A  CAJM article on African disease patterns.Perhaps every physician in Rhodesia today has an impression in the back of his mind that as the cultural patterns of the Africans change, so also do their diseases. The situation under which this study was undertaken seemed particularly favorable to the testing of this hypothesis

Donaldson, John .F.

Central African Journal of Medicine

English

Perhaps every physician in Rhodesia today has an impression in the back of his mind that as the cultural patterns of the Africans change, so also do their diseases. The situation under which this study was undertaken seemed particularly favorable to the testing of this hypothesis

Donaldson,  John .F.

National Research Database of Zimbabwe

Changes In African Disease Patterns With Western Acculturation

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Vol. 17. No. 3. M arch, 1971.
Changes in African Disease 
Patterns with Western 
Acculturation
BY
JOHN F. DONALDSON, m .d„ d ip .t .m .& h .
Medical Superintendent, Chikore Hospital.
Perhaps every physician in Rhodesia today has 
an impression in the back of his mind that as 
the cultural patterns of the Africans change, so 
also do their diseases. The situation under which 
this study was undertaken seemed particularly 
favourable to the testing of this hypothesis.
Plan and  M ethod
Commencing January, 1966, every patient enter­
ing the Chikore hospital was classified as T (tradi­
tional), ST- (semi-traditional), or W (western­
ised) , according to the degree to which his cultural 
mores seemed to depart from the customary to­
ward the modern. This evaluation was a total 
impression based upon such considerations as 
education, occupation, income, social position and 
fluency with English.
Although at first viewed with certain apprehen­
sion, such subcultural classification proved in 
practice relatively easy. Whereas some mothers 
arrive by foot carrying their children in goatskins 
on their backs, other arrive in this year’s car. 
Some patients have had no formal education; 
others have overseas degrees. Some come from 
families attempting to live at subsistence levels on 
incomes of $5 monthly or less; others on $150 or 
more. The subcultural designation was facilitated 
by the fact that many of the patients, particularly 
the westernised, were known to the staff per­
sonally and by the fact that the final categorisa­
tion was always done by the same person, the 
author, usually at the time of the first visit. 
Although initially the aim was to select off a 
sample of westernised Africans for comparison 
with a traditional group, the necessity for an 
intermediate semi-traditional group soon became 
apparent for those who seemed to fit well into 
neither extreme.
Regrettably, the scope of this study had to be 
limited. Excluded, for instance, are differential 
analyses of childhood disease patterns, obstetric 
and gynaecologic problems, orthopaedic cases, 
major surgical illnesses and malignancies.
R esults
A total of 5,376 cases were studied over a 
period of approximately 2 \ years. Of these, 
4,317 (80.3 per cent.) were classified as essentially
traditional in cultural habit, 881 (16.4 per cent.) 
as semi-traditional and 178 (3.3 per cent.) as 
westernised.
The results of this study are grouped below 
into four main disease categories: (1) a parasitic • 
group; (2) a nutritional group; (3) an infectious _' 
group; and (4) certain miscellanies.
A. Parasitic Diseases
The incidence rates of five parasitic diseases 
for the three subcultural groups are charted in 
Table I.
The general pattern, though not exceptionless, 
appears one of a significant 'decrease in parasitic 
disease with westernisation. Whereas the com­
bined incidence rate of , schistosomiasis for all 
ages was 9.9 per cent, in the traditional group, this 
was but 1.7 per cent, for the westernised. 
Ascariasis similarly decreased from 3.2 per cent, 
to 1.1 per cent., and enterobiasis from 3.0 per 
cent, to 1.1 per cent. Scabies dropped from 6.6 
per cent, to 3.4 per cent. The only exception to 
this trend was hookworm, which showed an in­
crease from 8 per cent, to 10.7 per cent.
The decrease in parasitic morbidity was even 
more pronounced in the contrast between- the 
semi-traditional and the westernised. The. unex­
pectedly high- incidence rates for the semi-tradi­
tional group will be discussed subsequently.
B. Nutritional Diseases
The nutritional diseases followed in this study 
show clear and consistent trends. Clinical mal­
nutrition, avitaminosis B complex. and kwashior­
kor showed decreases from. 4.9 per cent., 3.9 per 
cent, and 4.4 per cent, respectively to 0 per cent, 
in each instance. Anaemia decreased. from 19.5 
per cent, to 12.9 per cent. On the other hand, 
obesity . showed an opposite trend, rising from 
one in every 270 of the traditional patients to 
one in. every 22 of, the westernised. Semi-tradi­
tional rates, proved consistently intermediate. . .
An obvious increase in nutritional balance and 
adequacy underlies this entire, pattern. Whereas 
the traditional African is more, likely , to suffer 
from undernutrition or specific deficiency, the 
westernised African is more likely to suffer from 
nutritional excess.
C. Infectious Diseases
Incidence rates for bacterial, viral, fungal 
diseases and malaria are charted in Table III. 
These are listed mainly by anatomic region.
With westernisation a rising incidence appears 
to take place in such diseases as rhinitis, con­
junctivitis, upper respiratory infections, influenza, 
tonsillitis, pharyngitis, laryngitis, bronchitis, ring­
worm, other dermatitis and malaria. In marked
, T h e  Central African
J ournal of Medicine
51
M arch, 1971 PATTERNS OF DISEASE IN RHODESIA T h e  Central African
J ournal of Medicine
contrast, decreased incidence rates appear for 
bronchopneumonia, pneumonia and tuberculosis. 
Very little change in incidence rate appears to 
take place in infectious gastrointestinal disease, 
but venereal disease appears to increase slightly.
The above diseases showing higher incidence 
rates with westernisation are generally the less 
severe. Since it is. difficult to believe that the 
actual incidence of such ailments as conjunctivitis, 
influenza and ringworm are less in the traditional 
group, other explanations need be sought. The 
simplest would appear to be that, for various 
reasons, the more westernised African comes 
more readily for treatment. Thus milder infec­
tions are more likely to be treated and serious 
infections earlier. Conversely, the traditional 
African tolerates larger amounts of illness. Thus 
the bronchitis of the child in a westernised family, 
promptly treated, never becomes a bronchopneu­
monia, whereas the “normal cough” of the child 
in a traditional hut on a cold, rainy night does. 
Such an interpretation is - supported by the fact 
that the serious respiratory diseases followed in 
this study—bronchopneumonia, pneumonia and 
T.B.—reveal combined incidence rates four times 
as high in the traditional group compared with 
the westernised.
Malaria appears to present within the micro­
cosm of one disease the entire morbidity spectrum 
presented by respiratory tract diseases. As ob­
served in Table III, malaria emerges primarily 
one of the milder diseases for the African, for 
which the more westernised is more likely to 
come to the hospital for treatment. It seems 
significant that in this subcultural group not a 
single case of malarial complication or fatality 
occurred, in contrast to an estimated malarial 
complication rate of 21 per cent, among the 
confirmed positive cases of the traditional group, 
some of which were extremely severe.
Although the incidence of hand-to-mouth para­
sitic diseases, such as pinworm . and ascariasis, 
showed a decrease with westernisation, suggesting 
improved personal hygiene, the relative con­
stancy of the infectious gastrointestinal group 
suggests that effective house fly control does not 
occur until almost 100 per cent, latrine control 
is established in a given area.
D. Other Diseases
Hypertensive cardiovascular disease showed an 
increase from 1.5 per cent, in the traditional 
group, much of which reflects renal compensation 
in the elderly, to 4.5 per cent, in the westernised. 
For the latter an increasing importance of such 
other aetiologic factors as obesity and emotional 
tension are presumed. That emotional factors
begin to become increasingly important with 
westernisation was also suggested by the fact 
that a survey of secondary level students revealed 
an incidence rate of hypertension of 12.1 per cent.  ^
(Donaldson, 1970). The increase in rate of psy­
choses from 0.2 per cent, to 1.1 per cent, also 
suggests an increasing role of emotional tension. 
Many clinicians implicate emotional factors 
among the aetiologic agents in obesity (Cecil, 
1951; Harrison, 1966; Meakins, 1956).
The increase in incidence of caries requiring 
extraction from 3.5 per cent, in the traditional 
group to 16.9 per cent, in the westernised would ' 
appear to reflect in part the richer diet of the 
latter. The apparent increases in menstrual prob­
lems and minor traumatic injuries probably re­
flects the increased propensity of the westernised 
group to avail themselves of scientific medical 
help.
D iscussio n
The incidence rates quoted in this study’ prob­
ably err mainly conservatively. More intensive 
investigations elicitive of subclinical cases could 
undoubtedly increase appreciably the incidence 
rates of such diseases as malnutrition, avitamino­
sis B and scabies. The incidence of clinical 
malaria was appreciably greater than that for the 
positive blood slide cases quoted above. The in­
cidence rates of caries requiring extraction are 
probably high in this study, on the other hand, 
due to the reputation of an orderly at the hos­
pital for painless dentistry.
One limitation of this study was the subjective 
factor in the subcultural classification of patients. 
Several considerations suggest, however, that a 
reasonable objectivity was attained. The rela­
tively small size of the westernised group, 3.3 per 
cent., supports that a fairly select group was 
singled out, while the numbers of the three 
groups—4,317, 881 and 178—support statistical 
reliability. The common emergence of parallel 
trends, with semi-traditional results intermediate, 
also supports the study’s validity.
Quite unexpectedly, however, in at least ten 
disease categories maximal incidences emerged in 
the intermediate group. This occurred for schisto­
somiasis haematobium, hookworm, enterobiasis, 
ascariasis, venereal disease and the psychoses. 
Although such an increased incidence for one or 
two might be dismissed as a spurious statistic, 
this for so appreciable a group does not permit 
so facile an explanation. One possible explanation 
is that perhaps the persons in the semi-traditional 
group are at once, like the more westernised, • 
more cognisant of disease and more prepared to 
seek treatment, but also, like the more traditional,
52
March, 1971 PATTERNS OF DISEASE IN RHODESIA T h e  Central African
J ournal of . Medicine
not sufficiently the beneficiaries of better nutrition 
and sanitation. Nutritional adequacy, as Sigerist 
(1943) emphasises, is probably the most import­
ant background factor in the genesis of all disease.
An alternative explanation, particularly for the 
psychoses, could be that those attempting to adjust 
to two not always compatible cultural worlds 
become susceptible to greater amounts of disease.
The results of this study, viewed as an entirety, 
suggest a trend towards increased longevity with 
western acculturation. The pattern which emerges 
is one of decreased incidence of parasitic disease, 
improved nutrition and less severe infectious 
disease. On the other hand, partially offsetting 
these gains, arise increased incidences in diseases 
related to overnutrition and to nervous tension.
In comparison with the African living in 
Central Africa to-day, writes Gelfand (1968, 
p. 90), “the European can be said to be living 
in a different world. Parasitic disease is not im­
portant in his life. . . . These days European 
babies practically never die of malaria. Malnu­
trition in the European is exceptional, and I doubt 
whether classical kwashiorkor ever occurs. . . . 
Anaemia (is) . . . comparatively uncommon.” 
The present study, confirming such a two-world 
hypothesis, indicates that a cultural change from 
one towards the other becomes attended by 
correspondingly altered patterns of disease suscep­
tibility.
Far more questions than answers, however, 
are raised by this study. Why such frequently 
highest incidences in the semi-traditional group? 
What are the factors in the rise of hypertension 
with western acculturation? Does cultural dis­
ruption contribute to nervous or venereal disease?
What factors in “westernisation” are most evoca­
tive of disease?
Sum m ary  and Co nclusio ns  
A two and three-quarter year study is reported 
investigating incidence rates of disease in 5,376 
rural. African patients of varying subcultural 
backgrounds ranging from the traditional (80 
per cent.) to the westernised (3 per cent.). With 
western acculturation, these statistics suggest, a 
pattern of change in incidence of disease takes 
place. Parasitic diseases, such as bilharziasis, 
hand-to-mouth nematode diseases and scabies, 
markedly decrease. Nutritional deficiency diseases 
such as the avitaminoses, kwashiorkor and 
anaemia also decrease, but diseases associated with 
nutritional excess, such as obesity and caries, 
begin to increase. Infectious diseases tend to be 
less severe and to be treated earlier. Diseases 
associated with emotional tension, on the other 
hand, such as essential hypertension and psycho­
sis, appear to increase.
In brief, as the African departs from his 
traditional ways for those brought in by western 
civilisation, he also leaves his more traditional 
diseases in exchange for more western. The evi 
dence suggests, however, a significant overall gain 
in decreased morbidity and more favoured 
longevity.
REFERENCES
Cecil, R. L. & Loeb, R. F. (1951). Textbook of Medi­
cine. Saunders, Philadelphia.
D onaldson, J. F. (1970). C. Afr. J. Med., 16, 4. 
Gelfand, M. (1968). African Crucible. Juta & Co., 
Cape Town.
H arrison, T. R. et al. (1966). Principles of Internal Medi­
cine, 5th Edition. McGraw Hill, New York.
M eakins, J. C. (1956). The Practice of Medicine. 
Mosby, St. Louis.
Sigerist, H. (1943). - Civilisation and Disease. Univer­
sity of Chicago Press, Chicago; Paperback, 1962.
T able I
Parasitic D iseases
Traditional , Semi-traditional Westernised
Disease
No. Per cent. No. Per cent. No. Per cent.
S. haematobium 333 7.7 ' 74 8.4 3 1.7
S. mansoni ................................ 96 2.2 17 1.9 0 0
Hookworm 344 8.0 125 14.2 19 10.7
Ascariasis 138 3.2 32 3.6 2 1.1
Enterobiasis ............. 130 3.0 36 4.1 2 1.1
Scabies (clinical) ...................... 287 6.6 . 73 8.3 6 3.4
53
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