A Sociological Analysis of Ngomahuru Isolation HospitalSister Mary Aquina O.P,IntroductionLeprosy was once a widespread disease in manyparts of the world. In recent years, however,improved hygiene, the segregation of lepers andespecially treatment with sulfones and dapsone,which make open cases non-infective within twoyears, have greatly reduced the number of lepers,and have led to the arrest of the disease, or thecure of many. Yet in spite of this medical progressthere are still over two million known lepers in theworld, and the estimated number of infectedpersons who do not come for treatment is thoughtto be as high as twelve million (Harrison 1966:p. 1621).Leprosy today is confined mainly to hot andmoist climates, such as India and other parts ofthe tropics. In Central Africa more than one percent of the total population are suffering from thisdisease (Boyd 1961: p. 295).My interest in leprosy was roused in 1963, whenthe secretary of the Ngomahuru Isolation Hospitalinvited me to visit the camp. I paid several morevisits to Ngomahuru, during which both Africanand European staff gave me information about thecamp and showed me the various establishments.A young leper with an O-level certificate ofeducation offered to undertake for me a socialsurvey of all the lepers in the camp. It is mainlyon this survey and on my interviews with the staffthat this article is based.Because my stay in Ngomahuru was brief, andmainly confined to interviews with staff members,I had no personal contacts with the majority of thepatients. Consequently this article differs frommost ethnographic accounts in that it is not basedon participant observation. This lack of participantobservation has made a deeper analysis of socialprocesses in Ngomahuru impossible.The present article falls into two parts; Part Iis subdivided into the following eight sections:1. The history of the care of lepers in Rho-desia;2. The lay-out of the settlement;3. The settlement administration;4. The origin of the patients and their age-sexdistribution;5. Their education and occupation;6. Their marriage and family life;7. The daily routine of the settlement withspecial reference to work, schooling, religionand recreation;8. The cure of lepers.Part II shows a tentative comparison betweenthe leper population of Ngomahuru and the largeruniverse from which the lepers are drawn.The aim of Part I is to show the social charac-teristics of hospitalised lepers, the attempts oflepers to build up a new community in Ngomahuruand their difficulties in reintegrating themselvesinto the wider society once they have been dis-charged as non-infective or cured. Part II attemptsto draw some comparison between the socialcharacteristics of these lepers and the socialcharacteristics of the remaining African populationof Rhodesia.69PART I1. HISTORY OF LEPER CARE IN RHODESIANgomahuru is at present the only leper settle-ment in Rhodesia. But this is a recent develop-ment. Like its two northern neighbours, Zambiaand Malawi, Rhodesia had in the past, besidesGovernment sponsored leper settlements, anumber of smaller settlements run by variousChristian missions. In fact, care for the lepers inRhodesia was started in 1892 by the DutchReformed mission of Morgenster near FortVictoria. In 1927 these missionaries asked theGovernment to take over this responsibility andthe Ngomahuru Isolation Hospital was opened.By this time the Government had already openedanother leprosy hospital at Mtoko, called Mtemwa,which served the northern and eastern districts ofRhodesia. By 1956 steps were initiated to closeMtemwa, and its first patients were transferred toNgomahuru.Two smaller leper settlements were run byChristian missionaries at Mount Silinda in theeastern districts and west of Ngomahuru inBelingwe district. In the early 1950's both weretaken over by the Government and their patientswere transferred to Ngomahuru.By 1962 the last lepers were transferred fromMtemwa to Ngomahuru, At that time there wereonly some 300 lepers in Ngomahuru. With theclosure of Mtemwa some 200 new patients movedinto the camp. This number, however, was soonreduced when many many Africans from neigh-bouring territories were repatriated. Several groupsof lepers were returned to Malawi and PortugueseEast Africa. Yet in spite of the attempt to repatriatemost non-Rhodesian lepers, 89 people fromsouthern Africa, Malawi, Zambia, and PortugueseEast Africa were still in Ngomahuru in 1963 whenI had my census taken. The camp then accommo-dated 413 lepers. No information is available aboutthe social characteristics of those lepers who wererepatriated, so that no comparison is possiblebetween those non-Rhodesian lepers who left andthose who stayed. It is also unknown on whichbasis non-Rhodesian lepers were chosen forrepatriation.With the transfer of all lepers to Ngomahuru,Mtemwa has become a rehabilitation centre forcrippled ex-lepers. In 1963 Mtemwa counted some180 cured lepers, 70 of whom had come fromNgomahuru. These people have been so seriouslydisfigured by their disease that they found itimpossible to be reaccepted by their relatives intheir home villages. Consequently Mtemwa hasformed a permanent community in which itsresidents expect to stay for the rest of their lives.These people are looked after by a European doc-tor and an African staff of orderlies and nurses.Since they are no longer suffering from leprosy,but merely from its after-effects, i.e. they arecripples, attempts were made in 1963 to shiftresponsibility for them from the Medical Depart-ment to the Department of Social Welfare.2. THE LAY-OUT OF THE SETTLEMENTNgomahuru Isolation Hospital lies 30 milessouth of Fort Victoria. It is bordered in the west bythe Tokwe River, and in the north, east, and southby an African Purchase Area. The area coverssome 900 acres. Besides the Tokwe River, thesettlement is well watered by six streams, two ofwhich are tributaries to the Tokwe River. Allbuildings are situated in the western half of thecamp, between the Tokwe River and its twotributaries. The eastern and northern part of thecamp is hilly and used for agricultural purposes.The settlement is fenced off from the AfricanPurchase Area, and its three gates are attended bygate-keepers to prevent patients straying outsidethe camp. The nearest bus stop is five miles away.Ngomahuru Isolation Hospital falls into threesections:(a) six compounds for the patients,(b) the social centre with the hospital and theadministrative and recreational buildings,and(c) the staff quarters.The oldest of the six compounds, built in 1927, issituated near the main entrance of the camp. Theother five more recently built compounds lie on amain road leading to the Tokwe River. Two ofthese compounds are for women, and face thethree compounds for men, one of which is pre-dominantly occupied but cured by crippled,ex-lepers.A former T.B. hospital, the office buildings, theisolation hospital itself, and a Beit Hall used forschooling and recreational activities, form thelink between the old and the new compounds. Astore at the cross roads, rented by an African70from a nearby Tribal Trust Land, separates theseareas from the staff quarters.To the east of the store stand houses formerlyoccupied by European lepers. These lepers,however, have either died or been discharged ascured. (Note.ŠIn the 1950's there were fourEuropean lepers in the camp: two were discharged,one died and one committed suicide.) Hencethese houses are now occupied by African staff.South of the African staff houses lie the Europeanstaff houses, and east of these the school for thechildren of the African staff. Two pumps at theTokwe River supply the camp with water.(a) THE COMPOUNDSOf the six compounds, four are occupied by menand two by women. The oldest compound con-sists of five rows of twelve pole-and-mud hutseach, followed by a row of kitchens. All the doorsof the huts face north. Some of the huts aredecaying, and no longer inhabited. The huts wereoriginally built under the supervision of a Euro-pean. No patient ever built his own hut, but gangsof patients worked together, and were paid fortheir labour. The huts are rebuilt whenever neces-sary. Many of the huts are decorated with wallpaintings and each hut is occupied by one orsometimes two, men.The atmosphere in this compound is like thatof an ordinary village. The compound has also thedisadvantage of many a village that water has to befetched from a distance. However, many patientsprefer this compound to the others, because theyconsider it a great advantage that it is further awayfrom supervision than any of the other com-pounds. The majority of patients in this com-pound come from Malawi and the Zambezi valley.The other five compounds consist of white-washed stone houses, each containing one or twospacious rooms. Two to three persons live in oneroom. Adequate washing facilities and kitchensare provided. The majority of patients in thesecompounds come from the Karanga, Zezuru, andManyika and Ndau areas. These compoundsresemble modern accommodations in Africantownships. The men's and women's compoundsare separated by a fence and, officially, no personmay cross the fence during the night.At their arrival, patients can choose the com-pound in which they wish to live and unless thatcompound is overcrowded, which is rarely thecase, their choice is accepted by the administra-tors of the camp. In this way there is a slighttendency for men from the same home area to livetogether. No separation based on the type orseverity of the disease is enforced by the ad-ministration.(b) THE SOCIAL CENTREThe most important building of this part of thesettlement is the hospital itself. It is one of thebest equipped leprosy hospitals in Central Africa.It consists of an examination room, an X-raydepartment, a medical store with adequate drugsupplies, modern sterilisers, and a theatre whereamputations and other operations take place.Seriously infectious patients are kept in twowards, one for men and one for women. Thesewards, however, are seldom filled to capacity. Themajority of patients receive tablets, which they areexpected to take regularly in their compounds.Several checks, mainly through compound heads,ensure that medicine is regularly taken. Everythree months each patient has to report to thehospital where an exact examination of his healthtakes place. If his leprosy is arrested or cured, heis discharged.Next in importance ranks the Beit Hall, whichserves as a classroom for leper children, harboursa library of some 300 books, and accommodatesgroups for various recreational activities.(c) THE STAFF QUARTERSThe only social centre in the residential area forthe staff is the lower primary school for Africanstaff children. Europeans send their children toboarding schools. In fact, the social life of staffmembers, especially that of Europeans, takesplace outside the settlement and most of themvisit Fort Victoria to enjoy a full social life.3. THE ADMINISTRATIONThe most important person in Ngomahuru is themedical superintendant who is responsible for therunning of the settlement. He is not merely con-cerned with the health of the patients, but alsowith their social needs and problems. Conse-quently he is their highest court of appeal indisputes between them and staff members. Healso forms their only link with the outside world.For example, should employers still owe thepatients part of their wages, the doctor writes forthem to see that their money is sent to them andput in a Post Office saving account.71Ngomahuru Isolation Hospital ( MAP i )<3ateŁate3.75miles.NriverI I Compound1 a Bfrit Hall2 a Hospital3 a Office4 D T.B HospitalLEDGENDtrack5 a Store.6D School7 D African StaffS D kurofiean 5faffThe sections of the administration, with whichpatients most frequently come into contact, arethe compound administration, the medical estab-lishment, the educational section and the farmmanagement. The compound administration is ofspecial interest. A European compound managerforms the link between the patients and themedical superintendant. This manager is respons-ible for ensuring that the patients come regularlyfor examination, take their medicines, have suffi-cient food and clothing, and that cleanliness ispreserved in all compounds.compounds. If the matter is serious, the managerreports the matter to the doctor.The compound heads are responsible to thecompound manager for seeing that all patients intheir compound report regularly for treatment andtake the tablets given to them. They also have toreport any deterioration of health in any memberof their compounds.Compound heads frequently mediate betweenthe patients and various officials. For example, ifdisputes arise between the patients and theEuropean farm manager, the compound head firstIRhodesiaDiagram IOrigin of the Population of the CampForeign countriesIShona!NdebeleKaranga Zezuru Korekore ManyikaNdauThe compound manager is assisted by sixcompound heads, one from each compound, towhom he delegates part of his duties. All com-pound heads are men, even those of the women'scompounds. They play in many respects a rolesimilar to village headman in the rural areas ofCentral Africa. The office of compound headconfers prestige and certain privileges on itsholder, such as a monthly salary of £2. 5s. Od., andthe control over a transistor radio for the com-pound. Hence the position is an envied one.Every morning, the compound heads report to thecompound manager whatever happened in theirtries to settle the case, and only if he fails will thecase be forwarded to the compound manager ordoctor. The doctor has no judicial power, andwhen a law is broken the case has to come beforethe magistrate who visits the settlement regularly.A constable of the B.S.A. Police is constantlystationed at Ngomahuru.4. THE ORIGIN OF THE PATIENTS AND THEIRAGE-SEX DISTRIBUTIONThe African population in Rhodesia is drawn(a) from this country itself, and (b) from neigh-bouring territories that provide labour for Rho-desian industries. The indigenous African popu-TABLE IPlace and Origin of Lepers in NgomahuruBirth PlaceRhodesiaKarangaZezuruKorekoreManyika and NdauNdebeleForeign CountriesMalawiZambiaP.E.ASouthern Africa ,,,TanganyikaTOTALMalesFrequency200444870182075301918622750//o731618257727117621100FemalesFrequency124131476691444g11380/Tit891011565711334110073lation belongs to two large tribal groupings,namely the Shona and the Ndebele. The Shonaare subdivided into five dialect groups: theKaranga around Fort Victoria and Gwelo; theZezuru around Salisbury; the Korekore in theZambezi valley, and the Manyika and Ndau northand south of Umtaii.Various minor tribes live in these areas, such asthe Tonga in the Zambezi valley and the Shangaanin the south of the country. In this article they aresubsumed into the larger groupings, so thatKorekoreland, for example, includes the Tonga,and Ndebeleland the Shangaan.Lepers in Ngomahuru come from all theseregions, as Table 1 shows.In Part II the proportion of lepers from thesevarious regions will be compared with the popula-tions living in these regions.The following is the age-sex structure of thepatients in Ngomahuru:(Boyd 1961: p. 295). Another medical scientistagrees that the incubation period varies between6 months and 20 years, but contests the statementthat children are particularly susceptible to thedisease. On the contrary, he writes that only20 to 50 per cent of infants born to leprous parentswill show signs of leprosy by the age of five, ifthey remain constantly with their parents (Harrison1966: pp. 1621-2). This author in fact states thatchildren show a special resistance to leprosy, andoften recover unexpectedly in a very short spaceof time.In his lecture at the University College of Rho-desia in March 1968, Dr. Brown also stated thatleprosy is difficult to catch; that only five per centof all leprous husbands pass on leprosy to theirwives in spite of regular sexual intercourse; andthat children, breast-fed by leprous mothers,never catch the disease if the mothers are treatedwith dapsone. The reason is that through theirTABLE 2Age-Sex DistributionAge0Š 45Š 910Š1415Š1920Š2425Š2930Š3435Š3940Š4445Š4950Š5455Š5960Š6465Š6970Š7475Š79TOTALMalesFrequency15192428314042332912522112750/Ł41-86-98-710-211 -314-515-312010-54-41-8Ł7Ł7Ł4Ł41000FemalesFrequency1345101325212016643211380//oŁ72-22-92-93-67-29-418-115-214-511 -64-42-92-21-5Ł71000Table 2 shows that there are very few childrensuffering from leprosy, that the incidence ofleprosy decreases in the 50-years and plus agegroups, and also that the number of men far out-numbers the number of women. In fact, approxi-mately two-thirds of all patients are men, againstonly one-third of women.Boyd's "Textbook of Pathology" states thatinfection is believed to occur in early childhood,but that the disease may remain latent for 20 yearsmother's milk, children receive a low concentra-tion of dapsone, immunizing them. However, assoon as these children cease to be breast-fed, andso no longer receive this low concentration ofdapsone, they become capable of infection. Con-sequently the children at Ngomahuru are removedfrom their mothers after weaning, in order toreduce contagion as much as possible. Mothersare urged to send their newborn children to theirrelatives in rural areas or, if no relatives are willing74Q.O13O_CcrQ.O75to accept these children, the hospital staff findsthem places in orphanages. The hospital staff alsoprohibits children from visiting their sick parents.Both the natural resistence of children towardsleprosy, therefore, as also the precaution of thehospital staff, contribute to a very low number ofleprous children. The long incubation period too,may account for the low figure of leprosy amongchildren and adolescents.As to the decrease of the incidence of leprosyamong older people, a medical scientist statesthat clinically recognised leprosy decreases withage (Harrison 1966: p. 1622).other part of Central Africa. Further medical andsocial research is required to explain the differentpropensity to leprosy among men and women.E. EDUCATION AND OCCUPATIONBefore embarking on this study of the populationof the Isolation Hospital, I was under the impres-sion that the lepers come from the lower socialstrata of African society. Consequently informa-tion was gathered regarding their education andoccupation. The results are set out in Tables 3and 4. In Part II these findings will be comparedwith the education and occupations of non-leprous Africans.TABLE 3EducationEducationNilLower PrimaryUpper PrimaryPost PrimaryTOTALMenFrequency1181223232750/4344121100WomenFrequency1102531380//o80182100TABLE 4Occupation of MenOccupationRural unskilledUrban unskilledSkilledWhite collarBusinessTOTALFrequency103101571132750/37372141100The startling difference in numbers betweenmen and women patients is also accounted for inthe above study which states that "lepromatousleprosy is more prevalent in males." (Harrison1966: p. 1622). No medical research has as yetfound an explanation for the different reaction ofmale and female organisms to the disease. It doesnot seem that such social factors as the greatermobility of men contribute to a spread of leprosy,for in that case Korekore women should have amuch lower incidence of the disease than all theother categories of people represented in thesettlement, because these women have very littlecontact with the outside world. However, asTable 1 shows, more women of the Korekorecountry are in the settlement than people from any6. MARRIAGE AND THE FAMILYLeprosy is feared by Africans and many lepersare treated as social outcasts. Some families andneighbourhoods, however, are less severe ontheir sick than others. It still happens that a leper iskept by his relatives in the remote rural areas, isgiven a hut and fed and looked after. The fact thatleprosy is not as contagious as, for example,T.B., makes such behaviour possible.In the more developed areas of Rhodesia, how-ever, relatives tend to exert pressure on their sickto go to the Isolation Hospital for treatment. Thenews that this disease can now be healed hasspread and many persons come of their ownaccord. The attitude of friends and neighbours is,therefore, of great importance in studying marriage76stability and family life of the patients resident atNgomahuru.Families do not tend to break up when either thehusband or the wife falls ill. On the contrary,spouses frequently visit each other at Ngomahuruand visitors are allowed to stay for two days aweek in non-occupied huts. Special quarters forvisitors are not yet available. Visitors how comefrom afar are given accommodation for a week at atime. Only children are excluded from visiting theirparents. Hence leprosy does not necessarily leadto a break-up of marriage and family ties, as longas the patients are still in the settlement. Whathappens after their discharge, however, needsfurther investigation, because other concomit-tants of life in the Isolation Hospital, such as avery high rate of adultery, may produce divorcewhen the spouses are reunited.Ninety-six, or 34.9 per cent, of the male lepers arebachelors, and 28, or 20.3 per cent, of the womenare spinsters. Of the remainder, 139 men, or 50.6per cent, are married, and the marriages of afurther 40, or 14.5 per cent, ended in either death ordivorce. Among the women 75, or 54.4 per cent, aremarried, and the marriages of 35, or 25.3 per cent,ended in either death or divorce. Almost allwomen in this category are widows. The averagenumber of children per female patient in thesettlement is two to three.7. DAILY ROUTINE OF LIFE IN THE NGOMAHURUSETTLEMENT(a) WORKLife in Ngomahuru follows a time-table. Everymorning patients are asked to work for threehours. Their payment varies between 2d. and 6d.a day, depending on the kind of work they do.Some are said to earn up to £3 a month, themajority, however, acquire about £1 a monththrough their daily labour. This money is meantpurely as pocket money, since food, lodging,medical treatment and recreational facilities arefree of charge. Pocket money is desired to buygoods at the local store, beer brewed by thewomen, and sexual favours. The settlementadministration considers the three working hoursas therapy, helping people to adjust themselves totheir new community.After these three hours the patients are free todo what they like. Those who are interested ingardening, are allocated garden plots to growadditional food. These plots, usually about halfan acre in size, adjoin the compounds. They aremeant to supplement weekly food supplies bychoice food for which patients have speciallikings.Food in the form of mealie meal, vegetables,meat, sugar, and salt is given out every week on afixed day. Patients are also allowed to fish in therivers of the settlement, and fish constitutes adesirable addition to their food.(b) SCHOOLFor the younger members of the settlementschooling is the most important activity of life inNgomahuru. The school goes only up to Grade 5,yet even teenagers attend the classes because theadministration is keen to give them some basiceducation, as in their early childhood they had nochance of studying. Moreover, staff members areconcerned that boys and girls be regularly occu-pied during the day. Because leprosy is now curedwithin some two or three years, higher grades arejudged uneconomic. Those, however, who wish topursue private studies are given the help theyneed, and special evening classes are held foradults. Several people study up to Grade 8, andsome have passed their Junior Certificate bycorrespondence. Two teachers conduct theclasses, one of whom is himself a leper; the otheris Government employed.A second school is run at Ngomahuru for thechildren of African staff. This school was openedin 1957, going up to Grade 3, and by 1966 hadopened Grades 4 and 5. Owing to a constantreduction of staff at Ngomahuru, the school doesnot grow. In 1968, 39 boys and 23 girls were en-rolled. A further two teachers conduct the classesfor these children.(c) RELIGIONA large variety of churches are representedamong the lepers, especially the Roman Catholicand Anglican Churches. Table 5 gives the religiousaffiliation of the lepers.The strongest denominations in Ngomahuruare the Roman Catholics with 51 members; nextin strength are the Anglicans with 39 and theDutch Reformed with 37 members. These arefollowed by Watch-Tower with 20, the SalvationArmy with 18, and the Methodist with 17 members.The other Protestant Churches have feweradherents in Ngomahuru.Weekly religious services, presided over alter-77TABLE 5Religious Affiliation of LepersReligionTraditional Religion ...Various ProtestantChurchesRoman CatholicAfrican IndependentChurchesMoslemsTOTALMenFrequency107110371562750//o39401452100WomenFrequency654514141380//o47331010100nately by ministers of the major denominations,attract almost all patients in the settlement,irrespective of their own denomination. ManyAfricans from the more remote areas meet inNgomahuru Christianity for the first time in theirlives. Religious services become great socialoccasions to the lepers in their often monotonouslife. They are also the only social occasion onwhich patients and staff meet together.It is difficult to say to what extent religion plays apart in the lives of the people, apart from theseformal occasions. Much depends on the initiativeof individual patients. For example, in 1963 anAfrican Sister of a Catholic Congregation wasa patient in the settlement, and regularly gavereligious instruction to some 60 patients, both tothose already baptised and to those who were notyet Christians. When she was discharged, nomore religious instruction was given.(d) RECREATIONSocial life is well developed in Ngomahuru. Thehospital is a meeting place for gossip, and theadjoining Beit Hall for recreation and study. Fore-most among the various recreational activitiesranks the African Women's Club, organised by thewife of the medical superintendant. Together withthe matron of the hospital, she meets some 80women once a week for two hours, during whichshe gives instructions in mending, patching andsimple sewing. This club is not affiliated to thenational organisation of women's clubs, becausethe patients are financially unable to pay the yearlysubscription fee, and also because their stay inthe camp is too short to guarantee a permanentmembership. Consequently patients are advised tojoin local clubs in their home areas on their return.In the absence of Government assistance, theclub relies on free gifts from hospitals and otherorganisations providing them with simple materialand equipment. This club enjoys great popularityamong the women who love sewing their ownclothes, which they wear on Sundays and feastdays instead of the khaki clothes provided by theadministration.Other voluntary associations are scout and girlguides under their own leper leaders, and afootball club. Christmas and other feasts tend tobe marked by athletic contests, concerts andpublic celebrations. In most of these recreationalactivities people of the same area group together,and friendships which evolve out of such associa-tions are frequently continued through letters andvisits when patients are discharged as being nolonger infective, or as cured. This shows that asense of community is created in the settlementwhich, based on a common disability, lasts evenTABLE 6Fluidity of Patient Population in NgomahuruChanges in Patient PopulationPatients on the register in January 1964 ...Admitted during the yearReadmittedDischargedDesertedDiedPatients on the register in December 1964OutpatientsMalesFemalesTotal4172031218921541714378222767891142018863927919278329618231beyond the common stay in the Isolation Hospital.8. THE CURE OF LEPROSYThe number of patients in Ngomahuru fluctuatesover the years. In 1964 over 600 patients were inthe settlement, i.e. some 200 more than in 1963.The following figures give a brief impression ofthe turn-over of patients during a year.The fact that some 300 patients are admittedduring one year, and that just below 300 weredischarged, bears out the claim of the administra-tion that the population is very fluid. Moreover,these figures indicate that the average patientstays only a limited number of years in Ngomahuru,though few if any are discharged earlier than twoyears after their arrival.The possibility that length of stay in the settle-ment is correlated with the length of time a patientsuffered from leprosy before coming to Ngoma-huru is explored in Table 7.camp only for a short period, there does not exista correlation between the length a person hasbeen sick before seeking admission and thelength of stay in the camp, as the correlationcoefficient shows. A mere inspection of the tablealso indicates that the majority of those whowaited for many years before coming for treat-ment, have stayed two years or less in the camp,and the majority of the more permanent residentsof Ngomahuru were aware of their sickness foronly a short time before they came for treatment.The great majority of people whose stay inNgomahuru is brief, proves that with the intro-duction of new drugs leprosy has definitely ceasedto be a disease lasting the better part of a patient'slife.Leprosy is not a fatal disease. Few people die inNgomahuru and the settlement's Crude DeathRate of 14 per 1000 of the population is the sameTABLE 7Correlation between Length of Disease before Admission andLength of Stay in the SettlementYears of disease before seeking admissionc"$>rowo(0Ł*"Years012345678910+Total0/0733214823Š1Š13332-21544413613106ŠŠ14635-322516787412327518-231312311215-143113Š31122-9552Š71-765112.Š92-27 812 ŠŁjŠ Š1 Š1 ŠŠ Š6 Ši -4 Ž9 10 +Š 3Š Š\Š ŠŠ Š_ __Š 4Š 10Total18296392528201133244130//o44-123-29-46-1684-82-7Ł7Ł7Ł5101000Correlation coefficient = 000014. This shows that there is no correlation.Table 7 shows that over 67.5 per cent of thepatients were aware of their disease for a year orless before they sought admittance to the hospital,and 67.3 per cent were a year or less in Ngomahuru.Also only some 4.6 per cent lived for six years orlonger in their villages before they sought admis-sion to the settlement, and 5.6 per cent were sixyears or longer in Ngomahuru. However, althoughthe majority of patients sought admission to thecamp shortly after they became aware of theirdisease, and although the majority were in theas that of the African population of Rhodesia as awhole.No information is available for the 32 patientswho deserted the Isolation Hospital. It would bedesirable to know the reasons for their desertionand above all their place in the community to whichthey returned.Patients discharged as cured, or whose diseasehas been arrested, frequently find it very difficultto be readmitted in their village community. Someof them, therefore, prefer to stay at Ngomahuru.79As stated earlier, one of the male compounds ispredominantly occupied by cured cripples whohave been refused acceptance by their kinsmen.The policy of the administration in Ngomahuru isto send these men to Mtemwa at Mtoko, a settle-ment which now serves as a rehabilitation centre.The fact that many cured lepers refuse to betransferred and plead to be kept at Ngomahurushows that they have found a home there, whichsatisfies their social needs. I suggest that the fiveper cent who have stayed for more than six yearsin Ngomahuru belong predominantly to this sec-tion of the population.Although Ngomahuru is one of the bestequipped leper settlements in Central Africa,attention is not yet directed towards physio-therapy and reconstructive surgery, which wouldenable ex-patients to return more easily to usefuland productive lives in their communities. Thereason for this is, that the cost of such surgery,which involves long hospitalisation, is very high.In spite of the fact, therefore, that some 50 to 75 percent of all leprous patients heal completely, withoutsuffering any further evidence of leprosy (Harrison1966: p. 1623), African lepers in Rhodesia, becauseof the marks of their disease left on their bodies,find reintegration a major problem. Furtherendeavours to help cured patients to readjustthemselves to village life are therefore important.In order to understand the problems of curedlepers, a sociological study should be undertakenof the men and women at Mtemwa. The results ofsuch a study will throw light on the directionwhich such rehabilitation work ought to take inRhodesia.PART IIA comparison between the social characteristicsof lepers in Ngomahuru with the rest of the Africanpopulation in Rhodesia is beset with many diffi-culties. It is most important to remember that thefollowing analysis does not deal with the totalRhodesian leper population, but only with thoselepers hospitalized at Ngomahuru. As stated inPart I, not all lepers are brought for treatment,some are kept by their relatives in their homes.The hospital staff in Ngomahuru informed me thatthis happens with special frequency in remoteKorekoreland. I shall point out further complicatingfactors as the analysis proceeds.1. THE ORIGIN AND AGE-SEX STRUCTURE OFPATIENTSIn Part 11 have given the percentages of lepers inNgomahuru from the various parts within Rho-desia, and from outside this country. If thesefigures are compared with the proportions of thetotal population coming from, or living in, theseregions, striking differences emerge: (a) lepersfrom outside Rhodesia are overrepresented inNgomahuru, in relation to the proportion offoreign Africans in Rhodesia's African population.Whereas, according to the Population Census of1962, 13 per cent of all Africans in Rhodesia areborn outside, 27 per cent of all male lepers and10 per cent of all female lepers in Ngomahuru areforeigners. If a large number of these foreignlepers had not been repatriated in the early 1960's,this proportion would be still larger. I thereforesuggest that the Rhodesian leper rate is far lowerthan that of its neighbouring countries. Thefollowing observation corroborates this sugges-tion: it is reported (Boyd 1961: p. 295) that thepercentage of known lepers in Central Africa is1 per cent of the total population, but the percen-tage of known lepers in Rhodesia is only 0.02 percent.The analysis of non-Rhodesian lepers in Ngoma-huru is further complicated by lack of informationas to which territories the majority of patients werereturned. It is possible that more lepers werereturned to Malawi of Zambia than to otherterritories having lepers in Ngomahuru, or viceversa. Hence the percentages of non-Rhodesianlepers in Ngomahuru do not give us any indicationof the frequency of leprosy in these countries.It may be assumed that most of these foreignlepers are labour migrants because almost allAfrican male foreigners in Rhodesia are labourmigrants. Since few of these have their wives withthem in Rhodesia, the percentage of foreign femalelepers is relatively low. (b) Rhodesian born lepersin Ngomahuru show an unexpected distribution incomparison to Rhodesian born Africans, a differ-ence which significant at the 0.01 per cent level. Inbrief, the Manyika and Ndau, who constitute14 per cent of the country's population, accountfor only 9 per cent of the Rhodesian lepers inNgomahuru; the Ndebele constitute 20 per cent ofthe country's population, but only 12 per cent ofthe Rhodesian lepers in Ngomahuru; the Karangaconstitute 30 per cent of the indigenous popula-80tion, but only 17 per cent of the Rhodesian lepersin Ngomahuru; the Zezuru constitute 20 per centof the country's population, but 18 per cent of theRhodesian lepers in Ngomahuru; and the Kore-kore, who constitute only 16 per cent of thecountry's population, constitute as much as 44 percent of the Rhodesian lepers in Ngomahuru.These comparisons indicate that certain districtsseem to have a higher incidence of leprosy thanothers.However, before such conclusions can bedrawn, certain cultural and climatic factors mustbe taken into account. As stated above, theincidence of leprosy in Korekoreiand is probablyseriously under-estimated because of the practiceof local people who hide their lepers and care forthem in their homesteads. Yet even if this were notthe case, the available data in themselves suggestan exceptionally high leprosy rate in that part ofthe country.The low figure for Manyika- and Ndauland maybe influenced by religious factors. An indigenousZionist church, called "The Apostles of JohnMaranke", which originated in Manyikaland in theearly 1930's, forbids its adherents to attendhospitals. Since this church has many adherentsin the Eastern Highlands, a certain number ofpatients may be hidden. However, I have noinformation on this point.I suggest that relatively few lepers are hidden inthe other parts of Rhodesia, especially not on thecental high- and middlevelds. In 1967 I undertooka population census in the centre of Karangaland,including some 6,000 men, women and children.Although this sample included several personssuffering from mental illness, blindness, and otherphysical handicaps, it included not a single leper.It is unlikely that lepers would have escaped thenotice of my field assistants and myself, becausewe lived in the same villages with the people weinterviewed.A further point to be borne in mind is theremoteness of Korekoreiand from the mainEuropean settlements. Lack of close culturalcontact, lack of hospitals and schools, and a verylow standard of hygiene may well contribute to ahigher rate of leprosy in Korekoreiand than inother areas of Rhodesia.It has been suggested to me that the dietarypattern of the Korekore, which differs from thatof the remaining African groups in Rhodesia, maycontribute to a higher rate of leprosy. However, ilack information about diet.The Karanga and Zezuru are both under-represented in Ngomahuru; nevertheless theirpercentage is fairly high when their contact withEuropean culture is taken into account. Some pastcharacteristics of leper settlements may explainthis disproportion.The hospital staff at Ngomahuru informed methat in the past patients were allowed to visit thesurrounding areas, and so contributed to thespread of the disease among the Karanga. Ifrequently encountered great fear of leprosy inVictoria Tribal Trust Land, and a local chiefbitterly complained to me of the proximity of theleper settlement to his chiefdom. Again and againhe expressed his horror of "the people withwounds".If lepers of the former settlement at Mtoko werealso allowed to visit surrounding villages, therelatively high number of lepers from Zezurulandin Ngomahuru can be explained in the same wayas the high number of lepers from Karangaland.Accepting these cultural factors as possiblyinfluencing the percentage of patients coming fortreatment to Ngomahuru, I think that climaticfactors are of still greater importance. The medicalobservation that leprosy is particularly common inhot and moist climates, seems better to explain thepreponderance of patients from the Zambezivalley, and the relative absence of leprosy in thedry and cooler areas, such as Ndebeleland andManyika- and Ndauland, and also the lowerincidence of the disease in Karanga- and Zezuru-land on the healthy high- and middlevelds, than dothe possible cultural explanations.Population pyramids 1 and 2 show the profile ofthe leprous population in Ngomahuru, and thenational population pyramid of Africans, based onfigures published by the Census Report of 1962.A comparison between the relative absence ofchildren from the leper population and the greatnumber of children in the national population,where children below the age of 15 account foralmost 50 per cent of the total population, and therelative absence of old lepers in Ngomahuru withthe number of very old healthy Africans, corro-borates the observations made in the first part ofthis paper.81Population Pyramid of NgomahuruMales00toFemales11 10 98765432101 2 34 5 6 7 8 9 10 11tAGE & SEX STRUCTURE RhodesiaAfrican Population1962FemalesTotal: 3,616,600BR.48D.R.14 Fert.ratio 876,Source; iqt>A Cen5u5(66.832. EDUCATION AND OCCUPATION1 set out the educational achievements of lepersin Ngomahuru in Table 3, Part I. Table 8 gives thenational figures of education, as published in the1962 census.seems to contribute to more hygienic ways ofliving. The fact that we are dealing with adults andnot with children, that is, with men and women whodetermine life in the home, such a conclusionbears more weight than if we were dealing withEducationNilLower PrimaryUpper PrimaryPost PrimaryTOTALEducationFrequency448,769344,080106,96025,520925,329TABLE 8of all Adult RhodesianMen0//o4837123100AfricansWomenFrequency508,850280,02048,2808,160845,3100/603361100The x2 test of significance has been applied andshows that there is a significant difference betweenthese two groups at the 0.01 per cent level, if theeducation of men and women are combined. Thedifference in education between sick and healthymen is far less than between sick and healthywomen. This may mean that the educationalstandard of women has an influence on hygiene inthe home. Such a difference could hardly havearisen by chance. The healthy population hasachieved a much higher standard of educationthan the lepers in Ngomahuru. Among the men,the greatest difference exists in the numbers ofthose who obtained post primary education.Among the patients in Ngomahuru only one manholds a university degree, and another is a medicalorderly with O-level certificate of education. Allthe others achieved much lower standards ofeducation. Among the women, all levels of educa-tion are lower among the lepers than amonghealthy women.These findings are of interest, since Dr. Brownstated that leprosy occurs among upper classes aswell as among the poorest section of any popula-tion. He adds, however, that overcrowding,coupled with close contact with lepers, contributesto an increase of the disease. These conditions aremore prevalent among the lower social strata.These findings lead to the following considera-tions. Since in both sets of data we deal almostexclusively with an adult population (a few childrenare included in the Ngomahuru group), that is,with men and women well beyond school age, thepossibility is ruled out that lepers, because of theirdisease, lack access to schools. Also, educationschool children who, when returning from school,have to follow the customs of their parents.The fact that we do not know which lepers arehidden in their villages, the more educated or lesseducated, rules out further conclusions about theeducational standards of all lepers in Rhodesia.Very frequently, higher education leads to moreskilled occupations and to white-collar jobs. Thissuggests that healthy Africans with higher educa-tion may perform more skilled occupations.Unfortunately, no national figures of Africanoccupations are published. My own survey, basedexclusively on Karangaland, shows a much higherpercentage of skilled and white-collar workers thandoes the leper population. However, since thissurvey is localled based, no general conclusionscan be drawn from a comparison between thissample population and the lepers in Ngomahuru,who come from every part of Rhodesia andbeyond.3. MARRIAGE ANALYSISAn analysis of the marriages in which onepartner is a patient at Ngomahuru, and themarriages of healthy Africans, is beset by stillgreater difficulties than the preceding compari-sons. No national figures on African marriage arepublished. The only figures at my disposal arethose of my own census sample in Karangaland.Dr. Garbett published figures on marriage stabilityamong the Zezuru, but did not give information onthe length of extant marriages, nor on the averagenumber of children per family. Dr. Garbett showedthat 35 out of 172 marriages, that is 20 per cent,«ended in either death or divorce. Among thepatients in Ngomahuru 75 out of 289 marriages, '84that is 26 per cent, ended in either death or divorce.In my Karanga sample 205 out of 716 marriages,that is 29 per cent, ended in either death or divorce.The test between these percentages does notsuggest variations in marriage stability. I thereforetentatively suggest that variations in marriagestability between the other groups may also not besignificant.Keeping these reservations in mind, the follow-ing differences emerge between my Karangasample, and the leper population at Ngomahuru:in the Karanga sample, the median length ofmarriage was about 20-29 years, against the medianlength of marriages among lepers at Ngomahuruof only 10-19 years. In fact, 191, or 89 per cent, ofmarriage among the patients in the settlement havelasted 5-39 years, with very few marriages, namely16, or 8 per cent, less than 5 years, and only 7marriages, or 3 per cent, for longer than 40 years.I suggest that this peculiar distribution is areflection of the demographic characteristic of theleper population, where the majority are youngadults, with very few old people. This age distribu-tion affects the median length of marriages amongthe lepers.Keeping again in mind the serious reservationthat no valid conclusion can be drawn fromcomparing a locally based sample census withthat of the leper population drawn from all parts ofRhodesia, I would like to make the observationthat there does not seem to be a difference in thenumber of children per marriage between thesetwo groups. The difference is only significant atthe 0.20 per cent level (x2 test).This, however, does not reveal the whole story:since the patients in Ngomahuru are younger thanthe general adult population of Rhodesia, morechildren are expected in this group. For leprosydoes affect the fertility of men and women, especi-ally when the illness is already advanced. TheCrude Birth Rate at the settlement is as low as 20,against the country's total African Birth Rate of48 per 1000. Leprosy causes miscarriages andstill-births more frequently than these occuramong healthy women, and men tend to sufferfrom sterility when their illness is advanced.In addition to these factors, the unbalancedsex-ratio in the settlement too contributes to alower birth rate. Moreover, each time that awoman has a child, her health deteriorates. Inter-course between lepers is, therefore, discouragedfor reasons of health. Owing to the fact thathusbands and wives are not living together,adultery and prostitution are frequent at Ngoma-huru, and most of the children born to lepers areillegitimate.CONCLUSIONThe tentative analysis of Part II has shown thatthe problems involved in drawing conclusions, asto how far the leper population of Ngomahuru issimilar or dissimilar to the general African popula-tion of Rhodesia, are very great. Insufficientinformation about the social characteristics ofRhodesian Africans in general, prevents any validcomparison. It is hoped that the national census of1969 will fill in some of this lacking information,especially as regards occupations and marriagedetails of Africans. If this is done we will be leftmerely with the problem of the representativenessof hospitalized lepers for all lepers in Rhodesia, aproblem which faces all countries in all continents.BIBLIOGRAPHYBOYD, W. (1961 Textbook of Pathology, Kimpton, London.BROWN, S. (1968) Lecture at U.C.R. on recent developments in leprosy research.GARBETT, G. K. (1960) Growth and Change in a Shona Ward. Occasional Paper No. 1, U.C.R.N.HARRISON, T. R., et al. (1966) Principles of Internal Medicine, McGraw-Hill.SOUTHERN RHODESIA (1964) Final Report of the April/May 1962 Census of Africans in Southern Rhodesia, Centrali iNgomahuru Beit Hall.Weekly distribution of foodThe old compound at Ngomahuru.A new compound at Ngomahuru.