SECOND CARNEGIE INQUIRY INTO POVERTY AND DEVELOPMENT IN SOUTHERN AFRICA sone diseases associated with poverty Etlited by Peter Disler Chippy Olver Carnegie Conference Paper No.295 Cape Town 13 - 19 April 1984 ISBN 0 7992 0754 3 i PREFACE It is now nearly 50 years since the then Medical Officer of Health of Cape Town wrote in the SClUth African Medical Journa11• "Poverty is not only a cause of ill health and mortality; it is also a result of them ...... my object is not to discuss the prevention or palliative remedies for poverty, but only to emphasize once more its fundamental relationship to public health." In many ways these perceptive thoughts crystallize the motivation behind this manual. It is not our intention to discuss approaches to the management of poverty, nor to provide a comprehensive text for the medically qualified; neither is this a guide line for people afflicted by both poverty and illness (many of whom would anyway be illiterate by virtue of their economic status). The target group for this mnaual is the many non-medically qualified persons who work daily with poor people, who encounter illness and who do not have a basic knowledge of the diseases, their frequency and their management. It is hoped that this text will provide some insights which will enable them to deal with the general problems more thoroughly. As many of the diseases covered are based in similar environmental cir­ cumstances, to avoid repitition a general introduction has been provided by Cedric De Beer. This deals with many of the socio-economic factors associated with poverty that influence health in general and in the South African context, in particular. .ii Selection of the topics for discussion engendered considerable debate. The final list is a rather arbitary combination of the choices of the members of the Carnegie Inquiry health subcommittees in Durban, Johannesburg and Cape Town and based on our joint experience. Almost certainly there are deficiencies both in the format and selection: important diseases may have been omitted and others inappropriately included. If this booklet proves to be of value then it may deserve expansion and wider distribution in the future and modifications can be made at that stage. Suggestions and constructive criticism will thus be welcomed. References 1. Higgins, T.S. Public health aspect of social welfare, S Afr Med J 23.9.39, p.p. 675 - 77 iii INDEX ·Page Number Introduction Cedric de Beer Malnutrition Noms(l'ldaba & Chippy Olver 16 Tuberculosis Chippy Olver 27 Diarrhoeal Disease in Young Children Anton van der Merwe Cholera Anton van der Merwe 43 Sexually Transmitted Diseases Margie Duncan 49 Poliomyelitis Peter Disler 55 . Rheumatic Fever Peter Bundred 60 .. Measles Gerry Coovadia 66 Skin 'Infections Z. Hamed· 73 Tetanus M. Broughton 79 Parasitic Infestation M. Mackenjee 83 Disability and handicap Peter Disler 87 Occupational Lung Disease Derek Yach & Jonny Myers 94 Hypertension Chippy Olver 104 Road Traffic Accidents Noddy Jinabhai 115 Dental (oral) health and disease Hanif MoolIa 127 INTRODUCTION by Cedric De Beer Department of Community Medicine, University of Witwatersrand, Johannesburg In the last few decades the introduction of scientific method into medical practice has transformmed it from an art into a sCience. Through medical science, and the other sCientific disciplines on which it draws for its growth and development, we have gained considerable knowledge about the normal functions of the human body, the nature and cause of malfunctions and how this can be corrected. We now know that some infections are caused by bacteria or viruses. We know that the accun·ulation of various substances in the human body, transmitted from the environment or through diet, can cause a number of different disorders. We know that psychological stress can cause physical illenss. Yet this scientific approach to disease, although bringing many benefits is marked by certain inadequacies. Concentrating as it does on the diagnosis and treatment of individuals, it makes illness appear to be a random event which strikes down those who have been "unlucky" enough to be exposed to a hazardous extrinsic factor. In fact though, we know that this is not the case and that different groups of epople show different patterns of disease. This can be easily domonstrated by looking at statistics describing causes of death in different social classes, ranging from social class 1 (professionals and executives) to social class 5 (unskilled workers). If we compare the causes of death in classes 1 and 5 some interesting patterns emerge. For example in the years 1970- 72, British babies in social class 5 were 2,5 times more likely to die before they reached the age of 1 year than babies born into class 1. Turning to the main causes of death amongst men between the ages of 15-64 further illustrative data is found. Conventionally ischaemic heart disease is regarded as an "executive" disease. This is true in one sense. It is after suicide the most common killer of class 1 males and only the seventh most imnortant cause of death in class 5 males. Nonetheless class 5 males are more at risk of dying from heart disease 2 than class 1 males. Thus not only do members of social- class 5 suffer. from diseases that are not very important for those in class 1, but even those diseases which take the most serious toll ,in social class 1 are more common in class 5. It seems quite clear therefore that socio- economic status does have an influence both on kinds of illness that people have and how frequently they occur. A similar but exaggerated pattern can be found in South Africa. It is unfortunately impossible to ascertain precisely how great the difference is as there are no adequate health statistics kept for Blacks in this country, except on an extremely selective basis. Nevertheless if this is borne in mind, some important facts emerge from-the available data. In 1970 the infant mortality (number of deaths of children under the age of 1 per 1 000 live births) was 5 times greater amongst Coloureds and Indians than amongst Whites. Even more dramatic was the death rate amongst children between the ages of 1 and 4, being 15 times higher among Coloured children than in White. The significance of these differences becomes apparent if we accept what Van Rensburg and Mans have to say about them : "Infantile deaths are always a reliable reflection of the standard of hygiene and nourishment in a population, its standard of living and health care. Deaths in the age group 1 --4 years reflect the economic and social development of a population rather than the quality of its medical care. ,,1. As statistics are kept according to race, not class in South Africa it might be argued that these differences are genetically determined and independent of socio-economic status. There are however two strong counter-arguments. The first is that there is in fact an extensive overlap between race and social class in South Africa. For example the Industrial Health Research Group at UCT has argued that 82% of Africans 2 fall into social classes 4 and 5, while only 6% of Whites do. • The second point is that health patterns amongst racial groups change with time. For example the "Asian" population has a lower infant mortality rate at present than it did twenty years ago, and a higher rate of death from coronary heart disease, these changes corresponding with an improvement in the economic status of at least one section of the community. Similarly 3 in the 1920's and 1930's when there was a substantial ''poor White" element, this section of the population showed a pattern of disease similar to Blacks in South Africa today.3. With the almost complete eradication- of real poverty amongst Whites, this pattern of ill health has changed. Clearly, while race and social class are closely linked, the health profile of any group of people changes as their social and economic circumstances change and is not "fixed" by their race." Once this is accepted, it becomes clear that understanding illness and health is as much a question for social science as it is for medical science and that improving the health of the population (rather than of individual patients) may have more to do with social and economic change that with advances in medical technology. The truth of this 4 statement is aptly demonstrated by McKeown . who showed that a substantial reduction in the incidence of a number,of infectious diseases in the UnHed Kingdom took place years in advance of the development by medical science of the means to treat or prevent these illnesses. McKeown argues that the improvement was the result of changes in the economic and social conditions of the working classes in the United Kingdom which made people less susceptible to the diseases. The importance of these conclusions is that in the analysis of disease, medical principles must be applied to the nature of illness in society as a whole, rather than restricting them to the diagnosis of the disease in the single individual. Disease and poverty in South Africa It is beyond the scope of this introduction to examine either the extent or the roots of poverty in this country. These factors will presumably be extensively addressed in other papers presented to this conference. Suffice it to say that in South Africa, and in particular in the "homelands", poverty is both widespread and severe. It is also impDrtant to stress' that poverty is not an original state out of which people must "advance". It is rather a state of deprivation created by the position that groups hold within any particular set of social and economic structures.