50 BRITISH MEDICAL JOURNAL 6 OCTOBER 1973 were fewer late and more early developers tors suggested by Dr. Gonco contribute little is made on clinical grounds alone it does because at the chronological age of 15 girls to it. While Africans may have a higher indeed critically depend on a correct inter- are on the whole biologically more mature pain threshold than whites I pretation of the and the doctor Indians or carn- symptoms, Br Med J: first published as 10.1136/bmj.4.5883.50-b on 6 October 1973. Downloaded from than boys. By late developers I mean that at not believe that this is an important reason in a developing country may have very real 15 the child would pass for 14 or 13 cr- for the failure to diagnose I.HD. If they problems. But in Dr. Conco's own words even 12 chronologically. The medical neglect reach hospital in large numbers with other any assessment of the prevalence of coronary of this problem is evident in one of the heart disease (hypertensive, rheumatic pul- heart disease can only be based on "informed fallacies of the educational system, where monary, and myopathic) and feel and de- conjectures" if there is no E.C.G. evidence raising the school leaving age regards only scribe the pains of pleurisy, pneumonia, peri- to back up the clinical impression, and if the chronological age and not the immensely carditis, rheumatic fever, mnmingitis, and no necropsy material is available. At the important biological age, which has such a acute abdominal conditions, why should they Makerere Medical School there is now a vital influence on attitudes at the watershed not do so with I.H.D? A proDortion of pat- very great deal of E.C.G. and necropsy of puberty. Detention in unsuitable schools ients might die from I.H.D. before reaching material, and this material prov,des incontro- is particularly hard on the early developer, hospital, but what of the 70 or 80 % who vertible evidence for the infrequency of and leads to asocial behaviour. should survive the first attack? Why should coronary heart disease. It is not claimed that There appears to be a strong genetic link they, unlike other cardiac cases, selectively it is totally absent; the claim is that it is in the stages of development. In the great avoid hospital? Why should I.H.D. con- much rarer than in European and Asian majority of cases inquiry confirms that the sistently escape detection in African post- communities in the same countries. More- early developing boy has a father who de- mortem material? I.H.D. accounts for mor- over, in the indigenous peoples the ones at veloped early, and the late developer like- bidity among white and Indian hospital staff, risk are those who have tended to adout our wise father and brother who developed late. yet is not observed among the African staff. mode of life and especially those wuho are It is an axiom of paediatrics that if you This rarity of I.H.D. among Africans is members of our own profession. have a disturbed child you treat the parents. universal and not confined to the rural Knowledge about the prevalence of coron- If parents of "short boys" were more en- people who make up a large proportion of ary heart disease in any country in the lightened about their own development and the patients of this hospital.' It may be that world can only be obtained by analysing the .-roblems involved there would be even with increasing urbanization the incidence objective data. No doubt there are some fewer emotional difficulties, thus further of I.H.D. will increase2 but this trend is sudden deaths in Africa due to coronary reducing the need for any medication of the not evident in this population yet. If Dr. heart disease, just as there are in Britain. unfortunate child. The problem of the early Conco's postulates are valid, we should find But the knowledge of the prevalence of developer who then stands still and is over- niore I.H.D. among the urbanized, sophisti- coronary heart disease in Britain is based taken by boys he could previously master at cated, English-speaking African population. on sound objective criteria, and exactly the games would -be similarly helped. The water- This is not yet sig.ificantly apDarent here. same criteria must be applied in the African shed period of adolescence is often parti- Regarding communication, the language of continent. When such criteria are applied, aularly vulnerable, and requires much rnore a community will develop according to the the very striking differences in the pre- careful study.-I am, etc., needs it serves. If they have no words to valence of the disease are clearly seen and express cardiac pain, it is reasonable to infer objectively acceptable, and do not deLpend M. E. M. HERFORD that such pain is a rare exper ence in that on conjectures, nor do they derend on any Farnham Royal, more selection than is unavoidable.-I am, Bucks community. Lack of terminology does not seriously impede the diagnosis of countless etc., 1 Widdowson. F. M., Lancet, 1951, 1, 1316. other painful conditions. I agree that scien- J. R. BILLINGHURST Romford Group of Hospitals, tific terminology is lacking in Zulu, but this Essex is not relevant to symptoms. The fact that Diseases in the Tropics a patient's language has no words for menin- gococcal meningitis does not prevent him http://www.bmj.com/ SIR,-The suggestion by Dr. W. Z. Conco Social Workers in Hospitals (11 August, p. 331) that the rarity of ap- from complaining of headache. Even in pearance of ischaemic heart disease (I.H.D.) sophisticated European practice it would be SIR,-Dr. P. E. Baldry (15 September, p. among Africans is a consequence of high most unusual for patients to proffer the 589) is a lucky man to possess the in.tuitive pain threshold and failure of conmmuication complaints listed in Dr. Conco's taible IV, skills necessary to appreciate and handle the demands comment. In the interests of epi- the significance of which escapes me. unspoken problems of hospital inpatients, demiological accuracy I must submit that To my mind the evidence of true rarity but for the less fortunate may we support these factors cannot explain the huge dis- of I.H.D. in the African is overwhelming. Mrs. Carole Smith's plea (25 August, p. 443) between the incidence of I.H.D. My concern is that epidemiological en- for more effective deployment of hospital crepancy on 30 September 2021 by guest. Protected copyright. in Af,ricans and those of Eurooean or Asian thusiasm will be dampened by Dr. Conco's social workers? Though basic personality is stock. The 1,6004bedded general hospital specious explanation and the opportunity undoubtedly an essential prerequisite, we frTom which I write is fortunate in being for investigation of this important pheno- would suggest that the skills necessary to able to treat, and compare the incidence of, menon will be reduced. Also, if it can be understand and help anxious or disturbed disease in Indians and Africans (both rural shown that his African practice produces a patients who may ha,ve added difficulties of and urban). Electrocardiograms and chest significant number of cases of I.H.D., then cominunication are learned and not innate x-rays are done in all cardiac cases, at no this community should be an important fi!ld (psychiatrists are made and not born). A cost to the patients. Necromsies are per- for research, for that is an unusual pattern graduate degree in sociology or psychology formed in all cases of unexplained death in Africans at present.-We are, etc., may not equip a social worker entirely for when consent is available. Indian and African such a task, but we believe it to be of are the same J. E. COSNETT greater value in this respect than the average patients managed by group of Edendale Hospital, physicians. It was in this setting that a Pietermaritzburg, medical student's education, which considers survey of consecutive cardiac patients was Natal, South Africa the patient's persona to ibe of negligible im- made.' One of the conclusions reached was I Cosnett, J. E., British Heart Yournal, 1962, 24, portance compared with his lump or his was at 76. diabetes. Add to this the content of a hos- that "myocardial infarction least 15 2 Seftel, H. C., Kew, M. C., and Bersohn, I., times more common in the Indian than in South African Medical Yournal, 1970, 44, 8. pital doctor's work which is-necessarily- the Zulu." An extract of relevant statistics unlikely either to leave him time or to make gleaned from some 51,000 general admissions i.t a priority to stop and listen for half an during 1971 and 1972 yields a corrected Coronary Heart Disease in Africa hour to a querulous patient. If the social ratio of about 40 Indians to 1 African in worker can provide such a service, then the cases classified as "arteriosclerotic heart SIR,-I would like to make some conments medical profession should be grateful, not disease including coronary disease." on Dr. W. Z. Conco's paper "Diseases in jealous, for not only does it free them to I do not wish to minimize the well-known the Tropics; a Confrontation in African treat the illness (which is why most of them fallacies of hospital admnission statistics, but Rural Practice" (11 August, p. 331), having are in the business) but would encourage I am convinced, froom some 15 years' full- recently returned from the Makerere quicker rehabilitation of the patient.