Comment: Health transitions and regressions in Southern Africa

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Overall, the mortality decline has been impressive in sub-Saharan Africa in the second half of the twentieth century. Life expectancies below 40 years were common before 1950, whereas they could exceed 60 years at the end of the century. This health transition occurred in the context of the development of modern states, of modern public health and hygiene, of health personnel and technology (medicines and vaccines), as well as improving nutrition and levels of education. However, these transitions were not always smooth, and were sometimes halted by major political or economic crises as well as by emerging diseases. Furthermore, major changes in diet and lifestyle could also have a negative impact on mortality trends. The Agincourt case study provides solid evidence on mortality levels and major health problems, as well as positive and negative trends in age-, sex-, and cause-specific death rates since 1992 (see the paper by Kathleen Kahn et al. [1]). Mortality levels at baseline appeared relatively low for a rural area of Africa, with female life expectancy above 70 years and a wide gap between males and females. This level compares with that of Western Europe around 1950 despite lower levels of income. However, several features of cause-specific mortality stand in contrast with European patterns. Mortality from external causes (accidents and violence), from diarrhoeal diseases, from severe malnutrition (kwashiorkor), from maternal causes, and from cancers of the female genital tract was higher than expected at this level of mortality. Severe malnutrition and diarrhoea seemed related to the vulnerability of the poorest strata; maternal mortality with low coverage of maternal care among older women; female cancers with the epidemics of sexually transmitted diseases; accidents (household and road traffic) with the newer dangers of modern life; and violent deaths with the overall pattern in post-apartheid society and the weakness of gun control measures. Beyond the specific features at baseline, mortality trends revealed the new public health challenges of this transitional society. Above all, in just a few years, HIV/AIDS became the leading cause of death among young adults and young children, reversing