African Studies: Health

John C Caldwell, Australian National University, Canberra, ACT, Australia

Published by Elsevier Ltd.
This article is reproduced from the previous edition, volume 1, pp. 244–250, Ó 2001, Elsevier Ltd., with revisions made by the Editor.

Abstract

Health has been defined by the World Health Organization as a condition of complete physical and psychological wellbeing.
In common usage the term ‘good health’ is employed to mean that there is present no major manifestation of ill-health, and
this is also the most satisfactory way of scientifically determining the situation. The most clearly defined outcome of ill-health
(or morbidity) is death (or mortality), because it can be most certainly defined and measured, and because in its irreversibility
it is an index of the most extreme ill-health. This article focuses on mainland sub-Saharan Africa plus the large island nation,
Madagascar, omitting the smaller islands of the Indian and Atlantic oceans with their mixed historical, ethnic, and cultural
backgrounds. All of these have lower mortality than any mainland African country and most are richer. The advances in
health research since the mid-twentieth century are outlined. From 1950 to 1985 mortality declined and health improved
markedly in the region, if not quite as rapidly as elsewhere in the world. Since 1985, however, sub-Saharan Africa, in marked
contrast to all other developing world regions, has experienced a major health crisis. It began with problems in sustaining
economic growth, which led to both a fall in health investment and the acceptance of structural adjustment programs where
the ‘consumer pays’ principle was applied to both health and education services. Mortality decline almost ceased. Then, parts
of the region, conspicuously East and Southern Africa, were afflicted with an AIDS epidemic of far greater intensity than any
other world region. Mortality is now rising throughout East and Southern Africa to such an extent that Botswana and
Zimbabwe anticipate a drop of 20 years in their life expectancies between the late 1980s and the first years of the twenty-first
century. The improvement in health since the beginning of the twentieth century has been a product of better health services,
more universal education, the growth of a market economy, changes in attitudes towards children, and other factors. Many of
these factors are at present under threat, and this combination is intensifying the African health crisis.

Health has been defined by the World Health Organization as
a condition of complete physical and psychological wellbeing.
In common usage the term ’good health’ is employed to mean
that there is present no major manifestation of ill-health, and
this is also the most satisfactory way of scientifically deter-
mining the situation. The most clearly defined outcome of ill-
health (or morbidity) is death (or mortality) because it can be
most certainly defined and measured, and because in its irre-
versibility it is an index of the most extreme ill-health. This
entry will focus on mainland sub-Saharan Africa plus the large
island nation, Madagascar, omitting the smaller islands of the
Indian and Atlantic oceans with their mixed historical, ethnic,
and cultural backgrounds. All of these have lower mortality
than any mainland African country and most are richer. The
advances in health research since the mid-twentieth century are
outlined.
Researching Africa’s Health Levels
At mid-twentieth century sub-Saharan Africa was assumed to
be the unhealthiest region in the world, in spite of an almost
complete lack of data to confirm this view. That confirmation
was to be achieved later by reconstructing the situation with
data from subsequent research, which showed that as late
as 1950–5 the region was characterized by a life expectancy
at birth of only 37 years (United Nations Population Division,
1999). The problem in making such estimates was a complete
lack of vital registration, and of usable mortality and morbidity
information in censuses and demographic surveys. Compre-
hensive national counts of deaths or illness are still not avail-
able anywhere in the region.
This problem of inadequate data has been overcome in
three ways:
1. The so-called ‘indirect methods’ of estimating mortality
(and fertility) levels from inadequate data have been
invented by William Brass and colleagues associated in later
years with the London School of Hygiene and Tropical
Medicine, while the stable and quasi-stable population
model approach was developed by Ansley Coale and
colleagues at the Office of Population Research, Princeton
University. At first the ‘Brass’ methods provided estimates
only of child mortality, but later techniques were developed
for adult mortality, although the latter results were usually
less secure.
2. Censuses and national sample surveys with questions
allowing indirect or even direct estimates of vital rates were
developed. The first censuses with questions on births and
deaths were those in British East Africa in 1948. From the
1960 census round, the United Nations assisted African
censuses. From 1954, demographic sample surveys were
conducted in most francophone African countries. Subse-
quently, many African countries participated in the great
international survey programs: the World Fertility Survey
(WFS) (which contained mortality questions) from 1975
and its successor, the Demographic and Health Surveys
(DHS) from 1985. Nevertheless, by the year 2000 there still
had been no adequate censuses or surveys of the Congo
(Democratic Republic) or Angola, and only preliminary
reports had been issued for the DHS surveys of South Africa
and Ethiopia.
3. High-intensity surveillance projects had been established in
a range of areas. These provided demographic and health

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