At the time of writing (April 2020), Africa, accounting for only 0.8% of confirmed cases and 0.6% of deaths worldwide, is marginal to global analysis of coronavirus. This situation seems very likely to change, given the fragility of African health systems, the prevalence of underlying health conditions such as AIDS and tuberculosis, the density of urban populations, and the difficulties faced by many households in achieving social distancing, isolation, and frequent handwashing. These potentially catastrophic factors may be offset by Africa’s youthful age structure and practices of social solidarity which often remain very strong. We can certainly hope that the direct impact of the pandemic will continue to be limited across the continent. But the indirect consequences, such as the undermining of the World Health Organisation, the interruption and likely refocusing of global health research, and the abrupt interruption of networks of trade and investment, seem likely to be disproportionately negative in Africa. 

              Contributors to this journal have made vital contributions to African historical epidemiology; but, crucially, they have also enhanced understanding of the broader impact of outbreaks of disease. This virtual special issue draws together a selection of The Journal of African History’s many articles and book reviews analyzing epidemics and public health over recent centuries. Their range reminds us that pandemics operate, and need to be analyzed, at varying scales. COVID-19, like many diseases in the past, will reshape international relations, threaten the capacity of national economies and legitimacy of the state, and apply intense pressure to the mutual care and spiritual beliefs that sustain, connect, and sometimes divide communities and households.

              The breadth of Africanist historians’ contribution to understanding is best captured within the two contributions to the Journal’s 2013 forum: HEALTH AND ILLNESS IN AFRICAN HISTORY. Both James Webb and Tamara Giles-Vernick et al.emphasize the vital importance of ensuring that biomedical researchers engage with historians’ perspectives on disease processes. As Webb’s historiographical review points out, without an understanding of the social, cultural, political, and economic historical context of disease outbreaks and expansion, epidemiologists’ causal explanations can tend towards the naïve. His summary of his own research on malaria eradication emphasizes that ill-thought-out immunological experiments in the name of global health ultimately put local populations at risk. With regard to newly emerging infectious diseases, Webb notes that understanding how pathogens shift from animals to humans requires an understanding not only of food cultures, but also of broader ecologies. A narrow fixation on wet markets or hunters of bushmeat obscures the fundamental impact of biome conversion through urbanization and the domestication of natural environments. These themes are explored further in Giles-Vernick et al.’s analysis of how West African simian viruses were transformed into HIV a century or more ago. As the authors show, fully-fledged globalization and air travel may accelerate the development of a global pandemic, but they are not necessary preconditions. Global health is structured to explain how new pathogens emerge and spread, but why novel threats to our health develop requires an understanding of the historical evolution of specific socioeconomic conditions, not molecular surveillance.

              That epidemics are deeply political events is highlighted in William Cohen’s 1983 article examining the relationship between malaria control and French imperial expansion. Arguing against the thesis that European conquest was dependent on technological development, Cohen shows that effective state action, not medical innovation, led first to territorial gain and subsequently to a reduction in the incidence of malaria. In all modern epidemics, the risk of infection and the entitlement to health protection are unequally shared; as Cohen demonstrates, the logic of empire made such categorizations particularly transparent, with colonial regimes deliberately employing African auxiliaries to limit the risk faced by vulnerable yet valued European troops.

Imperial conquest permitted the control of some diseases, but facilitated the spread of others, most notably sleeping sickness. This disease, which killed more than half a million people across equatorial Africa at the start of the twentieth century, expanded through ecological and social disruption more than widening networks of communication. Colonial regimes’ partial recognition of their culpability underpinned intense efforts to contain sleeping sickness, but, as Maryinez Lyons’ 1985 article demonstrates, humanitarianism provided legitimation for the achievement of larger imperial goals. States not only define what constitutes an epidemic, but seek to contain disease outbreaks in ways which enhance their powers. Sleeping sickness established a culture of intrusive, interventionist governance in the Congo which outlasted the epidemic itself. As Lyons shows, programmes of identification and isolation drew on metropolitan methods of disease management, but the colonial context permitted social engineering on a new scale. Sleeping sickness controls in the Congo bear many similarities to those employed against coronavirus: mass confinement, the closure of borders, the issuance of medical passports, the rushed introduction of experimental medications with unanticipated side-effects, the separation of the sick and dying from their families, and the pressure from business interests to reopen local economies. The role of epidemics in reshaping the relationship between subject and state is clearly illuminated by Mari Webel’s 2013 article. By focusing on medical auxiliaries, Webel’s analysis of sleeping sickness illustrates how epidemics profoundly unsettle local power dynamics. Rather than securing the state untrammeled access to communities in Tanganyika, African intermediaries participated in evolving patterns of exchange, patronage, evasion, and negotiation, and served to demonstrate how precarious was the power of colonial rulers and their chiefly allies. Webel’s account also reminds us that popular acquiescence to public health controls cannot be guaranteed indefinitely.

              Historical analogies for COVID-19 have landed most frequently on the influenza pandemic of 1918-19, partly because of the rapidity with which it spread around the globe, but also because of symptomatic similarity. Like COVID-19, Africa has been largely written out of global accounts of “Spanish flu”, yet, as David Patterson reported in 1983, perhaps 2 million Africans died during that pandemic. The silence in the record, like the heavy mortality rates, reflected the limitations of the early colonial public health system, worsened by wartime underinvestment. Influenza in 1918-19 was both more infectious and more deadly than coronavirus, affecting perhaps 80% of the population and killing c.4%. As Patterson notes, its severity explains its brevity – within three months of arriving by ship, influenza had passed through the Gold Coast. Governmental awareness of its own inadequacy resulted in inertia and a dearth of accurate public health education – only communities’ observation of rising mortality forced households to isolate. The legacy of influenza in the Gold Coast took form in popular frustration at a system of governance which appeared uncaring and incompetent. South Africa fared little better, as Randall Packard’s review of Howard Phillips’ Black October reveals, although Phillips focused on using the epidemic to highlight the consequences for health of the structural inequalities of racial capitalism. This theme of structural vulnerability to epidemic, shaped in part by the prevalence of that classic colonial underlying condition, malnutrition, also features prominently in Jill Dias’ 1981 longue durée history of disease in Angola. In addition, Dias’ analysis of the interrelationship between disease outbreaks, economic disruption, and famine provides a valuable reminder of the fragility of food production and distribution across the continent.

              In 1993 Randall Packard used another respiratory disease, pneumonia, to highlight the devastating impact of poverty and political exclusion on medical outcomes. His analysis of the shockingly high morbidity and mortality among Central African workers in South Africa’s mines shows that while disease may not respect status, preventive and curative medicine do. His observation that economic elites found it cheaper to invest in vaccine research than to reduce the risk of infection holds important lessons for students of the current pandemic, as does authorities’ blaming the susceptibility of vulnerable groups on their own cultural and biological characteristics.

              Packard built on a theme developed in Maynard Swanson’s 1977 article exploring bubonic plague and South Africa’s sanitation syndrome. For Swanson, authorities viewed infectious disease as a societal metaphor which both required and justified racial segregation. Diseases which appeared to reflect lines of class and ethnic inequality associated the poor and people of colour with danger and disorder. As Swanson showed, epidemiology reflected anti-competitive racial logics more than objective science.

              Medically-justified segregation highlighted in extreme form the inequities inherent in systems of medical quarantine and isolation, as discussed with regard to colonial Senegal in Kalala Ngalamulume’s 2004 article and James Searing’s 2003 review of Myron Echenberg’s Black Death, White Medicine. These studies remind us how the threats posed by diseases evolve as they encounter new environments, with yellow fever, a disease of the forest, adapting to urban milieux, and plague, initially understood as a disease of globalization, quickly taking root in local ecological niches. For Ngalamulume, yellow fever caused the colonial state to seek to separate sanitary citizens, who supported epidemic controls, from unsanitary subjects, whose non-compliance was understood as part of a larger rejection of modernity. Both studies highlight the stigmatization and structured neglect of the urban poor on the one hand, and, on the other hand, the range of protest which disease and disease control engendered. In this context at least, the marginalization of the vulnerable was gradually reduced following public demonstrations, organized political engagement, and individual disobedience, often following religious leaders’ condemnation of authorities’ disregard for individual rights and private space.

              As societies are being fundamentally remodeled to limit the immediate mortality caused by COVID-19, already it is clear that morbidity and mortality from some other illnesses will escalate. Epidemics require and attract resources previously earmarked for less urgent needs; the impact of this reallocation on the management of conditions such as cancer, diabetes, and HIV are likely to be significant, but such problems may fall down global health agendas’ list of priorities. As Neil Kodesh’s 2015 review of Julie Livingston’s Improvising Medicine emphasizes, diseases are rendered invisible where they do not fit currently-dominant models of disease. Livingston’s work also reminds us that COVID-related clinical knowledge which develops in the Global North may not translate comfortably into African clinical contexts, where medical staff and families alike must negotiate avenues through complex, under-resourced medical systems. Such negotiations are defined by Livingston as contributing to illness and death as profoundly social experiences, reminding us that illness [typically] is a relational process that takes place between people. Coronavirus, ironically for a contagion, has of course imposed new forms of isolation. As in the past, isolation reveals privilege and marginality.

              Africa’s evolving position within a globalizing world is the subject of the final element in this virtual special issue, Laura Tilghman’s 2015 review of Abena Dove Osseo-Abare’s Bitter Roots. While Livingstone’s work focuses on clinicians’ relationships with their patients, Osseo-Abare emphasizes division within the world of bioprospecting. As the global quest for effective treatments for COVID progresses, so it seems likely that African medicinal plants will be mined for exploitable curative properties. Osseo-Abare shows that disease may be universal, but clinical knowledge is constrained by national, commercial, and professional barriers – an insight directly relevant to the present pandemic.

We hope that this collection of historical analyses provides new understanding of the links, and contrasts, between past and present, and helps connect us to some of the pioneering insights of scholars of African medical history.