Philip Setel

Injury morbidity in an urban and a rural area in Tanzania: an epidemiological survey

BackgroundInjuries are becoming a major health problem in developing countries. Few population based studies have been carried out in African countries. We examined the pattern of nonfatal injuries and associated risk factors in an urban and rural setting of Tanzania.MethodsA population-based household survey was conducted in 2002. Participants were selected by cluster sampling. A total of 8,188 urban and 7,035 rural residents of all ages participated in the survey. All injuries reported among all household members in the year preceding the interview and resulting in one or more days of restricted activity were included in the analyis.ResultsA total of 206 (2.5%) and 303 (4.3%) persons reported to have been injured in the urban and rural area respectively. Although the overall incidence was higher in the rural area, the incidence of major injuries (≥ 30 disability days) was similar in both areas. Males were at a higher risk of having an injury than females. Rural residents were more likely to experience injuries due to falls (OR = 1.6; 95% CI = 1.1 – 2.3) and cuts (OR = 4.3; 95% CI = 3.0 – 6.2) but had a lower risk of transport injuries. The most common causes of injury in the urban area were transport injuries and falls. In the rural area, cuts and stabs, of which two thirds were related to agriculture, formed the most common cause. Age was an important risk factor for certain types of injuries. Poverty levels were not significantly associated with experiencing a nonfatal injury.ConclusionThe patterns of injury differ in urban and rural areas partly as a reflection of livelihoods and infrastructure. Rural residents are at a higher overall injury risk than urban residents. This may be important in the development of injury prevention strategies.

Setting international standards for verbal autopsy

In many countries most deaths occur at home. Such countries often have civil registration systems that are limited or non-existent and therefore most deaths go unrecorded. Countries that cannot record the number of people who die or why they die cannot realize the full potential of their health systems. Health systems need reliable numbers and causes of death to function properly. But in these circumstances – in the absence of a complete picture of the population’s health – there are tools and techniques that can be used to obtain a fairly accurate representation of mortality trends. n nIt takes a long time for countries to achieve a fully functioning civil registration system with medical certification of cause of death. In the meantime, more and more countries are using verbal autopsies (VA) to meet the information needs of their health systems.1 Verbal autopsy is a method of ascertaining probable causes of a death based on an interview with primary caregivers about the signs, symptoms and circumstances preceding that death. n nDifferent institutions have been researching and developing all aspects of the verbal autopsy process over the past two decades. We have also been working on this process, particularly to improve the questionnaire and the methods of analysing the resulting information. However, this has been a largely uncoordinated effort and one that has not reached consensus on what to cover in the interview and how to analyse the results, despite previous attempts to promote standard tools.2–4 The main consequence of this failure to agree on a standard approach is that now we cannot compare results from different countries. Currently, 36 Demographic Surveillance Sites (DSS) in 20 countries, the Sample Registration System (SRS) sites in India, and the Disease Surveillance Points (DSP) in China regularly use VA on a large scale, primarily to assess the causes-of-death structure of a defined population.1 Despite such a widespread use of verbal autopsy, we are unable to assess how consistent and reliable the data are. We are also unable to replicate procedures used to assign cause of death. Because verbal autopsy data sets are not widely shared, it is impossible to independently assess the quality of the assignment. Really useful validation studies are rare and verbal autopsy research is often done on small and non-representative samples of the population. n nThe Millennium Development Goals (MDG) have put pressure on countries to track their progress in terms of population health. But to track that progress, countries need reliable numbers. In other words, they need a strong empirical basis for cause-specific mortality data. This is essential for evaluating the impact of disease control programmes and major global health initiatives. One way of dealing with incomplete information is to use models of mortality patterns. But cause-of-death information predicted by such models is not suitable for monitoring progress on what works and what does not.5 That leaves verbal autopsy as the only practical option in these countries and one that will play a key role in tracking progress towards the MDGs. Agreement on a core set of verbal autopsy tools (including technical standards and guidelines for their use) and their widespread adoption is needed now. n nTo tackle this challenge, WHO led an expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN), in developing the necessary standards. The expert group systematically reviewed, debated, and condensed the accumulated experience and evidence from the most widely-used and validated procedures. This synthesis was done to achieve a high degree of consistency and comparability across verbal autopsy data sets. n nWHO has now published the results of this collaboration as: Verbal autopsy standards: ascertaining and attributing cause of death. n n nThe new standards include: n n nVerbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); n n nCause-of-death certification and coding resources consistent with the International Classification of Diseases and Related health Problems, tenth revision (ICD-10); and n n nA cause-of-death list for verbal autopsy prepared according to the ICD-10. n n n nThe content is freely available on the WHO web site (www.who.int) and will be distributed in print; and incorporated into HMN’s resource kit. n n nThis is an important publication, but it is not the last word on verbal autopsy methods. Research is needed to validate these standard core procedures in several countries with different patterns of mortality. Other areas of research include further development of items included in questionnaires, and automated methods for assigning causes of death from verbal autopsy that remove human bias, while producing replicable and valid results.6 Operational issues need addressing: sampling methods and size when using verbal autopsy tools in research demographic surveillance sites; sample or sentinel registration; censuses; and household surveys. Research is also required when adapting these questionnaires to specific situations in different countries, taking into account relevant cultural, epidemiological and administrative considerations. WHO is working with partners to do this research and develop guidelines on these issues. With time, this guidance and experience will better inform the users of verbal autopsy, and improve the comparability and consistency of its results. For the present, we urge that these new international consensus standards become the foundation of verbal autopsy practices wherever possible. ■

AIDS as a paradox of manhood and development in Kilimanjaro, Tanzania

When AIDS emerged in Kilimanjaro region in 1984, many Chagga (the predominant ethnic group in the region) viewed it as a disease of development. Whereas AIDS was commonly seen in the West as a form of punishment for non-reproductive and non-productive lifestyles, in East Africa it represented paradoxes in reproductive and productive life--especially for young, mobile men. This article discusses the emergence of the conditions of risk for HIV among young adults in the 1980s and 1990s, and then explores the perceptions of local actors about the historical and demographic processes that have surrounded the symbolic associations of AIDS. The themes that AIDS evoked were different for men and women; from one perspective, AIDS was seen as an attenuated crisis of the productive and reproductive labors of manhood. For people in northern Kilimanjaro, this disease illuminated contested issues in historical dialogues about social change and the moral value of male participation in idealized forms of work and prescribed male/female unions. The implications of these cultural and demographic realities for AIDS prevention are discussed in the conclusion.

Histories of sexually transmitted diseases and HIV/AIDS in Sub-Saharan Africa

Introduction: Comparative Histories of STDs and HIV/AIDS in Africa by Philip Setel Sex, Disease, and Culture Change in Ghana by Deborah Pellow Sexually Transmitted Diseases and HIV/AIDS in Cote dIvoire by Jeanne-Marie Amat-Roze A History of STDs and AIDS in Senegal--Difficulties in Accounting for Social Logics in Health Policy by Charles Becker and Rene Collignon Medicine and Morality: A Review of Responses to Sexually Transmitted Diseases in Uganda Over the 20th Century by Maryinez Lyons Local Histories of STDs and AIDS in Western and Northern Tanzania by Philip Setel Sexually Transmitted Diseases in Colonial Malawi by Wiseman Chijere Chirwa The Social, Cultural, and Epidemiological History of STDs in Zambia by Bryan T. Callahan and Virginia Bond The Management of Venereal Disease in a Settler Society: Colonial Zimbabwe, 1900 to 1930 by Jock McCulloch The Origins of Sexually Transmitted Diseases in Nineteenth and Twentieth Century South Africa and the Development of Racially Segregated Approaches to Treatment by Karen Jochelson Bibliographies Illustrations

The Social Basis of Health and Healing in Africa

MAPS FIGURES TABLES PREFACE PART I * INTRODUCTION PART II * THE DECLINE AND RISE OF AFRICAN POPULATION: THE SOCIAL CONTEXT OF HEALTH AND DISEASE 1. The Demographic Reproduction of Health and Disease: Colonial Central African Republic and Contemporary Burkina Faso Dennis D. Cordell, joel W. Gregory, and Victor Pichi 2. Famine Analysis and Family Relations: Nyasaland in 1949 A/egan Vaughan 3. Socioeconomic Change and Disease: Smallpox in Colonial Kenya, 1880-1920 Afarc H. Dawson 4. Industrialization, Rural Poverty, and Tuberculosis in South Africa, 1850-1950 Randall AI. Packard 5. Industrialization, Rural Health, and the 1944 National Health Services Commission in South Africa Shula A/arks and Neil Andersson PART III* THERAPEUTIC TRADITIONS OF AFRICA: A HISTORICAL PERSPECTIVE PRECOLONIAL MEDICINE 6. Diffusion of Islamic Medicine into Hausaland Ismail H. Abdalla 7. Ideologies and Institutions in Precolonial Western Equatorial African Therapeutics John M. Janzen 8. Public Health in Precolonial East-Central Africa Gloria Waite COLONIAL MEDICINE 9. Medical Knowledge and Urban Planning in Colonial Tropical Africa Philip D. Curtin 10. Godly Medicine: The Ambiguities of Medical Mission in Southeastern Tanzania, 1900-1945 Terence 0. Ranger TWENTIETH-CENTURY AFRICAN MEDICINE 11. Cold or Spirits? Ambiguity and Syncretism in Moroccan Therapeutics Bernard Greenwood 12. Causality of Disease among the Senufo Nicole Sindzingre and Andras Zemplini 13. A Modern History ofLozi Therapeutics Gwyn Prins 14. Clinical Practice and Organization oflndigenous Healers in South Africa HarrietNgubane 15. Kutambuwa Ugonjuwa: Concepts of Illness and Transformation among the Tabwa of Zaire Christopher Davis-Roberts 16. The Importance of Knowing about Not Knowing: Observations from Hausaland Murray Last POSTCOLONIAL MEDICINE 17. The Social Production of Health in Kenya F. M. Mhuru 18. Health Care and the Concept of Legitimacy in Sierra Leone Carol P. MacCormack BIBLIOGRAPHY

The Heterosexual Transmission of AIDS in Africa

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