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This chapter brings the various strands of this study together. Previous studies of the 1970s have tended to emphasize the grimmest aspects of life during this decade, but the evidence suggests that the immediate demographic impact of worsening poverty and instability was rather modest. Moreover, the changes in sexual culture and behaviour seen in the 1970s were to a large extent a continuation of long-established trends, ensuring that patterns which had been initially associated with urban contexts dispersed far into the regions' rural communities. What was new in the 1970s was as much the result of aspiration as desperation. Similarly the onset of fertility decline in central Buganda was driven by an attempt to maintain existing standards of living. Evidence that postponing and stopping as well as spacing behaviour contributed to fertility limitation indicates that this region once again does not fit with widely accepted theories about African demographic change.

This chapter considers the role of long-term changes in patterns of fertility, mortality, and STDs in the emergence and control of HIV in this region. It emphasizes that in order to explain the rapidity with which HIV became a mass epidemic in a largely rural context, it is necessary to examine the long history of changes in marriage, adolescent sexuality, leisure, materialism, and perceptions of risk. Equally, the remarkable success of AIDS control programmes in both southern Uganda and Buhaya can only be understood through an analysis of the series of campaigns aimed at improving public morality beginning in the early twentieth century, which helped legitimize sex as a topic of serious debate. Finally, the chapter also examines in detail the intimate relationship between fertility and mortality in Africa.

This chapter introduces the three case study areas of Ankole, Buganda, and Buhaya, located today in Uganda and Tanzania, and explains the reasoning behind their selection. Most famously, it was within these neighbouring societies that HIV became a rural as well as an urban phenomenon, and also where the mechanisms of one of the world's most successful AIDS control programmes were developed. These societies were also remarkable for their unusual experience of demographic change during the twentieth century. The chapter examines the major theories which have attempted to explain changes in sexual behaviour and attitudes, fertility, and mortality in Africa, and considers the contributions made by this study to these debates. It also discusses the sources and methodology utilised in this book, focusing particularly on the use of oral evidence, family reconstitution, and hospital maternity records.

This chapter challenges assumptions about the universalist traditions of African sexuality, by examining what is known about the sexual behaviour of Ankole, Buganda, and Buhaya before colonial rule. It demonstrates that while some similarities existed, this small geographical region was characterized in regard to sexuality and reproduction more by the diversity of its attitudes and practices in relation to pre-marital sexuality and pregnancy, wife-sharing, legitimate and illegitimate extra-marital sex, ritualized sex, the duration of breastfeeding, and ideal family size. These ethnic differences were shaped by locally distinct patterns of clanship, inheritance, marriage, and moral politics.

This chapter argues that the intensification of long-distance trade from the 1860s increased mortality levels due to famine, heightened conflict, and new epidemic diseases in Buganda and Buhaya much more than in Ankole. The colonial takeover quickly reduced the incidence of war-related deaths, but only in the 1920s did the colonial state begin to exert a degree of control over crisis mortality. Early hospital data and vital registration records indicate that child survival had improved significantly by the early 1920s, due to a rise in birthweight, investment in sanitation, and the cumulative impact of mass inoculation campaigns against major epidemic diseases. By the mid-1920s medical data on cause of death revealed the emerging dominance of endemic diseases, a pattern that would survive, with some variation, until the emergence of AIDS.

This chapter examines why Buganda and Buhaya's population crisis was regarded by European observers as resulting much more from sub-fertility rather than excess mortality. The perception that urbanization, the cash economy, Christianity, and the legal protection of women's rights discouraged the young from marrying and undermined sexual restraint provoked a series of interventions aimed at reforming marriage, gender relations, and sexual behaviour, and so curbing syphilis, the presumed cause of these societies' low birth rates and high miscarriage and stillbirth rates. These reforms though were marked by ambiguity and inconsistency, tending to undermine the institutions that they aimed to support. The chapter also analyses the contrasting experience of Ankole, where the chiefly hierarchy was relatively successful in its attempt to stabilize marriage and maximize fertility.

This chapter details how in colonial Buhaya the scarcity of land suitable for coffee farming enriched elders, delayed young men's establishment of new households, and heightened pressures to secure an heir. Marriage was delayed and destabilized, sexual affairs grew increasingly commodified, and divorcees migrated to East Africa' s cities, where they dominated the region's sex trade, seeking to repay their bridewealth and secure their autonomy. From the 1940s many women who returned from the cities continued to accept money for sex when they resumed village life, trading on their reputation for exotic modernity as well as sexual skill. Meanwhile, many of the broader changes in sexual culture seen in Buganda also affected Buhaya, though the sexuality of young unmarried women remained carefully controlled until near independence. These developments unsurprisingly were the subject of repeated criticism and attempted regulation, but few of the interventions that resulted had a lasting impact.

This chapter reports that the main reasons why fertility rose in Ankole, Buganda and Buhaya were not associated with changing age at first marriage or a growing economic desire for larger families, but rather primarily because of the increased duration of women's reproductive lives. This was partly linked with declining divorce rates in Ankole and Buhaya; Ganda women's increasing willingness to have children outside marriage; and more importantly with a reduction in secondary sterility. A shortening of birth intervals in Buganda from the 1920s, in Ankole from the 1930s and Buhaya from the 1940s, was also significant. The chapter attempts to explain why fertility increase in Ankole occurred decades earlier than in Buganda and Buhaya, yet colonial Ankole was much poorer, less Christianized, and had inferior medical and educational services. This region's exceptionalism is explained mainly by Buganda and Buhaya's marital instability before the 1960s and surprisingly high disease burdens.

This chapter argues that while mortality levels fell at different times for different age groups in the three case study areas, what is most surprising about the pattern of morbidity and mortality in this region is that life expectancy in Ankole seems to have improved as fast as in the other societies. Yet Buganda and Buhaya enjoyed huge advantages in terms of medical and educational provision, and cash income. The case of Ankole emphasizes the significance of livestock, relative equality, preventive medicine, and low levels of malaria in offsetting the demographic effects of cash poverty and peripherality in colonial Africa, while the examples of Buganda and Buhaya illustrate the negative consequences of modernization, especially for child health, due to high levels of divorce, fostering, and bottle-feeding. Evidence from these societies also reveals unexpected outcomes associated with female education, income levels, and discrete medical campaigns.