The Early History of Tuberculosis in Central East Africa

The early history of tuberculosis in central East Africa: insights from the clinical records of the ﬁrst twenty years of Mengo Hospital and review of relevant literature

T. M. Daniel Case Western Reserve University School of Medicine, Cleveland, Ohio, USA

SUMMARY

SETTING: Mengo Hospital, in present day Kampala, of 93 cases of tuberculosis were included in 26 806 ad- Uganda, 100 years ago. missions to Mengo Hospital from 1897 through 1916. OBJECTIVE: To determine the presence of tuberculosis No secular trend in the prevalence of tuberculosis in the Bagandan population of central East Africa and among patients admitted was apparent. A review of the elsewhere in Africa at the time of early explorations by prior literature concerning tuberculosis in precolonial Europeans. Africa suggests that tuberculosis may have been present DESIGN: The case records kept by Albert Cook for two in several regions prior to European exploration, but decades beginning in 1897, 35 years after the ﬁrst visit of was probably absent elsewhere. Speke to this region, were reviewed for evidence of CONCLUSIONS: The concept of all of Africa and all of tuberculosis among Bagandans. Writings of other con- the people of Africa as virgin soil for tuberculosis is temporary medical observers were reviewed for evidence rooted in an archaic Eurocentric view of Africa, and can- of tuberculosis in pre- and early-colonial Africa. not be supported today by available data. RESULTS: Well documented cases of tuberculosis were KEY WORDS: tuberculosis; history of tuberculosis; East observed by Cook beginning in 1897. A minimum total Africa; Uganda; Albert Cook; Mengo Hospital

AS POINTED OUT eloquently by Stead and his col- sis in Buganda, East Africa, and elsewhere on the con- leagues,1–4 the early history of tuberculosis is impor- tinent. It is based on a review of the clinical records of tant today because it contributes to our knowledge of the ﬁrst twenty years of Mengo Hospital and a review the epidemiology of this world-wide disease and may of literature relevant to the early history of tuberculo- give insight into genetic resistance to tuberculosis in sis in Africa. modern peoples of diverse origins. The early records of Albert Cook at Mengo Hospital give information CLINICAL RECORDS OF THE FIRST TWENTY about the early history of tuberculosis in central East YEARS OF MENGO HOSPITAL Africa. Albert Ruskin Cook (1870–1951) committed him- The clinical records of Mengo Hospital are currently self to missionary work while still a medical stu- stored at the Albert Cook Memorial Library of Ma- dent.5,6 He completed his medical training in London kerere University School of Medicine in Kampala, in 1895, and in 1896 he embarked for East Africa, Uganda. These records, hand-written in ink with clin- landing at Mombasa on 1 October. He reached the ical notes by Cook and vital signs charts and nursing kingdom of Buganda, populated by a people who notes by Katharine Timpson, who later married called themselves Baganda and situated on the north Cook, and other nurses, are bound in volumes by shore of Lake Victoria with its capital at Mengo, now year. Prior to 1904 no record numbering system was part of modern Kampala, Uganda. The kingdom was used; in that year a system of record numbers was be- ruled by Kabaka (chief, king, sovereign) Mutesa, and gun, with renumbering beginning each year. During the indigenous language was Luganda, a tongue the ﬁrst seven years, an index alphabetized by patient which Cook had studied in England before his depar- name and listing diagnoses was kept by Cook and ture. In March 1897, Cook founded a hospital at bound with each volume. It is apparent that there are Mengo to serve the Bagandan people. a number of missing records, especially in the early This report explores the early history of tuberculo- years, and a rough estimate is that about 90% of the

Correspondence to: Thomas M Daniel, MD, Center for International Health, Room T-505, School of Medicine, Case West- ern Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4978, USA. Tel: (216) 368-6321. Fax: (216) 368- 8664. e-mail: [email protected] Early history of tuberculosis in East Africa 785 patients hospitalized are documented in these ar- dence from Mengo. In the great majority, no indica- chives. A fire destroyed the hospital in 1902, and tion of the reason for admission was recorded. most of the records for that year were lost. RESULTS METHODS Table 1 summarizes the data obtained by reviewing With the assistance of the librarians and staff of the the early case records of Mengo Hospital. It is appar- Albert Cook Library, all records were reviewed and ent that tuberculosis was present in the indigenous each record with a diagnosis of phthisis, tuberculosis, Bagandan population from the time of Cook’s arrival bronchitis, pneumonia, pleurisy, empyema, or other in 1897, 35 years after the first European contact pulmonary condition was flagged. The author then with these people in 1862 by Speke, the British dis- personally reviewed all of the flagged records with coverer of the source of the White Nile. One patient diagnoses of phthisis or tuberculosis and approxi- with a chronic knee infection with a draining sinus mately 10% of the other flagged records. Whenever considered by Cook to be tuberculous (but not docu- repeated hospitalizations of the same patient were mented in the record to have had acid-fast bacilli in recognized in this review, the case was tabulated only the drainage) and seen in 1897 was said to have had once. A representative admission note by Cook is the disease for ten years. reproduced in the Figure. Cook had brought two microscopes equipped with No information about the criteria used for admis- oil immersion lenses with him to Mengo, and he used sion to the hospital could be obtained from this acid-fast stained sputum smears to confirm his diag- review. In some cases severity of illness appeared to noses. Thus, there is little doubt that his diagnoses of have dictated admission, in others distance of resi- pulmonary tuberculosis were correct. In fact, the

Figure A representative admission note by Albert Cook describing a male patient with pulmonary tuberculosis. A history of cough, hemoptysis, and night sweats is recorded. As is typical of Cook’s notes, the physical ﬁndings over the left upper lobe are described in detail. A series of progress notes attest to the continuing hospitalization but provide little new information. A positive sputum examination is recorded, apparently on 24 August 1899, 12 days after admission. 786 The International Journal of Tuberculosis and Lung Disease

Table 1 Number of pulmonary and extra-pulmonary cases diagnosed at Mengo Hospital in Uganda, 1897–1916

Number of diagnoses of tuberculosis Number of Extra- Yearadmissions Pulmonary pulmonary Total 1897 250 3 3 6 1898 223 5 0 5 1899 255 5 1 6 1900 255 2 0 2 1901 623 1 1 1 1902 72* 1 2 3 1903 657 3 0 3 1904 843 2 0 2 1905 1 392 1 3 4 1906 1 690 3 1 4 1907 1 447 3 2 5 1908 1 354 5 1 6 1909 1 391 8 3 11 1910 1 696 4 2 6 1911 1 792 10 2 12 1912 1 764 2 1 3 1913 1 871 4 0 4 1914 1 786 3 4 7 1915 2 868† 80 8 1916 4 577† 20 1 21 Total 26 806 93 (0.35%) 27 (0.10%) 119 (0.44%)

*Many records were lost in a fire that destroyed Mengo Hospital in November 1902. † Admissions in 1915 and 1916 include war casualties. number of cases of pulmonary tuberculosis reported Cook reported a survey of the diseases seen among in Table 1 is almost certainly a minimum figure, for it 1500 patients admitted to Mengo Hospital during its is apparent from review of the case records that Cook first four years, from March 1897 to March 1901.7 In rarely considered the diagnosis of pulmonary tuber- the table in his report he listed 58 cases of tuberculo- culosis in the absence of hemoptysis. Many chroni- sis (3.9%); in the text 71 (4.7%), the figure given for cally ill patients with diagnoses of bronchitis or pneu- nontuberculous pulmonary disease in the table and monia were described as having rales or ronchi over probably an error in the text. Our review documented the upper lobes and apices of the lungs, and it is likely 1606 admissions to the end of 1901, with a total of that a substantial number of them had tuberculosis. 21 diagnoses of tuberculosis (1.31%). We were un- On the other hand, Cook may have over-diagnosed able to find a reason for the discrepancy between our extra-pulmonary tuberculosis, for his clinical records review and Cook’s report from either the records or suggest that he considered a number of cases of chronic from Cook’s index. It is possible that Cook included osteomyelitis and chronic cutaneous fistulas to be out-patients in his review, although the text of his pa- tuberculous without microscopic confirmation. How- per specifically states that his review was based on pa- ever, progress notes and laboratory results were not tients admitted to the hospital. as conscientiously recorded by Cook as admission Cook’s diagnoses of pulmonary tuberculosis appear notes, and the absence of recorded results cannot be to have been accurate and his treatment modern by equated with negative findings. contemporary European standards. He used acid-fast No secular trend of increasing or decreasing tuber- staining to examine sputum smears from the time of culosis is demonstrated by the data in Table 1. In fact, his arrival. As seen in Table 2, he later introduced these data suggest a stable situation. The increase in tuberculin testing and roentgenology to his hospital, admissions and cases of tuberculosis in 1915 and and his therapy was similar to that in practice in 1916 was due to an influx of casualties from the East Europe at the time. There can be little doubt that African front of World War I, and names of patients tuberculosis was present among the Bangandan hospitalized in these years suggest that for the first people at the time of Cook’s arrival only 35 years time a number of Europeans were being admitted to after Speke’s original entry into this region. How the hospital. prevalent it was cannot be judged, but its incidence was probably relatively stable. DISCUSSION LITERATURE REVIEW The records of Mengo hospital document a low and fairly constant prevalence of tuberculosis among pa- If Buganda was not ‘virgin soil in connexion with tients admitted to Mengo Hospital at the end of the tuberculosis’, as Africa was characterized by Cum- nineteenth and beginning of the twentieth centuries. mins,8 what can be said of other regions of Africa? Early history of tuberculosis in East Africa 787

Table 2 Significant events at Mengo Hospital related to the aware of whether phthisis exists to any great extent diagnosis and treatment of tuberculosis . . . I have had this year three cases of the disease. . . .” 1897 First recorded use of microscopic examination of acid-fast Thus, Moffat believed tuberculosis to be more com- stained sputum smears for the diagnosis of tuberculosis mon among the imported troops than the indigenous 1909 First recorded diagnosis of tuberculosis by autopsy in a people. Interestingly, James Bruce, a Scotsman and patient with miliary tuberculosis the first European to discover the source of the Blue 1911 First recorded use of roentgenography for evaluation of Nile in modern day Ethiopia, which he reached in 1770 tuberculosis from the Red Sea, set out on his adventure in hopes that 1913 First prescription of open air for the treatment of tuberculosis it would help him to recover from an illness that may 17 1914 First recorded use of tuberculin testing to evaluate a have been tuberculosis. suspected case of tuberculosis If, as seems likely, tuberculosis was established 1915 First prescription of absolute rest for the treatment of among the Baganda on the north shore of Lake Vic- tuberculosis toria before the arrival of Europeans, then it is rea- sonable to ask how it might have reached this interior region of Africa. One must first recognize that the Data are few, and sweeping or dogmatic statements concept of Africa as a ‘Dark Continent’ is a Eurocen- cannot be supported. In fact, it is likely that tubercu- tric one. In fact, the vast continent of Africa may have losis was not uniformly distributed on the continent, been unexplored by its northern neighbors from making general statements even more hazardous. Europe, but it was well known to Africans and criss- crossed by trade routes for millennia prior to the Coastal Africa colonial epoch. Tuberculosis was present in Egypt in Nubia, now part of northern Sudan, as early as 5000 Portuguese sailors opened the coastal areas of both years ago.18 The hegemony of predynastic Egypt East and West Africa to Europeans, beginning in the extended up the Nile River at least as far as Khar- fifteenth and sixteenth centuries. Arab potentates toum, including Meroë, a city on the Nile north of colonized the coast of East Africa and conducted a Khartoum populated by racially negroid peoples.9 slave trade there many centuries earlier, and Greek Trading routes to the south were well established, as sailors reached Mombassa on the east coast as early they were to the west across a vast savannah, which as 200 BCE.9,10 Neither the Arabs nor the early Eu- would soon enter an era of desiccation to become the ropeans ventured inland, except in Senegal. How- Sahel of today. By the sixth century BCE, Meroë had ever, they may have carried tuberculosis to coastal re- become a major iron smelting and trade center, with gions. Ziemann, in a report published in 1913,11 iron artefacts from Meroë found widely distributed data from which were subsequently summarized by across Africa. The people of Meroë retreated from the Cummins,12 pointed out that tuberculin reactor rates Arab invasion of the eleventh century, moving south in Cameroon, West Africa, were higher in coastal and west. When the earliest Europeans arrived in Africans with extensive European contact than in Buganda they found that north-south trade routes people of the interior. The earlier report of Budd were in regular use by Arabian caravans, the Muslim states that tuberculosis was a major cause of mortal- religion was established, and Mutesa, the Bugandan ity among Africans in coastal, but not interior re- kabaka, was fluent in Arabic.19 To think that the gions.13 However, Budd’s report is entirely anecdotal interior regions of sub-Saharan Africa were isolated and cites no data. from the upper Nile River area where tuberculosis is known to have been present for several millennia is to Central East Africa perpetuate an archaic, Eurocentric view of Africa that In the interior regions of central East Africa, several has little basis in Africa’s history. Tuberculosis was early observers in addition to Cook described tuber- probably present in precolonial Buganda, perhaps as culosis among the Bagandan people. Robert Felkin, a part of an endemic region that extended the length of British medical student, visited Buganda in 1878.14 the Nile. He reported seeing 20 cases of pulmonary tuberculosis and noted that the Bagandans recognized this dis- West Africa ease, treated it with cupping using a cow horn, and In West Africa, Borrel described an outbreak of tuber- considered it incurable. R U Moffat, a British military culosis among Senegalese soldiers impressed by medical officer, reported seeing a large number of France and garrisoned at Fréjus in southern France in cases of tuberculosis in 1900 among garrisoned 1917.20 Borrel states that he tuberculin tested “un troops.15 While the ethnic origin of these troops was certain nombre” of these recruits and found a reactor not described, it is likely they were primarily Sudanese, rate of 4 to 5%. He considered tuberculosis rare in and tuberculosis was prevalent among Sudanese troops Senegal, and described the Senegalese troops as “un conscripted by the British at that time.16 With respect terrain vierge au point de vue tuberculeux”. He cited to the Bagandan people, Moffat reported, “I am not a tuberculin survey by Calmette as evidence that 788 The International Journal of Tuberculosis and Lung Disease tuberculosis was uncommon in Senegal. In fact, Cal- report of a medical officer in Cape Town in 1907 mette’s data were misconstrued by Borrel. Calmette describing the ravages of tuberculosis among the performed an extensive tuberculin survey in Senegal, indigenous population.26 However, he commented using a scratch technique with crude tuberculin from that in his own experience in Pandoland, between Koch.21 He found over-all tuberculin reactor rates in Cape Colony and Natal, acute forms of tuberculosis Senegal of 2.4% for infants of 0 to 1 years of age, were not common. Packard’s scholarly review points 17.8% for children of 1 to 15 years, and 15.2% for out that there are credible descriptions of tuberculosis older persons. Reactor rates were higher in urban set- in the interior regions from the earliest incursions of tings than rural ones, reaching 10.0%, 34.0%, and Europeans and that Zulus of that era stated that 30.2% for the three age groups in the city of Saint tuberculosis “has always been with us”.27 Packard Louis. From these data we can estimate that the goes on to conclude that tuberculosis has probably annual rate of infection in Senegal early in the twen- been present in South Africa, “albeit at a low level of tieth century was of the order of 1.2%/year, corre- endemnicity, for a very long time, dating perhaps to sponding to a smear-positive tuberculosis incidence the earliest periods of African settlement in the of approximately 60/100 000/year, with the corre- region”. sponding figures for urban Saint Louis being approx- David Livingstone was perhaps Africa’s most imately 2.2%/year and 110/100 000/year.22 One must famous early European visitor. He traveled widely in remember that Europeans had been exploring coastal the interior of southern Africa, north of present day West Africa for several centuries by the time of Cal- South Africa, reaching as far north as modern Tanza- mette’s study, and tuberculosis might well have been nia. A physician, he went to Africa primarily as a brought to this region by Europeans. Penetration Christian missionary and explorer, and much of his inland occurred almost uniquely in Senegal, and the large volume of writings only sparsely described the first European explorations of other parts of the inte- physical health of the people he contacted. He visited rior of West Africa did not occur until the expedition the Bakwain people along the Limpopo River in 1849 of Mungo Park in 1795.23 Perhaps Calmette’s tuber- and noted the absence of pulmonary tuberculosis and culin data from Senegal reflect a general scenario for scrofula among them.28 Stead2 cites a 1908 report by West Africa, with tuberculosis prevalent in urbanized McVicar that he did not observe tuberculosis in the centers along coastal areas following early European region that is now Malawi. contact with the interior regions largely free of the disease. CONCLUSION It is possible to make some inferences from the experiences of West Africans enlisted as soldiers by In conclusion, the early records of Mengo Hospital the British beginning in about 1810, although it must provide evidence that tuberculosis was present in be recognized that West Africa had had extensive central East Africa at the time of the earliest Euro- European contact for decades or centuries prior to pean entries into that area. It may have been present that time. The majority of these individuals came there from early times, reflecting the situation fur- from Nigeria and Benin. Tuberculosis mortality among ther down the Nile River. Alternatively, it may have these soldiers rose during the nineteenth century from been introduced by Arab traders at an early date. initially low levels to eventually account for about Elsewhere in the interior of Africa, tuberculosis may one-third of all deaths in the 1880s.24 This rapidly ris- also have been an ancient plague, present for centu- ing death rate suggests a previously naive population. ries, perhaps reintroduced by Arab traders, perhaps A recent case-control study of four alleles of the further reintroduced by early Europeans, but it was human Nramp1 gene in tuberculosis patients and probably not uniformly distributed across the vast healthy control subjects from six ethnic groups in continent. Some areas of Africa, notably the interior Gambia may be relevant.25 This gene conveys resis- of West Africa, probably had little tuberculosis. At tance to the development of tuberculous disease least with respect to central East Africa and perhaps among Mycobacterium tuberculosis-infected persons, more generally, the general conception of Africa and and all of the alleles studied were associated with people of African origin as virgin soil for tuberculo- defective gene expression and increased tuberculosis. sis is rooted in an archaic, Eurocentric view of These alleles were differently distributed among the Africa, and cannot be supported today by available six ethnic groups studied. Such genetic diversity evidence. might have contributed to the inhomogeneous distri- Acknowledgements bution of tuberculosis in precolonial Africa. The author wishes to thank Maria Musoke, Eunice Sendikadiwa, Southern Africa Rachael Nakalembe, and Walter Omono, librarians at the Albert Cook Memorial Library of Makerere University School of Medi- Data from South Africa are conflicting. The prevail- cine, and their staff for access to and assistance in reviewing the ing view has been that tuberculosis was introduced Mengo Hospital archives and for help in retrieving other docu- into South Africa by Europeans. Millar noted a local ments relevant to the life and work of Albert Cook. Early history of tuberculosis in East Africa 789

References 15 Moffat R U. Uganda Protectorate—Report for the year ending December 31, 1900. J Trop Med 1901; 4: 326–330. 1 Stead W W. The origin and erratic global spread of tuberculo- 16 Cummins S L. Tuberculosis in the Egyptian army. Brit J Tuberc sis. How the past explains the present and is the key to the fu- 1908; 2: 35–46. ture. Clin Chest Med 1977; 18: 65–77. 17 Head F B. The life and adventures of Bruce the African traveler. 2 Stead W W. Genetics and resistance to tuberculosis. Could re- New York; Harper and Brothers, 1841. sistance be enhanced by genetic engineering? Ann Int Med 18 Morse D. Tuberculosis. In: Brothwell D, Sandison A T, eds. 1992; 116: 937–941. Diseases in antiquity. A survey of the diseases, injuries and sur- 3 Bates J H, Stead W W. The history of tuberculosis as a global gery of early populations. Springfield, IL; Charles C Thomas, epidemic. Med Clinics N Amer 1993; 77: 1205–1217. 1967: 249–271. 4 Stead W W, Eisenach K D, Cave M D, et al. When did Myco- 19 Cook A R. Uganda memories (1897–1940). Kampala, bacterium tuberculosis infection first occur in the new world? Uganda; The Uganda Society, 1945. An important question with public health implications. Am J 20 Borrel A. Pneumonie et tuberculose ches les troupes noires. Respir Crit Care Med 1995; 151: 1267–1268. Ann Inst Pasteur 1920; 34: 105–148. 5 Foster W D. Doctor Albert Cook and the early days of the 21 Calmette A. Enquête sur l’épidémiologie de la tuberculose dans Church Missionary Society’s medical mission to Uganda. Med- les colonies françaises. Ann Inst Pasteur 1912; 26: 497–514. ical History 1968; 12: 325–343. 22 Styblo K. The relationship between the risk of tuberculous in- 6 Billington W R. Albert Cook 1870–1951: Uganda pioneer. Brit fection and the risk of developing infectious tuberculosis. Bull Med J 1970; 4: 738–740. Int Union Tuberc 1985; 60 (3–4): 117–119. 7 Cook A R. Notes on the diseases met with in Uganda, Central 23 Carlson D G. African fever. A study of British science, technol- Africa. J Trop Med 1901; 4: 175–178. ogy, and politics in West Africa, 1787–1864. Canton, MA; Sci- 8 Cummins S L. “Virgin soil” -and after. A working conception ence History Publications, 1984: 5–10. of tuberculosis in children, adolescents, and aborigines. Brit 24 Curtin P D. African health at home and abroad. In: Kiple K F, Med J 1929; 2: 39–41. ed. The African exchange. Toward a biological history of 9 Bohannan P. Africa and Africans. Garden City, NY; The Natu- black people. Durham, NC; Duke University Press, 1987: ral History Press, 1964: 88–89. 110–139. 10 Miller C. The lunatic express. Nairobi, Kenya; Westland Sun- 25 Bellamy R, Ruwende C, Corrah T, McAdam K P W J, Whittle dries, 1971: 13–28. H C, Hill A V S. Variations in the Nramp1 gene and suscepti- 11 Ziemann H. Zur pathogenese, diagnose und prophylaxe der bility to tuberculosis in West Africans. New Engl J Med 1998; tuberkulose in den tropen. Centralbl f Bakt Abt 1913; 70: 118– 338: 640–644. 141. 26 Millar J G. On the spread and prevention of tuberculous dis- 12 Cummins S L. Tuberculosis in primitive tribes and its bearing ease in Pandoland South Africa. Brit Med J 1908; 1: 380–382. on the tuberculosis of civilized communities. Int J Public 27 Packard R M. White plague, black labor. Tuberculosis and the Health 1920; 1: 137–171. political economy of health and disease in South Africa. Berke- 13 Budd W. The nature and the mode of propagation of phthisis. ley, CA; University of California Press, 1989: 22–32. Lancet 1867; 2: 451–452. 28 Livingstone D. Missionary travels and researches in South Af- 14 Foster W D. The early history of scientific medicine in Uganda. rica including a sketch of sixteen year’s residence in the interior Kampala, Uganda; East Africa Literature Bureau, 1970: 4–7. of Africa. New York; Harper Brothers Publishers, 1858: 141.

RÉSUMÉ

CADRE : L’Hôpital Mengo, actuellement Kampala, en ont été observés par Cook dès 1897. Au total, au moins Ouganda, il y a 100 ans. 93 cas de tuberculose ont été inclus parmi 26 806 entrées OBJECTIF : Déterminer la présence de tuberculose dans à l’Hôpital Mengo entre 1897 et 1916. L’on n’a pas la population Bagandan de l’Afrique Centrale de l’Est, observé de tendance évolutive dans la prévalence de la ainsi qu’ailleurs en Afrique, à l’époque des premières tuberculose parmi les patients hospitalisés. Une revue de explorations par les européens. la littérature antérieure concernant la tuberculose en SCHÉMA : L’on a revu, en vue de mettre en évidence la Afrique pré-coloniale suggère que cette maladie peut tuberculose chez les Bagandan, les observations cli- avoir été présente dans diverses régions avant l’explora- niques faites par Albert Cook pendant 2 décennies débu- tion par les européens, mais qu’elle était probablement tant en 1897, soit 35 ans après la première visite de absente ailleurs. Speke à cette région. L’on a revu les écrits d’autres obser- CONCLUSIONS : La conception que toute l’Afrique et vateurs médicaux contemporains concernant l’existence que tous les peuples d’Afrique étaient un terrain vierge de la tuberculose dans l’Afrique pré-coloniale ou au pour la tuberculose, est enracinée dans une vue eurocen- début de l’Afrique coloniale. trique et archaïque de l’Afrique, et ne peut pas être main- RÉSULTATS : Des cas bien documentés de tuberculose tenue aujourd’hui sur la base des données disponibles.

RESUMEN

MARCO DE REFERENCIA : Hospital Mengo, en la actua- resto de Africa en la época de la primeras exploraciones lidad Kampala, Uganda, hace 100 años. de los europeos. OBJETIVO : Determinar la presencia de tuberculosis en METODO : Se han revisado las publicaciones de Albert la población Bagandan, en el Este de Africa central y en el Cook durante dos décadas a partir de 1897, a los 35 790 The International Journal of Tuberculosis and Lung Disease años de la primera visita a esta región por parte de secular en la prevalencia de la tuberculosis en los Speke, para poner en evidencia la existencia de tuber- pacientes hospitalizados. La revisión de la literatura culosis entre los Bagandans. También se revisaron los relacionada con la tuberculosis en Africa precolonial escritos de otros observadores médicos para demostrar sugiere que ella estaba presente en varios regiones antes la existencia de tuberculosis antes y al comienzo del de la exploración europea, pero no estaba diseminada. período colonial en Africa. CONCLUSIONES : El concepto de que toda la población RESULTADOS : Cook observó casos bien documentados de Africa era virgen de tuberculosis está arraigado en de tuberculosis en 1897. Se describieron por lo menos 93 base a un concepto eurocéntrico arcaico de lo que casos de tuberculosis en 26 806 ingresos al Hospital pasaba en Africa y no está apoyado por los conocimien- Mengo entre 1897 y 1916. No se observó una tendencia tos actuales.