Academic journal article Bulletin of the World Health Organization

Changing Causes of Death in the West African Town of Banjul, 1942-97

Academic journal article Bulletin of the World Health Organization

Changing Causes of Death in the West African Town of Banjul, 1942-97

Article excerpt

Voir page 139 le resume en francais. En la pagina 140 figura un resumen en espanol.


Over the past century, mortality has declined and life expectancy has increased in most areas of sub-Saharan Africa, as has happened all over the world. In the Gambia the estimated life expectancy at birth between 1973 and 1993 increased from 34.3 to 60.0 years for women and from 32.2 to 58.3 years for men. Reductions in child mortality accounted for 60% of these increases (1).

Several recent reports have called attention to the process of health transition in the developing world. The ageing of populations, reductions in fertility, improved preventive and therapeutic control of infectious diseases, and the Westernization of lifestyles may all contribute to a decrease in the disease burden attributable to communicable diseases and to an increase in that attributable to degenerative and man-made diseases and injuries. A health transition can be regarded as the combined effect of a demographic transition, involving changing fertility and mortality patterns, and an epidemiological transition involving changes in the environment and in lifestyles (2-4).

Murray & Lopez (5) developed criteria for a worldwide comparison of disease burdens by classifying causes of morbidity and mortality into three major groups (Table 1). A practical application of this classification indicated that, in sub-Saharan Africa, communicable diseases were still the major threat to health but that the burden of noncommunicable diseases and injuries could be expected to increase rapidly (6). Thus there is a double burden of disease in the developing world: the continuing burden of communicable diseases and the emerging burden of noncommunicable diseases resulting from a health transition (2).

Table 1. Classification of causes of death

Group I                Group II           Group III

Infectious diseases    Neoplasms          Traffic accidents

Pregnancy-related      Cardiovascular     Complications of
diseases               diseases           medical and surgical
Perinatal diseases     Gastrointestinal
                       diseases           Other injuries
Nutritional diseases                      (either intentional
                       Renal diseases     or unintentional)



This global classification may be intuitively appealing but it has also been criticized. Although shifting patterns of mortality in sub-Saharan Africa are being increasingly recognized internationally, very few reliable data are available on the subject (7, 8). There is virtually no information on causes of death among adults in sub-Saharan Africa (9). Data for sub-Saharan Africa as used by Murray & Lopez are based on registration data from South Africa only, as vital registration is neither complete nor accurate in most of the subcontinent (10). Even in South Africa the quality of vital statistics and routine census collections is considered inadequate for the purpose of obtaining accurate mortality data (11). Furthermore, the proposed three groups are heterogeneous, and there is not always a clear distinction between infectious and noncommunicable diseases; for instance, many neoplasms are associated with preceding infections (e.g. stomach cancer with Helicobacter pylori; cervical cancer with human papilloma virus).

Our objective has been to study trends in causes of death over time. The allocation of resources and the planning, monitoring and evaluation of health services require knowledge of the causes of death in populations. The availability of death records from 1942 onwards for Banjul, the capital of the Gambia, enabled us to analyse trends in proportional mortality ratios (PMRs). …

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