Disease burden in sub-Saharan Africa

Abstract

We agree with Richard Cooper and colleagues1Cooper RS Osotimenin B Kaufman JS Forrester T Disease burden in sub-Saharan Africa: what should we conclude in the absence of data?.Lancet. 1998; 351: 208-210Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar that the model-based methods adopted by the Global Burden of Disease study are blighted by their necessary assumptions. These are well described by the original authors whose estimates of adult mortality are often based on small-scale infant mortality surveys combined with life-expectancy data from the region. In the absence of other information, it is appropriate and helpful to use such model-based estimates, but these methods are not effective monitoring devices and their limitations will continue in the absence of quality data collection on adult health in developing countries. However, we take issue with Cooper's assertion that “there is little quantitative data about the health of adults in sub-Saharan Africa…[and] nothing which meets the standards of public-health science acceptable in developed countries”. In 1991, the recognition of the need for such data on adult health in Tanzania initiated the Adult Mortality and Mortality Project (AMMP), a collaboration between the University of Newcastle upon Tyne, the Tanzanian Ministry of Health, and the UK Government's Department for International Development. The continued monitoring of deaths from all causes in a population of more than 300 000 people from three different areas of Tanzania has given estimates of cause-specific and all-cause mortality among adults.2Kitange HM Machibya H Black J et al.Outlook for survivors of childhood in sub-Saharan Africa: adult mortality in Tanzania. Adult Morbidity and Mortality Project.BMJ. 1996; 312: 216-220Crossref PubMed Scopus (68) Google Scholar During the first 5 years of the project, we have recorded the deaths of more than 22000 adults.3Adult Morbidity and Mortality ProjectPolicy implications of adult morbidity and mortality. End of phase 1 report. Department for International Department and United Republic of Tanzania, Dar es Salaam1997Google Scholar These data have allowed us to estimate the relative burden of major causes of death for three large populations in Tanzania, including statistics on the use of health care by people before death. This information is of direct use to public-health planners locally, and data from this work have already been used by other governments in East Africa. Results of our work include the importance of infectious diseases, particularly AIDS, malaria, tuberculosis, and gastroenteritis, which account for most premature deaths among adults aged 15–59 years. There are also differences in the burden of disease between rural and urban areas. 90% of women who die during their reproductive years die from causes not related to childbirth. The importance of non-communicable diseases has also been noted, accounting for 15–30% of adult deaths. In Tanzania, age-specific death rates from diabetes seem to be similar4McLarty DG Unwin N Kitange HM Alberti KG Diabetes mellitus as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania. The Adult Morbidity and Mortality Project.Diabetic Med. 1996; 13: 990-994Crossref PubMed Scopus (26) Google Scholar and those from stroke substantially higher3Adult Morbidity and Mortality ProjectPolicy implications of adult morbidity and mortality. End of phase 1 report. Department for International Department and United Republic of Tanzania, Dar es Salaam1997Google Scholar than in North American or European populations.3Adult Morbidity and Mortality ProjectPolicy implications of adult morbidity and mortality. End of phase 1 report. Department for International Department and United Republic of Tanzania, Dar es Salaam1997Google Scholar In addition to these data, population-based studies of the prevalence of diabetes, hypertension, and other cardiovascular risk factors have been published from Tanzania.5Swai AB McLarty DG Kitange HM et al.Low prevalence of risk factors for coronary heart disease in rural Tanzania.Int J Epidemiol. 1993; 22: 651-659Crossref PubMed Scopus (81) Google Scholar The future of adult-health surveillance in Tanzania is to integrate data collection on adult health through a national sentinel district system to inform local health-service planners. Coordination of data collection with health-care planning in this fashion is true public health in action and will allow rational health planning, which will be the envy of many so-called developed countries. We agree with Cooper that more information is needed for sub-Saharan Africa, but data are beginning to emerge and should not be ignored.