Syphilis and the NHI

Two examples from the nineteenth century explain why successful public health interventions fail – and sometimes not

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One thing that the Covid-19 pandemic made clear is the trade-off between public health and personal freedom. On the one hand, vaccinations protected us against a flu pandemic; the more people vaccinated, the fewer people died. On the other hand, our freedoms of movement, association, and consumption were taken away with draconian rules and regulations.

However, these trade-offs are nothing new. Take the nineteenth-century Contagious Diseases Act in Britain. Around the 1860s, the British government intervened to limit sexually transmitted diseases among military men. The Act required regular health inspections of female sex workers. Infected women had to be isolated. These inspections began in two cities in 1864, and by 1870, eighteen cities were part of the program. It worked like this: All sex workers had to register with the police. The local court would then issue a summons for a medical examination. Women without sexually transmitted diseases could continue their work, but infected women were confined to hospitals for up to nine months. Not only were they isolated, but they were also regularly given mercury to drink, a treatment that was not only ineffective but also harmful. In 1870, more than 50,000 inspections of sex workers were conducted.

What is interesting is that the Act was undoubtedly successful in limiting the spread of sexually transmitted diseases (STDs). A fascinating new study by two economists, Grant Goehring and Walker Hanlon, proves this: they found significant decreases in STD rates, particularly among soldiers and sailors, large decreases in STD death rates among the general population, and a decline in infertility rates – a consequence of STD infections leading to infertility, stillbirths, infant deaths, and less sexual activity.

But here is the surprise: by the 1880s, the Act was repealed. Why would a health law that was so successful be repealed?

The answer, explain Goehring and Hanlon, is the unequal treatment of women. A protest letter written by Josephine Butler, the founder of the Ladies National Association for the Repeal of the Contagious Disease Acts (LNA), in 1869 sums up the curtailment of personal freedom well: ‘These measures are cruel to the women who come under their action, violating the feelings of those whose sense of shame is not wholly lost, and further brutalising even the most abandoned.’

Butler often told the story of Mrs. Percy. She worked in a music hall on a military base and one evening, along with her sixteen-year-old daughter, was stopped by the vice police. She tried to convince the officers that they were not sex workers, but the police required them to undergo medical examinations. Mrs Percy refused to sign the registration documents, which led to regular retaliatory actions by the police. She left her job, had to leave the district, and later had to change her name to clear her record.

The lesson is that the success of a public health intervention like the Contagious Diseases Act does not solely depend on its effectiveness. It also depends on whether it is perceived as fair; in other words, how the costs of the intervention are distributed among different parties. Most public health initiatives come at a certain cost. In the case of this Act, the design of the laws was such that the costs were borne entirely by female sex workers; if anything, the laws likely benefited male clients by making the purchase of sex safer. This was widely seen as unjust, which ultimately led to the repeal of the Act.

But there is also a second lesson.

A Contagious Diseases Act was also introduced at the Cape. To protect British troops who were being “decimated” by venereal diseases, the 1868 Act was limited to garrison towns: Cape Town, Simonstown, Port Elizabeth, Grahamstown, and King William’s Town.¹ It faced opposition here too. The Cape liberal politician Saul Solomon, like his British counterparts, argued that it was unjust towards women, open to corruption, and restricted personal freedom. Because it was seen as an imperial decision imposed on the Cape, the House of Assembly refused to approve the budget, and it was repealed in 1872.²

But unlike in Britain, there was more to the story. Although the 1868 Act was entirely an imperial instrument, the need for a second Act came from the local community. The historian Elizabeth van Heyningen links this to the publication of District Surgeoncy reports from 1882, which led to panic over the rising incidence of syphilis across the Cape, particularly in the rural districts.³ Earlier petitions from the inhabitants of Burghersdorp and Fraserburg had pressed for control of the disease, which they said was spreading among the region’s “respectable families [who] had become infected through their nurses and washerwomen”.⁴ Following the adoption of an ultimately ineffective Public Health Act in 1883, demands for a renewed Contagious Diseases Act increased.

The second Act was eventually passed in 1888. Because it was considered too expensive, it was again limited to Cape Town, Port Elizabeth, East London, and King William’s Town. Again, there was significant opposition, particularly in the form of petitions from ministers and middle-class white women who emphasized the injustice of the Act. But these groups’ political influence was limited. The vast majority of residents were more interested in curbing syphilis than in protecting personal freedoms.

The second lesson is that the success of public health measures depends not only on their immediate effectiveness but also on their ability to maintain social and political support over time. In Britain, the Contagious Diseases Act ultimately failed because it violated the community’s moral and fairness standards. Public opinion weighed heavily against the unjust treatment of women, leading to the repeal of the Act.

At the Cape, however, the second Contagious Diseases Act survived because local priorities were different. The community saw venereal diseases as a significant enough threat to accept the restrictions on personal freedoms and the potential unfairness of the Act. This focus on practical health outcomes over moral concerns allowed the Act to remain in effect until 1919.

This trade-off between public health and personal freedom is, of course, still relevant today. Take, for example, the idea of a National Health Insurance (NHI). On the one hand, an NHI could mean greater access to quality medical services for South Africans at the expense of the personal freedoms of those who currently have access to private medical services. On the other hand, an NHI could overload the healthcare system and lead to a decline in the quality of care. It could also limit individuals' freedom to choose their own healthcare and force people to rely on a system that may not have adequate resources. Furthermore, the financial burden of implementing and maintaining an NHI could harm the economy, leading to higher taxes and fewer funds for other essential services. In this scenario, the NHI could ultimately do more harm than good by restricting individuals' freedoms and negatively impacting the overall health of the population.

The two lessons from the Contagious Diseases Act teach us that any health policy, like for Covid-19 or the NHI, must consider both the practical health outcomes and the community's perceptions of fairness to achieve true sustainable success. Yes, the influence of authoritative voices, such as Josephine Butler in Britain and Saul Solomon at the Cape, can play a key role in shaping and sustaining these policies. But the ultimate success of such policies depends on how well they meet the broader community’s needs and whether they are perceived as fair by those most affected.

An edited version of this post appeared (in Afrikaans) in Rapport on 11 August 2024. I thank Kelsey Lemon for her excellent research support. The images were created using Midjourney v6.

1. Beukes, D.N. 2014. “‘It is not only the guilty who suffer’: Exploring gender, power and moral politics through the contagious diseases acts in the Cape Colony, c.1868-1885. MA diss., Stellenbosch University.

2. Malherbe, V.C. 2010. “Family law and ‘the great moral public interests’ in Victorian Cape Town, c. 1850-1902.” Kronos 36 (1): 7-27.

3. Van Heyningen, E.B. 1984. “The social evil in the Cape colony 1868-1902: Prostitution and the contagious diseases acts.” Journal of Southern African Studies 10 (2): 170-97.

4. Ibid., p. 177.