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In order to study the management of pulmonary tuberculosis among black and coloured adults in the Border region of South Africa in 1983, a historical inception cohort representative of tuberculosis hospitals and local authority health services was followed up over 15 months to assess how efficiently the national responsibility is discharged in a region. About 75% of patients were sputum-positive, and 81% were judged to have had active pulmonary tuberculosis. The mean service delay after radiography was about 1 1/2 weeks. About 26% of patients were treated with a rifampicin regimen, 50% were frequent attenders and 41% completed treatment, although about 21% were still being treated after 15 months. There was a deficiency of laboratory information for diagnosis and monitoring of response to treatment. Periodic cohort evaluation and improvement of diagnostic efficiency, of peripheral use of laboratories, and of spending on community service infrastructure are essential for closing the gap between policies and implementation.

X-rays of all while and mixed-race men employed in crocidolite and amosite mines and mills were read independently by three experienced readers according to the ILO U/C classification. Abnormality was regarded as present if reported by two or more readers. Parenchymal abnormality, defined as the presence of small irregular opacities of profusion 1/0 or greater, was found in 7.3% of the workers. Pleural thickening was found in 4.5% of the workers, costophrenic angle obliteration in 3.2%, and pleural calcification in 1.7%. The prevalences of both pleural and parenchymal abnormality were strongly related to the duration of exposure to asbestos at work. The overall prevalence of abnormality increase from 4.0% in men with exposure for 1 year or less to 47.9% in men with more than 15 years of exposure. After taking into account the effects of age and duration of asbestos exposure, the prevalence of pleural abnormality was not predicted by fiber concentration. However, white men working with amosite tended to develop a higher prevalence of pleural abnormality than did those working with crocidolite. Compared to whites, men of mixed race, who only work with crocidolite, had a high prevalence of pleural abnormality in each exposure duration category. In contrast to pleural abnormality, the prevalence of parenchymal abnormality, after taking into account the effects of age and duration of exposure, was significantly predicted by fiber concentration but not by race or asbestos type. Our results suggest that parenchymal abnormality in workers in South African asbestos mines could be largely prevented by reducing exposure to fibers visible under the light microscope. However, this may not be the case for pleural abnormality.

Two-thirds of all Black patients who attended the Medical Outpatient Department of the Johannesburg General Hospital for the first time during May 1975 had recorded diastolic blood pressures of 90 mmHg or above. Almost one-third of all patients were treated for hypertension. About half of the patients with diastolic blood pressures between 90 and 119 mmHg were started on treatment, a decision which was predicted by diastolic blood pressure, recorded symptoms and systolic blood pressure, but not by age. Four of the 50 patients with diastolic blood pressures of 120 mmHg or above were not treated. Less than one-third of all patients started on anti-hypertensive treatment were still returning for treatment at the end of 1 year. There was no difference in initial diastolic blood pressure between those patients who did and those who did not return for treatment. Hospital policies are required for standardizing initial decision-making and long-term treatment of hypertension. Strategies to improve compliance by altering health care delivery and changing patient behaviour must be developed and evaluated.

Sixty people with hyperglycaemia were admitted to Baragwanath Hospital as emergency patients during an 8-week study period in 1981, and one-quarter of them died in hospital. Many of these hyperglycaemic emergencies could have been prevented; 88% of the patients were known diabetics, one-third of whom required only oral hypoglycaemic agents for diabetic control. Sixty-one per cent of the patients had concomitant diseases, primarily infections. Earlier treatment might well have prevented deterioration of diabetic control, yet only 6% of the patients had attended the health services in the previous week in spite of recognizing that they were becoming progressively more ill. These patients were at high risk of subsequent admission, one-third of those discharged being readmitted within 3 months. Attendance compliance during a 3-month follow-up period was poor, and the discharged patients lacked the skills and knowledge necessary to maintain adequate diabetic control. One-quarter of those on insulin could not measure their dose correctly, most could not adequately test their urine and did not know what action to take if they had worsening symptoms of hyperglycaemia or developed intercurrent illness. Hyperglycaemic emergency admissions could be reduced by improving ambulatory diabetic services, thus saving costs of hospital care. Recommendations for improving the hospital service include maintaining a register of patients who have had hyperglycaemic emergencies and special care to ensure that they acquire the necessary knowledge and skills. Other methods of improving compliance regarding attendance and medication should be applied. These recommendations need to be implemented and their efficacy evaluated.

Childhood mortality rates in rural Transkei were calculated using data obtained from a sample survey of about 5 000 women who were questioned about the outcome of their pregnancies. There was almost a 1 in 5 risk of children dying before the age of 5 years. The greatest risk was in the 1st year; the infant mortality rate was 130/1 000. About 75% of infant deaths occurred in the postneonatal period. We suggest that many postneonatal deaths are probably caused by diarrhoea and could be prevented by community-based oral rehydration programmes. About 75% of the children were breast-fed beyond the age of 1 year; however, 66% of them were also given other milk before they were 4 months old. Over 80% of women attended an antenatal clinic at least once, although only about 33% of the babies were delivered by the health services. Health services had been attended by 85% of children over 3 months old. The survey methods used were found suitable for ascertaining childhood mortality rates in rural areas of southern Africa. They should be applied more extensively to provide information for planning health services.

Many laboratory tests have been recommended for monitoring factory workers exposed to lead. To select the most useful test the best predictor of selected measures of morbidity was sought. 639 lead-exposed workers in several factories were questioned about abdominal ache, constipation, and fatigue and were examined for hand tremot. Packed-cell volume, blood-lead, urinary lead, and delta-aminolaevulinic acid were estimated in 489 workers. About half of the values for the latter three tests fell into the "excessive" or "dangerous" category of lead absorption. Blood-lead was a better predictor of morbidity than any other laboratory test, and further information did not add appreciably to morbidity prediction. The findings suggest that blood-lead measurement is the most meaningful test for monitoring workers exposed to lead. The effect of lead on morbidity does not appear to depend on its action on the porphyrin metabolic pathway.

The regression of lung function change on the initial lung function level is biased when the initial level is measured with random error. Several methods have been proposed to obtain unbiased estimates of regression coefficients in such circumstances. We apply these methods to examine the relationship between lung function loss over 11 years and its initial level in 433 men aged about 20 when first seen. On theoretical and practical grounds the best method is the correction of the regression coefficient using the reliability coefficient. This is defined as the ratio of the error free variance to the variance of the variable measured with error, and is easily estimated as the correlation between repeat measurements of the underlying level. In young men the loss of some lung functions (forced vital capacity [FVC], forced expiratory volume in one second [FEV1], forced expiratory flow in the middle half of expiration, and the ratio FEV1/FVC) do not appear to be related to initial level.

Environmental and host factors have been implicated in the pathogenesis of emphysema. To assess the role of gold mining exposure (an environmental factor) and of various clinical features recorded early in a miner's career (host factors), a case control study was carried out as follows. From whole lung sections made routinely at all full autopsy examinations on South African gold miners, we selected 44 cases of emphysema and 42 controls without emphysema from among men 51 to 71 yr of age who died during 1980 and 1981. Exposure information was gathered and clinical records were reviewed for smoking history, symptoms, and the presence of rhonchi by decade before death. The presence and grade of silicosis (abstracted from the routine autopsy reports) was similar in both groups; so was bronchitis in the 49 cases and controls with histologic material adequate for review. However, cases were on average older, had worked more shifts in high dust, and had smoked more than controls; they had also exhibited symptoms and rhonchi more frequently before 1950, i.e., 30 yr before death. When these factors were examined in a multiple logistic regression analysis, shifts worked in high dust, smoking, and age were all shown to be strong and independent predictors of emphysema at autopsy; prediction, however, was not improved by addition of any of the clinical features examined. These findings agree with previous cross-sectional studies in South African gold miners showing an exposure response relationship between mining service and air-flow limitation measured by lung function tests in life.(ABSTRACT TRUNCATED AT 250 WORDS)

A study to measure the prevalence of motor disability and impairment using an interview survey and a follow-up medical examination has been carried out in a rural area in KwaZulu, South Africa. A 10% random cluster sample yielded 1659 individuals of all ages. One hundred and forty-three were reported to have motor disability, giving a crude motor disability rate of 86/1000. One hundred and twenty-six were followed up and 86 had demonstrable impairment, giving a crude motor impairment rate of 52/1000. The commonest impairment was osteoarthritis of the hips (20/1000) which may be the same disease as has been reported in neighbouring areas and to which the name Mseleni joint disease (MJD) has been applied.

Despite the availability of highly effective therapy, tuberculosis (TB) remains a major problem in South Africa, even in urban centres such as Soweto which is relatively well provided with health services. We therefore assessed two aspects of TB management in Soweto: (i) the proportion of known tuberculous patients adequately treated; (ii) whether case finding through investigation of home contacts of notified patients was effective. In 1978 patients with TB were required to take chemotherapy for at least a year. Only 28% of newly notified patients attended the clinics frequently enough and/or were hospitalized long enough to obtain 80% or more of the treatment they required during that first year. A major part of this problem of non-compliance was infrequent attendance; these patients received therapy of an adequate duration, but at an inadequate dosage. At least 17% of patients over 10 years of age had tubercle bacilli in their sputa on microscopy more than 4 months after therapy was started. About two-thirds of known home contacts were investigated by the health services in accordance with their stated policy, and 5% of contacts were subsequently notified. Home-contact tracing therefore seems worthwhile.

Systolic blood pressure was measured in a random cluster sample of three-month-old black (n = 532), colored (n = 496), and white (n = 637) infants in Johannesburg, South Africa, by means of a Parks Doppler ultrasound device with a random zero sphygmomanometer. The study was conducted during a nine-month period in 1981. Major predictors of systolic pressure measurements were which fieldworker had taken the measurement and whether the child was quiet or agitated. After adjustment for predictors as necessary, the mean systolic blood pressure of black infants was about 2 mmHg higher than that of coloreds, which was statistically significant, with suggestive evidence that coloreds have a systolic pressure about 1 mmHg higher than that of whites. Findings at age three months may represent ethnic differences in blood pressure distributions of genetic origin.

A randomized trial was carried out to test the effectiveness of nutrition education as a rehabilitation measure for childhood protein-energy malnutrition. The intervention comprised a series of home-based nutrition counselling sessions for the mothers/caretakers of 65 children (hospital outpatients) aged 7-36 months, who were suffering from mild to moderate protein-energy malnutrition. Both the intervention and control groups of children and their caretakers were assessed over a 12-month period: the children on admission and at 3-monthly intervals for weight-for-age, weight-for-height, height-for-age, triceps skinfold-for-age and clinical features; the caretakers on admission and at the final follow-up for nutrition knowledge. Although the nutrition knowledge score of the caretakers in the intervention group improved significantly, no significant differences developed between the two groups of children regarding any of the nutritional status measures assessed. Thus, nutrition education per se was not found to be a major factor in promoting recovery from malnutrition. Nevertheless, both groups of children showed highly significant improvements in all age-adjusted anthropometric assessments except height-for-age.

Painful arthropathy of the hips is common in the black population around Mseleni in northern Kwazulu. Despite considerable variability in clinical and radiographic appearance, the disorder has always been regarded as a single entity. This study addressed the possibility that 'Mseleni joint disease' embraces more than one condition. In a survey of 1659 people in the Manguzi Health Ward, 60 km north of Mseleni, 126 were reported to have hip pain and/or impaired walking ability; 92 of these subjects were examined radiographically. Osteo-arthritis (OA) of the hips was found in 33 cases, the prevalence increasing with age to over 16% in those aged over 60 years. In most cases the OA was associated with two distinct abnormalities: protrusio acetabuli, which affects mainly females and increases in frequency with age, and hip dysplasia, which has a constant frequency with age. The protrusio disorder is fairly common among women of other black populations and is attributed to environmental factors. The hip dysplasia is unique to the population around Manguzi; it is part of a generalized condition indistinguishable from multiple epiphyseal dysplasia, which is a known genetic disorder.

Serum lipid, uric acid and glucose levels were measured in four groups of Black male factory workers 1 hour after an oral glucose load. These groups comprised non-obese manual, obese manual, non-obese clerical and obese clerical workers. Obese men had significantly higher serum uric acid, total cholesterol and triglyceride levels and lower high=density lipoprotein (HDL) cholesterol levels than non-obese men. Serum glucose and low-density lipoprotein (LDL) cholesterol values were also higher in obese than in non-obese men, but the differences were not significant. Clerical workers had higher levels than manual workers for most of the biochemical variables measured, but only in the case of uric acid was the difference significant. Possible reasons for the fact that the effect of occupation on the variables was slight are briefly discussed.

Health education programmes aimed at improving infant feeding must be developed from data on current practices and growth. Infants born in Pimville, Soweto, were traced when they were 6 weeks old and again at 6 months and their mothers and child-minders were interviewed. Length of tay in the area, breastfeeding and weaning intention and practice, age standard of education, understanding of Boston growth charts, and infant growth data were investigated. It is suggested that more specific health education programmes need to be developed and that community-based health workers need to be selected and trained to assist and support mothers in learning better feeding practices.