Decline in the ischaemic heart disease mortality rates of South Africans, 1968-1985

The age-adjusted ischaemic heart disease (IHD) mortality rates (MRs) of white, Asian and coloured South Africans aged 35-74 years were studied for the period 1968-1985. Asians have the highest IHD MR in the RSA, followed by whites, coloureds and then blacks. Asian female have much higher rates than females in the other groups, especially in the older age groups. Asian males have noticeably higher rates in the younger age groups. Coloured females aged 35-44 years have a surprisingly high rate. Declines of 36.5% (from 482 to 306/100,000) for whites between 1970 and 1985, 27.5% (from 583 to 422/100,000) for Asians between 1973 and 1985, and 19.5% (from 287 to 231/100,000) for coloureds between 1976 and 1985 were observed. Rates declined among both males and females as well as in all the age groups studied. Trends in IHD MRs for black South Africans were studied for 1978-1985. The MRs for IHD among blacks are very much lower than those for South African Asians, coloureds and whites. The age-adjusted IHD MR for all South Africans was 162/100,000 in 1978 and had dropped to 121/100,000 in 1985, a 25.3% decline.     

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part II. Cerebrovascular disease

An analysis was undertaken of mortality from cerebrovascular disease in the RSA between 1978 and 1982 in whites, coloureds and Asians. This article details the age-specific mortality rates for each group and also comparisons between groups based on age-standardised mortality rates. Marked differences are seen between the various population groups, the rates for Asians and coloureds (particularly females) far exceeding that for whites. Comparison of these data with those published previously by Wyndham suggest that while mortality from this cause may be falling among whites and Asians, the rate is remaining relatively static in the coloured population.     

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part V. Hypertensive diseases

An analysis was undertaken of mortality from hypertensive disease in the RSA between 1978 and 1982 among whites, coloureds and Asians. The age-specific mortality rates for each group are presented and comparisons are also made between these groups based on age-standardised mortality rates. As with a similar study undertaken for the period 1969-1971, marked variations are seen between the various population groups. The rates for Asians exceeded those for coloureds substantially, and both these groups had far higher rates than whites. These results demonstrate an interesting variation when compared with mortality from ischaemic heart disease and recent prevalence studies of hypertension. The possibility that this variation is due to better control of hypertension in whites or is a result of a different ratio of risk factors in each group studied is considered.     

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part I. All causes

Previous reports, based largely on the 1970 census and the 8th revision of the International Classification of Diseases, (ICD-8) have suggested that marked differences in mortality exist between population groups in the RSA. In this article the ICD-9 classification of causes of death and 1980 census are used to assess whether the trends have continued through to the present time. Total mortality data in the RSA for whites, coloureds and Asians for the 5-year period 1978-1982 are presented. The 1980 national census provided the denominator population data. Annual age- and sex-specific mortality rates were higher for coloureds than for whites or Asians, the differences being most marked in childhood. There appears to have been little change in total standardised mortality rates among whites over the 5-year period, while increases have occurred among coloureds of both sexes and among Asian males. Analysis of proportional mortality stresses the relatively large proportion of deaths accounted for by external causes and infections among coloureds and by cardiovascular diseases among whites and Asians. There is an urgent need for the health services to take note of these data in order to provide for the varied needs of the population.     

Acute respiratory infections as an important cause of childhood deaths in South Africa

Compared with other major preventable childhood diseases, such as diarrhoea, acute respiratory infections (ARI) have received comparatively little attention as an important cause of death in children. In this study of mortality from ARI in South Africa, national data was examined for the period 1968-1985, and data for Greater Cape Town for 1987. Almost 90% of ARI deaths were attributable to pneumonia and large inter-group differences were found that favoured whites and Asians over blacks and coloureds. For example, during 1980-1985 the mortality rate for pneumonia in coloured infants under 1 year of age was 11 times that observed in whites (88 v. 981/100,000). Pneumonia accounted for 14.5% of coloured and 12.7% of black deaths under 1 year of age during this period, compared with 6.7% of white and Asian deaths. The mortality rates from pneumonia declined substantially (50%) over the 18-year period in whites, coloureds and Asians. Sequential data for blacks is not available. There was a marked seasonality of deaths among coloured and Asian infants, with rates peaking in winter months. In Cape Town, pneumonia is now a more important cause of death among white and coloured children than diarrhoea, while it ranks with diarrhoea as a cause of death in black children. In all population groups, death rates from ARI are from 7 times to 270 times greater than those recorded in Western European countries. Studies are urgently required to discover why South African children suffer such a high mortality from ARI and how these deaths can be prevented.     

Variations in mortality of the coloured white and Asian population groups in the RSA, 1978-1982. Part III. Rheumatic heart disease

An analysis was undertaken of mortality from rheumatic heart disease in the RSA between 1978 and 1982 in whites, coloureds and Asians. This article details the age-specific mortality rates (MRs) for each group and also comparisons between groups based on age-standardised MRs. The rates for Asians and coloureds markedly exceed those for whites, particularly in the lower age groups (under 45 years).     

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part IV. Respiratory diseases

Respiratory diseases are major causes of death in South Africa. The reported mortality rates (MRs) for: (i) pneumonia and influenza; (ii) chronic obstructive lung disease and allied conditions; (iii) pulmonary tuberculosis; and (iv) carcinoma of the lung and bronchus over a 5-year period are examined in relation to age, sex, ethnic group and year. Such data have not previously been reported in South Africa. MRs for all respiratory diseases (except lung carcinoma) were substantially higher in coloureds than in whites or Asians. In each ethnic group and for each disease category, MRs for males were higher than for females, especially in those over the age of 24 years. For all, except lung carcinoma, MRs were highest at the extremes of life. Changes in respiratory disease MRs over the 5-year period were examined by calculating the age standardised MRs for each condition in each of the 5 years. There was a clear decline in the MR for pneumonia over this period in all groups. The MR for chronic obstructive pulmonary disease rose in all groups, except Asian females. Similarly, the MR for carcinoma increased in all groups, except white females. The MR for tuberculosis was highest in coloured males (10 times greater than in Asian males and 100 times greater than in white females). The pattern of respiratory disease MRs in white South Africans is very similar to that in the USA, whereas in coloureds MRs for infectious diseases remain high and are added to by the burden of cigarette smoking-related deaths.     

Characteristics of infant mortality in the RSA 1929-1983. Part I. Components of the white and coloured infant mortality rate

Secular trends in white and coloured neonatal, post-neonatal and infant mortality rates are presented for the period 1929-1983. More detailed information is given for deaths in the first month of life. During this 54-year period the infant mortality rate for whites has declined from 64.2/1,000 to 13.5/1,000, whereas the rate for coloureds fell from 158.8 (1938) to 55.0/1,000. The greater part of the latter decline occurred after 1970. Since 1945 the neonatal mortality rate (NMR) for whites has exceeded the post-neonatal mortality rate (PNMR) but among coloureds the PNMR still exceeds the NMR.     

Changes in infant mortality rates among whites, coloureds and urban blacks in the RSA over the period 1970-1983

Using national mortality statistics, we found that infant mortality rates (IMRs) declined among whites and coloureds in the RSA over the period 1970-1983, the decrease in coloured IMR being from 134,8 to 50,7/1 000 and that in white IMR from 21,6 to 12,6/1 000. The decrease in the IMR among coloureds was mainly due to the decline in post-neonatal mortality rates (PNMRs). Since post-neonatal deaths are generally due to gastro-enteritis, pneumonia, malnutrition and measles, the decline in mortality is probably due to a decrease in these causes. The decrease in early neonatal mortality made only a small contribution to the decline in the IMR among coloureds. In the case of whites the decrease in the IMR was largely due to the decline in the early neonatal mortality rate (ENMR); these deaths usually result from low birth weight, the respiratory distress syndrome, asphyxia and infections. The decline in the PNMR played a minor role. National IMRs for blacks are not reported annually, but IMRs can be calculated for the two census years 1970 and 1980 for blacks in 34 'selected' (urban) magisterial districts, and were 124,4 and 85,9/1 000 respectively. A valid IMR for 'rural' Transkei from a well-conducted epidemiological study was 130/1 000 in 1980. The components of the IMRs for blacks can only be determined for certain urban areas with large black populations such as Soweto (adjacent to Johannesburg), where the IMR fell from 81,4/1 000 in 1970 to 25,5/1 000 in 1983. The decline in the IMR was due to decreases in both the ENMR and the PNMR.(ABSTRACT TRUNCATED AT 250 WORDS)     

Characteristics of infant mortality in the RSA 1929-1983. Part II. Causes of death among white and coloured infants

The relative contribution of different causes of death in the first year of life is presented for the period 1929-1983. Infections and perinatal and respiratory causes most commonly result in infant death among coloureds, while perinatal and congenital causes are commonest among whites. Over the 54-year period studied the mortality rate due to infections has fallen dramatically among whites but much less so among coloureds. The two causes of death for which the ratios of coloured to white mortality are highest, viz. infections (28 times) and respiratory causes (9 times), are those which have the greatest post-neonatal mortality component.     

Deaths related to smoking in South Africa in 1984 and projected deaths among coloureds and blacks in the year 2000

Using a World Health Organization/International Agency for Research on Cancer classification of causes of death, we found that 34.5% of deaths among whites were attributable to smoking-related causes in 1984. The comparable figures for Asians, coloureds and blacks were 24.5%, 14.5% and 3.9% respectively. Age- and sex-specific death rates in 1984 for 35- to 64-year-olds among coloureds were greater than those among whites. Taking into account the expected ageing of the black population and the increased use of tobacco by blacks, smoking-related deaths are expected to increase by between 140 and 1,200% by the year 2000. Smoking-related diseases by 2000 will make a severe impact on the delivery of health services.     

Deaths from accidents, poisoning and violence--differences between the various population groups in the RSA

The pattern of deaths from accidents, poisoning and violence of the four population groups in the RSA for 1980 was examined in terms of the number of male and female deaths, separately and together, of certain WHO International Classification of Diseases (ICD) groupings of deaths from those causes. The main findings were: (i) that motor vehicle accidents (MVAs) accounted for 3.6% of all deaths in whites, 3.7% in coloureds, 3.1% in Asians and 2.2% in blacks, male deaths being 4 times as frequent as female and more than 70% of those deaths occurring in people under 40 years; 6% of MVAs in whites, 38% in coloureds, 17% in Asians and 34% in blacks involved pedestrians; (ii) that the next most common cause of death under these ICD headings was suicide in whites (1.6% of total) and homicide in coloureds (4.8% of total) and blacks (3.9% of total); and (iii) that under the ICD grouping 'other accidents', 45% of those deaths in whites, 58% in coloureds, 79% in Asians and 36% in blacks were due to drowning, with over 80% of deaths from drowning in people under 40 years.     

Smoking and health in South Africa

In 1984 smoking rates among adults in South Africa were highest in coloureds (41.1%), followed by whites (34.9%), Asians (29.0%), and blacks (27.7%). With increased urbanisation, income, and education, black and coloured smoking rates are likely to rise. Current trends suggest that the proportion of smoking-related disease mortality and morbidity among coloureds and blacks will increase. Studies in South Africa and elsewhere have shown that smokers run an increased risk of coronary artery disease, lung, oesophageal, and cervical cancer, respiratory disease, gastrointestinal ulcers, and leukoedema. Non-smokers exposed to 'involuntary smoking' are also at risk, and smokeless tobacco is not a safe alternative to smoking. The evidence for smoking-induced health damage is so compelling that action against smoking is urgently needed. Surveys of smoking habits among specific groups show the importance of peer and role model example, and suggest guidelines for the targeting of health education.     

The impact of diarrhoeal disease on childhood deaths in the RSA, 1968-1985

Diarrhoeal disease remains a major cause of morbidity and mortality in children in the RSA. In 1984, 8,984 deaths from diarrhoea of children under 5 years of age were registered, representing 27.7% of all registered deaths in this age group. Assuming a case/fatality ratio (deaths per 100 episodes of diarrhoea) of 0.6, it is estimated that 1.5 million cases of diarrhoea in children occurred during 1984 in the RSA. Analysis of diarrhoeal disease mortality rates revealed that the group at highest risk is black and coloured children under the age of 1 year. Over the period 1968-1985 there have been steady declines in diarrhoeal disease mortality rates for whites, coloureds and Asians. Uncertainty exists as to the true mortality rate in black children. A marked seasonal cycle is evident in diarrhoeal disease mortality rates for blacks and coloureds with peaks occurring in the period December-March. No seasonal effect on mortality is evident in the white and Asian groups. A nationally co-ordinated diarrhoea control programme is urgently needed in the RSA. This would involve a primary prevention component involving improved water supply, sanitation and sewerage, and a death prevention component emphasising the use of oral rehydration solutions. The seasonality in mortality suggests that the health education component of this programme should be aimed at the period just preceding the summer/autumn epidemic.     

Cause- and age-specific mortality rates from accidents, poisoning and violence

Cause- and age-specific mortality rates (MRs) were calculated for 1980 for all four population groups in the RSA for certain accidents, poisonings and violence as they are grouped in the WHO International Classification of Diseases (ICD). Cause-specific MRs of coloureds, Asians and blacks were age-adjusted to the age-distribution of whites in 1980 in order to judge the relative importance of the various causes of death. This showed that in whites and Asians motor vehicle accidents (MVAs) head the rank order of MRs; furthermore the first three MRs in the rank order, namely for MVAs, suicide and violence, are common in these two populations. A similar situation exists among coloureds and blacks in that the MRs for homicide rank first and the first four causes of death in the rank order of MRs--homicide, MVAs, violence and other accidents--are common to those two population groups. The fact that deaths from MVAs and violence rank so high in the MRs for all four population groups lends support to the contention that the RSA is a 'violent society'.     

Maternal mortality in Cape Town, 1978-1983

During 1978-1983, 57 maternal deaths (23 in blacks, 32 in coloureds and 2 in whites) occurred among 131,288 deliveries (36,564 in blacks, 89,335 in coloureds and 5389 in whites) in the Peninsula Maternal and Neonatal Service, Cape Town. Data for whites were not analysed further. Maternal mortality rates (MMRs) were higher in blacks than in coloureds. Age- and parity-specific MMRs showed that black teenagers and primiparas and coloureds aged 20-34 years and of parity 2-4 had the lowest rates. Advanced age and grand multiparity had a much greater adverse effect in coloureds than in blacks. Eighteen per cent of deaths in blacks and 9% of those in coloureds were in unbooked patients. The main causes of death (obstetric and non-obstetric) in blacks were sepsis, abruptio placentae, eclampsia and pneumonia. In coloureds they were eclampsia, other manifestations of proteinuric hypertension, cardiac disease, sepsis, haemorrhage (grouped) and diabetes. Of those who died, 43% of blacks and 38% of coloureds had had a caesarean section. The perinatal mortality rate was 417 for blacks and 469 for coloureds. A number of avoidable factors were identified. Most, if not all, deaths occurred because simple perinatal rules were broken.     

The 1983 distribution of hospitals and hospital beds in the RSA by area, race, ownership and type

This study used published data to analyse the 1983 distribution of hospitals and hospital beds in South Africa by 'race', geographical area, type of hospital (academic, specialist, general or other) and the nature of ownership (e.g. state, for-profit). Hospitals and hospital beds were found to be inequitably distributed. Overall bed ratios were 150 whites per bed compared with 260 blacks/Asians/coloureds per bed. The distribution of beds by geographical area was 130 people per bed for urban whites, 260 for rural whites and 150, 460 and 300 for urban, rural non-'homeland', and 'homeland' blacks/Asians/coloureds respectively. These differentials are inefficient and unjust, and should be regularly documented to spur their decline. The continued collection of population group information from health service users is required to monitor changes in 'race' disparities. The analysis of distribution by ownership and type suggested that only the public sector is able to provide a hospital service with the appropriate balance of all levels of care for the entire population; but within this sector the dominant position of tertiary care needs to be re-examined. The study highlighted the absence of adequate information on health care resource allocation and utillisation. Appropriate studies in these areas are required and consideration should be given to unifying the planning and management of all hospital resources.     

Epidemiology of non-fatal injuries due to external causes in Johannesburg-Soweto. Part II. Incidence and determinants

A total of 3,535 trauma cases were enumerated in Johannesburg-Soweto between 1989 and 1990 in the course of 271 hospital ward rounds and 43 casualty watches. The overall trauma incidence was 2,886 new cases per annum per 100,000 population, rising to 19,872 for coloured males aged 20 - 24 years and to 8,761 for black males aged 20 - 24 years. Overall the male/female ratio was 2.9 rising to 6 or more in adolescence (15 - 19) for blacks and coloureds. There were some 156 new resident cases of trauma daily; half these were victims of interpersonal violence, and coloureds constituted 22% of this group, although forming only 8% of the denominator population. With regards to cause, most trauma among blacks and coloureds arose from interpersonal violence and significantly less from transport accidents. Among blacks injured in transport accidents (the majority of which involved motor vehicles) most were pedestrians, whereas most whites injured in such accidents were occupants of vehicles. For all groups trauma was most likely to be incurred 'in the street' although for white and coloured women the home was most dangerous. The implications of these and related findings for treatment and prevention and briefly reviewed.     

Mortality from external causes in South African adolescents, 1984-1986.

The external causes of death in South African adolescents are described. Nationally registered mortality data for 1984-1986 were used to calculate proportional mortality. Mortality rates were also calculated, except in the case of black deaths, since these deaths are known to be under-registered and the estimated population figures are known to be inaccurate. Of the 16,348 adolescent deaths registered in 1984-1986, external causes accounted for 56.8% and symptoms, signs and ill-defined conditions for 10.0%. A greater proportion of girls died from symptoms, signs and ill-defined conditions whereas a greater proportion of boys died from external causes. A larger proportion of black adolescent deaths were categorised as symptoms, signs and ill-defined conditions. The risk of death by external cause for coloureds aged 15-19 years was 1.7 that of whites, while in the 10-14 year age group it was the same as that of whites. In the 15-19-year age group assault was the most common external cause of death in blacks and coloureds, compared with road accidents for whites. The highest number of deaths by external cause per day occurred over the Christmas period. The analysis indicated that mortality rates in South African adolescents are high and that many deaths may be the result of risk-taking behaviour. With the increasing urbanisation of blacks, the impact of external causes of death can be expected to increase further.     

Has the character of gastric cancer changed? A descriptive study of a 10-year period

Over the 10-year period January 1976-December 1985, 446 patients with histologically verified adenocarcinoma of the stomach were treated at Tygerberg Hospital. Coloured patients made up 63.4% of the study population and a significant increase in the annual proportion of this group was observed. Coloured men comprised 47.6% of the total group. The mean age of white and coloured patients differed significantly (68.9 v. 56.5; P less than 0.001). The symptom complex was essentially similar in the two racial groups and in general the character of the symptoms had no bearing on the prevalence of resection. Although antral tumours were most common in whites and in coloureds, there was a significant increase in tumours located in the fundus in whites. The resection rate remained unchanged over the 10-year period. Only 4 cases of early gastric cancer were detected during this period without any signs of an increased yield of early lesions over time. This audit revealed no beneficial changes over time, which is in stark contrast with reports from Japan regarding the proportion of curable lesions.