This is an important book: beautifully researched, carefully argued and rich with insight. It contributes to our knowledge in several domains: the history of health care institutions and population in an important sub-region; the evolving nature of sexuality, fertility and reproduction; and the varying efficacy of health care interventions during the whole of the past century. The subject matter is sufficiently rich and complex that it bears reading and re-reading.

Before HIV: Sexuality, Fertility and Mortality in East Africa, 1900–1980 can be read on several levels. On one level, it is an intervention in a long-standing debate about the reasons for population growth in Africa. One school maintains that fertility had always been high in a region that had a strong cultural preference for reproduction. According to these scholars, population grew from the 1920s onwards as a result of declines in mortality that derived from new wealth, new roads and railways, the availability of western medicine, primary education and maternity care. The opposing school put an emphasis on repressive colonial exactions. The argument on this side is (in part) that demands for labour and taxes exerted economic pressure that resulted in women reducing the period of time that passed between pregnancies. Doyle reaches his own conclusion on all these issues, but his main contribution to the debate is not in supporting one side or the other (although he tends to favour mortality decline) but in escaping from the strictures of these generalisations altogether, and showing that local variations were so great that there is no one answer and that we need analyses that are much more fine-grained.

On a second level, Before HIV demonstrates that many of the usual ways of doing demography, or demographic history, which make arguments at the national level or that of the continent as a whole, cover over extreme local variation in social dynamics and in patterns of fertility and mortality. Doyle uses an approach that Evans-Pritchard, many decades ago, characterised as concomitant variation. In other words, he compares societies that are very much alike in many respects so as to frame a careful analytical argument about the sources of their difference. As the author explains, concerning what he defines as the Nkole, Ganda and Haya ethnic groups of Uganda and Tanzania:

The definitions of ethnic groups are not precise (nor can they be), but in practice the analysis of each grouping is deeply grounded in the data and in carefully identified social phenomena. The argument is made richer by the fact that Doyle published an earlier book about the same issues in yet another of the region’s societies: Bunyoro.Footnote ¹

At this second level Doyle is able to show, for example, that Ankole, which was poor in cash and in medical institutions, experienced rapid population growth much earlier than Buganda or Buhaya, which were both wealthy and well-endowed in education, medicine, missionaries and colonial development efforts.

Then there is a third level, one that draws me in and that I find extremely rewarding. At this level, Doyle gives us careful analyses of the changing texture of lineage and domestic life, sexual relations, marriage, health care institutions and disease in each of the three societies he studies. These local analyses raise important questions and offer significant interpretations on almost every page. They also work powerfully in the spirit of microhistory, or history written at the most local level, which has the power to challenge pre-existing categories of analysis. It does so by presenting what one practitioner called ‘new configurations of the social’.

Let me give an example of this. Jack Caldwell, a distinguished demographer who is accustomed to thinking at the opposite, or macrohistorical, level of scale, argues that ‘African family life has historically centered on the extension and multiplication of the lineage.’ Given the historically high levels of mortality in Africa, and the emphasis on growing the lineage, African societies are strongly pronatalist. There are, in this view, African styles of sexuality with practices that support high birth rates. Doyle shows that the local definitions of reproduction are social ones, with varying significance of fertility in each place, and that social reproduction is not at all the same thing as producing more children. His reconstructions show that people who place a high value on lineage increase can also be sexually austere and that lineage is not the central goal of reproduction in every instance. Beyond this, a key goal was to maintain an appropriate balance between reproduction and property, whether in land, cattle or some other thing. Doyle’s analysis shows that Caldwell’s position, with its tendency to abstract lineage and fertility from a wide and varied web of social relations, does violence to the logic by which people in the three societies have made decisions over time. One qualification I would make here is that, while Doyle pays careful attention to the consequences of kinship dynamics for reproduction, he pays less attention to how they influence intimate care. In this work it is the formal medical system that provides the relevant care, even though so much of the care has been given in household settings.

In general, Doyle sees the preventive and curative medicine introduced by the British as having great power to increase fertility and reduce mortality. For the 1950s in particular, some of the evidence he presents is quite stunning: ‘According to the Mengo and Nsambya mission hospital registers, levels of maternal mortality changed little until the 1950s when they enjoyed a massive and sustained improvement. Maternal mortality per 1000 fell from an average of 45 between 1924 and 1949 to 5 from 1954 to 1969’ (302–3). The improvement was marked, but less dramatic, in other places. Doyle attributes much of the mortality decline to the introduction of penicillin for post-partum infection and transfusions for blood loss. In the period between 1945 and 1970 in particular, all across the region, the spread of antibiotics and antimalarials was part of an injection culture, already in place before the War, that had powerful effects and achieved enormous popularity.

My one reservation about Doyle’s analysis on this count is that he very considerably underplays the damaging effects of a regime in which injections were administered on a massive scale by personnel who were not always well trained and who did not have access to appropriate technologies. William Schneider’s work on the history of transfusions in this region shows that, while the proper screening of blood happened in a few privileged places, thousands of transfusions were administered without screening for pathogens. In his argument, this carelessness was implicated in the early spread of AIDS. In other work, Jacques Pépin, writing about Kinshasa, points to a link between numbers of injections given and the disease’s early spread. Studies in Uganda two decades after the end of Doyle’s period show that the proper sterile administration of injections was more the exception than the rule. Doyle himself notes the rapid increase in resistance to antibiotics as time passed. By ending the book in 1980, Doyle is drawn away from a focus on the longer-term iatrogenic consequences of the medicine that saved so many lives. It was only after 1980 that the worst effects of widely distributed medicine without a full medical infrastructure were felt. At the same time, it is nothing short of churlish on my part to ask for another few decades of history. The assemblage of sources on which this book is based is nothing short of heroic: from national and British archives, to local archives, to hospital records, to parish records, to oral interviews, all of them analysed in very carefully considered ways. The book is based on a huge body of research, which is then analysed with a passion for the truth.

On a smaller point, the author borrows the word ‘modernisation’ from the literature on demography. It is taken to mean any of the identifiable institutions or practices brought by Europeans, such as mission churches, or schools, or roads. The question then is whether exposure to modernity leads to change in fertility, mortality and sexuality. In my own understanding, every change in the structure of laws (as in the end of precolonial methods of settling disputes), or in the rewards and constraints of the economic system, leads to change in the whole texture of daily life. Even something that looks, on the surface, to be traditional, such as a sacrificial rite to an ancestor or another kind of spirit, can be transformed in fundamental ways by these other changes. In the end, its functions and meanings are very different from those of the seemingly identical rite a hundred years earlier. As I understand things, this is now a modern rite, woven into the fabric of life at the time it exists. But then, if everything is modern, the term has no explanatory power.

Large numbers of academics in Uganda and Tanzania work on issues related to the core content of this book. I showed it to two of them, who knew immediately that they needed to have it and to rely on it. The price of the book, at £90, makes it inaccessible to them. I don’t know of plans to make the book more easily available in East Africa, but it is vital that this happen.

In conclusion, Doyle’s analysis is subtle and rich. The body of research on which it is based is monumental. It is a book we can all rely on in moving towards the next stage in studying the problems it addresses.