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Comments on Report by War Office Officials and background correspondence
Confidential
REPORT ON MEDICAL AND SANITARY MATTERS IN BRITISH EAST AFRICA 1917 and 1918
Itinerary
1. We landed at Mombasa on 6 December 1917 and proceeded the same day up country arriving at Nairobi on 7 December.
2. After an inspection of all Hospitals, Camps, etc,, including the sanitation of Nairobi itself, we went on to Kisumu on the Victoria Nyanza and crossed to Entebbe where we had interviews with the Acting Governor (Mr Wallis), and proceeded early next morning to Bombo, the 4 King’s African Rifles Depot, returning via Kampala to the steamer and crossing the Lake to Kisumu via Jinja.
3. From Kisumu we went to Kericho and on to Nakuru to inspect the new Convalescent Camp there, afterwards proceeding to Naivasha and Nairobi.
4. From Nairobi we went to Tanga via Voi and after inspecting these places left for Mombasa where the tour of British East Africa ended.
Remarks
5. As British East Africa is not a war area there is nothing to be said as to evacuation, roads, etc.
The elevated tableland in the interior is quite cool and healthy, and is infinitely preferable to any part of German East Africa as a health resort, but on the coast, at Tanga and Mombasa, the climate is practically similar to that of Dar-es-Salaam, Kilwa and Lindi. Kisumu on Victoria Nyanza is hot, moist and malarious.
6. The graph in the Report on German East Africa showing medical administration applies to British East Africa.
The Hospitals as a rule are, naturally, better built and equipped as, with the exception of the Voi-Tanga line, they have never been in the War area.
7. Inspections in detail, with a few exceptions, were entirely satisfactory and we will only refer to places where we found things unsatisfactory.
8. The sanitation of the line to Nairobi, and that of Nairobi itself, was very unsatisfactory and a full report is attached. (Appendix 1).
The Acting Governor (Mr CC Bowring, CMG) is anxious to improve the condition of Nairobi but states he has no funds. There does not appear to be much taxation, and the sanitary organisation is chaotic.
9. His Excellency had a conference with the heads of the Municipality and Sanitary Department, while we were at Government House, and asked us to attend and advise on sanitary matters; this we did, but practically all suggestions were met with the ‘no funds’ reply.
The site of the greater part of Nairobi is an extremely bad one, but much could be done to improve it if funds, which it would appear could be obtainable with efficient taxation, were provided for the purpose.
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10. At present Nairobi town is a standing menace to the health of any large bodies of troops in it, or its vicinity. Plague appears to be endemic there, and any epidemic disease would probably spread rapidly in the insanitary and crowded native houses, where every owner seems to have the right, and uses it freely, of fouling his own premises.
11. On 17 December we inspected the Depot, 4 King’s African Rifles, at Bombo, Uganda, with Major Carew the Officer Commanding and Captain HL Duke, Uganda Medical Service, the Medical Officer in charge. The huts etc, were clean and the latrines fair. A somewhat elaborate smoke latrine system was in use but the pits were improperly dug so that faeces and urine were deposited on the sides a few inches below the seat, and this of course rendered them useless in preventing access of flies to the excreta; we pointed this out to Captain HL Duke.
12. We next visited the hospital, which was being run by a Sub-Assistant Surgeon, Captain Duke not professing to know anything about the cases.
We visited the infectious section of the hospital of which Captain Duke stated he was in charge. Here we found a most disgraceful state of affairs. Patients dead, dying and sick, were lying together, no proper treatment was being carried out for the cerebro-spinal fever cases, no disinfectants were seen for the attendants or the Medical Officer who, however, admitted he had never visited these cases since he took over a week before. There were five cases of cerebro-spinal fever distributed as follows in four small ill-lit circular grass huts – No 1 A corpse and a delirious patient (naked); No 2 A corpse and a delirious patient (naked); No 3 A patient; No 4 was empty. There had been nine cerebro-spina fever cases; six were dead,
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two apparently dying, one might possibly recover.
13. In the small-pox enclosure there were fifteen cases, three lying dead, two of these with other patients lying beside them and one in a hut alone; there was no sign whatever of any treatment for patients or disinfectants for attendants. Captain Duke said he went there to superintend the building of the compound wall daily, and then saw the patients.
14. We called in the Officer Commanding, Major Carew, who we had asked to remain outside to avoid infection, and showed him the state of things in the cerebro-spinal fever compound. Thereafter we each prepared a Report (Appendix 2) and handed it to the Officer Commanding for action. Owing to the gross neglect and inhumane want of treatment of these patients by Captain Duke, we placed him under open arrest, as there was no other Medical Officer available, in which case we should have suspended him entirely. Later in the evening, finding that it would probably take at least three weeks to enquire into the case, or try Captain Duke, we directed the Assistant Director of Medical Services to go to Bombo and release him without prejudice to further re-arrest or trial. Captain Duke is totally unfit to have charge of patients. There had been nine cases of cerebro-spinal fever, six were dead, two were dying, and there was one which might recover; of twenty-five small-pox cases, thirteen had died and twelve were under treatment. These are excessive death rates for both of these diseases, due, in our opinion, to want of proper and humane treatment by Captain HL Duke. Lumbar puncture had not been done in any of the cerebro-spinal fever ases.
15. 2 January 1918. Inspected Kijabe Sanatorium for [Page 5] fourteen Officers and twenty-five men. Run by Miss V Donkin, East African Nursing Services.
This place has been much neglected by Lieutenant Colonel AL Scott, Royal Army Medical Corps, the Officer Commanding No 3 British General Hospital, who was placed in charge of it for administrative purposes in January 1916, vide Appendix 3, and has never since visited it.
He has left it to be entirely managed by Miss Donkin (without even an orderly or nursing orderly of any sort since August) and this was only put right five days ago by the Assistant Director of Medical Services, who after a visit at Christmas, sent two orderlies temporarily, one for ward and compounder work, and one for sanitation.
No instructions on the routine treatment of malaria (from which the majority of the patients suffer had been sent to Miss Donkin, whose treatment was, in consequence, not up to date and ineffective.
Lieutenant-Colonel Scott apparently took no interest whatever in Kijabe, and we consider it was shamefully neglected by him. We regret that we also consider the Assistant Director of Medical Services to blame in not having ascertained that Lieutenant-Colonel Scott never went there, and in not ordering him to inspect regularly.
16. On 5 January we inspected the King’s African Rifles Depot, Nairobi. Officer Commanding – Major Davis.
This is not on a good site, being too near the town and the subject has been brought before the Military authorities frequently during the War, vide Appendix 4.
17. With reference to Medical administration in British East Africa, we think the Assistant Director of Medical [Page 6] Services should have power to approve the proceedings of Medical Boards in Nairobi, instead of having to forward them to Dar-es-Salaam for approval by the Director of Medical Services, which entails a certain three weeks or month’s delay. He should also be in charge of Uganda and the King’s African Rifles as well as British East Africa. The present arrangement does not work at all well.
18. 8 January 1918. At our inspection of the Carrier Hospital, Voi, we noticed that the Medical Officer, supposed to do the microscopic work, did not seem to know much about it, and suggested to the Assistant Director of Medical Services that he, and others like him, should be sent for instruction to the Laboratory at Dar-es-Salaam, when they could be spared. This was done at once, a wire being sent to the Deputy Director of Medical Services asking when the Officer at Voi might go.
19. We also inspected the sanitary condition of Mombasa and a report will be found in Appendix 5.
20. The attached statistical tables (Appendix 6) furnished by Captain Shircore, East African Medical Service, Officer Commanding Native Base Hospital, Mombasa, merit careful attention because:-
1. they form a continuous statistical record for three consecutive years.
2. They afford useful information especially as regards the hospital death rate from backwater fever and cerebro-spinal fever.
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3. They furnish an interesting and useful comparison between the results obtained, not only amongst the various classes of ‘native’ troops treated in the hospital, but between them and the carriers, and also between the ‘native’ military and the civil population of British East Africa which latter in certain respects corresponds fairly closely, as regards racial composition, to our so-called ‘native’ troops (Asiatics and Africans) and the Carrier Corps.
5. They are probably on the whole very fairly reliable though it is true that all the malarial cases were not diagnosed by microscopic examination. Care, however, was taken to exclude helminthic infections which are so apt to simulate malaria in natives.
21. Although the East African Medical Service had started chlorination of water in British East Africa, vide ‘Instructions regarding the Sanitation of Camps and the Treatment of Water for drinking’ dated 11 August 1914, the Director of Medical Services on 31 October 1914, in telegram No 617 to Senior Medical Officer, Mombasa, and Officer Commanding Carrier Corps, Mombasa, stated that he was unable to supply any equipment for sterilizing water, vide Appendix 7.
This we consider was a very necessary procedure and we cannot understand the attitude which the Director of Medical Services adopted on this occasion.
22. At Nairobi an effort was made being made to provide a suitable emergency ration for the King’s African Rifles. In this work Lady Colvile [sic] took a prominent and useful part. After several trials a form of biscuit had been produced consisting of mealie meal, beans, ground nuts and salt, which, in addition to being satisfactory from a physiological standpoint, was palatable and easy of transport. We suggested that it might be well to allow the beans to germinate before crushing them, in order to include an anti-scorbutic element which we do not think would be destroyed by the temperature during baking.
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Reports should be rendered by the Assistant Director of Medical Services, King’s African Rifles, on the value of these biscuits as an emergency ration.
Additional Suggestions
23. Although pamphlets by the War Office and Major Christy for general distribution were available, we could find no evidence that these were issued regularly or under any fixed method.
The majority of white soldiers, other than those who had served in India, knew nothing of how to preserve their health in a tropical country. Many of them stated 1) They had heard no lectures on the way to East Africa, 2) They were given no quinine either on board ship before landing or on land for several days, 3) They were without mosquito nets for several nights after landing at Dar-es-Salaam. This last statement we can hardly credit, but it has been made.
We would suggest the following:-
1. That all troops be given lectures on the preservation of their health in the tropics while on board ship prior to landing, and a certificate to say that these lectures have been given be handed to the Embarkation Medical Officer at the port of disembarkation.
2. That prophylactic doses of quinine be given two days before arrival and continued regularly after disembarkation.
3. That all disembarkations take place in the morning, when at all possible, so as to allow the men to obtain and fix up their mosquito nets in time before sunset.
4. That all mosquito nets have an 18 inch calico band round the tuck-in border, so that should a man touch the net while asleep he cannot be bitten through it.
5. That the pamphlets above mentioned be distributed to each man at the first lecture on board ship, and be retained by him while on service.
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6. That at Dar-es-Salaam, and other very malarious spots, special medical officers should be appointed for the sole purpose of supervising prophylactic distribution of quinine and inspecting malaria nets. It is of the utmost importance that these officers become familiar with their duties before the advent of the rains and hence there should be no delay in selecting and appointing them.
24. The convalescent camp at Nakuru us well placed and well laid out. The only point in connection with it to which allusion need be made is the possible effect of the altitude (5,950 feet) on debilitated patients suffering from dilated heart or tachycardia. If the altitude is found deleterious in such cases care will have ot be taken not to send them to Nakuru. It is probable that they would do better at the Cape or elsewhere.
25. Watering of ships at Mombasa, see Appendix 8.
WW Pike
Surgeon General
Army Medical Service
Andrew Balfour
Lieutenant-Colonel,
Royal Army Medical Corps
Mombasa, 20 January 1918.