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During the early 1900s, African populations in South Africa were subject to very widespread infections which especially affected the young. This resulted in high mortality rates and a low life expectancy of 20-25 years. By the mid-century, mortality rates from infections had decreased considerably. Moreover, the occurrences of non-communicable diseases, even in urban areas, remained very low. In the 1970s, the proportion of Africans aged 50 or over that reached 70 years was 38.5%, higher than that in the juxtaposed white population, which was 35.5%. And by 1985, the life expectancy of Africans reached 61 years for males and 63 years for females, probably the highest in sub-Saharan African populations. Since then, however, the African continent has been devastated by the AIDS epidemic. In 2001, HIV was responsible for the death of a third of the African population in South Africa, but even higher proportions prevailed in Botswana and in Tanzania. The calamitous advent of the HIV infection has caused major falls in life expectancy, in the case of Africans in South Africa reducing this to just 43 years. With little hope of meaningful changes occurring in sexual habits or of an early vaccine becoming available, the infection's high morbidity/mortality burden is likely to continue.

In South Africa, a study has been carried out on a series of African patients with lung cancer, who were admitted in 1994-1999 to King Edward VIII Hospital (2000 beds), and who lived in Durban (population includes approximately 650 000 resident Africans). In the urban context, Africans have recently experienced numerous changes in environmental, socio-economic and dietary factors and in other respects, thereby undergoing considerable westernization of lifestyle, compared with the past and the situation still prevailing among Africans in rural areas. In the period indicated, the mean annual number of patients admitted with lung cancer included 56 men and 9 women, thereby yielding standardized incidence rates of 15.5 and 3.5, respectively, per 100 000. While such data have their limitations, it is noteworthy that in the South African Cancer Registry for 1993-1995 the corresponding rates (pathology based) for African men and women for the whole country, rural and urban, were 11.7 and 2.6, respectively, per 100 000. In comparison, in the Registry the corresponding rates reported for white South African men and women were 22.3 and 12.3 per 100 000. With the ongoing transitional changes prevailing, most particularly concerning rises in smoking among adolescents, there is little chance of controlling further rises in the occurrence of the disease. It is significant that in the US, African Americans have been reported to have the highest rate for lung cancer in the world.

Black African women in rural South Africa have a very low incidence rate of breast cancer, 5-10 per 100,000. The rate, however, is rising in the considerably increasing urban population. During the period 1994 to 1999 in Durban, enquiries revealed an average of 57 urban patients admitted to hospital each year, from a population of about 600,000 African women, indicating an age-adjusted annual incidence rate of 15.1 per 100,000. This incidence rate is very low in comparison with those in developed populations, which range from 40 to 89 per 100,000. In the African patients studied, the mean age on admission was relatively young, 54.1 +/- 10.9 years, almost a decade earlier than patients of developed populations. Moreover, the disease was very far advanced; 21.1% were at Stage III and 63.1% at Stage IV. As to exposure to risk factors, African women in general are characterised by certain protective factors. These factors, which closely resemble those of importance in patients in developed populations are, late menarche, early age at birth of first child, high parity (with usually prolonged lactation), and being physically active. However, with ongoing changes in the lifestyle of urban African women, the protective factors are decreasing in their intensity. Changes in these respects have been associated with rises in the disease's incidence rate. Clearly, because of the late stage of the disease at the time of the patients' admission to hospital, and hence their poor survival rate, intensive efforts should be made to educate women to seek help at an early stage of their disease. For its avoidance, feasible protective or restraining measures are primarily to adopt a 'prudent' lifestyle, in respect of both dietary and non-dietary components. However, the chances of these measures being meaningfully adopted in African urban communities, unfortunately, are negligible. In consequence, further increases in incidence rate would seem inevitable.

In South Africa, with changes in environmental factors, varyingly, there have been measures of westernization of diet, with slight rises in intakes of energy and fat, with more of animal, but less of plant foods, being eaten, and with a fall in dietary fibre intake. Smoking practice has increased, particularly in males, likewise alcohol consumption. Physical activity has fallen, especially in urban dwellers. Changes in cancer incidence rates, as reported in the South African Cancer Registry for the periods 1986 and 1993-1995 have been investigated. Additionally, changes in percentages of cancers in hospitals in Johannesburg during 1953-1955 and in Durban during 1994-1996, have been looked into. The high occurrences of oesophageal and cervix cancers have fallen slightly, although more so in respect of liver cancer. But there have been rises, widely varying, in the cases of cancers of the lung, prostate and breast. While some of these changes would be expected from the changes in environmental factors, many cancer occurrence situations remain problematical, e.g. the continuing low occurrence of colorectal cancer. Recently, the rapidly rising epidemic of HIV/AIDS has slightly increased the occurrence of certain cancers, particularly Kaposi's sarcoma and non-Hodgkin's lymphoma. Regarding prevention, chances of cancer control in Africans, through lessening personal risk factors, are very remote, which unfortunately also prevails in large measure in western populations, regarding their reluctance to make the recommended beneficial changes.

An enquiry has been made on a series of African patients with colorectal cancer who were admitted in 1995-1999 to Chris Hani Baragwanath Hospital (3200 beds), and who lived in Soweto (population about 1 million), Johannesburg, South Africa. In the urban context described, Africans have considerably more advantages, socio-economically, dietarily and in other respects, than their rural counterparts. The 126 patients comprised 58 males and 68 females, giving calculated incidence rates in their communities for colorectal cancer of 1.7 and 2.0, respectively, per 100,000 'world' population. In contrast, as indicated in the South African Cancer Registry for 1993-1995, the corresponding rates for white males and females were 24.7 and 19.3, respectively, per 100,000. The proportion of African patients under 40 years was 19.0%; but was only 4.0% in the white population. In contrast to this major disparity, there was only a minor interethnic disparity regarding cancers that are very common in Africans, namely, those of the oesophagus and lung. Hence, with ongoing transitional changes - in diet and other respects - the relatively high proportion of younger African patients probably indicates a rising occurrence of colorectal cancer in the urban African population.

The present population in South Africa, roughly 43 million inhabitants, is made up of Africans (77.2%), whites (10.5%), Coloureds (mixed race) (8.8%) and Indians (2.5%). In 1900 the infant mortality rate (IMR) among Africans was 330 per 1,000 live births; this has now fallen to 50-60. In Soweto, a primarily African city, IMR averages 20-25. Life expectancy in the past was only 25-30 years; by 1995, this reached 63 years. However, this could fall again due to the rapidly spreading HIV/AIDS epidemic. Life expectancy could fall to 40-45 years by 2010 with the AIDS epidemic being the cause of half of all deaths--a disastrous change from the previous relatively commendable public health situation. Formerly, the most common causes of deaths in young people were infections, diseases associated with malnutrition and gastroenteritis. Adults died almost solely from infections, including typhoid, dysentery, malaria and tuberculosis (TB). Even though diseases associated with malnutrition are less common today, many infections still remain a major problem, particularly TB, which is increasing. As late as 1970, Africans who reached 50 years had longer life expectancy than whites due to the low prevalences of the chronic diseases of lifestyle. This is no longer so, due to the recent rises in non-communicable disorders/diseases, principally obesity in women, hypertension, diabetes, stroke and the cancers of prosperity. In the not so distant future, the level of control of HIV/AIDS related diseases will be the major health/disease regulating factor among Africans. Among white, Coloured and Indian populations, there have been falls in the mortality rates of the young and, despite rises in lifestyle diseases, increases in life expectancy are continuing. For all populations other important public health regulatory factors include water supply, sanitation, clinic/hospital services and personal environmental factors, employment, dietary pattern and intake, smoking practices and alcohol consumption and physical activity, particularly in urban dwellers. Unfortunately, public health expenditure, also a highly regulating factor, has fallen from 8.2% of the gross domestic product in 1994 to 4.1% in 2000.

Background and Purpose: Stroke patients in western countries frequently have coronary artery disease (CAD). In black Africans, CAD has been reported as being rare in both stroke patients and the general population. In this study, an attempt has been made to determine the prevalence of CAD in a black South African stroke population., Methods: The prevalence of CAD was determined by indicators identified through a series of 5 observational studies in black patients diagnosed with stroke. CAD indicators included (1) bedside diagnosis in 741 patients; (2) resting ECG in 555 consecutively admitted patients; (3) a combination of clinical examination, cardiac ultrasound, radionuclide scintigraphy, and multigated blood pool studies in 102 consecutively admitted patients; (4) thallium scintigraphy in 60 patients; and (5) necropsy in 23 patients., Results: On bedside questioning, only 0.7% complained of previous angina. There was no history given of myocardial infarction (MI), but documentation of this was found in the clinical notes of 0.7% of the patients. In the resting ECG study, evidence of myocardial ischemia was present in 14.6% and MI in 2.1%. In the combined study, cardiac ischemia was documented on ECG in 12.7% of patients and evidence of previous MI in 5.8%. Cardiac scintigraphic studies revealed changes of myocardial ischemia in 31.7% and MI in 13.3% of the 60 patients studied. Four (17.4%) of 23 patients in the necropsy study had histological evidence of previous MI, and 50% of all patients had evidence of >50% atherosclerotic stenosis in 1, 2, or 3 coronary arteries., Conclusions: The prevalence of CAD in black African stroke patients is significantly higher than has been documented in the general nonstroke black population as well as in stroke patients. Black stroke patients may have a risk for CAD similar to that of their white counterparts.

Background: Evidence from studies involving small samples of children in Africa, India and South America suggests a higher dental caries rate in malnourished children. A comparison was done to evaluate wasting and stunting and their association with dental caries in four samples of South African children., Design: Cross-sectional study based on random sampling of birth records of two age bands., Methods: A total of 2,728 4- and 5-year-old South African children from one rural community and three urban communities were examined for nutritional status and dental caries., Results: In the total sample prevalences of wasting were mild (28%), moderate (4%) and severe (2%). For stunting the prevalences were mild (13%), moderate (3%) and severe (1%). For both conditions rural children showed higher proportions than the other groups. Statistical analysis showed statistically significant differences for wasting and stunting between the study groups. No significant association was found between the prevalence of caries and stunting or wasting, but an association was noted between wasting and decayed, missing and filled (dmf) surfaces (P = 0.003)., Conclusions: In the series of children studied, nutritional status was not found to be clinically relevant to dental caries prevalence and experience.

In emigrants from less to more developed countries, consequent changes in environmental factors are associated, inter alia, with changes in occurrences of the chronic diseases of lifestyle. In South Africa, most immigrants from India arrived in the early 1900s. To learn of the current pattern of cancer in the descendants of these people, enquiries were made on several series of patients admitted to RK Khan Hospital in Durban. The results were then compared with those of patients admitted to Ambojogai Hospital, North West India, the ancestral home of the majority of South African Indians. The most prominent differences were the lower percentages in South African Indians in respect of cancers of the mouth/pharynx in both sexes and of cervical cancer, and their considerably higher percentages, principally in the cases of stomach cancer in both sexes, of prostate cancer in males and of breast cancer in females. Discussion of risk factors indicates that in such populations there could be some control over the rises in some cancers, and on reductions in others. However, endeavours at prevention are hindered not only by the lack of knowledge prevailing, but also by their general indifference; likewise, this is the case with western populations.

The objective was to collect information from African and white pupils aged 15-16 years on their knowledge of and attitudes towards cancer, and their understanding of health-related behaviours in relation to their future experience. Questionnaires were completed by a series of 338 African and 378 white pupils in suburban secondary schools. African and white pupils knew most about lung cancer, and had some knowledge of skin and breast cancers. Smoking was seen by most as the chief cause of the disease. Half of both groups perceived a high intake of vegetables and fruit as protective. Television and printed media were the most important sources of information. The children in both groups were more anxious about unemployment and violence, and also, among African children, about AIDS, than about future ill-health. Thus, health was not perceived by many as the most important goal in life. Discussion indicates that white adolescents and also white adults, with more advanced understanding of cancer causation, make very limited use of their knowledge, dietary and non-dietary, to avoid the disease. In brief, level of cancer knowledge has very limited implications. Although young Africans in the course of their transition are very unlikely to seek to diminish their risk of cancer, there must be no lessening of urgent warnings and advice through the media on the avoidance of the disease.

Objectives: To determine the causes of death at Manguzi Hospital, in rural North Kwa-Zulu, over a three year period, July 1992 to June 1995., Design: A retrospective study using hospital records., Setting: Rural hospital., Subjects: Of admissions, total deaths numbered 1,275 (703 males, 572 females), of which 143 were from accidents and trauma., Main Outcome Measures: Deaths., Results: Of children under five years there were 430 deaths (34% of the total); 236 (55%) were from perinatal causes. Infections, chiefly gastro-enteritis, caused 124 (29%) of deaths. Of children five to 12 years, there were 39 deaths (3% of the total); 12 (44%) died from infections. Of adolescents and adults aged 13 to 59 years, there were 377 deaths (29% of the total); of these, accidents and trauma caused 88 (23%), and infectious diseases 82 (22%). In the elderly, 60 years and over, there were 429 deaths (34% of the total); infectious diseases predominated, 103 (24%). In this age group, there were 71 deaths (17%) from cerebrovascular disease; 63 (15%) from cardiac failure; 46 (11%) from cancer, but none from coronary heart disease. Of the 143 non-natural deaths, 30 (21%) were from assault, and 28 (20%) from motor vehicle and pedestrian accidents., Conclusion: The high proportion of deaths from infections, as likewise reported from other rural hospitals, emphasizes the need for increased public health endeavours for furthering immunizations, health education, provision of water and sanitation, and tuberculosis control programmes.

In all Third World populations, among preschool and schoolchildren, low weight- and height-for-age, i.e. below the 5th centile of US NCHS reference standards, are common, affecting 10-50%. Orthodoxly, shortfalls are attributed largely to insufficiency of food. In an attempt to throw more light on the situation regarding African schoolchildren, studies have been made on series of pupils, aged 10-12 years, at three rural schools in North West Province, South Africa. Of 396 pupils, 126 (31.8%) were below, and 270 (68.2%) above the 5th centile. Enquiries were made on each pupil's diet and meal pattern, their class position and games aptitude, and, regarding home characteristics, their family size, Parent(s) working, and the latter's interest in education. With minor exceptions, no significant differences in odds ratios were found between respective groups below and above the 5th centile. Evidently, there are multiple influencing factors. Hence, among children of school-age, there must be caution against overblaming undernutrition, and of overrating the health disadvantages from mild to moderate malnutrition. For definition clarification, long-term observations are necessary.

While coronary heart disease (CHD) is responsible for about a quarter of deaths in South African white, coloured and Indian populations, the rate is very low in the black population. Dietary risk factors for CHD include high intakes of saturated fatty acids and cholesterol, with low intakes of mono and polyunsaturated fatty acids. In a characterization study, plasma fatty acid profiles have been determined in seven groups of high school pupils aged 16-18 years, namely, white, rural black, urban black and middle-class and lower socio-economic class coloureds and Indians. Plasma fatty acids were measured by gas liquid chromatography in 20 subjects from each group. Contrary to expectation, urban and rural black pupils had the highest mean molar composition of saturated fatty acids, largely myristic (14:0) and palmitic (16:0) acids. Rural blacks and middle-class coloureds had the highest molar percentage composition of monounsaturated fatty acids, primarily oleic acid (18:1). Again unexpectedly, white, coloured and Indian groups had the highest level of polyunsaturated fatty acids, due entirely to linoleic acid (18:2). As the findings are unrelated to proneness to CHD mortality in the particular communities studied, plasma fatty acid levels are not predictive of the disease. Epidemiologically, there are many examples of lack of correlation in serum lipid levels and proneness to CHD.

An enquiry has been made into the causes of admission in 1994 of African patients to Gelukspan Hospital, North West Province, South Africa. The study concerned 3791 patients of whom 3533 (93.2%) were classifiable. Two groups were not included in this number, namely, 1584 'lodgers' (e.g. mothers of infants), and 1868 females admitted for normal pregnancy. Of the 3533 patients, 940 (26.6%) were aged 14 years and younger; 545 (58.0%) these were boys and 395 (42.0%) were girls. The main causes of their admission were pneumonia, gastroenteritis, trauma, poisoning, and infections. Of the 2593 adults, 1418 (54.7%) were males and 1175 (45.3%) females. Among males, chief causes were pulmonary tuberculosis, trauma and accidents, congestive cardiac failure, psychosis, cancer and diabetes. Of the females, chief causes were pulmonary tuberculosis, trauma and accidents, pregnancy related disorders, gastroenteritis, anaemia and pneumonia. Regarding other diseases, 4.5% of adults were admitted for cancer, and 1.8% for diabetes. The general pattern of admissions is similar to that reported in other rural hospitals. The causes of admissions are discussed, regarding; (i) public health improvements occurring, and (ii) means of promoting further improvements by community self-help, and by help from State health and other services.

Protein energy malnutrition (PEM) is a major cause of hospital admissions and death in most impoverished Third World countries. In the Gelukspan Health Ward, in rural Western Transvaal, a primary health care (PHC) programme, based on the GOBI-FFF strategy, commenced in 1980. Community health surveys on African under-five children were regularly undertaken. In 1990, to assess improvements achieved, anthropometric and other data were obtained on a representative series of 926 children. Harvard standards were used prior to 1984, and American NCHS reference standards thereafter. Low weight-for-age fell from 28 to 19%, low height for age from 33 to 17%, and low weight-for-height from 5 to 1%. The percentage with low arm circumference was unaffected, 3 and 4%, respectively. The improvements described are believed to be due in part to the PHC programme. Greater definition of the causes and extent of improvements are needed to optimize the State's present desire to intensify PHC, especially in rural areas.

Unlabelled: Diminished levels for fecal short chain fatty acids (SCFAs) have been linked to occurrence of ulcerative colitis, colorectal polyps, and colon cancer, diseases that are rare or uncommon in African populations., Purpose: The aim of this study was to determine fecal SCFA concentrations and fecal pH values in groups of black South Africans (African) and white South Africans (white) subjects., Methods: Twenty healthy Africans (all women; mean age, 35 years) and 17 healthy whites (7 women; 10 men; mean age, 32 years) were tested., Results: Mean total concentrations of SCFAs in the two groups were 142.1 (+/- 53.9) and 69.2 (+/- 26.0) mmol/kg wet feces, respectively (P = 0.0001). Mean values for Africans were significantly higher in all subfractions except butyrate. There was a significant inverse correlation between fecal pH value and total fecal SCFA concentration (r = 0.704; P = 0.001)., Conclusion: High concentrations of fecal SCFAs in the African group could protect against chronic bowel diseases.

An analysis has been made of causes of admission of black patients in 1991 to Murchison Hospital, Port Shepstone, Natal. Of 6675 total admissions, 6329 (95%) were classifiable. Of the latter, 1462 (23%) were aged 12 years and-younger, namely, 763 boys and 699 girls. Their chief causes of admission were pneumonia, gastroenteritis, trauma, acute glomerular nephritis, and malnutritional diseases. Of 4867 adults (73%), 1536 were males and 3331 females. Among men, chief causes were tuberculosis, congestive cardiac failure, hypertension and cerebral vascular accidents. Among women, apart from pregnancy, chief causes of admission were disorders of pregnancy, tuberculosis, congestive cardiac failure, pneumonia, diabetes, and hypertension. Of western diseases, 3.9% of adults were admitted for diabetes, and 2.8% for asthma. The general pattern of admissions is similar to that in other rural hospitals. The causes of admissions are discussed, regarding (1) public health improvements occurring, and (2) means of promoting further improvements by (a) community self-help, and (b) help from State health and other services.

Colon cancer was rare or uncommon in the past, and still is in traditionally-living third world populations. It now affects 3-5% of western populations. Epidemiological, case control, experimental and other studies suggest that proneness to colon cancer can be lessened by major dietary changes, principally decreasing fat intake by a third, and doubling the intake of fiber-containing foods, especially vegetables and fruit--recommendations similarly advocated for the avoidance of coronary heart disease and other degenerative diseases. Among nondietary factors, evidence indicates familiality, obesity and atmospheric pollution to be contributory, while parity, physical activity, solar radiation, high social class, estrogen use, and aspirin use, appear protective. Despite insufficiencies of knowledge of prevention, avoiding action should certainly be taken by those familially prone. For the rest, conceivably a prudent life-style could benefit a proportion avoiding colon cancer.

Ischaemic heart disease (IHD) in prosperous Western populations rose markedly in the 1940s, peaked between 1970 and 1975 and then fell variably--by about 50% in the USA and Australia. Undoubtedly, decreases in serum cholesterol levels, in the incidence of hypertension and in smoking frequencies are largely responsible. In South Africa, in all population groups other than blacks, IHD rates rose analogously, with Asians and whites attaining very high rates. However, from 1978 to 1989, the total death rate among white males (per 100,000 world population) fell from 1,002 to 631 (37%), and the IHD mortality rate from 312 to 139 (56%). Rates for Asians were 1,306-1,130 (14%) and 355-226 (36%), respectively, and for coloureds 1,691 to 1,392 (18%) and 171 to 110 (36%). For blacks, the total mortality rate remained unchanged; IHD rates were low, but these data are unreliable. Percentage falls in the IHD rate exceed those in the total death rate, especially among whites, indicating true decreases in IHD rate. Understandably, the accuracy of the data, as with such data overseas, is questionable. Local falls are none the less in line with those noted in Western countries. Rates for whites remain very high, and are even higher for Asians. While knowledge of the reasons for the rises and falls in IHD rates remains incomplete, whites have none the less taken some preventive action, although Asians and coloureds apparently little.