A CAJM article on disease patterns at selected Zimbabwean hospitals

Fraser-Ross, W.

Central African Journal of Medicine

English

IDS OpenDocs

iy iP M M r  i©  w jyM i n?D mumi^  hd «
iPMTOiag ajfifiictiim© urns ©m to m iii ®if 
»IFAT O » ?P ©IF S T O ia W M in i
HKf M M M Iim iL  @ ® m m ® m s
Am MttDXDJlh 3MlI!®mi|p afl 33fl HM&h £$@ ‘
Ek KL @C31M1^ 6!niliil51r[!M!D§i W&MGQ/MM,
T h e  Central African
J ournal of M edicine
f
Vol. 17. N o. 11. N ovember, 1971.
Patterns of Disease at Selected 
Rhodesian Hospitals*
BY
W. FRASER ROSS
b.sc., m .b., ch . b . (St. And.), d.p .h . (Lond.),
Department of Social and Preventive Medicine, 
University of Rhodesia.
It might be reasonable to think that the prime 
reason for admission to hospital would be on 
medical grounds, but on the other hand a variety 
of social conditions might well necessitate admis­
sion. When considering the problems which face 
the African of Rhodesia, many of the reasons for 
admission will be sociological, even when the 
underlying medical condition is relatively minor, 
as their conditions of living may present consider­
able problems as far as the provision of suitable 
domiciliary medical care is concerned.
In Rhodesia, as in many other parts of Africa, 
or for that matter other parts of the world, our 
lack of knowledge of population distribution pre­
sents problems of medical administration. In 
April, 1969, a census of the African population 
was carried out and we are hoping that we shall 
have some information shortly on a number of 
factors concerning their vital statistics which will 
allow us more adequately to define the population 
which our hospitals serve. As we have no accurate 
disease prevalence figures in relation to popula­
tion, it is necessary, therefore, to make use of in­
formation derived from hospital discharges if we 
are to look at the pattern of disease. ...
It would appear reasonable to conclude that if 
the pattern of discharges from urban and rural 
hospitals varied this might give some clue to the 
aetiology of the various diseases, because 70 per 
cent, of the patients in an urban hospital come 
from the urban area. We know that the pattern of 
living in an urban area is-in contrast to that in a 
rural area, and factors such as housing, dietetic 
habits, water supplies and sewage and refuse dis- - 
posal might well influence the incidence of disease. 
Furthermore, the occupational opportunities vary 
widely from town to country and some of the 
hazards of modern urban society such as traffic 
accidents and assault might well influence the dis­
ease pattern.
Coincidental with the opening of Mpilo Central 
Hospital in Bulawayo, an institution with nearly 
600 general beds for Africans, opportunity was 
taken to establish a medical record system on
*A'n address read at the General Practice Section of the 
1969 South African Medical Congress in Pretoria.
modern lines. A study has been made of all 
patients discharged from this hospital from 1959 
to 1968 inclusive. During seven years of this dec­
ade I was medical superintendent of this hospital 
and personally supervised the medical records de­
partment. For the remaining three-year period the 
staff who continued .to work in this department 
were those who had been trained by myself, and 
there is good reason to believe that over this 
period there was little variation in coding tech­
niques for the diseases. The coding system used 
was the International List of 150 causes for Tabu­
lation of Morbidity and Mortality (List A) as 
contained in the 1955 Revision of the Manual of 
the International Statistical Classification of Dis­
eases, Injuries and Causes of Death. During this 
period approximately 145,000 people were dis­
charged from the hospital, giving an average an­
nual discharge figure of about 14,500 patients. 
When we range these discharges by frequency for 
each year excluding tuberculosis of the respiratory 
tract because of a change of admission policy 
which took place during this period, we find 
there is little variation year by year in the top 10 
disease grouDS. These 10 diseases constitute just 
over 40 per cent of all discharges and in order of 
frequency they are—
No.
International 
Code (1955) Disease or Disease Group
1. A114 Diseases of the genito-urinary 
system such as salpingitis, cystitis, 
pyelitis, cervicitis, etc., but ex­
cluding acute and chronic nephri­
tis, urinary calculi and prostatic 
hyperplasia.
2. AN 140 Fracture of the limbs.
3. A118 Non-septic abortion.
4. A104 Gastroenteritis and colitis.
5. AN145 Lacerations and open wounds.
6. A89 Lobar pneumonia.
7. A90 Bronchopneumonia.
8. A137 Ill-defined and unknown causes of 
morbidity and mortality.
9. A121 ' Infections of skin and subcutane-. 
ous tissue.
10. AN143 Head injury (excluding fracture).
Although figures over a similar long period are 
not available from Harare Central Hospital, a 
hospital for Africans which is presently the teach­
ing hospital in Salisbury, it seemed worth while 
to compare the experience over one year, namely, 
1968, at Harare. When this is done we find that 
during this period approximately 18,500 people 
were discharged. Moreover, when we compare the 
top 10 diagnoses on discharge, we find that nine 
of these are similar, the only difference being that 
infections of the skin and sub-cutaneous tissue in
233
N ovember, 1971. PATTERNS OF DISEASE T h e  Central AfricanJ ournal of Medicine
Bulawayo are ousted toy benign neoplasms and 
neoplasms of unspecified nature in Salisbury. Does 
this mean that the gynaecologists in Salisbury are 
more enthusiastic for their fibroids, while the trau­
matic surgeons in Bulawayo favour the lacerated 
wound? Perhaps Salisbury women are more 
sophisticated in seeking gynaecological attention, 
while the Bulawayo men are more aggressive with 
their “flick” knives. However, both these diagnos­
tic groups figure in the top 20 diseases from the 
two hospitals.
There seems little doubt that the same basic 
problems account for the admissions to hospital 
in both these large urban areas, and it is fitting to 
compare these with the discharge diagnoses which 
would be encountered in a rural area. Early in 
1968 the faculty of medicine in the University of 
Rhodesia established a project in one of the Tribal 
Trust Lands where students would have the op­
portunity to study the sociological problems in 
such an area and see something of rural medical 
practice. The area selected was the Wedza Tribal 
Trust Land extending from 60 to 100 miles south­
east of Salisbury. In this area there are two small 
hospitals, one run by the Ministry of Health and 
the other by a Roman Catholic mission. Both these 
hospitals were under the combined clinical super­
vision of the senior lecturer in community medi­
cine and the mission medical officer.
All the discharges from these two hospitals over 
a 12-month period from 1st April, 1968, to 31st 
March, 1969, were recorded in a manner similar 
to that in the two hospitals above. When we range 
these discharges by frequency we obtain a some­
what different picture from that which we had 
in the urban area. The 10 most common diseases 
on discharge are—
No.
International 
Code (1965) Disease or Disease Group
1. A37 Bilharzia.
2. A87 4- A92 Acute respiratory infections.
3. A104 Enteritis and other diarrhoeal 
diseases.
4. A65 Avitaminosis and other nutritional 
deficiency.
5. A32 Measles.
Pneumonia (which includes 
bronchopneumonia and lobar
6. A89 - f  A90 pneumonia).
7. A114 Diseases of genito-urinary system.
8. A93 4- part Bronchitis, emphysema and
of
A97 and A66
asthma.
9. A121 Infections of skin and subcutane­
ous tissue.
10. A74 Inflammatory disease of the eye.
If we now compare the discharge patterns in 
the urban areas with those in the rural area, we 
find that only four of the diseases in the top 10 
in the rural area are the same as those in the urban 
area. The four which are common to both are—
(1) Diseases of the genito-urinary system.
(2) Gastroenteritis and colitis.
(3) Lobar pneumonia and bronchopneumonia.
(4) Infections of the skin and subcutaneous 
tissue.
It should be noted that in the rural area the 
1965 Revision of the International Classification 
of Disease was being used and thus pneumonia 
in this classification must be equated with lobar 
pneumonia and bronchopneumonia grouped to­
gether.
When these four diseases are considered we are 
presented with some of the problems associated 
with poor standards of living. Gastroenteritis is 
common in people who are unaware of the prob­
lems of food hygiene and storage; pneumonia may 
be related to inadequate housing provision; while 
the infections of skin and the genito-urinary sys­
tem are again frequently associated with lack of 
personal hygiene and lack of education. It might 
be concluded, therefore, that improvement in 
sooial well-being, particularly in the form of en­
vironmental changes, could do a great deal both 
in urban and rural areas to diminish the load on 
the hospital services.
When we consider those diseases which are dif­
ferent in the two areas, some interesting facts 
emerge. The second and third commonest diseases 
in the urban areas, namely, fracture of the limbs 
and non-septic abortion, do not feature in the top 
10 in the rural area and are only listed as nine­
teenth and seventeenth and are relatively un­
important. While it might be fair to conclude that 
the presence of heavy traffic, both in the form of 
motor cars and bicycles, may contribute in the 
urban area to many fractures, nevertheless assault 
is important, as only a small percentage of frac­
tures in urban hospitals are referred from rural 
areas. On the other hand, how do we account for 
the frequency of abortions? Are many of these 
self-induced and, if so, why are they commoner 
in an urban area than a rural area? Are the pres­
sures on a woman bearing an unwanted child in 
an urban area greater and is she consequently 
forced into the hands of the abortionist? It seems 
to me that this problem of abortion in urban areas 
highlights the need for adequate family planning 
facilities, as many of the patients', who feature in 
the group with diseases of the genito-urinary 
system undoubtedly stem from the aftermath of 
an abortion.
234
November, 1971. PATTERNS OF DISEASE T h e  Central AfricanJ ournal of M edicine
| The fact that head injuries, lacerations and 
open wounds feature prominently in the urban 
• areas also reminds us of the violence associated 
with urban living, be the violence personal or 
otherwise. It is evident that urban hospital services 
have to be geared to dealing with .trauma in a way 
quite different from that required in a rural area.
In looking at those diseases common in the 
rural areas we find that bilharziasis, acute respira­
tory infections and nutritional deficiency are three 
of the top four diseases. Does this mean that those 
diseases do not occur in urban areas? While it 
might be argued that bilharziasis is less likely to 
occur in an urban area, we must remember that 
many' of the so-called urban dwellers regularly 
move from town to country and vice versa. Simi­
larly, we would be foolhardy to conclude that up­
per respiratory tract infections are not frequently 
found in the urban area, although the evidence 
might be more correct in the case of nutritional 
deficiency.
Although there are' many hazards associated 
with the use of hospital discharges in determining 
the pattern of disease in the community, neverthe­
less some useful information can be derived from 
them. As it seems worth while comparing the dis­
charge pattern in an urban hospital with that in 
a rural hospital, it is necessary to try to ensure 
that the figures have some comparability in iso far 
as the accuracy of the diagnosis is concerned. 
Obviously the diagnostic aids in an urban area are 
more advanced than those in a rural area, so we 
are immediately faced with a problem. However, 
although consultant services in urban areas may 
make the diagnosis more refined, this may well 
be compensated for as the commoner diseases, 
which are easily diagnosed, will probably make 
up the vast bulk of the discharges.
The two diseases, bilharziasis and upper respira­
tory tract infections, illustrate one of the prob­
lems in making comparative studies based on hos­
pital discharges: Although this may be a real dif­
ference in the prevalence of disease, it is prob­
ably due to the selective process of admission to 
hospital. Because of the pressure of beds in the 
urban hospitals, it was hospital policy not to ad­
mit cases of bilharziasis for treatment, but to deal 
with it on an outpatient basis. Similarly, upper 
respiratory tract infections were dealt with as out­
patients in the urban hospitals, but in the rural 
hospitals, often because of the distance the patient 
had travelled for treatment, it was necessary to 
admit them. A policy of admission may, therefore, 
be an important factor in influencing discharge 
patterns.
Nor can we ignore doctor preference or patient 
preference as a possible cause of influence in hos­
pital discharge figures. A doctor may deliberately 
admit a particular type of patient as he is in­
terested in this disease, or a hospital may acquire 
a reputation, often on the flimsiest evidence, for 
the treatment of a disease which causes patients 
to present themselves in considerable numbers.
A further difficulty of comparison is the ability 
to make a diagnosis and this may not necessarily 
be at the rural hospital. The eighth commonest 
diagnosis in the urban areas was ill-defined disease 
and yet this did not feature in the rural area. As 
the central hospitals constitute the ultimate refer­
ence hospitals, not unnaturally the obscure cases 
are referred to them. Furthermore, the diagnosis 
is probably more critically examined in the larger 
hospitals with more staff available, and especially 
when students are around.
In relation to the problem of a policy of admis­
sion, it is important to remember that in urban 
areas all infectious diseases are admitted to isola­
tion hospitals, while in rural areas they are merely 
.admitted, where possible, to isolation facilities in 
the same hospital. This accounts in our study for 
the presence of measles in the rural hospital.
Despite all these pitfalls which we have men­
tioned, in my opinion this type of study is still 
important to us in the developing countries. 
Before long we hope to obtain some accurate 
prevalence figures for disease based on a better 
knowledge derived from population studies. 
Meanwhile, we have to make provision for the 
expansion of our health services and to do this 
we have to have some idea of our needs for per­
sonnel and buildings such as hospitals. To estimate 
these requirements some knowledge of the disease 
pattern, even despite its inherent inaccuracies, is 
of value. We can see from both the urban and 
rural figures in this study that the provision of 
facilities isuch as adequate environmental facilities, 
family planning services, nutritional advice and 
simple personal hygiene measures is of paramount 
importance in our health services. Although ade­
quate hospitalisation is required, particularly in 
the urban area, nevertheless in both urban and 
rural areas much improvement can be brought 
about in a developing country by use of para­
medical personnel supervised by the few medical 
practitioners available.
Considerable work has been done recently on 
the possibility of planning and evaluating train­
ing methods for medical and other health staff.
It is also necessary to have a quantitative evalu- _ 
ation of long-term staff needs. To do this it is 
important to have available as much information
235
V o l . 17. No. 11. N ovember, 1971.
on disease problems in a country as possible, and 
towards this end the studies of hospital discharge 
patterns are of use.
Summary
The contrasting pattern of disease seen in hos­
pitals in urban and rural areas affords an oppor­
tunity to consider the varying problems of aeti­
ology. A study was made of 145,000 discharges 
from Mpilo Central Hospital, Bulawayo, over the 
decade from 1959 to 1968 inclusive, and this pat­
tern of disease Was contrasted with a similar study 
made over a period of one year of disease as 
recorded at Harare Central Hospital, Salisbury, 
and in hospitals in a Tribal Trust Land. Variations 
in disease patterns between hospitals in urban and 
rural areas and the relationship of these disease
T h e  Central African
J ournal of Medicine \
patterns to the provision of suitable medical ser­
vices in urban or rural areas are considered.
The organisation of such studies presents prob­
lems of comparison and the difficulties of making 
such comparative studies are illustrated. Never­
theless, a case is submitted for the continuation of 
such studies as the information derived therefrom 
is vital to the medical services in a developing 
country.
Acknowledgments
Grateful thanks are due to the Secretary for 
Health for access to the records of Harare and 
Mpilo Central Hospitals and to Dr. M. E. 
Mackintosh for the information concerning the 
hospitals in the Wedza Tribal Trust Lands.
This work is licensed under a 
Creative Commons
Attribution -  Noncommercial - NoDerivs 3.0 License.
To view a copy of the license please see: 
http://creativecommons.org/licenses/by-nc-nd/3.0/
This is a download from the BLDS Digital Library on OpenDocs
http://opendocs.ids.ac.uk/opendocs/
Institute of 
Development Studies


Patterns of Disease at Selected Rhodesian Hospitals

Fraser-Ross,  W.

National Research Database of Zimbabwe

https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/4998/1/Fraser-%20Ross%2c%20W%20CAJM%20vol.%2017%20no.11.pdf

Patterns of Disease at Selected Rhodesian Hospitals

Abstract

Similar works

Full text

Available Versions

IDS OpenDocs

National Research Database of Zimbabwe