M. D. (1961). ft. Urol., 86, 4, 409. KING, A. J. & WISDOM, A. R. (1960). Roy. Soc. Hhh. ft., 80, 412.
648
VENEREAL DISEASE I N EAST AFRICA
LESLIE WATT (1961). Brit. med. J.~ 2~ 858. Proceedings of the World Forum on Syphilis and other Treponematoses. Sept. 4-8, 1962. U.S. Dept. of Health, Education and Welfare. RICHARDS,A. J. & REXNING,P. (1952). 20.8/31b. East African Institute of Social Research Makerere University College. SOUTHALL, A. W. & GUTKIND, P. C. W. (1956). East African Studies No. 5. E.A. Institute of Social Research, Makerere University College.